Occupy the Madness,
St. Pauls,
I bring you
greetings from
I guess I am
here in my role as an NHS psychiatrist. Psychiatry is variously depicted, often
demonised and generally opaque. What I want to do is tell you a little about
that from life on the front line.
Wherever you
look, from the medieval priest casting out demons, to current fashions in
diagnostic labelling, medical treatment and cognitive behaviour therapy you will
find arrangements of some sort to deal with the “problem” of the despairing, the
distressed, the confused, the anxious and the anxiety provoking. Sadly, abuse
and childhood neglect happen, and as a result some grow up limited in their
ability to relate to others comfortably and reliably. Tragedies happen and
people are left traumatised. Not everyone is equipped to negotiate all the
complexities of life and relationships. There is, there always has been and
there probably always will be a small sector of any community who at some time
or another find life unbearably difficult, confusing or distressing.
In the Mahatma’s words; “A
society is measured by how it treats its weakest members”. Christ says the same
in the form of: “Truly I tell you, just as you did it to one of the least of
these who are members of my family, you did it to me”. If I were a better
Islamic scholar I would surely be able to find a similar quote from The Holy
Qur’an – and were I a Jew, from the Torah. Care and concern for the marginalised
are essential features of any claim to social justice. What do arrangements we
have in place under the name of mental health services tell us of how well we
measure up to this?
Andrew [Samuels]
has already told you something about NICE guidelines. I don’t want you to think
that is all we have to share with you this morning but they do provide a readily
available and explicit account of what mental health (and other NHS) services
claim to wish to provide. In other words, what established services and
practices are or believe they should be.
In theory the
recommendations NICE makes are drawn from careful scrutiny of the scientific
evidence. Medicine holds its authority on the basis of privileged access to
scientific knowledge considered helpful in the mitigation of illness and
suffering. The NHS, and insurance based healthcare systems elsewhere, conform to
this. Ultimately decisions about what can and cannot be expected from your
healthcare system are based upon an interpretation of relevant scientific
knowledge. We call it evidence based practice. NICE guidelines are official NHS
policy seemingly drawn from careful academic review of the scientific evidence –
concerning this, that or the other condition.
There are
numerous criticisms of the way this process is conducted, and also of the value
of adopting it at all, but these are not my brief, here. Instead I want to
consider how well NICE guidelines even do what is said on the can, and where
they don’t, what is happening instead. What do they tell us about non-scientific
– social, political and/or commercial influences upon mental health service
policy?
For the purpose
I want to focus upon NICE guidelines for the treatment and management of
depression. The most recent edition was published in October 2009 and in theory
at least they serve as a template defining what services the NHS can be expected
to provide for people with depression and what can be expected of healthcare
practitioners; GPs, psychiatrists, mental health nurses, clinical psychologists,
counsellors and others.
The 2009 NICE
guidelines for depression are based upon the usual exhaustive review of the
scientific literature, in this case concerning depression. This has been
published and is publically available, for free download from the NICE website,
as the Full Guide.
http://guidance.nice.org.uk/CG90/Guidance It
is a voluminous document, over 700 pages with numerous appendices written in
technical language and if you like that sort of thing it
is a definitive resumé of agreed
scientific opinion on the subject.
Obviously this
is of no use to everyday practitioners and NHS managers who don’t have the time,
inclination or patience to work through such a tome. Aware of this NICE have
used the academic review as the basis of much shorter and more digestible
documents designed for different audiences. In the case of depression there is a
60 odd page NICE guideline for specialist practitioners and a 27 page quick
reference guide, which is what goes to all NHS practitioners and relevant
managers, and of course this is the most widely read and influential version. If
NICE have any impression upon what the NHS does for depression, then it is what
is said in the quick reference guide that influences policy and practice on the
ground.
Now you can’t
take a 700 page technical document with numerous appendices and turn it into a
27 page quick reference guide without cutting a few corners.
What I want to do with
you is illustrate how, in the case of depression, those corners have been cut so
much that what the quick reference guide says … and therefore what NHS staff
have been led to understand as their duty, and what the science says, are quite
different things. Then we can think a little about why the quick
reference guide says what it does.
Here is a copy
of the quick reference guide. Also freely available at:
http://guidance.nice.org.uk/CG90/QuickRefGuide
For the sake of
time I will just take three examples and hopefully you will get the drift. These
are but a small part of a complete comparison of these two documents. We can
look at more and in more detail if you wish.
If you look at
page 7 [of the quick reference guide] you will see that the management of
depression is set out around a series of steps based upon differing degrees of
severity, as if it is truly realistic to clearly identify and distinguish
between mild, moderate and severe depression. On page 13 of the full guide, in
summarising the scientific findings upon which this is based, the academics have
recorded “Depression refers to a wide range of mental health problems
characterised by the absence of a positive affect (a loss of interest and
enjoyment in ordinary things and experiences), low mood and a range of
associated emotional, cognitive, physical and behavioural symptoms.
Distinguishing the mood changes between clinically significant degrees of
depression (for example, major depression) and those occurring ‘normally’
remains problematic and it is best to consider the symptoms of depression as
occurring on a continuum of severity.”.
Moving on to page 13 of the quick reference guide you will see that a number of
psychosocial and psychological interventions are recommended, as if they are
clearly identifiable, discrete and effective treatments. In relation to these,
on page 182 of the full guide it says
“A range of low-intensity interventions (guided self-help, group-based
physical activity programmes and CCBT) have been identified as being effective
for subthreshold depressive symptoms and mild to moderate depression. … the GDG
[Guideline Development Group] took the view that the decision as to which
intervention to offer should, in significant part, be guided by the preference
of people with depression. … All interventions seem to require some form of
support or supervision to be fully effective”.
In other words, again according to the scientific evidence this is based upon,
there is actually nothing to choose between them, and what makes all of them
effective when they are, is probably the fact that they are credible ways of
providing an understanding and supportive relationship.
Finally, in
relation to medication. You will see that seven of the 27 pages (more than a
quarter) [of the quick reference guide] are given over to advice about the use
of antidepressant medication. Don’t worry if this reads like gobbledegook. It is
supposed to because this bit is for doctors! Actually, after an impressively
thorough review of the scientific data the full guide concludes, on page 411,
“…
that antidepressants have largely equal efficacy and that choice should largely
depend on side-effect profile, patient preference and previous experience of
treatments, propensity to cause discontinuation symptoms and safety in overdose
…”
and on page 319 that “These
results should be treated with caution because of publication bias (that is,
studies with statistically significant findings are more likely to be published
than those with non-significant findings).”.
Hardly the
ringing endorsement implied by coverage occupying more than three quarters of
the quick reference guide. Furthermore many academics outside the particular
medical-academic circle that conducted this review would be even more sceptical
about the value of anti-depressant medication than this, but the point is made.
That point is,
that the most widely
distributed and most influential presentation of NICE guidelines for the
treatment and management of depression goes far beyond the facts.
Where
does it go?
I think that is
not too difficult to discern this from the guidance you have in your hands
[quick reference guide]. Distress, despair, anxiety or confusion in others, are
very difficult to tolerate. They are disturbing, by definition and if any one of
us, even here, [
.