Occupy the Madness, Tent City,

St. Pauls, London. January 15th 2012.

Hugh Middleton, Occupy London, January 15th 2012


I bring you greetings from Sherwood Forest, the home of Robin Hood!

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, [Tent City] were to “freak out” I wager that it wouldn’t be very long before we took action to contain the situation. Over the centuries we have adopted one after another of different ways of doing that. At present we label such challenges to social order illnesses or psychological problems that professionals: doctors, nurses, therapists and others, can called upon to fix. We need to open full discussion about what that really means. Who actually benefits and in whose interests do we continue to follow that line? One thing it does do is reify the otherwise complex, threatening and inchoate phenomenon of human distress as a governable and transact-able commodity, available for professional and commercial exploitation. What the alternatives might be makes interesting speculation. If I was in a bad way I would probably rather take Prozac than be tortured by the Spanish Inquisition or incarcerated in a madhouse, but I would far rather be understood and cared for by supportive and understanding human beings.