Showing posts with label Research. Show all posts
Showing posts with label Research. Show all posts
Saturday, 26 February 2011
Thursday, 6 May 2010
Blood
I learnt something new today.
I do most days, mostly from nurses, but on this occasion it was after our monthly team CPD (continuing professional development) meeting. We'd rattled through a discussion of recent papers and how they should affect our practice, we noted the bias of one review and chewed over how we were doing with NICE guidance. We discussed depot olanzapine's evidence of what the pharmaceutical company report as a "post injection syndrome" and how everyone else calls it "a coma" and how this seemed bad.
It was noted that I brought a number of abstracts from British and US journals but nursing colleagues didn't. Yet they're very interested in the 10 minute discussion of each paper, grabbing the headline messages and learning points, with their "care pathways" having changed for the better over time through considering new research and reviewing what we do. A number of articles and papers have been published by us over the last year. If nurses embrace new research (in a balanced and critical way) then adopt the good bits, why aren't they sharing lots of papers at our monthly meeting?
It's all down to what's valued. Consultant Psychiatrists have time set aside each week for CPD. Nurses do not. Nurses are told what to adopt and articulate how they're not given time to provide even basic nursing care. I wonder how many nurses have time for CPD in their week? Do any have time to browse web sites, muse over abstracts, download papers and read through NICE, DoH and other advice, guidance and direction? I know of no nurses who do.
So for a hour a month we do it ourselves, rattling through a couple papers (no more than 10 minutes on each, just to distill what the issue was, what the paper shows us, the weaknesses of the paper and how we then could use it in our work) and any new guidance and obstacles to good practice.
At least this means we've a fighting chance of spotting quackery that's increasingly peddled in more mainstream literature. Like this, which I learnt of today. Live Blood Analysis (LBA). You take a spot of patients blood, both you and the patient just look at it on a big screen for 2 hours, you see stuff move and decide what this means. Such as, "Look at those moving, they must be alive, you have parasites in your blood, take this herbal medication that's expensive but look at your blood, it's so worth it."
A Dr Rubin looked at this and found no papers on LBA in the scientific literature. None. Yet there were 2.5 million hits on Google. Interesting. Someone's advertising and making a lot of money from this LBA thingy. So, does LBA work? Is the scientific community elitist and simply ignoring a helpful diagnostic intervention? Actually, no. It's pseudoscience and doesn't work.
That's a helpful paper. I've learnt today of a new entity, Live Blood Analysis, and learnt of rigorous review of LBA which found it to be so much stuff and nonsense. Which is worth knowing.
Should I charitably tag this post as "Complimentary Therapy" or should I generate a new tag of "Fraud" I wonder . . .
I do most days, mostly from nurses, but on this occasion it was after our monthly team CPD (continuing professional development) meeting. We'd rattled through a discussion of recent papers and how they should affect our practice, we noted the bias of one review and chewed over how we were doing with NICE guidance. We discussed depot olanzapine's evidence of what the pharmaceutical company report as a "post injection syndrome" and how everyone else calls it "a coma" and how this seemed bad.
It was noted that I brought a number of abstracts from British and US journals but nursing colleagues didn't. Yet they're very interested in the 10 minute discussion of each paper, grabbing the headline messages and learning points, with their "care pathways" having changed for the better over time through considering new research and reviewing what we do. A number of articles and papers have been published by us over the last year. If nurses embrace new research (in a balanced and critical way) then adopt the good bits, why aren't they sharing lots of papers at our monthly meeting?
It's all down to what's valued. Consultant Psychiatrists have time set aside each week for CPD. Nurses do not. Nurses are told what to adopt and articulate how they're not given time to provide even basic nursing care. I wonder how many nurses have time for CPD in their week? Do any have time to browse web sites, muse over abstracts, download papers and read through NICE, DoH and other advice, guidance and direction? I know of no nurses who do.
So for a hour a month we do it ourselves, rattling through a couple papers (no more than 10 minutes on each, just to distill what the issue was, what the paper shows us, the weaknesses of the paper and how we then could use it in our work) and any new guidance and obstacles to good practice.
At least this means we've a fighting chance of spotting quackery that's increasingly peddled in more mainstream literature. Like this, which I learnt of today. Live Blood Analysis (LBA). You take a spot of patients blood, both you and the patient just look at it on a big screen for 2 hours, you see stuff move and decide what this means. Such as, "Look at those moving, they must be alive, you have parasites in your blood, take this herbal medication that's expensive but look at your blood, it's so worth it."
A Dr Rubin looked at this and found no papers on LBA in the scientific literature. None. Yet there were 2.5 million hits on Google. Interesting. Someone's advertising and making a lot of money from this LBA thingy. So, does LBA work? Is the scientific community elitist and simply ignoring a helpful diagnostic intervention? Actually, no. It's pseudoscience and doesn't work.
That's a helpful paper. I've learnt today of a new entity, Live Blood Analysis, and learnt of rigorous review of LBA which found it to be so much stuff and nonsense. Which is worth knowing.
Should I charitably tag this post as "Complimentary Therapy" or should I generate a new tag of "Fraud" I wonder . . .
Wednesday, 28 April 2010
More drugs!
Although an American publication this year alluded to the message, "Drugs, just say no!" as discussed below, there's new news.
The British Medical Journal last month published a clinical review paper on, "Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants."
What did it show us?
It showed us 3 things.
1) We're prescribing more antidepressants.
They assume this is because people are prescribed them for longer (because that's what they found, so they're right). The assumption is flawed, though. We prescribe more antidepressants in the UK and USA than we did in 1993 because over the last 17 years prescribing practice has changed.
People with generalised anxiety disorder, adjustment disorder, post traumatic stress disorder and somatoform disorders used to get pretty rubbish drugs. If you had such a problem, with "neurotic" and not "psychotic" problems, and weren't clinically depressed, you often didn't get an antidepressant or antipsychotic (since you're not depressed or psychotic) so got an anxiolytic. Diazepam. Or another benzodiazepine of choice. They were liked because they worked and melted away distress well. Then, years on, problems emerged and subsequently "antidepressant" medication is commonly used in the management of anxiety states. Anxiety states often endure, hence such medication's needed for a long, long time.
Use of antidepressant medication's gone up not necessarily through changes in management of depression, but because "neurotic" disorders are managed with such medication now, instead of dishing out nothing or benzodiazepines.
2) If you continue on medication, you do better
Relapse rates are lower. Antidepressants drugs reduce the rate of relapse, significantly. Hurrah!
The drugs also cause side effects which are common (e.g. at best 24% and at worst 80% of people on antidepressants developed sexual dysfunction).
Stay on the drugs, but get side effects most of the time. Hmmmm.
How many do you need to treat to prevent relapse? They looked at that, too. 4. So for every 4 patients you keep on an antidepressant long term, 3 get no benefit and 1 won't experience a relapse they otherwise would. 3 have no benefit but all the side effects, 1 has benefit and side effects. Hmmmm.
3) The title lies
"Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants" is misleading. It suggests that the paper is about people with depression being on antidepressants long term and although most have serious/unpleasant side effects and for 75% it won't help, for 25% it will be beneficial.
Sadly not.
To their enormous credit, the authors do 'fess up to this. This is because the published papers have significant bias. Rather than taking people with depression, half having antidepressants and half having placebo, then seeing how they do over time (a randomised controlled trial), the studies reviewed were "discontinuation trials." This means that the (usually drug company sponsored) research involved getting a group of people with depression and giving them an antidepressant. Any who didn't respond are then excluded. So of your 100 depressed patients, it may well be that half got better anyway and a third didn't benefit from the drug, so only 10 patients progress through to the trial. What the "discontinuation" bit means is that the researchers then discontinue the antidepressant medication in half the people it's helping and swap them onto placebo.
So a more accurate take on this very good and detailed systematic review of 31 trials, mainly/all discontinuation trials, is :
"In patients with depression, who respond well to an antidepressant, continuing the antidepressant over a longer time (e.g. 12 months) can reduce risk of relapse for 1 in 4 patients."
It's not quite as catchy a headline, though.
Meh, maybe the drugs still don't work quite as well as we'd wish, or as pharmaceutical companies would lead us to believe. But at least if I've patients with chemical clinical depression, who respond to an antidepressant, and have a relapse, then this paper supports the ongoing use of an antidepressant over the longer teerm (over years). And that this works well, halving the risk of relapse. That's good news. It's certainly something folk will welcome, who've shown clearly that the antidepressants work well for them, as robust evidence that it's worth continuing and shouldn't be taken off them!
The British Medical Journal last month published a clinical review paper on, "Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants."
What did it show us?
It showed us 3 things.
1) We're prescribing more antidepressants.
They assume this is because people are prescribed them for longer (because that's what they found, so they're right). The assumption is flawed, though. We prescribe more antidepressants in the UK and USA than we did in 1993 because over the last 17 years prescribing practice has changed.
People with generalised anxiety disorder, adjustment disorder, post traumatic stress disorder and somatoform disorders used to get pretty rubbish drugs. If you had such a problem, with "neurotic" and not "psychotic" problems, and weren't clinically depressed, you often didn't get an antidepressant or antipsychotic (since you're not depressed or psychotic) so got an anxiolytic. Diazepam. Or another benzodiazepine of choice. They were liked because they worked and melted away distress well. Then, years on, problems emerged and subsequently "antidepressant" medication is commonly used in the management of anxiety states. Anxiety states often endure, hence such medication's needed for a long, long time.
Use of antidepressant medication's gone up not necessarily through changes in management of depression, but because "neurotic" disorders are managed with such medication now, instead of dishing out nothing or benzodiazepines.
2) If you continue on medication, you do better
Relapse rates are lower. Antidepressants drugs reduce the rate of relapse, significantly. Hurrah!
The drugs also cause side effects which are common (e.g. at best 24% and at worst 80% of people on antidepressants developed sexual dysfunction).
Stay on the drugs, but get side effects most of the time. Hmmmm.
How many do you need to treat to prevent relapse? They looked at that, too. 4. So for every 4 patients you keep on an antidepressant long term, 3 get no benefit and 1 won't experience a relapse they otherwise would. 3 have no benefit but all the side effects, 1 has benefit and side effects. Hmmmm.
3) The title lies
"Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants" is misleading. It suggests that the paper is about people with depression being on antidepressants long term and although most have serious/unpleasant side effects and for 75% it won't help, for 25% it will be beneficial.
Sadly not.
To their enormous credit, the authors do 'fess up to this. This is because the published papers have significant bias. Rather than taking people with depression, half having antidepressants and half having placebo, then seeing how they do over time (a randomised controlled trial), the studies reviewed were "discontinuation trials." This means that the (usually drug company sponsored) research involved getting a group of people with depression and giving them an antidepressant. Any who didn't respond are then excluded. So of your 100 depressed patients, it may well be that half got better anyway and a third didn't benefit from the drug, so only 10 patients progress through to the trial. What the "discontinuation" bit means is that the researchers then discontinue the antidepressant medication in half the people it's helping and swap them onto placebo.
So a more accurate take on this very good and detailed systematic review of 31 trials, mainly/all discontinuation trials, is :
"In patients with depression, who respond well to an antidepressant, continuing the antidepressant over a longer time (e.g. 12 months) can reduce risk of relapse for 1 in 4 patients."
It's not quite as catchy a headline, though.
Meh, maybe the drugs still don't work quite as well as we'd wish, or as pharmaceutical companies would lead us to believe. But at least if I've patients with chemical clinical depression, who respond to an antidepressant, and have a relapse, then this paper supports the ongoing use of an antidepressant over the longer teerm (over years). And that this works well, halving the risk of relapse. That's good news. It's certainly something folk will welcome, who've shown clearly that the antidepressants work well for them, as robust evidence that it's worth continuing and shouldn't be taken off them!
Wednesday, 21 April 2010
Antidepressants
Drugs work. They do. They can be very, very helpful indeed.
But as Richard Ashcroft of The Verve penned, regarding the effect of drugs on his father dying of cancer when he was 11 years old, "and I hope you’re thinking of me, as you lay down inside, now the drugs don’t work, they just make you worse, but I know I’ll see your face again."
We think drugs work well. But for an 11 year old boy, reality hit hard, seeing his dad die and drugs fail to change things.
Drugs work, but drugs aren't miraculous.
Having a discussion on this is always contentious. There are two wholly valid reasons for this. Firstly the statistical evidence can be challenged/critiqued/appraised. Secondly experiential learning (of having drugs and being cured/being worse) gives valid and wholly accurate evidence that they're brilliant/harmful. These two sources of information, aggregate trial data of large numbers and single patient therapeutic trials with an n of 1 both give different perspectives and facts, both supporting enthusiastic use/reticence to use antidepressant drugs.
DeeDee's comment stirred my thoughts on this, again.
Like any meaningful, complicated, multifactorial issue, in or out of health care, a dichotomous "this is good" or "this is bad" doesn't really work. Much as it's cozy and comfortable for a newspaper to publish that antidepressants are great and patients are missing out through not being properly treated, or antidepressants aren't wonderful and patients have shabby care through doctors dishing them out inappropriately, the truth is more complicated. Newspaper headlines can't be complicated. Many newspaper articles need to be timely, snappy and simple so can't be complicated. Complicated health issues (with personal and socioeconomic consequences) aren't easily discussed or debated in mainstream media. The issues are left to wither. So it goes.
If I was to be horribly reductionist and come down with a quick and easy message my thoughts'd be that antidepressants can work well as part of a package of care for some people some of the time so the message would be, "Use antidepressants appropriately and get it right!"
Which isn't massively helpful.
The crux of it is that it's incredibly useful for individual patients, as DeeDee describes. Or it's unhelpful/harmful for individual patients, as others describe.
Beyond patient numbers, we get the same pattern. Drug companies have had to evidence efficacy (that the drugs work) to get a marketting authorisation to sell their antidepressants. Clinical trial data shows that the drugs work in clinical trials. Out of clinical trials, in the really real world, a study this year published in the Journal of the American Medical Association showed that antidepressants work no better than placebo in mild, moderate and severe depression (with benefit emerging just through very severe depression).
This means if you're a GP seeing someone with mild, moderate or severe depression you're informed that, statistically, prescribing an antidepressant for the patient sat in front of you will have as much effect as prescribing placebo. Yet, clinically, some patients respond brilliantly.
It's a flaw of evidence based medicine that effects which are uncommon but highly significant for a small number of people get diluted/lost in the trial data. Trials aren't usually sufficiently powered to evidence statistical significance through rare but highly meaningful events. This is even more true in looking at clinical effectiveness of treatments (i.e. how it works in real clinical practice) rather than trials of efficacy (rigid clinical trials with strict patient inclusion/exclusion criteria).
In the really real world, outside clinical trials, people have low mood. A lot. Most people with low mood do not meet ICD-10 diagnostic criteria for clinical depression. Most people with low mood do not have a somatic syndrome, common in chemical (functional, endogenous) mood disorder. For most people, chemical solutions (of antidepressant medication) therefore has little benefit. Which is what patient and trial evidence, and clinical experience, shows us.
Yet, for people with chemical mood disorders, psychosocial interventions have some but modest utility and chemical treatments (or treatments effecting chemical changes in the brain, like ECT) can work brilliantly.
Antidepressants therefore have a very important and very valuable role to play, but in a very defined subgroup of people who have a mood problem. Of all those with mood difficulties, those with endogenous chemical depression do well. Those with reactive depression, feeling depressed because of events, responding (as most of us would) with depressed mood to a depressing situation, are low in mood through their situation not their brain chemistry, so plying medication 'pon them unsurprisingly effects little benefit.
Gets you thinking.
If appropriate and successful drug treatment hinges on accurate diagnosis and subtyping of diagnosis (it's pretty robustly evidenced and understood that chemical functional mental illnessness of ICD-10 recurrent mood disorders and bipolar disorders merit antidepressants) then is it fair to ask GPs to do this?
In older adults it's even more complicated. Loss of health, role, mobility, opportunity, income, friends and family is common in older adults we see. There's often been a lot of adversity. If life's not peachy, should folk be feeling peachy? Then, as well as loss events, there're cognitive changes. In neurodegenerative dementia like Alzheimer's Disease the limbic system, controlling mood, is always affected before memory is. Everyone with Alzheimer's Disease has brain damage affecting their mood area of the brain so frustration, irritability, low mood and changeable mood is common, before even accounting for the changes in their life that dementia causes. Teasing out if older adults have a mood disorder that's sufficient to attract an ICD-10 diagnosis of clinical depression isn't quick and easy. Determining if medication has a role to play is complex.
Our APC and PCT's been wrestling with this. Clinical care is one consideration. Cost of the drugs is another. So the question last month was, "Is it fair to ask GPs to initiate antidepressant medication, or should this always be undertaken within specialist care?"
I'm sure nobody will be bold enough to answer it.
But as Richard Ashcroft of The Verve penned, regarding the effect of drugs on his father dying of cancer when he was 11 years old, "and I hope you’re thinking of me, as you lay down inside, now the drugs don’t work, they just make you worse, but I know I’ll see your face again."
We think drugs work well. But for an 11 year old boy, reality hit hard, seeing his dad die and drugs fail to change things.
Drugs work, but drugs aren't miraculous.
Having a discussion on this is always contentious. There are two wholly valid reasons for this. Firstly the statistical evidence can be challenged/critiqued/appraised. Secondly experiential learning (of having drugs and being cured/being worse) gives valid and wholly accurate evidence that they're brilliant/harmful. These two sources of information, aggregate trial data of large numbers and single patient therapeutic trials with an n of 1 both give different perspectives and facts, both supporting enthusiastic use/reticence to use antidepressant drugs.
DeeDee's comment stirred my thoughts on this, again.
Like any meaningful, complicated, multifactorial issue, in or out of health care, a dichotomous "this is good" or "this is bad" doesn't really work. Much as it's cozy and comfortable for a newspaper to publish that antidepressants are great and patients are missing out through not being properly treated, or antidepressants aren't wonderful and patients have shabby care through doctors dishing them out inappropriately, the truth is more complicated. Newspaper headlines can't be complicated. Many newspaper articles need to be timely, snappy and simple so can't be complicated. Complicated health issues (with personal and socioeconomic consequences) aren't easily discussed or debated in mainstream media. The issues are left to wither. So it goes.
If I was to be horribly reductionist and come down with a quick and easy message my thoughts'd be that antidepressants can work well as part of a package of care for some people some of the time so the message would be, "Use antidepressants appropriately and get it right!"
Which isn't massively helpful.
The crux of it is that it's incredibly useful for individual patients, as DeeDee describes. Or it's unhelpful/harmful for individual patients, as others describe.
Beyond patient numbers, we get the same pattern. Drug companies have had to evidence efficacy (that the drugs work) to get a marketting authorisation to sell their antidepressants. Clinical trial data shows that the drugs work in clinical trials. Out of clinical trials, in the really real world, a study this year published in the Journal of the American Medical Association showed that antidepressants work no better than placebo in mild, moderate and severe depression (with benefit emerging just through very severe depression).
This means if you're a GP seeing someone with mild, moderate or severe depression you're informed that, statistically, prescribing an antidepressant for the patient sat in front of you will have as much effect as prescribing placebo. Yet, clinically, some patients respond brilliantly.
It's a flaw of evidence based medicine that effects which are uncommon but highly significant for a small number of people get diluted/lost in the trial data. Trials aren't usually sufficiently powered to evidence statistical significance through rare but highly meaningful events. This is even more true in looking at clinical effectiveness of treatments (i.e. how it works in real clinical practice) rather than trials of efficacy (rigid clinical trials with strict patient inclusion/exclusion criteria).
In the really real world, outside clinical trials, people have low mood. A lot. Most people with low mood do not meet ICD-10 diagnostic criteria for clinical depression. Most people with low mood do not have a somatic syndrome, common in chemical (functional, endogenous) mood disorder. For most people, chemical solutions (of antidepressant medication) therefore has little benefit. Which is what patient and trial evidence, and clinical experience, shows us.
Yet, for people with chemical mood disorders, psychosocial interventions have some but modest utility and chemical treatments (or treatments effecting chemical changes in the brain, like ECT) can work brilliantly.
Antidepressants therefore have a very important and very valuable role to play, but in a very defined subgroup of people who have a mood problem. Of all those with mood difficulties, those with endogenous chemical depression do well. Those with reactive depression, feeling depressed because of events, responding (as most of us would) with depressed mood to a depressing situation, are low in mood through their situation not their brain chemistry, so plying medication 'pon them unsurprisingly effects little benefit.
Gets you thinking.
If appropriate and successful drug treatment hinges on accurate diagnosis and subtyping of diagnosis (it's pretty robustly evidenced and understood that chemical functional mental illnessness of ICD-10 recurrent mood disorders and bipolar disorders merit antidepressants) then is it fair to ask GPs to do this?
In older adults it's even more complicated. Loss of health, role, mobility, opportunity, income, friends and family is common in older adults we see. There's often been a lot of adversity. If life's not peachy, should folk be feeling peachy? Then, as well as loss events, there're cognitive changes. In neurodegenerative dementia like Alzheimer's Disease the limbic system, controlling mood, is always affected before memory is. Everyone with Alzheimer's Disease has brain damage affecting their mood area of the brain so frustration, irritability, low mood and changeable mood is common, before even accounting for the changes in their life that dementia causes. Teasing out if older adults have a mood disorder that's sufficient to attract an ICD-10 diagnosis of clinical depression isn't quick and easy. Determining if medication has a role to play is complex.
Our APC and PCT's been wrestling with this. Clinical care is one consideration. Cost of the drugs is another. So the question last month was, "Is it fair to ask GPs to initiate antidepressant medication, or should this always be undertaken within specialist care?"
I'm sure nobody will be bold enough to answer it.
Saturday, 14 February 2009
Shock news!
You will not be startled to learn the results of the DART-AD trial.
The reason why we've Prescription Only Medicine (POM) is that it's thought to be, ". . . those preparations that are available only on a prescription issued by an appropriate practitioner."
It's the proper stuff. Stuff with risks and benefits. Stuff with real consequences (both good and bad). Rather than Over The Counter (OTC) medicine which anyone can get, over the counter, from a chemist, POM tends to be medication where risks, side effects, treatment emergent adverse events, monitoring, serious interactions or other elements of how the drug works needs careful thought and judgement made.
Hence the legal requirement for not just advice, not just safety netting and input from a manager or a scientist, these proper drugs require, "an appropriate practitioner."
A good turn of phrase, that. "An" suggests one, which pleases me. One GP (not polyclinics and walk in centres). One psychiatrist (not fractured models of a Community one, an Early Intervention one, a Crisis Resolution one, an Inpatient one, a Rehabilitation one etc etc). Optimistic, I know, but having one GP and one Consultant is a model I'm thoroughly wedded to.
"Appropriate" is a handy word, meaning that it's not just a practitioner, it's got to be an appropriate one. The pharmacist in my team's clear on what this means. It means someone who can make valid, rational prescribing decisions. Although, as a pharamcist, there's expertise in the drug's use and interactions, pharmacists don't do out-patient clinics so don't get to see all the consequences of medication used, so don't feel they're experts at prescribing. Sensibly, my pharmacist sees herself as a resource to inform on decisions (and explain medication issues to patients, and manage the governance systems around medicines management), she doesn't see herself as an "appropriate" prescriber.
The word "practitioner" is salient, too. It implies a need for someone in practice, someone practising clinical care. So not just someone who knows a lot about drugs, then. If asked, "Of the last 50 patients you gave advice on medication to, how many had no side effects (and you've documented that), and how many had side effects (which you've documented)?" a "practitioner" should be in a position to answer that, someone just giving advice couldn't. And if that someone's giving prescribing advice but not seeing the consequences of their clinical practice, then I'd suggest they're not "an appropriate practitioner" so should not be issuing prescriptions for Prescription Only Medicine.
Rant over.
POM are medicines that we shouldn't be cavalier with. They're drugs which have real effects, so often need judicious consideration on initiating, continuing, monitoring and withdrawing them.
Which brings me to this study. It's a good study. It's funded by the UK Alzheimer's Research Trust, not a drug company. It's a study that was conducted over an appropriate length of time. Each treatment arm was of a decent size. It's a very relevant research topic.
They looked at folk with Alzheimer's disease, for up to 3 years. They found that patients without antipsychotic medication lived longer than patients with antipsychotic medication. Shock news!
I'm ambivalent about this study, really. On the one hand, it's a well executed bit of credible research that's about a contentious and relevant theme. On the other hand, is it necessary?
In patients with crashing heart failure, with fluid pouring into their lungs, the dread and feeling of drowning, the weakness, then death, life isn't great. Diamorphine can be used to reduce the ghastly symptoms. Diamorphine causes respiratory depression. Stops you breathing. In a patient who's lungs are filling with fluid, reducing their breathing isn't a strategy conducive to a long life. But it's done, rightly, even though life may be shortened, because the clinical condition warrants this palliative care. Is a study necessary to show us that, in heart failure, patients dying without diamorphine live fractionally longer than patients on diamorphine? Probably not. We know diamorphine is a proper drug, a medicine with benefits and side effects that need to be weighed by "an appropriate practitioner."
The DART-AD trial shows us that antipsychotics generate risk in Alzheimer's Disease patients. Although my gut reaction is, "And?!" I do s'pose it's useful to have a well executed study evidencing that what we knew to be the case is actually the case.
So is there anything from this which will change my clinical practice? No. But it's good to know that what I thought (that the drugs were dangerous) is true, and decisions around their use should be very carefully throught through by senior clinicians with expertise in this area.
The reason why we've Prescription Only Medicine (POM) is that it's thought to be, ". . . those preparations that are available only on a prescription issued by an appropriate practitioner."
It's the proper stuff. Stuff with risks and benefits. Stuff with real consequences (both good and bad). Rather than Over The Counter (OTC) medicine which anyone can get, over the counter, from a chemist, POM tends to be medication where risks, side effects, treatment emergent adverse events, monitoring, serious interactions or other elements of how the drug works needs careful thought and judgement made.
Hence the legal requirement for not just advice, not just safety netting and input from a manager or a scientist, these proper drugs require, "an appropriate practitioner."
A good turn of phrase, that. "An" suggests one, which pleases me. One GP (not polyclinics and walk in centres). One psychiatrist (not fractured models of a Community one, an Early Intervention one, a Crisis Resolution one, an Inpatient one, a Rehabilitation one etc etc). Optimistic, I know, but having one GP and one Consultant is a model I'm thoroughly wedded to.
"Appropriate" is a handy word, meaning that it's not just a practitioner, it's got to be an appropriate one. The pharmacist in my team's clear on what this means. It means someone who can make valid, rational prescribing decisions. Although, as a pharamcist, there's expertise in the drug's use and interactions, pharmacists don't do out-patient clinics so don't get to see all the consequences of medication used, so don't feel they're experts at prescribing. Sensibly, my pharmacist sees herself as a resource to inform on decisions (and explain medication issues to patients, and manage the governance systems around medicines management), she doesn't see herself as an "appropriate" prescriber.
The word "practitioner" is salient, too. It implies a need for someone in practice, someone practising clinical care. So not just someone who knows a lot about drugs, then. If asked, "Of the last 50 patients you gave advice on medication to, how many had no side effects (and you've documented that), and how many had side effects (which you've documented)?" a "practitioner" should be in a position to answer that, someone just giving advice couldn't. And if that someone's giving prescribing advice but not seeing the consequences of their clinical practice, then I'd suggest they're not "an appropriate practitioner" so should not be issuing prescriptions for Prescription Only Medicine.
Rant over.
POM are medicines that we shouldn't be cavalier with. They're drugs which have real effects, so often need judicious consideration on initiating, continuing, monitoring and withdrawing them.
Which brings me to this study. It's a good study. It's funded by the UK Alzheimer's Research Trust, not a drug company. It's a study that was conducted over an appropriate length of time. Each treatment arm was of a decent size. It's a very relevant research topic.
They looked at folk with Alzheimer's disease, for up to 3 years. They found that patients without antipsychotic medication lived longer than patients with antipsychotic medication. Shock news!
I'm ambivalent about this study, really. On the one hand, it's a well executed bit of credible research that's about a contentious and relevant theme. On the other hand, is it necessary?
In patients with crashing heart failure, with fluid pouring into their lungs, the dread and feeling of drowning, the weakness, then death, life isn't great. Diamorphine can be used to reduce the ghastly symptoms. Diamorphine causes respiratory depression. Stops you breathing. In a patient who's lungs are filling with fluid, reducing their breathing isn't a strategy conducive to a long life. But it's done, rightly, even though life may be shortened, because the clinical condition warrants this palliative care. Is a study necessary to show us that, in heart failure, patients dying without diamorphine live fractionally longer than patients on diamorphine? Probably not. We know diamorphine is a proper drug, a medicine with benefits and side effects that need to be weighed by "an appropriate practitioner."
The DART-AD trial shows us that antipsychotics generate risk in Alzheimer's Disease patients. Although my gut reaction is, "And?!" I do s'pose it's useful to have a well executed study evidencing that what we knew to be the case is actually the case.
So is there anything from this which will change my clinical practice? No. But it's good to know that what I thought (that the drugs were dangerous) is true, and decisions around their use should be very carefully throught through by senior clinicians with expertise in this area.
Monday, 28 January 2008
New Ideas
I've been spending a lot of time with therapists of late.
No no no, I've not been going under quite yet, it's simply that we've had to generate business cases for more therapists, then job plans for them, then job descriptions and adverts, then interview questions and model answers, then the interviews.
Through this process it's been evident that Cognitive Behavioural Therapists (CBT) and Cognitive Analytical Therapists (CAT) have, for a good while, been preoccupied with (mindful of?) the concept of Mindfulness.
Since about 2000 it's been described in terms such as, "Mindfulness is a technique in which a person becomes intentionally aware of their thoughts and actions in the present moment, non-judgmentally."
It's a sort of acceptance (and mindfulness is at the foundation of Acceptance and Commitment Therapy).
It's been enthusiastically embraced by many clinicians and patient groups because intuitively it makes sense and because its roots are old (thousands of years old, linked to Buddhism and Sufism) so it's neither someone's new fangled get-rich-quick fad, nor a Government edict to change and try this for the sake of being seen to do things differently. Plenty of evidence supports its theory, application and outcomes.
Still, you've got to wonder, although it's been in vogue for 7 or 8 years now, it's not a new idea at all. Is it seen in EastEnders or Corrie this year? No, not yet, but it was foisted 'pon the masses over 400 years ago :
". . . for there is nothing either good or bad, but thinking makes it so."
- Hamlet, Act II, scene 2
No no no, I've not been going under quite yet, it's simply that we've had to generate business cases for more therapists, then job plans for them, then job descriptions and adverts, then interview questions and model answers, then the interviews.
Through this process it's been evident that Cognitive Behavioural Therapists (CBT) and Cognitive Analytical Therapists (CAT) have, for a good while, been preoccupied with (mindful of?) the concept of Mindfulness.
Since about 2000 it's been described in terms such as, "Mindfulness is a technique in which a person becomes intentionally aware of their thoughts and actions in the present moment, non-judgmentally."
It's a sort of acceptance (and mindfulness is at the foundation of Acceptance and Commitment Therapy).
It's been enthusiastically embraced by many clinicians and patient groups because intuitively it makes sense and because its roots are old (thousands of years old, linked to Buddhism and Sufism) so it's neither someone's new fangled get-rich-quick fad, nor a Government edict to change and try this for the sake of being seen to do things differently. Plenty of evidence supports its theory, application and outcomes.
Still, you've got to wonder, although it's been in vogue for 7 or 8 years now, it's not a new idea at all. Is it seen in EastEnders or Corrie this year? No, not yet, but it was foisted 'pon the masses over 400 years ago :
". . . for there is nothing either good or bad, but thinking makes it so."
- Hamlet, Act II, scene 2
Wednesday, 19 September 2007
Context
I've said earlier this week that a key trait in mental health work is an interest in the patient's experience. It's from this that we can sleuth out both meaning and management plans.
Often it's assumed we're in the business of making people "normal" or curing "pathology" which are goals largley abandoned long ago in favour of helping people understand and cope with their experiences.
What's important then shifts so the emphasis is not to be reaching stratospheric doses of multiple psychotropics simply to abolish one specific symptom.
Imagine we've a patient who was in their kitchen hears footsteps walking upstairs when nobody's there. They also smell aftershave when no man's been in their house for ages. At night they feel someone lying next to them.
Auditory, olfactory and haptic hallucinations, mostly in clear consciousness (I'll concede feeling a body in bed with you could be a hypnagogic or hypnopompic experience as they drift in or out of sleep). Not illusions, not misperceptions whilst in a dreamy oneiroid state, these is crisp fully formed hallucinations.
Solid evidence of psychosis?
Not necessarily. I remember reading a paper from 1971 by a GP in Wales who looked back at 293 bereaved patients seen near the end of a life long career in General Practice and found that hallucinations were common. 46.7% experienced the presence of their departed spouse at some point, 13.3% had auditory hallucinations and 2.7% had tactile hallucinations such as feeling a loved one still in bed next to them, for example. In 1985 another paper found 61% of the 52 widowers they interviewed experienced hallucinations.
Hallucinations are typically seen as the hallmark of major mental illness. These papers and a wealth of evidence suggests that hallucinations can arise in folk who are not mentally ill. It's not simply the presence or absence of psychopathology that's key (even important psychopathology like hallucinations). Even in specialist mental health work what's key is the patient's narrative, their experience and the context.
Citations :
1) Dewi Rees W: British Medical Journal, 1971 Oct 2; 4 (5778): 37-41
2) Olson PR, Suddeth JA, Peterson PJ, Egelhoff C: J Am Geriatr Soc. 1985 Aug;33(8):543-7
PS : Isn't it great that good quality enduring research, informing and educating psychiatrists decades later, was done by a rural GP in Wales?
Often it's assumed we're in the business of making people "normal" or curing "pathology" which are goals largley abandoned long ago in favour of helping people understand and cope with their experiences.
What's important then shifts so the emphasis is not to be reaching stratospheric doses of multiple psychotropics simply to abolish one specific symptom.
Imagine we've a patient who was in their kitchen hears footsteps walking upstairs when nobody's there. They also smell aftershave when no man's been in their house for ages. At night they feel someone lying next to them.
Auditory, olfactory and haptic hallucinations, mostly in clear consciousness (I'll concede feeling a body in bed with you could be a hypnagogic or hypnopompic experience as they drift in or out of sleep). Not illusions, not misperceptions whilst in a dreamy oneiroid state, these is crisp fully formed hallucinations.
Solid evidence of psychosis?
Not necessarily. I remember reading a paper from 1971 by a GP in Wales who looked back at 293 bereaved patients seen near the end of a life long career in General Practice and found that hallucinations were common. 46.7% experienced the presence of their departed spouse at some point, 13.3% had auditory hallucinations and 2.7% had tactile hallucinations such as feeling a loved one still in bed next to them, for example. In 1985 another paper found 61% of the 52 widowers they interviewed experienced hallucinations.
Hallucinations are typically seen as the hallmark of major mental illness. These papers and a wealth of evidence suggests that hallucinations can arise in folk who are not mentally ill. It's not simply the presence or absence of psychopathology that's key (even important psychopathology like hallucinations). Even in specialist mental health work what's key is the patient's narrative, their experience and the context.
Citations :
1) Dewi Rees W: British Medical Journal, 1971 Oct 2; 4 (5778): 37-41
2) Olson PR, Suddeth JA, Peterson PJ, Egelhoff C: J Am Geriatr Soc. 1985 Aug;33(8):543-7
PS : Isn't it great that good quality enduring research, informing and educating psychiatrists decades later, was done by a rural GP in Wales?
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