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!

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.

IAPT

The Improving Access to Psychological Therapies (IAPT) programme is seen in different ways.

Okay, I chide myself to remember as Billy Shakespeare penned in The Life Everlasting, "There is nothing good or bad, but thinking makes it so," yet I still think of IAPT and think, "Yes, but . . ."

It's a big "but" too. A really big arse of it all. Because IAPT piques me.

I had the fortune to work with pioneers (they really were called pioneers) who pilotted IAPT and wrote up how ace it all was. Of course, it wasn't, but who could present their work as a failure when their career/credibility and national policy and being seen to do something positive was necessary?

Subsequent external criticism and internal comment from IAPT workers 'fessing up that it's a service which is self-selecting the "worried well" generates concern. Why? Because IAPT uses a "step tiered" model and, arguably, uses it in an unhelpful manner.

If you're having mild problems, in theory there's "watchful waiting" but in practice these individuals who have contact with IAPT and then over time get better are evaluated by outcomes which suggests that IAPT have facilitated the recovery of someone who, through waiting, got better anyway. Okay IAPT may have a role in surveillance, but to argue that IAPT have improved this person's wellbeing in a meaningful and cost effective and active manner is rather overstating the case.

With mild and self limiting problems being seen within IAPT and then getting better, in spite of (rather than because of) anything that is done, simply through time passing and people recovering, IAPT claims success. Again I think it's disingenuous to suggest IAPT have major impact here because, of course, mental health services aren't amazingly brilliant at curing folk. Shock, horror, but usually we're good at facilitating improvement, hurrying along restoration of wellbeing as nature takes it's course, giving support to make things more understood whilst processes are unfolding, but by and large interventions aren't as miraculous as people would wish to believe.

People had depression before there were antidepressants. People got better. Effectiveness of antidepressants were reviewed in the Journal of the American Medical Association this year and found to work as well as placebo in mild, moderate and severe depression, with drugs only starting to work better than placebo in very severe depression.

We know that drugs, psychological therapy and ECT can help with depression for some people, some of the time. Some people get stunningly good results. Would paying for a good holiday help people with mild depression feel better? Probably. Would talking with IAPT mean that, 2 months on, things were better for someone with mild problems? Probably. Would not talking with IAPT but talking with friends/having a moan/challenging your boss/getting more sleep, mean 2 months on, things were better for someone with mild problems? Probably.

IAPT is attractive to politicians, it's seen as delivery of psychological therapy to large numbers of people. The presence of such a programme then satisfies the desire to do something, to have something.

But what of the process, what of the content?

The people usually have telephone advice. My patients have not felt listened to and heard and understood. IAPT screens for suicidality every contact. My patients weren't suicidal so felt that asking questions that weren't relevant meant they clearly weren't being listened to, with their agenda/needs not being addressed. This switched them off IAPT so much they disengaged. I asked IAPT what had happened in their care, after their GPs referred them to us. In 3 cases IAPT replied that the patient had worked with IAPT and, having made progress, then no longer needed contact. The patient sees their contact with IAPT as an unresponsive self-serving protocol driven process that's not helping them, with failure, resulting in GP contact and referral to mental health services. IAPT report it as a success with a positive patient outcome. In all 3 cases the patient was going through a normal bereavement and didn't need specialist psychological work or medication, yet IAPT couldn't support peoples' mental wellbeing through a normal but unpleasant time.

IAPT should, in tier 3, deal with "high intensity" need such as severe depression and PTSD delivered by CBT trained therapists but they don't. They say they're complex patients who need specialist services so turf them to us.

Mild, self limiting problems are seen within IAPT and reported to do well. Patients who drop out with bad outcomes are seen by IAPT and reported to do well. High intensity severe problems are part of IAPT's role which they fail to deliver on but since it's their role and they've no failures (referring them all) they report they do well.

IAPT therefore paint themselves as stunningly successful, seeking expansion and resourcing. There's only finite cash. Colleagues have described how psychological therapy that was historically accessed in Primary Care or Secondary Care no longer exists because IAPT has consumed those resources and is seen to meet the need, so alternatives aren't commissioned/delivered.

A cheap and cheerful high volume largely telephone advice protocol driven service, to meet most of the psychological needs of most of the patient population needing help . . . I can't help but think it's all gone spectacularly wrong. But we've an election, so I'm sure since the NHS and spending and return to work and family life are such big issues, parties will be offering us choices, no?

Erm, no.

So it goes.

Fridges

How do you practice psychiatry in hospitals, and clinics, as folk in the USA mostly do, with folk who have dementia?

I ask in the spirit of genuine inquiry since I find visiting folk at home to be a core and wholly necessary part of work. The bit that's most useful is, of course, the patient's fridge.

It's always good to look in a fridge, I find.

There's the opportunity to see what food and drink's in it. One once was stacked full (so full you couldn't see the fridge light at the top) of beer. An opportunity to talk about alcohol use and the amount drunk.

One had nothing in it but milk for tea and plasticky cheese slices. An opportunity to talk about diet and opportunistic health promotion.

One today had a mix of things. Greens, mostly. But not in a good way. The fridge was filled with food that was covered in green fur. Or, on some of it, black mould. In addition to the varied diet of mouldy food (the food long since obliterated so I've no idea what it originally was), was what Withnail and I would call, "matter."
Just semi solid stuff, composting down, with dark greenish black fluid seeping out of the bottom.
An opportunity to talk about a suboptimal level of function.

You can look in a fridge and see if food's out of date. "What is the date today, is this in date?" An opportunity to test orientation and decision making, without abstract instruments irrelevant to our patients but instead with tests of ecological validity.

Using fridges works too. "Fancy a cup of tea, doc?" "Why yes, thank you kindly, I rather would." Do they go straight for the tea or hunt around several cupboards for it? Do they sequence with cold water in the kettle, then heat it, then mix hot water with tea, leave it to brew (but not for too short or too long a time), place the hot tea in a cup, add milk, all in the right pace and order? Is there a tremour? Do they get muddled? Is the milk in date? An opportunity to talk about organisation and sequencing.

Seeing someone at home, seeing what's in their fridge and how they use it, beats 20 minutes of questions in clinic any day!

Desperation

A couple of patients a day are seen within the acute Trust down the road by our liaison psychiatry service. I am involved in all of them, managing all referrals and seeing many folk on medical and surgical wards.

All is not good.

Again I've had a week of misery and depression and despair. Mercifully, that's not my patients. Nor my team. Nor myself. The low mood and low morale and consequent, "fuck it all!" attitude is increasingly pervading the acute Trust's wards. Staff are desperate.

This is bad.

If staff truly weren't bothered then they'd not care. They'd turn up, do their 37.5 hours a week, go home and collect their pay cheque and repeat it all next month (or a few days into next month, after taking a few days off sick, 'cause everyone does, right?). But no. They're mostly concientious, frustrated staff who want to do a good job, want to do things better but feel impotent.

As many folk have articulated, Nurse Anne better than most, the bottom line is that the medical and surgical wards simply don't have enough qualified nurses and support staff to deliver clinical and practical care, now. Modern health care needs staff to do a lot and to do it well. You need good staff simply to do the work. What else is our work? Almost all "work" in the NHS is an interaction (direct or indirect) between a patient and a practitioner. Fewer staff, fewer interactions, less meaningful activity and less purposeful healthcare. Quality falls. Care becomes shabby. Not because staff are bad but because there aren't enough staff to do the work asked of them.

Liaison psychiatry used to be about both proactive presence on wards/in A&E to improve how things were done and reactive response to referral requests to sort out specific goals or issues that had to be managed through liaison psychiatry input into in-patient care/couldn't be picked up by mental health services on discharge.

That's changed.

Now ward staff on medical and surgical wards are less interested in what liaison psychiatry assessments are. They're less interested in how formulations can impact on care plans. There's less interest in advice on how care can be more person centred to be more effective in delivering personal care/interventions. There's strikingly less interest in rationalising drug regimens and reducing psychotropic medication use. Ward staff see me on wards now and, with faces filled with desperation and despair, simply wish for me to make patients' problems go away, or take the patients away, or both.

As clinical care is causing me more concern, not because staff are bad but because the Trst doesn't have enough nurses on wards, as the election looms nearer, I find myself thinking more and more of a post I've bookmarked from a year ago by Dr Grumble on NHS spending. It's sobering stuff. It seems that the NHS spent 7 billion quid, in 2008, on Primary Care. In the same year it spent 12.6 billion quid on management of the NHS. That's excluding each hospital's management costs. Grim reading. NHS managers in Strategic Health Authorities or DoH or "support" roles cost much, much more than all we spend on Primary Care in it's entirety.

It's a scandal.

It's a scandal that's affecting patient care.

If as a country we need to save squillions, I know where I'd be making "cost efficiency savings" and I know where I'd be enriching front line care. Too many managers. Too few nurses. Loss of half the managers would only improve things in my world. That's 6.3 billion saved. Let's use just half of that to pay off national debt, since we're altruistic folk in the NHS, and ring fence just 3.15 billion for more ward nurses.

It's a policy I'd vote for.