Heroes Not Zombies

A study by Platform 51 claims that one in three women in the UK taken antidepressants in their lifetime. A quarter of those have taken them for over ten years.

Whatever the actual figures, clearly antidepressants are being prescribed for an awful lot of people. Are all those people suffering from a disease called depression? And do the drugs cure them? Dr Clare Gerada seems to think its not a problem and certainly seems to believe the drugs not only work, but they “save lives”.

But doctors’ leaders dismissed the poll as “alarmist”. Dr Clare Gerada, chairman of the Royal College of GPs, said the drugs were a vital treatment. “Antidepressants save lives. In the past GPs have been criticised for being cautious about prescribing them and not prescribing them for long enough or in a high enough dose,” she said.

Maybe I should send Dr Gerada a copy of Irving Kirsch’s excellent summary of the evidence base for antidepressants. I think he makes it very clear that the issue of antidepressant prescribing is a complex one, and that while there is evidence the drugs do help people with the most severe forms of depression, there isn’t the same evidence they help people with mild or moderate depression (that’s most people).

There is a vast over-prescribing of antidepressants. Wouldn’t it be better to construct a health service around good mental health rather than around the prescribing of drugs? Wouldn’t that be more likely to both reduce suffering and to increase resilience and well-being?

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The excellent Daran Leader, who wrote “Why Do People Get Ill?”, has written in the Guardian about the current state of Mental Health Services. Many of his points and conclusions are applicable across the board into the whole of the Health Service, not just “Mental Health”.

Mental health services become like a garage where people are fixed and put back on the road, rather than subjects to be listened to. But once we start listening we might well question our beliefs and prejudices about normality. As old psychiatry recognised, many of the phenomena that are seen to define mental illness are in fact efforts to battle against it. A delusion, for instance, may provide a meaning to one’s world, and to try to remove it may deprive the person of a crucial resource.

Listening is a crucial part of health care, which is sadly, all too frequently absent. The “restitution narrative” of quick fix, sort out the broken or troublesome part, reigns supreme. Yet illness remains an intensively personal, subjective experience, different in every circumstance, and understood only in terms of the patient’s values and beliefs.

Bhugra is right that more therapy must become available, but there must be diversity. At present therapies that mimic drugs in their aims clear the field: promising swift outcomes, localised intervention and precise targets, they use the very language of drugs. Yet they all too often buy into a discourse of normality and rehabilitation that ignores the specificity of the patient – and their ways of making sense of their situation. Mental health services need to learn more from patients, questioning the values of efficiency and autonomy fetishised by contemporary society.

Trying to fit individuals into protocols created around cohorts and averages reduces the subject to an object. We need diversity in health care, because, really, one size does not fit all.

Daran rightly highlights how the drug model is sweeping the field of alternative approaches to therapy and care, no doubt because of the vast marketing resources poured into the promotion of drugs and the manipulation of the “evidence base”. But Medicine should never have been reduced the prescribing of drugs, or to treatments which can demonstrate their drug-like abilities.

We’ve lost our way.

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A pretty extensive review of research which has looked at empathy in medical students and young doctors concludes that

empathy declines during medical school and residency compromises striving toward professionalism and may threaten health care quality. Theory-based investigations of the factors that contribute to empathy decline among trainees and improvement of the validity of self-assessment methods are necessary for further research.

(How often do you read a paper by researchers which doesn’t conclude that there should be more research!). This is a sad, but also dangerous finding. Sad because there’s something desperately wrong with medical education and training if empathy declines as a result of it, and dangerous because without empathy “quality”, and I’d argue, “safety” are under threat.

Meanwhile, Vaughn Bell, across on the Mindhacks blog doesn’t only highlight this study under a title of “Is medical school an empathotoxin?”, but he has a useful collection of links to other research which shows the importance of empathy in medical practice.

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A recent paper in the BMJ has argued that we should focus on the concept of “value” when making decisions about health care and health care spending.

“Value” is a simple concept to describe: useful outcomes divided by the cost of achieving those outcomes

This paper makes a couple of interesting points – not least that “useful outcomes” must be outcomes which are useful to the patient.

Value emphasises the importance of doing whatever we do efficiently. It also highlights the importance of viewing health and disease along a continuum of prevention; of early diagnosis followed by proactive intervention in long term conditions; and of linking healthcare to social care and public health. Most of all it emphasises that what matters to patients and population is not healthcare in itself but health. Healthcare is often a means to health, but it is not the only means. This highlights the importance of establishing a quality numerator in the value equation that truly describes outcomes that matter to patients. We think that quality should encompass clinical outcomes, outcomes reported by patients, and patients’ experiences, measured along whole pathways of care.

Whilst I support this argument and particularly appreciate the emphases on patient reported outcomes and patients’ experiences (which are almost entirely neglected by RCTs based on measurement of a narrow range of biological quantities), I think there’s a crucial missing part of their proposed spectrum of “prevention; of early diagnosis followed by proactive intervention in long term conditions” – health.

If we only start by considering disease and its prevention we will be caught up in an endless pursuit of moving targets. It’s important to be able to reduce the risks of preventable diseases, and it’s also important to treat disease, acute or chronic, but we’re only going to improve the health of the population and reduce the burden of disease if we understand what “health” is, and seek to create the conditions for optimal health.

Value in health care, therefore, has to include policies and processes consciously created to support and develop health, not just to try to prevent or treat disease.

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Pharmageddon – interesting title captured on the BBC News site.

It’s been coined in relation to a veritable epidemic of addiction to prescription drugs – I’ll say that again PRESCRIPTION DRUGS.

I believe I can safely say that over 80% of the inmates in the Pike County regional detention centre are in there for something dealing with their addiction to prescription drugs,” said Dan Smoot, director of law enforcement

80%?!

the average age at which users first abuse prescription pills is 11. It’s a statistic that makes him angry. “We have basically robbed our children of a childhood.” The pill crisis, which some are calling pharmageddon, is only now receiving national attention.

There are just too many drugs being prescribed. Too many, too carelessly, and too easily. Add to this the toll from Adverse Drug Reactions, and the rapidly escalating drugs bills of all health services, and isn’t it about time we came up with a radically different health care strategy? One which emphasised health and non-pharmacological interventions as much as possible and reduced drug interventions to only where really necessary?

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Strangely, a letter to the Lancet from a group of scientists, and an early day motion in Parliament calling for more human-based as opposed to animal-based testing of drugs, has gone fairly unn0ticed in the news. If I hadn’t just stumbled onto Sky News yesterday, I think I’d have missed it entirely.

The call is based on some pretty disturbing statistics –

Adverse drug reactions have reached epidemic proportions and are increasing at twice the rate of prescriptions.The European Commission estimated in 2008 that adverse reactions kill 197 000 EU citizens annually, at a cost of €79 billion. The cost of new medicines is rising unsustainably, creating an ever-increasing burden on the National Health Service (NHS). Meanwhile, many increasingly prevalent diseases, such as Alzheimer’s disease, diabetes, many cancers, and stroke, remain without adequate treatments. The major reason for the rising cost of new drugs is the fact that more than 90% of them fail in clinical trials

In our collective zeal to summarise, we have too often ignored the fact that a vast and growing proportion of those original studies are industry sponsored, which means that they tend to exaggerate benefits and play down harms. Summarising that bias doesn’t make it go away. Medicine’s prized evidence base has become debased.

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David Cameron today is defending his government’s proposals to change the English NHS. Interestingly, this debate seems to be happening as if there isn’t another functioning model in Scotland! There is – why not refer to it? Maybe there are aspects of the Scottish NHS which are better than the English model? Why not learn from them? Maybe there are aspects which are worse. Why not learn from them too?

The fundamental problem with all the health services of course is that they are actually disease management services, not health services at all. Almost all of health care has a primary focus on disease, and only a secondary one on health. Cameron says the NHS in England has to change – and in particular he says “we’ve got and that is to change and modernise the NHS, to make it more efficient and more effective and above all, more focused on prevention, on health, not just sickness. We save the NHS by changing it.”

He’s right about that, but what exactly within his proposed changes will produce an NHS “more focused on prevention, on health”?

The BMJ this week has a lead editorial on the issue of disease definition. The problem is that the definitions of diseases keep changing and as they change, more people become “eligible” for drug treatments, and there is enormous drug company influence on disease definition.

the definitions of common conditions are being broadened, so much so that by some estimates, almost the entire adult population is now classified as having at least one chronic disease.

This makes no rational sense. As Fiona Godlee says

I’m struck by the quote from Allen Frances, the psychiatrist who chaired the task force for DSM-IV. “New diagnoses are as dangerous as new drugs, he says. “We have remarkably casual procedures for defining the nature of conditions, yet they can lead to tens of millions being treated with drugs they may not need, and that may harm them.”

Moynihan’s article is a fascinating and thought provoking one. But I finished up reading it thinking, hang on, we don’t even have an agreed definition of health, let alone a host of diseases! Shouldn’t we agree what health is, and then craft a health service towards maintaining and developing health in individuals and the population, instead of one focused on the continually expanding definitions of disease which, literally, plays into the hands of those who want us on drugs for life?

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