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?

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.

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.