Wednesday, May 28, 2014

Dr Druin Burch, Consultant in Internal Medicine at the John Radcliffe Hospital, Oxford writes

Since 2000, each year has seen the Mental Health Foundation sponsor and deliver a springtime week of mental health awareness. Stigma, friendship, attempts to find and continue in work, attempts to balance work and life (the phrase suggesting them to be different things), and mood occupied the first 5 years. Then came exercise, alcohol, friendship, anger, fear, loneliness, sleep, benevolence and physical activity. Exercise is good for you, said one of The Wombles some years ago, laziness is not. It's a message which may not have originated in that old children's TV series but has been endlessly repeated ever since. This year Mental Health Awareness Week brings us anxiety, and in doing so it makes me worry. Might it be that fretting about the existence of anxiety does not immediately solve its problems? Exercise is good for you and laziness is not, yet repeating that in various ways does not seem to have resulted in a world where everyone is now slim, fit and athletic. As I write, the next few days offer up World Lupus Day, Eat What You Want Day (raising awareness of those going hungry), International ME Awareness Day, Spinal Cord Injury Awareness Day, World AIDS Vaccine Day (I was unaware we had one), Lost Sock Memorial Day ("donate your unwanted socks to homeless shelters") and the start of Dementia Awareness Week. "Be aware!" goes an old joke, "Your country needs wares!"

By attempting to make us all more conscious of mental health, the Foundation is trying to help those in need and to make the world a better place. Benevolence of intentions, however, doesn't mean results are worthwhile. A doctor prescribing an ineffective treatment with a good heart is still dishing out something which doesn't work, and they may be doing so at the expense of something else that might. Some awareness of this, at least, has reached the Foundation. "Research and practical evaluation lie at the heart of everything we do," they say, adding that "this evidence-based approach helps us to recognise the key issues affecting the nation's mental health and wellbeing." Looking through their historical records of past mental health awareness weeks, the superb quality of the press releases are easy to appreciate. They are professionally and eye-catchingly done, and each year I am sure they received significant media attention. It is notable that their display is unaccompanied by any evaluations of their effects.

For every problem, wrote the American humourist H L Mencken, there is a solution which is neat, simple and wrong. Faced with an endless stream of days, weeks, months and years in which we are encouraged to be more aware of some problem or other, it is reasonable to ask what the overall effect is. Do endless reminders via mass and social media to recognise men's health, disability, cancer, mental illness and other genuine problems help ease them? Do these skilled public relations exercises do good? (The popularity of the old "Keep Calm and Carry On" slogan suggests we may feel in need of a little less awareness of misery, not necessarily more.) Might these events even do harm, covering over gulfs of inaction, inability and ignorance with a soothing appearance of activity and sympathy?

"One in six of us," says this year's Mental Health Awareness Week campaign, "struggle with mental health issues at any one time." Since the WHO tells us that health is not merely the absence of illness but "a state of complete physical, mental and social well-being" the Foundation is probably under-estimating the problem. Factor in a third of us being asleep, ineligible to be asked about our state of mind without waking up and ruining it, and 1 in 6 still implies that at all times a full half of us are walking around in a state of unblemished bliss. One gets a sense of statistics being enrolled not in pursuit of a clear sight of truth but of sound bites and press coverage. Good intentions, of course, are at their most enthusiastically infectious when they are not being dampened by an awareness of the world's complexities.

I am attempting to make a serious point. Antibiotics were a miraculous medical development. (Their name comes rather oddly from the fact they are anti-biosis, anti-life, since they were the germ warfare by which one micro-organism attempted to kill another.) Psychiatry, appropriately impressed by the immense success of targeted treatments in other medical disciplines, developed classes of drugs whose names echo the marvels of sulfonamides, penicillin and streptomycin. Antidepressants, antipsychotics and anxiolytics are reassuring terms, suggesting biochemical specificity and targeted solutions to clearly identified problems, analogous to so much that works well in other areas of medicine (What's in a name?). If your appendix has grown inflamed and ruptured, you undergo an appendicectomy. If your hip osteoarthritis is disabling, you have a joint replacement. If you are admitted to hospital with meningococcal sepsis, you are treated with antibiotics. These are direct solutions to plainly identified problems. Antidepressants, antipsychotics and anxiolytics are terms which too easily give the impression of representing similarly accurate responses to well-understood insults. They are not, however, and their false reassurance is hazardous.

What are the long-term effects, in the wide range of people in which they are used, of SSRIs and tricyclics, or of the drugs we call antipsychotics and which modulate mixes of dopamine and serotonin and other neurotransmitters in the brain? What do they do to the long-term natural history of depression or psychosis, let alone for the host of other off-label reasons they are prescribed? (In many, and particularly the dying or the elderly, arguably RCT data is not required. If one is in the position of reaching for a pill to control short-term distressing symptoms, when lifespan and physical function are already limited, then clinical experience and "n-of-1" trials really can offer correct answers to those who are thoughtful and observant.) But do we know what these drugs do to physical function, to morbidity and mortality, to overall quality of life? Flick through the Cochrane reviews of treatments for psychosis or depression and the extent of our ignorance is immediately on show. Even non-pharmacological interventions whose benefits we are repeatedly told of - like exercise, the theme of a previous Mental Health Awareness Week - are often poorly supported by good evidence (Cochrane review). Worse, where apparently good evidence exists, it has too often been shown later to be an artefact of selective publication and of poor or perhaps deliberately misleading trial design (Initial severity and antidepressant benefits). Writing journal reviews for, I have just reviewed a paper looking at a drug for stable coronary disease. Darapladib is a selective oral inhibitor of lipoprotein-associated phospholipase A2, the latter being an enzyme known to be involved in the creation of unstable plaques. Had it been a psychiatric drug one feels it might have been used purely on the basis of such an obviously beneficial mechanism of action, or perhaps as a result of trials in a few hundred people showing it reduced some measures of plaque instability or even of angina symptoms over weeks or at best 6 or 12 months. Cardiology has learnt to do better, and this was a trial of 16,000 people with a median follow up of getting on for 4 years and a primary outcome resting not on any surrogate but on the hard endpoint of death.

The fact we don't know the long-term psychiatric effects of psychiatric drugs is bewildering. The fact that they appear to have significant physical side effects - that they seem to lead, amongst other things, to weight gain and an increased rate of cardiovascular death - makes this bad situation abysmal. We have neither properly measured the harms nor the benefits of many psychiatric interventions in many settings and over anything but the short or medium term, and as a result we use them without knowing reliably that we are doing more good than harm. This isn't good medicine, nor even what David Sackett, one of the fathers of EBM, kindly called "hopeful guesswork". We have moved on since leeches (which made agitated and febrile patients calm; a sure sign of it being good for them) and we understand that the only way to properly assess the impact of certain interventions is to test them in long-term properly blinded randomised controlled trials. In psychiatry, as out of it, that should often mean using an “active placebo” so patients cannot infer their allocation from a dry mouth or other side effects. The degree to which blinding is successful must be tested and reported. Imagine if a drug company sought to market an agent for angina which conferred short-term relief of symptoms, but whose long-term impact on them was unknown and which was noted to make patients more likely to die of cardiovascular disease - there would never be the slightest chance of it being taken seriously. The tradition of evidence in psychiatry as opposed to many other medical specialties is weakness. This should disturb us and make us angry. It should upset us sufficiently to give us no peace or calm until we improve the situation.

Campaigning for more diagnosis and treatment of mental illness seems an odd choice of emphasis when we are yet to reliably assess existing interventions. Not that we are even short of other useful things to do aside from these overdue investigations. Much of good practical sense has been suggested in the BMA's May 2014 report, Recognising the importance of physical health in mental health and intellectual disability. Despite being a report dealing with those suffering from mental illness, it focuses on the physical:

"People with mental health problems and intellectual disability have a shorter life expectancy and increased risk of early death when compared to the general population. The evidence outlined in this report makes it clear that excess morbidity and premature mortality predominantly result from the under-diagnosis, treatment and prevention of co-morbid physical health problems in mental health and intellectual disability patients. In the worst cases, people from these vulnerable groups are receiving less than optimal medical care and are suffering unnecessarily with unmet health needs.

The wealth of evidence on excess morbidity and mortality has not been consistently acted upon, scant attention has been paid to individuals’ physical healthcare needs, and an undercurrent of low expectations for the physical health of intellectual disability and mental health patients has persisted. Delivering ‘whole person care’ has been further hampered by the geographic, institutional, and professional division of mental health, intellectual disability and physical healthcare that remains apparent across the healthcare system. Recent years have seen cuts to mental health budgets, the commissioning of mental health and intellectual disability services separately from their physical health counterparts, an absence of integrated care, and gaps in healthcare training and workforce planning. These factors inhibit the delivery of a coordinated response to the multiple needs of patients presenting with co-morbidities."

There is a lot to be said for the BMA's sensible reminder to focus on those things we properly understand and yet are still doing badly at. Beyond that, it seems a manifestation of mental ill health to be complacent about that which merits anxiety. Uncertainties in psychiatry should make us uncomfortable. What do our drugs do to our patient’s mental and physical health over the years and decades ahead of them? Why do we not know? It can be productive and helpful to be reminded of our ignorance, even to have our noses forcibly rubbed in it. We do not understand the biochemical and molecular bases of mental ill health and it may be that we never fully will. (Some properties exist only at certain levels of complexity. The aesthetic impact of a painting cannot be understood by a list of the colour saturations of its pixels but has to be considered as a whole. It may be that aspects of personality and psychological health and illness require the same, and will never be reducible into neurotransmitters and scan results. And even if they become reducible in such a way, they aren't presently. Mental health interventions, be they drugs or talking therapies, cannot be judged worthwhile on the basis of fitting a biochemical or psychological model - they must be tested.) The changing shape of post-traumatic stress disorder - it presented differently in the American civil war to how it appeared in World War I, or how it appears now, yet it was real throughout - suggests that the presentation of psychiatric problems may well shift over time in a manner quite alien to, say, appendicitis or meningococcal septicaemia.

Mental health and illness are too important to be treated glibly. They merit having their complexities and their influence honoured with seriousness and with effort, and they lend themselves better to puzzlement and painstaking long-term trials than to awareness weeks, sound bites and drug classes whose reassuring names gloss over their lack of evidence. At best, and in a small minority of cases, we know with confidence what some of the psychiatric interventions we use do over the medium term. Yet psychiatric problems afflict us over the long term, as do many of the known (but not fully measured) harms of their treatments. Since it was set up, the Mental Health Foundation has never yet used an awareness week to try and raise the profile of our ignorance, of psychiatry’s known unknowns, or to remind us of how little we know compared to what we should. The Foundation’s creditable attempts to get more funding for mental health research deserve to be matched by an awareness week reminding us how much knowledge we presently lack.

"Be true to yourself," says this year's campaign. Perhaps whoever wrote that was unaware who they were quoting. "To thine own self be true," was part of the well-intentioned but famously pompous and purposeless advice which Polonius gave Hamlet. ("Tedious old fool," concluded the latter.) Next year's Mental Health Awareness Week, this October's Mental Health Day or even some future Lost Sock Memorial Day might helpfully focus on how little we know and how uncertain even the best of our advice, if it is to remain honest, needs to be. It seems something worth being aware of.

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