Tuesday, 22 April 2008

Embarrassing illnesses

Who the hell is so embarrassed about their illness that they don't see their GP about it for years, yet will go on TV to show their ulcerated genitalia and other yucky bits as soon as Channel 4 roll into town?

Monday, 21 April 2008

The doctor who hears voices

Watching this at the moment - know how it ends (of course the average length of a manic episode is about 6 months anyway) - might share my thoughts later.

So, not a bad film (certainly better and more interesting than Poppy Shakespeare), a bit of background: It's the story of a junior doctor who has a past diagnosis of bipolar disorder (manic-depression) and appears to be having a psychotic episode (including suicidal command hallucinations). She's naturally not allowed to work as a doctor and is currently trying to get over the episode and back to work, who she needs to convince she is safe and taking her medication, but clinical psychologist (and recovered schizophrenic) Rufus May is helping her to recover without medication (May gives the background here). Naturally they don't show the real doctor but instead she is played by an actor, Rufus May apparently plays himself.

Her symptoms don't appear to include overactivity or other typical manic symptoms (more like a mixed episode maybe), they seem to be mainly hallucinations of some sort (it is never established if they are true hallucinations), mostly a single voice talking to her, and some fairly transitory delusions, including persecution, reference, and grandiosity. She also appears to have a history of self harm and there is some family bereavement (but no other social or family information). May himself seems a rather volatile and 'interesting' personality (I don't think I'll say any more than that).

After over six months of May's therapy (they're never clear what that exactly involves but from his comments I take it that it is somewhat psychodynamic, perhaps a bit cognitive, see here) which seems to involves her getting worse rather than better (she starts off with mostly the hallucinations) she fools the hospital review board and returns to work as a doctor. They imply that they have some kind of breakthrough where she 'discovers' the voice is someone who bullied her at school, and that she is then able to deal with the voice (although she seemed to deal with it ok before the breakthrough) and she still has the voice at the end (this is potentially less worrying than it sounds, I've met a few patients recovered from psychotic illness with residual voices that I'd be happy practising medicine).

Obviously you can't make a diagnosis from a dramatisation, but you'd want to consider a personality disorder, affective disorders like depression, bipolar, and schizoaffective disorder, and obviously schizophrenia. It is difficult to see what the current episode is supposed to be, she isn't very manic, her mood seemed low, but she was certainly somewhat psychotic with some grandiosity.

So how revolutionary is this treatment from Rufus May then? Well the average length of a depressive or manic episode is six months, so I'd say taking over 6 months for remission plus continuing residual symptoms is not exactly spectacular, particularly given that we know both depression and psychotic symptoms will respond to CBT. I suppose she wasn't hospitalised, and the psychiatrist (Trevor Turner) in the piece indicates that he would probably have sectioned someone with these symptoms and refusing medication if necessary to bring them into hospital*. On the other hand, Rufus May sails rather close to the wind with her safety, and looks pretty worried at one point, whereas most psychiatrists would be held legally liable for that sort of behaviour, which is why they are rather more cautious about suicide risk (May says at one point, 'she's only a risk to herself' - which is really rather the point, although she also says the voices tell her to kill others, and I don't think I'd have been too happy being her patient while she had her delusion about having a cure for AIDS, or that a fish tank was an ECG).

Plenty of doctors have bipolar disorder so there's no reason to think she can't function as one, the real question is whether she's going to relapse - you'll expect most bipolar people to relapse at some point, on average every couple of years. A good psychoeducation programme will help you to identify early signs of relapse early enough to take action (e.g. sorting out your sleep to avoid a manic episode) so let's hope she's been given these skills by May. Drug prophylaxis has a proven benefit in reducing relapse, and residual symptoms are a poor prognostic indicator, let's hope she's ok, but until we know she's 'cured' (which will take years) you can't really conclude anything.

* Actually I think if he'd actually seen her, rather than just heard a hypothetical description by a TV producer, he would have seen that she actually had pretty good control and insight, resisting the voice and delusions, and managing to hold down a job as a care assistant. But she'd probably have benefitted from engagement with local mental health services with crisis team involvement checking up on her everyday and access to formal psychological therapy rather than being managed at arms length by someone in Bradford.

Friday, 18 April 2008

Charlie's compendium of woo

Heard Edzard Ernst on the radio this morning, nullifidian discusses it here, Ernst (and Simon Singh) have written to the Times saying:
"...we strongly advise that the Prince of Wales and the Foundation for Integrated Health withdraw the publications Complementary Health Care: A Guide for Patients and the Smallwood report. They both contain numerous misleading and inaccurate claims concerning the supposed benefits of alternative medicine. The nation cannot be served by promoting ineffective and sometimes dangerous alternative treatments."
Nullifidian finds this passage in the guide:
"Some homeopaths think that particular medical treatments or strong smelling substances, including certain aromatherapy oils or mint toothpaste, can affect homeopathic remedies." [PJ's emphasis]
And argues that:
"What this promotes is the idea (keyword “think” in this case) that any bona fide medical treatment might prevent the efficacy of a homeopathic treatment, and I don’t see it being outwith the realms of possibility that a credulous person might therefore be led to think that the homeopathic preparation is in fact the most important facet of any treatment, which for some illnesses or diseases may indeed be quite dangerous."
I agree that this is a particularly disturbing idea to be promoting, and highlights the dangers of homeopathy that transcend the essentially benign pharmacological effect of water - in the last fortnight I saw a patient who refused treatment (that would arguably have improved their quality of life significantly) in case it interfered with their homepathic treatments.

Wednesday, 9 April 2008

[From one of those round-robin emails]

Monday, 7 April 2008

More or Less Depression?

Thanks to lemmuslemmus (and also via the badscience forums) here's a BBC Radio 4 episode of More or Less talking about and to Kirsch et al. Nothing new here to be honest, More or Less was better under Andrew Dilnot.

Friday, 4 April 2008

New Labour, New NUS

Ah, the poor NUS executive, trying and failing to 'reform' its governance, cannot possibly be filled with New Labour wannabes, it's:
"...obviously one of the...massive arguments of spin...we're not close to the government...everything we say in public is bashing the government...on tuition fees..."
Good job the very next thing the NUS (lead by the executive) has done is dropped opposition to tuiton fees!

Ah, shrewd little political technocrats in training for their roles in whatever political party looks like it might come into power. Hasn't it been ever thus?

Tax the poor

Brown's wonderfully redistributive tax cut rather reminds me of this graph doing the rounds. Gotta love political cowardice and vote buying.