Monday 18 June 2012

Why the worried well trump real mental illness


"The "scandalous" scale of the NHS's neglect of mental illness has been described in a report which suggests only a quarter of those who need treatment are getting it.The report claims that millions of pounds are being wasted by not addressing the real cause of many people's health problems. Nearly half of all the ill-health suffered by people of working age has a psychological root and is profoundly disabling, says the report from a team of economists, psychologists, doctors and NHS managers, published by the London School of Economics. 
Talking therapies such as cognitive behaviour therapy relieves anxiety and depression in 40% of those treated, says the Mental Heath Policy Group led by Lord Layard. But despite government funding to train more therapists, availability is patchy with some NHS commissioners not spending the money as intended, and services for children being cut in some areas. "It is a real scandal that we have 6 million people with depression or crippling anxiety conditions and 700,000 children with problem behaviours, anxiety or depression," says the report. "Yet three quarters of each group get no treatment."
"IAPT has created a revolution in mental health by establishing a national competency framework for therapists, by training them to a high standard and by carefully monitoring their outcomes. Many readers will be amazed to hear that 10 years ago only 11% of British psychiatrists regularly administered any objective measure of mood when treating depression. Now all IAPT workers do so and the results, which are available on the NHS Information Centre website, are in line with the assumptions of the economic case. Latest figures show that 44% of people who have some form of treatment in IAPT recover. Many more (around 65%) show worthwhile improvements. In addition, the number of people who have moved off sick pay and benefits exceeds expectation. 
...The same story emerges with service budgets. IAPT is expected to offer treatment to a modest 15% of people with depression and anxiety by 2014. On average services currently provide for around two thirds of that. However, instead of expanding, there are signs that cash-strapped commissioners are cutting back. For example, one well-performing London IAPT service recently had its budget cut by 30%. Such cuts make no economic or humanitarian sense. As evidence-based psychological treatments save the NHS more than they cost, we should be doing more, not less, in tight economic times."
Well bollocks to that. IAPT (Improving Access to Psychological Therapy) provides a few sessions of crappy telephone or group based therapy 'inspired' by CBT and delivered by minimally trained therapists to people with mild symptoms of life stresses who barely meet criteria if at all) for mental illness.
Meanwhile people with significant mental illness are excluded by their services and sent to secondary psychiatric care where the same old waiting lists for CBT and other therapies exist as they did before IAPT was invented. All because they're too 'risky' or 'complicated' to be dealt with by IAPT (read that as 'actually mentally ill'). Of course 40% of people get better, most would have got better anyway!
Patients hate it, clinicians think it is a joke. So inevitably more and more money will be diverted in its direction, probably at the expense of people who know what they're doing.
The report itself is a magnificent example of eliding different definitions of depression and other mental illness -pretending that those in community prevalence estimates of depression are the same as those in morbidity studies of depression are the same as those on incapacity benefit for 'mental health problems' are the same people as those in clinical trials of depression in order to make breathtakingly speculative claims about how CBT can save the economy millions.
Yes, fund mental health better, no, don't piss millions more away treating mild unhappiness at the expense of real illness.

Tuesday 21 February 2012

All too predictable

From the Guardian:
"Doctor who criticised NHS reforms is threatened with disciplinary action...
Prof John Ashton, county medical officer for Cumbria, received a letter from his PCT last week after he joined 22 other signatories to a letter in a national newspaper criticising Lansley's health and social care bill. The letter read: "You are bound by the NHS code of conduct and as such it is inappropriate for individuals to raise their personal concerns about the proposed government reforms." Ashton will have to "explain and account" for his actions at the hearing."

Saturday 12 November 2011

Score one for Sertraline

On the basis of some accumulating evidence of dose dependent QT prolongation with citalopram the manufacturer Lundbeck has issued new guidance on its use. The long and the short of it is that they advise the maximum dose is now 40mg (20mg in the elderly), that it shouldn't be used concomitantly with drugs that also prolong the QT interval (e.g. methadone, tricyclic antidepressants, amiodarone and sotalol), and that it should only be used with caution in those at risk of Torsade de Pointes (CCF, recent MI, bradyarrhythmias, predisposition to hypokalaemia or hpomagnesaemia, including due to medication). This risk also likely applies to escitalopram.

Citalopram is probably the first-line antidepressant in medical practice, partly due to the lower rates of interactions, but give recent evidence that sertraline is more effective, at least compared with straight citalopram (rather than escitalopram), I think sertraline is going to become the go to SSRI of choice now, particularly in the elderly (the maximum dose of 20mg is also the minimum therapeutic dose - so not much scope for increasing it).

Friday 4 November 2011

Yet more tales of woe from the medical Gestapo

Another affair where the GMC demonstrates how it pisses away the hundreds of pounds in fees paid by doctors to hound those self-same doctors for minor mistakes (highlights below, my emphasis in bold):
The appellant...submitted an application on 8th December 2005 for the post of specialist registrar in plastic surgery in the Oxford and Wessex Deanery. Candidates were required to complete an application form in full.

On 17th May 2011 the panel found that the application form submitted in December 2005 contained seven inaccurate statements which were both dishonest and misleading; that her fitness to practise was therefore impaired; and that she should be suspended from practice for 12 months. She appeals against those findings and the sanction.

Section 6 of the application form required the candidate to list her postgraduate medical qualifications. One of the bullet points states "if you are in the process of working towards a higher degree please say so, indicating expected completion date". [She]..."MD; Leeds University Medical School, UK, Thesis and Viva"; and then, in the final column, which is headed "date passed":
Completion January 2006"
 the panel's finding was as follows:
"...The truth was that far from a VIVA being awaited, your thesis had not even been completed. To imply that is was, applying the test in Ghosh, the Panel is satisfied was dishonest. In reaching its decision the Panel took account of the seriousness of the allegation and your good character. The Panel did not accept your evidence that it could have been worded better. The Panel was satisfied that it was worded in such a way to convey to the reader that your VIVA was expected and by inference your thesis completed and submitted"
Section 7 of the form required the candidate to state what relevant medical or professional courses other than those leading to a post graduate degree or qualification she had attended. [She] listed seven of these. The first was ATLS (advanced trauma life support), which she stated had been attained at the Mayday Hospital, Croydon. Under the heading "date certificate attained" she wrote "2001 C [ie completed] (recertification booked)".

...had in fact successfully completed a 3 day ATLS course at the Mayday Hospital from 13-15 September 2000. The certificate states that it expires on 15 September 2004, that is to say on the fourth anniversary of the last day of the course.

The panel found:
    "...The Panel is satisfied that it was untrue to say that you completed your ATLS course in 2001. In the context of an important job application, truthfulness is expected. You knew this to be untrue. The Panel did not accept your evidence that this was a mistake. This was a certificate relevant to the application. Your application form implied that it was current when it was not. Applying the test in Ghosh, the Panel is satisfied that this was dishonest."
The last entry stated that from August 2004 to December 2005, a period of 17 months, she had worked at Pinderfields Hospital, Wakefield in the speciality of plastic, reconstructive, hand and burns surgery as a "Research Registrar" funded by Action on Plastic Surgery....Section 9 is a single line reading "time in full-time research" and seeking an answer in years and months. The answer [she] gave was 1 year, 5 months. Section 11 asks about "time in plastic surgery (do not include research)". [She] answered that she had spent 24 months as an SHO and 17 months as a registrar. In oral evidence (Day 8, page 378) she said that during this period she spent 50 hours per week on research and her clinical hours were between 40 and 90 per week.

The panel found:
    "...The Panel determined that it was not true that you spent 17 months in a full time research post and spent 17 months in a full time clinical post. That is what your application form conveys to the reader. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh, the Panel is satisfied that this was dishonest."
Paragraph 3(g) of the list of allegations made by the GMC against [her] referred to a statement in the application form "that, during your research project, you had (1) produced 11 publications, (2) produced 21 national and international presentations". This was alleged to be dishonest and misleading. The findings of the panel were as follows [emphasis added]:
    "The period of your research was from August 2004 to December 2005. There were fewer than 11 publications related to your research within that time frame...There were fewer than 21 national and international presentations related to your research within that time frame...The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh the Panel is satisfied that this was dishonest."
In a narrative section headed "Other achievements" in the "additional information" section of the application form there were 8 sentences, the fifth of which was "I have produced medical video packages for television which was broadcast internationally on CNN". The charge in relation to this was that it was a dishonest and misleading claim.

The Panel had before it a letter from CNN dated 29th October 2010 which confirmed that [she] "worked as an intern in the medical news department at CNN Atlanta in 1998 and was involved in writing, production and editing of medical news packages produced for CNN Health which were broadcast nationally and internationally." 

In their findings after referring to this letter and the application form the Panel went on:
    "...The Panel determined that it was not true that you had produced medical video packages for television that were broadcast internationally on CNN. It was not true that you were solely responsible for the production of these packages. You were involved in the production with others as part of your internship. The Panel is satisfied that these are matters within your own knowledge and you must have known them to be untrue. Applying the test in Ghosh the Panel is satisfied that this was dishonest." [emphasis added] 
    The findings of the appeal judge were a little more reasonable:
    The above paragraphs of the judgment were circulated to the parties in draft on 1 November 2011. Counsel are agreed that in the light of their contents there would be no reasonable prospect, in the event of remission of the case to the GMC, of a Panel finding that her fitness to practise is impaired, nor of a warning being issued under section 35D(3) of the Medical Act. Accordingly the finding of impairment, the sanction of suspension and the direction for immediate suspension pursuant to section 38(1) of the Act will also be quashed. The GMC must pay the appellant's costs of the appeal, which have been agreed in the sum of £22,000
    What a farce. "Protect, promote and maintain the health and safety of the public" my arse - it's a self-perpetuating and self-interested quango which acts as a tool of the medical and NHS bureaucracy to keep the footsoldiers in line.

    And yet, compare:
    A GUILDFORD doctor who was suspended from medical practice for misconduct last year will be allowed to practise from next month following a case review by the General Medical Council.
    Last year, the GMC found that between 1995 and 2003, Stephen Carr-Bains entered into sexual relationships with two of his patients - both of whom were vulnerable and suffering from mental health problems.

    Dr Carr-Bains, who worked for the Guildowns Group Practice at the University of Surrey, got one of his patients pregnant and then helped her to arrange a termination.
    Following the abortion, the doctor did not put a letter from the British Pregnancy Advisory Service into the woman's records, failed to make any record of the abortion and did not refer her for post-termination counselling.

    Several years later, in 2005 and 2006, the doctor pressurised the woman not to reveal her relationship with him to her counsellor.

    The 56-year-old GP had sex with the other woman while ­‘staying over’ at her university accommodation.
    And contrast:

    The Panel is of the view that you have shown contrition for, and insight into, your actions...the original misconduct took place several years ago in the context of an otherwise unblemished record. Taking into account these matters and all of the public interests at stake, it has, therefore, determined that your fitness to practise is no longer impaired by reason of your misconduct.

    I will leave a comparison of age and ethnicity to the reader. The GMC is not fit for purpose.

    Thursday 29 September 2011

    Medical students 1 Grumpy old GP 0

    Lovely rant in the Daily Mail about how these new fangled young doctors 'can't diagnose for toffee'. It contains this gem about tactile vocal fremitus:
    If they had pneumonia, and therefore fluid on the lungs, the voice would sound high-pitched, and the vibrations would be reduced. Maybe not infallible, but pretty slick, right

    Oh dear, we'll leave aside that vocal resonance is a better test, and that you wouldn't test for vocal fremitus if the rest of examination was normal anyway, no, the point here is that the vibrations would be increased in pneumonia!* I'd expect my medical students to know this, let alone a GP. What a clown.

    * Don't give me any obfuscatory crap about a parapneumonic effusion - if that's what he meant that's what he'd have said.

    Wednesday 3 August 2011

    If wishes were horses...

    I've talked about animal experimentation before (e.g. here and here) but I was pointed to this discussion on the Guardian website:

    Dr Sebastien Farnaud of the Dr Hadwen Trust and Prof Roger Lemon of UCL debate the ethics and uses of tests on monkeys

    The opening piece by Dr Farnaud contained so many anti-vivisection tropes I was moved to repeat it here (with my comments):
    "I thank you very much for giving me the opportunity to start this discussion about a very controversial matter, the validity of the use of non-human primates in medical research, a subject in which, as a medical research charity, the Dr Hadwen Trust is particularly interested."
    No, the Dr Hadwen Trust was set up specifically to oppose animal research.
    "The first thing to consider is the aim of the Bateson report, which has just been published, its standpoint and who wrote it.
    This report is an independent review commissioned by all the major research funders in the UK, to assess the quality, outputs and impacts of research carried out on non-human primates, and their benefits to human health. This review follows the publication in 2006 of the Weatherall report by a working group chaired by Sir David Weatherall that recommended that the major funding organisations should undertake a systematic review of the outcome of all their research using non-human primates (NHPs) supported over the last decade.
    Interestingly, whereas the Weatherall report was unambiguously in favour of the use of NHP in medical research, the Bateson report adopts a more challenging position. Professor Bateson, who is emeritus professor of ethology at Cambridge University and president of the Zoological Society of London, is very well respected within the scientific community.
    It is therefore very important that statements in his report, indicating that almost one in 10 research projects that used monkeys in the UK result in no scientific or medical benefit, are not ignored. He also states that the justification for some projects carried out over a 10-year period from 1996 was "inadequate or insufficient" and that future projects involving non-human primates that could not demonstrate plausible medical or social benefits should not be funded."

    I think only 1:10 experiments showing no scientific or medical benefit is a surprisingly high proportion  showing benefit. I'd imagine most scientific research is of minimal use, even medical research, and a figure as high as 90% showing benefit is amazing. Justification for most experiments, when considered outside the narrow question of what people in a particular scientific field think is interesting, is generally poor anyway. So again, I see little to criticise primate experiments over any other area of science.
    "The reviewers also reported the unnecessary and unjustified repetition of work published a decade earlier."
    To be fair, there are plenty of reasons to repeat experiments done a decade earlier, including replicating a study to show that the effect is robust and repeatable, and verifying that you are performing a particular technique correctly by reproducing a know effect so you can then go on to develop that further.
    "These points underline that the issue is not simply an ethical issue but also a scientific one. This simply questions the scientific validity of NHP use in medicine."

    No it doesn't. 10% does not equal 100%.
    "The report recommends the promotion and development of alternatives to the use of NHP in research."
    Well, duh! I imagine 'mom and apple pie' also get a mention.
    "Since most diseases studied in NHP are human diseases that do not naturally occur in NHPs, it seems logical to try to develop models which are from the start human-relevant. Here we have to make clear that nobody is proposing we use invasive methods on human subjects. On the other hand, advanced techniques, which were barely mentioned in the Weatherall report, are highlighted in the Bateson report.. These techniques include, for example, magnetoencephalography (MEG) and transcranial magnetic stimulation (TMS), non-invasive imaging techniques that are already in use to help us understand diseases and the needs of patients who suffer from neurological disorders. Organisations such as the Dr Hadwen Trust have promoted and funded these techniques for over a decade."

    Yeah, because if fMRI doesn't have the anatomical resolution then MEG or TMS are going to do the trick. If wishes were horses...
    "One very important point that the report makes concerns regulation. It emphasises the importance of and the need for a robust system of regulation for animal experiments, at a time when the Home Office is preparing the implementation of the new EU directive for the protection of animals used for scientific purposes."
    Good job UK regulation is the tightest in he world (which is not to say it doesn't focus excessively on process and paperwork rather than welfare).
    "To conclude I would say that although this report will not please everybody, I like to believe that it is a first step towards major changes, a different attitude that will challenge the use of NHPs in medical research."