Latest postings (up to 7th October 2011) now at DrNMblog.wordpress.com. All older postings will be moved by the end of October. Some of the postings are quite technical, so interested non-professional readers might want to discuss them with their GP, or a patient group such as AADD-UK, ADDISS or DANDA, or with myself.
10th June 2011
Should weight-loss surgery be rolled out widely on the NHS,
when effectiveness has been shown for less than 1 in 50?
So many adults become chronically obese, and we are now so aware of childhood obesity, that an overweight person's history of normal weight and eating, or bulimia, or even anorexia nervosa, can be overlooked. The low cost of calories, and other “obesogenic” factors such as increased screen time and reduced exercise can also lead to therapeutic pessimism, despite nearly one-third of adults having normal weight (1).
Given the apparent failure of appetite suppressants and psychotherapy to treat obesity, a more hands-on surgical approach has gained a lot of ground (2). Reviews of bariatric surgery seem to make a well-founded case for wider use of this treatment: randomised controlled trials (RCT’s), the hallmark of proper testing, have been abundant.
But, despite well-documented cases of obesity remitting and relapsing in response to a range of interventions, sometimes with long intervals (Oprah Winfey, perhaps most famously), there has never been a single- or double-blind trial of bariatric surgery, compared with a true “placebo” which would be “sham” surgery: entering the abdomen under anaesthetic but making no further intervention.
Such genuine placebo-controlled surgical trials have been performed in many disorders where psychological factors have been felt to be significant (3). The RCT’s which give an impression of “a good evidence base” for bariatric surgery are mostly of one form of surgery compared with another, or surgery compared with a perhaps dubious non-medication-based intervention.
And anyway, according to a 2009 UK government-funded and -published meta-analysis, research into bariatric surgery has established its effectiveness for only 1 in 50 people who are at risk of health problems from being overweight: “The evidence base for the clinical effectiveness of bariatric surgery for adults with Class I [BMI 30-35] or class II [BMI 35-40] obesity is very limited.” (4).
Although I support bariatric surgery, and tried unsuccessfully to have it considered for one of my very obese learning disabled patients, four years ago, it appears to be at risk of being over-promoted for less severe disorders. Just like many other treatments in the history of medicine. It is possible, in my view, that psychotherapists of all kinds (CBT, psychodynamic, 12-step-orientated) have simply not tried hard enough for a group of patients that attracts negative and even punitive public attention (5). Before proper randomised controlled trials of bariatric surgery, it must make sense to keep looking for non-surgical treatments.
(1) 31.7% of English adults were “normal weight” in 2006. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgry for obesity: a systematic review and economic evaluation. Picot et al. Health Technol Assess 2009: 1-190, 215-357. [p3]. Available at http://www.hta.ac.uk/execsumm/summ1341.htm
(2) See my Blog piece “No” to the knife, “Yes” to Ritalin? 6th August 2010 (scroll down below)
(4) See (1): p157. 67.1% of English adults were either “overweight” or “obese” in 2006, of which 2.2% (1.5% of the whole population) had a BMI above 40. See (1) p3
Manufacturing Depression: the Secret History of a Modern Disease had been in my “to read” pile for a few months. I was in no hurry, assuming from the title that it was a re-hash of the “marketing by pharmaceutical vested interests” arguments of David Healy and others.
But after a patient recommended it, I had a look. The author Gary Greenberg is a psychotherapist, who has episodes of severe depression himself, possibly related to his “inexhaustible penchant for dithering”. He tells a very interesting story, especially about taking part in a double-blind, placebo-controlled trial of an antidepressant. I will not reveal the ending, but do think the book should come with a bit of a health warning because the lack of black-and-white conclusions may make some readers irritated or even depressed.
Another thing I liked about Manufacturing Depression was Greenberg’s willingness to say that pharmaceutical companies and medication prescribers are not the only vested interests in the mental health “industry”. For example: “…even though I am a psychotherapist, I don’t think the only alternative is what I sell in my office one hour at a time”. And, as what Greenberg calls a “depression doctor” myself, I agree with his view that “Depression is surely an affliction, one that at least in some cases may well have a specific, although still undiscovered, brain pathology – a disease in the usual sense of that word.”.
Quotations from Manufacturing Depression: the Secret History of a Modern Disease (2010, Bloomsbury hardback): pages 365-6, 297-8, 13
15th April 2011
The Human Condition
This was the title of a talk by the philosopher and journalist Robert Rowland Smith, at London’s School of Life two days ago.
I have known Robert for a couple of years, during which he has published two books exploring how philosophy is relevant to the everyday dilemmas of modern life: Breakfast with Socrates and Driving with Plato.
The essence of the talk, I think, was that despite regular reminders throughout history of humanity’s less than fully rational nature, we still tend to overestimate our self-control. The constant development of technology not only distracts us from evidence to the contrary, but creates neurotic dissatisfaction which we tend to worsen by seeking relief in materialism rather than by improving our interpersonal relationships.
I’m not sure that Robert is right in seeing the Western rational “Enlightenment” as perhaps now needing some sort of counter in the form of an “Endarkenment”, because I think that contemporary philosophies and psychotherapies, as well as older Romantic Western culture, offer a whole range of ways to explore what Jung called our “shadow aspects”. And some people who are stuck in over-rational ways of life are suffering from biologically-based problems such as depression (1) or autistic spectrum disorders: they may need medication or other treatments to fully take part in philosophical or psychotherapeutic discourse.
It might seem odd that medical technology is sometimes necessary to enable a less technologically-dependent life. But in my view this is just a particular case of science liberating rather than oppressing (2). Philosophy too contains many paradoxes of this kind, such as Wittgenstein’s recommendation that we should simply stop chattering about “things of which nothing can be said”: his non-silence was required first, so that therapeutic silence could follow.
(1) In general the more severe and long-lasting the depression the greater is the need for medication. But some severe depressions may respond well to psychotherapy and/or philosophy, and some mild depressions may respond only to medication.
(2) Of course, technology and science are often used oppressively, or at least with neglect, whether deliberately or by mistake. Antidepressants prescribed after a ten-minute consultation with a GP (rather than a much longer consultation with a GP, psychiatrist or clinical psychologist), including little or no discussion of psychotherapy, amounts to state-sanctioned neglect in my view.
20th March 2011
The Gift of ADHD?
Presentation / Debate at SimplyWellBeing adult ADHD group meeting:
Hammersmith Irish Cultural Centre, 20th March 2011
“Thanks again to Andrew [Lewis] for inviting me to offer a few comments on whether ADHD can have advantages, or should even be seen as a gift, rather than a disorder.
Just to mention that when I talk about “ADHD”, I mean what I usually write as “ADD / ADHD”, because the distinction is important to many people who do not have significant hyperactivity.
It’s now just over a year since I first met Andrew. In that very first meeting, he suggested I give a talk in this Sunday morning group, on ADHD diagnosis and medication. The fact that I’m back now suggests that he does not entirely regret that impulsive decision.
If we look at impulsivity, rather than the other two aspects of ADHD, inattention and hyperactivity, it’s probably easiest to see the potential advantages. Another word for impulsivity is spontaneity, and many people who are the opposite of impulsive, who never do anything unless they have thought through all the possible consequences, often feel oppressed by their lack of spontaneity. People who lack spontaneity may well have mild Asperger syndrome or autistic spectrum conditions.
One interesting thing about ADHD, which Andrew and I have discussed, is that if you look at perhaps the four most prominent US specialists, the psychiatrists Ed Hallowell and John Ratey say that ADHD often, maybe always (1), has advantages of creativity and originality; while the psychologists Russell Barkley and Thom Browne both tend to say that abilities and talents in an individual are separate from ADHD.
Who is right? Despite what Andrew may be going to say, I think this is logically a very difficult question. I really don’t know the answer, and for the moment I’m not convinced that it really matters, as long as the individual person with ADHD is advised that the self-understanding, and possibly treatment, which goes with the diagnosis, tends to free up previously undeveloped abilities and talents. Both sides of this particular debate agree on that.
Hallowell, Ratey, Barkley and Browne are working and writing in the US, and not the UK. There is a reason, I think, why we should perhaps make sure the psychologists’ views are heard over here, maybe even at the expense of the psychiatrists’, at least for a while. And I am speaking as a psychiatrist myself.
The more you stress the advantages of any disorder or condition, the less serious you tend to make it sound. Even before the current climate of financial savings, which is affecting the NHS, public opinion in the UK was very sceptical about ADHD.
The idea that you need assessment by a professional, for a neurodevelopmental condition that is a hidden gift, could sound like an indulgence to many people. I might be wrong though, because diagnosis of dyslexia has increased substantially over the last couple of decades, despite similar claims.
The idea that you need treatment for a hidden gift, with ADHD medication which can have side effects, and can sometimes be abused, will probably sound like “enhancement” rather than “treatment” to many sceptics. I am not at all sure that the UK is ready to allow psychological enhancement with Ritalin right now.
Again, I might be wrong, and it could be that concerns of this kind motivate the better development of non-medication-based approaches, as well as medications other than Ritalin.
But for the moment I will stick to talking about treatment of a “disorder” rather than a “diversity” or even a “condition”, and leave it up to my patients to decide whether the gifts that their ADHD has been holding back, are part of their ADHD or not."
(1) I think they lean towards “always” rather than “often”. But they are not fully explicit on this: see pages 5 and 14-15 of Delivered from Distraction (2005)
4th March 2011
Using the L-word may damage your health
Psychotherapy has been in the news recently, with the announcement that a further 400 million pounds will be made available through the so-called IAPT (Improving Access to Psychological Therapies) programme.
But although the government has stated the money is “new”, a senior IAPT adviser has been sacked, apparently for saying that is “a lie” (1). Certainly, savings are to be made elsewhere in the NHS mental health budget.
Somewhat lost in the discussion has been a shift away from the idea that IAPT is just about CBT (cognitive-behavioural therapy). In theory, IAPT has for years accepted that Interpersonal Therapy (IPT), and couples therapy, are just as valid for problems such as depression and anxiety.
At a seminar on IAPT eighteen months ago, a regional manager told me that it was proving difficult to recruit therapists for these approaches. That seems to be changing, and the British Psychoanalytic Council’s recent comments appear to be positive about psychodynamic therapies gaining significant funding alongside CBT (2).
In my view that is a good thing. Since the early 1990’s, I have been sceptical of the established NHS wisdom that psychodynamic treatments had been demonstrated to be generally inferior.
Oliver James (see the previous Blog piece, 4th February) is unpopular with many people and parents affected by ADD / ADHD. Not a big surprise, given his strong view that genes have been over-emphasised, and early parenting neglected, as causes of all the common mental and behavioural disorders. Also his rampant anti-Americanism (1) (it is probably significant that ADD / ADHD diagnosis and treatment, especially for adults, has largely developed in the US).
I think that he is largely wrong on those key issues, but also that his books still contain interesting and sometimes valid points. He is right, for example, to suggest that many people can gain as much “insight” from “work, sport or art”, as from psychotherapy (2).
There is no magic formula to reveal who will, or will not, be helped by psychotherapy. And James even implies that “therapy culture” could make you worse (3), although this is more of a comment on reality television than ordinary professional practice.
His linking of the Positive Psychology movement with materialism and consumerism is doubtful to say the least, because academics like Seligman have constantly stressed the primacy of interpersonal relationships for promoting happiness and preventing depression. I wonder if James was trying to make a somewhat different point about the limits of his own “Affluenza” argument: below a certain level of material provision family and social life become difficult, and psychotherapy of any kind should not collude in denying that.
As for ADD / ADHD, it is disappointing that books written in 2002 and 2007, while recognising that autism may be substantially genetic, do not accept the same might apply to other developmental conditions.
Where I agree with Oliver James most of all, in these books, is the sense that exploration of the past through psychotherapy is an uncertain process, and that objective sources such as accounts from others, or school records, should be sought wherever possible. His recommendation to “Interview your mother or father or a sibling or an adult who was close to the family when you were small” (4) sounds close to a description of the diagnostic history-taking approach used by psychiatrists and clinical psychologists.
Therefore I think it a bit of a regression when he appears to suggest, in Affluenza, that psychotherapy may reliably uncover buried memories from childhood (5). Despite a clear non-endorsement of transference-based reconstruction (6), he fails to offer any warning about the possibility of “false memories”, either overly negative or positive, being created in the psychotherapy process itself.
(1) TFYU (2002) p228(2) p259(3) p246 (4) p182
(5) Affluenza (2007) p442: “...help with directly recalling what went on in my childhood”
(6) p442: Avoid the therapist “...if they fob you off with ‘We will investigate how your past is affecting you through the way you relate to me’”
I only share James’ views about using transference as investigation: the therapeutic technique may be useful for some people, as long as the therapist does not make claims for reliable historical reconstruction.
Thanks to Andrew Lewis and Richard Sherry for comments on these two pieces.
4th February 2011
To be
Aware that this Blog has not covered psychotherapy as much as originally intended, I have spent the last ten days catching up with two best-selling books by the psychologist Oliver James: They F*** you up (2002), and Affluenza (2007).
My verdict? Very interesting, lively, recommended. But...
...perhaps the thing that struck me most were certain passages in Affluenza, which develop TFYU’s warning that the UK should not “follow in the footsteps of the most pathological developed nation on earth, the USA...[but should]...emulate the example set by so many of our European neighbours, like Denmark and France”(1).
By 2007, this trans-national analysis has focused on two particular evils: the “American way” of marketing, advertising and consumerism (2) and “the hollow ring of...American positive psychology”, with its “crude deletion of negative thoughts (3).
The basic idea is: “Studies from fourteen countries reveal that people who favour the key Virus values – money, possessions, physical and social appearances, and fame – are at greater risk of emotional distress”(2).
The author provides apparently clear answers: seek “authenticity” in activities and relationships; although beware that some apparently non-consumerist activities may be pursued for inauthentic “people-pleasing” reasons (4).
Conversely, if you “would like to be rich”, this may well be an authentic means to pursue such ends as “not to have to work all the time...[leaving] enough time to hang out with friends and family”(4). Presumably this applies to James himself, who happens to be in the “upper echelons” of society (5) (although I doubt he would describe himself as “rich”).
To sort these pitfalls out is partly the task of psychotherapy, and I share the author’s approval of cognitive-analytic therapy (CAT), having myself had some experience of practising it in the early nineties, and knowing a senior CAT therapist for many years.
Few would argue that the US is not a world leader in marketing, advertising and consumerism, however I think there is a bit of grit in the oyster of James’ well-marketed argument. He relies on international data recording rates of distress and depression; but these are “soft”, difficult to make non-subjective, and depend on translation between languages and cultures.
The ultimate “hard” data relating to distress and depression are suicide rates, and the statistics have for decades indicated that Danish and French people deliberately end their lives much more often than Americans (6), despite living in cultures of “Being” rather than “Having”.
(6) http://www.who.int/mental_health/prevention/suicide/country_reports/en/index.htmlThe suicide rate of Denmark has come down markedly since 1990, and in 2005 was the same as the USA, whose rate has been stable (and not high in international terms) since the mid-1950’s. Oliver James states that Denmark’s suicide rate is lower than that of Edinburgh (p109), but he gives no reference for this. The French suicide rate has also fallen, however in 2005 it remained 50% higher than that of the USA. The 2005 USA suicide rate for 15-24 year olds is double that of Denmark and 150% that of France: Affluenza mainly discusses older age groups, but it could be predicting sustained shifts in psychology and behaviour.
21st January 2011
The British Medical Journal’s measly editorial policies
Over the last three weeks the BMJ has published several articles by the investigative journalist Brian Deer, and an editorial co-written by a leading GMC member, alleging that ex-Doctor Andrew Wakefield’s research linking MMR to autism was a fraud.
Brian Deer, The Sunday Times and Channel Four’s Dispatches should be congratulated. The current BMJ editor is right to say that medicine needs more investigative journalism, and to highlight the need for wider vaccination against measles.
But several problems remain. The neutral observer might well ask how the “good” investigative journalism of Mr Deer is to be reliably distinguished from the “bad” of the Daily Mail, the Daily Telegraph and Private Eye (1). Is it really just the detail, the lengths to which Mr Deer went? I am not convinced that if the Mail’s Melanie Phillips (say) had spent the same amount of time on the story, she would have ended up believing Andrew Wakefield to have been fraudulent, or even deliberately dishonest.
Mr Deer himself seems to recognise the limits of his three BMJ pieces. In a Press Gazette interview last year he indicated that there is no real distinction between scientific journals, newspapers and magazines. He stated in a Guardian Blog (12th January 2011) that the BMJ was part of an “insidious cartel”. What difference does it make, then, that his first BMJ piece was “peer reviewed”, anonymously as usual? Perhaps it would have been more consistent for him to decline such a closed process.
The Lancet’s Richard Horton is alleged to have acted from largely “medical establishment” motives. But in my view there are two significant flaws in the Deer/BMJ account, across the several pieces and editorials. First, it distorts and minimises the history of the “autistic enterocolitis” construct, which developed from a decade or more of speculative but “peer reviewed” research, and not merely Wakefield’s undisclosed legal action.
Second, it ignores the wider context in which the worldwide anti-vaccinationist movement has grown. The British Medical Journal and the Lancet have both played an important role in the current debate, following Vioxx and other cases, about “industry” conflicts of interest and the right balances between openness, promotional claims, and business interests.
However, the BMJ has gone much further, even at the height of the MMR scare in the UK, in promoting scepticism about the “inappropriate domination of the Western view of mental health”, a process in which “doctors and the pharmaceutical industry” irresponsibly push both “Western cultural ideas” and “a rapid growth in the numbers of children diagnosed with conditions such as attention deficit hyperactivity disorder and autism” (Timimi, BMJ, 2005).
Two days after Brian Deer’s second article, a Blog piece entitled “How to stop the medical arms race” by a former BMJ editor revealingly set out the default position of the journal (Smith, BMJ, 13th January 2011): select evidence of “technology” and “doctors” leading to worse outcomes, not better. That Richard Smith’s Blog piece was typically urbane and self-deprecating might suggest that here, rather than in the Lancet, lie the real views of the “medical establishment”.
The BMJ has also published many opinion pieces by the “No Free Lunch” campaigner Des Spence which strongly criticise Western medicine. For example: “big pharma use[s] political lobbying to pervert the course of medical justice” (11th March 2009), and “A medicated childhood is blunt, defies reason, and is just bad medicine.” (21st July 2010).
Dr Spence has stated that because of the need to “protect the consumerist patient from themselves”, he and other GP’s suggest “complementary treatment, and even placebos” (4th February 2009). This seems to be a lesser-evil approach, but I have been unable to find any acknowledgement that such GP behaviour, rather than patients’ “health neurosis” (2), could cause the rejection of MMR vaccination (29th July 2009).
Taken together, when some parents, journalists and politicians read views like this, in the light of their own experience of the indifference shown by the “medical establishment” to neurodevelopmental disorders (3), it is not very surprising that they prefer a different version of events: Andrew Wakefield’s continued fight against Western medicine’s vaccine industry, which scored a temporary victory during the fitness to practise (FTP) panel’s 45 days of deliberating in secret (to use Brian Deer’s preferred term, rather than the GMC’s euphemistic in camera). The Wakefield FTP hearing transcript is still not publicly available on the GMC website (4), despite the BMJ’s declaration two weeks ago that it had been published.
Finally, the eminent “evidence-based medicine” expert Professor Trisha Greenhalgh appears to risk inflaming the situation further by repeating a comparison of the MMR sceptics with “flat-earthers” (rapid response, 18th January). This perhaps shows how remote the BMJ is perceived to be from the concerns of ordinary patients, and the “front-line” staff who do not have the luxury of engaging with pro-MMR families only.
If medical journals are really just newspapers with mystique, might it follow that a way out would be for medicine to become an honest trade rather than a dodgy “profession”? No doubt the size of the financial transaction between the BMJ and Brian Deer was small; and it remains open whether the journal’s new policy of modestly remunerating “good” investigative journalism at the expense of “bad”, will have the desired result in respect of the larger dragons of commercialised medicine, which the BMJ appears to see as its mission to slay.
A version of this piece was submitted as a “rapid response” to the last of Brian Deer’s articles, on the day of it’s publication (18th January). Four days later, no “rapid responses” had been published, which will only add to the suspicion that the BMJ is attempting to rig the debate.
(1) I attribute this simplistic good/bad dichotomy to the BMJ. It is not my own view, as it should be clear from the rest of this piece that I consider the BMJ itself to have partly caused what is now denounced. The current Private Eye health editor, Phil Hammond, has said that the magazine should not have reported on the Wakefield /MMR issue in the way that it did.
(2) [“Health neurosis” is a quotation from Dr Spence’s 28th July 2009 article: note added 28th February.] This could be called “blaming the victim”, although Des Spence would perhaps argue that the “neurotic” MMR-sceptic is primarily the victim of Western medicine, rather than some GPs’ well-meant promotion of homeopathy and other alternatives.
(3) The prominent vaccine specialist Paul Offit acknowledges this, in the latest introduction (readable with Amazon’s “look inside”) to his book Autism’s False Prophet’s. [Notes 2 and 3 were incorrectly transposed: corrected 28th February]
(4) Searching for “Wakefield transcript” or even just “Wakefield”, on http://www.gmc-uk.org/ .
7th January 2011
Raise your glasses
England have today won the Ashes in Australia for the first time since 1986. The media have contrasted the travelling England supporters’ cheerful optimism through the last two dozen years, with the fair-weather Australians, who deserted the stands as this Tour played out.
Like the “Tartan Army” who support the Scotland football team, many of England’s cricket supporters abroad are said to drink heavily and yet stay good-humoured. This “Barmy Army” has attracted the attention of academic sociologists, who suggest that they have created “a new form of English national identity” (1).
“Barmy” of course means “mad” or “insane”. As far as I know, no charity or professional group has censured the “Barmy Army” for the name they have chosen for themselves. To do so would itself be seen as crazed political correctness, which shows the importance of context for language like this (2).
English, (mostly) male sports fans who have been drinking: the more usual image is of football supporters facing off against baton-wielding European riot police(3). Both the Barmy and Tartan Armies show that it is not alcohol itself that inevitably leads to public disorder (4): for that to happen there has to be an advance expectation of hostility and violence. Perhaps the message in the “Barmy” name is that expectations can be changed.
So if toasting England’s Ashes victory tonight, pay attention to context and expectations; before downing those units of fizzy chardonnay, Aussie or otherwise.
(1) Parry M, Malcolm D (2004) England’s Barmy Army: Commercialization, Masculinity and Nationalism. International Review for the Sociology of Sport. March 75-94. I have only read the abstract, at: http://irs.sagepub.com/content/39/1/75.abstract
(2) See "Nutters", "Fruitcakes" and "Loonies", 30th April 2010, below
(3) Documented in Bill Buford (1990) Among the Thugs
(4) A recent article in the Bulletin of the World Health Organisation seems rather confused. Despite the title – Governments confront drunken violence – implying a strong causative role for alcohol, the experts quoted appear to differ widely about social factors. Just one example: France is stated to have a growing problem, but the overall consumption of alcohol in France has continuously fallen in recent decades. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2930368/pdf/BLT.10.010910.pdf?tool=pmcentrez
24th December 2010
The Real Scrooge
Why is Scrooge "secret, and self-contained, and solitary as an oyster": does he have a developmental disorder such as autism?
At the end of A Christmas Carol, "some people laughed to see the alteration in him". Presumably, such a dramatic change was seen as unlikely. But does that mean we should be so sceptical as to conclude his "self-contained" nature is biologically-based, and therefore unable to be altered?
When he revisits his early adulthood, with the first ghost, he sees himself as having been not at all solitary then: the younger Scrooge happily helps to get ready for Fezziwig's party, and joins in the dancing, eating and drinking, along with everyone else (1).
It is only a few years later that Scrooge begins to be dominated by his "master-passion" for money. At the same time, he loses interest in ordinary human relationships, although he is arguably right about the hypocritical and (un-) "even-handed dealing of the world".
So he is not autistic, at least in the sense which would fully explain "old Scrooge", in terms of a continuous, life-long, pattern of thoughts and behaviour.
Of course, he is only a fictional character; and some might find the description, of his early adulthood, to be as implausible as his later transformation.
At the end, he is still Bob Cratchit's boss, and although he promises that he will "endeavour to assist your struggling family", we have to trust Dickens that Scrooge followed up the impulsive gift of a "Turkey...as big as a...boy", by really being "better than his word".
(1) I refer to Dickens' original 1843 book. All quotations can be found in the text at http://www.gutenberg.org/ebooks/46. Film and television adaptations have often subtly altered the story.
(2) On Christmas Day, Dr Who: A Christmas Carol was broadcast by the BBC. Loosely based on Dickens' classic, the Scrooge-like central character needs the intervention of the time-travelling Doctor, altering his young adult past to include non-solitary experiences and memories. The dramatic force of the Dr Who story perhaps depends on the fact that film, television and stage adaptations have tended to omit the original content pointed out in my piece. Note added 27th December.
10th December 2010
Another Nobel for Cambridge University
One of my past teachers is to be awarded the Nobel Prize for Medicine today.
Professor Robert Edwards, who developed In-Vitro Fertilization, gave an annual series of seminars on embryology to about a dozen Cambridge students specialising in physiology. I was a member of the 1982-3 class, when Edwards was a prominent public figure; not only as a scientist, but also because of his decision to publicly discuss the ethical aspects of IVF in a very proactive way.
Unlike other aspects of the course, where we did experiments on rats, pigs, cats, and ourselves, there were no “practicals” in embryology. So the seminars were, to be honest, a bit dry and theoretical. The realities of fertility only became apparent when I was a clinical student in obstetrics and gynaecology, a couple of years later.
But on one occasion, Professor Edwards’ partner, the pioneering obstetrician Patrick Steptoe, came to tell us about the early days of IVF in Oldham, and we heard also about how they overcame opposition from the various establishment bodies of the day. The scientist and the clinician both loosened up and brought the subject, appropriately enough, to life.
26th November 2010
Is the “Adult Autism Scan” available to the NHS or not?
“…the scan which will enable doctors to diagnose autism more cheaply and quickly. The rapid test has already proven more than 90 per cent accurate in adults…”
“What the computer can do very quickly is to see that a patient has autism…even though their brain, to the naked eye, looks very normal.”
These bold statements appear on the website of the MaudsleyHospital’s national specialist services department (1). They appear to have been recycled from press releases and media interviews back in August, after publication of a study which looked at computerised pattern recognition of MRI brain scans, in adults with autism.
At the time, the “90% accurate” claim, and the suggestion that the scan could replace current clinically-based diagnoses, was heavily criticised by the head of the authoritative Oxford-based Centre for Evidence Based Medicine (2). A very different “5% accurate” was Dr Carl Heneghan’s view.
The key issue is that because the scan gives a “false positive” result in 20% of people without autism, it is unlikely ever to be useful, on its own, for diagnosis. If the prevalence of autism in the whole adult population is around 1%, then the “false positive rate” of the test would probably have to be at most 0.1% (3).
I wish the researchers (based at the Maudsley’s academic partner, the Institute of Psychiatry) the best of luck in getting their false positive rate down from 20% to this extremely low figure. I won’t be holding my breath.
What may be more feasible, and is implied by some of the comment back in August, is to combine the scan with a shorter (and cheaper) clinical assessment than the one which the Maudsley uses currently.
But I think patient groups, particularly the large and influential National Autistic Society (NAS), would want to see proper testing of such an approach.
Following the criticisms in August, the lead researcher responded: “we have clearly stated that we are not yet ready to make our approach available in the NHS just yet.” (2) (4).
So I was surprised to see the Maudsley website piece, dated November 4th, say“Adults who are interested in being scanned will need to ask their GP, consultant or health professional for a referral letter to the Behavioural Genetics Clinic. Privately funded assessments or scans are not available.” (1). There is no mention of any research showing the “Autism Scan” to have been improved.
Next week I am meeting with a board member (7) of DANDA (Developmental Adult Neuro-Diversity Association) (5), and will suggest that patient groups might want to clarify these apparently inconsistent statements (6) before recommending the “Autism Scan” to their members and supporters.
(1) http://www.national.slam.nhs.uk/about-us/media/mediareleases/slam-experts-win-heal-award-for-autism-scan/ (2) http://www.guardian.co.uk/science/blog/2010/aug/12/autism-brain-scan-statistics?intcmp=239 (3) That would mean about 1 false positive diagnosis in 1000 people, which I think would be the most any orinary clinician would allow. To demonstrate such a small false positive rate would also require a much larger study than the one reported. Because the “Autism Scan” is said to be “90% Sensitive”, 9 people in 1000 with autism will be diagnosed correctly, while 1 person with autism will be “missed”. Dr Heneghan does not mention the issue of the lack of so-called “confidence intervals” in interpreting the false-positive and false-negative figures from such a small study (20 patients with autism, and 20 controls without), but this seems important to me, especially for a test being offered to the NHS. (4) Two “yet”’s in the original. (5) The study also looked at whether the Scan could distinguish between autism and ADHD. It could, but even less well than between autism and no-autism. DANDA is concerned with the overlaps between autism, ADHD, dyslexia and dyspraxia, so I think this will be of interest to them. (6) In addition to the other points, the 4th November piece (quoted in my first line) states “more than 90 per cent accurate”, but the abstract of the research paper (link from (1)) has “sensitivity…of up to 90%” [my italics]
(7) changed from "the acting head" on 3rd December. My thanks to Erika Musselwhite of DANDA for pointing out that noone has yet taken over the national coordinator role which Mary Colley so energetically pursued until her recent much-regretted death.
12th November 2010 The Call of the Bottle
Books “should, like alcohol, dissolve barriers”, according to the literary academic and journalist John Sutherland, who explored the early history of Alcoholics Anonymous (AA) in a short programme last week on Radio 4 (1).
But for some people (including Professor Sutherland himself, sober only through two decades of attendance at AA meetings) alcohol has the opposite effect: ‘drinking recreated the conditions of childhood. Solitude; myself alone’(2).
Of these two apparently contradictory explanations for excessive drinking (alcohol dissolves interpersonal barriers; alcohol creates an interpersonal barrier), the first has been widely held for decades. “Social anxiety” was seen as a cause of alcoholism (3), and a problem in itself, well before pharmaceutical companies supposedly invented it in the 1990’s (4).
Anyone with the slightest interest in English Literature is likely to have read at least one of Sutherland’s reviews, books, or introductions to classics by authors such as Wilkie Collins and Anthony Trollope. They are invariably well-organised and structured, with a light touch but not at all “dumbed-down”, so achieving their aim of engaging academics and the general reader.
Alcoholics Anonymous has the reputation of having a rather black-and-white view of addiction. This is probably helpful, even necessary, for many people with severe problems, especially those in the early stages of “recovery”.
But this academic abstainer is not afraid to explore complexity or uncertainty. For example, in his Introduction to Jack London’s `Alcoholic Memoirs', he suggests that the “chronic boozer” London later brought his own alcohol intake under control “easily enough”, and then continued to drink in part “socially”, but also because of the creative possibilities gained from alcohol withdrawal (not intoxication) (5).
Therefore, for anyone looking to remove or reduce moderate or mild addictions, a period of solitude spent reading Sutherland’s extensive works is highly recommended, and is unlikely in my view to have any harmful effects.
(5) The whole Introduction can be read with Amazon’s “Look Inside” facility. The book’s full title is John Barleycorn: ‘Alcoholic Memoirs’.
29th October 2010
Playing the game
A boy who had to leave a "big sporty" independent school because of ADHD, was so good at rugby that he helped his team to win a match by scoring a try on his last day, according to an account written anonymously by his mother in last Friday's Daily Telegraph (1).
Although I currently see teenagers only from eighteen years of age, a couple of years ago I saw some children in their mid-teens at independent schools, because of my association with Professor Peter Hill. Many of my adult patients have had non-state education.
It is clear that some schools in the private sector are more accepting of ADD / ADHD and other developmental problems than others. It seems surprising, though, that the school in the Telegraph article, which in 2008 apparently claimed to welcome children with special educational needs, was not more helpful in guiding the parents towards proper diagnosis and treatment at an earlier stage.
The story had a happy ending, with a good response to ADHD medication, and "...a course of therapy with a psychologist from our local authority’s Child and Adolescent Mental Health Service." enabling the boy's settling in to another independent school.
The original school may well have changed its attitudes and procedures by now. But other parents in a similar situation may want to consider whether obtaining early external assessment and perhaps intervention can save the relationship with a school. It might have been the fear of the anonymous parents in the Telegraph article that the school would be antagonised, but that rarely seems to happen in practice.
A little more openness and transparency about the “not fair and open minded” 2007 Panorama ADHD programme (1)…
…has been achieved by reluctantly becoming a complainant to the BBC myself.
On 1st October the Panorama archive page entry for What next for Craig was changed (2), after I pointed out that it still showed the flawed programme summary (“…new research shows how giving children drugs for ADHD works no better than doing nothing in the long-term.”) (3), eight months on from the BBC Trust ruling. Also, the programme title now clicks through to the Trust ruling itself, rather than “page not found”.
On a number of other points I will be consulting with AADD-UK and DANDA, who supported my initial (March 2010) enquiry and subsequent complaint, before taking the issue further to the BBC’s head of News and Current Affairs.
The primary aim is to obtain unedited interviews with professionals and academics from the 2000 and 2007 programmes, which could be very useful for our interpretation of US-based research into ADD / ADHD. Panorama’s current editor claimed that this would not be possible due to “BBC policy”. But this was clearly inaccurate given the increasingly common media practice of releasing unedited material, and the subsequent complaint has resulted in an acknowledgement that BBC editors have wide discretion to make such unedited interviews available.
In due course I intend to place all my correspondence with the BBC on this website.
None of this would be possible without the immense persistence of the original complainant (not myself) to the BBC, who finally obtained the “not fair and open minded” ruling and the rare on-air apology. It has been suggested that this original complainant was a “front” for the pharmaceutical industry, but I can confirm that this is not accurate.
The issue will be pursued with an emphasis on fairness to all concerned.
(1) See Blog pieces on 5th March, 19th March, 28th May
The history of psychiatry is littered with over-hyped claims for biological causes and treatments. Sceptical clinicians and the public often over-react by failing to acknowledge and put into practice more modest, but genuine, biomedical advances.
Now it seems to be happening again with ADD / ADHD. A large study appears to have shown that about one in seven children with ADHD have a genetic variant, while only one in fourteen apparently normal children have it.
But the senior author of the study has been widely quoted as stating "Now we can say with confidence that ADHD is a genetic disease and that the brains of children with this condition develop differently to those of other children." This appears to be Professor Thapar’s real view, because the statement came from the press release (1), rather than an interview with a journalist trying to get a striking soundbite.
"What about the six out of seven who don't have this genetic variant, and how come you can have the variant but not have ADHD?" has been the response, quite rightly, from journalists and commentators.
Whether poor use of words, or poor use of ordinary logic, either way Professor Thapar's error must put some doubt over the study itself, although I would be surprised if other research centres fail to confirm the main findings over the next few years.
For me, another missed opportunity was the failure to highlight that these ADHD-linked variants were also strongly linked to learning disability (low IQ). Both children and adults with learning disability have poor access to diagnosis and treatment of psychiatric disorders, including ADD / ADHD, in the UK.
According to the website of the UK’s biggest ADD / ADHD charity ADDISS, next week (19th – 26th September) “ADHD Awareness week will be celebrated across Europe”.
My own activities will be fairly low-key: just a mailing to independent GP’s in the UK (in fact, there are very few outside London). It will stress how non-NHS psychiatrists and GP’s have a common interest in actively promoting our practice, rather than keeping quiet and just picking up patients who are dissatisfied with the NHS enough to seek us out.
“Moderate” clinical views will also be emphasied. Eighteen months ago I received some comments that I was too skeptical about the pharmaceutical industry, after stating (1) that I thought the 2009 NICE ADHD guidelines were too pro-medication for adults, and not favourable enough about non-medication treatments.
More recently I have been advised that I have come across (within the London independent medical scene) as a bit “biological”, which can mean “uses medication too freely”.
I’m not sure how reliable this report is, but it is true that I have not blogged much about psychotherapy in the last few months, and my only piece wholly on the subject (22nd January) suggested that cognitive-behavioural therapy (CBT) had been “hyped”.
Plenty of discussions have in fact taken place between myself and psychotherapists based at 17 Wimpole Street, especially Max Cohen and Richard Sherry. Plus others who include the energetic ADHD coach Andrew Lewis, clinical psychologist Katingo Giannoulis, and ADHD-coach-turned-integrative-therapist Sue Dives. Many patients have had psychotherapy or coaching, of various kinds, recommended. More than a few are taking these suggestions up.
In April I took my poster presentation on Vincent Van Gogh’s possible ADD / ADHD to an influential psychotherapy conference (2), where I stressed the potential for psychodynamic therapies to help ADD / ADHD and other developmental disorders.
Now that I think about it, it might be just as well to print off this Blog piece for my independent GP colleagues, and do a brief covering note. There’s only so much “awareness” raising one can do, especially if one is stressing “moderate”, safe, and therefore possibly less attention-seeking views.
(1) In my talk at the 2009 ADDISS conference, and on this website.
(2) The RoyalCollege of Psychiatrists Faculty of Psychotherapy Annual Conference, in Cambridge.
3rd September 2010
Busy Busy Busy
After the August bank holiday, its time to get organised again. Like many people with mild ADD / ADHD (1), plans mulled over while taking a break from work during August are coming up against the reality of having to do several things, some not anticipated, at once.
Medical doctors, rightly, are regulated, and the regulation is increasing. We are both on a medical register, and licensed. This year a separate registration with the Care Quality Commision has been introduced, the application forms and guidance for which were only published at the beginning of July, and have to be submitted, with a lot of accompanying documents, by 1st October.
I’m not moaning, but it is quite a tight deadline, and I may have to ask for a couple of weeks extension. In the meantime lots of other interesting things are happening, and it would be nice to think a bit more about national ADHD week (19th – 26th September).
Got to go.
(1) See 23rd July posting
This post appeared late due to problems with technology and…organisation
20th August 2010
Giving up EU subsidy: so hard to do
Are holidaymakers from the UK still seeing EU-subsidised tobacco growing in Southern Europe?
The EU’s website states that “In the interest of public health, direct tobacco subsidies were phased out by 2010.” But in February this year, UK members of parliament expressed “disappointment at the continuing subsidy…to the tune of some £260 million each year”.
I can report seeing just as much of the large-leaved crop this year in the part of South-West France I have visited every August since 2007, although a friend who knows a different area well says tobacco planting is much reduced.
Readers may remember the EU tobacco subsidy being a big focus of campaigning throughout the 1990’s. It was said that much of the tobacco was too low-grade to be smoked by Europeans, so it was dumped on non-EU countries at a loss, encouraging people on low incomes to become nicotine-addicted. If that is true, then stopping (or greatly reducing) the subsidy has taken a long time.
Tobacco is linked to ADD / ADHD in two ways. Symptoms in teenagers predispose to starting smoking, and also to difficulty in giving up later. This is often said to be due to risk-taking, but some of my patients report big improvements in cognitive function when they smoke. As mentioned two weeks ago, the UK-licensed smoking cessation drug Zyban (bupropion) can be effective in reducing ADD / ADHD features.
Secondly, children of mothers who smoke during pregnancy go on to develop ADD / ADHD more frequently. A recent study suggests this is more of a genetic than a brain-toxicity mechanism (1), but there is a wide range of other evidence which strongly indicates maternal smoking to be bad for the developing foetal brain.
Many people find a Southern European field full of mature tobacco, with white trumpet-shaped flowers rising several feet above the leaves, to be a beautiful thing. But it is a deadly beauty which we seem to be in no hurry to get rid of.
This post appeared late due to problems with technology and organisation
6th August 2010
“No” to the knife, “Yes” to Ritalin?
Obesity surgery has grown in the UK, as it has worldwide. But unless it can be shown that it saves money which could be transferred from elsewhere (diabetes care, for example), less than 5% of eligible patients might receive NHS operations in the next few years.
With couple of internet searches, today I found plenty of advertisements for self-funded surgery, including centres in India and Central America. The demand is clearly huge.
On Wednesday this week Joan Bakewell’s Radio 4 medical ethics programme addressed the previously little-publicised problems with obesity surgery (1). In particular, careful follow-up is needed as banding operations may need to be repeated or redone. For patients who go abroad, continuity of care may be less than optimal if they need to turn to the UK NHS later.
A study published last year (in a Nature group journal) suggested ADD / ADHD may be a significant, and treatable, cause of obesity (2). One third (78/242) of patients in an independent Toronto weight loss clinic were found to have ADD / ADHD, and with treatment they lost 10% of body weight. That is as good as obesity surgery.
More research is of course needed, but I find the idea that some people with ADD / ADHD overeat makes clinical sense. Many of my patients, successfully treated, get on with their lives more effectively, and find they “snack” less. Because the underlying dissatisfaction and discomfort is reduced, so is the need for “comfort eating”.
In my view this treatment effect is separate from the “appetite suppressant” effect, which is often transient anyway, of medications such as methylphenidate and amfetamine.
Interestingly, another large study on obesity, recently published in The Lancet(3), showed good results for a medication combination which included bupropion (available in the UK only as the smoking cessation drug Zyban, but more widely used in the US for years). Bupropion is thought by many developmental disorder specialists to be effective in ADD / ADHD.
I am sure we will see many overweight and obese people in the UK considering whether they might have ADD / ADHD. Surely having assessment and possibly treatment in London is a reasonable thing to try, before flying off for surgery in Cancun or Delhi (4)?
(4) No disrespect to Mexican or Indian surgeons intended at all. The point is about continuity of care. It also seems possible to me that people with severe ADD / ADHD might have a poor outcome with apparently successful surgery: I understand this is not uncommon.
23rd July 2010
Does NHS “General” Practice support adequate assessment and treatment of mental and behavioural problems?
I have never met anyone working within the NHS who believed that more than a minority of UK general practitioners have a great interest in mental health issues. As a trained and qualified GP myself, I have much affection and regard for my non-specialist colleagues. But unfortunately because their views are often so much in line with mainstream opinion (hence those persistently high “public trust” ratings?), that can sometimes include a dismissive approach to human frailties.
A confidential survey of GP’s, published last week by the leading mental health charity Rethink, appears to have confirmed this (1). The new government wants general practitioners to decide on funding priorities for specialist services, and over three quarters are happy to do this for physical conditions, but less than a third want to be involved in mental health.
This is despite GP’s having a very negative view of existing specialist mental health services. When asked “To what extent would you feel confident in the quality of care one of your relatives would receive if they were referred to the appropriate NHS services” only 50% said they would feel confident for depression (as against 92 – 95% for physical conditions). For obsessive-compulsive disorder (OCD) the figure was 32% and for post-traumatic stress disorder it was a miserable 22%.
I don’t blame GP’s for not wanting to take on the re-funding of NHS mental health services. To do so in the current financial climate would probably mean advocating cuts to clinical services for physical conditions, which would be deeply unpopular. Privately, many of them support their better-off patients seeing independent non-NHS specialists, which in itself at least expresses a degree of discontent with the current situation.
But keeping this issue at arms length might lead patient groups to further question the ordinary good sense, even the fairness, of general practitioners. Rethink continues to highlight a previous survey as showing that “23% of people with mental illness report experiencing discriminatory treatment from GPs” (2). It could be a good time for the minority of GP’s with a special interest in mental health issues to become a majority.
The beautiful game: Americans can play (and watch) too
Writing in TheHuffington Post, an American novelist has stated that football will never catch on in the United States, because it is too boring to watch (1). “American sports fans…crave the excitement presented by the chance of a score on every play.”
One of his European readers responds by suggesting that high rates of ADD / ADHD might account for this drive towards instant gratification. But is it true, anyway, that people in the United States generally lack restraint, live more “in the moment”, thoughtlessly follow their impulses and desires?
If so, the US would, for example, have higher rates of alcohol and substance misuse compared with other cultures. Recent large-scale studies do not confirm this (2). The best physical indicator of alcoholism, cirrhosis of the liver, is still much more common in supposedly non-impulsive France (3). Moreover, despite a steady fall in the real price of alcohol, and relentless promotion (not least within sporting events) both overall alcohol use and misuse have declined in the US over recent decades (4).
The sport of the aspiring American businessman is golf, and US television ratings for major tournaments indicate an abundance of patience to follow such events over four days, far in excess of a ninety minute football game.
This Sunday the world cup climaxes. If the USA team had gone even further than the last sixteen (drawing against England), if they were playing against the current European champions, Spain, in the final, would football have become more of a credible spectator sport for Americans? I think so.
(2) McBride et al (2009): Further evidence of differences in substance use and dependence between Australia and the United States. Drug and Alcohol Dependence
(3) World Health Organisation (2004 figures – published 2009)
(4) Zhang et al (2008): Secular Trends in Alcohol Consumption over 50 Years: The Framingham Study. The American Journal of Medicine . This study found that “heavy” use had declined, but not alcohol dependence.
25th June 2010
Dyspraxia, or developmental coordination disorder (DCD)
Last weekend I was asked a difficult question: “do you diagnose dyspraxia?”. My answer can hardly have inspired confidence: “well, I never have, but I’m thinking of doing so in the future.”
The question came in a workshop (1) I was giving at the annual conference of DANDA (Developmental Adult Neuro-Diversity Association), an organization which supports the concept of dyspraxia in adults, alongside the much better-known conditions of autism, ADD / ADHD and dyslexia.
I think I have only seen one or two people with a main diagnosis of dyspraxia, as compared with at least a dozen with dyslexia. DANDA recognises that many people have different combinations of these developmental conditions, and the conference was, for me, a useful opportunity to catch up with some of the literature (2) on DCD (developmental coordination disorder, as some prefer to call it).
The problem, from DANDA’s point of view, is that very few specialists are prepared to diagnose dyspraxia in adults. Talking with the workshop participants, I began to see how, although many people with dyspraxia have interpersonal and organisational issues which I would usually see as either falling into the autistic spectrum on the one hand, or ADD / ADHD on the other, the “dyspraxia” concept is most meaningful for them. Perhaps this is because problems are experienced as much more within the body, and not just the mind.
Anyway, in the closing discussion I did give something of a promise that within six months I would be able to give a more definite “yes or no” answer to whether I diagnose DCD. For the moment my “official” position is “maybe...but do you think you might have anxiety, depression, ASD, ADD / ADHD...etc...as well?”
(1) “Managing anxiety and depression in neuro-developmental disorders” Workshop at DANDA annual conference, London, Saturday June 19th 2010
(2) Such as Living with Dyspraxia: A Guide for Adults with Developmental Dyspraxia (2006) by Mary Colley
11th June 2010
The reality of NHS adult ADD / ADHD services
Yesterday I attended the second annual meeting of UKAAN (UK Adult ADHD Network), which is led by academics and funded by a leading pharmaceutical company (1).
It was very interesting to hear how local NHS adult services, all English, were coping with increased referrals of patients. What seems clear is that many people are screened out, often by so-called “gateway workers”, who tell patients that they do not “meet the criteria”.
When the NICE guidelines came out, I wondered if patients with ADD / ADHD would often be found to not “meet the criteria” on the basis that their condition was “only” mild. However, it looks as though a lot of mild and moderate ADD / ADHD is simply being diagnosed as “no ADD / ADHD”.
I have already seen many people with moderate-to-severe disorders, who should fall within the NICE guidelines, but have been told that they should stop “medicalising their past failures” and just get on with their lives.
The President of UKAAN, Professor Phil Asherson, told the meeting that in many areas services are being closed. This means that people who have been on waiting lists for months may end up being told that they will not be seeing a specialist after all.
I will be suggesting to ADDISS and AADD-UK that they consider telling their members and supporters about the reality of all this in greater detail and that, for those who can afford it, paying to see an independent specialist may be the best option for at least the next 2-3 years (2).
(1) There appeared to be no promotional activity at all within the meeting itself.
(2) “2-3 years” is based on the wide perception of how long the most intense NHS spending restraint may last.
28th May 2010
Panorama’s bad news still buried
An article in Education Guardian this month(1) received some interesting online responses, two of which pointed out that Ritalin (methylphenidate) has been used clinically in ADD / ADHD for fifty years. There did not seem to be overwhelming agreement with The Guardian’s scourge of health misinformation Ben Goldacre, who has stated “Big Pharma is evil”(2).
There was, however, little picking up on the valid concern expressed in Are drugs the solution to the problem of ADHD among young people? that NHS specialists who diagnose and prescribe may be forced to cut corners in their assessments and monitoring(3). Just one parent with an ADD child, and a mixed experience of services, posted on this: “The best treatment involved regular visits to the psychologist (every 6 -8 weeks) with ALL the family so we could all work out what was working and what was not.”
Unlike the BBC, The Guardian is free to be opinionated. Even so, it is disappointing that all the paper’s print and online articles mentioning ADD / ADHD continue to avoid reference to Panorama’s two programmes on this topic, both of which had complaints upheld against them. The more recent one was found to be “unfair and not openminded”, resulting in a rare on-air apology (4). Given the BBC’s massive online and broadcasting influence, and Panorama’s “flagship” status, this seems to be essential context for understanding public and professional attitudes to ADD / ADHD.
I was also concerned that an academic educationalist who does not “acknowledge that ADHD is even a medical condition” because “You can't do a blood test to check whether you've got ADHD” appeared to go unchallenged. Epilepsy, bipolar disorder, migraine, schizophrenia and depression all lack definitive physical tests, and may improve with psychological treatments, but does that mean no one should ever take medication for these conditions?
As the online responses to this article showed, Guardian readers should not be stereotyped as simply following the line that mental and behavioural disorders are, in general, just “marketing” tools for pharmaceutical companies.
(2) Bad Science (2009, paperback edition) page 201. From the context, Goldacre appears to be half-joking.
(3) See “Critical Psychiatry”, 2nd April 2010, below
(4) See my postings on Panorama, 5th and 19th March, below
14th May 2010
Bright teenagers: at risk for what?
A recent study from Sweden, published in the British Journal of Psychiatry (1), appears to confirm a link between high ability and bipolar disorder. Over seven hundred thousand teenagers were followed up to see if they were admitted to psychiatric hospital in their twenties and thirties. Then their school examination grades at 16 years were compared with those of the other students who had not developed such severe mental and behavioural problems.
The adults with bipolar disorder had done better in exams as teenagers, especially in humanities subjects such as Swedish and History (but not Art). Those who had been good at Sport seemed to have a lower chance of developing bipolar disorder later.
This is an interesting study which is in keeping with the suggested link between bipolar disorder and creative ability. However, it does not mention the possibility that adult ADD / ADHD, which also can sometimes lead to hospital admission, may have been the real problem in many cases. Like much research of this kind, the diagnosis was made a long time ago (1988 – 1997), when there was even more scepticism about adult ADD / ADHD than there is now (2).
(2) For an example of how creative ability may be linked to ADD / ADHD, see my 5th February Blog piece on Vincent Van Gogh.
30th April 2010
"Nutters", "Fruitcakes" and "Loonies"
Nick Clegg has apologised for using the word “nutters” to describe the conservatives’ East European allies in the 22nd April leaders’ debate: ''I am acutely aware that the stigma of mental health causes great distress to many people and my use of language that could be considered derogatory was entirely unintentional.''
This seems a bit strange, because much of the language used in these events is pre-planned. Also, only four weeks before the debate, the mental health charity Rethink obtained an agreement from Mr Clegg, together with the other leaders, not to use “mental health slurs” during the election campaign (1).
Less than a year ago the former Labour minister, Denis MacShane, made exactly the same point about the Conservative allies, but using the more derogatory “loonies and wierdos”. This was in the House of Commons, where there appears to be a guideline against “insulting, coarse, or abusive language”, but perhaps significant is the qualification “particularly as applied to other Members [of Parliament]” (2).
Back in 2006 David Cameron talked about UKIP as being “fruitcakes, loonies and closet racists, mostly”. UKIP’s Nigel Farage demanded an apology over the racism allegation, but interestingly he said that “fruitcakes and loonies” was fine, because “we have a sense of humour”.
So Nick Clegg may have thought that his own language was an improvementon “loonies”.
(2) Some Traditions and Customs of the House: House of Commons Information Office. January 2009
16th April 2010
How mentally healthy should mental health professionals be?
People drawn to the “helping professions” are often seen as having problems of their own. Whether this is really true, in a clinical sense, for just a few individuals or more widely is difficult to know.When I first had experience of psychiatry as a student in the mid-1980’s this was a fairly common subject of discussion.
It seems to have gone more underground now, presumably as a result of thewidening of the “worried well” concept in official NHS thinking. Psychiatrists, psychologists, nurses and others may be less willing to risk being seen as self-obsessed whingers, when they work in services focused on “severe and enduring illness”.
Will ADD / ADHD prove to be any easier for us to be more open about? With 2 million adults in the UK having the severe or moderate condition, and another 8 million with less clearly defined milder problems, the numbers are similar to common disorders such as depression and obesity.
For someone like myself, now working independently, it is relatively easy to acknowledge mild ADD, which has probably been a causative factor for depression in the past. I have not had major symptoms for nearly two decades, and believe that I have developed mental resilience. However, given that most of my current practice comes from the growth in adult ADD / ADHD, a semi-experimental trial of a non-stimulant remains a possibility.
But for those still working in the NHS, a more cautious approach might be wise, especially at a time when spending cuts and political rhetoric create uncertainty. Managers keen to prove themselves as more than pen-pushing bureaucrats can respond to “stop moaning” calls from the top (1) in unpredictable ways.
Unlike the BBC’s Panorama (1), The British Medical Journal (BMJ) gives space to a wide range of views on mental health and behavioural disorders. An article on adult ADD / ADHD last week is an example of how polarized debates can become. One side repeated, as fact, Panorama's “unfair and not open-minded” opinion on the poor long-term outcome for medication in ADD / ADHD (2).
The BMJ published my own comment online (3), pointing out the need to test and monitor new nurse-led adult ADD / ADHD diagnosis and treatment (4). Of course, the Department of Health is quite right to look for the most cost-effective ways of delivering services, and nurses bring their own distinct and valuable skills to a wide range of clinical settings. But I have already had two conversations with specialist NHS nurses working with children and teenagers, who were concerned at being pushed into taking on too much responsibility too soon.
“Critical Psychiatry” is generally skeptical about all “medicalisation” of problem emotions and behavior. So it seems a bit odd to me that the authors of this piece attacking adult ADD / ADHD suggest that “more established diagnoses…depression, anxiety, and modern conceptions of bipolar and bipolar spectrum disorder” be kept in preference.
This does, though, raise a further question about clinical specialists. Why should adults with “non-established” ADD / ADHD have less direct access to NHS psychiatrists and clinical psychologists, than people with “established” conditions? Surely it is more logical that they have more?
The BBC’s recent bad news, about Panorama’s flawed ADD / ADHD programmes (1), seems to have been buried by the general pre-election media coverage. I have been assured that the BBC Trust’s delayed decision (itself still a subject of the complaints process) was not deliberate “news management” timing; but myself and ADDISS did find it interesting last year that the initial recognition of a problem with the 2007 programme was made public in early August (2), a traditionally quiet time when press releases often don’t get followed up.
Therefore it may take some months to discover the changes, if any, to the way mental health and behavioural disorder issues are now dealt with by the BBC.
For me, the problem with the 2007 programme (3) was not just the one-sided presentation of research on medication. It was the avoidance of any exploration of why Craig, the teenager whose ADHD and perhaps other problems caused him to end up in Court, was not receiving any input from local NHS services. No local professionals or managers were questioned (they were in the 2000 programme), and the interview with NICE’s Dr Tim Kendall was extremely limited.
By making the overall issue about medication, rather than local services, the 2007 programme in effect promoted the Department of Health’s policy that specialist mental health services are focused on “severe and enduring” problems, and can therefore exclude moderate and mild ones. This policy has now been in place for nearly two decades and has undoubtedly removed billions of pounds from the DOH’s “frontline services” balance sheet. However, many ADD / ADHD specialists believe that failure to intervene earlier, in these less severe disorders, results in substantial financial costs later in terms of underemployment, prison places, and adult mental health problems. Dr Kendall might have been asked some difficult questions on NICE's narrow money-orientated evaluation process, but that didn't happen.
Perhaps Panorama has unbroadcasted material which would throw light on all this. A fuller review of the reasons for the “unfair and not open-minded” programme might also include emails and other communications from and to the Department of Health (4).
(3) The BBC Trust ordered the programme to be removed from the BBC website. Today, weeks later, I was still able to view it at http://www.bbc.co.uk/accessibility/win/hearing/alt/panorama/sub_3.shtml . It has also been placed on YouTube as “A Panorama report on the life of a young child hooked on medication prescribed for his so called ADHD condition. “
(4) I remain open to a range of explanations for the problems with the programmes; and I am not suggesting that Panorama deliberately colluded with the Department of Health, to be misleading.
5th March 2010
The flagship investigators need further investigation – but perhaps help and support as well
The BBC Trust has ruled that Panorama, in its 2007 program questioning ADHD medication, was "not fair and open minded"(1). It has ordered an "on air" apology: Panorama’s first in years (2). The headline message is that the Trust has handed out a strong reprimand.
But the Trust also says that viewers were not deliberately misled: the program makers could have "misunderstood the underlying material". I think that families and patients affected by ADD / ADHD will find this contradictory: how can a lack of fairness and open-mindedness arise solely from a misunderstanding?
It appears even less credible when the experience of the journalist involved is taken into account: on the Panorama website Shelley Jofre is presented as a specialist in this area who has made many programs, "instrumental in forcing an overhaul of how drugs are prescribed". In a “meet the team” video the risks "when you take on a major multinational drug company" are said to be just part of the job. The 2007 complaint pointed out that the ADHD program was a follow-up to one made in 2000, about which Panorama had, years ago, accepted a previous complaint was valid (and the “flagship” Panorama rarely concedes error). No mention is made of all this in the BBC Trust’s written reasons for its finding of a possible misunderstanding: the impression given is of a single rogue episode.
Many people who have sought diagnosis and treatment for their children with ADD / ADHD have been angry about these programs, feeling that they were portrayed not only as gullible dupes of the pharmaceutical companies, but also, by implication, as bad parents. I doubt that they will be happy with the BBC Trust’s decision to close the matter by having a quiet word with the BBC’s deputy director-general.
However, I have a degree of sympathy with the Trust’s implied view that the underlying issues are difficult to understand. As a non-academic adult psychiatrist I still find that the MTA (3) study of pre-teen children with ADHD, which generated dozens of published papers, does not reveal its meaning easily. I think I understand that the follow-up study was always likely to be difficult to interpret, given that the patients in the treatment groups were no longer encouraged to stick to their randomly assigned treatments (medication, behavioural, and “treatment as usual”). But even after the BBC Trust’s investigation I am still unclear why Professor Pelham, the psychologist who was co-author of the study, and whose views on the poor longer-term outcome of medication were ruled to have been given undue emphasis, appeared so confidently to disagree with his psychiatrist co-authors, when I understand that he had not done so in print.
Therefore I think Panorama should make available the video of its full interview with Professor Pelham, as well as other material, because it may still have relevance for how we interpret the MTA study and the follow-up. We might even see whether Panorama had the potential to make a good and genuinely interesting program, rather than the flawed one, which is regarded by many people as simply biased. If parent and patient groups want now to see a deeper enquiry or review, of all Panorama’s mental health related output, I would support that.
But I think it should be kept in mind that poor journalism and editing might be due to other causes than ordinary bias. I was unable to find any research directly bearing on precisely this context, but a comprehensive study of war reporters (4) has shown that substance misuse, depression and post-traumatic stress disorder (all problems that might even be linked to ADD / ADHD) are more common than in “ordinary domestic” journalists. Shelley Jofre’s “taking on the pharmaceutical Goliath” video might not exactly indicate the “macho values” which draw people to conflict zones, but she does talk about the “sleepless nights” that her work brings.
(2) I was unable to find mention of a previous Panorama apology on the BBC website. Incidentally, I could find no mention either of the BBC Trust’s findings on the Panorama website, which continues to state that the 2007 program “reveals that new research shows giving children drugs for ADHD works no better than doing nothing in the long-term.”.
(3) Multimodal Treatment Study of Children with ADHD: background explained in the BBC Trust report
“Autism is a serious, lifelong and disabling condition” (1) according to the chief executive of the National Autistic Society (NAS), which continues its excellent work in raising awareness about developmental disorders. But I wonder sometimes if this all-or-nothing headline message might discourage people from seeking treatment, when they see themselves as having milder problems.
The idea that autism is a spectrum not just of how it presents, but also of how severe it is, shading into normality in both respects, has been around for a while now. I have recommended Simon Baron-Cohen’s book The Essential Difference to several patients, because I thought it might be helpful to see how one leading researcher into autism views this issue.
It is likely that there are many people who are functioning, perhaps working, but not really doing very well, who probably have mild autistic spectrum disorders. Traditionally, psychiatry has assumed that “perfectionism” or “rigidity” are fixed and untreatable personality traits. This has been challenged by many studies now, and this week a report from researchers in Lyon, France (2) adds to the evidence that medications can improve the core features of autism.
Treatments (or “interventions”) in severe or moderate developmental disorders do not usually cure in the sense of moving the features of the condition into the spectrum of “normality”. A change from severe to moderate, or moderate to mild, would be considered a good response. But by starting off with a mild disorder, and moving towards normal functioning, whatever that is, you might have good reason to think that you had been cured of your disability.
In a letter, written in English and currently on display in London, Van Gogh describes procrastination and hyperfocusing:
"My dear Russell…for ever so long I have been wanting to write to you – but then the work has so taken me up. We have harvest time here at present and I am always in the fields…when I sit down to write I am so abstracted by recollections of what I have seen that I leave the letter. For instance at the present occasion I was writing to you and going to say something about Arles as it is…instead of continuing the letter I began to draw on the very paper the head of a…little girl I saw this afternoon whilst I was painting a view of the river with a greenish yellow sky."
There is also a suggestion of the regret and self-blame which many adults with ADD / ADHD experience:
"I enclose the slip of scribbling, that you may judge of my abstractions and forgive my not writing before as such."
Van Gogh calls his subjective inability to control and focus attention his "abstractions", and he refers to this again towards the end of the letter:
"I must hurry off this letter for I feel some more abstractions coming on and if I did not quickly fill up my paper I would again set to drawing and you would not have your letter."
Biographies of Van Gogh do not provide much detail of his earliest childhood years, but in his late teens and twenties he certainly showed a restlessness and impulsivity in work and relationships which would be compatible with ADD / ADHD. A more difficult question is whether treatment, in perhaps enabling him to combine his artistic talents with just a little commercial success in his lifetime, would have dulled his creativity. I don’t think so, because that is not what ADD / ADHD treatment appears to do, when used properly.
The letter to John Peter Russell, written in April 1888, can be seen in Room 6 of the Royal Academy in London until 18 April 2010. It is a good idea to book in advance for the exhibition, called The Real Van Gogh: The Artist and His Letters.
22nd January 2010
The pursuit of Happiness
Exactly five years ago, at 10 Downing Street a group of politicians and academics came together to discuss how to improve the well-being of the British people.
Professor (Lord) Richard Layard had written a paper for the meeting: in it he noted how NHS funding in mental health had been reduced for less severe but still disabling conditions, and that many of the two million people who were receiving medication from non-specialists, in consultations of just ten minutes (still standard in general practice today), were keen to try psychotherapy.
Previously, in his 2004 book Happiness Professor Layard had suggested that UK income tax should increase to the levels of other West European countries, because higher taxes increase happiness, by discouraging people from working too hard. The French, at least, seem to have disagreed by voting for Nicolas “work harder and earn more” Sarkozy as their President in 2007.
Following the Downing Street seminar, new funding over 2009 – 2011 means that more people will be able to receive NHS cognitive behavioural therapy (CBT). But at least two questions remain. Firstly, the referring GP’s consultation will still probably be only ten minutes, so will the newly-trained CBT therapists adequately assess the patient’s diagnosis? As Professor Layard himself noted “…it is estimated that GPs misdiagnose mental illness at the first GP visit on a third of occasions”.
Second, is CBT really as evidence-based as claimed?(1) Parts of the Layard group’s glossy The Depression Report: A New Deal for Depression and Anxiety Disorders sound rather similar to the “sales talk from drug companies”(2) which the Professor noted in his seminar paper. CBT is “new...forward-looking” rather than “backward-looking”, “short” as opposed to “endless”. There are “Hundreds of clinical trials” mentioned, without making it clear that this includes therapies other than CBT; or that only recently have psychotherapy trials begun to be registered in advance, so we cannot be sure how many negative trials up to 2006 remain unpublished.
In private, many clinical psychologists agree that CBT has been hyped. I must get round to asking them what they think about higher taxes as therapy.
(1) As I said in my talk at the April 2009 ADDISS conference, I would generally encourage anyone who is offered CBT on the NHS, to try it. I will look at why people with developmental conditions might do less well, or even be harmed, by “standard” CBT in a future posting.
(2) In fact, I doubt that any 2005/6 pharmaceutical marketing material would have been so “hard sell”.
The documents referred to can be found on the LondonSchool of Economics website.
