Oh dear, Lord Layard will not be happy, but Zoe Williams will be. It looks like the wheels may be coming off the UK government’s plans to provide cognitive behavioural therapy for all - Improving Access to Psychological Therapies. With reports that there aren’t enough suitably-qualified therapists to go around and that funding may be in jeopardy, The Observer reports:

A flagship government strategy to train an army of therapists to get the nation off antidepressants and into work could be dramatically scaled back amid claims it is experiencing problems. More here.

I wonder if there is any provision for psychotherapy in David Cameron’s ‘Get Britain Working’ programme?

With the recording of a narrative verdict following the inquest, the death of Kerrie Woolterton is once again making headlines. I wrote about this case of a young woman presenting with self-poisoning and refusing treatment one year ago, in a blog which attracted some thoughtful comment. The coroner stated: “She had capacity to consent to treatment which, it is more likely than not, would have prevented her death. She refused such treatment in full knowledge of the consequences and died as a result.” Sheila McLean, a Professor of Law and Medical Ethics, concurs with this view and clarifies the law in a commentary for the BMJ. She is correct, of course, in highlighting that if Ms Woolterton was thought to have capacity to make a decision about her treatment at the time of assessment the presence of an advance directive was indeed irrelevant.

Yet I still find the outcome of this case troubling. We are relying on details of events reported by the media, but given the context of this woman’s suicide would the presumption that she had capacity to decline treatment be so straightforward? Professor McLean makes the point that the presence of mental illness or indeed personality disorder is not in itself evidence of a lack of capacity. I would agree, but that does not mean they have no potential to influence or impair decision-making. Ms Woolterton had repeatedly presented after self-poisoning and would have known that treatment would be offered. That she still chose to call an ambulance to take her to hospital, albeit that she stated she was only seeking comfort and company, suggests to me a degree of ambivalence.

Key to the concept of capacity is the determination that a person understands the information relevant to a decision, and can use or weigh that information as part of the process of making the decision. As a legal concept that’s pretty clear but in a clinical setting where so many factors can be at play that determination can become murky. And of course, people often do not say what they mean or mean what they say.

In the last year I have discussed this case with a range of clinicians, and although the majority state that given this scenario they would have questions about the patient’s capacity and opt to treat them in their best interests, opinions are mixed. So the outcome (life or death) may have as much to do with our variable views as any objective measure of capacity which makes me uneasy. Vivienne Nathanson, head of science and ethics at the BMA, said the Mental Capacity Act had clarified the law for doctors. Maybe so, but it hasn’t made challenging dilemmas such as this any easier to resolve.

This was the response of a spokesman for the charity Rethink to the results of the national survey of mental health inpatient services published today by the Care Quality Commission (the regulator of health and social care for England). You can see both the national results and those for individual trusts here. Of course, his comments were not a reaction to the three quarters of patients who rated their care as good, very good or excellent. Or the 85% who felt they were made welcome on admission. No, the headline findings are that the majority of respondents felt unsafe at times during their stay on a psychiatric ward, information about their care was lacking, and that only a minority were offered any sort of talking treatment.

I tend to view these surveys with scepticism. The questions are often worded ambiguously and how representative can you be with a response rate of 28%? Yet, the results here surely come as no surprise. It was only last year that the president of the Royal College of Psychiatrists, Dinesh Bhugra, lambasted inpatient units, calling them unsafe, overcrowded and uninhabitable: ‘I would not use them, and neither would I let any of my relatives do so.’

So why are mental health wards so unsatisfactory? Inpatient psychiatry has been neglected as a consequence of the emphasis on community care, a development not limited to the UK (see a previous post ‘A Place of Greater Safety’). Resources were diverted from comparatively expensive inpatient units, with a reduction in bed numbers leaving room only for the most severely ill: in the inner cities detention under the Mental Health Act is almost a requirement for admission. This has led to overcrowded, high-turnover wards filled with patients at their most unwell – is it any surprise that people feel unsafe at times? And faced with this pressure cooker environment the most talented and motivated staff soon joint the flight to fashionable, well-resourced, specialist teams in the community.

The Care Services minister Phil Hope is, um, hopeful: “We will make sure that the experiences people have shared in this report feed into New Horizons, our new vision for mental health.” Of which more later…

Last week NHS Yorkshire and Humber released the findings of an external investigation into the care and treatment of Benjamin Holiday. You can find the report here. In January 2005 Holiday, a young man with schizophrenia, killed a pregnant woman, Tina Stevenson, stabbing her in the street close to her home. He was under the care of a community mental health team and living at home with his mother. Having no recollection of the attack he pleaded guilty to manslaughter with diminished responsibility and has been detained indefinitely in a special hospital.

Department of Health guidelines (shouldn’t that be directives?) call for a series of reviews when a homicide has been committed by a person who has been in contact with mental health services:
1) A fast-track (72 hours) investigation to identify any necessary immediate action
2) An internal mental health trust investigation (within 3 months)
3) And finally, an independent investigation commissioned by the Strategic Health Authority.

The reasons for an external investigation are obvious: lessons must be learned to prevent such events happening again. But do they work? They certainly provide a revealing insight into the day to day care of someone living with a severe mental illness, affording a degree of transparency for relatives and carers that is rarely available elsewhere. And outcomes? There have been at least 400 homicide inquiries in the last 15 years yet the rates of homicide by people with mental disorder remains unchanged: 30-50 from 800 homicides annually, with fewer than 10 committed by people with a psychotic illness (the remainder largely related to personality disorder and drug misuse). The recommendations have become familiar too: improved risk assessment, better communication and better record-keeping. Another report isn’t needed to tell us that. The Holiday Inquiry illustrates their inefficiency. Tina Stevenson was killed in 2005; the inquiry reports four years later in which time things have changed. We have a new Mental Health Act, community treatment orders, crisis resolution teams and I’m sure that like elsewhere, services in Hull have been completely reorganised. The authors acknowledge that much of what they say was reported in 2006 by the mental health trust’s internal review.

Much has been made of bringing an end to the ‘blame culture’ in the NHS which encourages staff to cover up errors for fear of retribution. The new focus is on systematic factors that allow such errors to be made. It is human nature, however, to search for a scapegoat and in this inquiry: “…if we are allowed to indulge in one piece of viewing this investigation through a ‘retrospective-scope’ we would conclude this was a missed opportunity to possibly break into the cycle”. What they are referring to here is the decision by a social worker not to complete an application to detain Holiday under Section 3 of the Mental Health Act two months before the homicide. At the time however, he was agreeing to an informal admission, and following his discharge one month later he was seen by a nurse on two occasions and given his depot antipsychotic injection. It is just as plausible that by detaining him at that time he may have become less cooperative with treatment and disengaged completely - a classic example of hindsight bias.

Of course these points have been made before. In 1999 the DoH’s Safer Services report recommended that homicide inquiries be scrapped but they keep on coming. Clearly they fulfil a social need. The Department of Health guidelines state that mental health services must ‘be seen to investigate’ any serious incident and though not explicit, the allaying of the publics’ anxiety about the mentally ill is key. We used to have asylums to contain the mad, but now we have community care – an idea that now attracts as much vilification as political correctness. The fear of mental illness is as potent as ever and homicide inquiries serve to remind us that whilst they may live among us, they remain alien and dangerous - as illustrated by headlines such as this: Crazed Killers - trust’s failings exposed.

So writes Zoe Williams in the Guardian newspaper. To be fair, she is taking a swipe at the UK government’s latest wheeze: cognitive-behavioural therapy for anyone finding themselves unemployed in the recession. I’m no CBT evangelist myself and think it gets an all too easy ride, often at the expense of other talking treatments. It’s no quick fix and certainly not a panacea. Like other evidence-based treatments for anxiety and depression CBT works for some people but not for others, and I am not at all convinced that Lord Layard’s army of CBT therapists will cure the nation’s ills. However, Ms Williams’s assertion that cognitive behaviour therapy is bogus is frankly, er, bogus. In fact this article is typical of the lazy, ill-considered journalism that serves to reinforce the stigma that shadows mental illness and its treatment.

I appreciate the difficulties of unravelling professional jargon in a short newspaper article but her attempt to describe CBT in a prison workshop is laughable: “[it] dismantles cognitive illusions, of which prisoners have many (among them high self-esteem, which causes them to esteem their own needs over other people’s)”. Does that make sense to you? For a rather more comprehensible explanation of cognitive-behavioural therapy have a look at this leaflet.

The next step of course is to rope in a guru, in this case the ubiquitous Oliver James, a psychologist who reigns supreme in the field of media-shrinks following the excommunication of Raj Persaud. Apparently James is the pre-eminent anti-CBT fury [sic] and his evidence for the bogus nature of this treatment? One study published in 2004 showing that after 18 months CBT was of little benefit in comparison to no treatment, James summarises, “CBT gives sufferers the illusion that they’re feeling better…it’s hypnosis basically”. Actually this paper isn’t a study or a trial of CBT. It’s a review, a critique of the problems involved when using randomised trials to provide evidence for talking treatments in general. Not quite the same thing then…and no mention of hypnosis either. There are however, an increasingly large number of trials and reviews of trials showing that CBT does work particularly well for anxiety disorders, but also for depression. Rather than relying on one expert and one paper you might be better off sticking with Google.

When it comes to discussing health, the Guardian journos might learn a thing or two from the oft-maligned Red Tops. Take a look at these pieces by ‘Dr Keith’ of the Sun on epilepsy and risk: clear, concise, and importantly, comprehensible.

Start with a curry, followed by chocolate with red wine and tea. Toss in some grilled vegetables with olive oil (Mediterranean diet) and a Nintendo DS, to be played with not eaten of course, and you will be practically dementia-proof. OK, maybe not, but the chances of you developing Alzheimer’s will be significantly reduced…won’t they?

‘Foodstuff prevents dementia’ seems to have become a genre of epidemiological study and a new one pops up with a press-release every few weeks. I’ve just noticed this one on the BBC Health website, ‘Vitamin D is mental health aid‘, so it may be time to head for the sun or failing that, gorge yourself on some fatty fish. You can take a look at the abstract here and - surprise, surprise - the usual flaws are present. Firstly, it’s a cross-sectional study, so they have found an association but causation doesn’t come into it. And were they looking at dementia? No, the survey included the Abbreviated Mental Test Score which is a 10 point screening, and not diagnostic, tool for cognitive impairment. To be fair to the researchers, they do point out these limitations (along with several others) in their paper but it always seems to get lost in translation. And just to make sure you don’t miss the dementia link, these articles never appear without a spokesperson from an Alzheimer’s charity calling for more research.

I do wonder where these epidemiologists get their research ideas from: trawling the local supermarket? Of course there is only one sure-fire way to avoid dementia, as The Who memorably sang…and no, it wasn’t ginkgo biloba.

The fall in share prices was unprecedented. His stocks were now worthless and the President of the New York County Trust Bank, J.J. Riordan, had lost a fortune. As the bank closed for the week, he took a pistol from a teller’s desk, went home and shot himself. The year however was not 2008, but 1929 and Riordan’s suicide followed the Wall Street Crash. Recent weeks have seen a number of modern day versions of this story reported in the press: on the 6^th of January, a German billionaire, Adolf Merckle, threw himself in front of a train after his business empire was threatened with collapse. In December, Christen Schnor, HSBC’s head of insurance, was found hanging by a belt in the closet of a hotel room in London. Unsurprisingly, it’s a big story on the internet: have a look at the Daily Beast. You can even follow Greenspan’s Body Count, named after the former head of the Federal Reserve, keeping a grim tally of suicides (and murders) attributable to the financial meltdown. So are we on the verge of a ‘suicide epidemic’?

In my view certainly not, and comparisons with the Great Crash of 1929 are instructive. The US suicide rate in the months following the Crash actually declined when compared with the previous year, even in New York. Rates did rise in the following years, from 14 to 17 per 100000 between 1929 and 1933, although it’s by no means clear that this change was solely due to the Depression. The incidence of suicide had been increasing gradually for some years prior to 1929. In addition, some states only started reporting mortality statistics to the government during this period, and more of them were western states with above average suicide rates. Unemployment is associated with suicide but the relationship is not straightforward – factors such as social isolation and notably mental illness all add to the mix. Paradoxically, with a history of mental illness your risk of suicide goes up if you are in active employment or have a higher income. Changes in the suicide rate are more likely to be due to gradual changes in the economy, with unemployment growing from 3 percent to 25 percent during the Depression, than a specific response to the stock market Crash.

“…the newspapers and the public merely seize on such suicides as occur to show that people were reacting appropriately to their misfortunes. Enough deaths could be related in one way or another to the market to serve. Beginning soon after Black Thursday, stories of violent self-destruction began to appear in the papers with some regularity.” That was JK Galbraith writing in 1955 on the Great Crash. Take a closer look at Greenspan’s Body Count – how many of those suicides really are a direct consequence of the economic downturn? 

I came across both of these statements in the medical press last week:

1. Abortion does not cause mental health problems, says large review
2. Abortion is bad for your mental health

Which one to believe? The first was a news headline in the BMJ, referring to a recently-published systematic review published in Contraception, a journal dealing with matters related to…contraception. The second is the editorial summing-up of a cohort study in the current issue of the British Journal of Psychiatry. In the hotly-contested battle over abortion and choice these contradictory findings will be welcomed as further ammunition by both sides.

Have a look at the two papers though, and it’s not so clear that their findings really are in such stark opposition. The systematic review summarises 21 studies looking at elective abortion and long-term mental health outcomes. As is usually the case with observational research poor quality studies found the biggest differences. The highest quality studies (using better methods) found few, if any, differences in psychological outcomes between women who had abortions and the comparison groups. The second study is an analysis of data from a birth cohort in New Zealand – it arrived too late for inclusion in the systematic review but would clearly be considered good quality. Here some differences were found: abortion was associated with a small increase in risk. Women who had an abortion were 30% more like to have subsequent mental health problems (depression, anxiety, or drug misuse) when compared to other pregnancy outcomes.

You can try and explain this positive finding by looking at the differences in methods and comparison groups, as well as differing abortion legislation in the UK, US and New Zealand, but it’s difficult to argue with the authors’ comment that “for a minority of women abortion is a highly stressful life event which evokes distress, guilt and other negative feelings that may last for years.” That seems pretty obvious to me and raises the question of whether in this instance more research really is needed.

So do these studies inform the debate on abortion? I’m not convinced that they will add much to what are primarily moral arguments but one consistent finding is the lack of evidence that abortions reduce the risk of mental health problems for women with an unwanted pregnancy. Despite this, over 90% of abortions in the UK are undertaken on the grounds that to proceed with the pregnancy would pose a serious threat to the mental health of the woman. Isn’t it time that the law acknowledged reality: that access to abortions in the UK is largely unrestricted?

That’s not exactly what he said but Andrew Lansley, the Conservative Party’s shadow health secretary, has been slapped down by the party leadership for suggesting that the economic recession may bring health benefits. This is what he did actually say on his blog:
I’ve been reading up on the impact of previous economic downturns on our health. Interestingly on many counts, recession can be good for us. People tend to smoke less, drink less alcohol, eat less rich food and spend more time at home with their families.

You can’t read this now as the post was swiftly removed from the Conservative Party website but to be fair he prefaced his statement by emphasising that for many the everyday reality of recession does mean human misery. Furthermore it certainly is the case, as he reports, that some economists have identified a variety of health indicators that improve during a depression, a notable exception being that of mental health. His comments have caused the inevitable political spat with calls for his head and Mr Lansley has apologised (presumably through gritted teeth).

What does this rumpus have to do with mental health? Well, Lansley was actually trying to highlight the impact of a recession on mental health. He suggests that the recession may lead to a 26% rise in the number of people suffering with mental health disorders by 2010. I’m not sure where those figures come from - they sound rather speculative to me - but what is clear is that debt and mental health are inextricably linked. Seemingly self-evident, it is a point reinforced by good epidemiological data. A study by Rachel Jenkins and colleagues using data from a national cross-sectional survey demonstrated this association, showing that one quarter of people with mental health problems are living with debt or arrears (compared to one tenth of the general population) and 10% have had a domestic utility disconnected. A timely joint initiative has just been launched by the Royal College of Psychiatrists and the First Step Trust. The aim is to provide guidance on supporting patients with debt and mental health problems, an area of ignorance for many health care professionals. The leaflet ‘Final demand – Debt and Mental Health’ can be accessed here and is informative whether you have mental health problems or not. So Mr Lansley’s comments, deemed nonsensical by many, are actually noteworthy. It’s a pity that they will be lost amidst the shrill cacophony emanating from the Westminster village.

A BMJ blogger, William Lee, writes of his disquiet following a visit to a meeting held by Dr Philip Nitschke, director of EXIT International, who is in the UK promoting his new ‘guide to suicide’. He describes a strange-sounding meeting with little consideration of the relationship between suicidality and mental illness, and the issue of mental capacity warranting only a cursory mention, including the bizarre recommendation to ‘get a friend to do an MMSE test before your suicide to demonstrate possession of capacity’. Assisted suicide and the ‘right to die’ feature prominently in the news media at the moment. A 45-year-old woman, Debbie Purdey, is seeking clarification of the UK law relating to assisted suicide. She doesn’t want her husband to be prosecuted should he support her in visiting Dignitas, the Swiss organisation providing facilities for euthanasia. Police are currently investigating the case of David James, a 23-year-old left with quadriplegia after sustaining a spinal injury while playing rugby. After several previous attempts he committed suicide at a clinic in Switzerland

Another case has been less widely reported, although I consider it to be no less significant (read about it here). It’s a common scenario that will be familiar to anyone with experience of working in an emergency department – someone presenting with self-poisoning and then refusing treatment. The inquest began last week into the death of Kerrie Wooltorton, a woman with a history of borderline personality disorder, who was taken to Norfolk and Norwich University Hospital after drinking antifreeze (ethylene glycol). On arrival she stated that she did not want treatment and was ‘100 per cent aware of the consequences’. She also brought in a living will (advance directive) that she had written three days previously. The physician responsible for her care thought that she had capacity to make decisions about her treatment and reported that she was ‘calm’ and ‘not agitated’. He felt that it was his ‘duty to follow her wishes’. After consultation with the hospital’s medical director and legal adviser she was not given treatment and died the following day.

The law in the UK (recently codified in the Mental Capacity Act) is clear on the question of treatment for physical illness without consent. If the subject has capacity such treatment would constitute an assault or battery. Yet there are aspects of this case which are troubling. Ms Wootorton had attempted suicide by swallowing antifreeze on nine occasions in less than a year and had previously accepted treatment (including dialysis). She also had a number of recent psychiatric admissions and had been detained under the Mental Health Act. A psychiatrist who saw her in the months before her death said he believed she had the mental capacity to make the advance directive but how can he be certain that this was the case when she wrote it? Given the context of her recent history would there not have been reasonable grounds to doubt her capacity? It’s not uncommon for people turning up in A&E after deliberate self-harm to express ambivalence about treatment and subsequently change their mind, especially in those with borderline personality disorder where impulsivity is a prominent feature. Also, suicidality fluctuates in this group, and if her intent was so clear why come to hospital at all?

These decisions are always difficult and not really made any easier by the Mental Capacity Act. My inclination would have been to treat her on this occasion with an agreement that if she maintained her wish to decline future treatment and in the cold light of day clearly had capacity, an advance directive could be drawn up with the acknowledgment that it was valid by people involved in her care. A paternalistic abuse of a person’s autonomy? Maybe, but what do you think?