If you were at a loss for something to do in London this weekend, and the marathon didn’t sound appealing, you could have opted to ‘increase your heterosexual potential’ by listening to psychologist Joseph Nicolosi speak at the 2009 Sex and the City conference.

Then again, maybe not. This was no ordinary conference on sexual health. Organised by Anglican Mainstream, a Christian organisation “committed to the traditional biblical teaching on marriage, the family and human sexuality”, Sex and the City was billed as a Judaeo-Christian conference for all and featured Arthur Goldberg, author of Light in the Closet: Torah, Homosexuality, and the Power to Change. The keynote speaker, however, was Dr Nicolosi of the US National Association for the Research and Therapy of Homosexuality who apparently has “a proven track record over almost 30 years in helping people exit the gay world”. Despite the opposition of both the American Psychiatric and Psychological Associations to psychiatric treatment or psychotherapy designed to change a person’s sexual orientation, Nicolosi considers homosexuality to be a consequence of a ‘gender-identity deficit’ and as such advocates a treatment, reparative therapy, which he claims provides a complete cure for 75% of his patients. I’d like to see the supporting evidence for that.

You can hear Dr Nicolosi on the benefits of so-called reparative therapy here; and this salon.com article gives a view from a therapist’s couch. You might just dismiss all of this as half-baked ideology coming from a screwball fringe but last month Annie Bartlett and colleagues published their survey of UK mental health professionals finding that 1 in 6 responders had attempted to help lesbian, gay or bisexual people become heterosexual.

Unfortunately, even if you really were interested in spending your weekend listening to Dr Nicolosi “redeeming sex today” you would have to uncover the conference’s secret London location. Such discretion seems unnecessary, given the popular appeal of his last London meeting: Time for Truth – Is Gay Real?

With free market capitalism seemingly spinning off into oblivion, despite the best efforts of our Supreme Leader and his G20 disciples, the benefits of globalisation for the world economy are looking a little shaky at the moment. Whilst it has brought an unprecedented increase in prosperity for some, for others low wages and an economy underpinned by massive debt mean that the world seems a more unequal place than ever before. These inequalities are of course not just international but intranational: countries are made up of classes.

In 2004 Michael Marmot charted the impact of inequality on health in The Status Syndrome. This month his text is joined on the shelf by The Spirit Level (Richard Wilkinson and Kate Pickett). Both books marshal an array of epidemiological studies to present a robust bottom line: there is a strong correlation between a country’s level of economic inequality and its social and environmental problems. What’s more, it isn’t just the poorest in the most unequal societies that suffer but the richest too. So according to Wilkinson, “countries such as the US, the UK and Portugal, where the top 20% earn seven, eight or nine times more than the lowest 20%, scored noticeably higher on all social problems at every level of society than in countries such as Sweden and Japan, where the differential is only two or three times higher at the top.” And those social problems range from obesity to big prison populations, from teenage pregnancy rates to, of course, mental illness.

That an unequal society leads to more mental distress may seem self-evident but a study recently published by the World Health Organisation – Mental health, resilience and inequalities – amasses a broad range of evidence to show that mental health problems are not only more pronounced in unequal societies, but that mental health is also key to understanding the impact of inequality on a range of other health outcomes. Dr Lynne Friedli, the report’s author, maintains that the chronic stress of struggling with material disadvantage is intensified by doing so in more unequal societies. In turn chronic stress has a deleterious effect on the neuroendocrine, cardiovascular and immune systems increasing the risk of disorders such as coronary heart disease and metabolic syndrome. Maybe so, although the strength of the evidence is contestable. But what’s to be done? Dr Friedli’s wish list seems rather optimistic:

• social, cultural and economic conditions that support family and community life
• education that equips children to flourish both economically and emotionally
• employment opportunities and workplace pay and conditions that promote and protect mental health
• partnerships between health and other sectors to address social and economic problems that are a catalyst for psychological distress
• reducing policy and environmental barriers to social contact

This sounds too much like ‘motherhood and apple pie’ to me, although a strident call for wealth redistribution would probably be asking a lot of WHO. Of course, the UK government would claim that they have made considerable progress in all of these areas over the last decade. If that is the case, why is there a need to convene a new National Equality Panel to show how your chances in life are influenced by, among other things, ‘how much money you earn’? We are also awaiting another review of Health Inequalities in England to show us the way.

Gordon Brown is busy trumpeting the need for economic and financial reforms ahead of the G20 meeting, or as it has now been rebranded: the London Summit. An opportunity to redress global imbalances? Not bloody likely. I’m more inclined to believe this pithy observation from the Financial Times: “A crisis-torn world is in no mood for the heavy lifting of global rebalancing. Policies are being framed with an aim towards recreating the boom. Washington wants to get credit flowing again to indebted US consumers. And exporters – especially in Asia – would like nothing better than a renewal of demand led by the world’s biggest consumer. It is a recipe for disaster.”

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.

I recently stumbled across the homepage for The Prince’s Foundation for Integrated Health and found this. Yes, HRH is coming to the rescue of mental health services in the UK by introducing guidelines on nutritional therapy, reflexology and aromatherapy. No specific mention of homeopathy or intercessory prayer but we live in hope. These guidelines will “set out the governance infrastructure for bringing these therapies into NHS mental health services and will provide a guide to service development”. Prince Charles’s partners in this venture are the Mental Health Foundation, Mind and of course the Royal College of Psychiatrists (of which he is the patron). The guidelines are due to be published in May but the funding comes from Lloyds TSB…oh dear.

St John’s wort has been discussed here before, but if you want a balanced overview of complementary treatments in mental health, Ursula Werneke’s article in Evidence Based Mental Health is this month’s Editor’s Choice (so it’s free to access). For a slightly more jaundiced view of alternative medicine in general David Colquhoun’s blog is well worth a look.

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.

No, don’t worry; this isn’t a blog about metaphysics. It was over 100 years ago that Emil Kraepelin, widely considered the father of contemporary psychiatry, divided psychosis into two discrete disorders: dementia praecox (schizophrenia) and manic-depressive insanity (bipolar disorder). Hence the dichotomy, which remains a hallmark of the classification of mental illness.

This categorical approach to diagnosis has plenty of critics but the divide remains firmly in place. Why? Partly because making a psychiatric diagnosis is often an uncertain business. It’s inherently appealing to have just two options to choose from when trying to make sense of a complex clinical picture. Plus the textbooks tell you it’s straightforward: schizophrenia means an enduring illness, with a flat, unreactive mood, and inevitably a poor outcome, in contrast to bipolar illness which is episodic with dramatic changes in mood, and of course that flair for creativity. Well life’s not actually like that. In clinical practice it’s often difficult to discriminate between the two. Take a look at the casenotes of a person with schizophrenia and at some point it’s likely someone will have made a diagnosis of bipolar disorder, and vice versa. In fact we’ve even had to invent a new diagnosis – schizoaffective disorder – for those cases when you just can’t make up your mind. So there has been disquiet about Kraepelin’s dichotomy for some time and now we have a behemoth of a study which may well prove to be the final nail in its coffin.

Published in the Lancet this is a population-based study including over nine million Swedes, that teases apart the genetic and environmental contributions to both schizophrenia and bipolar disorder. Previous genetic studies have been nowhere near as big so the findings are compelling. We know that genes are important in both schizophrenia and bipolar disorder but here it’s demonstrated that they share a common genetic cause. First-degree relatives of people with bipolar illness had an increased risk for schizophrenia, including adopted children to biological parents with bipolar disorder. Similarly, relatives of those with schizophrenia were at increased risk of bipolar disorder.

So what next? Out with the old diagnostic criteria? Perhaps…it certainly gives the committees debating the next version of the psychiatrists’ diagnostic manual (DSM-V) plenty to think about. Maybe it’s time we moved toward a psychosis-spectrum disorder with a renewed emphasis on symptoms. After all, it’s the symptoms that predict response to a specific treatment, not the diagnosis. And what of Kraepelin, would he approve? Well he was having doubts about his own dichotomy back in 1920, “No experienced psychiatrist will deny that there is an alarmingly large number of cases in which it seems impossible, in spite of the most careful observation, to make a firm diagnosis…. It is becoming increasingly clear that we cannot distinguish satisfactorily between these two illnesses and this brings home the suspicion that our formulation of the problem may be incorrect”.

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? 

The debate has been rumbling on for a year, but last month the US Food and Drug Administration (FDA) announced that manufacturers of antiepileptic drugs will have to add warnings to package inserts stating that these drugs increase the risk of suicide. They have also issued a public health advisory requiring that “health care professionals should notify patients, their families and caregivers of the potential for an increase in the risk of suicidal thoughts or behaviors so that patients may be closely observed”. These alerts arrive following a review of 199 clinical trials that showed a doubling of risk of suicidality (not completed suicide) in people using antiepileptics. So warning patients makes sense doesn’t it? But then why are so many neurologists, psychiatrists and notably the American Epilepsy Society unhappy with the decision?

It boils down to the perception of risk and the old relative vs. absolute question. The trials included over 40000 patients and found that the absolute risk of suicidal thinking or behavior was 0.43% in the group taking antiepileptics versus 0.24% in the group on placebo. That equates to one additional case of suicidality (again, not completed suicide) for every 500 patients taking the active drug. Do antiepileptics seem quite so scary now?

The FDA says that the warnings are needed to promote monitoring for a significant, even if small, risk. Given that epilepsy itself is associated with a threefold increased risk of completed suicide watching for signs of depression should be routine. As well as epilepsy antiepileptics are also used in bipolar disorder and with chronic pain – conditions with their own significant risk of suicide. But a regulator urging increased monitoring doesn’t seem to affect clinical practice. Take the case of antidepressant prescribing in adolescents (see an earlier post). When trials indicated an increased risk of suicidality with SSRIs the FDA slapped on a black box warning. The adolescent suicide rate went up (possibly coincidental) and prescribing rates plummeted (probably not coincidental). That’s the concern with this latest alert: people will be put off taking antiepileptic drugs, and unlike antidepressants there is no alternative treatment. Providing information is important but so is context and I think this is a decidedly dubious decision by the FDA.

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.