Adrian James: Why mental health treatment should only ever be “patient-first”

adrian_james2Earlier this month I spoke at a conference on Psychological Therapies for Severe and Prolonged Mental Illness in London. I was one of only two psychiatrists on the bill, among many psychologists putting forward a “therapies first” approach to the treatment of severe mental health problems.

As I said at the conference, I have a problem with this insistence on indicating a preference. And that’s not a matter of me protecting my own ground; it’s a matter of protecting patients. I’ve argued the need for more psychological therapies on many occasions. I have no interest in turf-wars. I have an interest in providing patients with the most appropriate treatment, in the most appropriate way.

Much is made of the argument that patients want a therapies-first approach. I think that boils it down too far. Patients want to be listened to. They want to be heard, and be given the opportunity to co-produce care plans. They want to be informed and have choices, to be presented with evidence on effectiveness, but also risks and side effects. They don’t want one single thing—they want to know what will work best for them, as an individual.

Too often people put psychiatric practice in a narrow frame. They associate it solely with the prescription of drugs, setting it far apart from other areas of mental health practice. That couldn’t be further from the reality. Psychiatric practice encompasses biological, psychological, and social approaches. It brings all areas of mental health treatment together. It’s not often talked about, but psychiatrists have led the way in developing many of the approaches used in psychological practice, and are committed to all treatment forms following evidence for effectiveness. If we put the patient at the centre of all we do then there can be no battle between these modalities and no room for dispute.

In favour of a blended approach

I know of no psychiatrist who would say psychological therapies should not be part of our therapeutic armoury. When treating depression for example, NICE guidelines recommend that “treatment and care should take into account patients’ needs and preferences” and that “people with depression should have the opportunity to make informed decisions about their care and treatment, in partnership with their practitioners.” For those with mild to moderate depression, guidance is to offer individual self-help based on the principles of cognitive behavioural therapy (CBT), computerised CBT and/or a physical activity programme and to be steered by the patient’s preference. Only when symptoms are more severe or persistent is medication considered as a treatment.

Even when a condition is severe enough to warrant drug treatment, for many moderate to severe mental health conditions, recommended treatment regimens include both medication and psychological interventions. For example, the 2014 NICE guidance on psychosis recommends that, for people with a first episode of psychosis, and those experiencing acute and subsequent episodes, an oral antipsychotic medication should be offered in conjunction with a psychological treatment. Those who want to try psychological interventions alone should, it adds, be advised that these are more effective when delivered in conjunction with antipsychotic medication.

As all those working in mental health know, when people are extremely unwell, when they are experiencing an acute psychotic episode, feeling frightened and overwhelmed by their symptoms, medication is an essential part of treatment. It is necessary, in these situations, to provide medication in order to settle those symptoms, so that psychological therapies can be used.

Relapse rates support the importance of medication as part of the response, where necessary. Early estimates from the big Leucht meta-analysis [i], which published outcomes over a 12 month period, shows 64 out of 100 people experience a return of their symptoms with no medication, reduced to 27 in 100 where regular medication is used.

Celebrating diversity

On this basis, there can be little doubt that what is needed is a united response to severe and prolonged mental illness. We need to pull the full spectrum of approaches together, and be ambitious for our patients and service users, offering them everything that will help. Far from trying to establish a one-size-fits-all policy, we should be celebrating the diversity in our work, and promoting what each of us can bring to the table, from both the psychiatric and psychological models.  It shouldn’t be “therapy first,” nor should it be “drug first.” It should only ever be patient first.

[i] Leucht S, Tardy M, Komossa K, et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet. 2012;379:2063–2071.

Adrian James, registrar, Royal College of Psychiatrists.

Competing interests: None declared.