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Skype, freemasonry, and the International Healing Foundation: more strange tales of reparative therapy

7 Feb, 10 | by Steven Reid, Evidence-Based Mental Health

Following last year’s Sex and the City conference in London, Patrick Strudwick writes in the Independent of his undercover exploits in the world of reparative therapy: therapists claiming great results in switching a person’s sexual orientation and “helping people exit the gay world.”

Struck by a study published in BMC Psychiatry reporting that 1 in 6 of UK mental health professionals surveyed had tried to help lesbian, gay or bisexual patients change their sexual orientation, he went in search of such treatment and came across a psychotherapist (accredited with the British Association of Counsellors and Psychotherapists) and psychiatrist willing to oblige. And what a bizarre experience it proves to be:

I ask how she views homosexuality – as a mental illness, an addiction or an anti-religious phenomenon? “It’s all of that,” she replies. “At the heart of homosexuality is a deep isolation, which is where God needs to be”. A search for cause follows with questions about birth: “It’s just something I have noticed. Often [with homosexuality] it is quite traumatic, the baby was put into intensive care and because of the separation from the mother there can be that lack of attachment.” Excuse me? And what about family: “Any Freemasonry in the family? Because that often encourages it as well. It has a spiritual effect on males and it often comes out as same sex attraction.”

Sessions with the psychiatrist are by webcam, and include a recommendation to join Christian men’s groups. I’m not sure what the Royal College of Psychiatrists would make of that. If you want to know more, you should head for the International Healing Foundation where you can find therapists and ‘ministry leaders’ to guide you, and a compelling introductory video. Alternatively, if you’re interested in the evidence you might want to look at an overview on the RCPsych website. However, do bear in mind that, in the words of one correspondent, this may have been written by ‘active homosexuals’.

What would US health care reform mean for mental health?

8 Nov, 09 | by Steven Reid, Evidence-Based Mental Health

“I look forward to signing comprehensive health insurance reform into law by the end of the year. ” President Obama sounds confident following the passage of the health bill through House of Representatives. Others are not so optimistic. Senator Graham from South Carolina says the bill “is dead on arrival in the Senate.”

Amid all the furore about the supposed superiority, or not, of health care in the US, there has been little mention of mental health. It’s not clear what the bill as it stands would add other than the requirement that all health insurance plans would provide mental health and substance misuse coverage at the same level (parity) as general medical care, which is obviously a good thing. Jessa Crispin from The Smart Set magazine writes here about the difficulties involved in getting treatment for mental illness in the States, and even with insurance the hurdles can be pretty daunting. I’d like to think that signing up for a drug trial just to get hold of some antidepressants and follow up care would be unthinkable here in our socialist or fascist (depending on your perspective) NHS.

IAPT: The best laid schemes

5 Oct, 09 | by Steven Reid, Evidence-Based Mental Health

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?

Respecting the right to die…revisited

2 Oct, 09 | by Steven Reid, Evidence-Based Mental Health

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.

These are shocking figures

25 Sep, 09 | by Steven Reid, Evidence-Based Mental Health

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…

Do we need yet another homicide inquiry?

17 May, 09 | by Steven Reid, Evidence-Based Mental Health

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.

Evidence mounts that CBT is bogus

12 Mar, 09 | by Steven Reid, Evidence-Based Mental Health

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.

100 Ways to Prevent Dementia

29 Jan, 09 | by Steven Reid, Evidence-Based Mental Health

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.

Financial Suicide

19 Jan, 09 | by Steven Reid, Evidence-Based Mental Health

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 6th 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? 

A Tale of Two Studies: abortion and mental health

17 Dec, 08 | by Steven Reid, Evidence-Based Mental Health

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?

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