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November 2005
Research Round-up
Julia Hyde and colleagues report this month on a study exploring how GPs decide to prescribe antidepressants. They conducted five focus groups with a total of 27 GPs. They found the preferred strategy is ‘wait and see’, but in accordance with current guidelines, antidepressants are prescribed earlier when symptoms are perceived as severe or persistent. They also found that organisational constraints determined the prescription of medication eg time pressures or no available alternatives. They also concluded that GPs need to be convinced that alternatives to antidepressants are effective for patients with mild depression.
Hyde J et al A qualitative study exploring how GPs decide to prescribe antidepressants. (2005). BJGP 55: 755-762
Arroll and colleagues have found that adding one question to two screening questions improves the specificity. The two questions previously validated as screening tool in general health care are: during the past month have you often felt down, depressed or hopeless?’ and ‘during the past month have you had little interest or pleasure in doing things?’ These two questions alone have a sensitivity of 77% and a specificity of 86%. The authors added the question ‘is this something you would like help with?’ and found specificity improved to 94% though sensitivity remained the same.
Arroll B et al. Effect of the addition of a “help” question to two screening questions on the specificity for diagnosis of depression in general practice: diagnostic validity study. (2005). BMJ. 331: 884-886
Paul Walters, Primhe’s trustee
Hartlepool Mind – Holistic Mental Health in Action
All around the country Primary Care Trusts are struggling to develop mental health services despite significant investment. Since the National Service Framework in mental health came out in 1999, every Primary Care Trust has been busy setting up secondary care teams in assertive outreach, crisis resolution and home treatment, as well as looking at ways of treating the anxious and the depressed that are so prevalent in GP’s surgeries. A single visit to Hartlepool MIND has convinced me that community mental health services, for all grades of mental illness can be brought together under one roof.. What Hartlepool MIND are achieving is truly revolutionary and enlightening.
Last year Hartlepool MIND saw 800 clients, nearly 1% of a 90000 population. Most of these walked in off the street, though more and more are being referred to them by the health services including the Psychiatric Consultants and local GP’s. Some are referred whilst on the psychiatric ward. They are now even getting clients sent direct from the courts, though the first they knew of this was when the clients arrived on their doorstep..
Most of us who work in the Health Service are aware of the “law of chaos”, whereby any useful effective service soon gets snowed under and waiting lists quickly form. How does Hartlepool MIND prevent this? Their answer is that they help the patients rehabilitate themselves, so that they become active members of the community, often with employment, by teaching them to discover the mental resources that they never knew they had, but are in us all. The client then has better things to do with their time than attend mental health services and there is always an open door should they need to return, which is unusual. They have thus done away with drop-in-centres and the like, which they see as fostering dependence. The goal is to give the client as intensive care as they need, but to keep them in the service for only a short period.
The average stay in treatment is around four months, with only the very rare exceptions being more than eight months. The centre works nine to five, five days a week, but clients can attend daily at first, if it is felt appropriate. Money for running the centre in this manner, at first came from the “New Deals for Communities” grant, a regeneration package for the most deprived areas in the country. Most of the funding still comes from voluntary sector grants, though we did meet the PCT commissioner, whilst we were there, as the Primary Care Trust is also a contributor.
The Centre works based on a “Human Givens” Approach. Human Givens uses the theory that in us, Human Beings, have the resources and indeed are genetically programmed to seek our needs as human beings, but if these needs are not met, then we don’t thrive mentally or indeed physically. When our needs are not met this may show in a number of ways including depression, anxiety, psychosis or delinquency. These needs can be summarised in the following list:-
New clients are assessed by one of the centre managers to identify their unmet needs and an action plan is formulated. The action plan looks at who needs to be involved and what activities need to be carried out, with target dates. A positive approach is then taken to therapy, the client is made to feel it is going to work. Then, working on the Human Givens basis that we all have the resources to gain our human needs, though some of us may never have learned how to access them due to their circumstances, or they may not be using them appropriately, clients are taught life skills. Social needs are also fully investigated and clients may be taken to see a housing officer, a debt counsellor or a job broker.
A client may get the benefit of attending one or more of the 27 courses which they run according to demand and are listed.
The approach is totally individual and is fitted to the patient’s requirements. Ian Caldwell, director of the centre, says that they are totally honest with their clients. “If someone is not a very nice person, then we have to tell them” he says, “there’s no use beating about the bush. If we don’t point it out to them, but also saying that we can show them how they could change, so that people might start liking them, how will they ever get some friends and how are they ever going to recover? And of the centre does have some ground rules, they will not see patients who are drunk or aggressive, but will ask them to come back another day. Despite this they had only one patient last year who they had to exclude totally.
I’m sure one of the major keys to their success, is that they don’t give up on anyone, and the clients must become aware of this. They then ensure that every client is rehabilitated into an active life before they are discharged. Therapists are only paid for the work they do and lose out if the client does not turn up, so they are further incentivised, to ensure that the patient is motivated to continue their therapy. They are all totally pragmatic in their approach and have the philosophy that the patient will recover, but that to do so the patient must make changes and this will take effort on the patient’s part. They told us of a mother who had not been able to get out of her bed for 2 years and her house for even longer. The client’s mother was carer for both the client and her children. The client had been receiving home visits from a Cognitive Behavioural Therapist for 5 years. So how did they get her out of bed to be able to start therapy? They got her a noisy alarm clock, which was set and placed on the other side of the clients bedroom door. The children and their grandmother were instructed not to touch it. A few months later the client was functioning well as a mother again.
The “Human Givens” approach should not be under-estimated. This practical approach has been devised by two psychologists, Joe Griffin and Ivan Tyrell, and written up in their book Human Givens. They accuse modern psychology of being in the stone age and much of psychiatry to be flawed, because of its dependence on the medical model. To have over four hundred schools of psychological therapies seems nonsense to them. “Why”, they ask, “don’t we just get the stuff that is effective and works form the individual schools of psychotherapy together and treat psychology as the evolving science that it should be?” They also say that being so hung up on evidence based practise, holds us back. What we should be using is practise based evidence. For instance, in Hartlepool we can see the effectiveness of their approach and hear anecdote after anecdote of patients regaining their lives, (practice based evidence), but without a random controlled trail, which would be practically impossible to do with individualised care, it will never become the so called gold standard of medical practice (evidence based practice).
As a GP with special interest in mental health I was particularly challenged by Tom (surname) one of their trainers, who suggested that depression and anxiety had no place in general practice. Medicalising it, instead of treating the underlying causes, .means that we are creating dependency and avoiding the client’s needs. In other countries things are not the same, in Germany for instance, no-one would go to the doctors with non-physical problems. He also pointed out that most people with mental health problems do not go to the doctors anyway. Maybe they know that the doctor can do little to change their social circumstances. Iain Caldwell also pointed out that if psychosis is left alone then clients will recover in about two thirds of cases, whereas if treated medically, there is a eighteen per cent recovery.
And they just love difficult and challenging patients. If someone is hearing voices, then the attitude is that they will make the patient’s life so busy that the voices will no longer be important and they tell them so. They will give the Human Givens explanation of hearing voices, that it is Dreaming in the Waking State. Iain has also found that many of the clients who the medics would label as psychotic, started off by daydreaming, to escape from the real world which may not have been pleasant for them and eventually the fantasy world may become so different to the real one, that they are tipped into madness.
The therapist see four patients a day, four days a week and five on the other day, so they have plenty of time to plan therapy and to discuss their cases with the rest of the team. All the team, including the administrative staff, have had some Human Givens training, which gives the team common strategies for treating depression, anxiety, psychosis, phobias and Post Traumatic Stress disorder.
Depression, so the Human Givens institute believes, is related to excess dreaming. Joe Griffin has conducted research suggesting that we dream to empty our brains of unresolved emotions from the previous day. If, for instance, we have a row with our someone but then sort things out, then this will not produce a dream, but if we go to bed with feelings festering, then it will produce a dream. We dream in metaphor, which is why dreams are strange. Depressed people are generally very anxious and because they ruminate over doom and gloom, their high number of unresolved emotions produce excess dreaming and REM sleep, so that the normal seventy to thirty percent ratio of restorative to REM sleep can be reversed and the lack of restorative sleep together with vivid dreams that wake the patient up, causes the tiredness and lack of energy associated with depression. Treatment involves showing the patient progressive relaxation to calm them down When they are more rational, they cam then explore how they can start to do things differently. Exercise is encouraged, we know that this raises serotonin levels and is at least as effective as antidepressants.
Possibly the most effective single Human Givens treatment is the “Rewind technique”, a single session treatment for Post Traumatic Stress Disorder and Phobias (PTSD). Despite the Human Givens team offering to cure the two lay advisers to the recent report on Post Traumatic Stress Disorder for the National Institute of Clinical Excellence (NICE), this technique was not investigated by NICE. It is unbelievably effective, which is in some ways its downfall, as we seem to have been conditioned by the psychological communities that therapy needs to take a long time. Phobias and PTSD do not however take a long time to be conditioned in our brains. The rewind technique uses guided imagery in a relaxation state, in a way that forces previous sub-conscious material to be processed by the left temporal lobe, which can then look at the material in an objective manner. I have known patients literally get bored repeatedly reviewing the material that an hour ago they could not face without severe negative emotions.
The success of Hartlepool MIND is certainly a major challenge to the medical model. Whilst they use some alternative therapies, particularly those that induce relaxation such as aromatherapy and hypnosis, they are sceptical of many of these too, as they are aware that it can be very easy to suck vulnerable people into therapies which may not be of benefit, yet be costly to the patient.
I visited Hartlepool with a team that included the Chief Executive of our Mental Health Trust, the team leader of our Community Mental Health Team and the Chairperson of our Services User Group. Already we are planning how to set up a similar service, so that our patients can at least have a choice of therapeutic models. Like all traditional services, our patients are currently having to be first labelled with a mental illness and then either given medicine to contain or control their illness, or referred to counselling or psychology. When one of these treatments fails to work, we usually try another, which may make the patient feel that it is they who are failing, when of course it is us, and they get stuck in the system, doing rounds of the various services. Everyone was impressed by their holistic system and its effectiveness.
Recently Richard Layard presented a paper to the Prime Ministers Office, showing that mental illness costs us two per cent of our Gross Domestic Product . His solutions include doubling the numbers of psychiatrists and psychologists in training and for every future GP to have six months in psychiatry. Having visited Hartlepool I would seriously question this way forward. Their service is effectively taking patients out of the psychiatric service, we heard for instance, of patients who had been supported in the psychiatric system for fifteen years, but rehabilitated in a few months by Hartlepool MIND. They are helping people off benefits and into work, reducing family breakdowns and relieving carers of their duties.
With only five full time workers, a manager, a support network co-ordinator, a complementary therapy co-ordinator, a senior recovery support worker and an administrator, as well as some sessional workers, they should make the impact on the economy that Prof Layard seeks. It would seem to be a much more cost effective approach. The cost of running the centre for a year, is about half a million pounds. If MIND’s success continues, then in the next five years about five per cent of the most needy population in Hartlepool will have found that they have the capacity to live a better and more rewarding life. This must produce a major positive impact on their health of the population and the GDP of Hartlepool.
Ian Walton, Primhe’s trustee
This article has been published in Journal of Holistic Health
Cannabis – a Class C drug
We are all aware of the dangers of alcohol abuse. We are all aware of the dangers of drink driving. Most of us will probably know personally at least one person, friend or family who is a current or ex-alcoholic.
However are we really aware of the dangers associated with the use of Cannabis? Are the right messages coming across to our young people via the press, the police and the medical and allied health professionals? I think not. When this drug was reclassified it led to inevitable misunderstanding; my teenagers were convinced that it had been legalized – I do not think this was an unusual misinterpretation judging by their subsequent surprise and the reactions expressed within their social circles. The fact is that most young people will at the very least try Cannabis – it is estimated that 35% of 11-15 year olds will have imbibed. It is a cheap and readily available recreational drug.¹
A Cannabis induced psychosis is not an everyday occurrence in the A&E department but once seen, it is hard to forget. Take Chris for instance. He was a young man of 21 and a regular Cannabis user.
He first visited our department in the early hours of the morning saying that he felt frightened and he felt as if people were watching him. However he was insightful and was easily reassured by the SHO that this was a relatively common phenomenon which could be directly attributed to his heavy use of Cannabis the night before.
He returned to the A&E department a few hours later. When I saw him, he was extremely fearful requesting our protection. This time, he required far more than simple reassurance. A member of the nursing staff was assigned the task of sitting with him, while we covered over the window in the relative’s room- his paranoia was such that he was convinced that assailants could see in and were spying on him. By now he could not recognize that his state of mind was anything to do with his Cannabis use. This was real – the delusion was set.
The security staff played a vital role – we had to prevent him from leaving the department and fortunately were able to persuade Chris that they were there to protect him. This calmed him down to a degree since by this time he had become extremely agitated and we needed to obtain an urgent Mental Health Act assessment. Chris had been co-operative initially and agreed to take oral medication in an attempt to relieve his symptoms, but the situation was escalating.
His sister arrived and confirmed to us that Chris had never before suffered any mental health problems. She also helped to calm him being a familiar face and she enabled us to win over his trust once again.
Unfortunately this did not last long. The little insight which he had retained left him and his demeanor changed. We could no longer persuade him that he was unwell and that we were there to help. A section was applied by the interviewing psychiatrist but while we waited for an ambulance to transfer him to the local psychiatric hospital, Chris knocked a picture down from the wall. He used the broken glass to attack one of the nurses. To him it was self defense, to us he posed a very real danger. The police were called to take charge of the situation and it took four of them to gain control of the by now crazed and violent patient.
A few days later, he told staff how he believed that the police were holding him down in order to chop off his arms and legs. He could not believe what had happened and was saddened and ashamed at his behaviour. One week later he was discharged from hospital under strict instruction never to touch Cannabis again.
Declassification of Cannabis may have made life easier for the police and the Crown Prosecution Service, but re-education is urgently needed. This drug has known dangers associated with its use, particularly to mental health² and there may be more problems that have not yet been proven³. Chris was fortunate that the nurse was not seriously injured as a result of the attack – he could be facing charges of assault and have a criminal record to add to his problems. He had no ideas of the dangers Cannabis imposed. Few people do.
Cathy Wield
14/11/20005
1. CLINICAL REVIEW:
Russell Viner and Robert Booy Epidemiology of health and illness BMJ, Feb 2005; 330: 411 - 414 ; doi:10.1136/bmj.330.7488.411
2.Cécile Henquet, Lydia Krabbendam, Janneke Spauwen, Charles Kaplan, Roselind Lieb, Hans-Ulrich Wittchen, and Jim van Os
Prospective cohort study of cannabis use, predisposition for psychosis, and psychotic symptoms in young people BMJ, Jan 2005; 330: 11 ; doi:10.1136/bmj.38267.664086.63;
3.John A Henry, William L G Oldfield, and Onn Min Kon
Comparing cannabis with tobacco BMJ, May 2003; 326: 942 - 943 ; doi:10.1136
A Mindset for Europe
GAMIAN-Europe Annual Convention, Bucharest, Romania
29 September – 2 October 2005
Some 80 delegates from 38 countries gathered under the auspices of GAMIAN-Europe to hear about the latest mental health reforms, policies and their implementation in different countries across Europe.
Dr. Laurentiu Mihai, Director of European Integration and International Relations, Dr Matt Muijen from the WHO and Jurgen Scheftlein from the European Commission set the scene. They covered mental health in Europe, the role of NGOs and notably the European Commission’s Green Paper on mental health.
Other thematic presentations included:- England - initiative on stigma by Ingrid Steele, Director of Underpinning Strategies from National Institute for Mental Health, England; Mental Health reform in EU countries by Rodney Elgie, former president of GAMIAN Europe.
One significant event was the development and adoption of the GAMIAN-Europe standards for the management of patients with a severe mental illness in the community. The standards were presented by Albert Persaud, Chairperson of the GAMIAN Scientific Committee for the standards and a Board Director of GAMIAN-Europe. An extensive discussions took place at the convention, following which the Standards were formally adopted by all of the GAMIAN-Europe members during the General Assembly.
Another highlight was the presentation of a GAMIAN-Europe Award to the Prime Minister of Malta, Dr. Lawrence Gonzi, and his wife, Mrs.Catherine Gonzi, in recognition of their personal and political contribution in the area of mental health, both in Malta and across Europe.
The feedback from the Convention was extremely positive. For a long time, mental health has not been a priority in Europe nor received the heightened profile it deserves. Finally, there is recognition of the fact that mental illness is a real and serious problem affecting a significant proportion of the population that, in turn, has a major detrimental impact on the economic performance of Europe. Politicians, NGOs and healthcare professionals alike are at last making substantive efforts to take forward reforms and implement changes for the benefit of users of mental health services and their families on a pan-European basis.
Shun Au, Chairman of Chinese Mental Health Association, UK
Copies of the standard can be obtained from Albert Persaud. [email protected]
Ezine news:
Issue 33 of NIMHE West Midland’s E Bulletin is now available from their website and can be accessed using the following link:
Come to Primhe’s First Annual Conference!!!
It is with great pleasure that we invite you to join us at Primhe’s first national primary
care mental health conference. As you will see from the day’s agenda we have a
line-up of eminent speakers, including Professor Louis Appleby who will be discussing
policy for mental health care.
The conference is for all health professionals managing patients with mental health
problems in the primary care setting. It has been documented that at least 1 in 4
consultations in primary care are initiated because of a mental health problem, and
as many as 1 in 3 people with severe mental illness are not known to secondary
care services; they have contact solely with primary care. Some 75% of people with
a mental health problem are not even formally engaged with any service.
To see more details and to book a place, please view our website:
Primhe, November 2005
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