Schizophrenia

On advertising psychiatric drugs, or how van Gogh could have kept both his ears

It’s no secret that psychiatry (and psychology, come to that) has a blemished history and that our forbears have been responsible for many crimes against humanity. It’s difficult, in an age of medical ethics and patient involvement, to consider what it must have been like to have been subject to treatments such as trepanning and lobotomy, and I know that many modern-day professionals wrestle with the treatments with we continue to prescribe and provide, even though we tend not to force people into submission. One significant exception is Sectioning, however, which effectively removes an individual’s rights and, depending on the type of Section (named so because the conditions of detention refer to specific sections of the Mental Health Act), can compel people to be treated, whether they consent or not. This perhaps merits a blog post of its own, but, regardless, it will be apparent that the concept of treatment by compulsion is fraught with dilemmas. However, as a general rule, we try to give people the right help and to only do what they are happy for us to do.

 

As a psychologist, I do not prescribe medication and I struggle with the notion that psychological distress can be cured by a pill. Some medications may reduce ‘symptoms’, such as we think about them, but I’ve never taken the view that all ‘mental ill-health’ is the result of chemical imbalances. Sure, there is may be an association between dopamine levels and what we call ‘psychosis’, or between serotonin and that which we term ‘depression’ but my clinical experience leads me to believe that difficult experiences are often implicated in suffering. Early adversity and trauma tend to have long-lasting effects; many of them profoundly negative. Big Pharma, of course, peddles the theory of chemical imbalance and their tactics are, whilst hardly subtle, rather dubious. Drug company-sponsored lunches at hospitals and medical schools are common, and lots of clinicians have offices containing freebies, though usually they’re nothing to get excited about. In addition, drug companies market their products like any other manufacturer would, although anti-psychotic medication is, of course, rather different to a top from H&M. This is a fairly typical ad for an antidepressant drug, although it’s a little old:

 

The premise being ‘take this and you’ll enjoy life. The insinuation, therefore, being ‘don’t take this and you won’t enjoy life’. In the UK such marketing is permitted only in specialist publications such as medical journals, although there is research which suggests that the more a drug is marketed the more likely it is to be prescribed. In the US, on the other hand, marketing regulations are rather more lax and it wouldn’t be unusual for the public to come across such things on public transport, in magazines and on television. Unsurprisingly, patients often go to their doctors asking for particular medications. It’s a bit of a minefield, frankly.

 

So far so standard. Over the weekend, though, I came across a couple of adverts on Twitter which made me deeply uncomfortable. They were tweeted by @psychiatrypics and, frankly, they didn’t go down too well with the social media collective. Exhibit A:

 

 

Ludicrous to describe bipolar disorder, characterised by extreme highs and lows in mood, as akin to ‘war’ and offensive to suggest that ‘peace’ can only come in the form of a pill. Stigmatising as well, to suggest that everyone who has such highs and lows would necessarily want and need medication; that one could not live normally and well, despite such fluctuations. Hugely powerful, nevertheless. Exhibit B, then:

 

 

A more abhorrent load of tosh I could not imagine. There are so many things wrong with this I barely know where to begin. Let’s start with the facts. van Gogh died in 1890. The term ‘schizophrenia’ was coined in 1911 by Eugene Bleuler, although its linguistic  predecessor, dementia praecox, was in use in the early 1890s.  Regardless, van Gogh never received a diagnosis of any kind and it is crass and unhelpful to diagnose him posthumously. He was obviously a troubled man, but a troubled man who created some of the greatest art the world has ever seen. To assume that a tablet would have stopped him being troubled (look at his lovely smile!) is nothing more than marketing hocus pocus; completely impossible to prove one way or the other. And then there is the small matter of the fact that, had it not been for the fact he was a troubled man, we might never have had a self-portrait to begin with. We might never have had Night Stars or Cafe Terrace, two of my favourite paintings. Yes, van Gogh was touched by things which were obviously painful; he was also touched by genius. Perhaps those attributes could only exist in tandem. Perhaps Zeldox would have calmed the things which tormented him but we will never know for sure. To suggest that it would have prevented him cutting his ear off trivialises his suffering, and that of all those who are similarly troubled. It  is offensive, and, because of the implicit promise it makes to people who may be in deep distress, and those who care for them, it is manifestly dangerous.

On advertising for Jinn in mental health services

Despite having worked in mental health for some years, I know very few people outside work who earn their living in quite the same way I do. Since going back into academia (a fancy way of saying ‘trying to qualify’) three or four years ago that has changed slightly, but it’s only since I began to use Twitter for work purposes that I’ve started to build networks in psychology outside of the region in which I live and work. On the whole, my interactions are with people at a roughly similar stage of their careers, but the great thing about Twitter is that there are no restrictions on who you talk to or what you say.

Over the weekend, I came across this, and it provoked a little debate:

Jinn

For the unmitigated, a Jinn is essentially a spirit. They are a common concept amongst people from Africa, Asia and the Middle East, but most cultures have equivalents. Jinn can possess you and they are generally seen as bad. The only way to rid yourself of the spirit is to go to some kind of religious or spiritual healer and I believe that such folk do a creditable trade, even in the secular metropolis that is London. My colleagues on Twitter were rather uncomfortable with it. I confess I took a rather different view. I should state that I have not verified its authenticity but that I have no reason to doubt it. My colleagues thought that the flyer was deceptive, because it suggested that if you made contact you would be provided with a spiritual approach when, in fact, the service would give you Western medicine. I disagree in several ways. I see the flyer and its careful choice of language more as a ‘hook’ with which you can encourage people to approach services when they would otherwise be reluctant to do so. Services are generally set up so that you have to see your GP and request a referral. This does not work well for all groups and we are well aware that there are an awful lot of people, often from groups which are already marginalised, who do not access services simply because of the rigmarole required to do so. Being of Asian origin myself, I have a fairly good understanding of the fear that surrounds statutory services and the avoidance that can result.

But there remains the issue of the help that will be offered. We do not, routinely, offer spirit healing in the NHS. There is no reason that MH services cannot be culturally sensitive, however. I know lots of clinicians who are sympathetic to non-medical approaches to what is commonly-labelled ‘mental illness’. The region that this flyer refers to, South & West Yorkshire, includes areas such as Bradford, well-known for its South Asian population. I would imagine that clinicians would be trained to work with people from a range of backgrounds and with a range of beliefs and that they could help those in distress without dismissing their beliefs. Additionally, this flyer relates to an Early Intervention Team. Such teams typically work with young people who have recently noticed unusual experiences. They try to work with the young person and their family for a couple of years (family work is a precious commodity and one that is rarely available in adult services), helping the person to either rid themselves of the things which are distressing them, or, if not, aiding them to live full lives despite them. They try to help the person to get better and remain well .EITs try to get people put of mental health services, not stay in them, but they can’t do that unless the person comes to them in the first place.

Is it still deceptive? I don’t think so. On the contrary, I actually think that attributing unusual beliefs and perceptions to Jinn could be quite useful clinically. One approach that psychologists use is called narrative therapy. This simply allows the person to tell their narrative; their story. It encourages them to name the thing that is causing them difficulty and externalise it. This enables a person who is experiencing low mood to call their experience ‘depression’, for example, and see it as separate from themselves. Thus, they are not staying in bed all day because they are lazy or feeble; it is ‘depression’ which makes it hard for them to do the things they want to. Again, this is a subtle difference: narrative work allows the person to recognise that they have strengths and the motivation to change but that there is something powerful which they find it difficult to overcome. In narrative therapy, the person is not the problem, the problem is the problem and we help the person become stronger than the problem by building on their skills and increasing their confidence in their own ability. If someone already attributes their unusual experiences to a Jinn, they have externalised the problem of their own accord and an approach such as narrative therapy could well be appropriate. It is also an approach based on the person’s view of the problem and has the potential to be very culturally-sensitive. It can be combined with family work and there is good evidence of its effectiveness when applied in this way.

So, all in all, I don’t share my colleagues’ scepticism of the flyer. It may be a stab in the dark, certainly, but, really, what does it cost to print a few flyers and stick them up? It’s hardly a drain on resources. But it indicates that, finally, we are trying to adapt our ways to encourage people to seek help. If it works, terrific. If not, we’ll have to think again. Crucially, though, we’re finally thinking about it and trying to make ourselves more accessible and less frightening. All statutory services need to do that and for too long, we’ve failed to do so adequately. This may not be the start of a wholesale revolution, but it’s a start, and as far as I’m concerned, it could well be the beginning of something rather interesting.

In which I am furious at the Sun for promoting stigma against those with mental health problems and I shout at the Government

I have been meaning to blog for ages. I recently went to a very interesting conference in Copenhagen and spent three days discussing personality disorder, which is one of my primary clinical and research interests. Unfortunately, I’ve been incredibly busy and it’s had to fall to the bottom half of the to-do list. I thought I would make an extra effort today, however, since it is World Mental Health Day.

This seems an apt time to consider some of the issues which persist in mental health. There is the very concept of ‘mental illness’ of course, the battles between the pro- and anti-diagnosis camps, the bickering over effective treatments; all stuff that often goes on in the ivory towers that some of us inhabit. I have always believed that there are two main issues which really affect people with mental health problems and their families: stigma and funding.

i think we’re often quite proud of the way we have come to acknowledge mental health issues in this country, and, to some degree, rightly so. But often success is only lauded because it comes in a sea of perceived failure. So when MPs talk about their mental health problems in Parliament I am pleased, but the very fact that it is such a big deal suggests we still have a long way to go before we truly have an open discussion about the prevalence and impact of mental health problems.

On Monday, the Sun ran this front page:

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‘1200 killed by mental patients’. Now the term ‘mental’ went out of use many years ago amongst those us who have some compassion and humanity. News International publications are not, if you will indulge me, known for either their compassion or their humanity. Despite the story admitting that most people who have committed serious violence in the context of a mental illness, the headline will do nothing to eradicate the image of the knife-wielding patient (an image that persists, as we recently saw of the Hallowe’en costumes being sold by Asda and Tesco).

So what are the real figures, the contextual ones? Well, here are a few:

– 1.2 million people in the UK use adult mental health services

– 95% of all murders are committed by people who have NO mental health problem (remember Harold Shipman, who killed hundreds of people?)

– Half of all violent crimes are committed by people under the influence of alcohol

– Around a fifth are committed by those who are under the influence of drugs

– People with severe mental health problems are 10x as likely to be the victims of violence as they are to be the perpetrators

– They are also more likely to harm themselves than anyone else: 90% of people who kill themselves have mental health problems

Given that 15 million people in the UK will have a mental health problem at some point in their lives, and that substances are implicated in the vast majority of all violent crime, this witch-hunt against those who are often very unwell is appalling. But let’s take a look at some more stats:

– Mental health services in the UK have had funding cut by £150m since the Coalition government came to power

– 2000 psychiatric beds have been cut in the last two years. No one, not even the Sun, got angry about that. But I know psychiatrists, good psychiatrists, who openly admit that they are discharging people from hospital when they are still unwell just because of pressure on beds. I have worked on wards where there are three people to a bed and you just hope to God that no one has a relapse whilst they’re on leave, because the chances of finding a bed anywhere in three boroughs is so slim.

– Mental health NHS trusts (which are distinct from physical health, as a general rule) have lost up to 20% of their staff since the cuts came into force. These cuts affect everything from secretarial support to the number of social workers and psychologists available to see those who need such intervention.

– Some of the areas most significantly cut: crisis resolution, early intervention, home treatment teams. In short, the very people who take care of those in crisis; the very people who can intervene if they see that risk is escalating. But they can’t, can they; not when they have caseloads of 60 or 80 people. As someone who works in community mental health services, I tell you this: it is impossible to look after that many people who present a moderate risk to themselves or others and to do it well. As the cuts take hold, services have increased their thresholds and increasingly, only take those deemed to be at high risk. 80 high-risk people cannot be managed by fewer than 2 professionals, and even then they will need intervention from other members of the team.

The fact is this: mental health services are buckling under the strain. Staff are overworked and under-resourced; many are simply burning out. It doesn’t take much intuition to realise that in a job which requires you to deal with people who often have complex needs, this is unsustainable. Newspapers could do a terrific job, if they could be bothered, of putting mental health on the agenda in a positive way. They could get angry about those people who are being denied services they need, not because we don’t want to provide them, but because we simply haven’t the resources to do so. They could make services better for the one in four of us who will have mental health problems – your brother, you best friend, your partner, your mum, your neighbour, your child. They could, if they wanted to. But, like so many others, they simply add fuel to this ghastly fire which means that those with mental illness are further stigmatised, further dehumanised and increasingly seen as the ‘other’.

Schizophrenia: Does psychological therapy make symptoms worse?

In the field of mental health, schizophrenia is one of the most famous labels out there. It’s often misunderstood, but it’s also relatively common in the general population. Antipsychotics are often criticised for the effects they have on the physical health and mortality of those who take them and emotions on both sides of the argument run rather high.

Psychologists don’t prescribe medication and we often like to think that the treatments we dispense have far fewer side effects. That’s not necessarily the case though – if you’re working with someone who’s traumatised, it’s perfectly possible to retraumatise them through therapy (although we try our absolute best to avoid doing so. But we’re not immune and it would be pompous to pretend that we do nothing but nothing but good.

This paper appearedn recently in The Journal of Nervous and Mental Disease. It was designed to investigate the effect of psychological therapy on symptoms associated with schizophrenia. Schizophrenia symptoms are typically divided into ‘positive’ and ‘negative’ (there is a third category but it simply refers to cognitive functioning). The former are the things we tend to associate with the label: delusions, hallucinations and unusual or disordered thinking. The latter are less flamboyant: they tend to be a certain ‘flatness’ in mood, lack of spontaneous speech and limited pleasure from daily activities. Often, the negative symptoms look very much like depression and they can be the first things you notice.

This study looked the effect of cognitive-behavioural therapy on negative symptoms. It’s an interesting study, because CBT is the recommended intervention fro depression and is one of the recommended interventions for schizophrenia. At the same time, there has been little investigation into the adverse effects of CBT in this population. Psychologists may not be medical doctors, but the old adage of ‘first do no harm’ remains pertinent. CBT was compared to cognitive remediation therapy. For those unfamiliar with either, CBT looks at the patterns between thoughts, feelings and behaviours. It considers how you interpret events and how these interpretations affect the way you respond. CRT is designed to diminish the cognitive decline associated with schizophrenia by providing training in domains such as attention, memory and learning. 198 patients (only 1/3 of those who were eligible) consented to participate and were randomly allocated to receive either CBT or CRT. The effect of random allocation is that you even the sample out – if you knowingly allocate you might skew the groups in terms of age, gender or severity of symptoms. Because we’re all vulnerable to biases, it’s preferable to randomise and to have the randomisation done by machine so that the research team doesn’t know which participants are getting which treatment (this is referred to as ‘blinding’ and the researchers will get the data collected rather than carrying out the treatments as this would obviously mean they knew who was getting what).

So. The results. No one died through suicide during the course of the study, which is good, especially as there is a higher suicide rate associated with schizophrenia. One made an attempt, however, and one had a ‘suicidal crisis’. Those allocated to CBT had slightly elevated scores on a measure of psychotic symptoms compared to those given CRT following treatment, but it was a very light increase; essentially, the risk only increases from a baseline of 1 to 1.1. However, those allocated to CBT were significantly more likely to report elevated depressive (negative) symptoms than their CRT colleagues.

So what do we make of it? Negative symptoms may protect against suicide and some research suggests this is the case. But equally, we don’t want to exacerbate negative symptomatology. In general, CBT had no more ‘side effects’ than CRT: some of those given CBT reported more symptoms at the end of treatment, but their symptoms were no more severe than those of the participants with CRT. Unfortunately, there was no ‘control’ group; a group of people who had similar demographic characteristics to the rest of the sample but who were given no treatment. So although we can state that there is an association between CBT and this increase in symptoms, we can’t attribute one to the other.What this means clinically is that we still don’t know how bad CBT is for your health. What we do know is that it doesn’t prevent those receiving it from going through a crisis (that probably won’t come as a surprise to many) but that, for some people, it may be linked to more negative symptomatology. What clinicians have to do, therefore, is closely monitor the people they see and ensure that crisis and risk plans are both kept updated and implemented as necessary, as well as be prepared to offer more intensive interventions when necessary. Crucially, we need to remember that there are potential risks when engaging in psychological work, just as there are when taking medication.