It’s a bad time to be an SSRI antidepressant.

Strike one:

In January a paper in the NEJM found that the evidence base for the use of these drugs was incomplete, with a large publication bias towards positive results.  When negative results had been published, it was in such a way as to give these results a positive skew.  This publication bias in itself does not mean that a drug is ineffective, but hardly instills confidence.  There have been rumblings about this sort of thing going on for a long time….

Strike two:

A paper published today in the Public Library of Science Medicine Journal entitled Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration collected (via the freedom of information act) what it believes to be all the trial data available before their licence was granted (published and unpublished, positive and negative) on Fluoxetine, Paroxetine, Venlafaxine and Nefazodone, and found via meta-analysis their effects for mild and moderate depression to have no clinical improvement over placebo. 

This raises a number of concerns for psychiatrists and the population at large, several million of whom were taking these medications at the last count.

• Already not especially convincing, where does this leave the monoamine theory of depression?
• Have pharmaceutical companies deliberately mislead the doctors and patients as to the effectiveness of their product, thereby costing health providers billions of pounds and subjecting millions to ineffective medication and unnecessary side effects?  If so, shouldn’t we take them to court or something?
• What should we tell our patients?  There are plenty of people out there on the above medications for mild/moderate symptoms of depression.  See end of piece for a quick summary of how depression is categorized.  Doctors who prescribe antidepressants in these circumstances will be aware that it’s not the best treatment, but wouldn’t wish to give somethings that really doesn’t work at all.  If these antidepressants were working because of a placebo effect then, with all this publicity, they won’t be working now.
• What are we going to do instead?  NICE already recommends that counselling/therapy is the most appropriate intervention in mild/moderate depression.  However waiting lists are very long and many people crave a quick fix to their problems, which in any case are more ingrained than that which is amenable to a course of cognitive behavioural therapy.

Classification of depression

Depression as an illness is somethings that’s talked about a lot these days.  The first thing to say is that the difference between ‘depression’ as an illness and simply feeling ‘gloomy’ is not qualitiative but quantitative.  There is also no test for depression, but rather a line in the sand that when (methaphroically) overstepped people say that you are depressed.  The diagnosis of depression is made on clinical grounds rather than via a test.  This is not unusual in medicine, epilepsy for instance is diagnosed in the same way.

When we as psychiatrists, (but also as lay people, but in a less formalised way) say that someone is depressed, what me mean is that they are displaying a number of symptoms that suggest to us that their main problem is of low mood.  In order to make diagnoses more consistent and also to aid in professional communication psychiatrists use diagnositic guidelines for their diagnoses.  In America these guidelines are called the Diagnostic and Statistical Manual edition IV and in Europe we mostly use the International Classification of Diseases edition 10. 

(I’m almost there.)

Although mood and hence depression exists on a dimension, i.e. there is a continum from ‘not depressed’ to ‘very depressed indeed’ with no breaks in between, we choose to draw further lines in the sand and make categorical diagnoses - this is where the mild/moderate/severe depression diagnoses come from. 

So, when the above study talks of ‘mild depression’ it’s saying that a person meets the criteria for either the DSM-IV or ICD-10 criteria for depression.  The ICD-10 criteria are:

F32.0 Mild Depressive Episode: Diagnostic Guidelines
Depressed mood, loss of interest and enjoyment, and increased fatiguability are usually regarded as the most typical symptoms of depression, and at least two of these, plus at least two of the other symptoms described above should usually be present for a definite diagnosis. None of the symptoms should be present to an intense degree. Minimum duration of the whole episode is about 2 weeks. An individual with a mild depressive episode is usually distressed by the symptoms and has some difficulty in continuing with ordinary work and social activities, but will probably not cease to function completely.

If you’re interested in classification of depression then try this site

Roundup

Bad Science on SSRIs and criticism of media response to PLOS paper

Guardian articles on PloS paper: Ann Robinson - If the drugs don’t work; Allegra Stratton - A bitter pill; Sarah Boseley Prozac, used by 40m people does not work, say scientists; Mark Lawson Something for Nothing

I was interested to read an article in The Independent recently where psychologist Oliver James wrote that of comic peformers ‘most but not all - are either depressive or personality disordered’. 

James is a psychologist of some experience or, failing that, exposure.  Clearly it takes a particular sort of person to wish to earn their living by entertaining other people – and to subject themselves to the scrutiny this entails – but to make a blanket diagnosis of this nature cannot be right or fair.  Psychiatrists are often almost as guilty, it is a term often used in my by my colleagues to refer to patients or professionals we find difficult or do not like. 

Here’s an introduction to this difficult area.

Definitions

ICD-10 defines personality disorder as follows:

‘A severe disturbance in the character logical condition and behavioural tendencies of the individual, usually involving several areas of the personality, and nearly always associated with considerable personal and social disruption’

And DSM-IV:

‘an enduring pattern of inner experience and behaviour that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment’

There are nine categories of ICD-10 personality disorder and ten of DSM-IV.  DSM-IV divides its personality disorder classifications into three ‘clusters’.

ICD-10 
(F60.) Specific personality disorders
(F60.0) Paranoid personality disorder
(F60.1) Schizoid personality disorder
(F60.2) Dissocial personality disorder
 (F60.3) Emotionally unstable personality disorder
 (F60.4) Histrionic personality disorder
(F60.5) Anankastic personality disorder
Obsessive-compulsive personality disorder
(F60.6) Anxious (avoidant) personality disorder
(F60.7) Dependent personality disorder
(F60.8) Other specific personality disorders 

DSM-IV
Cluster A (odd or eccentric disorders)
Paranoid personality disorder
Schizoid personality disorder
Schizotypal personality disorder

Cluster B (dramatic, emotional, or erratic disorders)
Antisocial personality disorder
Borderline personality disorder
Histrionic personality disorder
Narcissistic personality disorder

Cluster C (anxious or fearful disorders)
Avoidant personality disorder
Dependent personality disorder
Obsessive-compulsive personality disorder

Problems with the diagnosis

The diagnosis and treatment of people with personality disorder is one of the trickiest areas of psychiatric practice.  Although established as a diagnosis and enshrined in both the ICD-10 and DSM IV, there is not a consensus concerning to what extent behaviours of a negative social and moral value should be considered psychiatric disorders and as a diagnosis personality disorder has a number of problems. 

• There is no definitive definition of ‘personality’ to be disordered, and it is at best a semi-technical term.  Most definitions are based on personality being an enduring combination of traits that serve to characterize an individual’s thoughts feelings and actions which are relatively consistent over a range of situations.  Some people would argue that personality is not a stable entity, but varies with time and situation. 
• Few personality types would fit into a single category listed above.  With its three clusters, DSM-IV goes some way to address this.
• There is an instability between raters when trying to diagnose personality disorder - this occurs even when rating scales are used.
• There is a large overlap of the behaviour of people with personality disorders with those of ‘normal’ people.  ICD-10 and DSM-IV offer categorical diagnoses, whereas in fact personalities exist on a spectrum i.e. they are dimensional.
• It is a hard area to conduct research into, partly due to the changing definitions of personality disorder over time and changing emphasis on personality traits not asked about on entry to the study.
• There is a great deal of stigma attached to the diagnosis
• This diagnosis allows significant deviance from societal norms, such as conscientious objection to a social regime, to be classified as a mental disorder. There is concern that this will be used to justify treatment of political dissidents as though they were psychologically disturbed.

Prevalence

Problems aside, people fitting the criteria for personality disorders are very prevalent in society, between 7 and 13 per cent in the general population and of 20 to 30 per cent in general medical practice.  It is also believed that 40% psychiatric outpatients and 50% inpatients would qualify for a personality disorder diagnosis.   Personality disorders rarely present to services in isolation and are associated with a high co-morbidity frequently being associated with alterations of eating behaviour, alcohol and substance abuse, other mental disorders, antisocial behaviour, and sexual promiscuity.  When someone meeting the criteria for personality disorder presents to health services an in-patient length of stay is likely to be longer and costs higher.

What causes Personality disorder?

As with a lot of mental illnesses, the answer to this question is not clear and genetic and social factors have been implicated.  There is evidence for the involvement of difficult upbringing with people having suffered physical or sexual abuse being over represented in personality disordered people.  Behaviour problems in childhood are also implicated, including severe aggression, disobedience, and repeated temper tantrums.

Treatment

It was felt for a long time that people with personality disorders were not treatable. There has been a perception that people with difficult personality traits can change themselves if they really wish and that it is therefore their fault if they do not. We therefore tend to blame people who have a personality disorder.  The tide has turned somewhat these days, and people are engaging those with a diagnosis of personality disorder in a number of ways.  These include trials of drug treatment, for example for comorbid depression, psychotherapy including dialectical behavioural therapy and therapeutic communities.

What research has been conducted suggests that over 10-30 years the outcome for people with personality disorders is generally favourable, with two-thirds improved at follow up with milder residual symptoms.  The severity of symptoms decreases with age and only one quarter would retain a diagnosis of boarderline personality disorder age 50.  Whilst employment is fairly common, marriage rates are half the average and odds of having children one quarter. 

I was seeing a patient the other day.  A fairly young bloke, he’d had a bit of stress at work, and subsequently what he’d called a nervous breakdown, and what I’d call an acute stress reaction.  He’d gone to this local A&E and had been seen by the psychiatrist on call and had spend a few days in hospital. 

The next thing he said struck me:

‘I didn’t think that I needed to come into hospital, but they told me that they thought that I did and if I didn’t come in voluntarily then they would think about making me come in’

This sort of thing happens all the time.  No one likes to bring a patient into hospital against their will (sectioning).  It doesn’t feel like a nice thing to do and psychiatrists like to think that they’re nice people.  A lot of patients would rather not be sectioned either, as this is seen as a very stigmatising thing by a lot of people you might meet.  So people come into the ward ‘informally’ i.e. not under section.

So, what’s the problem with that?  I’m not saying that all patients who are admitted to a psychiatric ward should be under section.  There is a place for informal admissions.  However if a patient is being informally admitted then a question should be asked: if this patient tries to leave will we let them?  If the answer to this is ‘no’ then a section should be considered. 

To my mind if an informal patient will be sectioned if they try to leave then they’re actually not there informally at all, but under a defacto section.  Worse still,  being under defacto section means that there is no legal protection; if you are on a section you are entitled by law to reviews of your status under the Mental Health Act, if you are an informal patient you receive no such protection. 

There have been similar, but not identical, concerns the context of patients with learning difficulties as a result of the Crown vs. HL. This case involved Bournewood Hospital in Surrey where the hospital’s authority to keep a person in hospital and give treatment, when they have neither actively consented nor refused, was challenged. 

Because of this case a situation where there is an issue of the rights of mental health inpatients who lack the capacity to make decisions for themselves and therefore cannot consent to their treatment has come to be known as the "Bournewood Gap".  Many such patients are given hospital treatment informally because they accept hospitalisation and treatment ‘compliantly’.  You can read more about the mental health charity Mind’s concerns about this here

Paul Gascoigne detained under the mental health act 

Here’s a famous definition of delusion:

‘A belief held with unusual conviction that is unamenable to logic whose erroneousness is manifestly obvious to others’ - Jaspers (1959)

This came to mind the other day when I was reading about Mohamed Al Fayed’s peformance in court at the inquest into the death of Princess Diana.  Al Fayed spent time outlining the extent of the international conspiracy which had been involved her death and that of his son, stating that conspirators included Tony Blair, Robin Cook, MI5, MI6, the CIA, the French intelligence service and the French ambulance service, who drove to the hospital deliberately slowly so that she might die. 

This doesn’t strike me as very likely and this view appears to be shared by the inquiry’s coroner, who asked Mr Al Fayed: ‘Do you think that there is any possibility, however remote that your beliefs about conspiracies may be wrong and that the deaths of Dodi and Diana were in truth no more than a tragic accident?’

Fayed replied: ‘No way.  I am 100% certain’. 

I think this would count as ‘unusual conviction’.  In ICD-10, there is a diagnosis of ‘delusional disorder‘, which is defined by the presence of persistent, non bizarre, delusions.  A non-bizarre delusion is plausible; this is in contrast to a bizarre delusion which is not.  For instance a person who thinks that they are under survelliance by the security force may be delusional, but this does happen to a small number of people. This is non-bizarre; a person would hold a bizarre delusion if this had no chance of being true, for instance if they felt that there was a goat living on their head.  Delusions also need to be outside what is considered to be culturally accepted for instance, in isolation, some religious practices might be considered odd, but they are widely accepted and so not delusional. 

If you were to meet a person with a delusional disorder you might not notice anything obviously odd about them.  This is in contrast to someone who is suffering from a psychotic delusional disorder, when their behaviour may appear manifestly odd.  They are able to continue functioning normally, although may make some strange decisions based on their world view. 

Finally, sometimes people are labelled as being delusional, when in fact they are not.  This is called the Martha Mitchell Effect this is when a psychiatrist mistakes a patients perception of real events as delusional and misdiagnoses accordingly.  It is named after the wife of the attorney general in the Nixon administration who alleged that White House staff were engaged in illegal activities.  Her claims were attributed to mental illness, but the outcome of the Watergate scandal vindicated her. 

I’m not talking here about visits to Brixton, but about how people are acquiring medications without proper safeguards and with potentially dangerous consequences.  Here are some of the methods employed

1. Go to your local doctor and simply ask nicely.
Last month the papers told us about a parliamentary inquiry which concludes that doctors are prescribing drugs such as analgesics, benzodiazepines and night sedation for much longer than they should and will sometimes renew repeat prescriptions without even seeing patients.

2. ‘Over the counter’
There is also concern about the availability of medicines in this way; some of them are actually quite potent and there are reports of people becoming ‘hooked’ on analgesics bought in this way.  Apparently Neurofen Plus and Solpadeine are the worst in this regard, both contain codeine which is an opiate. 

3. Buy them abroad, customs permitting. 
Recently I went to Syria and was interested to note that drugs available on a prescription-only basis in the UK could be purchased from the pharmacist without a doctor’s involvement.  Drugs available in this way included Clozapine, which can cause fatal side effects. 

4. The Internet
A simple websearch reveals a number of websites happy to supply a wide variety of medications without prescription and available to ’ship worldwide’.  This includes methylphenidate which is a restricted drug in the UK.

Please note that I do not advocate medicines acquisition by any other method than via a sensible discourse with your doctor. 

In order to become a psychiatrist in the UK you have to become a member of the Royal College of Psychiatrists (RCPsych).  Becoming a member of the RCPsych involves passing a number of membership exams (Membership of the RCPsych - MRCPsych).  To this end I sat MRCPsych papers 1 and 2 yesterday.

Yesterday was the first time papers 1 and 2 have ever been sat, replacing the old ‘part 1′, so no one knew exactly what to expect and at what level the expected knowledge would be set; the college had made available a syllabus, but this was rather brief. 

I didn’t think that paper 1 was too bad actually, as it covered a lot of what used to be contained in the written section of part 1 and I had used part 1 materials to revise.  The exam was most notable for the arctic temperature of the hall and the fire alarm going off eight minutes before the exam’s conclusion.  We all filled out into the cold and then filed back in again fifteen minutes later, several people having taken the opportunity to steal a sneaky peak at their revision notes in between times.

Paper 2 was a complete horror. 

In retrospect it was rather ambitious taking papers 1 and 2 on the same day.  But oh my!  I’ve sat a large number of exams over the past ten years (an occupational hazard when you’ve spent as many years as a student as I have) but I’ve never set eyes on such a stinker.  Despite having spent a month revising I’d somehow managed to totally miss anything that the college was seeing fit to ask questions upon. 

Most of my selections were based on whatever answer gave me the ‘right feeling’ (impressionable youth note: as a strategy, this is unlikely to succeed).  I wasn’t the only one finding it hard: as I looked around the room, there were a lot of furrowed brows and later, in conversation with my peers I discovered that they had had a similar experience.  There was a lot of statistics in the exam, but my colleague couldn’t do these despite having just been on a statistics course.  The genetics questions required in-depth knowledge of DNA mutations, and a number of questions may have required knowledge of papers of which I have never heard.

I’ve been looking at the SuperEgoCafe forum concerning this exam and candidates are annoyed.  There is talk of complaints.  I’m a a little more sanguine.  Now for next time I know what to prepare for. 

But before I finish, I would like to offer a small prize to whomever can tell me why knowing the specific tracer used in PET scans to highlight specific neurone receptors makes me a better psychiatrist.  I’m not seeing it myself. 

Where I work  there are several psychiatrists who wear corduroy suits.  Most of them are consultants, but one or two are junior colleagues of mine.  For the moment these pretenders are wearing a jacket only, which suggests the possibility that this is a disease that spreads from the top down.

Why? Oh why?

Not one to keep a gnawing question to myself, I was at an academic meeting when I decided to tackle one of our registrars on this subject.  He’s normally got a sense of humour and so I thought I was on safe ground. 

‘Do you own a corduroy suit?’ I ventured.

‘No’ he shot back.  ‘Why’

‘Just wondering, it’s just that Dr X. has one and so does Dr Y, and I don’t think that they’re very cool’

He looked displeased.  I realised that I had blundered; I didn’t dare talk to him again for the rest of the evening. 

But, why in these days when psychiatrists might wish to be seen as approachable and patient centred, do we seek to distance ourselves from the rest of the human race by our penchant for such disastrous apparel?

The word is that people consider the corduroy is worn by ‘relaxed’ people.  People who are approachable and trustworthy.  They are non threatening and put people at ease. 

So our taste for corduroy brings us closer to our patients.  Which sounds pretty good, and maybe I’ll get one after all. 

But it’s quite a lot for a suit to live up to.

I’ve written a previous post about celebrity lives and why they predispose people towards problems with their mental health.  In it I mention Britney Spears, who has been regularly described in the press as ‘troubled’ for some time now.  Things took an altogether more serious turn when on Thursday she was taken to a psychiatric hospital under a 72-hour detention.  This was the second time she has been taken to hospital in recent weeks, the first was after she refused to relinquish her children  who were to be taken into the care of her ex-husband.  On this occasion, in a pantomime show some 30 cars trailed her ambulance, twelve of them belonging to the police.  By way of contrast, here in London it can take a week to get one police car to attend a section.

Recent news is that Ms Spears period of involuntary stay in hospital has been extended to 14 days.  Not that I have given it a great deal of thought, but I’d always considered that Spears’ problems were likely to be personality based, that is to say as the result of learned behaviour, rather than because of a serious mental illness.  Even if I am right, it appears that her problems have become much more severe than just throwing her toys around when someone refuses to pick out the blue M&Ms. 

Her behaviour certainly has been bizarre, Associated press report that

Since her breakup with Federline, Spears has been seen at public events in short skirts and without underwear, has shaved her head bald, run over a photographer’s foot with her car, left the scene of a fender bender, flogged another car with an umbrella and abandoned a car in traffic when it had a flat tire. Recently, she was seen sitting on a sidewalk, holding her pet dog and crying

elsewhere it is said that before she was admitted she had not slept for five days.

It’s impossible from this vantage point to know what’s wrong with Spears.  The diagnosis of mental illness requires a period of assessment and often is only settled with response to treatment.  Emma Forrest writing in the Guardian seems to have decided that she’s got bipolar disorder and writes an article sympathetic to Spears detailing her own experiences.  Biopolar has become quite a fashionable diagnosis these days - I’ve been toying with the idea of doing a survey where I ask people whether they think it’s okay to be bipolar now that Stephen Fry says that he has it. 

Let me finish on a confession: I’m more than a bit disgusted with myself for writing a post about Britney Spears when the best medicine for her is for us all to leave her alone.  But that won’t happen. 

Britney’s perfume still selling well - Britney and the Sweet Smell of Distress Laura Barton Guardian 25 February 2008

Lisa Appignanesi’s Out of Control Guardian 10 March 2008 - an excellent article discussing her mental health problems in the context of how differently she would have been treated were she a man.