I wrote a post about this the other day before I’d actually seen it and I’ve watched it now.

For anyone who didn’t see it, ‘The Doctor Who Hears Voices‘ was a film shown during the past few days on Channel 4. It concerns a doctor called ‘Ruth’ – her identity has been changed, but we are told that the documentary is a mix of film of Dr May taken throughout the actual treatment, spliced with reenactments of Dr May’s sessions with ‘Ruth’ with Ruth being played by actress Ruth Wilson.  Ruth has no wish to take psychiatric medications and is currently off work with depression; she has a diagnosis of bipolar disorder.  She is sure that if she tells her work that she is ‘hearing voices’ then she will be sacked and sectioned.

I thought that I’d start this post by listing the things that I liked about the documentary.  So far I’ve only been able to think of one – that it’s good that mental health issues are being given airtime by a major television channel.

There were lots of things I found objectionable about the film. 

1. The subject’s suitability was questionable:

Was it really suitable to film a documentary over a seven month period of a vulnerable patient having a mental health crisis?  I cannot believe that this helped in her recovery, and I suspect that it simply served to raise Dr May’s profile.  Sure, she must have consented before broadcast, but by then the damage could have been done.

2. The film is misleading

Dr May is described as a doctor – whilst this is strictly true, he has a doctorate, most people would interpret this as meaning that he is a medical doctor.  He is not, he is a psychologist.

The film implies that people who have voices are always sectioned, this is not the case.  The film also gives the impression that were ‘Ruth’ to admit to be suffering auditory hallucinations, then she would be sacked and sectioned on the spot.  In fact her dismissal would have to be sanctioned under employment law, and if she were to be sectioned, this would require two independent doctors and an appropriately qualified social worker. 

No attempt is made in the film to put the treatment of this patient in context.  All that one can legitimately say about this film is that Dr May’s interaction with this patient coincided with partial recovery for this patient during one of her relapses.  Many people will leave this film thinking that because of Dr May’s limited ‘success’ that current mental health treatment is all wrong.  This cannot be concluded on basis of one case. 

3. The film is unrepresentative and unrealistic:

‘Ruth’ is not a particularly representative patient.  She is above average intelligence, and I cannot help but notice, is played by a young and beautiful actress.  I wonder if this film would have been made if its subject matter was a typical London inner city patient.

Whilst Ruth Wilson played the role believably, her depiction was not challenging to the viewer.  The most chaotic thing she does is put her head under a stream and walk out in front of a slow moving lorry.  She remains coherent and well turned-out throughout.  What if she did other things less palatable to the body beautiful: neglected personal care, started to have sex with (unattractive) strangers or lived in a filthy house?  Let’s consider how much publicity a conventional psychiatrist, offering medications to a patient who would go home much better the following week, would muster – not much I expect. 

Early on, we are told that Dr May sees Ruth in an unofficial capacity in addition to his NHS work.  Even if it worked, about which I remain dubious, there is simply not the capacity within the health service to allow all patients with serious mental health problems this sort of intensive input. 

At the end of the film, we are encouraged to think that ‘Ruth’ has managed to return to work successfully, despite continuing to have auditory hallucinations.  It is implied that this is because Dr May and ‘Ruth’ manage to pinpoint the identity of the voice which is troubling her; this is over simplistic.  We are told nothing of the long term outcome of this case.  Remember that both bipolar affective disorder and schizophrenia (the two terms are used interchangeably during the film) are chronic disorders of a relapsing and remitting nature. 

4. Dr May is deeply unprofessional:

Dr May shows a total distain for other professionals working in the psychiatric field.  Informed by his own experiences, he says that people who work on psychiatric wards consider their patients to be ‘degenerate’.  Psychiatric wards are not nice places, but they are staffed in the main by caring people who do an extremely difficult job with very difficult patients.  It is insulting to suggest that, to a person, they all consider patients with mental health problems in this way.   

Dr May’s relationship with ‘Ruth’ seriously blurs the boundary between patient and professional.  Ruth is seen to stay with his family and there is no mention of any other important relationships in Ruth’s life, for instance the support which might be available from parents or friends.  Instead, Dr May positions himself as a svengali character and it appears that his professional zeal for alternative psychiatric treatment may be an expression of his own personal distaste for the psychiatric profession with Ruth as a unwitting pawn.

Ruth is an extremely vulnerable patient.  The programme takes place over the course of seven months, during which time who, if anyone if managing the risks she poses to herself and others?  At one stage Dr May admits that she has been told by the voice that she hears that she should kill her parents.  He simply considers this to be ‘useful’.  At another Ruth goes missing and Dr May is concerned that she may have committed suicide.  When asked about why he is reluctant to talk to camera about this he admits that he is reluctant, in our risk adverse age, to implicate himself on camera, perhaps realising how far out on a limb he has gone. He is also described as using a technique which many psychiatrists think ‘irresponsible and dangerous’.  Imagine if your surgeon told you he wanted to try a procedure on you that other surgeons thought ‘irresponsible and dangerous’ – you would not be impressed, and neither should we be. 

In discouraging Ruth from seeking any professional advice but his own, Dr May steers her away from evidence based (but I grant, imperfect) methods of treating mental illness, towards his own paradigm.  In the film she is portrayed as manic for in excess of six months, and would have been unlikely to have been so were she on appropriate medication.  In addition to not seeing a psychiatrist, in isolating her, Ruth would also not be helped by the array of other professionals who work in community mental health.  We see her at the end, apparently recovered, but where on earth is her follow-up?

Dr May has a professional case to answer in his attitude to the panel that is to decide whether Ruth is safe to be practicing as a doctor.  This panel is not there simply to get in Ruth’s way, but to make sure that vulnerable patients are to be treated safely by competent doctors.  Whilst being aware that Ruth has symptoms of serious mental illness, Dr May encourages Ruth to lie to the panel and also coaches her to do so. 

This is in direct contradiction to the GMC good practice guidelines which state:

‘If you know that you have, or think that you might have, a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must ask for and follow their advice about investigations, treatment and changes to your practice that they consider necessary. You must not rely on your own assessment of the risk you pose to patients.’  (my italics)

I don’t doubt that a lot of patients are not keen on taking antipsychotic medications.  It’s widely known that people with mental health problems have trouble finding and keeping employment.  If Dr May’s work aims to help people with their mental health problems get back into employment and deal more effectively with their illness, they we’re on the same side.  And perhaps there’s a four hour version of this film which would clear up all of the above concerns.  But this film is unbalanced and unhelpful.

Here’s a guardian review of the TV show and some interesting comments.

Kathryn Flett in the Observer didn’t like it much either 

Addendum: Dr May has kindly commented on this piece below.  There’s a BMJ review of TDWHV available on his website, which raises some interesting points. 

I was at a course the other day and someone piped up from the back:

‘In an ideal world everyone needs a counsellor, that they can talk to every week about their problems’.

I expect that quite a lot of people would agree with this statement, but not me.

Different psychotherapies (’talking therapies’) are easily confused and I’m not talking about directed therapies such as cognitive behavioural therapy, family therapy or behavioural therapy.  These therapies are aimed at specific psychiatric conditions, are goal directed and administered by trained practitioners.  

Counselling on the other hand is difficult to define, and tends to be performed by those with limited training and aimed at people without strictly classifiable mental health problems.  As such it seriously encroaches on normal experience and the implication of the statement above is that people going about their everyday life need professional help to deal with common problems of everyday living.   

There is little evidence that counselling helps, and some evidence that it actually makes people worse.  There is a danger that attending a counsellor for a problem will introduce the expectation of experiencing distress and in some way validate it.  Some people regard simply attending counselling as a mentally healthy thing, but is airing your problems suitable for everyone, and could it be that people attend counselling as a proxy for real action?  Counselling is popular and this is given as justification for it continuing to be available, but what people want and what’s in their best interests is not always the same thing. 

An argument could be made that the counsellor is taking the place of the parish priest in these godless times.  With many of my patients I feel that what they really need is some good friends, who can offer support, sympathy and real world feedback.  Friends are also a lot cheaper.

Frontier Psychiatrist is sick today, and has been off work.  Ordinarily I might enjoy a day in front of the television working through a box set of Prison Break but I’ve been feeling really low all day.  I knew things weren’t right when I got up this morning and and simply stared at my toast rather than eating it. 

But what better time to examine physical illnesses (’organic causes’) that cause psychiatric symptoms?

Psychiatry and physical medicine have a complicated relationship.  Psychiatric and physical disease can occur at the same time by chance or physical disease can cause psychiatric symptoms and vice versa. Psychiatric medications also have a large number of side effects.  

Whenever a patient comes into the hospital with psychiatric problems, a full ‘work-up’ should include looking for a physical cause for the problem.  Psychiatrists were a bit rubbish at doing this, but are getting better; the hospital where I work audits whether patients admitted have a physical examination whilst they are on the ward. Patients usually get blood tests and often a CT scan, especially if the presentation is atypical.

Depression has a lot of organic causes: cancer, infection, neurological disorders including dementia, diabetes, thyroid disease, Addisons disease, and systemic lupus erythematosis.  Just having one of these diseases in themselves may be a cause for depression as they can result in substantial disability.  Psychiatry blogger Lake Cocytus tells a tale of delayed diagnosis of metastatic breast cancer due to confusion with depression. 

Anxiety also has a number of organic causes: hyperthyroidism, hyperventilation, phaeochromocytoma, neurological disorders and drug withdrawal. 

Finally, psychosis may also be triggered by an organic cause and these include neurological conditions (e.g. epilepsy and strokes), metabolic conditions (e.g. porphyria), endocrine conditions (e.g. hyper- or hypothyroidism), renal failure, electrolyte imbalance (especially calcium), or autoimmune disorders.

Addendum: I’ve now seen this film and it annoyed me so much that I’ve written another post about it 

Tonight there’s what may be quite an interesting programme on television - Channel 4 2200.  I can’t watch it as I don’t have a TV, but here’s the blurb:

‘The Doctor Who Hears Voices tells the true story of Ruth, a junior doctor, who has begun to hear a male voice telling her to kill herself. Suspended from her job, she turns to clinical psychologist Rufus May who is known for his unconventional approach to treating people with severe mental health problems.

Although she admitted feeling depressed and suicidal to her employers, Ruth knows they would have sacked her immediately if she had told them about the voice.’

Furthermore:

‘Rufus May is a maverick psychologist. He believes there is no such thing as schizophrenia, that medication can destroy lives and that there’s nothing wrong with hearing voices. Rufus is an authority on the subject. He was diagnosed with acute schizophrenia aged 18.’

I hadn’t heard of Rufus May until this evening; I’ve now looked at his website so I’m getting clued up.  He’s a little bit more circumspect than the Channel 4 would have him:

‘I am not against people using psychiatric medication I just would like people to be able to make informed choices and have the chance if they so wish to try out other approaches to their mental health problems.’

Which sounds a little more balanced, but also less exciting.

It’s rather a poor show to criticize a TV programme I haven’t seen, although this never stops politicians.  I’ve got quite a lot of sympathy for people who say that schizophrenia doesn’t exist.  In a way it sort of doesn’t, in that our understanding of its aetiology is patchy and it could easily be a number of similar diseases based on different genetic defects.  If he is helping people to deal with their psychosis with means other than medication, this is also to be applauded. 

As usual though what’s necessary for the highest level of evidence for May’s methods is a controlled trial and I can’t see him having been involved in one of those.  If he chooses the patients he treats, he can thus pick the ones he would expect to have a better outcome - those that have a higher intelligence and better social support.  There are a lot of patients out there with psychosis and May has treated but a few of them.  Twenty % of schizophrenia patients make a full recovery without any psychiatric intervention.

As a final thought, if the doctor in question had a serious psychosis then you could also argue that he would have had a duty of care to reporting her to the GMC.  

Like I say, I’d better watch it. Here’s Rufus May’s Bradford page

PS. There’s an interesting transcript on the Rufus May website of a debate entitled ‘Psychiatric drugs do more harm than good’ For: Dr Peter Breggin, seconded by Dr Joanna Moncrieff.  Against: Dr Mark Salter, seconded by Dr Trevor Turner 

John Prescott has come out in the papers today as saying that he was suffering from bulimia nervosa whilst he was Deputy Prime Minister.

With two jags, an affair, some punches and a poorly timed croquet game and now a psychiatric illness, I’m impressed with how much mileage John Prescott has provided the red tops with other the past few years.  Bulimia is quite something for someone who was right at the top of the political pile to admit to.  Food’s a difficult thing - if you have a problem with it, eating too much or too little, you can’t just stay away from it.  And everywhere there are pictures of perfect bodies reproving you for not being just like them.   

Here’s a bit about eating disorders for the curious: 

The International Classification of diseases recognises a number of eating disorders, of which are two major flavours identified - anorexia nervosa (F50.0) and bulimina nervosa (F50.2).  If someone presents with a difficulty with their eating which doesn’t fit into either of these patterns then they are classified as having an eating disorder, unspecified (F50.9) 

Anorexia Nervosa is characterised by deliberate weight loss resulting from under-nutrition with associated with endocrine and metabolic disturbance. It occurs most commonly in adolescent girls and young women with males of the same age affected rarely.  For a definitive diagnosis:

• Body weight must be maintained at 15% below that expected
• weight loss is maintained by the avoidance of ‘fattening’ foods
• There need be body-image distortion, where dread of fatness persists as an intrusive overvalued idea. 
• Amenorrhoea (lack of periods) in women and loss of libido in men. 
• Delay or arrest of puberty.

In contrast bulimia nervosa is characterised by repeated bouts of overeating and an excessive preoccupation with the control of body weight.  The age and sex distribution is similar to AN, with the age of onset being slightly later.  Bulimic patients often have a history of anorexia nervosa.  For a definitive diagnosis:

• There is a persistent preoccupation with eating and a craving for food; the patient binges
• The patient attempts to counteract the ‘fattening’ effects of the food by vomiting, but could also attempt control by purgative abuse or use of appetite suppressants. 
• There is a morbid dread of fatness

There are two subtypes of BN - purging (with regular use of vomiting/laxatives etc.) and non purging (where compensating behaviours are exercise or fasting). 

Both these diseases are serious.  The death rate for suffers of AN is twelve times that of the general population, the worst of any psychiatric disorder.  Suicide rates for those with AN are two hundred times that of the general population.  The two conditions are also often associated with other psychiatric difficulties such as depression, personality disturbance and alcohol abuse. 

Given his age and presentation Mr Prescott’s case is atypical and and it will be interesting to read about it in his forthcoming biography (this can’t have done his sales any harm) 

Addenda

Here’s a Guardian article by Decca Aitkenhead about Prescott

NHSblogdoc is rather less charitable than I am

It’s not easy doing night shifts.  When I was a medical student I used to think that they were a bit cool - the doctor, all alone, there to deal with whatever comes their way.  A sort of intrepid traveller travelling through the medical twilight, with nothing but his sharpened wits to see him through. 

Alas, the reality is somewhat different.  Tired and bored, nights lead to a very real personality deterioration.  I become rude, intolerant and I steal other people’s food from the fridge.  Work comes in dribs and drabs, a drug chart to write up here and a new patient to clerk in there.  Then occasionally it goes ballistic and I have four patients to see in Accident and Emergency and eight jobs to do on the wards.  This gives me a headache. 

I can tell I’m tired when I start to think that the patients are being sick deliberately to piss me off; and that colleagues are giving me work simply to vex me.  It also drives me crazy when people call me to sort out something as an emergency but it’s actually been a problem for three days, but no one has bothered to do anything about it.  This happens all the time.

My bed is a sofa that is four feet long;  I am six feet long.  I’m not meant to sleep on it anyway. And there’s an appalling collection of videos that I cannot stop myself watching. 

Yesterday for instance I reacquainted myself with ‘Dirty Dancing’.

Before the advent of antipsychotic medication the treatments available to the psychiatrist were, with the exception of ECT, ineffective.  Things changed in 1950 when chlorpromazine was first synthesised; now for the first time people working with the mentally ill had a way of improving the previously pretty dismal outcome for sufferers of schizophrenia.  As discussed by Trevor Turner, this also improved the respectability of the psychiatric profession and provided the basis of an aetiological theory for psychotic illness. 

Other medications followed in Chlorpromazine’s wake.  These have become known as the ‘typical‘ antipsychotics and examples are Haloperidol and fluphenazine.  Although good at reducing some of the symptoms of schizophrenia, they also produced some horrid side effects, most notably Parkinsonian symptoms and another movement disorder called tardive dyskinesia.  

In 1958 Clozapine was developed.  This was the first ‘atypical’ antipsychotic.  Its difference was that it wasn’t nearly such a good blocker of D2 receptors, but had more activity at many other receptors including dopamine D4.  It causes no tardive dyskinesia and leads to some improvement in schizophrenic negative symptoms.  Other atypical drugs have followed, these include Olanzapine, Quetiapine and Risperidone.  They too are less potent D2 receptor blockers, and are less likely to cause tardive dyskinesia.  These newer drugs are currently the most widely used, although there is research that they are no better than the older and cheaper drugs at improving patient outcome. 

Clozapine is the ‘psychiatric domestos’ of the title. It’s what psychiatrists use when all the other treatments of psychosis have failed and when it works it’s pretty impressive.  As a medication it’s not without a chequered past and during the 1970s it was withdrawn because of its association with neutropaenia (3% of patients) and agranulocytosis (0.8%); however it was reintroduced following a study which proved it was more effective than other antipsychotics.  Although it does not cause movement disorders, it does have a lot of other side effects, most notably hypersalavation, sedation and diabetes. Why it works more effectively than other drugs is unknown; although its action at D2 receptors is reduced, this still appears important.  No one has ever synthesised an antipsychotic with no D2 activity.  

So, these days, Clozapine is given to our most treatment resistant schizophrenic patients.  It’s an expensive operation.  Each patient requires strict monitoring including regular blood tests and there are dedicated ‘Clozapine clinics’.  I hope that within my lifetime we’ll look upon it as a hopelessly antiquated way to treat our most difficult patients, but for now its the best we’ve got in an area where the search for new medication is frustratingly slow.  

If you had a cough and were expectorating  lots of green phlegm then you might think that something was amiss; if you broke a bone in your foot, it might hurt to walk.  Either way, if I suggested to you that you had a problem with your health you’d probably agree with me.  With mental illness it is possible to be very severely ill and believe yourself to be well; in fact, on the contrary, you might believe yourself to be at the top of your game.  This ability, or inability, to recognise illness is called ‘insight’ and psychiatrists talk about it a lot. 

Loss of insight is a symptom of severe mental illness and is seen with diagnoses such as schizophrenia and bipolar affective disorder. 

It has been proposed that insight consists of three overlapping dimensions

1. The ability to relabel unusual mental events as pathological
2. The recognition that one has a mental illness
3. Compliance with treatment

Rather than just being an indicator of the severity of other symptoms, lack of insight is thought to be a distinct phenomonological feature in its own right, being similar to anosognosia where a patient shows an unawareness of neurological symptoms.  This is associated with lesions to the frontal lobes and the right parietal lobes.  

It’s important to note that insight is not an all or nothing thing.  Someone with complete lack of insight may deny that anything at all is amiss.  Sometimes though we describe a patient as having ‘partial insight’.  An example of this might be someone who thinks that MI5 is passing messages to  him/her via messages written on Tescos carrier bags.  He or she might concede that this was rather a strange thing to be happening, but would insist on its veracity nevertheless.  With recovery of full insight he or she might say that now they realise that the messages on carrier bags were a function of their illness. 

Loss of insight is also important because it has prognostic implications.  As you might expect, if you don’t think that you have a problem, you’re likely to carry on as before, and won’t be opening the door to health care professionals.  As well as this it is linked to poorer functioning across all areas of a patient’s life.