Today’s claim that some anti depressant drugs are little or no better than pretend pills for all but the most severe kinds of depression poses some interesting questions about medicine on the NHS.
The drugs bill is huge and growing. All too many patients expect a visit to the doctor to produce a prescription as a solution. Many doctors have learned that offering tablets is the best way to handle their patients, and to ensure a swift and satisfactory consultation. I can understand the pressures and why they might come to that conclusion. The last time I went to a doctor some years ago I found it quite difficult to get out without a prescription, when I had merely gone on the insistence of a family member for a check up. People are less willing to hear that changing their diet, their lifestyle and their routine might do them more good than swallowing another tablet.
Depression is all in the mind. Some depressed people come to see their MPs. They may have a genuine case for an MP, but sometimes they are externalising their unhappiness. I take the problem they tell me they have seriously, but sometimes have to explain that I do not think anything can be done about it as I do not wish to raise false expectations. It is a pattern I well remember, from years of family experience. The depressed person often thinks there is an objective external cause of the unhappiness. If they can change their job, their home, the conduct of their wife or husband, their friends or their neighbours, they believe their unhappiness will vanish. All too often they discover that having made the change they are still unhappy, so the search for another cause begins and the pressure for another change builds up to try to appease the depression gods.
Taking a pill that is nothing but well disguised sugar might well work. If the patient believes in it, it could bring some relief from the inner darkness. The problem is the NHS feels it has to prescribe the expensive real thing, and not the substitute, so the doctor-patient relationship is not based on a white lie. The placebo pill is cheaper. It might be almost as good in its effects, according to today’s study. It is guaranteed not to have side effects, but under the rules it cannot be widely used. It poses an interesting ethical dilemma. What should the doctor do? What should the NHS require?
February 26, 2008
John,
Depression is not "all in the mind."
Part of the problem is that when people feel a little fed up they are said to be depressed, just as someone with a bit of a cold insists they have flu or someone with a bit of a headache insists it's a migraine.
Clinical depression is a serious illness. True clinical depression can be measured, as there are real chemical changes in the brain. I doubt if you have ever reached the stage where you feel life is not worth living and that you are worthless and society would be better off if you were dead. This was the reality of the people that I used to be involved in the treatment off. One of the worse things you can say to a truly depressed person is that they should cheer themselves up or pull themselves together. It is also unhelpful to belittle their condition by such clumsy ignorant sayings as "It is all in the mind."
It is all very well politicians saying that all that a depressed person needs is a job and that will cure all, this is wrong. Someone with a true depressive illness will not be able to do a job, just as someone with a real bout of flu could not even get out of bed.
It is true to say that the talking therapies can help in the treatment of depression and electro convulsive therapy (ECT) has also had success especially in the treatment of postnatal depression.
Within the NHS, GPs do not have long enough with patients to actually perform a proper diagnosis. Too much pressure is put on GPs to tick boxes and see numbers rather than patients. The NHS has become target and cost led rather than needs led.
I suspect that the report is just another way to justify saving money and yet again, it will be the most vulnerable that will suffer.
I wonder why both the main parties have got involved in a bidding war to see which party can be the toughest on the most vulnerable in society.
February 26, 2008
I'm not convinced that it is entirely ethical to prescribe placebos for a diagnosed illness. After all, that deception destroys the bond of trust and honesty between physician and patient.
That said, I particularly welcome the discussion about Depression and its debilitating effects and treatment. The stigma of mental illness is still widespread. Yet it affects a very large proportion of the populace in one way or another.
The Black Dog is still amongst us and it is time we put more resource into its treatment. Its cost to the nation has never really been quantified, but I'd hazard that it is so much greater than any other illness. If we're serious about reducing the NHS bill then maybe we should look more closely at the reasons for visits to GPs.
I do know that my local GPs spend considerable time (and prescriptions) on mental health issues. Drugs are prescribed because other treatments are at a premium. What do you do with a seriously depressed patient who will have to wait for as long as nine months before receiving psychiatric help?
Thank you raising this in/on your blog.
February 26, 2008
Firstly, this research says little about what goes on in the medical profession and a lot about what goes on in research departments of universities. We are inundated with 'reseach' results and we pick out the ones that we rather like the sound of, as you have done here. Remember how we were advised to only eat two eggs a week?
Whoops! Or how Type A personality posed a greater risk of heart attacks? Whoops! To say nothing of the research that has been shown to be based on poor methodology or even fraud.
Secondly, your comments on depression betray a deep ignorance. Depression and unhappiness are not the same thing. Miserable people are everywhere and there are plenty of cheerful, even funny, depressives – check out most comedians. However, you can be forgiven for your views. After all some years ago a brilliant young psychiatrist, Garth Wood, wrote The Myth of Neurosis – Overcoming the Illness Excuse (very popular in many circles) where he said much the same thing as you have. He claimed that unless you satisfied certain very strict criteria you weren't 'really' depressed and should jolly well buck your ideas up. If you were functioning and not losing weight etc then you certainly weren't depressed. A few years later in fine physical health, tanned and on holiday he killed himself using the suicide kit he had kept in his briefcase for several months. Maybe he just needed a break. Oh, wait! he was on holiday when he did it. Whoops!
Reply: You have read my comments in a way I did not intend. I fully understand how serious depression and obsessive mental conditions can be. I was inviting comments on the current story of the relative efficacy of anti depressant drugs and placebos.
February 26, 2008
I'm afraid that depression is not 'all in the mind' and, in extreme cases, is potentially life-threatening if the patient is suicidal.
Unfortunately I have first hand experience of caring for someone with suicidal depression.
It is true that anti-depressants are not a magic bullet solution, but they are an important tool in the fight against this condition. I do agree that people often say "I'm depressed" when they mean they are having a bad day, and I can understand that there are pressures on clinicians to prescribe anti-depressants when their use is not always justified.
What's probably needed is more time for GPs to talk things through with the patient and persuade those who are not clinically depressed that pills won't help them. Instead, we reduce costs by setting unrealistic surgery throughput targets, but lose out by over-prescribing in cases where drugs are not the solution.
February 27, 2008
Robert Dilts, an American NLP trainer and therapist, tells a story from the '70s when he was a 'researcher/gofor' to Richard Bandler and John Grinder, the co-founders of NLP (Neuro Linguistic Programming). Dilts at the time was a student at UCSC Santa Cruz where Grinder was a professor.
Dilts was instructed by Bandler to gather data from drug trials that had used placebos and to determine an average efficacy for them. Dilts found that placebos were effective in about 30% of patients. (I can't remember the exact % Dilts told us but it was in this sort of ball park)
Bandler then decided to market sugar pills with the brand name of 'Placebo'. His plan was to be absolutely open about the content of the tablets and to explain that they contained nothing but sugar. The punch line was to be something like "Research has shown that 'Placebos' work, on average, with 30% of all medical problems"
According to Dilts the idea fell apart when the American Food and Drugs authorities refused to play ball. Evidently the Food & Drug wallahs needed to sign off 'Placebos' before they could be put on sale.
I've often wondered what would have happened had 'Placebos' hit the market. Maybe Badler would have become the first 'Bill Gates'!
March 2, 2008
I was once prescribed one of the class of depressants now being described as "sugar pills". It was alarmingly unlike a placebo. I lost two and a half stone for a start and had many other unpleasant side effects as well, the most disconcerting of all being a wish to kill myself and others. Luckily we all survived, but no-one should be under any illusion about the power of some of these psychotropic drugs to disrupt the body's workings. The doctors know very little about what they are prescribing – only that in some cases "they seem to work". That is so with a whole range of neurological drugs, and one day people may look back on our drug-based medicine as we do now on skull-opening and bleeding.
March 6, 2008
John, I like your post. There is a prescription drug epidemic. As the director of Novus Medical Detox we see many people addicted to alcohol and/or opioids, CNS, who are put on antidepressants because they are depressed. Generally, when they come off the alcohol/opioids, then they can stop taking the antidepressants because they don't need them. Frankly, because of the studies that show they work no better than placebos and the side effects and the fact that there is no scientific test to determine if someone meeds seratonin. There is also the study of female suicides in Sweden in 2006 which showed that 52% were on antidepressants. Coupled with the fact that almost all of the school shooters were on antidepressants, we have a terribly dangerous set of drugs.
Steve Hayes http://novusdetox.com
March 18, 2008
I do agree with you at the fact that depression is all in the mind.
I also believe though that depression doens't exisit in general. How I see it to be is that someone is really sad. I wouldn't perfer to use the word depression for someone who is just going through the "blues."
It tis really pathetic that people are able to go talk to someone and say "I feel suicidal" and they are able to get antidepressants.
A while ago I told the coulnser I was having suicidal thoughts and that I cut and what not; she called my dad. After my father came I got brought to a counslor in a bigger city and saw a doctor. He was talking to me and he asked me if I would like to go on antidepressants. Straight forward I said no because they don't do anything to help. But I just told a complete story to them all. I really wanted to just get into the hospital my friend was in to make sure he was okay. (Well not a complete story but close enough.)
That is a brilliant idea to give out sugar pills instead. That way the drgus won't affect them in a negitave way. I like that! : )
Pardon any of my mis spelling. I don't have time right now to fix it but I really liked the article.
July 20, 2009
Could you recommend any specific resources, books, or other blogs on this specific NLP topic?
August 18, 2009
Dear John Redwood,
You probably do not suffer from depression as you are successful and affluent. Many people do however and anti-depressants such as seroxat have transfomred their lives as they have mine.
I suspect you do not like the idea that a pill can suddenly do this, which it often can as it breaks the link between effort and reward which denizens of you mean spirited view of the world regard with distaste and hence fatuosu remarks like "pull your socks up" or "its all in the mind"
Its interestig that Leon Kass, the chair of George W Bush's council on Bio ethics puvlically mused about how such intereventions could "damage" humanity. The Christian Right in the United States is the acme of mean spiritedness and ignorance so it is no surprise to hear this view come from the likes of Kass. It is not pleasant to hear a British politician utter it but I'm glad to knwo that you and your type are a minority in your own party.
Reply: You grossly misrepresent my views. I understand how depressed some others are all too well, and of course wish them successful treatment