Out of the frying pan…

Indeed, it reads to me as pretty hopeless - “the tablets are no good - but we haven’t put anything in place instead yet, though we think it would be a good idea to have more talking therapies”.

Speaking personally, I know that every time I have tried to stop taking the tablets, I get to a certain point and then my mood drops dramatically. I return to the tablets and things (eventually) recover.
Of course, this could all be a placebo / self-fulfilling prophecy effect, but I don’t think so. I think it likely that medication is overprescribed (I’ve experienced that too) but until the talking therapies are properly funded and properly provided, I think many GPs may feel they have few other options. I know in my own area getting talking therapies is really hard, unless like me you are prepared to be incredibly persistent about it.

I’m just browsing through that BBC Have Your Say page now….

Added: Tuesday, 26 February, 2008, 15:35 GMT 15:35 UK

Life is Great, London

Dazedandconfused, have you been doing CBT over the net again?

This surely won’t surprise anyone working in mental health, will it?

Most folk with mild depression have reactive depression, or a (self limiting) adjustment disorder, or dysthmia . . . very few have an endogenous chemical brain disorder that chemicals (antidepressants) can fix. So it’s not surprising that mild depression doesn’t do well with drugs, but we all knew that.

As to feedback on therapy, it’s poor. The Improving Access to Psychological Therapies (IAPT) projects have been found, so far, not to deliver.

They have stunnning success with the worried well, who instead of starting to get better in a month now start to get better in 28 to 31 days.
They have rejected many patients with mental health problems, skewing their outcomes (e.g. I know one colleague who’s not had one single patient treated by the service since its inception since they’ve punted each and every one back saying they’re too ill or too complex so need to be managed within specialist Secondary Care services). A bit like the vogue for counselling (Nondirective Counselling) in Primary Care that was shown to be ineffective (long term outcome for patients unchanged, consultation rates seeking help unchanged), this community treatment is seeming to be similarly ineffective for those really needing help.

So it’s not great for benefit. What about consequences and risk? Firstly it costs oodles which could be used on more formal talking therapies. Secondly it’s been harmful, raising issues that IAPT have been unable to address. Thirdly patients it’s not helped have had failed experiences with inexpert CBT so then are hugely prejudiced and don’t respond well to CBT done by specialists in Secondary Care when punted over to them. Lastly, the therapy’s in isolation and not undertaken in an MDT framework so other elements of advice, governance, appropriate intervention, support, surveillance (of side effects, in particular) and care simply don’t happen.

Much badness.

Great post, as ever, Shrink. Thank you. Your comments made me feel less guilty.

Ann Robinson (no, not that one) has published her own take on the issue over on the Comment is Free website.

As with anything that gets published on Comment is Free, the discussion thread that follows varies from informed and insightful to utterly batshit.

This is just another battle in the long and ongoing war between psychiatrists and psychologists over the bodies of the mentally interesting (once upon a time, the neurologists had a go as well, but they dipped out in the early stages).

If I ever get depressed, I want the pills. I don’t want some earnest woman in a cardigan trying to talk me out of my faulty cognitions, I want those faulty cognitions extinguished by chemicals.

I would rather chew my own arm off than go to any form of counselling or therapy for my depression! just the thought of it makes me want to despair. Give me the pills any day, i’ll deal with the side effects.

Where is the research into counselling and therapy? why don’t they talk about the people who refuse to go, or those that quit and never return having got absolutely no benefit from the process - oh sorry they do, yep its blame the patient time, its all our own fault, were not cognitively orietated or ready to face up to the work necessary or just plain prepared to put up with what looks to us like a bunch of snake oil salesmen.
If you really want to assess the benefits of counselling and CBT etc then you need to rigourously compare it with antidepressants, you can’t just evade responsibility by saying that its the patients fault or that the therapist wasn’t trained properly etc etc. failure is failure and should be treated as such as it would be in a clincal trial for antidepressants.

my only hope is that i can stave off a relapse long enough for the backlash against this nonsense to have started!

Shrink do you have any cast iron phrases that will guarantee my GP etc will not try and force this nonsense on me everytime i go,! saying no just seems to encourage them.

I see the canned worms are still freely available. If this controversy will lodge the point (as made by Shrink) in the public mind that most of what we know as “depression” is self-limiting and doesn’t need pills to resolve it then a positive outcome will have been achieved.

And thank you Beakie, for so publicly celebrating your preconceptions with the phrase “earnest woman in a cardigan”. Get your facts right, please, it’s actually a hand-knitted cardigan.

I heard at a recent research conference that the external evaluations of the Doncaster and Newham IAPTs will report in a couple of years. How can I stand to be on tenterhooks for so long?

“. . . external evaluations of the Doncaster and Newham IAPTs will report in a couple of years.”

A fair point, my rather critical view has formed from talk with folk who work there and isn’t “externally validated.” But since the processes are flawed, any validation of a flawed process isn’t going to really illuminate anything useful for patient care. A penny to a pound that it’ll be written up as a stunning success and all therapists will advocate more jobs for them . . .

Shrink, I’ve also had discussions with folk with first-hand experience of IAPT, and have heard the same tales of people batted back-and-forth because of “high risk” and “complexity”. The view from within secondary services is not bright. The view from those who’ve received treatment seems to be quite positive - but it would be, they’ve been offered something instead of nothing. In an area with a dearth of mental health provision at primary level, there has at least been some sort of provision for those people who have the type of need the IAPT services can meet, and it has given secondary services something to pass those with less severe problems on to, so that resources can be devoted to those with more severe problems. So it’s not entirely crap, but I share your scepticism about the outcome of the external evaluation - it will, I feel, find what the powers that be want it to find. (And please note my careful use of the phrase “external evaluation”. On a slacker day I might have said “independent evaluation”.)

Get your facts right, please, it’s actually a hand-knitted cardigan

I stand corrected and ashamed.

I can deliver CBT. A variation on a Greek philosopher’s slant:

I think you are alright therefore you are alright.

Hows about that?

………………….” train those with enduring MI to deliver the CBT.”

There is a school of thought that suggests this has been happening for years.

Mandy - your suggestion once more illustrates the gulf between psychiatry and psychotherapy, the psychiatric approach being “I think you’re ill therefore etc”.

One of the commentators on that thread pointed out that the researchers at Hull only followed patients up for 6 weeks before concluding that medication was no more effective than a placebo. Some people (myself included) have been taking antidepressants for a lot longer; any placebo effect would have been lost a long time ago in my case but possibly not in the study carried out by the researchers at Hull.

Hi Jan

Blimey, I highlighted the gulf between one school of learning/practise and another and I didn’t even know it. lols

What I was actually trying to highlight is the ineptitude I think CBT is being handled with and the political reasons behind that. Only what I forgot to do was say that.. and what it became was a sarky comment.

It has become the latest wonder treatment. Only, I have read that getting CBT is like finding a needle in the Pacific Ocean.

I do agree with you that people with mental illness do a rather good job of looking after others (although that can depend where someone is - mentally - at the time). But I think that is because of the gaping holes in service provision and often lack of useful follow on and/or continual care.

Yesterday, I was once again, on the phone to ‘MH professionals’ trying to sort something out viz a viz a game called ‘Whose Responsiblity Is It Anyway’. Needless to say, no phone calls back. Although I encountered some slightly friendly answerphone messages!!!!!!

I’ve always said that clinical depression needs medication and crappy life depression needs therapy. How did I get to be so brainy? I have no idea, but brainless people really annoy me. (It’s the crappy life depression that makes me so intollerant by the way, but I’m greedy so I have both)

I have this friend, and apart from the fact that she never takes the damn pills properly she also has crappy life depression and then wonders why the magic pills don’t work. In the end she lied to the doctor and said she was suicidal when she wasn’t so that she could get the particular magic pills that she wanted - y’know, those ones that are better than all the others (?) Being very experienced at living with all kinds of depression, I’ve been trying to tell her for years that no one pill is better than another - just we’re all different and respond to different medications differently. She’s tried many of them now, and I can’t help wondering if she expects the tablets to make her happy 100% of the time.

I give up. People are only stupid because they want to be.

Whatever the cause of the depression, looking after yourself will help. That includes avoiding extra stress and doing positive things for yourself.

Oh and the comment by E just really says it all doesn’t it? Once again results are manipulated to say what people want them to say. Everyone knows (or should) that anti-depressants take 6 weeks to get into your system. So they knew what the results were going to be before they even started the study.

Hehehe thanks Mr Ian.

Umm… ignorance is bliss? Or were you looking for a more eloquent and long winded approach? Something which may confuse those to whom it applies?