Should Policy Makers Tell GPs How Often to Diagnose?

I’m sure NHS England were surprised by the response to their plans to pay GPs £55 every time they diagnosed dementia. What started as a seemingly simple idea to help the Government hit their diagnosis target before the election caused such a furore that Simon Stevens declared the end of the policy before it had really begun, making it clear that it would end at the end of March.

What was striking about the reaction was not the objection among GPs – policy makers are used to that and well accustomed to ignoring it – but the strength of feeling among the public. I’m sure this is what made the difference – no politician wants to lose in the arena of public opinion. It’s not hard to see how this happened. There was something innately wrong about paying GPs to diagnose; no in-depth analysis was needed, no exploration of the evidence – it was just so clearly a bad idea and both doctors and patients were alarmed at want it meant for the doctor-patient relationship.

What continues to concern me, though, is that policy-makers still think they know best when it comes to how many patients GPs should diagnose with a variety of conditions – from heart disease to asthma, diabetes and even depression – and have an even more powerful mechanism for enforcing this, which is to put pressure on practices with low diagnosis rates through naming and shaming, and the threat of inspection. A practice may have the moral courage to resist a financial bribe, but what about if the reputation of your practice is at stake?

I have written in the British Medical Journal about this, published this week, and this is a toll-free link if you are interested. What is crucial is that at the moment of diagnosis there should be nothing in the mind of the GP other than what is best for the patient – it is fundamental to the doctor-patient relationship and something well worth shouting about.

On Pacing Spoons and Resolving to do Less

Falling between the claims last week that we would all be subject to Frazzled Friday, and the hazards of negotiating the alleged (and dubiously unscientific) Blue Monday later in January, falls New Year – and the opportunity to make New Year’s resolutions as we face the year to come.

No doubt gym memberships will rise, tobacco sales will suffer a temporary blip, and our eating and drinking levels will return to their pre-Christmas norm. For some of us this will be a powerful opportunity to make significant changes to our lifestyles, while for most I suspect our resolve will be packed away with the Christmas decorations and a promise to try harder next year.

With the busy-ness and stress of our modern lives the bias for New Year resolutions towards trying harder or taking on new things may not be doing us any favours. I wonder if we could change our mindset to resolve to try less hard, and even stop doing something. We could look beyond the usual suspects of cigarettes, alcohol and chocolate and stop doing things which in themselves are not bad – but which conspire with a host of other activities to overwhelm us, leading to stress on family life, a loss of perspective of what really matters, and ultimately ill-health through burnout.

We could resolve to stop worrying so much about making our house into a set for ideal home – by dropping our house-keeping standards just a little or deciding that the bathroom really is ok and maybe we don’t need the hassle of all that DIY this year. We could learn to delegate more effectively at work, and rationalise what we do in the workplace, shedding things that stress us but don’t really matter. We could allow our children to do less – maybe they would really prefer to swim once rather than five times each week, and have been trying to find a way to tell us that they aren’t really hoping to go to Rio in 2016 after all. For the self-employed perhaps we need to find a way to cut our finances so that we really can have that holiday we’ve been promising ourself, but never quite felt able to justify. I’m well aware that I need to be talking to myself here as much as anyone – maybe I need to blog less, Tweet less…oh dear!

I often find myself talking to patients about the importance of pacing. Whether it is recovery from an operation, a debilitating viral infection, depression or living with a chronic illness the principles are the same. Each day you should do something, but still have some energy in reserve by the day’s end. It is sometimes called the rule of 75% – aim to use up about 75% of the pot of energy that you started the day with. That way, if something unexpected happens you still have something left to give – and if it doesn’t then you go to bed with a positive energy balance, so are more likely to wake up the next morning with a bigger starting pot of energy to work with.

A patient of mine has developed an ingenious method for doing this in practice, which she has given permission for me to share here – the idea of pacing spoons. She has to live with a chronic illness which is significantly hampered if she gets her pacing wrong. She has two tubs in her kitchen, containing twelve spoons between them. Each morning the spoons start their day in one tub, and throughout the day she transfers a spoon (or sometimes two) into the other tub whenever she feels she has used up a unit of energy. She makes a deal with herself that there should always be at least one spoon left in the starting tub by the end of the day – and I’m sure that some days she is better at achieving this than others.

The genius of her method is that she has a visual cue for how much she has already done in a day, and so can decide what to take on later in the day and what to defer for another day. Her family can also take a quick look at the spoons when they want to know how things are going. Her children have learnt that a day when the spoons are running low might be a good time to volunteer to cook the dinner, while an evening with plenty of spoons in reserve would be the best time to ask for help with that really tricky homework project. I’m yet to ask her how the family eat dessert when all the spoons are otherwise engaged, but so far this is the only flaw I can find in her system.

If any one else has developed techniques to help with pacing, or you would like to share something that you have resolved to stop doing, it would be great to hear from you.

Wishing everyone a happy, and not too busy 2013!

Antidepressants and the Long Shadow of Stigma

This blog is also to be published as a guest blog on the Mental Health blog The Mental Elf on Monday 6th August – this is an excellent, evidenced-based blog with reliable information on a range of mental health issues and is well worth a browse.

“Are GPs prescribing antidepressants too readily?” This is the title of the Today programme article on Radio 4 which went out on Thursday morning. Clare Gerada, Chair of the Royal College of General Practitioners, was invited onto the programme to defend the case of GPs. She made several important points in the interview, but one in particular stood out for me: That there is an underlying betrayal of stigma in the very way this question is being asked.

Dr Gerada rightly pointed out that the assumption inherent in the way the article was presented, and in John Humphries’ questioning, was that increased use of antidepressants must be a problem. Of course, it might be something to be concerned about, but we need to ask why antidepressants are so often presented in such a negative light. Had there been an increase in the prescribing of statins, for instance, GPs would be congratulated for tackling the challenge of heart disease so effectively; were there to be a rise in the number of women having surgery following breast cancer screening, the country would be applauding the increased use of resources in the fight against disease. For antidepressants, however, we are left to deal with headlines like “Prozac nation” and “Happy Pills“.

I am not concerned that GPs might be blamed for this – as a profession we are used to being knocked by the press and can deal with it – but I do worry about anyone suffering from depression who is either taking antidepressants, or thinking about taking them. It is only natural to translate what is happening nationally down to the individual level: If it is bad for the country to be taking so many antidepressants then is it bad for me?

Mark Easton’s report raises some important questions, and we should not be afraid to ask them. There has certainly been a considerable increase in the number of prescriptions for these medications in the last decade. Maybe they are being prescribed too often, but this is just one of many possible explanations, and it is likely that the truth is a complex mixture of many factors.

For starters, the research looks at the number of prescriptions, not the number of tablets. 10 years ago our practice frequently gave prescriptions for 3 months at a time whereas now we have tightened up on this considerably to reduce waste, and give no more than 2 months worth – well that is a 33% increase in prescriptions at a stroke. Perhaps the data reveals to us underlying social concerns – if increased prescribing means a higher incidence of depression what does this mean for where our society is heading? Or are we just getting better at diagnosing depression? GPs are criticised often enough for failing to diagnose sufficiently quickly, maybe we are just getting this one right?

The most positive interpretation of these findings is to consider that maybe, at last, people are willing to go and see their doctor when they become unwell with this debilitating illness. Perhaps we are actually breaking down some of the stigma, getting the message through that depression can be treated, and deconstructing the mythology around the use of antidepressants which we inherited when Prozac was so inaccurately introduced to the nation as a ‘lifestyle drug’ all those years ago.

More of a concern is that, despite Government promises of extra resources being poured into talking therapies in the Improving Access to Psychological Therapies initiative, I have patients who have been waiting over a year to see a counsellor. In Surrey the counselling service is in its worst state than at any other time I have known it over the last 10 years. Any wait over three months becomes a treatment for trying to help someone stay well, rather than something that might get them well. If I am reduced to only one treatment for a certain condition, don’t be too surprised if I use it.

The decision to use antidepressants is a complex one, which requires careful consideration by doctor and patient working together, balancing benefits against harms. Medication is certainly no cure for unhappiness, but it is an effective treatment for a distressing illness, and deserves to be freed from the shadow of stigma. And what we must remember is that, unlike drugs like statins, behind each and every one of those prescriptions is a person who actually feels unwell – this is good old-fashioned doctoring in action, that outdated notion of trying to heal the sick.

Will Exercise Help Your Depression? Only You Can tell

The long-held belief that exercise can be beneficial in treating depression was brought into question last week by a study, published in the BMJ and widely reported in the news, which reported that exercise did not improve recovery in patients suffering from depression.

As you can imagine, the study has prompted much debate. Can such a definite statement be made about so complex and varied a condition as depression? (probably not); how do you define exercise? (your guess is as good as mine); is that really what the study showed? (not really, it just showed that patients encouraged to undertake a programme of exercise got better at the same rate as those who did not). Interesting and erudite as these discussions might be, they are not really relevant if you have depression and want to know whether or not to get your trainers on – because you don’t want to know if exercise will treat depression, you want to know if it will help withyour depression. Thankfully there is another clinical trial you can refer to – the ultimate clinical trial where n=1 – that means there is only one patient (you) trying one treatment and seeing if it works.

We do a lot of n=1 trials in medicine. Every time we try a cream for a rash, a medicine for indigestion or an antibiotic for tonsillitis we are essentially conducting an experiment: Here’s a symptom, there’s a treatment, see if it helps. If it doesn’t, try something else. It’s not great science, but it is good medicine.

Of course, an n=1 trial won’t work for everything in medicine. Firstly, you need to be sure that the treatment you are about to try doesn’t carry a significant risk (which is why frontal lobotomy as a cure for depression has somewhat gone out of fashion), and then you need to be able to know if it has worked, and in a reasonable timescale. For this second reason, a trial of treatment is not much help when it comes to deciding many of the big questions in medicine – like whether or not to take a statin for cholesterol, or to have your PSA measured to try to detect prostate cancer – for these dilemmas there is no escaping the need for large-scale clinical trials to help guide us. A statin is not going to make you feel better, so how would you know it was working? Even if it lowers your cholesterol, how do you know that this will do something that actually matters to you – like stopping you having a heart attack? There’s no value in a ‘try it and see’ approach here.

Exercise in depression, however, is ideal for an n=1 trial. Exercise is clearly a safe treatment to try – more than that, we know it has many health benefits beyond any help it might be for depression. What is more, there is good reason to think it might help lift mood – whether it is just the benefit of feeling fit, effects on serotonin levels or the magic of endorphins it seems worth looking into. What is more, those who testify to its benefits report that they actually feelbetter soon after exercise – no need for a 2-6 week trial like there is for antidepressants. Of course, you may have to try it a few times to get a feel for it. You might overdo it one day and feel worse, or find one form of exercise works better for you than another, but the message is clear – if you are going to benefit, you will feel the benefit of your experiment sooner rather than later.

So what should you do if you have a negative trial – if you give exercise a go and feel as flat as ever, or maybe even worse? Well there is still a more general principle that will work for everyone, and it is this: When you are depressed there will be some things that, when you do them, help you to feel a little bit better. Whether it is exercise, gardening, music, art stroking the cat or just getting up on time in the morning doesn’t matter – whatever it is, you’ll feel better if you do it, so try to do it more!

Courage in Dying

I was deeply saddened last month by the need to attend the funeral of a dear friend who had taken his own life. The service was handled with great sensitivity by both the minister and my friend’s family. There was no attempt to hide the tragedy of what had happened, while still allowing us all to remember the warmth of the friendship we had lost. And yet.

And yet you couldn’t help thinking that had he died of cancer we would have all felt very differently as we remembered his life. It didn’t seem fair that because he had been dealt the hand of depression, rather than a more obviously physical illness, we would think more of the means of his death than his battle with his illness. Had he died of cancer we would have talked of his brave fight against the disease; had his killer been meningitis we would have railed against an illness that could so tragically and indiscriminately take such a young life. As it was depression that killed him, it was hard to think other than with regret that no-one had managed to stop him.

Of course, I would have wanted to stop him if I could. I would have wanted to tell him that the despair and overwhelming sense of worthlessness that he felt were not the truth, but part of an illness. I would have wanted to stand by him and remind him gently that if he just stood there long enough, if he could go through the mundane cycle of waking, eating and sleeping enough times, then hope would start to glimmer in his life once again, as I know it would. But I was not there. He chose, with the private dignity that he always prized when it came to his illness, to keep his true feelings to himself – to remove himself from those who loved him, and to face his pain alone. A tragic choice, but a brave one nevertheless.

Many people suffering from depression will think of suicide at some stage. Thankfully, far fewer will actually consider doing anything. Often people will tell me they are ‘far too much of a coward to actually try to kill themselves.’ Hooray for cowards I say! But there is something here – there is a great stigma against suicide in our society, an underlying shame that someone ‘gave up’, an under-current of feeling that there is something cowardly about not being able to continue with this life. As a doctor I will always do everything in my power to prevent suicide, but I refuse to remember my friend in shame, even in the manner of his death, or to consider that there was anything cowardly in his actions. Which requires more courage – to die of cancer in your own home surrounded by your family and supported by good medical care, or to be so destroyed by the ravages of Churchill’s Black Dog (the term that he famously applied to his own depression) that you have to face death alone?

The 16th Century French Essayist, Michel de Montaigne, writes about the importance of the manner of our death in his essay That no man shall be called happy until after his death. He quotes the Greek General Epaminondas who, “when asked which of the three he thought the best, Chabrias, Ephicrates, or himself, answered: ‘No one can decide that question till he has seen us all die.'” Death is such a taboo subject in our post-modern world that we no longer talk about a ‘noble’ death as the Greeks or the Tudors used to. What is fascinating to me is that our perception of what constitutes a worthy death has changed just as much as our ability to speak about it. Montaigne quotes many examples of good deaths in his essay – not least Scipio, the father-in-law of the Roman military leader Pompey who ‘by a worthy death…redeemed the bad name that had dogged him up to his last day.’ And how did Scipio die? He committed suicide.

Learning to Love the Right Side of Your Brain

“I just sat down and thought about the things that make me feel better,” a patient said to me the other day, “and remembered how good I feel when I listen to classical music.” He went on to tell me that he had started making time to listen to it, and even been to a couple of concerts. It had done him a world of good, and had lifted his mood far more than any of the solutions I had suggested. I can’t know for certain, but I suspect he had tapped into the right side of his brain.

The two halves of the brain certainly have different functions. We have known that the left side of the brain is crucial for the use of language ever since a doctor called Paul Broca conducted an autopsy in 1861 on a patient who died of syphilis. This patient had acquired the nickname ‘Tan’ as it was the only word he could say clearly, and a particular part of his left cerebral hemisphere had been destroyed by the syphilis bacterium. This area of the brain is now known as ‘Broca’s area’.

The left side of the brain helps us to interpret the world through words and language. It can deal with order, structure, timetables and lists. Whenever you are aware of an almost audible, or internally visible, running commentary going on in your head, that is the left side of your brain at work. The commentary might be as highbrow as a complex analysis of an intellectual debate on the radio, or might be as a banal as wondering why the woman in front of you on the train is wearing that top with those trousers. The important thing is that its currency is words and language. It is logical and questions everything, sometimes flitting about with countless thoughts that seem to whirr around inside our head. It is good at tasks and keeping to time. It is vital if we are to get things done – but it finds it hard to stop, to slow down, to “lie down in green pastures and be led beside quiet waters,” – and so it is vulnerable to stress and burnout.

The right side of our brain is more aware of concepts and mood – if it listens to sounds it will pick up the feel of a piece of music, and often experience something ‘that words cannot describe.’ When the right side of the brain sees, it is happy to look in the abstract. The left will always try to pick out patterns – is that a face in that tree? A dog in the cloud? – while the right will take pleasure in the forms themselves, whatever they might represent – will enjoy the feel of wind on the face without wondering whether or not this means it might rain later and what about a rain coat?

Artists are keen to develop the right side of the brain. When someone first tries to learn how to draw a face, the left side will often dominate. It thinks it knows what an eye or a nose looks like, and will convince the artist to draw it the way it thinks it should be, rather than drawing the often odd collection of shapes in front of them that actually make up a human face – and then the left side will scold the would be artist for drawing the face wrong and being rubbish at art. If, however, the artist can allow the right side to take over it will be more content to deal with abstract forms, lines and shadows and then, eventually, the left side will be amazed that a face has appeared – and that it looks right!

You know you are in ‘right brain mode’ when your internal conversation begins to slow down, when times passes without you realising it and you are ‘lost’ in something, when you don’t have to think about what to think, and you couldn’t make yourself think about anything else anyway, even if you tried. I cannot quote you any medical research to prove it, but I am absolutely convinced that this must be good for us, that it allows the left side of the brain to rest for a while and, as the psalmist puts it “restores my soul.”

What fascinates me is that what taps deep into the right side of one person’s brain might barely cross the midline in another. A friend of mine enjoys running. When she is outdoors, speeding along a muddy track somewhere, she completely loses herself – afterwards she would struggle to tell you what she was thinking as she ran, she just knows how good it felt. When I go for a run I get bored. I find myself scratching for things to think about, calculating again and again how far I’ve run, and how far I have to go. No, if I want to engage the right side of my brain I’d do far better to get out into the garden with a trowel, or pick up a pencil and get drawing. For my patient at the beginning of this post it was listening to classical music, for another it will be playing the music themselves. It seems to me that an important way to protect ourselves from burnout and depression is to find out the way to get our own right brain engaged, and make time in our week to exercise it.

The apostle Paul says these words in the letter to the Phillipians (Chapter 4 v 8): “Whatever is true, whatever is noble, whatever is right, whatever is pure, whatever is lovely, whatever is admirable – if anything is excellent or praiseworthy – think about such things.” Regardless of our religious persuasion, I’m sure we can all agree that to spend time on things that are good – and do us good – must be something to aim for. Maybe the right side of the brain is the key to finding some of these things.

Can Technology Turn the Tide of Family Breakdown?

When I am talking to someone who is recovering from depression, I often ask the question “If you start to go downhill, who will notice first?” All too often, this is greeted by a thoughtful pause, and the realisation that the people who are nearby probably wouldn’t notice, and the people who would notice just aren’t nearby. Maybe the closest family tie is with a brother who lives in North London, or a sister who has just moved to Edinburgh, or parents who live on the other side of the world. The extended family has long since dispersed, and even the nuclear family is struggling to cope in our modern world.

We can engage in a round of nostalgic finger wagging and berate families for succumbing to the temptation to live apart, or maybe we can adapt to the opportunities of our modern world and find new ways of staying in touch and supporting those who are close to us. If better transport systems and social mobility mean we no longer live cheek by jowl with any number of siblings, aunts and cousins, maybe better communication systems mean we can find new ways of overcoming the vast distances that stand between us and those we care about. And so I was very interested to hear about a couple of new and innovative websites Moodscope and Mood Tracker. These sites offer a novel way of monitoring your mood, and also give you the option of sharing this information with other people – maybe now you can help those who want to notice to be close enough to notice.

The principle behind these sites is that if you are concerned about your mood it makes sense to monitor it regularly – just as someone trying to lose weight would jump on the scales every morning, why not assess your mood at the start of every day? It’s a very simple suggestion, but it makes sense. Users of the sites often find that just pausing each morning to ask themselves how they are feeling can bring a greater sense of control, and this in itself can bring an improvement in mood. The sites record your past mood, which allows you to spot patterns. Maybe you can start to recognise that your mood often dips for a day or two, but always comes up again, or that it always dips when you don’t have enough sleep, or maybe it would help to spot that things are really not going well and you need to seek help.

The main difference between the sites is the way mood is assessed. Mood Tracker uses a simple self-assessment of mood, irritability and anxiety – easy and quick to do, but quite a blunt tool that could give the same answers time after time. Moodscope has a more sophisticated test which uses 20 questions to achieve an overall mood score. It has a fun way of asking the questions, involving spinning and turning cards on the screen in order to give an answer. This takes more time to complete and so may not suit everyone – although it is still only a couple of minutes and the extra time needed might actually be beneficial if your mood is low, as it gives an opportunity to stop and think about how you are really feeling.

An optional extra on both sites is to involve one or more friends to support you and receive your scores via e-mail. While this might not be for everyone, knowing that someone is journeying with you can be a lift in itself. If your scores are falling you can have the person you want to notice be the person who will notice – even if they are thousands of miles away. And perhaps, with an e-mail, or a text, or even a Skype, those miles won’t seem quite so long and recovery from depression won’t seem quite so lonely.

So, can technology turn the tide of family breakdown? No, I’m sure it’s much more complicated than that – but perhaps if we use it right we can make a ripple or two in the other direction.