By Professor Richard Gray [pictured]Image credit
"If I'd asked my customers what they wanted, they'd have said a faster horse." Henry Ford
Today is world mental health day. Looking at mental health practice right now it feels sadly devoid of the revolutionary, imaginative and creative thinking that we take for granted in so many other areas of our lives. In a very real sense the outcomes for patients with long term mental illnesses like schizophrenia are getting worse, not better.
This is a tragedy; mental illness is painful and distressing. It is hard to imagine the torment that someone with schizophrenia experiences when they hear voices telling them that they are evil and deserve to die. To understand the pain of these symptoms we have to recognise that this is their reality and it is absolutely terrifying. These are symptoms of an illness, an illness where there is dysfunction in the patient's brain.
Medicines are essential to alleviate the distress and torment of psychotic symptoms. Reducing the intensity of the delusion or pushing the voices into the background antipsychotic drugs rarely completely eliminate symptoms and are certainly no cure.
In many respects, the medicines we have now are little different to those like chlorpromazine, that we used in the 1950s. The new generation of antipsychotic drugs are more refined and cause fewer side effects, but fundamentally they work in the same way. Metaphorically drug researchers have bred slightly faster horses, there has been no great jump forward.
Where will new treatment advances come from?
There is a sense that investment, both intellectually and financially, in the development of new drug treatments has faded and shifted; in part because of the negative public perception drugs for mental illness have, and an increase in demand for talking treatments as an alternative to pills.
Sensational media stories of antidepressants making patients suicidal are ill informed but attention grabbing and have contributed to our negative image. Even among mental health professionals there is widespread "anti medication" sentiment. A senior and influential Clinical Psychologist suggested to me recently that pharmaceutical industry research was "little more than propaganda".
Do psychological (talking) treatments represent the paradigm shift from horse to car that we need? I want to argue that our current obsession with improving access to psychological treatments reflects society's Freudian belief that mental illness is located in the mind and not the brain and can be sorted out by talking.
Cognitive behavioural therapy (CBT) is probably the most popular talking treatment.
Researchers have demonstrated that when delivered by a skilled therapist, CBT is as effective as antidepressant medication in the treatment of depression. Against schizophrenia and bipolar disorder, CBT also seems to be effective for example in helping patients cope with voices. But, and it is an important but, CBT only works (in schizophrenia and bipolar disorder), if patients are already on medication.
CBT, like all talking treatments, are complex interventions that need to be provided by skilled therapists. The problem; there simply aren't enough to meet demand and there never will be. A major initiative to improve access to psychological therapies (IAPT) consumed £170 million of new money.
Mental health practice is littered with countless examples of effective but complex interventions that work in theory but not in practice. The reason that they don't work is that they are too complex. Perhaps rather than focusing on ever more complex intervention we should consider simple intervention that can be reliably provided to all patients with mental illness. In a time of austerity making sure that everything we do really counts makes a lot of sense.
Back to medication. Mental illnesses such as schizophrenia , bipolar disorder and quite often depression, are long term conditions that require patients to stick with their medication, often indefinitely.
Whilst we need new treatments we could get much more out of the medicines we already have. Virtually every patient with schizophrenia or bipolar disorder misses doses of medication; this increases the risk of relapse and the return of painful and distressing psychotic symptoms. In fact the single biggest cause of relapse is that patients stop taking medication. There are many simple things that we can do to enhance adherence to treatment. I passionately believe we should be more positive about promoting the benefits of medication to our patients and their families.
For many patients, those with schizophrenia and bipolar disorder particularly, medication is a foundation to effective treatment and we should do everything to make sure that they stick with treatment. This is perhaps one of the most important things we do as mental health professionals.
There are other things we can do to help patients manage their medication; help them make choices about which drug will suit them best; closely monitor the effects and side effects of medicines, offer long acting injections rather than daily pills, use mobile phone text prompts to remind patients to take pills, prescribing a tablet that can be taken once once rather than four times a day. Simple things that work and help patients stick with treatment.
Ever more complex treatments that can never be scaled up to meet the need within the population seems to me like flogging, if it's not extending a metaphor to far, dead horse.
Our customers (patients) want greater access to talking treatments. I am far from convinced that the investment in psychological therapies has reaped the rewards that were promised when the IAPT programme was launched.
We need new medications and this requires intellectual as well as financial investment. When Henry Ford launched the Model-T, when Apple launched the iPad, these were leaps of imagination.
I want to argue for a simple revolution; we stop doing the complex badly and focus of doing simple things exceptionally well. But my real plea on world mental health day is to stop listening quite so much and start imagining.
Now more than ever we need real invention in mental health care and treatment.
Model-T image credit