The Emperor's New Clothes
Next month was supposed to see the finalisation of the new NICE guidelines for the treatment and management of depression in adults. Since depression and anxiety are far and away the most common mental disorders, and depression appears to be implicated in every other mental disorder, this is a very big deal: it will determine our treatment protocols for the condition identified by WHO as the world’s leading cause of ill-health and disability.[1]
The guidelines are now expected at the end of June. They’ll be the first update since October 2009 and those 13 years saw a dramatic increases in reported mental health issues (and a doubling of antidepressant prescriptions[2]) with the Royal College of Psychiatrists forecasting mental health referrals to increase by a further third as a result of the pandemic.[3] The process started back in September 2014, has involved an unprecedented three consultation documents and part of the reason it’s taken so long has been a series of unedifying turf wars between sections of the highly fragmented mental healthcare community.
Since there have been three consultation documents, we can have a pretty good idea of what it’s going to say. It is going to introduce a suggested hierarchy of treatments, which will place more emphasis on therapy (particularly group therapy) relative to medication than was previously the case, though individual practitioners will be free to make their own choices, and it will make more explicit reference to some interventions such as physical exercise, meditation and mindfulness, which are already being employed. In substance – in terms of what people encounter when they come for treatment – things are going to look very much the same. The Committee’s own verdict on its latest draft guidelines is that they reflect current practice but may reduce variation across the NHS. It’s going to be business as usual – which is odd because business isn’t at all good.
According to the NHS, just under half of the people who completed a course of psychological therapy for anxiety or depression in 2021 were considered to have recovered[4] – so that’s more than half who didn’t. And those figures only include people who completed a course – as around half drop out of treatment, the real recovery rate for people who receive treatment is much lower.[5]
Even where there is recovery, it’s difficult to know whether it’s the treatment that was responsible – things can just get better over time. There have been plenty of studies questioning whether therapy achieves better outcomes than ‘usual care’ or, say, acupuncture.[6] The largest ever review of randomized controlled trials into the effectiveness of antidepressants concluded that they do work better than placebos but their effect was modest.[7]
And where people are considered to have recovered, there’s virtually no evidence on whether those recoveries persist.
And it’s not as if it’s working well for anyone: thousands of counsellors and psychotherapists work in unpaid ‘honorary’ roles because there aren’t enough salaried roles or opportunities in private practice.[8] Most of the NHS’ psychological therapy is provided by unpaid trainees - so it’s remarkable that mental health still somehow manages to absorb 15% of the NHS’ budget.[9]
Even when provided by unpaid trainees, therapy is time consuming and expensive. About ten times as many people still receive medication for mental health issues through the NHS as receive therapy.[10] The search is on for new low intensity, high volume, high impact interventions, or it should be, but you wouldn’t know it from the new NICE guidelines.
One promising candidate is psychoeducation – telling people what’s going on; helping them to understand their own states of mind, and other people’s, better. Supported by evidence across a range of different conditions,[11] psychoeducation was included as a core element in the stepped care programme under the 2009 guidelines and was found to be well-tolerated by users and reliably effective.[12]
And if you take the role of self-esteem in mental health seriously, psychoeducation makes immediate sense. If you educate people about their mental experiences, you provide a social context. Everyone’s felt that sense of release and relief at some point from learning that something difficult or unpleasant which they imagined was peculiar to them was shared by other people. It’s an experience routinely celebrated by participants in group therapy and support groups. Ideas of aberration and defectiveness go right to the heart of mental health issues; it’s a powerful experience discovering that the things that bother you most (about yourself) are shared by other people.
A study in the Lancet a few weeks ago comparing different interventions for schizophrenia relapse found that psychoeducation was more effective than more active psychotherapeutic intervention and psychoeducation alone more effective than psychoeducation in combination with more active psychotherapeutic intervention – telling people what’s going on and leaving the shrinks out of it worked better than the shrinks.[13]
Psychoeducation had a minor but explicit role in the old guidelines but there are no references to it in the latest draft of the new ones.
Also reported a few weeks ago, arising out of concerns from the inquest for victims of serial killer Stephen Port, police guidance on unexplained deaths is to be re-written. The coroner’s report described several serious and basic failings by the police but singled out ‘a lack of professional curiosity’ about their cases for particular criticism.
It’s easy in any job to do what you do because that’s the way you do it – the ways things are done can slide naturally towards the convenience of the providers rather than the benefit of the users – but people working in mental healthcare often show a really profound lack of professional curiosity. People do what they do because (in that particular area of qualification or that school of psychotherapy) that’s what you do. Very often they have no knowledge of, or interest in, the evidence as to whether its effective.
The usual narrative is that the big problem is persuading uncaring politicians and administrators to devote the resources required to deal with an evolving mental health catastrophe. The bigger problem is the complete inability of mental health professionals to make a convincing case for investment.
It would be easy to see the preservation of the status quo in the new NICE guidelines, despite the obvious lack of support from the evidence, as a massively complacent and self-serving response to a situation whilst telling everyone there’s a crisis.
It’s more a reflection of something that runs right through mental healthcare – which is knowing that you don’t really know what you’re doing and a persistent lack of confidence that it’s doing any good.
[1] https://www.theguardian.com/society/2017/mar/31/depression-is-leading-cause-of-disability-worldwide-says-who-study
[2] https://www.theguardian.com/society/2016/jul/05/antidepressant-prescriptions-in-england-double-in-a-decade
[3] https://www.telegraph.co.uk/news/2021/10/24/nhs-mental-health-referrals-surge-third-due-pandemic/
[4] https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services/january-2022-final-including-a-report-on-the-iapt-employment-advisers-pilot/activity
[5] https://digital.nhs.uk/data-and-information/publications/statistical/psychological-therapies-report-on-the-use-of-iapt-services/january-2022-final-including-a-report-on-the-iapt-employment-advisers-pilot/activity
[6] Acupuncture and counselling for depression in primary care: a randomised controlled trial – PubMed https://pubmed.ncbi.nlm.nih.gov/24086114/ Humanistic counselling plus pastoral care as usual versus pastoral care as usual for the treatment of psychological distress in adolescents in UK state schools (ETHOS): a randomised controlled trial – ScienceDirect https://www.sciencedirect.com/science/article/pii/S2352464220303631 Cost-Effectiveness Analysis of Acupuncture, Counselling and Usual Care in Treating Patients with Depression: The Results of the ACUDep Trial https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0113726
[7] Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis - The Lancet https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32802-7/fulltext
[8] https://blogs.lse.ac.uk/businessreview/2016/11/21/in-the-absence-of-proper-jobs-therapists-turn-to-precarious-work/ https://www.bacp.co.uk/news/news-from-bacp/2018/17-april-2018-working-for-free/
[9] https://www.england.nhs.uk/mental-health/taskforce/imp/mh-dashboard/
[10] Mental health statistics: prevalence, services and funding in England - House of Commons Library https://commonslibrary.parliament.uk/research-briefings/sn06988/
Prescribed medicines review: summary - GOV.UK https://www.gov.uk/government/publications/prescribed-medicines-review-report/prescribed-medicines-review-summary
[11] Effectiveness of psychoeducation for depression: a systematic review Mariana Flávia de Souza Tursi , Cristiane von Werne Baes, Fabio Ribeiro de Barros Camacho, Sandra Marcia de Carvalho Tofoli, Mario Francisco Juruena Aust N Z J Psychiatry. 2013 Nov;47(11):1019-31. doi: 10.1177/0004867413491154. Epub 2013 Jun 5. Efficacy of psychoeducational approaches on bipolar disorders: a review of the literature. Rouget BW, Aubry JM.J Affect Disord. 2007 Feb;98(1-2):11-27. doi: 10.1016/j.jad.2006.07.016. Epub 2006 Sep 1.PMID: 16950516 Review. Psychoeducational interventions in adolescent depression: A systematic review. Bevan Jones R, Thapar A, Stone Z, Thapar A, Jones I, Smith D, Simpson S.Patient Educ Couns. 2018 May;101(5):804-816. doi: 10.1016/j.pec.2017.10.015. Epub 2017 Oct 24.PMID: 29103882. Effectiveness of a brief psychoeducational group intervention for relatives on the course of disease in patients after inpatient depression treatment compared with treatment as usual--study protocol of a multisite randomised controlled trial. Frank F, Wilk J, Kriston L, Meister R, Shimodera S, Hesse K, Bitzer EM, Berger M, Hölzel LP.BMC Psychiatry. 2015 Oct 23;15:259. doi: 10.1186/s12888-015-0633-4.PMID: 26497218 Therapeutic benefit of a registered psychoeducation program on treatment adherence, objective and subjective quality of life: French pilot study for schizophrenia. Sauvanaud F, Kebir O, Vlasie M, Doste V, Amado I, Krebs MO.Encephale. 2017 May;43(3):235-240. doi: 10.1016/j.encep.2015.12.028. Epub 2016 Sep 19.PMID: 27658989
[12] Burns, P., Kellett, S., & Donohoe, G. (2016). “Stress Control” as a Large Group Psychoeducational Intervention at Step 2 of IAPT Services: Acceptability of the Approach and Moderators “of Effectiveness. Behavioural and Cognitive Psychotherapy, 44(4), 431-443. doi:10.1017/S1352465815000491
[13] Family interventions for relapse prevention in schizophrenia: a systematic review and network meta-analysis https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(21)00437-5/fulltext