'Pursuit of happiness' is the answer say UK mental health experts

This month, the CentreForum Mental Health Commission concludes what is being described as a 'landmark study on the state of mental health in England'. The 12-month commission has identified five key priorities for implementation between now and 2020. The final report calls for policy makers to:

• Establish the mental wellbeing of the nation or 'the pursuit of happiness' as a clear and measurable goal of government
• Roll out a national well-being programme to promote mutual support, self-care and recovery, and reduce the crippling stigma that too often goes hand in hand with mental ill-health
• Prioritise investment in the mental health of children and young people right from conception
• Make places of work mental health friendly, with government leading the way as an employer
• Better equip primary care to identify and treat mental health problems, closing the treatment gap that leaves one in four of the adult population needlessly suffering from depression and anxiety and one to two percent experiencing severe mental illness such as schizophrenia

Now, I don't know about you, but while the intention of these recommendations may be noble, when you start to try to grab hold of these points, it seems there is nothing to sink your teeth into - the image of a toothless doberman springs to mind.

For instance, there is a big difference between establishing 'the mental wellbeing of the nation' and establishing 'the pursuit of happiness' as a measurable goal of government. As any therapist worth their salt will tell you 'mental wellbeing' and 'happiness' are not synonymous - it may well be that, in order to establish mental wellbeing, a period of decided unhappiness may be indicated, whilst difficult feelings are discussed and worked through.

Then there's the reality that what makes one individual 'happy' may not be in the interests of the social good - how about the paedophile whose greatest happiness is derived from, well, paedophilia?

And how exactly would one propose going about measuring the level of societal happiness - should the government decide the parameters? And, in any case, how can measuring in generality possibly tell you anything meaningful about individual suffering?

Moving to the second point, nothing wrong, on the face of it, with the idea of 'rolling out a national well-being programme', but again, who's to say what constitutes well-being? And are we not already steeped in national mental health well-being programmes, from support given through the NHS and other government-funded mental health organisations? Just what is being proposed here? And is there still a 'crippling stigma' surrounding mental ill health? Really? It seems to me that this is one area in which there has been much progress made in the last ten years - to the point where we risk actually enabling sufferers of mental ill health, through sheer sentimentality.

Other gripes - how exactly does one prioritise the mental health of a baby in utero (note the use of the word 'conception' in the third point) apart from letting it live, of course (but that's a whole other story) and is it true that people needlessly suffer from depression and anxiety?

Again, as any good therapist will tell you, depression and anxiety are often the clarion call to growth, the only way an individual can be woken up from painful, destructive and, yes, often crippling ways of being in the world.

At very best, these recommendations demonstrate a lack of insight and understanding into the true nature of mental ill health and at worst, they risk creating more suffering and frustration for those who will be told that the answer to their manifold difficulties is to 'get happy'.

What are your thoughts about the report? Is the pursuit of happiness the answer? Please leave your comments below.

Written by Jacqui Hogan 

An OCD treatment we'll keep coming back to?

Obsessive Compulsive Disorder (OCD) is a condition characterised by unreasonable thoughts and fears (obsessions) that lead to repetitive behaviours (compulsions). The archetypal example is hand-washing, but there are many different forms. In the case of hand-washing, to ease the fear of contamination, one may compulsively wash one's hands until they are chapped and sore (i.e. self-harm), yet still be unable to rid oneself of the conviction of ongoing risk from germs.

In fact, every addiction is an expression of OCD - the alcoholic compulsively returns to drink to ease (often unconscious) obsession, and the food addict returns to the fridge to avoid underlying emotional disturbance. Given the incidence of addiction in our culture, the level of need for effective treatment of OCD is clear.

A German research team has recently reported on an internet-based writing approach, with some promising results.

In an article published in Psychotherapy and Psychosomatics, whose title begins 'No talking, just writing', the team describes how 34 volunteers with DSMIV-classified OCD were randomised into a treatment and a control group, with follow-up at eight weeks and six months. The internet-based writing intervention consisted of 14 sessions and the main outcome measure was change in severity of OCD symptoms.

Symptoms were significantly improved in the treatment group and the effect remained consistent at six-month follow-up. Compliance was excellent, with only four participants (12%) leaving the study prematurely. Of the thirty completers, 90% considered their condition improved and would recommend such intervention to their friends.

So is internet-based writing therapy the way ahead for OCD? Obviously, larger sample sizes are needed, but this research clearly suggests positive potential.

What's your treatment experience with OCD, either as a patient or a clinician? How effective is medication and/or talk therapy in your experience and can you imagine a role for the internet in managing the condition? We'd love to hear your thoughts and insights.

Written by Jacqui Hogan

Herbal doesn't always mean harmless; news for St John's Wort

St John's Wort has, for centuries, been used as a treatment for mental disorders and nerve pain. Named after St John the Baptist whose feast day on 24 June coincides with its full bloom, its five yellow petals are thought to represent a halo, and characteristic red sap the blood of the martyred saint (St John the Baptist was beheaded for calling into question Herod's morality).

It seems there is good justification for its use. A review of 29 trials in 2008 concluded that, in major depression, St John's Wort is superior to placebo, as effective as standard antidepressants and exhibits fewer side effects than standard antidepressants - not bad going for a herbal remedy. Indeed, it is currently the number one alternative treatment for depression in the USA, a common resort for those who are not comfortable with formulations like Prozac.

But a new study published in the Journal of Alternative and Complementary Medicine suggests that care should be exercised when choosing to take, dispense or prescribe St John's Wort. Though a natural extract, it is proven to interact with many commonly prescribed drugs, resulting in impaired effectiveness and, sometimes, treatment failure. Treatments with which it interacts include the contraceptive pill, anticoagulants, some chemotherapy drugs and antihypertensives.

Lead author of the study, Sarah Taylor, rightly observes that 'patients may have a false sense of security with so-called 'natural' treatments like St John's Wort'. What most people don't understand is that just because an agent is derived directly from nature does not mean it is any less potent than a synthetic pharmaceutical - one only needs to look at the case of digitalis (extract of foxglove and powerful heart anti-arrhythmic) or aspirin (derived from willow bark) to prove this point.

This latest research (conducted in the city of Winston-Salem, North Carolina, from medical records compiled between 1993 and 2010) sought to quantify the scale of the potential problem, by looking at how often St John's Wort was taken with other medications, and how often the combination might have been harmful.

In an astonishing 28% of cases, St John's Wort, taken with another drug, may have caused problems for the patient, though this is probably an underestimate, since patients often do not report on the use of natural remedies. 

With results such as these, it's little wonder that France is now banning the use of St John's Wort, and that the United Kingdom, Canada and Japan are introducing drug-herb interaction warnings on packaging.

The good news is that St John's Wort seems to be helping patients with depression and, if it comes with the benefit of fewer side-effects than prescription medications, this can only be a bonus. The greater the awareness of its broader impact (with particular reference to drug interactions), the greater its potential as a safe and viable alternative antidepressant treatment.

Written by Jacqui Hogan

The truth about lies

Believe it or not, there is such a thing as 'deception literature' - that is the study of lies in the practice of communication. I'm not sure whether it's a good thing or a bad thing - good, I suppose, in that someone is actually bothering to take account of mankind's propensity to deceit, and bad, in that there is a bona fide market for it.

Data collected as part of a public engagement project by the Science Museum in London in 2010 has recently been used to generate a new online survey (n= 2,980), in which participants reported how often they told small lies (so-called 'white' lies) and how often they told big lies. The researchers, Kim Serota from Oakland University, Rochester and Tim Levine from Korea University, Seoul, also asked participants to share their attitudes to, and experiences of, lying.

The results reveal that almost 10% of the UK sample were prolific liars, who averaged over six white lies per day and almost three big lies. This was compared with the average of a little over one white lie per day and one big lie per week told by 'everyday liars', who made up the bulk of the sample. There was consensus between the two groups as to what constitutes a big lie, with lying about whether you love someone being the most popular example.

Prolific liars are more likely to be younger and male and to work in more senior occupational roles (scary, no?). They also tend to be unrepentant, considering their behaviour not something they expect to grow out of. They are more likely to lie to their partners and children than everyday liars, who tend to lie more to their mothers. Lies, it seems, are first and foremost a family affair.

Previous work by the same researchers on a sample population from the USA reveals that, on average, Britons are bigger liars than Americans, telling just over two lies per day to Americans' one to two per day.  Around 25% of the UK sample said they lie on a typical day, compared with almost 60% of the US sample - problem is, who do you believe?!

The authors report in their paper summary:

"[This] recent research and reanalysis of previous studies reporting the frequency of lies shows that most people are honest most of the time and the majority of lies are told by a few prolific liars."

That's all well and good, but what I find fascinating is that what we're dealing with here are just two groups - prolific liars and everyday liars - is there anyone out there who actually tells the truth? The researchers' assessment above that 'most people are honest most of the time' is still referring to everyday liars - I would find it far more reassuring to know there are people out there who simply don't tell lies at all!

There's an adage in the popular 12-Step recovery movement (Alcoholics Anonymous being the best known example) which goes 'you are as sick as your secrets.' If that statement is true, it would seem we are living in a frightfully ailing culture.

What are your thoughts about truth and lies? How important is the truth to the sustenance of good mental health - is it important at all? Is it even possible not to tell lies? Let us know what you think by commenting below.

Written by Jacqui Hogan

The high price of the Great Recession

You've heard of 'the Great Depression', but a new paper published in the British Journal of Psychiatry from the University of Oxford and London School of Hygiene and Tropical Medicine refers to 'the Great Recession'- the economic crisis which rocked the world, starting in 2007.

The research team have analysed recently released data on suicide from the World Health Organization, covering 26 countries across the European Union (EU) and North America. and discovered that at least 10,000 suicides - which they term 'economic suicides' - can be attributed to financial hardship. They describe this finding as 'conservative' and note that the rise in the period between 2008 and 2010 (the study period) is substantially greater than could have been expected.

The figures show that a downward trend in the rate of suicides in the EU reversed when the crisis hit in 2007 and rose by 6.5% by 2009, remaining at this level through to 2011. Between 2007 and 2010, the number rose by 4.5% in Canada, and in the USA by 4.8% for the same period.

The main risk factors were found to be job loss, home repossession and debt. Antidepressant prescription rates rose dramatically in some countries - in the United Kingdom a rise of 19% between 2007 and 2010 occurred.

One of the questions raised by the study is whether an increase in suicide rates in response to recession is inevitable. Despite the general nature of the recent recession, not all countries have experienced an increase in suicides - for example in Austria, Sweden and Finland, rates did not increase at all, despite rising unemployment. In fact, in Austria, the rate declined.

Lead author, Aaron Reeves, of Oxford University's Department of Sociology, observed:

"A critical question for policy and psychiatric practice is whether suicide rises are inevitable. This study shows that rising suicides have not been observed everywhere, so while recessions will continue to hurt, they don't always cause self-harm."

The team estimates that for each US $100 spent per capita on programmes offering assistance to the unemployed, the risk of suicide could be reduced by 0.4%, and they suggest that a range of interventions, from return-to-work programmes through to increased antidepressant prescribing may reduce the number of deaths in the event of future adverse economic events.

Of course, underlying this radical response made by some individuals to economic hardship is the mistaken notion that their worth is tied up with their jobs, money and what they own. Breaking the attachment to money in a society fuelled by voracious capitalism is no small ask - but for some, such a crisis may be the beginning of a very real return to the things that actually matter.

Written by Jacqui Hogan

New help weighing up antidepressants

I have a cousin who has suffered from depression for years. Like many in her position, she'll go through a period when things are OK, during which time she might stop taking her medication; never a good idea.

As a consequence, she's sampled lots of different antidepressants, with doctors using her lack of compliance to try on different drugs to see which one will suit her best.

From time to time, she complains that her medication is making her put on weight, which greatly adds to her burden - as one who is under the delusion that her worth is linked to her appearance, you can understand why. Sadly, she is not alone.

Studies to date do, indeed, suggest that antidepressants are associated with weight gain, but little is known about the long-term effects and the differences between various types of medication.

A recent study in JAMA Psychiatry offers a little more clarity on this issue, showing that there are small, but significant differences between the level of weight gain associated with different types of antidepressant.

The researchers, in Boston, used digital health records to obtain prescribing data and body weight measurements for adults who had been prescribed eleven different antidepressants. Over 22,000 patient records were analysed over 12 months, and antidepressants ranged from the older types, amitripyline for example, to the more modern SSRIs and SNRIs.

The results showed that there was a modest difference in weight gain between patients taking different drugs. Of note, there was significantly lower weight gain on bupropion, amitriptyline (widely believed to contribute to weight gain) and nortriptyline, compared to citalopram (Cipralex - 2.5 pound gain on average), fluoextine (Prozac - 1.5 pound gain on average) and sertraline (Zoloft - nearly 2 pound gain on average).

The authors concluded:

"Taken together, our results clearly demonstrate significant differences between several individual antidepressant strategies in their propensity to contribute to weight gain. While the absolute magnitude of such differences is relatively modest, these differences may lead clinicians to prefer certain treatments according to patient preference or in individuals for whom weight gain is a particular concern." 

This is good news for my cousin, who resists the suggestion of talk therapy (and therefore might reasonably be expected to remain on medication for the foreseeable future) and has recently been diagnosed with hypertension. She might now be prescribed for in accordance with her clinical risk and preference for weight maintenance.

Written by Jacqui Hogan

Babies and antipsychotics don't appear to mix

Drug safety is very much on the agenda in the UK, with the government's Early Access to Medicines Scheme unveiled to great industry acclaim earlier this year. The scheme allows patients with serious illness to gain access to drugs before they are approved, with lobbyists making much of the popular benefit of 'greater choice'.

A seven-year observational study has recently reported on the impact on babies of antipsychotic medication taken during pregnancy. The results provide pause for thought.

Apart from raising concern about the use of high doses of antipsychotics in this context, they also raise a question about the wider issue of drug safety - when even licensed drugs can yield such unexpected results, what hope for drugs which are being promoted and used off licence?

The study, conducted by the Monash Alfred Psychiatry Research Centre and Monash University in Australia, showed that the use of mood stabilisers or high doses of antipsychotics during pregnancy increased the need for special care among newborns, with 43% of babies placed in Neonatal Intensive Care Units (NICU) or Special Care Nurseries (SCN) - almost three times the national average.

Aside from increased need for specialist post-natal care, 18% of such babies were born prematurely, 37% showed signs of respiratory distress and 15% developed withdrawal symptoms.

The investigators commented on the dearth of research in this area, with lack of data making it difficult to provide informed advice to expectant mothers on drug safety.

Noting this deficit, in 2005 the Monash Alfred Psychiatry Research Centre established a National Register of Antipsychotic Medications in Pregnancy (NRAMP), recruiting women from all around Australia. A total of 147 women were interviewed every six weeks during pregnancy and followed up until their babies were one year old.

Around 25% of people in the UK experience depression over the course of a year, with women more likely to suffer than men. Women have higher rates of anxiety and there is roughly equal distribution between the sexes with schizophrenia and bipolar disorder. These results, then, may apply to a significant proportion of the population.

On the positive side, the research has shown there are no clear associations with congenital abnormalities associated with antipsychotic drugs and, on top of this, clinicians may now be better prepared to address potential problems for newborns whose mothers are taking medication.

No drug comes without side effects and it is incumbent on government regulators to go to every possible length to protect the sick and vulnerable from such effects outweighing the benefits. Let us hope that the prevailing trend towards medicating first, assessing later will not lead to future harm.

Written by Jacqui Hogan