A better response to depression

Depression may be "invisible", but it can be known and understood (Editorial, 4 August). There is increasing evidence that mental health problems are developmental in nature, and up to three-quarters of adult difficulties start in childhood. Psychotherapy frequently reveals present and past losses, in keeping with known risk factors. Drugs and brief cognitive therapies can help greatly, but they do not engage our complex emotional histories, the rejections, separations and bereavements revived by current adversity..

Self-referrals to a doctors’ mental health service over 10 years

Background: The adverse impact on doctors’ health of constant organizational change in healthcare is well established. Aims: To investigate the change in self-referral rates to a doctors’ mental health service, and associated morbidity over a decade. Methods: All doctors attending a doctors’ mental health service between 1 January 2002 and 31 December 2011 were asked to complete the Clinical Outcomes in Routine Evaluation questionnaire and Maslach burnout inventory as part of routine assessment before treatment. Univariate analysis of variance was used to test for statistically significant differences between severity scores in different years. Results: Between 1 January 2002 and 31 December 2011, 1062 doctors attended the service; 852 (80%) completed both questionnaires and 64 (6%) completed one of them. The overall response rate was 86% (916/1062). Referrals increased >4-fold, from 44 in 2002 to 185 in 2011. Sixty-one per cent scored above the threshold for psychological distress and 59% for burnout. There were no significant changes in morbidity over time. Conclusions: Increasing numbers of doctors sought help from the doctors’ mental health support service. More than half scored above the thresholds for burnout and psychological distress and these proportions were consistent over 10 years. Doctors may be more willing to seek help than a decade ago. Further research is needed to confirm the underlying reasons for this. More resource is needed to meet the increase in demand

The fatal outcome of an individual with anorexia nervosa and Sheehan's syndrome as a result of acute enterocolitis: A case report

Objectives: To illustrate the close association between a disturbed psychosocial up-bringing, frequent physical illness, and medical interventions. Method: We report a case of a 44-year-old woman with anorexia nervosa (AN) and Sheehan's syndrome who died as a result of a toxic cardiac arrest. Results: The patient presented with a BMI of 13.6 kg/m2. She refused any intensive-care treatment and died from toxic cardiac arrest. Postmortem examination revealed an acute gastroenterocolitis. Discussion: The history of this patient illustrates how psychological deprivation led to eating disturbances, early pregnancy, and the life-threatening delivery of twins. This resulted in a diagnosis of Sheehan's syndrome, hepatitis C, and a ventricular ulcer. A psychosocial event triggered a late exacerbation of her AN. A helpful alliance between patient and staff did not occur as she rejected it

Epistemological flaws in NICE review methodology and its impact on recommendations for psychodynamic psychotherapies for complex and persistent depression

The UK draft NICE guideline on depression in adults was sent out for stakeholder consultation between July and September 2017. The final guideline publication date currently remains ‘to be confirmed’. This paper sets out key concerns with the methodology employed in the guideline and its impact on recommendations for psychodynamic psychotherapies for complex and persistent depression. The draft largely ignored the subjective experiences and voices of service users, carers and members of the public, using out of date limited evidence of service user and carer experiences. The guideline fails to incorporate what limited qualitative evidence it reviewed into any treatment recommendations. The Guideline Committee created its own method for categorising depression by longevity, severity and complexity. This has resulted in erroneous and unhelpful classifications of research studies under groupings which do not match clinical and service user experiences or US and European approaches, rendering analyses and conclusions unreliable. We also outline instances of incorrect classification of psychodynamic treatments (such as inclusion of non bona fide treatments or exclusion of relevant bona fide treatment studies) which enables the omission of a recommendation for psychodynamic psychotherapy for complex and persistent depression. Depression is often a long-term condition or can become so if immediate care is inadequate; yet the draft recommendations are all made on the basis of short-term outcome data (with often less than eight weeks between baseline and outcome). NICE guidelines for long-term physical conditions would treat this evidence as inadequate. Finally, the draft guideline used the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system of assessing methodological quality in such a way as to produce a systematic bias in favour of drug trials, selectively omitting trial data with long-term follow-up points and those which used non-symptom outcomes. Herein, we consider the increasingly evident limitations of the paradigm NICE works within for ensuring patient choice and equity of access to a wide range of therapies

The economic cost of treatment-resistant depression in patients referred to a specialist service

Background: Patients with treatment-resistant depression (TRD) suffer very significant morbidity and are at a disadvantage concerning optimal clinical management. There are high associated societal costs. Aims: A detailed analysis of health economic costs in the United Kingdom in a group manifesting a severe form of TRD in the 12 months before their participation in a major randomized controlled treatment trial. Methods: The sample consisted of 118 participants from the Tavistock Adult Depression Study. Recruitment was from primary care on the basis of current major depression disorder of at least 2 years’ duration and two failed treatment attempts. Service utilization was assessed based on self-report and general practitioner (GP) medical records. Generalized linear models were used to identify predictors of cost. Results: All participants used GP services. Use of other doctors and practice nurses was also high. The mean total societal cost was £22 124, 80% of which was due to lost work and care required of families. Level of general functioning was found to be the most consistent predictor of costs. Conclusions: Severe forms of TRD are associated with high costs in which unpaid care and lost work predominate. Treatments that improve functioning may reduce the large degree of burden

Non-strategic ignorance: Considering the potential for a paradigm shift in evidence-based mental health

Randomised controlled trials form a central building block within the prevailing evidence-based mental health paradigm. Both methodology and paradigm have been widely problematised since their emergence in the mid-late twentieth century. We draw on the concept of ‘strategic ignorance’ to understand why the paradigm still prevails. We present focus group data gathered from 37 participants (service users, public, carers, general practitioners, commissioners) concerning the way they made sense of a randomised controlled trial of psychotherapy for treatment-resistant depression. Thematic analysis of the findings revealed an overall critique of randomised controlled trial methods which we refer to as ‘non-strategic ignorance’. Specifically, participants problematised the construct of depression, unseating the premise of the randomised controlled trial; they were sceptical about the purpose and highlighted its failure to show how therapy works or who might benefit; the randomised controlled trial was seen as inadequate for informing decisions about how to select a therapy. Participants assumed the treatment would be cost-effective given the client group and nature of the therapy, irrespective of any randomised controlled trial findings. Each area of lay (‘non-strategic’) critique has an analogous form within the methodological expert domain. We argue that ‘expert’ critiques have generally failed to have paradigmatic impact because they represent strategic ignorance. Yet parallel non-strategic critiques have common sense appeal, highlighting the potential power of lay voices. The discussion considers whether the evidence-based mental health paradigm is faced with epistemological problems of such complexity that the conditions exist for a new paradigm in which service user views are central and randomised controlled trials peripheral

Why do some voluntary patients feel coerced into hospitalisation? A mixed-methods study

This study aimed to investigate factors linked to perceived coercion at admission and during treatment among voluntary inpatients. Quantitative and qualitative methods were used. Two hundred seventy patients were screened for perceived coercion at admission. Those who felt coerced into admission rated their perceived coercion during treatment a month after admission. Patient characteristics and experiences were tested as predictors of coercion. In-depth interviews on experiences leading to perceived coercion were conducted with 36 participants and analysed thematically. Thirty-four percent of patients felt coerced into admission and half of those still felt coerced a month later. No patient characteristics were associated with perceived coercion. Those whose satisfaction with treatment increased more markedly between baseline and a month later were less likely to feel coerced a month after admission. In the qualitative interviews three themes leading to perceived coercion were identified: viewing the hospital as ineffective and other treatments as more appropriate, not participating in the admission and treatment and not feeling respected. Involving patients in the decision-making and treating them with respect may reduce perceived coercion

Tavistock Adult Depression Study (TADS): a randomised controlled trial of psychoanalytic psychotherapy for treatment-resistant/treatment-refractory forms of depression

ABSTRACT: BACKGROUND: Long-term forms of depression represent a significant mental health problem for which there is a lack of effective evidence-based treatment. This study aims to produce findings about the effectiveness of psychoanalytic psychotherapy in patients with treatment-resistant/treatment-refractory depression and to deepen the understanding of this complex form of depression. METHODS: INDEX GROUP: Patients with treatment resistant/treatment refractory depression. DEFINITION & INCLUSION CRITERIA: Current major depressive disorder, 2 years history of depression, a minimum of two failed treatment attempts, [greater than or equal to]14 on the HRSD or [greater than or equal to]21 on the BDI, plus complex personality and/or psycho-social difficulties. EXCLUSION CRITERIA: Moderate or severe learning disability, psychotic illness, bipolar disorder, substance dependency or receipt of test intervention in the previous two years. DESIGN: Pragmatic, randomised controlled trial with qualitative and clinical components. TEST INTERVENTION: 18 months of weekly psychoanalytic psychotherapy, manualised and fidelity-assessed using the Psychotherapy Process Q-Sort. CONTROL CONDITION: Treatment as usual, managed by the referring practitioner. RECRUITMENT: GP referrals from primary care. RCT MAIN OUTCOME: HRSD (with [less than or equal to]14 as remission). SECONDARY OUTCOMES: depression severity (BDI-II), degree of co-morbid disorders Axis-I and Axis-II (SCID-I and SCID-II-PQ), quality of life and functioning (GAF, CORE, Q-les-Q), object relations (PROQ2a), Cost-effectiveness analysis (CSRI and GP medical records). FOLLOW-UP: 2 years. Plus: a). Qualitative study of participants' and therapists' problem formulation, experience of treatment and of participation in trial. (b) Narrative data from semi-structured pre/post psychodynamic interviews to produce prototypes of responders and non-responders. (c) Clinical case-studies of sub-types of TRD and of change. DISCUSSION: TRD needs complex, long-term intervention and extended research follow-up for the proper evaluation of treatment outcome. This pushes at the limits of the design of randomised therapeutic trials,. We discuss some of the consequent problems and suggest how they may be mitigated. Trial registration Current Controlled Trials ISRCTN40586372