The current concerns about easily-rupturing and possibly toxic PIP breast implants do not seem to be leading to much debate on: (1) Should psychotherapy for body image problems be made more available? (2) Should cosmetic surgery, in general, be more restricted?
In 2007, the BBC3 series Say No to the Knife did attempt to address this issue. It is no longer available on the BBC’s iPlayer, so I can’t check my own recollection that it was fairly superficial, offering not much more than styling and clothing tips Trinny and Susannah-style. No disrespect intended to those particular small screen goddesses, who probably never intended their message to be a universal panacea.
There were only seven episodes of Say No to the Knife, and we may never know why. Perhaps a further series would have risked drawing attention to poor NHS mental health services, which is likely to be a factor for some people seeking surgery in the UK.
Susie Orbach, well-known for her 1978 Fat is a Feminist Issue, addressed breast implants, liposuction and similar procedures in her 2009 book Bodies. Usual suspects appear: mistaken female bodily ideals, the market-driven, consumerist Western society and its commodification of emotion. Well, I respect the choice of anyone to opt out, as much as they can, from all of those things. But I know lots of people living ordinary Western lives, who wouldn’t think of having cosmetic surgery, so I somehow think there must be other causes as well.
Last month’s radio programme about lobotomy (1) is interesting because it slightly departs from the usual historical scripts, which are: evil psychiatrists used lobotomy as a destructive form of social control, or well-meaning but weak ones rubber-stamped the decisions of others, such as Nurse Ratched in One Flew Over the Cuckoo’s Nest.
It emphasises that the inventor, and two of the main promoters of lobotomy were in fact not psychiatrists. Politician and neurologist Egas Moniz started the ball rolling. Then, American neurologist Walter Freeman, and the British surgeon Sir Wylie McKissock, both continued to do thousands of operations despite evidence for uncertain therapeutic results.
Historical radio and TV programmes about the bad aspects of the old asylum system (which I don’t advocate returning to, but will say it was always underfunded) are often a means, I think, of deflecting attention from current NHS mental health failings. Other occasional broadcasts about the mental health systems of second- or third-world countries generally have the same function.
At least this one is a little different. However, it seems to me that there is a clear parallel between lobotomy and another kind of invasive operation for a serious behavioural (and often psychiatric) disorder today.
Although obesity surgeons are not household names (yet), there has never been a proper trial of gastric banding or the more serious procedure of partial gastric reduction, despite thousands of operations being done annually (2). The rush to surgery is delaying the development of new non-surgical treatments, and the application of at least one recently developed and partially tested treatment (for obesity-linked ADD / ADHD).
The programme-maker did not draw attention to this obvious parallel. Was he or his boss warned off by England’s Department of Health, which for much of the last decade had surgeons both as chief medical officer and as a health minister? Or was it (perhaps more likely) BBC self-censorship?
BBC journalists don’t themselves seem to believe, any more, that the “licence fee” protects their independence because it is supposedly “not a tax”. But they continue to resist the suggestion that their work should be subject to the Freedom of Information Act.
So ordinary patients who have experienced poor results, infections or other complications from bariatric surgery, may never be able to discover the extent of any such BBC collusion. The same goes for relatives who, following one of the thankfully few deaths directly caused by bariatric surgery, may take a retrospective interest in how this surgical descendant of lobotomy was promoted.
(2) See my previous pieces on obesity: http://drnmblog.wordpress.com/category/obesity/
Drafted 2nd December; final version 8th December
Should weight-loss surgery be rolled out widely on the NHS, when effectiveness has been shown for less than 1 in 50?
So many adults become chronically obese, and we are now so aware of childhood obesity, that an overweight person’s history of normal weight and eating, or bulimia, or even anorexia nervosa, can be overlooked. The low cost of calories, and other “obesogenic” factors such as increased screen time and reduced exercise can also lead to therapeutic pessimism, despite nearly one-third of adults having normal weight (1).
Given the apparent failure of appetite suppressants and psychotherapy to treat obesity, a more hands-on surgical approach has gained a lot of ground (2). Reviews of bariatric surgery seem to make a well-founded case for wider use of this treatment: randomised controlled trials (RCT’s), the hallmark of proper testing, have been abundant.
But, despite well-documented cases of obesity remitting and relapsing in response to a range of interventions, sometimes with long intervals (Oprah Winfey, perhaps most famously), there has never been a single- or double-blind trial of bariatric surgery, compared with a true “placebo” which would be “sham” surgery: entering the abdomen under anaesthetic but making no further intervention.
Such genuine placebo-controlled surgical trials have been performed in many disorders where psychological factors have been felt to be significant (3). The RCT’s which give an impression of “a good evidence base” for bariatric surgery are mostly of one form of surgery compared with another, or surgery compared with a perhaps dubious non-medication-based intervention.
And anyway, according to a 2009 UK government-funded and -published meta-analysis, research into bariatric surgery has established its effectiveness for only 1 in 50 people who are at risk of health problems from being overweight: “The evidence base for the clinical effectiveness of bariatric surgery for adults with Class I [BMI30-35] or class II [BMI35-40] obesity is very limited.” (4).
Although I support bariatric surgery, and tried unsuccessfully to have it considered for one of my very obese learning disabled patients, four years ago, it appears to be at risk of being over-promoted for less severe disorders. Just like many other treatments in the history of medicine.
It is possible, in my view, that psychotherapists of all kinds (CBT, psychodynamic, 12-step-orientated) have simply not tried hard enough for a group of patients that attracts negative and even punitive public attention (5). Before proper randomised controlled trials of bariatric surgery, it must make sense to keep looking for non-surgical treatments.
(1) 31.7% of English adults were “normal weight” in 2006. The clinical effectiveness and cost-effectiveness of bariatric (weight loss) surgry for obesity: a systematic review and economic evaluation. Picot et al. Health Technol Assess 2009: 1-190, 215-357. [p3]. Available at http://www.hta.ac.uk/execsumm/summ1341.htm
(2) See my Blog piece “No” to the knife, “Yes” to Ritalin? 6th August 2010: http://drnmblog.wordpress.com/2010/08/06/%e2%80%9cno%e2%80%9d-to-the-knife-%e2%80%9cyes%e2%80%9d-to-ritalin/
(3) Laparoscopic excision of endometriosis: a randomized, placebo-controlled trial. Abbott et al. Fertil Steril 2004: p878. http://www.ncbi.nlm.nih.gov/pubmed/15482763
(4) See (1): p157. 67.1% of English adults were either “overweight” or “obese” in 2006, of which 2.2% (1.5% of the whole population) had aBMIabove 40. See (1) p3
[includes comments from the then Royal College of General Practitioners chairman, Professor Steve Field]
Drafted by 10th June 2011; published at DrNMblog.wordpress.com on 7th October 2011
An article in Education Guardian this month (1) received some interesting online responses, two of which pointed out that Ritalin (methylphenidate) has been used clinically in ADD / ADHD for fifty years. There did not seem to be overwhelming agreement with The Guardian’s scourge of health misinformation Ben Goldacre, who has stated “Big Pharma is evil” (2).
There was, however, little picking up on the valid concern expressed in Are drugs the solution to the problem of ADHD among young people? that NHS specialists who diagnose and prescribe may be forced to cut corners in their assessments and monitoring (3). Just one parent with an ADD child, and a mixed experience of services, posted on this: “The best treatment involved regular visits to the psychologist (every 6 -8 weeks) with ALL the family so we could all work out what was working and what was not.”
Unlike the BBC, The Guardian is free to be opinionated. Even so, it is disappointing that all the paper’s print and online articles mentioning ADD / ADHD continue to avoid reference to Panorama’s two programmes on this topic, both of which had complaints upheld against them. The more recent one was found to be “unfair and not openminded”, resulting in a rare on-air apology (4). Given the BBC’s massive online and broadcasting influence, and Panorama’s “flagship” status, this seems to be essential context for understanding public and professional attitudes to ADD / ADHD.
I was also concerned that an academic educationalist who does not “acknowledge that ADHD is even a medical condition” because “You can’t do a blood test to check whether you’ve got ADHD” appeared to go unchallenged. Epilepsy, bipolar disorder, migraine, schizophrenia and depression all lack definitive physical tests, and may improve with psychological treatments, but does that mean no one should ever take medication for these conditions?
As the online responses to this article showed, Guardian readers should not be stereotyped as simply following the line that mental and behavioural disorders are, in general, just “marketing” tools for pharmaceutical companies.
(2) Bad Science (2009, paperback edition) page 201. From the context, Goldacre appears to be half-joking.
(3) See “Critical Psychiatry”, 2nd April 2010: http://drnmblog.wordpress.com/2010/04/02/%e2%80%9ccritical-psychiatry%e2%80%9d/
(4) See my postings on Panorama, 5th and 19th March, below
Unlike the BBC’s Panorama (1), The British Medical Journal (BMJ) gives space to a wide range of views on mental health and behavioural disorders. An article on adult ADD / ADHD last week is an example of how polarized debates can become. One side repeated, as fact, Panorama’s “unfair and not open-minded” opinion on the poor long-term outcome for medication in ADD / ADHD (2).
The BMJ published my own comment online (3), pointing out the need to test and monitor new nurse-led adult ADD / ADHD diagnosis and treatment (4). Of course, the Department of Health is quite right to look for the most cost-effective ways of delivering services, and nurses bring their own distinct and valuable skills to a wide range of clinical settings. But I have already had two conversations with specialist NHS nurses working with children and teenagers, who were concerned at being pushed into taking on too much responsibility too soon.
“Critical Psychiatry” is generally skeptical about all “medicalisation” of problem emotions and behavior. So it seems a bit odd to me that the authors of this piece attacking adult ADD / ADHD suggest that “more established diagnoses…depression, anxiety, and modern conceptions of bipolar and bipolar spectrum disorder” be kept in preference.
This does, though, raise a further question about clinical specialists. Why should adults with “non-established” ADD / ADHD have less direct access to NHS psychiatrists and clinical psychologists, than people with “established” conditions? Surely it is more logical that they have more?
(1) See my last two Blog postings
The BBC’s recent bad news, about Panorama’s flawed ADD / ADHD programmes (1), seems to have been buried by the general pre-election media coverage. I have been assured that the BBC Trust’s delayed decision (itself still a subject of the complaints process) was not deliberate “news management” timing; but myself and ADDISS did find it interesting last year that the initial recognition of a problem with the 2007 programme was made public in early August (2), a traditionally quiet time when press releases often don’t get followed up.
Therefore it may take some months to discover the changes, if any, to the way mental health and behavioural disorder issues are now dealt with by the BBC.
For me, the problem with the 2007 programme (3) was not just the one-sided presentation of research on medication. It was the avoidance of any exploration of why Craig, the teenager whose ADHD and perhaps other problems caused him to end up in Court, was not receiving any input from local NHS services. No local professionals or managers were questioned (they were in the 2000 programme), and the interview with NICE’s Dr Tim Kendall was extremely limited.
By making the overall issue about medication, rather than local services, the 2007 programme in effect promoted the Department of Health’s policy that specialist mental health services are focused on “severe and enduring” problems, and can therefore exclude moderate and mild ones. This policy has now been in place for nearly two decades and has undoubtedly removed billions of pounds from the DOH’s “frontline services” balance sheet. However, many ADD / ADHD specialists believe that failure to intervene earlier, in these less severe disorders, results in substantial financial costs later in terms of underemployment, prison places, and adult mental health problems. Dr Kendall might have been asked some difficult questions on NICE’s narrow money-orientated evaluation process, but that didn’t happen.
Perhaps Panorama has unbroadcasted material which would throw light on all this. A fuller review of the reasons for the “unfair and not open-minded” programme might also include emails and other communications from and to the Department of Health (4).
(1) See my previous blog post (5th March)
(3) The BBC Trust ordered the programme to be removed from the BBC website. Today, weeks later, I was still able to view it at http://www.bbc.co.uk/accessibility/win/hearing/alt/panorama/sub_3.shtml . It has also been placed on YouTube as “A Panorama report on the life of a young child hooked on medication prescribed for his so called ADHD condition. “
(4) I remain open to a range of explanations for the problems with the programmes; and I am not suggesting that Panorama deliberately colluded with the Department of Health, to be misleading.