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.
Until recently, most of my ADD / ADHD patients who did well on a trial of medication, were then able to obtain further NHS prescriptions from their GP.
My website highlights the 2009 NICE (National Institute for Health and Clinical Excellence) ADHD guidelines, because the guidelines are strongly in favour of diagnosis and treatment choice. When NICE was set up as a state-funded body in 1999 there was a commitment, which was made legally stronger in 2005, that the NHS would be provided with enough money to follow its recommendations.
Last year, the new Government’s Conservative Health Secretary, Andrew Lansley, abolished this legal commitment for GP’s to follow NICE guidelines.
Under financial pressure to reduce prescribing, GP’s look at adult ADD / ADHD, and see that no medication is licensed. Unless the GP has direct experience of treatment benefits, this relatively new diagnosis inevitably becomes a target for cost reduction.
The fact is, medication licensing is really about the claims that a pharmaceutical company can make for its product, rather than what clinicians can prescribe (and the NICE guidelines are more relevant to that). But such distinctions make little difference to GP’s, especially when fully licensed ADD / ADHD treatment in children and teenagers is still often opposed by prominent NHS academic psychiatrists.
My own experience is that ADD / ADHD medication, together with counselling and psychotherapy which takes diagnosis properly into account, can improve interpersonal and work functioning enormously. If patients do have to fund diagnosis and treatment themselves, it is likely to be well worth it, as long as they have moderate or severe ADD / ADHD. Treatment could even be cost-effective if the ADD / ADHD is milder: what price can you put on better relationships?
Drafted by 2nd July 2011, published at DrNMblog.wordpress.com on 6th October 2011
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
Obesity surgery has grown in the UK, as it has worldwide. But unless it can be shown that it saves money which could be transferred from elsewhere (diabetes care, for example), less than 5% of eligible patients might receive NHS operations in the next few years.
With couple of internet searches, today I found plenty of advertisements for self-funded surgery, including centres in India and Central America. The demand is clearly huge.
On Wednesday this week Joan Bakewell’s Radio 4 medical ethics programme addressed the previously little-publicised problems with obesity surgery (1). In particular, careful follow-up is needed as banding operations may need to be repeated or redone. For patients who go abroad, continuity of care may be less than optimal if they need to turn to the UK NHS later.
A study published last year (in a Nature group journal) suggested ADD / ADHD may be a significant, and treatable, cause of obesity (2). One third (78/242) of patients in an independent Toronto weight loss clinic were found to have ADD / ADHD, and with treatment they lost 10% of body weight. That is as good as obesity surgery.
More research is of course needed, but I find the idea that some people with ADD / ADHD overeat makes clinical sense. Many of my patients, successfully treated, get on with their lives more effectively, and find they “snack” less. Because the underlying dissatisfaction and discomfort is reduced, so is the need for “comfort eating”.
In my view this treatment effect is separate from the “appetite suppressant” effect, which is often transient anyway, of medications such as methylphenidate and amfetamine.
Interestingly, another large study on obesity, recently published in The Lancet (3), showed good results for a medication combination which included bupropion (available in the UK only as the smoking cessation drug Zyban, but more widely used in the US for years). Bupropion is thought by many developmental disorder specialists to be effective in ADD / ADHD.
I am sure we will see many overweight and obese people in the UK considering whether they might have ADD / ADHD. Surely having assessment and possibly treatment in London is a reasonable thing to try, before flying off for surgery in Cancun or Delhi (4) ?
(4) No disrespect to Mexican or Indian surgeons intended at all. The point is about continuity of care. It also seems possible to me that people with severe ADD / ADHD might have a poor outcome with apparently successful surgery: I understand this is not uncommon.
Does NHS “General” Practice support adequate assessment and treatment of mental and behavioural problems?
I have never met anyone working within the NHS who believed that more than a minority of UK general practitioners have a great interest in mental health issues. As a trained and qualified GP myself, I have much affection and regard for my non-specialist colleagues. But unfortunately because their views are often so much in line with mainstream opinion (hence those persistently high “public trust” ratings?), that can sometimes include a dismissive approach to human frailties.
A confidential survey of GP’s, published last week by the leading mental health charity Rethink, appears to have confirmed this (1). The new government wants general practitioners to decide on funding priorities for specialist services, and over three quarters are happy to do this for physical conditions, but less than a third want to be involved in mental health.
This is despite GP’s having a very negative view of existing specialist mental health services. When asked “To what extent would you feel confident in the quality of care one of your relatives would receive if they were referred to the appropriate NHS services” only 50% said they would feel confident for depression (as against 92 – 95% for physical conditions). For obsessive-compulsive disorder (OCD) the figure was 32% and for post-traumatic stress disorder it was a miserable 22%.
I don’t blame GP’s for not wanting to take on the re-funding of NHS mental health services. To do so in the current financial climate would probably mean advocating cuts to clinical services for physical conditions, which would be deeply unpopular. Privately, many of them support their better-off patients seeing independent non-NHS specialists, which in itself at least expresses a degree of discontent with the current situation.
But keeping this issue at arms length might lead patient groups to further question the ordinary good sense, even the fairness, of general practitioners. Rethink continues to highlight a previous survey as showing that “23% of people with mental illness report experiencing discriminatory treatment from GPs” (2). It could be a good time for the minority of GP’s with a special interest in mental health issues to become a majority.
(2)http://www.mentalhealthshop.org/products/rethink_publications/stigma_shout_survey.html# Quotation from (1). In this 2008 survey psychiatrists did not do much better, which I would interpret as further evidence for the inadequacy of NHS services.
Yesterday I attended the second annual meeting of UKAAN (UK Adult ADHD Network), which is led by academics and funded by a leading pharmaceutical company (1).
It was very interesting to hear how local NHS adult services, all English, were coping with increased referrals of patients. What seems clear is that many people are screened out, often by so-called “gateway workers”, who tell patients that they do not “meet the criteria”.
When the NICE guidelines came out, I wondered if patients with ADD / ADHD would often be found to not “meet the criteria” on the basis that their condition was “only” mild. However, it looks as though a lot of mild and moderate ADD / ADHD is simply being diagnosed as “no ADD / ADHD”.
I have already seen many people with moderate-to-severe disorders, who should fall within the NICE guidelines, but have been told that they should stop “medicalising their past failures” and just get on with their lives.
The President of UKAAN, Professor Phil Asherson, told the meeting that in many areas services are being closed. This means that people who have been on waiting lists for months may end up being told that they will not be seeing a specialist after all.
I will be suggesting to ADDISS and AADD-UK that they consider telling their members and supporters about the reality of all this in greater detail and that, for those who can afford it, paying to see an independent specialist may be the best option for at least the next 2-3 years (2).
(1) There appeared to be no promotional activity at all within the meeting itself.
(2) “2-3 years” is based on the wide perception of how long the most intense NHS spending restraint may last.