Category: Mental health and physical illness

Medical assistance in dying is another name for physician assisted suicide
  • February 8, 2023

The rebranding should not blind us to the risks involved.

The argument for what is now called ‘assisted dying’ is often framed in terms of personal autonomy – the right to choose the time and mode of one’s death.

Individuals included in media reports as pressing for that right are typically mentally competent, educated, and supported by a partner or family member who affirms their desire to die. Campaigners pressing for change suggest (at times in strikingly gothic terms) that if their wishes are denied, the likely alternative is a difficult death during which pain is inadequately treated and distressing symptoms are mismanaged. ‘Assisted dying’ is thereby positioned as a form of patient-centred care – a death with ‘dignity’.

Put like this, the case can seem incontrovertible. Who wouldn’t want a ‘dignified death’ in which their own wishes were central to any decisions about their treatment? But this is a narrow and unbalanced way of framing the discussion; it fails to communicate the full range of questions that arise when thinking about serious illness. “Assisted dying’ is a euphemism for physician assisted suicide; it involves prescribing lethal drugs to somebody who will then self-administer them to end their life. Framing the practice like this gives a different perspective that is masked by the rebadging as assisted dying. What we know about suicide more widely becomes relevant in informing what we think about doctor-assisted suicide.

People living with severe, persistent physical illness can of course feel that their condition is intolerable. Indeed, research shows that about one in ten describe having thoughts that their life is not worth living, or that they might be better off dead. And suicide rates in people with a severe health condition are double those of the general population.  Even so, recent data from the Office for National Statistics suggest that in absolute terms fewer than 10% of suicides are in people with a severe health condition. Some of the study findings come as a surprise; for example of 17,195 suicides identified from 2014-2017, only 58 (0.3%) were in people with what the study called low survival cancer. This is about three times the general population suicide rate but accounts for only 3 in every 10,000 of those recorded as having low survival cancer in the study period. In other words the great majority of people (more than 99%) with negative thoughts about their circumstances do not take their own lives.

What does research into suicide in the wider population suggest might make suicide more likely? Many of the leading risks are social – loneliness, living alone, low income and lack of employment, and a lack of social support. A history of problems with alcohol or drugs is also common, especially in men. So is a history of mental health problems – typically not psychotic illness but recurrent episodes of depression. More than half of those who take their own lives have a history of previous self-harm. These risks are also prominent when suicide occurs in the setting of severe physical illness, even among those who are simultaneously in contact with mental health services.

Suicide associated with severe physical illness occurs most commonly in the first year after diagnosis, especially in the first six months. This observation is in line with research showing that rather than intolerable and untreatable symptoms it is concerns about the future and loss of independence that motivate many requests for physician-assisted suicide.

US psychologist Thomas Joiner has outlined an influential interpersonal theory of suicide that makes much sense of these findings. He outlines three risks for suicide – thwarted belongingness (closely-related to the idea of lack of social connectedness), perceived burdensomeness, and acquired capability (overcoming the fear of death). Thinking about suicide in this way helps us to be clearer about the nature of suicide in the physically ill and therefore ‘assisted dying’, which is a risk for exactly those people whose suicide we are used to working to prevent, by actively helping people to “acquire capability”.

The response to these concerns rests upon assurances that only carefully selected cases will be accepted into a programme of assisted suicide. We can have no confidence that such “safeguards” will be adhered to.  For example in one study from the Netherlands, 12% of those accepted failed to meet the criterion of there being no alternatives for palliative treatment and 7% were not reported has experiencing unbearable suffering. I have yet to see a statement from supporters of medical assistance in dying about their opinion on what is an acceptable error rate in the system.

There is another reason for concern about doctor-assisted suicide – less tangible perhaps but with far-reaching consequences. It fundamentally changes our approach to suicide, Under the Suicide Act 1961 an act “intended to encourage or assist suicide” is a criminal offence. There are no exclusions – it is an all-encompassing approach that is reflected in our National Suicide Prevention Strategy. What is proposed is a radical overhaul of the way we approach suicide – a move away from trying to prevent all instances to a world in which we attempt to prevent suicide except when we decide to make it easier.

We are facing in medical assistance in dying a privileging of personal preference over social concern. It represents not just a modification of individual clinical practice but a societal intervention designed to change how we think about and respond to suicidal wishes. I find it hard to believe that the longer-term consequences, intended or otherwise, will be of universal benefit to those most in need of our care.

Picturing Long COVID – time to drop a subtly undermining visual rhetoric.
  • October 13, 2021

Usually I ignore the accompanying pictures when I am reading a newspaper article about health. Just recently however, I have noticed something about the pictures that accompany articles about Long COVID.

Here’s a typical example – a picture of somebody, and it’s nearly always a young woman, reclining on a sofa looking exhausted. Of course we don’t need a photo to help us understand the idea of being exhausted, in the way that we might want an illustration for an article about recent floods or trouble at a street demonstration. So I took to wondering what was going on.

The use of such pictures may represent no more than a desire to break up blocks of text.  But there are a couple of features that drew me to thinking of how similar images have been used to convey something about other conditions.

First, here’s a rather typical image from an article about the 19th Century malady neurasthenia: a woman reclines and does not look, if truth be told, especially discomforted by her experience.

From a different era and with another typical feature (hand on forehead) I didn’t have to look far to find this illustration (left) from an article about premenstrual syndrome.  

And just to counter the idea that these things are entirely gendered here’s a picture (below) with another typical feature – it’s the back of the hand on the forehead – from an article about man flu’.

Perhaps what I’m seeing is no more than a lazy use of stock images but regardless of motive it occurs to me that there’s more to be said. The visual rhetoric hints at connections that the written text may not – between Long COVID and a group of conditions that have over the years shared some degree of being dismissed, of dubious provenance and melodramatic in presentation. And by implication, faintly ridiculous.

I don’t think this representation of illness does any favours to the discussion about the nature of Long COVID – not just to the question of possible underlying pathophysiology but also to the question of whether some cases are psychosomatic (functional) in part or whole.

My solution would be twofold: time to drop the use of the term Long COVID for the trouble it causes by bundling together so many disparate conditions. And when writing about the sequelae of COVID infection it’s time to drop the use of pictures of tired people resting, hand-on-forehead, on the sofa.

Mental health problems in the COVID-19 pandemic: we need more careful presentation and interpretation of facts and less melodrama.
  • June 24, 2021

Since early on in the COVID pandemic there have been expressions of concern about its impact on mental health and, at least as reported in the mainstream media, those concerns have been couched in frankly melodramatic terms.  In May 2020 the then president of the Royal College of Psychiatrists expressed fears1 that “lockdown is storing up problems which could then lead to a tsunami of referrals.” The (by comparison) rather more muted claim that the pandemic was having a “major impact” on mental health came in the reporting of a questionnaire survey conducted later that summer2. The current president of the Royal College of Psychiatrists, who has echoed his predecessor’s use of the tsunami analogy, attracted headlines towards the end of 2020 by suggesting that the consequences for the nation’s mental health will be the greatest since the second world war3. The doom-laden tone has persisted into this year, with The Prince’s Trust declaring4 that “The pandemic has taken a “devastating toll” on young people’s mental health” and a report from Bradford in West Yorkshire suggesting5 that “The pandemic has had a deep impact on children” who are “a lost tribe in the pandemic”.

There’s a tiresomeness to this sort of coverage, with its implication – familiar to those who regret the stigmatising of mental disorders – that there is something frightening and uncontrollable going on. But melodrama has other more tangible disadvantages.

First is the lost opportunity to conduct, and demonstrate how to conduct, a balanced discussion about the difficulties and uncertainties that attend the interpretation of data. Much of the media coverage consists of anecdotes – the personal interest stories so favoured by journalists – or small-scale interview studies. Data on health service contacts are problematic because of the degree to which disruption caused by the pandemic changes the relation between population prevalence of disorders and attendance rates. So what is, for now, the best evidence probably resides in population surveys.

However, results from self-report symptom questionnaires require more cautious interpretation than they are often given. Self-reported symptoms are mainly markers of distress, and although very high scores can be an indication of mental disorder the likelihood that is so depends upon the context. Two studies that have taken repeat measures suggest that most of the distress created by conditions during lockdown resolves quite quickly 6,7. The major impact headlined in one report2 proved due to a difference between 10% (previously) and 12% (at the time of the survey) in endorsement of a question about thoughts of suicide but did not spell out how often such thoughts are an accompaniment of distress and lead neither to suicide attempts nor to suicide – suicidal thoughts in population surveys are about 1000 times more common than suicides in the same population.

A bias in thinking about attribution arises with this use of language. A few attempts have been made to link Government policy to an increase in mental health problems among the young8, but for the most part no explicit suggestions are made. Instead the resort to analogies with war or natural disaster and talk of unprecedented crisis implicitly leads to foregrounding of the pandemic as the main explanation for mental health problems. To be sure, there are stresses in the current situation but there are also longer-term forces at play9-11. Years of government austerity strategy have done great damage not just to mental health services but to community assets, employment stability and family security – the main resources that constitute resilience for the most vulnerable in society.

Mental health is a vague umbrella term that is used to cover everything from the boredom and frustration that so many of us feel for being unable to see friends or go out socially, to severe mental illness. Not all mental health problems require treatment from the mental health services. Even before the pandemic something like a third of those identified in the Adult Psychiatric Morbidity Survey12 as having depression had not been so diagnosed by a professional. A third of adults referred to the Improving Access to Psychological Therapies (IAPT) service do not attend for the first appointment – voting with their feet 13.

Of course we need better mental health services. We also need to repair the damage done by years of austerity to schools, community resources and the quality of life of the poor and disabled. And the mental health services need to be planning about exactly where their efforts are best placed – blanket statements about mental health do not help with thinking about who needs exactly what sort of assistance, either preventive or therapeutic. These are challenging tasks the public and government support for which isn’t going to be recruited by melodrama rather than reasoned analysis and careful presentation of the facts.

  1. https://www.bbc.co.uk/news/health-52676981 accessed 12 February 2021
  2. https://www.bbc.co.uk/news/health-54616688   accessed 12 February 2021
  3. https://www.theguardian.com/society/2020/dec/27/covid-poses-greatest-threat-to-mental-health-since-second-world-war accessed 12 February 2021
  4. https://www.princes-trust.org.uk/about-the-trust/news-views/tesco-youth-index-2021 Accessed 12 February 2021
  5. https://www.bbc.co.uk/news/health-55864573 Accessed 12 February 2021
  6. Fancourt D, Steptoe A, Bu F. Trajectories of anxiety and depressive symptoms during enforced isolation due to COVID-19 in England: a longitudinal observational study. The Lancet Psychiatry. 2020 Dec 9.
  7. Shevlin, Mark and Butter, Sarah and McBride, Orla and Murphy, Jamie and Gibson-Miller, Jilly and Hartman, Todd K. and Levita, Liat and Mason, Liam and Martinez, Anton P. and McKay, Ryan and Stocks, Thomas V.A. and Bennett, Kate and Hyland, Philip and Bentall, Richard P., Modelling Changes in Anxiety-Depression and Traumatic Stress During the First Wave of the COVID-19 Pandemic in the UK: Evidence for Population Heterogeneity in Longitudinal Change. Available at SSRN: https://ssrn.com/abstract=3749211 or http://dx.doi.org/10.2139/ssrn.3749211
  8. Townsend, E COVID-19 policies in the UK and consequences for mental health, The Lancet Psychiatry, 2020; 7(2): 1014-1015,
  9. British Medical Association. Cutting away at our children’s futures: austerity and child health. https://www.bma.org.uk/media/2060/cutting-away-at-our-childrens-futures-austerity-child-health-guuk-2016.pdf accessed 12 February 2021
  10. Cummins I. The Impact of Austerity on Mental Health Service Provision: A UK Perspective. Int J Environ Res Public Health. 2018 Jun 1;15(6):1145. doi: 10.3390/ijerph15061145.
  11.  https://blogs.bmj.com/bmj/2020/05/21/young-people-were-reporting-deteriorating-mental-health-even-before-covid-19-struck-we-need-to-take-their-concerns-seriously-going-forward/ accessed 12 February 2021
  12. Adult Psychiatric Morbidity Survey, 2014 https://files.digital.nhs.uk/pdf/t/6/adult_psychiatric_study_ch2_web.pdf accessed 12 February 2021
  13. Improving Access to Psychological Therapies Annual report 2019-20 https://files.digital.nhs.uk/B8/F973E1/psych-ther-2019-20-ann-rep.pdf accessed 12 February 2021

A shorter version if this comment appears in BMJ Opinion

Severe mental illness (SMI): another muddled idea from psychiatry
  • February 22, 2021

Not all psychiatrists recognize this explicitly, but there is an assumption in psychiatric practice that mental disorders are arranged in a hierarchy with those at the top being more serious than those lower down. The hierarchy has often been represented in a pyramid introduced some 50 years ago by two academics working in Edinburgh. 

At the bottom of the pyramid are states of personal distress (in the original account called dysthymic states) characterised by symptoms such as anxiety, irritability, low mood and non-specific physical symptoms. In the so-called neurotic disorders the symptoms are still recognizable as part of distress, but one or more of them seems to have taken on a life of its own – out of proportion to other symptoms of distress and perhaps distorted or expressed in an unusual way. Higher up the pyramid are delusional (psychotic) states, characterised by the emergence of symptoms that are not part of mainstream experience – like holding delusional beliefs or hearing voices. At the very top are extreme states where mental life is so disrupted that a stable sense of self is difficult to find.

This arrangement represents a hierarchy in another sense, that of progressive deterioration in the organisation of mental function so that those higher up can have symptoms from any of the states lower down in the hierarchy without their diagnosis needing to change, but not vice versa.

The hierarchy is nodded at in the arrangement of the two standard diagnostic manuals – current editions DSM5 and ICD11 – in which schizophrenia and related disorders appear before severe mood disorders and then move on to the neurotic disorders.

Over time, perhaps especially in the UK, it has become common practice to talk about severe mental illness, initialised (always a bad sign) as SMI, and SMI has come to mean “any psychotic disorder”. This was never a good idea. In many branches of medicine the diagnosed disorder can be a pointer to severity but the coupling is not so strong that diagnosis can be taken as a severity statement. Some diabetes is more severe than some cancer and some COPD is more severe than some leukaemia.

So, what do we mean by severity? The answer takes us into matters that are more important to patients than the classificatory ordering of symptom states – for example impact on life expectancy, quality of life, ability to function physically (impairment or handicap) or socially (participation) come into the frame.

Is there a tension between these two ways of looking at severity? The UK government’s vaccination policy in the COVID pandemic certainly suggests some lack of clarity about what severe mental illness is and why it matters. The official order of priority for receiving the vaccine is described in a series of Priority Groups, defined by likelihood that COVID infection will be serious and could lead to death. Thus, age defines the top groups.  Priority Group 6 includes adults aged 16 to 65 years in an at-risk group defined by clinical conditions one of which, in an uncomfortable change of grammar in the list, is “are severely mentally ill”. Further clarification comes in the COVID-19 Green Book Chapter 14a which defines severe mental illness as (again the weird change of grammar)  “Individuals with schizophrenia or bipolar disorder, or any mental illness that causes severe functional impairment.” A recent commentary in The Lancet described the rationale as follows: “Patients with severe mental illness, which is patients with psychotic disorder, bipolar disorder, or severe depression, are at a significantly increased risk of being hospitalised or dying from COVID.”

So, the Green Book definition takes it both ways – severity as psychosis and severity as illness causing severe (not defined) functional impairment – whereas the research underlying the decision seems to refer only to the diagnosis-based definition of severity. The advantage of the latter approach is that it is logically consistent with the other priority groups, taking likelihood of hospitalisation or death as the indication for vaccination, and there are at least some plausible mechanisms for such poor outcomes. The disadvantage is that equating severe mental illness with psychosis is clearly wrong and leads to a sense of injustice among those whose illness is severe by quite reasonable more person-centred criteria. The disadvantage of the former (Green Book) approach is that while it acknowledges a wider definition of severity of illness – including, as recommended by some experts, people such as those who have eating disorders or have been given a diagnosis of personality disorder – it is no longer clear why severity thus defined puts somebody in a priority group for vaccination.

It is difficult to escape the conclusion that there is something inherently wrong with the term Severe Mental Illness (SMI). When equated with psychosis it fails to recognize that severity is not adequately captured by diagnosis. When the initials are dropped and it refers to any mental illness, it lacks specificity as a criterion for decision-making.  It would be better replaced with a more accurate and specific terminology.

Mental health in the COVID pandemic: searching for historical comparisons
  • December 31, 2020

I was struck by this week’s variously-reported claim from Adrian James, the current president of RCPsych, that the pandemic is “the biggest hit to mental health since World War 2” (Mail Online) or “poses the greatest threat to mental health since second world war” (Guardian). My initial response was heartsink – yet more melodrama with yet another wartime analogy, especially something I could do without as plucky Britain goes it alone again as we leave the EU. But then I got thinking – where would you look for comparator epochs if you wanted to take this claim at face value? Two candidates come to mind; each covers 5 years.

The threat

First up, the post-war years 1947-1951. Winter 1946/47 was one of the worst winters on record, exacerbated by a fuel shortage for which the Labour Govt (personified in Manny Shinwell) was blamed, at least by the press. Industrial output is estimated to have fallen by 10% in the following year. The Labour Party held on at the 1950 general election but lost the snap election called the next year. In that year, 1951, there was a major influenza epidemic which is estimated to have increased all-cause mortality in those over 65 years by about 50% and causing the greatest number of excess winter deaths in any year in the second half of the twentieth century. Peak death rates in Liverpool were higher than during the Spanish flu epidemic of 1918.

My runner up is the years 1980-84. Thatcherism had a grip and there was social unrest with riots in 1981 in Brixton and Toxteth. On the economic front unemployment ran at 2.5-3 million (more than 10% of the working age population) and the hugely disruptive and divisive miners’ strike dominated 1984.

Set against these threats we have to ask about resilience in the population. The post-war years saw continued rationing and poor housing and poor physical health at levels we go nowhere near approaching. The NHS was founded but will have had little impact on mental health provision. It is difficult to know what to make of any sense of national unity and social solidarity at this time; much is made of growing disillusion with Attlee’s government but in 1951 they still gained more of the popular vote than did Churchill. They lost to our electoral system. Society in the 1980s was more affluent and physically healthier and the NHS had grown hugely, but it was undoubtedly troubled. Thatcher was a divisive leader of a divisive government, notwithstanding populist moves like selling off our social housing and privatising services in support of the idea of a laughably-named share-owning democracy.

The hit

So, there are elements of our current predicament in these previous epochs. How could we judge each in terms of their mental health impact? I find this pretty much impossible to say and we don’t get a clue from the press coverage. As with all NHS bed numbers, psychiatric bed numbers have fallen dramatically from about 155,000 (1953/54) to 67,000 (1987/88) and 18,000 (2019/20) so numbers of admissions won’t help. The Mental Health Acts of 1959 and 1983 will have dramatically changed practice and patterns of service delivery. The only robust measure of population mental health – the suicide rate – has fallen pretty steadily over the decades, with the most consistent evidence for deterioration coming at times of economic recession and mass unemployment.

It would be interesting to see a thoughtful analysis of these questions about the nature of major social upheavals and their consequences for mental health, but if it’s going on it’s not making it into the public domain. A note from March 2020 states that SPI-B received input from academic specialists in history; that committee’s terms of reference for October 2020 do not mention historians as one of the academics from whom advice is being sought.  What a pity.

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