Last week the Academy of Medical Royal Colleges announced that it would be bringing ‘Choosing Wisely’ to the UK. The US initiative, which has spread to more than 12 countries worldwide, encourages leading medical organisations to list tests, procedures and medications with little evidence behind them and advise doctors to think twice before using them.
This is a good thing. In many areas, medical intervention has expanded way beyond the point of usefulness, resulting in extra risk to patients for little gain.
Though the Patients Association reacted cautiously, fearing it might mark the beginning of ‘rationing’ of interventions, the reception was overwhelmingly positive. No one really buys the ‘rationing’ worry – the ethos of the campaign is openly directed at empowering choice not withholding, and you have to wonder what the harm would be in rationing ineffective treatments in any case. Atul Gawande hit the nail on the head in his utterly readable New Yorker piece ‘Overkill’, saying that these types of intervention aren’t just ‘low-value care’ but no value care.
I’ve been thinking about how this all applies to mental health services in the UK.
The Royal College of Psychiatrists has signed up for Choosing Wisely, as is right and laudable. And there definitely are interventions in psychiatry which could potentially be cut down on. Antidepressants for mild depression, for example, are next to useless but prescriptions continue to rise suspiciously. Antipsychotics for behavioural disturbance in dementia are only temporarily helpful (if at all) but result in a significantly increased risk of stroke. Antipsychotic polypharmacy for schizophrenia is poorly supported by research, associated with increased side-effect burden, but not rare.
However, we need to keep things in perspective. Unlike most other medical specialties, psychiatry faces the paradox that though we can prune a few treatments back as unhelpful, our main problem is that we’re vastly undertreating most people.
A lot of the time this is fairly convincingly not our fault, due to there not actually being a service in existence to do the treating. Only half of women in the UK have access to perinatal mental health services. Liaison psychiatry provision is so patchy that no official statistics exist, but a recent survey found that even in London only 50% of hospitals have a 24 hour service. Only 25% of people with depression or anxiety access help; the proportion of children with a mental illness in treatment is similar.
But even patients who are lucky enough to find their way to a psychiatrist can somehow avoid being offered effective treatment. Clozapine, the antipsychotic which works significantly better than all others, is meant to be offered after two failed trials of different antipsychotics lasting 6 weeks each. But recent research suggested that the average time to be offered clozapine – which is associated with vastly improved functional and symptomatic outcomes – was 4 years. Similarly, despite the fact that it probably works better than anything else for prophylaxis and suicidal prevention in bipolar disorder, lithium prescribing rates have dropped. Most likely due to the the lack of pharma interest (you can’t patent an ion) and the need for annoying blood test monitoring, patients aren’t getting the best treatment. Moreover, antidepressants aren’t increased to effective doses and aren’t switched in a timely enough fashion if they don’t work. Using an algorithm can help.
And it’s not just medications that are underprovided. According to the National Audit of Schizophrenia less than half of people with schizophrenia who aren’t in remission are offered CBT, just 59% of smokers get offered advice and a measly 25% get counseled on their high blood pressure. Doubtless this is frequently due to clinicians being pressured for time, but the facts remain.
In short, though cutting out pointless and potentially risky interventions is always desirable, in mental health it can hardly be our main focus. We’re way behind the luxurious curve that other specialties find themselves on. Managing to identify and reduce ineffective decisions while introducing effective ones will demand considerable mental dexterity and vigilance of psychiatrists. And of course, they’ll only be able to make those calls if services for them to work in are commissioned in the first place. Choosing wisely is great, but it requires having a choice to start with.