World Mental Health Day – Let’s celebrate Human Values
By Dr Alastair Dobbin, Foundation for Positive Mental Health
The global burden of diseases 2010 study has identified depression as the second most common cause of disability worldwide, Nick Clegg said on Wednesday that three-quarters of patients needing “talking therapies” for conditions such as depression will be guaranteed treatment in as little as six weeks, with 95% starting treatment after a maximum wait of 18 weeks. While this is a great soundbite there are major problems with this approach. There are 4 million people in the UK with depression and despite good intentions the Increasing Access to Psychological Therapies (IAPT) programme started in 2006 is not treating anything like the numbers of people it was planned to (800,000 in 2006), in 2012/13 out of 760,000 referrals only 127,000 depressed people attended for therapy. So the referral model is not working for depression, it’s just not reaching the people it needs to. Vikram Patel of the Kings Fund, looking at the European figures on depression in 2010 recommended that treatment should be devolved to the front line.
And yet this idea of referral is clung to as the best chance to help those with depression. We need to look at it in another way, and we need to learn the lesson from studies of depression. As I outlined in my recent editorial in the British Journal of General Practitioners (BJGP), one of the most comprehensive studies in depression, the Treatment of Depression Collaborative Research Programme (TDCRP) in 1985 identified that the therapeutic relationship with the therapist and the expectation of recovery were by far the most important predictors of recovery, the type of therapy (CBT, interpersonal therapy, antidepressants) contributed virtually nothing to the recovery and placebo was as effective as the therapies. The blindingly obvious conclusion from this was that more should be invested in researching and facilitating the interpersonal relationship factor, and other ways of increasing expectancy. But the outcome of the study was ‘Business as Usual’ nobody wanted to hear the message and the study was quietly ignored.
Can we increase the use of interpersonal factors and put it in the front line? Certainly we can, there is a group of therapists, who work in the front line, who see and deal with 90% of depressed patients on their own and who are on most surveys the most trusted profession in Society, General Practitioners. Most patients prefer a psychological therapy to antidepressants, when we did a study offering a GP guided self help psychological treatment or antidepressants 86% of patients chose the psychological therapy. GPs were not recognised in the LSE report that started the IAPT programme as anything other than a referral agency. But there are ways of helping GPs to enable recovery , as a good starting point they need to understand the implications of the research of studies like the TDCRP study, and understand the nature of distress and recovery, and offer programmes that they themselves supervise so that they can authentically model to patients how they will recover. Just to say to a depressed person ‘I have seen and helped many people like you and I know you can recover and I will help you, you can get better’ can be the start of a process of recovery. GPs need to be supported and valued for the work they do and recognised for their contribution to recovery, this whole area needs to be looked at and researched from a human values standpoint. In our experience GPs who are supported and encouraged by such an approach report added benefit for themselves and their patients. The cost savings of using the front line in this way could be enormous, not to mention helping the 2/3 of those who it is recognised receive no treatment at all. We should celebrate the fact that a trusting warm relationship and optimism are what really count and invest more in the relationships that already encompass such values. 1985 was a long time ago, but its not too late, indeed it’s never too late to start accepting this message.
About the author
Dr Alastair Dobbin qualified in 1976, working in London and Australia before becoming a full time GP in Edinburgh where he became interested in hypnotherapy. Along with Edinburgh University and Imperial College London, he researched the impact clinical hypnotherapy had on patient health in primary care, from which he developed the idea of using Positive Mental Training to treat depression. Since then he has conducted research into Positive Mental Training in a General Practice setting, Irritable Bowel Syndrome, and is currently researching the effects of positive reappraisal with McGill University, Montreal.
Alastair writes for journals, lectures to students and conducts workshops with primary care workers and GPs in Scotland and England. He is an Honorary Fellow of the School of Clinical Sciences and Community Health, University of Edinburgh.