I wrote a post about rational suicide a few weeks ago which attracted a lot of interest, and even spawned a post on another site dedicated to debunking my viewpoint.  This issue and that of physician assisted suicide is rarely far from the headlines and clearly is a subject which excites strongly held opinions.  Most recently conductor Sir Edward Downes and his wife are reported to have died together at the controversial Swiss assisted suicide clinic Dignitas.  For a small organisation it attracts an impressive amount of coverage and its actions may have a substantial influence on future UK legislation.

For many people the discussion of the right to die is a simple one: people should not have to suffer toward the end of their lives and have the right to choose the time and means of their own passing.  This attitude is in line with the increasing emphasis on choice and self determination in our society of which suicide is perhaps the ultimate expression.  There are strong emotions involved and polarized viewpoints, but shouldn’t mean that we shy away from discussion both about philosophical underpinnings as well as more practical aspects.

I am concerned that where assisted dying to become legal in this country doctors would be expected to take a central role and this would sit unhappily with our usual duties.  Psychiatrists would regularly be called up to make difficult assessments about capacity and some of us might find being asked to assist in someone’s death very distressing.  Outside these professional concerns, and more fundamentally, is the message that legalised assisted dying would send out to vulnerable people who are near to the end of their lives.  Elderly people may worry that they are a burden or that their care is costing too much, and with a legal way of reaching a swift resolution may feel a duty to move on.  I cannot see how we could safe guard against this.

Sir Edward was elderly and frail but not terminally ill when he chose to take his life.  Apparently decided that he could not live without his wife and choose to end his life when she was choosing to end hers.  Most discussion about assisted suicide has focused on incurable conditions, which Sir Edward did not have.  Enabling people in similar situations to Sir Edward to take their own lives is disquieting to me.

Addendum 16 July 2009
What I think about Sir Edward Downes’ decision to ‘die with dignity’ Guardian

Psychiatric drug critic Joanna Moncrieff and biomedical model champion Dr Trevor Turner were talking on the Today programme this morning.  The bone of contention is Moncrieff’s assertion, that we should not consider psychiatric drugs to be correcting an inherent ‘chemical imbalance’  and thus correcting a physiological abnormality, but rather to be drugs that alter brain states sometimes in a useful way.  I quite like this approach, it seems more humble and moves away from a ‘disease and correction’ model toward a more pragmatic symptom based model, which may be more compatible with non-pharmaceutical intervention.

Today discussion - 15 July 2009

Moncrieff’s paper - How do psychiatric drugs work?

Co-incidentally, I’ve volunteered to oppose the motion ‘this house believes that our lunch should continue to be funded by the pharmaceutical industry’ at a meeting today.  The ‘no free lunch’ debate is an ongoing one arising from concerns that pharma’s influence on doctors leads to a medical model biased towards ever increasing prescribing, a situation which is better for the pharmaceutical companies than for our patients or wider society.

Here is it, as ever I’d like to know what you think, unfortunately unless you comment in the next 30 minutes I’ll be unable to change the text!

”

I wish to oppose the motion “this house believes that our lunch should continue to be funded by the pharmaceutical industry”.  This is important for both our independence as doctors and is in the interests of our patients.  I will outline here why we should be wary of the pharmaceutical industry and why we should not accept their hospitality;

First a bit of history.  Before the 1930s doctors were pretty useless.  We had insulin, morphine and had worked out the benefits of conducting operations in sterile conditions, but that was about it.  Then miraculously an era of advancement between 1930-1970 produced an impressive array of medical cures such as antibiotics, transplants, ITUs, dialysis and during this time pharmaceutical companies grew big by producing and promoting innovative medicines for major diseases.

However of recent years it has become ever more difficult and expensive for these companies to repeat such successes and the number of genuinely innovative new products being released by them has significantly reduced.  I would argue that the continuing benefits of prior triumphs have led us to view pharmaceutical companies in the positive light of their past achievements, and we do not sufficiently scrutinize their current practice.

Today’s situation is that faced with maintaining their profits without the support of truly innovative products, pharmaceutical companies have engaged in refashioning and repackaging old products as ‘innovations’ and, worse, identifying and promoting new diseases for their medicines.  Many of the truly innovative treatments that have emerged in recent years have come from the funding of public bodies, whilst pharmaceutical firms have concentrated on ‘me-too’ drugs which aim simply to gain footholds in established and lucrative markets.

Psychiatry is particularly vulnerable to drug company tactics.  Our sketchily defined diseases provide opportunities for increasing product sales as they allow scope for expanding definitions of sickness, for instance depression, social phobia, female sexual dysfunction, to include more and more areas of social and personal difficulty not previously within the medical realm and thereby sell more medication.  Overall this has been  a very successful tactic and antidepressant prescribing increased 173% from 1991 to 2001.  The UK’s overall drug spending has increased from 3.9% GDP in 1960 to 7.7% GDP in 2002.

There are other concerns too.  The industry’s heavy involvement in the organisation of research into psychiatric drugs and the dissemination of research findings raises questions about the scientific objectivity of this research and the extent to which the industry is able to shape the research agenda. They also seek to gain advantage by political lobbying and funding drug-friendly patient support groups.  There has been disquiet about the burying of negative trials and over the exaggeration of drug benefits as newer expensive treatments such as SSRIs and atypical antipsychotics have not proved more effective than older and cheaper alternatives.

Pharmaceutical companies have thus sold us a reductionist biomedical model of the world.  They haven’t done this on their own of course, as it suits the purposes of many to live in a world where there are simple problems requiring simple solutions, but they have done their best to make sure that their voice is heard above any of those that might provide an alternate, non pharmaceutical vision.  For human beings can survive without endless drugs to cure every possible ill, but the companies that prescribe them cannot.  Pharmaceutical companies are primarily commercial concerns, and their major motivation is maximizing their profits.
But does this knowledge necessarily stop us accepting a free lunch from the dark side?  After all it saves us from buying our own thus allowing us to conserve funds in these uncertain times.  Can we not use our contact with pharmaceutical company representatives to evaluate what they tell us and learn about their products?

I argue no and for one simple reason: because we are weak.

Ask yourself this question: why would a commercial company, to whom profits are key, spend money on buying us lunch if they felt it would make no difference to our behaviour?  The answer is that they wouldn’t.  They know that by their engagement with us they can persuade us to use their products despite any other reservations we might previously have had.  They know that they can influence us to choose the treatment that is best for them, and not necessarily best for the patients we seek to treat.

You don’t need to believe me on this one.  Believe the authors of an article in the JAMA, who found that meetings with pharmaceutical representatives were associated with changes in prescribing practice.  And the next time you use your sponsored pen, consider an article in the Am J Bioethics, which concluded that ‘considerable evidence from the social sciences suggests that gifts of negligible value can influence the behavior of the recipient in ways the recipient does not always realize’.

The true situation is that pharmaceutical companies realize that in order for their products to find a market, they must first influence doctors to prescribe them and they spend a lot of money ensuring this takes place.  From early in our careers they win our favour by providing small gifts, and by taking part in medical education seek to inculcate us with their world view.

We should realise our vulnerabilities and not tempt ourselves so.  I’m not saying that drugs have no place in modern medical health care.  What I am saying is that as doctors we have but one duty, and that is toward improving the health of our patients; any action we may take to place ourselves at the risk of being influenced by another competing agenda is unwise and should be avoided.

For these reasons I commend you to join with me and oppose this motion.  Thank you.

”

Further reading:

Jackie Law Big Pharma - a comprehensive guide to this subject

Extract from Richard Bentall’s book Doctoring the Mind

Ben Goldacre on Medicalisation from his book Bad Science

Well before the rise and fall of Michael Jackson, aka ‘Wacko Jacko’ the idea that the gift of exceptional creativity or ‘genius’ is all too often packaged with mental ill health, has long had cultural currency.  If someone mentions this within our earshot at a party, should we mercilessly expose their naivety, or is there substance to this?*

There’s an immediate problem with definition; ‘exceptional creativity’ or ‘genius’, ‘madness’ or ‘mental disorder’ are in themselves difficult to exactly define and a full examination of their meanings would amount to a weighty tome. All these terms are in fact more or less vague and at best we can try to offer them a degree of precision by anchoring them within a set of terms we hope are more exactly understood.  There is no agreed definition of mental ill health, and indeed the various ways to which psychiatric problems as a category are referred - mental ill health/disorder/disease are three - are not synonyms. Equally, the Oxford English Dictionary  offers eight meanings for ‘genius’, the most relevant of which for this purpose is ‘native intellectual power of an exalted type, such as is attributed to those who are esteemed greatest in any department of art, speculation, or practice; instinctive and extraordinary capacity for imaginative creation, original thought, invention, or discovery’.

With this difficulty noted, what can studies tell us?  Looking in the past the mood disorders of poets in Britain and Ireland born in the hundred years 1705 - 1805 have been investigated.  This time period includes esteemed figures such as Lord Byron, Samuel Johnson, William Blake and William Wordsworth. A high rate of mood disorders was found, with this group 30 times more likely to suffer bipolar disorder and five times as likely to commit suicide.  These results are striking, but problematic.  It can be difficult enough to determine whether someone whom you are directly interviewing is mentally disordered, so the reliability of a diagnosis made over the passage of centuries from biographical data is seriously in question.  Furthermore we have really no idea what minds were like in the past, and in diagnosing historical figures with mental disorders characterised well after their deaths, we must recognise that we project ourselves onto them.

Looking at living people avoids some of these difficulties and another study interviewed a group of 47 eminent British writers and artists and found that 38% had been treated for mood disorder.  The poets involved were particularly unfortunate and half had needed hospitalization.*  In line with speculation that bipolar patients are particularly creative, many of the subjects reported changes in mood, cognition and behaviour either preceding or coinciding with the creative process.  In a similar study on the other side of the Atlantic, a group of 30 creative writers living in Iowa was interviewed.  The researcher was actually expecting to find a correlation between creativity and schizophrenia but actually no such was seen.  There was however abnormally high levels of mood disorder in both the writers and their relatives;   eighty percent of the sample had experienced at least one episode of major depression, hypomania or mania compared with 30% in the control group.  The group was followed for the next 15 years and it was found that 43% had bipolar disorder compared to only 10% of the control group and 1% of the general population.

A further two ore studies seem to confirm these findings.  In Denmark bipolar patients and their relatives were interviewed about their lives and their responses were evaluated using a standard measure of lifetime creative achievement.  The patients and their relatives both scored higher than the control group.  A Stanford university study found that people with bipolar disorder and creative discipline controls scored significantly higher than healthy controls on a measure of creativity called the Barron-Welsh Art Scale.

As well as mood disorders at least one study has suggested that schizophrenia may also be implicated.  An investigation of the occupations of the relatives of Icelandic patients with schizophrenia found evidence of high levels of creativity.  Do then psychosis and creativity have common genetic roots?

I haven’t looked at these studies of living patients closely but they do suggest that the correlation between creativity and mental ill health cannot be dismissed as their findings are quite consistent.  It is interesting that the creative process does not appear to be restricted to a single category of mental ill health; this may either mean that the distinctions we make between different mental states are overconfident, or that it is the altered state that is important, but not its precise nature.   The studies are still relatively few however and the numbers of patients included appear limited.  Their definition of creativity is also narrow, being restricted to the arts and such a one dimensional view of creativity may reflect familiar prejudice against the merits scientific disciplines.  It seems unlikely that a person who is successful in science, business or politics will not have to show creative thinking.  There is also no discussion of the direction of causation; those with mental health problems may choose to work in creative areas as the discipline required for full time employment is not necessary.  Equally it is also possible that the isolation, rumination and mental effort required for the act of artistic creation will also have an effect on mental health.  Also note that if there is a connection between mental disorder and exceptional creativity, these may not necessarily both be in the same individual; it is possible that there could exist an excess of mental disorder within the family of the creative individual who is him/herself in fact largely unaffected.

Yet even if studies were uniformly unsupportive I think that the idea of the madness and genius being co-dependent would persist.  The creative process is generally romanticized, a phenomenon in itself unremarkable as this maintains privilege, impresses patrons, and recruits muses.  Perhaps there something mysterious and unexplainable about the creative process such that we feel it requires something equally mysterious and unexplained – mental illness - to account for it; or do we feel that dramatic works must necessarily have dramatic conceptions?  Or in order to soothe the doubts we have about our own achievements do we wish to see talented artists as in some way ‘other’.  Another advantage of mental ill health and creativity being in some way connected – and one that is more likely to mean that a possibly spurious correlation is paraded as fact - is that this allows something positive to come from mental illness.  Note also the idea of ‘genius’ is in itself culturally dependent, being as it is a Western individualistic notion that genius exists within a single person, a great man or woman without whom society would not move forward.  A discussion of the good fortune that lead to their recognition is not generally undertaken.  What constitutes either genius or madness is of course highly subjective and hostage to the gaze we bring and the assumptions and values that gaze has implicit.

Presumably, if the association is genuine, mental ill health must at some level help with the creative process.  A creative person may differ from others in that he or she is more open to experience, is more exploratory, shows increased risk taking, and is more tolerant of ambiguity.  A particularly creative person may experience the order and structure that others find comforting as inhibiting and may feel the need to confront norms and conventions.  Such traits may make him or her more perceptive but also more vulnerable to emotional turmoil.  It does seem likely that artistic creativity will benefit from a variety of experiences and perhaps the struggle to come to terms with personal emotional extremes supports the process as certain thoughts may only be accessible to us when in certain states of mind.  Times of mental health could draw on times of mental ill health for inspiration as Lewis Wolpert has commented.  Depression could help put into perspective thoughts and feelings that have been generated during a more manic phase and in this way it could take an editorial role.

Mental health is however also necessary for great work, as this requires concentration, discipline and great effort. Mental ill health is clearly neither necessary nor sufficient for genius given that not every creative person has a mental health problem.  There does seem to be something to ‘madness and genius’ but how strong a correlation is unclear and is likely to remain hostage to where we choose to draw our lines in the sand.

***
* A recent debate at the Maudsley Hospital took this on and debated the motion ‘this house believes that madness is the price we pay for exceptional creativity’.

None of the speakers were particularly perceptive alas.  It’s available as a podcast, so no need to take my word for this.

** Comedians are classically seen as depressives.  Oliver James certainly thinks so.  In their book The Naked Jape, Jimmy Carr and Lucy Greeves discuss the ‘sad clown’ stereotype and basically disagree with it. They quote a 1992 study by psychologist James Rotton which found that comedians were actually no more prone to suicidal depression than any other group and there was no difference between the life expectancy of a comedian and any other sort of  entertainer.

Assuming that we buy the line that childhood trauma or hardship can, in some cases, spur individuals on to high-profile achievements, it’s not surprising that many successful and famous jokers have less than Walton-esque family backgrounds. But would you find any fewer damaged individuals if you were to look at rock musicians, or actors, or any other deeply competitive profession where the stakes are high, your personality is exposed to harsh public criticism and you have a bit too much time on your hands?

Lucy Greeves was kind enough to reply to my emails and said that she’s found from her own experience that the trait that most exemplifies comedians is competitiveness rather than melancholy.

I think the thing that strikes a lot of people as odd when they first realise it is how serious most professional comics are in “real life”. I’m not sure why this surprises us, though. We don’t expect opera singers to converse in arias. But because a really good comedian’s trick is to convince his audience that he’s not using a script, we buy into that illusion that he’s just a really hilarious guy who has agreed to be our mate for the evening. Imagine our disappointment when he doesn’t say funny stuff all the time – perhaps he’s depressed?

Interesting huh?

***

These three books have sections on this subject:

Madness explained Richard Bentall
The meaning of madness Neel Burton
Malignant Sadness Lewis Wolpert

In a lecture he gave in October 2008 Consultant Psychiatrist Dr Pat Bracken spoke strongly in favour of engagement of psychiatrists with consumers of mental health services.  He put it rather strongly actually: 

‘If we say that we are working to develop user-centred services, training and research programmes then is it simply unethical to carry on as if the user movement did not exist’.

True to this insight, during my time as a psychiatric trainee I’ve had very little to do with user organisations, and they have therefore had little or no impact on my thinking or clinical practice*.  Just like Bracken says, for me they have not existed.  I am unable to say if this is the experience of all psychiatric trainees, or whether my training establishment is particularly indifferent, but I fear that I am not a unique case.  This must be a regrettable oversight.  Any sensible commercial entity (to which health services are becoming increasingly compared) listens to people who take the time to lodge a concern, knowing that if they do not, not only will their disgruntled customer brief others of their dissatisfaction, but also that they will be missing an opportunity to improve.  Within psychiatry, patients can make complaints and are sometimes asked to participate, but they act predominantly as advisors and expertise still resides with professionals. 

Why, you might say, does this matter, and why should we single psychiatry out on this?  Perhaps we should not; I personally have seen from working in other medical specialties that psychiatry’s reluctance to engage with user groups is shared by other branches of medicine where there reside doctors who are very unwilling to engage with patients.  Many people return from a stay in a hospital medical or surgical ward with reports of offhand medical staff and have been so uninvolved in their care that they are barely aware of what has happened to them.  However, whilst psychiatric disorders resemble those of physical medicine in many ways, their formulation cannot easily be captured with the same lexicon and the interaction between psychiatrists and their patients is different.  You can, at least in theory treat, a patient’s coronary arteries without so much as exchanging the time of day with them.  A cardiologist who takes into account their patients’ community role and psychological well being may have more satisfied patients, but it is not their primary business.  Psychiatry, on the other hand, deals with thoughts, feelings and behaviours and is entirely cited in the social world.  Our outcomes are less mechanical and more nuanced than those of other parts of medicine.  We have power to define normality, to bestow stigmatizing labels and to take freedoms where we think fit**. 

Psychiatric disease is often chronic, so a beneficial relationship between doctors and patients can only be to mutual benefit.  The fuller dialogue with patients and with user groups could lead us to devise services that genuinely engage people with mental health problems and inform our theories as to the nature and boundaries of psychiatric illness.  Such engagement will lead to responsibilities for our patients too; they, as well as the wider public need to be will to be understanding over the particular areas of difficulty in our practice, such as the use of the mental health act.  Recognition will also be needed of the fact that user groups do not speak with one voice and potentially have contradictory messages. 

If you have worked with user groups in any capacity, please leave a comment below and tell of your experience.

***

*Criticism of psychiatry from former users is, of course, not new.  In 1620 for instance the House of Lords received the ‘Petition of the Poor Distracted People in the House of Bedlam’ a complaint against the inhumane treatment of the Bedlam Asylum inmates. 

** Not that I was there, but this transcript of a 2006 debate organised by the James Naylor Trust gives an idea of how upset some people are with psychiatrists.

Links:

Users’ movement and the challenge to psychiatrists - 1998 British Journal of Psychiatry

Addendum 5 July 2009

An interesting new publication by Pat Bracken and Phil Thomas on the user groups subject:

Beyond consultation: the challenge of working with user/survivor and carer groups

Common sense, nonsense and the new culture wars within psychiatry. Invited commentary on . . Beyond consultation

Authors’ response. Invited commentary on … Beyond consultation

There a debate held by Intelligence Squared tonight Psychotherapy has done more harm than good.  Lord Layard and Jeffrey Masson were talking about it on Today this morning.  Both presented arguments lacking in nuance to my mind.  It’s sold out, but I probably wouldn’t have gone anyway as tickets were £25 (grumble, grumble acting to keep knowledge the preserve of privileged elites… - if anyone is going or downloads the mp3 from iTunes please let me know if it was any good)

This article The woman who hates food is interesting.  MeMe Roth President of the National Campaign Against Obesity appears to have an abnormal relationship with food.  Her parents used to be fat and on the day of the interview she’s not eaten anything and it’s 1530.  I’m not good at defence mechanisms - projection or projective identification?

Today I saw a female patient who has problems with use of multiple recreational drugs and alcohol.  I was the first psychiatrist that she has ever seen, she has however for the past two years been taking mirtazapine - an antidepressant - and this is prescribed by her hospital physician.  I almost never prescribe medications outside a psychiatric remit, however antidepressants are regularly prescribed by doctors whose area of expertise is not psychiatry.  GPs, ITUs and stroke wards often start their patients on these medications, and hospital physicians can also be very fond of them. 

The notion that there is a very common disease called ‘depression’ that can be addressed with the use of antidepressants is very prevalent in our society and although psychiatrists are ‘experts’ in it, the general abandon doctors show with antidepressant prescribing would suggest that its treatment is something on which all doctors have purchase and is not just the preserve of shrinks.  Yet can this be a good idea?  Many doctors’ insight into this area may be no more nuanced than that gleaned from their teaching at medical school, which from my recollection was simplistic and dogmatic.  Is low mood such a problem that we cannot but afford to have all doctors tackling the problem, or has the diagnosis gone feral and now needs to be tamed by expert tamers with chairs and whips?

In truth ‘depression’ is a very difficult thing to define and any doctor who says that they can reliably differentiate it from sadness is deluding themselves.  Our current best shots at a definition, or at least the one that most people agree on, are the vague aggregation of symptoms offered by DSM-IV and ICD-10.  These definitions are so broad however that they stand accused of pathologizing everyday sadness and have in part lead to the ridiculous notion, useful to some, that one in four of our population suffers from a disorder of their mental health. 

Standing aside whether widely used criteria are worthy, most doctors – including psychiatrists - pay little heed to operational criteria, and instead simply going to a doctor once or twice and stating that you’re ‘not quite yourself’ is most often sufficient for a prescription of antidepressants, which is a de facto diagnosis of depression.  It’s illuminating often to ask people who say that they are ‘depressed’ what meaning they attach to this; the selection of responses I have had range from those equating to mild dysphoria to those expressing unremitting misery.  It is also not unusual for a question about someone’s supposed mental distress to be framed in more concrete terms: ‘I’ve got a lot of trouble with my housing’ being an unfortunate favourite.  If the first doctor won’t provide you with antidepressants, the second surely will.  Doctors we feel they must help and antidepressants allow them to avoid admitting the boundaries of their efficacy.

Thus a patient who entered a consulting room simply sad, and often unfortunate, leaves anointed as ‘depressed’ having now a stigmatizing mental health disorder, and as this is a disease that sits independent from a life narrative, other avenues of relief which might have otherwise been explored are tacitly discouraged.  Now take the patient we started with.  Anyone standing next to you at a bus stop would tell you that if someone was already taking four psychoactive substances on a daily basis, then addressing these might be the first place to start.    This is what I’d have said to them, but in this rights-based society if I think this and a patient thinks differently, who’s right?

You might think then that this is a call for psychiatrists to act as gatekeepers to the prescribing of antidepressants.  Actually no, depression and antidepressants are one of the stories of our age, which means that they effect everybody and everyone has a part to play in their sensible use.  I’m not going to go so far as to say that there is no such thing as ‘mood disorder’ but in recently years we have all reimagined humans as intensely vulnerable beings, which inevitably means that people will view themselves in this light.  As the prominence of religion in European communities fades and market capitalism continues to propagate the excluded, medicine has become the place to turn for suffering of all kinds, social, physical and mental but this is no substitute for a supportive community.  They don’t teach us at medical school how to know the limits of our business, so we’ve been simply blundering on.  If all doctors can prescribe antidepressants, then all doctors should be part of the conversation about when we’ve gone too far and we should tell people that they’re a lot tougher than they think.

There is I think an episode of Inspector Morse when Morse, whose investigation has conveniently developed to involve an alluring female psychoanalyst, is told by her ‘I’d love to get you on my couch’.  Not like that of course, and such a clichéd line embodies why treatment of the mind can be so fascinating.  It’s a chance to ask questions that would usually be considered rude, and to peer into people’s psyche, so far as they’ll let you. 

Such curiosity, combined with a dollop of the bizarre is amply sated by Alex Boese’s book Elephants on Acid and other Bizarre Experiments.  Here hoax aficionado Boese covers a wide range of scientific enquiry all of which has been published in scientific journals.  Some of it comprises a freaky sideshow but most of the experiments - despite their boldness – have actually represented a leap in our understanding of the human condition.  It’s predictably psychology heavy; Milgram’s grisly experiments in obedience lead him to conclude ‘if a system of death camps set up…of the sort we had seen in Nazi Germany, one would be able to find sufficient personnel for those camps in any medium-sized American town’.  Meanwhile his erstwhile school classmate Zimbardo was the instigator of the infamous Stanford experiment, were mild mannered college students rapidly lost themselves in their adopted social roles.  Festinger tested his ideas on cognitive dissonance by infiltrating a cult that believed in the imminent end of the world. 

Also mentioned are ultimately unsuccessful efforts to get dogs, having seen a bookcase fall on their master, to seek help; the title tale of the consequences of injecting an elephant with LSD, the effects on cockroaches on racing in front of their peers and the effects of LSD on the terminally ill.  It’s all told with a jaunty lilt and, unlike a lot of books I review here, is easily read on the bus.

I went to a debate on complementary medicine recently, hosted by the KCL Social Medicine Society.  Despite being held on Guy’s Hospital Campus, a supposed stronghold of conventional medicine, the lecture theatre was awash with complementary therapists and when the pre-debate votes were taken the numbers were two to one against critics – like me - of complementary practice.

The speeches for and against the motion, although equally disadvantaged by the lack of anticipated audiovisuals, were, by and large, as I had expected as they rehearsed well known arguments on medical evidence and the primacy of double blind randomized control trials.  What I hadn’t been expecting was the degree of tension between the two viewpoints; for instance several audience members felt regularly moved to heckle Simon Singh, co-author of Trick or Treatment – a paean to evidence based medicine, not content that he is already subject to a libel lawsuit from the British College of Chiropractors.

After the addresses, relations deteriorated further when participation was invited from the floor.  It wasn’t just that some of the points made were verbose and closer to statements than actual questions, the vehemence of the complementary therapy supporters disagreement with a conventional medical approach was striking.  It was almost as if they felt that those opposing their view not only disagreed with them, but did so malignly with murderous intent.

Of course the sample of people I saw was self-selecting, but why would people feel so strongly that conventional medicine, and by extension doctors, wished them ill?  A partial answer as to the schism between complementary and conventional medicine is provided by Bad Science guru Ben Goldacre, who in his recent book lists reasons why ‘clever people believe stupid things’.  His argument is psychologically based: people are biased; see patterns where there is only random noise; see causal relations where there are none and overvalue and seek out confirmatory information.  From these beans a beanstalk grows all the way up to Matthias Rath.

I don’t doubt Goldacre’s assessment, but it cannot wholly account for the hostility which I witnessed.  The supporters of complementary medicine at the debate seemed to feel entirely disenfranchised by conventional medicine, and alienated even from cordial debate.  The root of this emotional intensity may be that although the majority of people tolerate the NHS’s faults and are basically satisfied with the service they receive, some people’s experience of conventional medicine can be poor.  Consider the people who feel unheeded by their doctor who can only allot them seven minutes, or those upset and resentful about their parent who died from the effects of chemotherapy; or those suffering from medicine side effects or whose operations lead to complications. For some, it won’t just be the message, but the messenger too: doctors nearly all come from a privileged swathe of society and our relative erudition and advantage will make some patients, whose achievements may on the face of it seem more humble, feel unpleasantly diffident.

Other factors against doctors are wired in from our training.  Despite modern efforts, it all too rarely leads us to heed that a patient’s experience of receiving their healthcare can be even more important than the healthcare itself and we still tend to see people in terms of aggregations of symptoms, ignoring that most of our patients come to see us for reasons only partially related to an identifiable disorder.  Although improvements have been made and medical schools have pulled up their socks, the MRCPsych and other membership exams give pitiful consideration to the cultural forces behind poor health.    Overall, and especially post graduation, our manner with our patients and our ability to help them in any way beyond a narrow biomedical confine it is not treated as central to what we do but rather something we are expected to pick up as we go along.

Could complementary therapy for its staunch adherents be then one in the eye to all the people like doctors who ‘think they’re clever’ and fail to adequately assess or understand patient difficulties?  Is it an inevitable outcome as the result of some people wishing for a more equal partnership for healing? For the disenfranchised, complementary medicine may be something that they can own, and a haven from the people whose education unfortunately makes them seem intimidating and unapproachable.

Addendum 4 June 2009:  In an earlier version of this email I used the spelling complimentary as in ‘to offer praise’ rather than the correct complementary as in ‘to act as an accompanyment’.  Gradually chipping away at my ignorance….  Indebted to TimA for his wise counsel.

In 1986 whilst working for the now ex-newspaper Today, journalist Alastair Campbell suffered a mental breakdown.  This would have remained a relatively private affair, but Campbell’s subsequent role as Tony Blair’s right hand man has meant that it has since become the second most famous mental health breakdown by a figure in current British public life*.  But there’s a happy ending: twenty-three years later, Campbell has not only become an extremely prominent public figure but has recently won the Mind Champion award for his work to reduce stigma surrounding mental health problems.  As well as representing the anti-mental health stigma campaign Time to Change, his contribution has included the BBC2 documentary ‘Cracking up’, and the novel ‘All in the Mind’.  Accounts of Mr Campell’s breakdown can be found on the internet, of which Wikipedia, One in Four magazine and a Ruby Wax interview provide four viewpoints. 

For my part, and as part of my ongoing project to read every book about mental health ever written, I have just finished Mr Campbell’s abovementioned novel ‘All in the Mind’.  A curious book, and mostly dreadful, it takes place over three days in the life of reputable psychiatrist Professor Martin Sturrock.  Although highly regarded by his patients and colleagues, protagonist Sturrock is a man on the verge of a crisis, his mood nosediving and no less in need than his patients; his personal life is a mess; he is distant from his children, semi-estranged from his wife/in love with a patient and has a penchant for visiting prostitutes. 

Besides breathing and standing up straight, Sturrock’s psychiatric work is the only thing he seems to be able to do to his own satisfaction.  Perhaps because of this he feels toward his patients a great responsibility and he is reluctant to cancel their appointments under any circumstances.  The book opens with Sturrock fretting over the consultations he has that day with five people whose own stories are subsequently woven amongst that of Sturrock’s throughout the book: a disfigured young lady, a mood disordered young man, a former victim of sex trafficking, an alcoholic cabinet minister and a straying husband.   Outside these consultations Sturrock’s boundaries with his patients are blurred and during them his methods unorthodox, with his enthusiasm for dream interpretation and conspiracy to mislead a patient’s wife examples.  Sturrock’s patients take his sessions very much to heart, and his sage pronouncements and homework assignments – which they are expected to email to him the night before their appointments - dominate their lives. 

Occasionally All in the Mind’s simple tales of the woe are rather touching and the plot as a conceit is not a terrible one, but the central problem is that Campbell’s prose basically lacks the dexterity to convincingly render his characters’ mental states on the page and more than once the writing was so leaden that I wondered whether a blood vessel might burst in my eye.  A brilliant study of depression this is not, despite Campbell’s first hand experience. Furthermore, although it would be a mistake to come down on a work of fiction too hard for lack of verisimilitude, I do wonder whether Campbell has talked to a psychiatrist about what the job is actually like; Sturrock’s enmeshment with his patients is never criticised and his clinical unorthodoxy never acknowledged, the narrative being purely concerned with the tale of an excellent psychiatrist whose deftness with patients contrasts his own inner turmoil.  Campbell even goes so far as to suggest that psychiatrists have mind reading powers:

 She would tell herself he was the psychiatrist not her.  He was the one who understood the human mind, not her

***PLOT SPOILER: do not read on if you intend to read this book***

As it informs the experience of the rest of the book I cannot but mention the ending.  During the closing chapters Sturrock’s depression takes a sudden, and frankly unlikely, turn for the worse and a florid psychosis leads to his death as he steps in front of a lorry.  Campbell then uses this tragedy to set up a mawkish and contrived ending, as before he dies Sturrock sends a text message to his wife asking that the patients about which we have read should make speeches at his funeral.  They duly do, and the church is unexpectedly full of people Sturrock has formerly treated, all wiping tears from their eyes.

The coffin was carried out.  Hundreds of mourners, many in tears rose to their feet as Mrs Sturrock and her family filed out behind it: pew upon pew of flawed people come to bid farewell to a man who healed many of them; who preached forgiveness, but could not forgive himself

Oh dear.  Campbell is a novelist only for the most undemanding reader.  He clearly feels grateful for the help he has received in the past, but I fear this is not the way to show it.

Other reviews:

Byron Rogers The mannekins don’t walk The Spectator 12 November 2008
Peter Kemp All in the Mind review Times Online November 2nd 2008
Sahmeer Rahmi All in the Mind review Telegraph 6 November 2008
Derek Draper Inside the sick world of the spin doctor Guardian 9 November 2008 - a notably more positive review than the rest, from the former labour insider turned psychotherapist before he revisited disgrace.

*Can you guess which the best known one is?

It has been estimated that approximately 1 000 000 people die of suicide yearly worldwide  and whilst most studies indicate that people who commit suicide have a disturbance of mental functioning this does not exclude a relatively small number of people who, for whatever reason, might express the wish for an early death but yet lack any state that may impair their mental function.  For these people the paternalistic approach applied to many with a desire for suicide appears less appropriate and has lead to the notion of a ‘rational suicide’.  Many people feel strongly that this option for rational thinkers to end their lives should be available and argue that there is a historical precedent; it was in reference to manner of Socrates’ death that Compassion and Choices, an American euthanasia pressure group, was initially called the Hemlock Society.

The emergence of rational suicide as a concept has happened within a framework of contemporary era cultural, technological and philosophical shifts where individualistic attitudes lead people to treat their own goals and desires as paramount whilst advances in medical treatments have lead to increased lifespan.  Therefore at the end of life we are both encouraged, and afforded more opportunity, to contemplate the manner of our own passing.  Judgement of suicide has simultaneously moved away from assigning a successful suicide to be a moral or religious failure towards one where most suicides have come to be seen as the result of disturbance of mind.

Werth and others have suggested criteria under which a rational suicide should be allowed.  That these are notably circumscribed reflects the negative value that suicide generally holds and the concerns of others with this approach.  Proposed are that for a suicide to be considered rational the person in question must have an unremittingly hopeless condition, should make their decision as a free choice and have engaged in a sound decision making process, including assessment by a mental health professional.

Despite the face validity of this line, analysis of what is meant by ‘rational suicide’ and its implications reveal a more nuanced situation than the casual inquirer might anticipate.  From the definitions of the word ‘suicide’, taken from the latin sui meaning ‘of oneself’ and cidium meaning ‘to slay or kill’, and that of rational, an act that it is characterized by reason or is intelligible, sensible, or can be understood , one can surmise that ‘rational suicide’ is self slaying that is characterized by reason or ‘makes sense’ to others .  The arguments in favour of rational suicide generally come in two flavours.  The first emphasizes the need to respect an individual’s autonomy, the modern meaning of which was developed by the philosopher Kant.  In common usage it implies ‘being one’s own person or being able to act according to one’s beliefs or desires without interference’.  Kant expressed it as a respect for persons and wrote that to violate a person’s autonomy is to treat them as a means rather than as an end in themselves.  The ‘right to die’ is then an expression of the most extreme form of autonomy, that is the right to choose the time and manner of one’s passing.  The second argument in support of rational suicide involves the ability of an individual to make rational assessment of utility or ‘good’ that is gained by ending their life and here proponents argue that suicide can provide freedom from painful and hopeless disease.  In this argument the consideration that an individual has for their quality of life is of paramount importance.

However the concepts of autonomy, utility and rationality alone are inadequate arguments for the acceptance of rational suicide as none are ever identifiable in so pure a form as to be considered a philosophical trump card.  Werth’s guidelines are first and foremost pragmatic and with an irreversible decision at stake the standards of rationality must of necessity be high.  To come to a conclusion that an act or intention of suicide is reasonable is not a straightforward matter.

We must also recognize that in seeking a rational suicide, the components that inform this decision are culturally determined, thereby introducing considerable subjectivity and possible external disagreement.  Furthermore if the decision to end one’s life is informed by persistent suffering, then it is unlikely to be made on entirely non-emotional grounds and likely to be subject to cognitive distortions.  It is a curious position to seek to solve a problem in life, by ending the life itself and those intending a rational suicide would presumably actually prefer to be alive, just not under the current circumstances, indicating the presence of significant ambivalence regarding their decision.

There are few people who would argue that autonomy for a patient, at any stage of care, is not important.  However when we respect autonomy we are respecting a person’s right to exercise their right to make independent decisions about their life and these decisions will be made on the basis of considerations which are consistent with a person’s moral values or a personal code.  These values or code would ideally be independently derived; however this is not possible as people are heavily influenced by such things as their culture, parents and friends.  Thus the sense of autonomy as the exercise of independent thought is compromised.

Alternatively, if one wishes to frame rational suicide as the outcome of an audit of a life’s merits and demerits a pertinent question is what the continuation of this life is to be weighed up against.  If the decision is to be truly informed this should involve gaining all possible facts and imagining all consequences.  However since the experience of being dead is entirely unknown it is questionable whether it is possible to adequately foresee the outcome of one’s actions in this regard.

These concerns indicate that it may be difficult to satisfactorily reach a conclusion that rational suicide is possible.  The concept of a suicide being ‘understandable’ is probably more meaningful and suitable although may not carry the same weight.

Comment on this piece

Life is a disease so cut the bullshit please

Further reading:

Autonomy, rationality and the wish to die Clarke Journal of Medical Ethics 1999;25:457-462
A Primer on Rational Suicide and Other Forms of Hastened Death Werth and Holdwick The Counseling Psychologist, Vol. 28, No. 4, 511-539 (2000)
Rational suicide: uncertain moral ground Rich and Butts Journal of Advanced Nursing Volume 46 Issue 3 270 - 278

Encyclopedia of  death and dying - suicide types

Suicide - a rational choice?

The economics of suicide - Slate magazine

Thought for the day 9 June 2009

Addendum 23 June 2009 Neither euthanasia nor suicide but end of life choice,  Guardian 23 June 2009.  More about physician assisted suicide than rational suicide but the comments are interesting, as they touch on many of the issues raised above