AUTHORS: Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov
In this series the Medspire team interviews doctors about their career, their specialty, the choices they have made and their advice for doctors and medical students.
Today, the subject is Professor Ulrika Schmidt, head of the department of psychological Medicine at the Institute of Psychiatry, Psychology & Neuroscience (IOPPN) at King's College London. Professor Schmidt has developed an multi-award winning early intervention programme for eating disorders.
A podcast of this interview is available here:
How did you get to where you are today?
I came to London straight after medical school with a one-year scholarship to the Maudsley, and I have never looked back. Many years later I am still here.
I loved the Maudsley, did my training there, got into eating disorders through a lucky accident, then had a little detour into general psychiatry in my first consultant job. Since 1998, I've been a consultant and then an academic in eating disorders, so most of my professional life in psychiatry has been in that field.
What attracted you to psychiatry as a specialty?
This goes back many years to my time as a medical student in Germany. What I really loved was the psychosomatic lectures we had on a Friday afternoon at five o'clock. It was a packed house, despite the time of day and the day of the week.
There was this woman psychotherapist who had wonderful conversations with people with a mixture of physical and psychological problems. She looked with them, to try to understand where they had got to, where they were, and what had caused and contributed to their difficulties.
I absolutely loved this, and thought I'd like to be doing something like this. I then did an elective in straightforward psychiatry and absolutely hated it, because it was very custodial and old-fashioned in Germany.
When I got the opportunity to have a one-year scholarship at the Maudsley, I saw that the training over here was very different. I went on a rotation - you could learn about all the different branches of psychiatry - and thought: ‘That's what I want to do’. I have never regretted it.
Tell us about the eating disorder unit at Maudsley Hospital and the Institute of Psychiatry at King's College London
Going back 150 years, we could say King's Health Partners really invented eating disorders. In the 1870s, William Gull was the physician to Queen Victoria. He was one of the first to describe anorexia nervosa.
He also gave very good clinical descriptions of anorexia nervosa for the first time, and wrote about it in The Lancet. He picked up that people often found their anorexia, or aspects of it, quite rewarding, so he was a very astute clinician, and he had lots of good ideas about treatment. Then there was a big gap.
But then, in the 1970s, Professor Gerald Russell, who was the first person to properly describe bulimia nervosa, opened up the eating disorders unit at the Maudsley. His right-hand woman is my colleague, Janet Treasure, who is my ‘big sister’ in the research world. She became my PhD supervisor. The unit has grown, and now has seven consultants.
The unit is known worldwide for its research with family therapy for adolescents with anorexia, which was developed under Professor Gerald Russell. It's now the standard treatment for young people with anorexia.
How has the treatment of patients with eating disorders changed?
There's a lot more public awareness. This also means patients and their families are much more aware of what the problem is, and what help is available. Better awareness often means earlier detection, and earlier detection means earlier treatment and better outcomes.
We know that eating disorders really do better if you treat them early. Psychological therapies are now the mainstay of first-line treatment for any eating disorder, and have become much more established over this time.
So cognitive behavioural treatments for bulimia, binge eating disorder, various online and guided self-help formats for the briefer forms of therapy, and various forms of family and individual psychotherapy for anorexia nervosa. We've also had NICE guidelines that say this is what people should be getting, and this has been rolled out nationally.
Is there less stigma surrounding mental illness?
I think things are definitely improving, and this is partly to do with the fact that psychiatry is now much more recognised. The physical and neurobiological basis and genetic basis of mental disorders is key, and that has helped both the public, and also the medical profession, to see them as biopsychosocial illnesses.
There is also a lot more public awareness about mental disorders. Thinking about my own field, in recent years a number of men have come forward who are in the public eye, for example, Freddie Flintoff, who has talked openly and made a television programme about his bulimia.
Those kinds of things are helpful in terms of destigmatising mental health problems. In terms of what we can all do, we need first to look to ourselves and if we perhaps hold stigmatising views of people. In the eating disorders field, people have become much more aware of anorexia as a lethal disorder.
Where there are still stigmatising attitudes is more in relation to binge eating, and where people have obesity as well - where there are thoughts about people not being very self-disciplined. There's a stigma against obesity.
So, people need to always think: ‘Do I hold those beliefs? What can I do to recognise that in myself? And what can I do in myself not to act on that, to keep an open mind, to try to keep the whole person in mind, and not to judge’.
Are there any particular misconceptions about eating disorders amongst doctors?
There has been the idea of the self-inflicted nature of eating disorders, which people are moving away from. I often hear that people see our patients as manipulative and as not telling the truth.
Where this comes from is that sometimes patients with anorexia - especially if they're really put into a corner and are treated against their will - try to fight the system, and they may falsify their weight.
This happens rarely - on the whole our patients are incredibly honourable. But if they're cornered they may, out of self-defence, try to protect themselves and this has given them - in some quarters - a bad reputation.
What makes a great psychiatrist?
You've got to love people, be very curious about them, and be open-minded - not judge people if they're different, if they're eccentric, if they're doing things that seem unusual or strange, and to really try to understand it and be curious about it.
You've also got to be able to tolerate uncertainty and ambiguity, because there are not many diagnostic tests in our field. Sometimes, you have to be open to the idea that you will see change only slowly over a period of time.
Having said that, you can make a tremendous difference to people's quality of life. You can also help people really turn their lives around completely and recover from mental ill health.
In my own field it's clear that one of the prejudices people hold is once you've got anorexia you will always have it, but actually that's not true. We can really help a lot of young people to make full recoveries, to live very happy, fulfilled lives and to put their eating disorder behind them.
How did you become involved in research?
I did a small research project when I was a psychiatric trainee - we all had to do one. By chance, I did one on eating disorders. That paved the way for me to become more fully involved in eating disorder research as a higher trainee.
I was working clinically in the eating disorders unit as a senior registrar, and was offered a research job for three years to work on a big clinical trial, which combined medication and cognitive behavioural therapy in bulimia.
Once I had started with this paid research job, I also did my PhD in the eating disorders unit, so it was a gradual development. Over time, I began to develop my own ideas of what I wanted to do. As part of this trial I saw so many women with bulimia.
I wanted to write a self-help book for them, and put all the ideas of cognitive behavioural therapy into it. I did this, and then I had the idea to try using that instead of therapist-led treatment.
The more I immersed myself in research and the more I became part of a research community, the more I developed ideas. Research was a happy accident, and I have never looked back.
What do you love about research?
What's not to love about research? Apart from the tremendous bureaucracy that's attached to it these days. I love it when I have a question that I want to research - I really enjoy developing a research proposal, and grant writing.
It forces me to take an in-depth look into a particular area - what's already known, how what I want to research is going to make a difference, how it's going to improve on what's there before, how it's going to add value, how it's going to be value for money when you go to fund this, and how it links to need in the population.
I love to make a really strong case for my project because it's a real intellectual challenge. When you actually get funding, you have to set it up and apply for all sorts of regulatory approvals. Then it's more of a logistical problem.
There's a lot of bureaucracy involved, and that's not one of my strong points or something I particularly enjoy. Actually doing the research is also very rewarding. Nowadays, I have lots of PhD students and research workers, so I mainly supervise people doing the research. Getting the data, analysing them, and making sense of what you have found is also really interesting.
Often you find the opposite of what you hypothesised, and you try to make sense of it, writing it up. The beginning and the end are the most exciting bits, and the bits in the middle are more mundane.
What are your current research interests?
I'm very much a treatment researcher, and have spent a lot of time doing psychological treatment research. In recent years, there's been much more interest in the neurobiology of eating disorders, and we know much more about how over time certain behaviours become more rewarding and habit-like in eating disorders, and how this links to changes in the brain in the frontostriatal circuit.
I've become more interested in brain-directed treatments, such as non-invasive brain stimulation that can be used essentially to reset brain circuits in people with anorexia or bulimia. We did the very first trial of transcranial magnetic stimulation in severe enduring anorexia - these were all patients who'd had a long history of illness, had been inpatients for 10-14 months on average, and were very unwell.
They did really well with this brain stimulation, and we found initially it improved their mood a lot, and over time it also improved their eating and weight. That was exactly the right way round, because you wouldn't want someone to put on weight and feel very upset and unhappy about it, you would want them to feel better first and then change what they're doing with their eating.
I'm keen to do more work in this area. Some of my PhD students are using another form of brain stimulation - transcranial direct current stimulation - which often can be used with some form of cognitive training.
You get people to learn to make different associations when they're looking at pictures of high-calorie foods, to learn to push that away whilst having their brain stimulated, and to facilitate new learning.
There are a number of projects on the go in this area in relation to bulimia and binge eating disorder, again with promising results, but there is a lot more work to be done.
That's one area I'm really keen on - not to replace traditional psychological therapies, but as an adjunct to those treatments, and perhaps also thinking about people who are not responding to these more usual treatments to achieve a full recovery.
Is this type of brain stimulation routinely used in clinical practice?
No, it's not. It's an approved treatment for depression, approved by the FDA, and I think NICE have also said it can be used as a second-line treatment for depression. There have been lots of different randomised control trials in depression of different types of this kind of brain stimulation.
It's very well tolerated, it has very few side effects, and it has no negative cognitive side effects, which is really important. We were the first to use this in relation to eating disorders, and specifically to this group of people with anorexia who had received all the other treatments that we usually offer.
Tell us more about the FREED programme for early intervention of eating disorders, which has won multiple awards
We started with FREED about six years ago, and at the time we had these enormous waiting lists for patients, which was a problem nationwide. We recognised this was really affecting our youngest patients the most.
We see adult patients in our unit, but it was the aged 18-20-year-olds who were coming to us for the first time who had a recent onset - often they were just starting university or had just left home for the first time, and we were letting them sit on a waiting list. We wanted to do something to see them quickly.
We were also aware of the neurobiological literature on brain changes becoming more permanent over time in relation to eating disorders, and there was a good blueprint from psychosis, where people for the last twenty to thirty years had tried to delineate first episode cases and get them into treatment quickly to get better long-term outcomes.
We tried to get people into treatment quickly, but also tailoring our existing treatments to the needs of a young adult population. We tried to get the message across that nutritional changes needed to happen quickly - because early on in the illness the brain changes are still very malleable - and to help people to have the best chance of a full, rapid recovery. We also wanted to help people with a lot of the issues they were battling with around transitions.
The period of emerging adulthood is the one time in your life when you have so many changes all the time. Where you live, what you study, what you do, where you work, your relationships - this is very stressful. Some people manage this okay, but there are some casualties, and we wanted to help our patients to manage this better.
We've produced all sorts of written resources which can be found on our FREED website to help people think about this period in their lives a bit differently, to think about how you can survive with an eating disorder if you are going back to university, for example. With FREED we involve parents as much as we can if that's appropriate.
Not everyone wants that, so it's a tricky balance, because these are young adults, they're autonomous agents, but they're still often very young and need support, and don't know how to negotiate the NHS. We received some money to evaluate FREED and compared it against how we had previously seen those young people. We found enormous differences in outcomes.
FREED really improved the outcomes. We were given more money, and then we replicated FREED across a range of other services, and had exactly the same findings. It dramatically improves outcomes. On the basis of that, we were adopted for national rollout by the Academic Health Sciences Networks.
Then the pandemic struck, so we were nationally rolling out FREED while all of this pandemonium was going on, and that's obviously quite difficult. There are now about 45 services up and down the country that are using FREED. People are very positive about the model, but the difficulty at the moment is that all services are very overloaded. We are trying the best we can to manage this.
Tell us about the Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA), which is recommended by NICE
I developed this with my colleagues at a time when we began to know a bit more about the psychobiology of anorexia - that people with anorexia often have subtle differences in their thinking style to others, are less flexible, not particularly good at thinking about the bigger picture, very detail focused, and have a number of difficulties in relation to recognising and managing emotions.
We wrote all of this into our treatment manual, and, with a lot of our very talented clinicians, translated this into therapeutic tasks, homework and games that people could try out to experiment a bit with their particular way of managing their lives.
So for people who are very inflexible, to try to get them to think how this gets them into trouble in relation to what they're doing with their eating, but also with their wider life and how they can make changes to that. What we found is that this treatment is not better than other models, but it is much better accepted, and that patients really like it.
We've shown that this treatment works particularly well if people are more unwell. We also have some unpublished data to show that it works well if you give it as a treatment early on in the illness for those FREED patients.
This is because it’s based around the workbook for the patient, and it has an educational value for those who don't know very much about the eating disorder at that point, which patients really like.
Tell us about your on-going randomised control trial (DAISIES)
The DAISIES trial is, in theory, a very large pragmatic trial, which compares inpatient treatment as usual for anorexia - the condition has long inpatient admissions of usually on average about three months - against a stepped care approach, where people either receive day treatment straight away or a very brief admission only to stabilise them and then day treatment.
It's what we call a ‘non-inferiority’ trial, where you're trying to show that the stepped care treatment - which is less restrictive and potentially less costly - has as good clinical results as the gold standard inpatient treatment.
However, this trial started at the point when the pandemic started, so this was a time when a lot of units shut down their day services and reduced their inpatient capacity because of social distancing rules.
We have started recruiting patients, but recruitment is slow - we have to recruit nearly 400 patients, and are a long way off from that. The hope is this will really tell us a lot about what works for whom.
There has been a similar trial in adolescents - our trial is in adults. The adolescent trial, which was done in Germany, found that the stepped care day treatment was almost better than the standard inpatient treatment.
Certainly, weight and eating disorder outcomes were as good as the other standard treatments, and the social outcomes were better because people didn't get institutionalised.
What are some of the proudest achievements for you as a researcher?
I am immensely proud of FREED and how quickly that evolved, and how quickly we got, within six years, from a little pilot project locally to national rollout. I really believe that this is going to make treatment and services for young adults with eating disorders a lot better. I am very proud of that.
I was always very proud of my self-help book for people with bulimia, written as a psychiatric trainee and then trialling that in various clinical trials. It's still available, we've updated it, and we still get letters from patients saying: ‘This is very useful for us’.
What I did at the time was to write lots of case stories from people I had seen, obviously disguised. But people always say they really love these case stories because it's so helpful not to feel alone with your illness.
What research questions would you like to answer over the next five to ten years?
I have just received a big programme grant for the next four-and-a-half years. The aim of this programme is to try to get a much better understanding of illness stages in eating disorders. Much like we know in psychosis or in various physical disorders - that's where it comes from.
And where in different cancers you have different illness stages, and have different treatments depending on what illness stage is there. We want to see whether that model is applicable to eating disorders as well.
We think there is certainly evidence for an early illness stage which is much more responsive to treatment, but we want to learn much more about what happens over time, why some people develop more chronic illnesses than others, and what happens at the point where the illness becomes less treatable and more entrenched.
Conversely, we also want to learn much more about recovery processes early on, and as part of this big programme we will be using smartphone data - ‘active and passive sensing’ - which is just data around how often people use their phone.
We'll look at how many people they talk to during the day., and if we can we find some of these passive sensing indicators of recovery early on, because we might be able to tailor treatment according to some of those predictors.
Over these next four years, we'll be looking much more at illness stages, illness trajectories, and recovery trajectories, and mapping them very carefully across all the eating disorder spectrums.
What advice would you give to aspiring researchers within psychiatry?
Start with a small, manageable project. All of us want to do something ambitious, and like the next person, I had lots of grand ideas at the beginning which were totally unrealistic - especially if you're moving about quite a bit.
Try to find a decent supervisor or mentor who is responsive to you and gives you a bit of time. Also, if the first project doesn't work out, move on, find something else, find another mentor, shop around, look around a little bit, be flexible, and then build from there.
What lessons have you learned?
Over time, I have become much better at dealing with setbacks and failures. I just want to say there are many in medicine - whether it's clinical medicine, or research.
You think you've written this lovely paper, and actually the reviews are not very kind, or you've applied for this grant and you've spent months writing it and it gets rejected, or you don't get the job that you have prepared for and dreamt about.
My advice would be to ‘dust yourself down’, that tomorrow is another day, try again, try a bit differently, see it as a learning experience, and just hang in there.
Are there any habits that you have developed that have helped you along the way?
Persistence and ‘dusting yourself down’ are good habits to have, and not to be too disheartened. I do get disheartened - one never stops getting disheartened when one has had a setback. But I can cope with it much more quickly now, so there is learning in that.
The other habit I've always had is that I have allowed myself to meander a bit. People always tell me you've got to be focused, and driven, and strive for excellence, but you've also got to know what you're striving for. So it’s really important to let yourself look around and meander a bit, be a bit uncertain, and take your time to figure out what you want to do.
Have there been any particular role models who have shaped you as a clinician or a researcher?
My first role model was my English teacher at school, who was a middle-aged lady who would occasionally come to school wearing her pullover inside-out - she just said: 'Oh, well’. She had a great sense of humour.
If the class flagged, she would stop teaching, put some music on, and get us to do some line dancing or something equally crazy. At the time I didn't appreciate this quite so much, but she was someone who was not a perfectionist, who was trying to be in tune with the young people she was working with, and who had a good sense of humour. She was a great role model.
In my work as a clinician and researcher, one of the first people I worked with was a very inspiring man called Isaac Marks, who was a researcher. He worked with people with anxiety disorders and obsessive-compulsive disorders, did a lot of developed behaviour therapy, and treated them.
Forty years ago, he had thought very broadly about how to get treatments out there to people without patients needing to jump through multiple hurdles. Very early on, he wrote books for patients which gave them the skills that they needed to overcome their anxiety disorders.
He was also great at training people, so he developed comprehensive training programmes for those who wanted to learn his methods. I have a great deal of respect for him. In fact, I admired him so much that when he suggested that a colleague of mine and I should go up Mont Blanc with him, I said: ‘Let's go up Mont Blanc together’ - and we did.
And I think he nearly died from exposure on the trip, and I nearly had an anxiety attack coming down, because I nearly fell into a crevasse. I also have a great deal of admiration for Janet Treasure, who is my ‘big sister’ in research in the eating disorders unit and a very accomplished researcher.
One of your hobbies is hiking. Where are your favourite hiking destinations?
Lockdown meant more hiking in Britain. There are lots of great hiking destinations here - the Peaks, the Lakes, and I also love the North West of Scotland.
I like high peaking mountains as well. As a medical student I went hiking in the Andes, and I've also done lots of walking in the Alps, and the Pyrenees, on and around Mont Blanc, and did the tour de Mont Blanc, which takes ten days.
Most recently I've explored the mountains of Albania - they're called the ‘Accursed Mountains’, and that's for a reason, because they are incredibly strenuous to walk up, very steep and hard terrain, but incredibly beautiful. I'd recommend these Accursed Mountains.
Tell us about winning the NHS 70th Women Leadership Award in 2018.
Having come from Germany I've spent most of my professional life in the NHS, and I'm totally dedicated to it. I think it's an amazing way to deliver healthcare to people, and we should be very protective and proud of our NHS.
It pains me greatly - and I will be like a lioness - if I hear anyone being unkind about the NHS. So I was particularly delighted to get this award.
What's your favourite book?
I always re-read The Tin Drum every few years, written by Gunter Grass, a German author who won the Nobel prize for literature for this book. It's a book about the rise of fascism in Germany.
It's also got magical realism in it, but it's a very wonderful book both in terms of the stories it has, but also what it means for someone who is German, and for someone who grew up in the post-World War II West German world.
A professional book I would recommend to all medical students is by an American called Bill Miller, together with Steve Rollnick, called Motivational Interviewing. It's about a communication strategy for talking with people who are ambivalent about change.
It comes from the addictions field, but it's very useful in primary care - and in any walk of medicine - where we will come across people who are ambivalent about adhering to certain medical regimes. It helps you to understand where the person is coming from and to help them move on - so very useful, very easy to learn, and it makes a lot of sense. A great book.
Medspire podcasts are produced by Dr Sanketh Rampes and Dr Anvarjon Mukhammadaminov, both full-time junior doctors. They aim to inspire the next generation of doctors and scientists by exploring the career journeys of leading clinicians and researchers.