Poppy love

Dear Editor,

Pain (with or without a medically explained cause),
depression and distress typically present in the ‘swamp’ of
primary care, where up to 90% of people with them are
“dealt with”. Psychological causative factors for GP
consultation are still widely quoted as being the reason
for up to 40% of attendance.

Those with depression and pain are more complex in their
presentation, often less well-managed (because, for
example, the depression is seen by the practitioner as an
‘understandable’ consequence of the pain or age) and more
resistant to treatment. Such people also have higher rates
of disability, reduced psychosocial functioning and
impaired life quality. The greater the depression, the
poorer the pain-related prognosis; the more the pain
symptoms, the more severe the depression.

Optimising a person’s overall predicament unsurprisingly
delivers the best outcomes; the biopsychosocial approach to
care requires that the doctor is not the only fruit.

At least 33% of somatic symptoms are medically unexplained,
and these symptoms are chronic or recurrent in 20% to 25%
of patients. There is a highly significant number of
primary care consulters and those referred to hospital who
will still be told by a conventionally trained doctor, at
some stage, that “there is nothing physically wrong with
them”.

This time-expired and non evidence-based statement
perpetuates the legacy of Descartes and creates the
separation of physical from mental health care and all the
fruitful pickles that are derived therefrom. These include
revolving door referral activities, defunct commissioning
for the parts and not the whole, blighted lives and
demoralised, ineffective practitioners.

Dr Gillespie highlights the potential for ‘poppy love’ to
mature into a full-blown addictive affair and demonstrates
the long lineage that derives from our inattention to the
lessons of history and the lustful intentions and potential
dependencies of our synapses. Since more recent evidence
suggests that a major predictor for a consulter to have a
medically unexplained physical symptom (MUPS) is the
prescribing of an antidepressant and/or an opiate, we
should be thinking very hard about the major need to skill
up our front-line practitioners in psychological
mindedness, so that if any medicine is prescribed it is
appropriate and not a substitute for due care and concern.

Perhaps there is light at the end of the tunnel – or
nearer? The Improving Access to Psychological Therapies
(IAPT) Programme is going to make a major dent in the
general indifference of the NHS to brainmind issues.

The opportunities need to exist, through increasing
psychological skills training at undergraduate level, and
through contact with increasing numbers of psychological
therapists at postgraduate level, for many practitioners to
become skilled up in such interventions as Cognitive
Behaviour Therapy (CBT), that are proven to be effective in
working with many of the above patients.

Such training and exposure would also do much to improve
the wellbeing of those same practitioners in their day-day
work with those who are distressed.

100 liaison psychiatrists cannot visit everyone in hospital
with a psychological problem – we need all practitioners to
be able to liaise psychologically with their patients and
commissioners to understand how ‘mental’ permeates all NHS
work and agendas.

Yours Sincerely

Dr Chris Manning

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Competing interests:
None declared