EDITOR-I would like to thank Bracken and Thomas(1) for their
refreshing look at the link between the evolution of attitudes and that of
service development within mental health services. I was particularly
interested in the author's scepticism surrounding the assertion that
mental disorders are mediated by neurological dysfunction, and that they
can consequently be cured by specifically targeted drugs. I believe such
doubts to be well-founded since this formulation ignores the range of
personal and psychosocial factors that may affect the patient's engagement
with services and compliance with medications. For the more severe mental
illnesses, with the notable exception of clozapine, differences in
efficacy rates between the range of psychotropic agents currently
available are minimal. Therefore, positive therapeutic effects probably
depend more on levels of engagement and compliance than the exact receptor
specificities of the various pharmacological agents available. The
magnitude of the compliance problem is illustrated, for example, in the
case of bipolar affective disorder, where rates of poor compliance have
been shown to be in the region of 40-60%. (2,3) This would indicate that
the focus should be switched to approaches that might effect changes in
levels of compliance and other such related variables. Such approaches
may include the utilisation of culture-sensitive services and a move away
from coercive care, as suggested by the authors, or indeed a range of
psychosocial interventions and modes of service delivery. The example of
assertive outreach springs to mind.
The authors gave an interesting example of the use of a novel
approach in a 53 year old Sikh woman with a history of affective disorder.
However, at the same time they lay themselves open to criticism from the
proponents of evidence based medicine. They state that, with the approach
used, she remained well over a period of 12 months, "needing no drugs".
However, they had earlier stated that she had a history of two admissions
in the previous six years. Clearly it could be argued that follow-up over
one year would be insufficient to evaluate the efficacy of the approach
used both per se and in comparison to any earlier treatment packages tried
in her case. Indeed the latency between episodes of affective disorder
can often cause difficulties in the interpretation of studies of other
treatments for this condition, particularly mood stabilisers. Hence, the
recognition of the need for longer duration studies, of 2.5 years or more.
(4) In this day and age there will be pressure to ensure that novel
interventions whatever their nature be subjected to comparison to existing
treatment modalities that have already been evaluated against the existing
evidence base.
Erik Milner consultant psychiatrist E.Milner@Sheffield.ac.uk
Villa 4, Walton Hospital, Whitecotes Lane, Chesterfield, S40 3HW.
1 Bracken P, Thomas P. Postpsychiatry: a new direction for mental
health. BMJ 2001; 322:724-7.
2 Colom F, Vieta E, Martinez-Aran A, Reinares M, Benabarre A, Gasto C.
Clinical factors associated with treatment noncompliance in euthymic
bipolar patients. J Clin Psychiatry 2000;61:549-55.
3 Keck PE Jr, McElroy SL, Strakowski SM, Bourne ML, West SA. Compliance
with maintenance treatment in bipolar disorder. Psychopharmacol Bull
1997;33:87-91.
4 Kleindienst N, Greil W. Differential efficacy of lithium and
carbamazepine in the prophylaxis of bipolar disorder: Results of the MAP
study. Neuropsychobiology 2000;42 (Suppl.1):2-10.
Rapid Response:
Postpsychiatry: what a refreshing change?
Postpsychiatry: What a refreshing change?
EDITOR-I would like to thank Bracken and Thomas(1) for their
refreshing look at the link between the evolution of attitudes and that of
service development within mental health services. I was particularly
interested in the author's scepticism surrounding the assertion that
mental disorders are mediated by neurological dysfunction, and that they
can consequently be cured by specifically targeted drugs. I believe such
doubts to be well-founded since this formulation ignores the range of
personal and psychosocial factors that may affect the patient's engagement
with services and compliance with medications. For the more severe mental
illnesses, with the notable exception of clozapine, differences in
efficacy rates between the range of psychotropic agents currently
available are minimal. Therefore, positive therapeutic effects probably
depend more on levels of engagement and compliance than the exact receptor
specificities of the various pharmacological agents available. The
magnitude of the compliance problem is illustrated, for example, in the
case of bipolar affective disorder, where rates of poor compliance have
been shown to be in the region of 40-60%. (2,3) This would indicate that
the focus should be switched to approaches that might effect changes in
levels of compliance and other such related variables. Such approaches
may include the utilisation of culture-sensitive services and a move away
from coercive care, as suggested by the authors, or indeed a range of
psychosocial interventions and modes of service delivery. The example of
assertive outreach springs to mind.
The authors gave an interesting example of the use of a novel
approach in a 53 year old Sikh woman with a history of affective disorder.
However, at the same time they lay themselves open to criticism from the
proponents of evidence based medicine. They state that, with the approach
used, she remained well over a period of 12 months, "needing no drugs".
However, they had earlier stated that she had a history of two admissions
in the previous six years. Clearly it could be argued that follow-up over
one year would be insufficient to evaluate the efficacy of the approach
used both per se and in comparison to any earlier treatment packages tried
in her case. Indeed the latency between episodes of affective disorder
can often cause difficulties in the interpretation of studies of other
treatments for this condition, particularly mood stabilisers. Hence, the
recognition of the need for longer duration studies, of 2.5 years or more.
(4) In this day and age there will be pressure to ensure that novel
interventions whatever their nature be subjected to comparison to existing
treatment modalities that have already been evaluated against the existing
evidence base.
Erik Milner consultant psychiatrist
E.Milner@Sheffield.ac.uk
Villa 4, Walton Hospital, Whitecotes Lane, Chesterfield, S40 3HW.
1 Bracken P, Thomas P. Postpsychiatry: a new direction for mental
health. BMJ 2001; 322:724-7.
2 Colom F, Vieta E, Martinez-Aran A, Reinares M, Benabarre A, Gasto C.
Clinical factors associated with treatment noncompliance in euthymic
bipolar patients. J Clin Psychiatry 2000;61:549-55.
3 Keck PE Jr, McElroy SL, Strakowski SM, Bourne ML, West SA. Compliance
with maintenance treatment in bipolar disorder. Psychopharmacol Bull
1997;33:87-91.
4 Kleindienst N, Greil W. Differential efficacy of lithium and
carbamazepine in the prophylaxis of bipolar disorder: Results of the MAP
study. Neuropsychobiology 2000;42 (Suppl.1):2-10.
Competing interests: No competing interests