Monthly Archives: February 2013

4. Getting over the mind brain problem

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What it looks like inside your mind.

One of the biggest barriers to tackling Depression is getting hung up on the Mind / Body, or more specifically the Mind / Brain problem. Its the mind part that’s the issue. As soon as the word ‘mental’ comes into play, people get all upset.

Its hard to adjust to the fact that we may be nothing more, or nothing less, than very clever machines. Its also hard to believe that consciousness can emerge gradually from a wiring network, providing that network is large enough.

Surely, if all you needed for consciousness was a massive wiring system, then British Telecom would be a god like super-creature bent on world domination. Hmm…

So can consciousness, or the mind, be considered a separate entity from the body? This argument still hangs heavily for many when they think about mental health problems.

The mind / brain issue did preoccupy philosophers for many centuries and still occupies a large section of Wikipedia. Some philosophers thought that mind and body were entirely separate devices. This idea is called ‘dualism’ and tends to persist in the way people think about the human control system.

If mind and body were different ‘dual’ entities altogether, like sound and light, then how could they interact? Some kind of transducer device, as proposed in the pineal gland by Descartes? Or simply, (cheating really) bringing God into it to solve the problem, God acting as a cosmic DJ, operating the twin turntables of mind and brain, making sure they were synchronised properly at all times?

(This school of thought was termed ‘occasionalism’ and probably did not influence the Faithless song ‘God is a DJ’ nor even Pink’s cover version. Pink was yet unknown in ninth century Iraq).

Glossing over Philosophy and Religion for a short moment, there is a lot to support the argument that the brain is a very sophisticated computer system.

For instance, nerve cells which make up the brain are long and thin and transmit electrical charge, just like wiring. The nerve pathways in the brain look a lot like the wiring loom in your Honda Civic. Damage to part of the wiring system, such as after a stroke, can clearly bring about symptoms, like loss of movement to a limb.

Higher up the brain, the nerve networks get more complicated and seem to provide for various different types of mental activity. There is the completely automatic type that controls basic physical functions like the operations of the lungs, heart and gut. Then there’s the largely automatic thinking system that does things like drive you to work and make toast. And then there is the reflective part of the mind that chooses what to think and do, or thinks it does, or you think it does.

Computer speak has given us a new ‘dualist’ model to consider, the division between hardware and software. Sometimes it can be helpful to think of the brain as the computer and the mind as the operating system. As an analogy it is both helpful and unhelpful.

The plus points are that factors such as social learning and experiences and memory can be seen as software, running within the brains basic wiring network, which starts off as a largely empty system and gradually fills up. The mind’s ability to process information and store it, or create actions, are similar to an operating system.

There is also a nice computer analogy to be made between the mind’s two main memory systems, long term and short term. Stored memory can be seen as similar to a computer’s hard drive, whereas short term or ‘working memory’ has features similar to RAM. Working memory is far more limited than long term and easily exceeded by multiple or complex tasks, such as chewing gum and walking at the same time.

Many memory problems, such as those found in Depression, occur within the process of moving memory between the two systems. Depression very often reduces the power of concentration, which is needed to retrieve information from the storage system, and also to file memories away.

Against the software / hardware model however is the following problem; the brain is not a fixed system like your PC or Mac. It can create, remove or change its physical structure as it goes along. The changes are not just electrical, as in hardware, or even just chemical – the brain is continually creating new connections. This is why the brain is called ‘Plastic’ – the term is used to mean flexible and open to structural change.

In babies and children there is a huge and continuous rebuilding program of nerve cells. In adults there is a much more limited program of nerve cell slum clearance but sadly not much in the way of inner city regeneration. Depressed people may lose their ability to generate new nerve connections in certain parts of the brain. In fact an attractive theory of antidepressant therapy (both drugs and psychological therapy) is that these may work by stimulating nerve cell growth in certain key areas.

And this brings us, a little early, to the punch line. Which is that structure and function are inseparable features of our control system. They are so interactive that it make no sense to identify two entities called Mind and Brain.

In practical thinking this dilemma presents itself frequently in thinking about mental disorders. For instance in thinking of some illnesses as either mind based or brain based. In particular illnesses that were once considered to be ‘psychosomatic’ such as bowel or fatigue syndromes. Within Fatigue Syndrome there have been heated arguments by some sufferers that they should not be regarded as mental health patients, even though CBT may well be very helpful, as it can be in ‘physical’ illnesses like chronic pain.

The law has frequently got itself into a pickle by trying to separate what is due to the mind and what is due to the brain. We have seen concepts such as ‘non insane automatism’ invented to illustrate this area. The newish Mental Capacity Act speaks of a disorder of ‘mind or brain’, to get over the possible argument about which one was disordered. Could one ever be disordered without affecting the other?

Within Education, we have seen concepts such as ‘Brain Based Learning’, or ‘Mind Brain Constructivism’ as it is more properly known. Here again the proponents are careful to use the term mind/brain as a portmanteau concept. Strangely, educators have been rather uncritical about the supposed ‘Brain’ aspects, such as improving food and water consumption for students. The ‘healthy mind in a healthy body’ notion has been about for a long time in schools. Before Michael Gove, and in fact before even Socrates, neither of whom would have seen the mind as a wiring loom.

One of the more interesting findings from Brain Imaging has been the recognition that psychotherapy may bring about structural brain changes. For instance, changes have been found to the mid-brain serotonin transporter system, after psycho-dynamic psychotherapy. A much larger number of studies have shown changes to nerve cell functioning during and after therapy.

It could be argued that these sorts of changes are not actually ‘causal’ but rather just a secondary indicator of mood change. Nevertheless, there is clearly a mood control system in the brain that is represented in physical structures.

So we have the Fatigue Syndrome lobby who resent being considered as having a mental health problem, and we have the ‘anti-psychiatry’ lobby who hate the so called ‘biological’ model of Depression.

The fatigue lobby would be delighted if one day a clear biological cause is shown for the illness – presumably then it becomes like MS or any other ‘proper’ illness?

And the anti- psychiatrists would be delighted if absolutely no biological change could be found in the brains of depressed people. They have been similarly delighted by the findings that antidepressants are not as effective as people used to think. Their response is not at all to suggest finding a more effective antidepressant, but rather to debunk the whole concept of Depression.

If you need to ask how can simple chemicals substances change the way people think and behave, then you have (wisely) not visited Nottingham city centre at 11pm. If you doubt that faults can occur in complicated electronic control systems, and that such faults are impossible to diagnose and treat, try using a 10 year old Beko washing machine. It has a mind of its own.

It seems the learning point is never to try and assign a problem to mind / or body, and always to recognise that the two are one. If that makes us just a brilliant machine or merely thirty nine dollars worth of chemicals dressed in a suit of similar value, so what?

Well, for one thing, less stigma, and less guilt. If we have defective mood control systems, whatever the basis, then this is a health problem and not shameful.

I was taught by Irish Nuns that ‘man thou art dust and to dust you will return’. (Its the kind of thing Rugby Forwards say to each other before a game). The dust cost less than thirty nine dollars in those days.

And if God is really acting as DJ, is he playing enough soul?

3. It looks a bit DIY

Experts - do we need them?

Experts – do we need them?

There are surprisingly restrictive laws to prevent you doing bits of wiring and plumbing around your own home. Anything gas related is particularly strict, needing someone who is CORGI registered.

If you replace your gas hob, despite the fact that you can turn the gas off with a big tap, that the hob uses a simple bayonet joint, that gas is very smelly in case of leaks, that you have watched the CORGI man do it several times, that you don’t intend to do it with a lighted cigarette behind your ear – despite all that, if you disconnect it yourself you will be placed in the Tower of London for 100 years and tortured every Tuesday. Your crime is that you thought you knew better.

Surprisingly, when it comes to helping people with health problems, things are much looser.  There are professional bodies regulating the top end of the market – doctors, nurses, psychologists, but even here there is very little regulation of what types of therapy they actually do.

Lower down, blurring into the alternative therapy market, pretty much anything goes. This market is full of therapists who think they know better. Better, that is, than any evidence they can produce to support their work.

Its often fascinating, as a psychiatrist, to see how people have attempted to deal with mental health problems prior to ‘calling in’ the NHS.

We know people delay seeking medical advice for health problems. People tend to adjust to symptoms for a long while, often attributing them to random and coincidental events such as biological washing powder or a mystery virus.

Such accommodation to symptoms only breaks down if something happens – you notice specks of  blood over your white piano keys, like Chopin; your mum makes you an appointment for the GP. Or you are arrested in a public place under section 136 of the mental health act and taken to a place of safety.

Before we get to the point of needing professional advice, how long have things been deteriorating? In the case of psychotic and depressed patients, we know they have been unwell on average for many months before seeing anyone for help.

Some events are so traumatic that the person goes straight to hospital without passing GO or collecting £200. But the majority of medical events develop slowly, more like accepting a £10 fine, or, like Mr Huhne, taking a chance card instead. The first part of any illness is usually in our own hands to manage.

That means we have to consider health issues within the reflective mind, however much that part of the mind wants to sweep them under the conscious carpet.

When it comes to mental health problems there are times when we need an objective person to give advice. Another person can be a vital source of insight. Often just talking to another person helps us reflect better. Before we tell another person we are on our own and at the mercy of the limited perspective of the single view.

Even after we have convinced ourselves, and maybe our mums, that we have a problem, we encounter barriers around the health care system. These have been built good and high to filter out the excess demand placed upon a free health system.

The ‘culture of fear’ that NHS-managementism has created extends downwards towards service providers and users.

Firstly there is a healthy scepticism about what motivates the NHS  behind the scenes: 1. the nanny state; 2. targets that determine payments; 3. drug companies.

Then there are simple filters such as a permanently engaged phone line, KGB receptionists and a lack of appointments.

Perhaps more of a barrier for most people is just not knowing how to engage. What should you take to the doctor, how do you describe it, how do you present it? Should you take someone with you, should you write things down on a bit of paper, should you google it first?

Once into the mental health system we are very unlikely to find an ideal therapist we can relate to. One reason is that the demography of the NHS workforce nowhere near reflects the demography of the population it serves.

Another reason is the very small number of trained professionals relative to the number of people who suffer from mental illnesses.

For example, our GP has 2000 patients on average. Lets assume 3% of them (more later about the 3% issue) have severe depression – that’s already 60 people. Our local psychiatrist serves – again on average – 40,000 people. He or she will have a caseload of several hundred.

How many hours are there in a week? In the NHS, about 12, by the time we have allowed for bureaucratic intrusions, mandatory training, focus groups, and having our hair done.

Without wishing to denigrate anyone involved, or indeed undermine the foot-ware industry, the NHS mental health services are run on a shoestring. The negative halo effect that surrounds mental health issues also effects prioritisation and funding, relative to hotter specialities like Fever.

Having thought about all these barriers – starting with our own reluctance to think about our health, stigma, bureaucracy, shortages, shouldering our way into a system that feels like rush hour in Naples – its amazing that anyone gets treated at all.

Luckily, unlike with the CORGI fitter, a lot of it can be done by yourself. Often using equipment you can find in your own kitchen, such as another person.

But the first rule has to be: don’t think you know better (until you can prove it).

The second rule is: no cigarettes.

2. Where will the war take place?

The war against Depression begins with an attempt at building a strategy (unlike some recent wars I could mention).

Firstly we must identify the enemy. Then we must identify our resources. Then we must deploy our resources to where the enemy is weakest.

And we must look at where previous similar campaigns have come unstuck.

A few years ago, the UK Royal Colleges of Psychiatrists and GPs ran a campaign called ‘Defeat Depression’. Traditional campaigns designed to improve public health usually involve screening – trying to detect cases of the illness that have not been discovered. For a successful campaign the following ingredients are needed:

We have a way of discovering cases using some kind of test.

We have a treatment option to offer those found to be suffering.

The treatment option is effective enough to cover the costs of running the program.

The Defeat Depression campaign was based on the notion that a large number of depressed people were undiagnosed and suffering in relative silence. If they were diagnosed, using simple screening tests, they could be given antidepressants and/or therapy that would improve their condition.

Recent types of antidepressants such as selective serotonin re-uptake inhibitors, (SSRI) seemed to be effective, non – addictive and low in side effects. So the balance had tipped in favour of prescribing them, if not exactly spraying the countryside with them.

Sure enough, there has been an enormous increase in the diagnosis and treatment of depression in  the UK. GPs use a screening tool called PHQ-9 to uncover cases. For moderate or severe depression, antidepressants are recommended, starting with an SSRI, either Fluoxetine (Prozac) or Citalopram (Cipramil).

Possibly, one day, SSRIs will become ‘over the counter’ remedies rather than prescription only. After all, you can now buy own – brand Ranitidine at hardware stores. Its not that long since Ranitidine was ‘Zantac’, and available only from proper doctors in white coats and half- moon glasses, probably after an endoscopic exam or barium x ray.

People used to warn that taking Ranitidine might mask the symptoms of more serious stomach problems, delay people seeking medical advice, and thus prove harmful. Such fears seem to have been overly pessimistic, but doctors and pharmacists are always going to want to steer the medicines trolley.

Making antidepressants freely available in Lidl, or Boots at least, might have a greater impact than any other measure, if we are seeking to get the greatest number of people on to antidepressant medication. Yet there has been no campaign to make this happen. Why?

Is it because antidepressants can be harmful if not carefully monitored? For instance they need to be taken for several weeks at least rather than as and when we feel like it.

Or is it because we are reluctant to see medication as the answer to Depression? Or maybe because existing antidepressants have a relatively poor benefit to risk ratio?

The defeat depression campaign attracted a fair amount of criticism behind the scenes. On the one hand there was something of a doubt over how effective antidepressants really were.

Also they had side effects that were troubling, some real and some imaginary. It was suggested that they could make some people more impulsive and – in the case of teenagers – more suicidal. Some of them seemed to have ‘discontinuation effects’ causing flu like symptoms a day or two after stopping treatment. Their effect of reducing libido was more common than people recognized.

People warned that the Depression concept was being stretched to include unhappiness, ‘medicalising’ peoples responses to social ills such as call centres and poor quality sausages .

Some people even went as far as suggesting the depression industry was part of a capitalist conspiracy to make people feel dissatisfied with their lot in life. It was alleged that such dissatisfaction would serve to fuel consumer demand and get the proletariat back on the treadmill of purposeless consumption, indebtedness and hard labour.

In the background, a few psychiatrists remained highly skeptical about the effectiveness of newer antidepressants, even preferring older drugs that had a better evidence base.

It looked to many as though the Royal Colleges had been swept along by the SSRI companies, without thinking the strategy through. Two favorite stereotypes for Psychiatrists are Dr Dippy and Dr Evil. So, not looking clever, and seeming to be in cahoots with drug companies, damaged our image. When the Prozac bubble burst within the liberal consensus, British psychiatry was badly splattered.

The most deadly germs are those that can change their form and structure. The same is probably true of terrorist organizations. By adapting to different situations they can often go undetected. Germs can pretend to be other organisms, or part of your own body.

Terrorists can pretend to be religious men. Gangsters can pretend to be politicians.  A lot of it is down to packaging and presentation. Depression is an entity that resorts to camouflage in response to a conventional attack.

In response to the Defeat Depression campaign many people remained in denial. Few were convinced that Depression could be treated in the same way as a germ based illness. Few were convinced it was easy to identify and treat. And even fewer trusted psychiatrists and GPs to tackle the problem.

Lots more antidepressants were finding their way into our sewerage systems one way or another, (often cutting out the middle man), but was anyone much happier?

There is a lot of conflicting thinking about Depression – whether it exists within society, and whether it exists in an individual. It can hide within a heap of what looks like unhappiness. It can hide within what looks like a life crisis or drink problem. It can hide within a cranky view of the world.

Essentially, all this needs to be tackled on a personal level. Depression exists in individuals, not in towns or countries. All that matters is what Depression means for you.This means that the battle against Depression will take place mainly in your kitchen. Luckily, you choose the weapons.

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At exactly 0600 we go over the wall.

1. The War on Depression Starts Today

Car parks can be beautiful if you look at them the right way

 Don’t be frightened – it’s only a car park.

 

The War on Depression: where is the enemy weak?

These pages are mainly about Depression. The starting point is to understand how Depression comes about and the finishing point is dealing with it better.

As an individual psychiatrist it may not be possible to make much of an impact on the wider problem of Depression, which affects so many millions of people.

But there are many fronts to fight on, outside the hospital.

There are a few themes to these pieces. One is to do with how toxic modern life has become. One is to do with how the mind works and in particular how people make choices. And a third one is to explain how health systems such as the NHS operate for (or sometimes against) people with mental health problems.

However we regard Depression, as an illness, as wear and tear, as a reaction to loss or as a social barometer, there is always another perspective to take.

Rather than ask the question, ‘why do some people get depressed?’ we might just as well ask why everyone isn’t depressed all the time.

Lets get the bad news out of the way right now: people get older. Generally when they get older they get more ill, and (don’t say it, please) eventually die.

In some ways that fact, the D word, is a potential party – pooper, even when we are young and have a fabulous future to look forward to.

Worse than that, even younger people can get ill, and they certainly can be subjected to terrible events (such as school).

Its been said that all political careers end in failure. Partly that’s because of the scoring system in politics, which tends to be ‘sudden death’, either by way of an election, or by way of sudden death.

But the same is not true of most sportsmen and women, who are somehow able to retire at the right time. In boxing, that’s while the brain is still working. For the rest of us, its a matter of recognising changes and adjusting to them .

If we adjust too much too quickly we are hypochondriacs and wimps. If we adjust too late we are foolhardy and in denial.

Life is very complicated and dangerous and a lot of us don’t make it, either in terms of quality or quantity of life. Some of us spend a lot of time ‘off the road,’ on the hard shoulder of life, but that doesn’t make us burned out ruins.

In seeing Depression as a wear and tear or stress related illness, we are not really explaining it very much. I prefer to see it as a natural phenomenon that is also an enemy, like rust. Or, at times, Gravity. Black ice. Wind. Electricity. Biscuits. Etc

All necessary but dangerous when out of control.

Depression happens when the system that controls mood is defective. The system has failed to calibrate correctly, or feed back on itself, or stay at a level. Most of what we do in treating Depression, one way or another, is to try and get the control system working better.

Often that’s a matter of seeing the situation differently: reflecting, reframing, resetting, recalibrating. (4 Rs. Much better than 3.)

The way we see Depression, in its widest contexts, affects very much how we deal with it. Depression is a very isolating experience, both in terms of reduced social contact, and reduced range and quality of thinking.

But if Depression was inevitable, or even an overwhelming likelihood, why is it that many people never get depressed, whatever happens? Do they have a very sophisticated chemical control mechanism? Or do they reflect upon the world in a different way? Or do they have some protective factor, like a guardian angel?

After this length of time, over 50 years of antidepressant and drug therapy, it doesn’t look as though we have a breakthrough solution, at least by way of a tablet. It would be nice to think a magic bullet would get discovered, much as saltwater killed the Triffids in one of the Day of the Triffids films, or the Common Cold killed the Martians in War of the Worlds.

While we wait to find the enemy’s weak spot, we continue to fight on all fronts. Depression’s Achilles Heal is in fact the thing that makes it strong, its incoherence as a diagnostic concept.

Could Depression fall apart under the weight of its own complexity, like the coalition government?

More to follow.