Tag Archives: guidelines

95. Acuphase wins by one vote.

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All this talk about plastic in the environment has made me think about our second favourite acetate (after vinegar). Acuphase, more properly known as Zuclopenthixol Acetate, has been widely used in acute mental health settings. For those unfamiliar with it, it is given in the form of an injection and its effect is that of an antipsychotic drug lasting between 2 to 5 days. Typically, the recipient becomes calmer and may sleep for a long period. The duration of its effect is particularly useful when treating acutely disturbed psychotic patients.

The alternatives, if the patient will not accept tablets, are repeated injections of shorter acting medications such as lorazepam or haloperidol, which need to be given at least twice a day.

Acuphase was widely used in the nineties but gradually fell out of favour.

Firstly, it is a ‘typical’ or ‘first generation’ antipsychotic. These drugs, for better and worse, were overtaken by second generation drugs such as Olanzapine and Aripiprazole. Olanzapine comes in the form of a ‘velotab’ which melts very quickly in the mouth. Aripiprazole does come in the form of an injection which theoretically lasts a few days, as well as a depot version which lasts a month. However, there are problems with both of these in terms of perceived effectiveness, or ‘street cred’. A substantial number of clinicians don’t believe that Aripiprazole is effective for rapid tranquillisation and the large majority still use lorazepam and haloperidol injections for this purpose.

Secondly, word got round that Acuphase could be a bit dangerous, causing cardiac arrhythmia or even sudden death.

And on a sub-cultural level, the use of Acuphase became associated with certain types of authoritarian ethos units, where the day staff look like nightclub bouncers and the night staff don’t like to have their poker game interrupted.

Last week I met a consultant who had wanted to use Acuphase, only to find that it was not on his hospital formulary and could only be used if approved by a Committee. On this occasion the vote in favour of Acuphase had gone through 4 to 3 in favour, continuing the Brexit – Trump trend of surprises. It’s hard to know which way the pendulum is swinging, especially with some of the older antipsychotics, which may be coming back into fashion.

You may be surprised that an NHS Consultant Psychiatrist doesn’t have the clinical freedom to prescribe a drug that has been widely used for over 30 years, but that’s another story. Some consultants don’t even drive Porsches nowadays.

This particular consultant did not work in Sussex. But if you google the word ‘acuphase’, one of the top results comes up as the Sussex NHS Trust Guidelines.

(If you google Sussex Trust what mainly comes up is headlines like: ‘NHS trust criticised for underestimating risk of patients who killed 10 people’, but that’s another story.)

According to the Sussex Guidelines:

‘Acuphase has often been too widely and possibly inappropriately used, sometimes without full regard being given to the fact that it is a potentially hazardous and toxic preparation with very little published information to support its use.

There are many treatments in use where the evidence is not that strong.

Why pick on Acuphase then? After all, Zuclopenthixol is widely used in the form of Decanoate, where it is called Clopixol Depot Injection, and also in tablet form. Cannot one extrapolate to some extent that the acetate version will act in a similar way to the tablets or depot form? That is exactly what generations of clinicians have done, the distilled wisdom being that Acuphase works well in real life situations.

OK I accept that the distilled wisdom of clinicians can be entirely wrong, yes bleeding and cautery were in vogue for 2000 years, but in general…

The ‘finding no evidence’ game, ostensibly scientific, is highly politicised and has been used to exaggerate or diminish the fortunes of many treatments, from ECT and Lithium to psychotherapy and social treatments like day centres and walking pet dogs through care homes. Remember when our commissioners stopped the Badminton group?

The more you narrow down the focus of your question, the less likely you will find research evidence that exactly addresses the point. And if you refuse to generalise from research to your own situation, you will conclude there is ‘very little evidence to support’ treatment X or Y.

Sticking with Trusts that begin with the letter S, here’s a bit more Guideline, this time from South Staffordshire and Shropshire Trust.

These start a bit more positively than Sussex:

The (2012) Cochrane Review did not find any suggestion that zuclopenthixol acetate is more or less effective in controlling aggressive acute psychosis or in preventing adverse effects than intramuscular haloperidol and did not have a rapid onset of action. The use of zuclopenthixol acetate may result in less numerous coercive injections and low doses of the drug may be as effective as higher doses’.

But the same guidelines quickly go on to say:

Zuclopenthixol Acetate should only be considered appropriate after repeated injections of short acting antipsychotics e.g. haloperidol, olanzapine, aripiprazole.

Would you rather have one injection or several? You might get to choose though. Patient choice trumps even the drugs and therapeutics committee. If you want to have Acuphase if you get very ill, as I would, bearing in mind the alternatives, you can make an advance directive to this effect. Sussex again:

‘If used to good effect and the patient feels that they may benefit from its use in thefuture, then consideration should be given to the preparation of an advance directive’.

Sussex has the only Green Party MP in Britain. But I have checked on this and there is no evidence at all that the acetate from acuphase is affecting marine wildlife.

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62. Displaying the pottery fish, with pride.

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My alarm clock rings to tell me it’s behavioural activation time, also known as Nike Therapy, which means just do something and think about it later, if ever.

My eventual aim is to re-write the classic publication ‘365 things to make and do’ in an updated style to suit these post-ironic times. Also, I’d like to add a 366th project before 2016, which is the next leap year.

Today’s project is to shred a few copies of the NICE guidelines for Depression, mix them with PVA and turn them into hats.

As I shred, I realise that these guidelines do mention the term ‘behavioural activation’ but don’t explain how to do it. They say nothing about arts, crafts, music or hats. Which is surprising, given that there is a long tradition of arts and music therapy in mental health.

My hypothesis is that people need to do something with their hands to feel properly human. Manual work, crafts and organised sport have declined, leaving the hands as mere vestiges of devices that once could dig or sew or fire an arrow. Most people still prefer a mouse to a touch screen, when there is a choice. Many people still prefer a manual gearbox, even though automatics are now superior in all respects.

I have another project coming along which is more complicated. This involves taking photos of bits of stained glass windows, printing them in different sizes, using all the different, clichéd image filters in Pixelmator (such as the ‘ennui’ tool), tearing them up and sticking them onto a collage, which in itself looks like a stained glass window.

For some reason I’m having trouble (as though it was the printer’s fault rather than incompetence on my part) getting them printed at the right size, so they are coming out like postage stamps instead of A4.

If I had to give this activity an hourly rating for mood improvement, I’d have to rank it slightly below checking the lawn for cat faeces, collecting it on a special trowel and flinging it over the garden fence onto the railway line. But it might improve.

Either the picture is going to be postcard size, saving a lot of PVA, or I’m going to have to ask a teenager how to resize the images. Or perhaps find an art therapist, just to check whether this whole activity is artistic or not.

There are no art or music therapists in my local area and come to think of it, none in the hospital where I work. This demise of arts and crafts based therapies has been insidious and largely unreported. This seems like a pity, and I wonder who’s to blame.

Somewhere or other, the mental health establishment has got the idea that ‘therapy’ has to involve a bus journey across town to speak to a person in an office for about an hour once a week for about 20 weeks. True, these activities are evidence-based to an extent. It’s just that the evidence has been collected along narrow strands of enquiry, being derived mainly from a ‘clinic’ context.

No-one has bothered to see whether listening to good music or watching football or making rhubarb crumble can treat Depression effectively. And imagine the practical difficulties in conducting such studies.

Therapies where numerical ratings are intrinsic, such as computerised CBT, have the advantage in terms of generating evidence of improvement. They have largely taken over from other modalities, leaving a long queue of psychoanalysts at Jobcentre Plus.

There’s perhaps a lesson to be learned from Interpersonal Psychotherapy, (IPT). This therapy was invented by Klerman, Weissman and colleagues in the eighties. It’s a standardised approach with a proper instruction manual, which makes it amenable to testing. In particular, it was tested against drug therapy – in those days mainly tricyclic antidepressants.

Its designers were highly scientific individuals with an excellent grasp of the various different ‘models’ of Depression: biological, family, cognitive, psychoanalytic, feminist etc. They knew how to fund and conduct controlled trials and publish the evidence properly. And thus IPT is one of the two types of therapy that NICE bother to endorse.

Compare that approach with a study by Mike Crawford in 2012, purporting to show that weekly attendance at a group arts project had no benefit for patients. I quote:

‘Members of activities groups were offered activities that did not involve the use of art or craft materials’.

My italics, meaning ‘why on earth not?’ It’s not the full Blue Peter, not without the sticky-back plastic.

This is what the new version of ‘365 Things’ should try and achieve – a standardised arts and crafts therapy manual. So we can finally show that meaningful activity is good for people. Each task should be spelled out clearly, like in Marguerite Patten’s 1000 favourite recipes.

And include proper materials like policy documents, shredders, glue and paint. For a long time the surest way to upset an occupational therapist was to mention basket weaving. Now, I say it’s about time for a raffia revival. And it’s time to display the pottery fish, if you’re lucky enough to have one.

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 Detail from Queen of Heaven, by M Healey, 1933, St Brendan’s Cathedral, Loughrea