84. Learning lessons from cleverer sorts of creature.

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Dolphins. They don’t do SATS.

Matisse and Chase are action dogs who won Britain’s got Talent. The fact that dogs can be taught to walk across a tightrope should make the education establishment pause briefly over its tall latte. As legions of children are subjected to ever-changing methods of learning and testing, has it never occurred to teachers that all they need is a packet of food pellets and a buzzer? If not, they should try writing the learning objectives and lesson plans for a dolphin show.

The problem seems to be in the notion that learners need to ‘understand’ things.

Once you start down the road of Understanding, sooner or later, you will lose your way. As Spinal Tap observed, it’s a very thin line between clever and stupid.

The road to understanding ends with a Philosophy experiment, like how Schrodinger’s Cat can be alive and dead at the same time. The pursuit of Understanding has killed off skills learning and almost no-one can walk across a tightrope nowadays, not even Matisse if safety rules are respected. Apparently Matisse hasn’t got a great head for heights.

As I understand it – which I don’t need to – operant conditioning happens as follows: People (or dogs) blunder around randomly, certain behaviours get associated with nice or nasty experiences. This, in turn, makes it more or less likely the behaviour will be repeated. Rewarding behaviours with biscuits or fish allows trainers to create showbiz animals. It’s embarrassing to accept that operant conditioning remains the strongest determinant of our behaviour. But there are examples all around us if we look.

In front of me for instance is a jar of eucalyptus honey, which I am putting on my elbows. Although I have sat through countless hours of training in evidence – based medicine and statistics, my experiences with honey are completely homespun, not to say stupid. Like most experiments, it started randomly at a hotel somewhere. A particular constellation of circumstances occurred: sore elbows / time to waste / poor impulse control / spare sachet of honey / no-one looking / short sleeves / suspension of disbelief / random fluctuation of self limiting condition / not liking honey as a food.

Add to that perhaps the knowledge that many great discoveries really did happen by chance.

I am not saying – GMC fitness to practice committee, please note – that you should put honey on your sore places. I don’t think I should be doing it myself to be honest, since it is wrecking my reputation and my wool jumpers. And honey just does not fit into a touch-screen world.

I’m aware I am falling victim to Attribution Error. Being aware of it doesn’t stop it happening though. Placebo can still work, even if the subject is told it is a placebo. Even if there are neon lights flashing the word ‘Placebo’ in front of you and a fifty-strong male voice choir singing the word ‘Placebo’ right behind you. That’s why Understanding just isn’t necessary and might even be dangerous.

Which is also why it may not be quite as necessary to try and explain things as the current versions of User Involvement dictate. Some psychiatrists have got into trouble saying stupid things to patients in an attempts to explain how drugs work. The worst thing you can say, apparently, is ‘chemical imbalance’. It’s OK to say ‘chemical’ I think – though some people struggle with the notion that the brain is made of atoms –  it’s the ‘imbalance’ part that does the damage.

Once you start using words like ‘imbalance’ you can be sure you’re on slippery foundations. Next thing you’ll find you’ve said ‘Time’ or ‘Nature’ or ‘Rest’. Then its only a short step to mumbling something like ‘striving officiously against the inevitable darkness’ and ‘tickets to Switzerland’. If you say the words ‘balance’ or ‘imbalance’ you will hear the examiners screaming with laughter behind their one way mirror.

Psychiatrists might use the word ‘deficiency’ in the context of brain chemistry, but not ‘imbalance’. Not that deficiency (e.g. of serotonin) is a proven cause of depression. But the monoamine theory of depression did guide people’s understanding of the illness for many years. ‘Increasing’ serotonin was the simplistic explanation for how antidepressants might work, particularly those named serotonin re-uptake inhibitors.

There are reams of internet pages given over to an argument between anti-psychiatrists and the psychiatric establishment about whether any psychiatrist has actually used the phrase ‘chemical imbalance’. And indeed as to whether the monoamine theory included notions of balance.

Further reams explore whether it was a term that used to be used but has now been abandoned and the usage covered up, like documents in 1984.

Anti-psychiatrists  argue that psychiatrists concocted the notion of Imbalance with big pharma, in return for free logo pens. One of them scoured the literature to find use of the ‘I-word’ and came up with this example from a 2003 textbook:

Sometimes the explanation is as simplistic as ‘a chemical imbalance,’ while other patients and families may request brain imaging so that they can see the possible psychopathology or genetic analyses to calculate genetic risk’

As far as this paragraph goes, the stupidity of the chemical imbalance part is overshadowed by the rest of it, such as the idea of seeing psychopathology on an image of the brain. Even so, the usage seems to be an example of low-end explanatory waffle, rather than as a deliberate falsehood the board of Eli Lilley dreamed up as they circled their cauldron.

When talking about drugs, or honey, smart people know how to say ‘I don’t know’ But it’s not OK, as Ed Milliband found out at the election, to say ‘who cares?’

Just to reassure you, I am not keeping the medicinal honey anywhere near the food honey, and I have labelled it ‘Medicinal Use Only’ and ‘Not for Internal Use’, just like the Boots chemist would have done in 1965. It works by Osmosis I think, which is quite different from correcting an imbalance.

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65. Sleepwalking blindfold, into an amorphous tapestry.

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Historians agree that modern times began in 1980, with the invention of Pac-Man.

When did it all go wrong? The answer it seems is 1980. And, to a lesser extent, 1988.

Certainly, quite a few things went wrong in 1980. John Lennon was murdered, the Iran / Iraq war began, Robert Mugabe was installed and worst of all, the post-it note went on sale. In mental health, our particular Chernobyl was an explosion of toxic diagnostic heterogeneity. 1980 saw the invention of the concept ‘major depression’ (MDD). With the publication of the DSM3 diagnostic manual, most emotion-based illnesses was fed into a diagnostic Magimix. This turned out to be very convenient for certain people. One, (sloppy) people who don’t like making diagnoses. Two, the (wicked) inventors and propagators of so-called SSRI antidepressants. Rampant heterogeneity was very inconvenient for anyone who wanted to investigate the possible causes and treatments of Depression. Edward Shorter explains the story much better than I can.*

Certain discrete entities, that should have been studied much more carefully, got lost in the new, amorphous tapestry of MDD. One of these was the notion of ‘biological symptoms’ such as appetite and weight loss, early waking and diurnal mood variation (DMV). The classic ‘melancholic’ patient felt much worse early in the morning. Studies of cortisol and other hormone levels throughout the day showed a changed pattern in most depressed people. Of particular interest was the finding that most depressed patients failed to reduce their cortisol levels even when given a steroid tablet the night before. This led to the ‘dexamethasone suppression test’ and other early attempts to find a definitive lab test for Depression. Old school psychiatrists regarded DMV as a cardinal symptom of melancholia. They separated melancholia from other types of depression with barbed wire, landmines and a no-fly zone.

Today, research into circadian rhythms in organisms and the body clock in humans is a major strand of research in life science. Gene expression studies are the way forward.  And this week, even the BBC acknowledged this by holding a ‘Day of the Body Clock’.

Quite what the editors had in mind for the body clock day remains a mystery. Each news program had to slot in a body clock item but the presenters looked bewildered as to why. We heard that sportsmen performed better in the evenings. Some brave schools are shifting their timetable for teenagers later into the day, when they are more likely to be awake, although the teachers are more likely to be asleep. More interestingly, scientists told us that society was guilty of a ‘supreme arrogance’ in trying to over-ride our need to get enough sleep. Prof Russell Foster, at the University of Oxford, said people were getting between one and two hours less sleep a night than 60 years ago. We were warned that ‘Modern life and 24-hour society mean many people are now “living against” their body clocks with damaging consequences for health and wellbeing’. Further support then for the Blur Theory – Modern Life is Rubbish. Sleep, like lunch and the concept of Melancholia, was abolished in the eighties.

Studies continue to reveal that a sub-group of depressed patients show an abnormal expression of clock genes. Several promising types of non – drug therapy for depression were based on trying to adjust the body clock: Sleep Deprivation, Phase Advance and Bright Light therapy. Unlike SSRI antidpressants, these are treatments that cost hardly anything and can easily be implemented at home. Also unlike SSRIs, these are treatments that no-one ever tries. The post-it note and Robert Mugabe are here to stay, but Shorter is correct to say that MDD must go: ‘melancholia and non-melancholic depression are quite separate illnesses’. I’m having the bumper stickers printed now.

The idea that deliberately reducing sleep can act as an antidepressant seems counter-intuitive. But it’s possible that the insomnia in depression is the body’s attempt to defend itself against low mood. Which means that society as a whole may be trying to stave off existential despair by staying up late.

*Edward Shorter, 2014, The 25th anniversary of the launch of prozac gives pause for thought: where did we go wrong? BJPsych, 204, 331-2.

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.