47. Predicting the New Year, without proper guidelines.


Psychiatrists are able to read the future. That’s why there are very few about – most have made a killing on the stock market or at the bookies and have retired to Tahiti. Or so our managers think.

Just to prove the point, here are some predictions for the New Year:

1. Badgers will launch a surprise counter attack on David Cameron. They are already digging a tunnel towards Downing Street. Badgers are classic terrorists, with long memories and sharp teeth. In panic retribution measures, Brian May will be blamed and sent to the Tower of London.

2. People will begin to notice that google searches are getting more polluted by advertising. Google will offer a premium service where you pay a subscription for an ad free version.

3. Universities will begin a series of mergers and takeovers, so that eventually there are only four big players, as with supermarkets, petrol, energy etc. University Challenge will start at the semi finals.

4. There will be an upsurge in Placebo based treatments of all kinds, and NICE will issue lengthy guidelines on how to choose and use them, with a forward by Prince Charles.

5. Private GP practices will develop in the larger cities. They will give you the sleeping tablets, painkillers and Betnovate cream that you have longed to obtain, without any tut-tutting.

6. Building regulations will be tightened up, so that new buildings will have wider letterboxes, to accommodate take-away pizza.

7. Swiss cheese makers will be stopped from injecting carbon dioxide into the holes to make it weigh heavier on the scales. Conversely, Ryanair will check for Helium in your hand luggage.

8. The forces of social control – police, probation, mental health and social work – will increasingly blur together. The new force will be re-branded as Lifestyle Services. The uniform will look suspiciously like G4S.

9. Further updates in nomenclature. G4S to G5S, E45 cream to E46. Boots 7 goes to 7.1. Players No. 6 are re-launched as Players Number Free. They pre-empt the packaging ban by going for a plain white carton. It worked for the Beatles after all.

WD40 surprises everyone by going straight to WD million.

10. Liverpool FC will embrace Mindfulness. Their new kit will be orange robes.

If you want a more accurate prediction, and you don’t know any psychiatrists, you can do equally well or better yourself, using a set of dice or random number tables. Please note, NICE do not recommend the use of tea leaves, bones, fund managers or even physicists. Prediction is very difficult, said Niels Bohr, especially about the future.

From Tahiti, I wish you a Happy New Year.


10. Insuring the uninsurable.

ImagePendleton’s headquarters.

Might you get depressed one day?

If you answer yes to any of the following questions, this is quite likely:

Do you tend to play a Party App on your computer rather than attending a real party? Do you support a perennially unsuccessful football team? Has everyone in your extended family been treated for depression? Do you regard your pet snake as the best friend you have ever had?  Have you been depressed every single day of your life so far?

Depression is likely to affect a sizable minority of us at some point. I’m skeptical of surveys that tend to show practically everyone in some areas (Slough?) is suffering from depression, but suffice it to say it is a major common condition on a par with blood pressure or diabetes. So, is it worth insuring yourself against getting depressed? There are several reasons why not, at least in terms of popping into Swinton or calling Direct Line.

When we consider insurance we are embarking on what is now grandly termed Risk Management. By this is meant that we need to look into the possible future and explore some hypothetical events, such as burglary or fire. Whether we might get ill or not is rather hard to predict. And also it is something we are most reluctant to think about. Some people do take out health insurance, but most of us do not.  Perhaps the main barrier is thinking that it will never happen to us.

And people are right to be skeptical about the insurance industry. Everyday someone texts me to urge me to claim back mis-sold PPI. Please can we go back to Nigerian banking scams? I have never seen a specific Mental Health Insurance Policy, though some aspects of mental health may be included within a wider health policy. Why?

First – insurers tend to specialize in more concrete types of illness like cancer or heart disease. They like to know you have not had previous episodes of the same illness. They like to be able to say categorically whether the illness has happened or not, whereas a diagnosis of depression often falls within a grey area.

Second – depression is so common that the premiums would likely be very high and riddled with snags and get out clauses.

And third – it’s not as though you can really buy a guaranteed effective treatment with your payout. The treatment of depression is as much a lottery as selecting an appropriate insurance policy.

A policy might pay out to protect your income if you cannot work due to depression. But this can lead to a horrible situation where a person is locked in an insurance- perpetuated sick role, much like the benefits trap, where it makes sense financially to continue to act like a depressed person.

But there are other ways of insuring against depression, without troubling the man from the Pru, or his modern day equivalent, lurking in the dark recesses of a Sunderland call centre. (Just redressing the north south balance, having mentioned Slough earlier on.)

Be Prepared, as Baden Powell advised. I am sure he meant this in a specific and practical way, such as keeping a spare credit card in your sock. Preparing for very unlikely events, such as a Harlem Shake breaking out in the library, or the invention of punk rock, is beyond the scope of ordinary scouting.

Can we prepare for Depression? I am referring to getting the roof of the house in order before the rain comes, as David Cameron would probably put it.

When depression hits, the mental functioning is decreased in certain key areas such as reduced concentration and energy levels. That means, if you are stretched to function properly even when you are well, then when you get depressed you may go under. That will lead to a vicious circle of more stress caused by failing to keep up, leading to worsening depression. Finally comes a crunch point where things officially go to Hell and High Wycombe.

That means if you are well at present you should be operating with spare capacity. What does that mean? I’m not your mum, but ideally:

You should keep at least a million pounds in your current account.

OK, that’s stupid, but: You should have a system for organizing and dealing with any paperwork including financial stuff. You should know where everything important is, like your birth certificate and passport. In particular some way of keeping the electronic passwords you need for online banking etc. You will never remember them if you get depressed, and you won’t even remember where you put the bit of paper you wrote them on. Then you will worry that you have lost the bit of paper or worse, someone has got the bit of paper and has taken your money. Morbid thoughts about poverty and ruin are common in Depression, and  suspicious ideas about others can occur.

So, strategy one is the tin box. Ideally take the biscuits out first and eat them.

Strategy two is more complicated, and involves working out your attitude to certain key issues. What is my policy on taking medication? What is my threshold for making an appointment with the doctor?

Strategy three is making sure none of the library books and dvds are overdue. Think how those fines could mount up.

It is clear that Risk Management is something of a myth when it comes to individuals. Actuaries – experts in statistics – work with very large sample sizes, for instance in predicting how long people will live. That makes it possible to run pension schemes and predict how much money will be paid out in future years.

When the sample size gets smaller, the effects of chance become much more significant. We have a similar problem when it comes to predicting the behavior of individuals. In particular we have been carried away with the idea that we can predict violence and self harm. We could probably predict a homicide rate for the whole population, but for smaller samples or individuals we might just as  well throw dice or read the tealeaves.

In fact a rather cynical movement has broken out within mental health work, which goes as follows: We are scientists of a kind, and we know that it is impossible to predict violence or suicide in individuals with an accuracy that could affect our practice.

Recognizing however that we work in a political context, we know that the standard on which we are judged will not be: Did a Homicide / Suicide occur? but rather: Was everything done, that should reasonably have been done, as judged by the man on the 7.15, to have prevented the tragic event?

Luckily, medical services tend not to give written guarantees, acknowledging that we are hardly in control of all the variables that predict how illnesses will affect people. Even Dixons, perhaps especially Dixons, do not guarantee that things will not go wrong. They only guarantee to fix or replace the  eg Beko if it eg explodes.

Patients cannot therefore expect infallibility, but only ‘reasonable care’.

Aware of the political context, clinicians have created an ingenious analogue of what looks like reasonable care, just in case something goes wrong. Take for instance the so called HCR20 scale, which purports to predict risk of violence.

It has a series of numerical scores, which must not be added up to make a sum total. The main function of the scale is that it shows you have considered the proposed risk factors and given some thought as to what might happen in a range of future scenarios.

Calling it ‘arse – covering’, as I heard an angry service user describe it this week, is inaccurate, as such a process is just as likely to create unexpected new buttocks.

Very few health managers and even fewer politicians are experts in statistics. It would be nice to see more actuaries in parliament. I can’t help thinking that actuaries need better PR compared with lawyers, such as a hit TV show. There was never a show called ‘Sun Life: Miami’, for instance. Or even ‘Canada Life: Canada’.

Based quite a bit on ‘Minority Report’ a theme could be a panel of (maverick) actuaries who have learned to predict actual events – sudden deaths – in individuals, rather than just rates in large populations.

Using the dark arts of prediction – going against the fuddy-duddy regime at the Institute Of Actuaries – they would race round to the person’s house just in time to stop the victim poking metal forks in the toaster, or mistaking the Paraquat for Green Chartreuse.

The hero would be called Pendleton I think, and he would drive a lightweight trail bike or use parkour to beat the inevitable traffic jams.

In the first episode Pendleton would skim a CD copy of Microsoft Excel disdainfully into the river.

Each episode would end with a party at Pendleton’s cool loft apartment, and include a minor accident he had foolishly failed to predict, such as a champagne cork hitting someone on the forehead, or someone breaking a tooth on an olive.  ‘I never saw that one coming’, Pendleton would chuckle.

Health managers and Inquiry panels would announce, ‘what we need here is a Pendleton’.

Preparation is not the same thing as insurance.

Both depend on subjective assessment of risks and putting documents in a tin box, but for insurance you need to haggle with another person and give them money.

Its quite likely that subjective risk assessment is impossible beyond simple and likely events in the very near future. Beyond that we might as well use random number tables or a horoscope (which are the same thing).

By the way, there’s a free copy of Excel floating in the river.  And is that a trail bike I can hear in the distance?