Give Me Novocaine

Firstly, apologies for this being a couple of days late.  So far I’ve managed to be posting consistently every other Thursday but just didn’t have enough time to write this on Thursday!  Anyway, as always I hope you find this to be a good read…

This post is actually a response to a comment someone made about my previous post, which discussed raising awareness of, and the possible prevention of, mental health problems.  In relation to when people develop mental health problems, this person asked me “It seems that cocktails of pills seem to be the answer to a lot of mental problems, what are your views on that?”  So, I decided to put together a little post about my views on that, and in the process of doing this explain a little bit about the current guidelines for treating mental health problems.  The title Give Me Novocaine comes from a Green Day song with the same title; obviously novocaine isn’t a drug that is used to treat mental health problems, but the song seems to allude to the notion of just taking pills to make everything better, whereas this isn’t always going to work.  Also, I love Green Day and it’s a great song so why not use it?! 

In answer to the question - what do I think about the use of drugs to treat mental illnesses? - my simple answer is that drugs can be necessary but should not be the first port of call in all cases of mental health problems.  Some illnesses (e.g.: psychotic ones) are more likely to warrant the use of medication.  What I find concerning is GPs’ propensity to administer anti-depressant medication willy-nilly.  (As you may have already noticed in previous posts, I will tend to use the example of depression, firstly because it is the main thing I have a knowledge base in and secondly because it’s such a common illness that needs addressing.)  

My view on this comes from the National Institute for Health and Clinical Excellence (or, aptly abbreviated, NICE) guidelines.  These are formed on the basis of evidence, which basically means that NICE only recommends therapies that evidence suggests are effective.  In terms of common mental health disorders, NICE recommends that a stepped care model should be used (NICE, 2012).  This essentially means that the ‘least intrusive, most effective’ intervention should be provided first.  In other words, if, for instance, a person has mild depression, they will be treated accordingly for this; similarly, a person experiencing severe depression will be treated accordingly for the severity of the problem (see the stepped care image below, from IAPT Programme, 2012).  

  

IAPT stands for Improving Access to Psychological Therapies and is another key element of the NICE guidelines on treating mental health disorders.  By using the stepped care model, we are using resources more efficiently, which means more people can be treated.  In turn, this means that people don’t have to wait so long to be treated.  Let’s take the example of depression: for mild depression, cCBT (computerised Cognitive Behavioural Therapy) and guided self-help are recommended.  This means the patient uses resources at home and has periodical guidance from a professional such as a PWP (Psychological Wellbeing Practitioner).  These are known as low-intensity therapies and are less intrusive for the individual and free up more of the professionals’ time, meaning more people can be treated at once.  For moderate to servere depression, on the other hand, high-intensity therapy is recommended.  This could be in the form of face-to-face CBT.  

 

The important thing to remember here is that these guidelines are all based on the evidence relating to treatment for mental health disorders, which I why I tend to agree with them.  For example, CBT, IPT (Interpersonal Psychotherapy) and BA (Behavioural Activation), all therapies recommended by NICE for depression, have been found to be as effective in treating depression as antidepressant medication (e.g.: Hougaard & Jørgensen, 2007).  These treatments have also been shown to be more effective than medication in prevention depression relapse (Dobson et al., 2008).  Hence, my view that a cocktail of pills is not the answer to mental health problems!

Don’t get me wrong though; I don’t condemn the use of medication altogether.  In depression for example, the severity could be so high that the patient simply won’t be able to engage in CBT or BA.  In these cases, antidepressant medication can be really useful in making the patient feel more able to engage in these.  The guidelines also recommend medication for patients who have not responded to other therapies.   

Another important consideration though is the fact that antidepressant drugs have a slightly delayed effect on cognition (thoughts) compared to behaviour.  As a result, a person who is feeling suicidal may find themselves feeling more able to act on their thoughts before these types of thoughts start to subside or change.  Hence, very careful consideration should be given before prescribing medication to treat depression. 

So, to summarise, my most basic answer to the question “should drugs be used to treat mental health disorders?” is yes, where the evidence base suggests this is effective.  In terms of depression, I think drugs should only be used where this is necessary due to the severity of the illness or non-responsiveness to other, less intrusive therapies.  I think one of the problems is that anyone who is medically qualified (e.g.: GPs) can prescribe anti-depressant medication, even if they do not have specialised knowledge in this area.  Therefore, GPs seem too often to prescribe drugs when a patient presents with mild depression, when they should be referring them into the IAPT service.  This need to change!

As always, thank you for reading and I would be interested to hear about other people’s views on this so please do leave a comment.  Also feel free to suggest a topic for my next post and I’ll see what I can do!  See you in two weeks…

References:

Dobson, K. S., Hollon, S. D., Dimidjian, S., Schmaling, K. B., Kohlenberg, R. J., Gallop, R. J. … Jacobson, N. S.  (2008). Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the prevention of relapse and recurrence in major depression. Journal of Consulting and Clinical Psychology, 76, 468-477.

Hougaard E. and Jørgensen, M. B. (2007). [Psychological treatment of depression.]. Ugeskr Laeger, 169, 1444-7.

IAPT Programme (2012). Services. Retrieved from  http://www.iapt.nhs.uk/services/services/

NICE (2012). http://publications.nice.org.uk/common-mental-health-disorders-cg123/key-priorities-for-implementation. Common mental health disorders: Identification and pathways to care. Retrieved from http://publications.nice.org.uk/common-mental-health-disorders-cg123/key-priorities-for-implementationhttp://publications.nice.org.uk/common-mental-health-disorders-cg123/key-priorities-for-implementation