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The Royal College of Psychiatrists Improving the lives of people with mental illness

Are we doing too much?

"We need more of this." How many times have we heard that? Doesn’t matter what it is – a new drug, a different psychological therapy, more social care. It’s a bit like the mantra “more research needed” which ends most academic papers. Have you ever read a paper that ended “Less research needed”? Actually, there was one once – a report on aromatherapy. But you know what we mean.

But actually, the truth is that the real problem we face is not having too little, but too much. Too much treatment. Too many tests. Too many diagnoses (as psychiatrists we should plead guilty to that charge). Some of this is obvious. Anything that does good can also do harm, and sometimes considerable harm. Investigations that aren’t needed are wasting money. And so on. But it’s worse than that.

The opportunities to cause harm are many and various. It's not just exposing people to the risk of physical side-effects for no good reason. It can reinforce beliefs and behaviours. It can convince people that they are suffering from serious illness that the doctors have not yet found, but will be uncovered by further and increasingly expensive investigations. It can create disorder where there was none before – look at the evidence that single session psychological debriefing increases, not decreases, the risk of PTSD. In short, as Proust said:

"For each illness that doctors cure with medicine, they provoke ten in healthy people by inoculating them with the virus that is a thousand times more powerful than any microbe: the idea that one is ill."

MARCEL PROUST, "The Guermantes Way,"
Remembrance of Things Past

Now we have an opportunity to play our part in what is a global campaign to do something about this. It's called Choosing Wisely, and it aims to increase awareness and understanding about where the hotspots of overuse are in today’s clinical practice.

To add to this dilemma, patient expectations are increasing, and there is often an onus on psychiatrists to ‘do something’ at each consultation. This can undermine balanced decision-making, where minor potential patient benefit with a minimal evidence base can outweigh significant potential harm and tremendous financial expense. Alternatively, look at the unintended consequences of NHS 111 - nearly all the algorithms that they use end with advising the caller to see a medical practitioner. Result: 3 million extra GP visits last year.

One of us, SW, qualified at the start of the Evidence-based medicine movement, and indeed was a committed supporter. And it has heralded an era of great advances in clinical care – after all who would want an evidence-free medicine? However, it has tended to provide more information about new things we could be doing, rather than providing evidence about what we should not be doing any more, for many obvious reasons. So how can we ensure that patients are provided with the right tests and treatments and are not over-investigated or over-treated? NICE have created a ‘Do Not Do’ recommendations database of close to 1000 interventions, but almost no doctors have heard of this. A different approach is needed to address the potential overtreatment of patients. This approach will need to engage individual doctors and patients to change their conversations to discuss risk more clearly and realise that often doing ‘less’ is actually doing ‘more’.

A potential solution to this issue has come from a surprising source, when considering the sheer volume of waste that occurs in their health system – namely the US. The ‘Choosing Wisely’ campaign aims to reduce overtreatment in health care by attempting to stop the use of various interventions that are not supported by evidence and stop tests that are duplicative of other tests or procedures already received.

The ‘Choosing Wisely’ campaign in this country was launched last month by the Academy of Medical Royal Colleges in the UK in a BMJ editorial. The Academy is requesting that all Medical Royal Colleges in the UK identify a 'top five' list of tests or procedures that are commonly used in their specialty, but whose necessity should be questioned. These tests or treatments should either be stopped altogether, or their routine use should be stopped.

We, as a college, are currently compiling a list of tests, interventions or treatments that should either stop being used routinely, or at all, because of a lack of evidence for clear benefits over harms. We are asking all members to contribute their suggestions for what should be on this list. An expert reference group will be created, chaired by our new Registrar, Adrian James, that will decide what should make our top five list. This list will be submitted to the Academy, which will then be widely publicised.

What can you do?

We need your input and would really welcome any thoughts or suggestions you may have for this list. Be bold. We might at some stage collect together the suggestions that we cannot use, especially if witty. But please give this some thought – involve your trainees for example or medical students – it would make a great discussion or teaching point.

And then submit your ideas to Deborah Hart.

Remember – doing less. You know it makes sense.

Professor Sir Simon Wessely and Dr Daniel Maughan

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Comments

Re: Are we doing too much?
1. 3 monthly Li levels in fit people with NO signs or symptoms of lithium toxicity and no intercurrent illness. Over 34 years of practice, they are sometimes a bit low, but never once, in all the thousands I've presided over, has anyone had a worryingly high level. Once a year is sufficient, with TFTs and eGFR. if people are lithium toxic, they have symptoms. Just ask them.
2. Anger management. It doesn't work. An anger management group is a fight waiting to happen.
3. CTOs (following Burns argument). We are too preoccupied with controlling people.
4. Fixed regime alcohol detox over 3-5 days. Pointless. Detox patients if there's evidence of a need and use a sliding scale. A fixed regime means they develop DTs the evening after discharge.
5. rTMS. 'Works' but results are minor. A modern version of Franz Mesmer's smoke and mirrors
6. EMDR for non-PTSD related problems. See 5, except it doesn't work (except PTSD, or so I'm told)
7. Am I the only person who thinks that Mindfulness has turned into a cult, whose adherents exaggerate its value? It certainly works for some patients, but I half expect them to be offered an LP with George Harrison on it.
Re: Are we doing too much?
In Egypt, prescribing medicine shortly after provisional diagnosis ( a complete course of medicine is conducted before the next follow up visit 14 days later) sometimes seems to be over needed, as the main complaint of the patient might be of psychological origins. While the patient shows very speed recovery, the duration of taking the medicine is not enough to explain such improvement (could be explained by placebo effect). So, it may be recommended to arrange the follow up visit shortly after prescribing the medicine ( within 24- 48 hr. at maximum ), then, either continuing the medicine course or make a referral to a mental health professional.
Re: Are we doing too much?
1. Memory clinics and early diagnosis of dementia when we don't basically have any effective treatments. What's the point in early diagnosis exactly? The evidence for acetylcholinesterase inhibitors is pretty poor and the evidence for poor tolerability pretty convincing. Some occasional patients see very good individual benefits but I'm unclear why you need a psychiatrist in the picture as part of 'shared care' unless there are complex psychiatric or behavioural needs - specialist nurse at GP practice with a GP prescription is sufficient. Huge resources have been pumped into memory services when the money should be going into other aspects of psychiatry or into good social care for dementia patients. The only exception I’d make to this is perhaps early onset dementia which would indicate specialist review in all cases I think.
2. CBT for psychosis. I can understand how patients with chronic distressing hallucinations or delusions refractory to medications may be helped by psychotherapy helping them integrate better cognitive perspectives on these experiences into their daily living to improve function, but advocating CBT for psychosis as a 'single agent' first line treatment for first episode psychosis with intentional delays to medication of a month, not accounted for by the patient’s capacitous decisions, are a complete disgrace (see Taylor & Perera’s editorial in BJPsych a month or two ago for discussion on this).

I would prefer to see a blog entry on ongoing UNDER-treatment in psychiatry, however. Considering patients wait so long to access psychotherapy services for affective/anxiety/personality disorders, have to go through IAPT-equivalents first line which can't do much beyond basic depression and anxiety, and the stigma around accessing services in the first place, I'd like to see the RCPsych try to put their efforts into that to be honest. Plenty of 'anti medication' mental health zealots out there compromising people's care too; maybe they should be reminded of the evidence for more treatment not less. Plenty of examples of under-treatment no doubt.
Re: Are we doing too much?
Antipsychotics (other than clozapine) for PD

Counselling for anything
Re: Are we doing too much?
long term medication for patients with (cluster B) PD's.

NICE guidelines are clear and generally poorly adhered to

pressure to do something is imense
SSRI's overused and often show no benefit in many as well as giving patients the message that we can help by prescribing.
Re: Are we doing too much?
In the week where the government has urged GPs and others to investigate more aggressively for cancer, encouraging people to ask for or provide less will be challenging. As yet the college hasn't obviously involved itself in thinking constructively about quality and safety or the Berwick principles of reducing harm, waste and variation that seems to be driving the quality agenda throughout the rest of medicine currently. There are some great projects where psych has involved itself in the work of the IHI and various UK Safety and Quality Projects to address these areas for patients with good results and less waste. The other medical specialities are leaving us behind in this regard.
Re: Are we doing too much?
A comment on regaining the balance.

'To add to this dilemma, patient expectations are increasing, and there is often an onus on psychiatrists to 'do something' at each consultation'.

Maybe some parts of the profession are not easily engaging in the co-production/partnership concept with the patient - working together towards a personalised, resourceful and co-ordinated approach to recovery, using the skills of both the clinician and the patient. The underlying driver for most patients is wanting to address the question of how to move towards recovery and aspiration with the clinician, not to access the latest test or treatment.

The integration of a values-based and evidence-based approach in psychiatric practice, in my view, is a more secure and sustainable approach. The questions arising from this approach are the ones that we should also be addressing and out of that conversation should naturally come the valid aims of 'Choosing Wisely' and 'Prudent Healthcare' and the wise use of diagnoses and resources.
Re: Are we doing too much?
I agree that the evidence base for memory clinics is extremely poor and I think there is no doubt that they have diverted money and energy from other services for older people with mental health problems.
I also think that the evidence for work place based assessments is extremely poor and they are in many cases a waste of time -with little or no correlation with external assessments. They could be replaced with fewer (but more external) assessment. The best way to maintain standards would be if everyone had to submit a selection of their notes and correspondence (scanned and by e-mail) to either their TPD (for trainees) or the Medical Director for appraisal (for other doctors) once a year. The College could audit a random sample and the CQC could compare the submitted evidence with the notes on the ward -to ensure it was representative.
This would really improve record keeping and history taking and thus feed back into better and more thoughtful care for patients.
Re: Are we doing too much?
1) Referring people for CBT ( or any psychotherapy for that matter) where the individual does not have a prior basic understanding of what the therapy entails, does not wish to want to participate in that treatment approach, do homework, or address change. This would shorten waiting lists and improve access for those that can benefit. Psychotherapy is not something that is done from without, but from within.
2) Use of Z drugs or benzodiazepines for anxiety or sleep for periods longer than 2-4 weeks. All guidance supports this yet many patients find themselves on these drugs for months or years. Any prescription of these drugs should be accompanied by a stopping plan as well from day one.
3) Routine blood testing for baseline prolactin in those who are about to start an antipsychotic medication that will be expected to raise prolactin. In the absence of relevant physical symptoms, this generates further reviews, tests and referrals to endocrinologists for what is a recognised expected consequence of CNS dopamine blocking.
Re: Are we doing too much?
1) Referring people for CBT ( or any psychotherapy for that matter) where the individual does not have a prior basic understanding of what the therapy entails, does not wish to want to participate in that treatment approach, do homework, or address change. This would shorten waiting lists and improve access for those that can benefit. Psychotherapy is not something that is done from without, but from within.
2) Use of Z drugs or benzodiazepines for anxiety or sleep for periods longer than 2-4 weeks. All guidance supports this yet many patients find themselves on these drugs for months or years. Any prescription of these drugs should be accompanied by a stopping plan as well from day one.
3) Routine blood testing for baseline prolactin in those who are about to start an antipsychotic medication that will be expected to raise prolactin. In the absence of relevant physical symptoms, this generates further reviews, tests and referrals to endocrinologists for what is a recognised expected consequence of CNS dopamine blocking.
Re: Are we doing too much?
I seem to have come late to this but often think we overtreat, but i think the main problem is rivalry between different subspecialities-who is going to say their bit should or could do less? I continue to be most exercised over overprescribing-i have inherited several patients with pd s from CAMHS recently who are on loads of medication-this is treating the doctors' or the team's anxiety, not the patient.
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