The Mind Gap

Roger Jones

doi:10.3399/bjgp19X701357

Getting on for 50 years ago, after his presentation to an undergraduate medical society, I had dinner with William Sargent, the great proponent of insulin therapy, ECT, and psychosurgery. It was not exactly a light-hearted occasion. I don’t think that evidence-based medicine or the transparent reporting of the harms, as well as the possible benefits, of interventions were on anyone’s agenda in those days. Not long before that I had read the subversive work of RD Laing, who viewed psychosis as something else altogether. Labelled an anti-psychiatrist, Laing was a cult figure in the sixties, although his views on the causes and treatments of psychosis appear, from today’s perspective, as weird and muddled. Both men had themselves suffered from mental illness. Yet, in a recent book about depression written from the standpoint of Darwinian evolutionary psychology,¹ Randolph Nesse, an academic psychiatrist at Arizona State University, says that the treatment of schizophrenia has hardly changed in the last 50 years and depression scarcely in the past 20. We still have not found the fundamental cause of any of the major mental disorders.

This creative uncertainty forms the backdrop to what I think is an outstanding issue of the British Journal of General Practice, on the theme of Mental Health, and I hope you can find time to read through some really excellent contributions. Sir David Goldberg opens the batting with a trenchant critique of the current classification systems for anxiety and depression and of their relevance and utility in primary care. He proposes re-thinking and re-labelling common problems such as medically unexplained symptoms and hypochondriasis with less pejorative descriptors, and also advocates the use of simpler rating scales to detect anxiety and depression in primary care. This editorial is accompanied by two related articles which look, in different but overlapping ways, at how depressive symptoms develop, emerge, are experienced, and can best be confronted.

An editorial by Richard Byng and his colleagues and a Debate & Analysis article by Ella Bekhuis and her co-authors both report the development of a ‘network’ model to conceptualise and understand depressive syndromes which, they believe, can lead to more collaborative, personal approaches to treatment. Their ideas certainly make intuitive sense.

In an important editorial, Elizabeth England and Faraz Mughal reflect on the parlous state of community mental health services for children and young adults in this country, a topic that has received a good deal of media coverage in recent months. Despite the rhetoric, they aren’t convinced that the development of joined up services for children and young people at CCG/Local Transformation Plan level is progressing anything like quickly enough and also recognise that the NHS workforce problem is a significant barrier to achieving waiting list and other targets. Ten months is far, far too long for the distressed family of a disturbed child to wait for expert help.

There is more: a comprehensive look at which first-line antidepressant to choose, and guidance on the prescription of benzodiazepines in primary care. The mental health of older people is another subject of research. A systematic review carried out by Rachael Frost and colleagues, found that despite being open to and benefiting from psychological therapies, older patients with depression are far less likely to be referred for these therapies than younger people with depression. In the time-constrained general practice consultation the physical health of older people is frequently prioritised over their mental health. In a similar vein, Dan Liu and colleagues report that, although incentive schemes designed to increase the diagnosis of dementia were associated with a positive impact on QOF outcomes, they also appear to have some negative effects, including evidence of diminished patient-centredness of consultations, and poorer access to care.

Finally, Sanju George and Clare Gerada sound a warning note about the stresses affecting the medical profession itself, the importance of being personally aware and able to recognise the warning signs, and most of all, to do something about it. Doctors should take more responsibility for their mental health.