A ray of hope in the long fight against depression
It’s exciting to be involved in a project which can offer some new hope for those affected by severe and enduring mental health problems. So Friday was a good day when the Today Programme covered the results of the Tavistock Adult Depression Study which over a period of 10 years has been evaluating the impact of long term psychoanalytical psychotherapy at the Tavistock Clinic for people affected by treatment resistant depression. This is the first randomised controlled trial in the NHS for this kind of intervention and its results were encouraging.
The study showed that 44% of the patients receiving an 18 month programme of weekly psychoanalytical psychotherapy no longer met the criteria for a major depressive disorder when followed up after 2 years. This compares to 10% of the control group receiving treatment as usual. 14% of the group receiving treatment had fully recovered compared to 4% from the control group.
Not everybody with this condition will benefit from this treatment but it is very promising news for a group of patients with a serious condition who otherwise have had little on offer. Those who have been affected by long term, recurrent depression know its awfulness. A condition which robs life of all pleasure and meaning, so much so that in too many cases ending that life is preferable to carrying on in suffering.
In times of austerity there will be no easy path to making this treatment more readily available to patients who could benefit from it. There is a case for more research to confirm the results of this trial and to help better understand why some patients can benefit from this approach and why others do not. I hope that NICE will take serious note of these new findings and consider how they should be reflected in their guideline on Depression in Adults. There should be for patients and GPs to argue for this treatment using patient choice but, despite some clear policy statements under the Coalition Government, the mechanism of choice in mental health remains obscure and underutilised.
The study has also made me think again about the battle we still need to fight to get a genuine parity of esteem for mental health. It remains a scandal that in overall terms while over 90% of people with a physical condition such as diabetes will receive treatment there is a treatment gap for depression of over 50%. More people with the condition do not receive treatment as do and for those who receive treatment the options remain limited.
For many years the only option available to people presenting in primary care was the prescription of anti-depressants. The Improving Access to Psychological Therapies (IAPT) programme has broadened access to short term CBT and has been beneficial for many patients. Neither intervention, however, is a panacea and there are many patients who need an alternative approach. IAPT, in particular, has been an enormously important initiative in quickly and relatively cost effectively broadening access to psychological treatment but it has undoubtedly taken a lion share of any additional investment in mental health services and there is a real danger that policy makers overestimate the scope of what it can achieve.
In the case of cancer it would be inconceivable to contemplate the debate about services being limited to a simple set of medication or a time limited course of treatment. The Cancer Drugs Funds shows a willingness to invest in new treatments with an unproven economic case but which offer some hope of extending life. Are we ready to bring the same arguments to mental health in respect of longer term treatments, where the arguments in terms of the relief of suffering are equally strong and for which there is probably a better economic case given the chance of longer term benefits relating to improved social functioning and reduced care costs?
The study is, for me, another reminder of the importance, in particular in times of scarcity, of the value of improving the evidence base in the effectiveness of different interventions. Parts of the psychological and psychotherapeutic community have not always heeded this advice and found themselves at a disadvantage when arguing for resources in difficult times. Evidence based medicine does not reach to all aspects of understanding the value of different kinds of clinical work but without evidence there is unlikely to be any new investment and even what is currently in the system may, increasingly, be at threat.
The purpose of the NHS, in my view, is the alleviation of human suffering. I hope that our study has been able to offer a ray of hope that there may be more we can do to relieve the suffering of people who experience long term depression. If we are able to make a reality of that then perhaps we are on the road to parity of esteem.