Welcome to the Oxford Psychiatry Podcast series brought to you today by Daniel Maun, I'm an advance trainee here at Oxford Deanery.
Today I have Michael Short with me. He is professor of psychological medicine here at the Oxford University Department.
He's recently moved back to Oxford from Edinburgh. And he's here to talk to me today about psychological medicine and about his recently
completed randomised control trial into treating depression in those that suffer with cancer.
So thank you for coming today. Pleasure. Maybe you could begin by telling us what psychological medicine is.
What is very confusing, isn't it? Because people use different terms.
What we're talking about here is the area of overlap between psychiatry and other bits of medicine and indeed psychology.
And the term that's often used for this is liaison.
Psychiatry liaison means linking.
So this was linking psychiatry and medicine, psychological medicines often preferred now because it isn't just linking psychiatry and medicine,
it's a speciality of psychiatrists exists within medicine. So most departments in the UK are now referred to as departments of psychological medicine.
Thanks. So what does the day to day work of a psychological Medick look like?
Well, you know, it varies a lot between hospitals.
Some hospitals still have the now slightly old fashioned liaison psychiatry type services where they would just visit
people that seem conspicuously mentally ill and perhaps just deal with the level of self-harm in the cash department.
The step up from that is to actually have a base in the hospital, a department of psychological medicine,
and see a greater proportion of patients, perhaps with less conspicuous psychiatric problems,
including problems with patients such as medically unexplained symptoms and severe adjustments to illness, and then is exciting step further,
where psychological medicine becomes fully integrated with the Department of Medicine and a psychiatrist,
work as the same team side by side with the physicians.
And that's the type of service we've recently established in the John Radcliffe here in Oxford.
Great. Sounds like recent developments have really made an impact into integrating psychiatry back to medicine.
We're going to talk about that in a bit. But what was it that initially sparked your interest in psychological medicine?
Well, I have to admit, I didn't do medicine in the first degree. I did my first degree in experimental psychology here in Oxford.
And then I went on to do medicine in London and Cambridge. And I really enjoyed the medicine.
I did medicine up to medical membership.
But I once I found I could put all the tubes in the right places and get most of the front door diagnosis right.
I thought there's something missing here. And whether or not it was because I first studied psychology,
I felt that there was a part of the person that I was not able to adequately engage with doing that rather technical quick fix medicine.
I agonised for a long time whether to train in psychiatry and some of my senior consultant,
senior consultant colleges colleagues in medicine were less than encouraging, but others were encouraging.
And I made the leap. It did seem like a leap at the time, so I moved back to Oxford and trained in psychiatry.
Okay, that's that's an interesting interesting to hear your your personal journey there.
I know you've spoken quite a bit about how liaison psychiatry is key to the future
of psychiatry and understanding the professional role of the psychiatrist. Could you tell us a little bit more about that?
Well, let's go back. And of course, once upon a time, there was no psychiatry.
There were just physicians and and and latterly, of course, surgeons.
And then we go back 100, 200 years, there were separate lunatic asylums.
And these require doctors to staff them. And that was really the origins of psychiatry and medicine moved on ever more reductionist,
ever more successful in finding mechanisms of disease, but sort of lost the whole patient bit of medicine, at least hospital medicine.
Did psychiatry isolated from those developments, if you like,
the fruits of its failure to find mechanisms of disease led to it retaining some of those skills and perspective?
So I think psychiatry has a lot to put back into medicine and help medicine regain a more whole person integrated view and.
The failures of straightfoward reductionist medicine are becoming ever more apparent with a complex ageing population,
with multi morbidity, with unexplained symptoms that cannot be addressed with simple mechanistic medicine.
So it is becoming essential to have the skills of psychiatry mixed back in with general medicine.
And that's becoming widely recognised.
In a sense, completing the picture of a holistic treatment package for patients in hospital, one sometimes shies from the word holistic.
It somehow sounds a little bit flaky, but I think the sense is there a whole patient view?
And one of my favourite quotes from the great physician, William Owsla,
it was a Canadian physician who spent time here in Oxford and wrote the main medical textbook
in the world a little over 100 years ago was that the good physician treats the disease,
but the great physician treats the patient who has the disease.
And I think that's the sentiment that was there in medicine, that we need to bring back a good place to move on.
That's an excellent way to finish that bit.
So let's move on to talking about your trial, a randomised controlled trial into treating depression and those that suffer with cancer.
Maybe you could just begin by telling us what your reasons were for beginning that trial, for wanting to do that trial.
Well, I've always had an interest in patients and doing things to help patients have a combination of what we call medical and psychiatric illnesses.
Of course, those very terms are slightly artificial and reflect the split we've just talked about.
But one example of that would be and an example I encountered in my time in medicine
was someone who had a severe condition such as cancer and also had depression.
And my experience in the literature shows that that depression is rarely diagnosed and if it's diagnosed, is rarely adequately treated.
And I was very impressed by the suffering that unrelieved depression caused.
And so was when I first moved to Edinburgh.
I had the opportunity to start doing some work in relation to the cancer centre and thereafter followed some more than 10 years
of work developing and testing a better way of identifying and treating depression in patients attending a cancer centre.
So could you tell us about your trial and. Yes. Well, there was two bits.
The bit that isn't really part of the trial, but it's an essential underpinning is we have to know who is depressed.
And the first problem there is in medicine is that depression is not well detected.
Patients don't want to say doctors don't want to ask. That can be a condition of silence.
And so we implemented a very large scale screening system and depression outpatient in cancer outpatients for depression,
which enabled us to identify which patients are technically more depressed.
And it's about 10 percent of cancer outpatients. Then we wanted to be able to there's no point screening for patients unless you have a treatment.
So we want to be able to implement an effective treatment.
And here I was very influenced by work in the United States and so-called collaborative care,
which is actually taking the best shot we have of treatments and pushing them together in a system that optimises the patient's care.
So in some ways, there's nothing terribly novel about this.
So what do we know works for depression, antidepressants, some talking treatments like cognitive behavioural therapy and problem Problem-Solving?
And you need to get the patient to want to take these and cooperate with it and follow them up to make sure they're properly delivered.
It sounds very simple. So we constructed a essentially common sense treatment based on those ingredients.
So in a sense, bringing the the evidence based good quality care to the coalface, to the patients,
rather than making them look for it and often not for not finding it themselves.
So the thing that can't be underestimated here is I think if someone didn't know, they'd assume, well, sure,
the GPS will deliver this treatment or sure, if they're going to a specialist cancer centre, they will get depression treated.
We studied, identified 100 consecutive patients with depression and less than 10 percent were getting any useful treatment.
So the problem isn't that we have to discover a whole new treatment for depression.
The problem is we have to discover and develop and create a system to make sure that patients get the treatments that we already have,
which, incidentally, is an issue a lot of other areas of medicine. But I digress.
And what were the reactions of those in cancer services, the professionals working in that cancer services to this trial and where they
pleased for the option of you sort of being there and screening of their patients?
What was the response to to the trial? Well, I think in general, they were very happy for this to go on.
I think that, of course, like any group of doctors, some are wildly enthusiastic and some are more sceptical.
I think oncologists have a very hard job dealing with often incurable illness, certainly giving often distressing treatments.
And most of them, I think, are aware that a lot of their patients are depressed and most of them feel they should be doing something about it,
but feel it's just too much for them to manage on top of everything else.
They lack the skills. They lack the time.
So to have someone come in and set up a system to address this problem is something that that certainly most of them
welcomed because it's it's good to see that they realise it's amazing that they were welcoming in and into the trial.
But I guess it's sometimes that the age old split of psychiatrists and medicks we can that can sometimes be some some teething problems.
Well, in the sort of getting you're absolutely right.
And I made it sound far too easy, which, of course, it isn't.
And I should say that we did work in the same cancer centre for some 15 years and colleagues had worked there previously.
And I think that's generally the experience that the default is because of this historical split.
We keep coming back to physicians often see psychiatry as other as alien and don't really know what to make of it.
And they have some wedding fantasies about it.
And like most worrying fantasies, they're best addressed by personal contact with a normal psychiatrist and even better,
seeing some of that patients benefit from their treatments. And I think this applies to most of this area of linking psychiatry and medicine.
Right. It just needs some time, some exposure and being there together, seeing the same patients together and those problems pretty much disappear.
So let's press on to the results. Yeah, you might not have all the figures to hand, but I can give you something to give you the broad brush figures.
And I should say this paper isn't actually published yet. So I'm going to be a little bit broad brush.
So we recruited to this trial 500 patients attending cancer outpatient clinics who all have depression of a severity called major depression.
In the end, there was a majority of women and the majority of women breast cancer.
And that's we didn't seek to recruit predominantly those kind of patients.
But that's who you pick up. If you screen them, that's another story.
And those patients were randomised to either have their GP told they had depression, they were told to have depression.
Their oncologist was told they had depression and they were all encouraged to get on and do something about it.
So that was one arm that was, if you like, optimised or informed, usual care.
So you might think that should do.
The job really so we set ourselves quite hard task of seeing if we could do better than that and the other arm got that.
Plus the patients saw nurse for an average of about eight occasions.
That nurse was trained and followed a treatment manual delivering education about depression, helping the patient become active,
helping the patient to problem solve their difficulties and ensuring adherence to antidepressants.
That nurse was closely supervised by a psychiatrist who got given information about the
progress of the patient's depression and about their treatment and made adjustments.
The general practitioners prescribed the antidepressants. Psychiatrists did.
So we communicated with the GP and saying, well, we'd recommend an increase in antidepressants or a change, for example.
So really, you might say we're comparing usual care,
encouraging people to do a bit better with adding something in to what was essentially the same kind of thing.
All right. So you might say, well, you wouldn't expect to make much of a difference with this.
We got results which were so surprising. If we hadn't had about three statisticians working on the trial,
I would have been I would have thought they made a mistake at six months after coming into the trial.
The patients who had that very informed usual care, the percentage who had a really useful improvement in their depression,
a 50 percent drop in score was only was less than 20 percent.
All right. So that means if you go to a cancer centre now, you're screened for depression.
Everyone's told you have depression. The patients told they had depression.
Get treatment you can expect six months later, less than 20 percent will be usefully better.
When he said, well, maybe depression with cancer is very difficult to treat.
So the other on the arm where we put in this additional treatment at six months, more than 60 percent, what had that improvement?
So we actually had an absolute 45 percent difference between the groups of six months.
We measured lots of secondary outcomes, the patient satisfaction with their care, anxiety, pain, fatigue, patient rated quality of life and so on.
And every single one was statistically significant. And those differences were all maintained at the 12 month follow up.
That's 12 months. And as far as we went, so I can't say after 12 months. So this is a very striking of just the most striking trial result I've had.
And it really is quite surprising because we didn't do anything that special.
What we did is make sure patients get the treatments that we know work and did that in a very systematic, carefully controlled way.
And really, it's rather an indictment of what usual care is.
Yes, because all those treatments were available potentially to people in usual care.
But the lack of patient education, the lack of proactive monitoring, the lack of insurance,
the treatments were delivered and changed where necessary means you get very poor outcomes.
The results, in a sense, are a challenge actually to to ask a psychiatrist to to actually go to these places where there are this
this cohort of patients with unrecognised mental illness to actually to not wait for them to come to us,
but to go and find them in these general medical settings. Yeah, I think there are two challenges.
One is I you know, understandably, because psychiatrists can't see everybody with psychiatric illness,
but the management of depression, of the major depression has largely been given up to primary care.
And the reality is, at least for patients with comorbid physical illness, primary care, that good at it.
All right. The second thing, you're right, these are people who normally, most of whom wouldn't come near a mental health service.
See, you need to go and find them.
But the thing is, if you use this kind of model, when most of the treatments given by a nurse and prescribed by the GP,
the amount of specialist psychiatrist time needed is quite small.
So you couldn't plausibly say all those 250 patients had to be seen by a consultant psychiatrist.
That wouldn't make any sense. But actually having a system where the psychiatrist just provides supervision means it becomes cost effective.
And indeed, we know from the analysis that this was a cost effective treatment costing less than 10000 pounds of Qualys,
which is a long way under the kind of threshold that Nice would say is too expensive.
And another interesting aspect of your trial, and I mentioned it to you before,
was that you chose to use the the cancer specialist nurses for the delivery of some of the talking therapy,
which I thought was a very interesting method that you used to really get fully integrated into that cancer service.
I think one can always be more integrated.
Certainly would this that the thought was and this was based on what patients told us, that they wanted to see someone who understood depression,
but they also want to see someone who understood cancer and cancer treatments and they were not comfortable
saying just a mental health person had no idea what their cancer treatments and cancer experience have been.
So they felt more comfortable with someone who had both. That did mean we had to provide quite intensive training for the cancer nurses.
But the proof of the pudding is in eating. And it worked well.
Thank you very much for giving us the outline of your trial. So we look forward to reading about that in more detail.
And when it comes out in press, I was just wondering before we finish, Professor Sharp,
whether you could or whether you have any words for some of the listeners out there who might be contemplating a career in psychological medicine?
Well, yes, I I as you know, my particular thing is to enhance the position and the contribution of psychiatry in relation to the rest of medicine.
And I think there's two main ways that this is working at the minute.
Now, one way is to go into biology research that the neuroscience of psychiatry is linking with neurology
and basic neuroscience and is bringing psychiatry back into medicine and the biological level.
Right. And a lot of people are attracted to that. And it's important work at the clinical level.
There is now very considerable interest with multiple government reports recommending integration as a clinical level.
So integrating psychiatric care with medical care is what psychological medicine is all about.
And I think those two strands are going to be the things that keep psychiatry alive and integrated with the rest of medicine.
And if you're a young medical student or a young doctor who's interested in holistic,
a whole patient medicine, psychological medicine might well be the thing for you.
Thank you. First of all, there's been a actually quite an inspiring interview.
Talk to you about your opinions, your views and and your your your striking results from trials.
So thank you very much for being here today. And thank you, listeners, for tuning in.
Please do listen to my podcast at the Oxford University Psychiatry podcast series.
Thank you. Thank you.