1 00:00:00,810 --> 00:00:08,640 Welcome to the Oxford Psychiatry Podcast series brought to you today by Daniel Maun, I'm an advance trainee here at Oxford Deanery. 2 00:00:08,640 --> 00:00:16,620 Today I have Michael Short with me. He is professor of psychological medicine here at the Oxford University Department. 3 00:00:16,620 --> 00:00:23,490 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 4 00:00:23,490 --> 00:00:29,940 completed randomised control trial into treating depression in those that suffer with cancer. 5 00:00:29,940 --> 00:00:38,460 So thank you for coming today. Pleasure. Maybe you could begin by telling us what psychological medicine is. 6 00:00:38,460 --> 00:00:42,990 What is very confusing, isn't it? Because people use different terms. 7 00:00:42,990 --> 00:00:52,080 What we're talking about here is the area of overlap between psychiatry and other bits of medicine and indeed psychology. 8 00:00:52,080 --> 00:00:55,830 And the term that's often used for this is liaison. 9 00:00:55,830 --> 00:00:58,590 Psychiatry liaison means linking. 10 00:00:58,590 --> 00:01:08,520 So this was linking psychiatry and medicine, psychological medicines often preferred now because it isn't just linking psychiatry and medicine, 11 00:01:08,520 --> 00:01:18,420 it's a speciality of psychiatrists exists within medicine. So most departments in the UK are now referred to as departments of psychological medicine. 12 00:01:18,420 --> 00:01:24,570 Thanks. So what does the day to day work of a psychological Medick look like? 13 00:01:24,570 --> 00:01:29,550 Well, you know, it varies a lot between hospitals. 14 00:01:29,550 --> 00:01:37,770 Some hospitals still have the now slightly old fashioned liaison psychiatry type services where they would just visit 15 00:01:37,770 --> 00:01:45,000 people that seem conspicuously mentally ill and perhaps just deal with the level of self-harm in the cash department. 16 00:01:45,000 --> 00:01:50,580 The step up from that is to actually have a base in the hospital, a department of psychological medicine, 17 00:01:50,580 --> 00:01:57,300 and see a greater proportion of patients, perhaps with less conspicuous psychiatric problems, 18 00:01:57,300 --> 00:02:07,200 including problems with patients such as medically unexplained symptoms and severe adjustments to illness, and then is exciting step further, 19 00:02:07,200 --> 00:02:14,070 where psychological medicine becomes fully integrated with the Department of Medicine and a psychiatrist, 20 00:02:14,070 --> 00:02:18,030 work as the same team side by side with the physicians. 21 00:02:18,030 --> 00:02:23,640 And that's the type of service we've recently established in the John Radcliffe here in Oxford. 22 00:02:23,640 --> 00:02:31,540 Great. Sounds like recent developments have really made an impact into integrating psychiatry back to medicine. 23 00:02:31,540 --> 00:02:38,580 We're going to talk about that in a bit. But what was it that initially sparked your interest in psychological medicine? 24 00:02:38,580 --> 00:02:46,740 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. 25 00:02:46,740 --> 00:02:52,140 And then I went on to do medicine in London and Cambridge. And I really enjoyed the medicine. 26 00:02:52,140 --> 00:02:54,840 I did medicine up to medical membership. 27 00:02:54,840 --> 00:03:01,910 But I once I found I could put all the tubes in the right places and get most of the front door diagnosis right. 28 00:03:01,910 --> 00:03:08,130 I thought there's something missing here. And whether or not it was because I first studied psychology, 29 00:03:08,130 --> 00:03:17,250 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. 30 00:03:17,250 --> 00:03:23,400 I agonised for a long time whether to train in psychiatry and some of my senior consultant, 31 00:03:23,400 --> 00:03:28,980 senior consultant colleges colleagues in medicine were less than encouraging, but others were encouraging. 32 00:03:28,980 --> 00:03:39,450 And I made the leap. It did seem like a leap at the time, so I moved back to Oxford and trained in psychiatry. 33 00:03:39,450 --> 00:03:45,990 Okay, that's that's an interesting interesting to hear your your personal journey there. 34 00:03:45,990 --> 00:03:49,800 I know you've spoken quite a bit about how liaison psychiatry is key to the future 35 00:03:49,800 --> 00:03:57,000 of psychiatry and understanding the professional role of the psychiatrist. Could you tell us a little bit more about that? 36 00:03:57,000 --> 00:04:03,690 Well, let's go back. And of course, once upon a time, there was no psychiatry. 37 00:04:03,690 --> 00:04:09,600 There were just physicians and and and latterly, of course, surgeons. 38 00:04:09,600 --> 00:04:17,340 And then we go back 100, 200 years, there were separate lunatic asylums. 39 00:04:17,340 --> 00:04:27,990 And these require doctors to staff them. And that was really the origins of psychiatry and medicine moved on ever more reductionist, 40 00:04:27,990 --> 00:04:36,360 ever more successful in finding mechanisms of disease, but sort of lost the whole patient bit of medicine, at least hospital medicine. 41 00:04:36,360 --> 00:04:41,220 Did psychiatry isolated from those developments, if you like, 42 00:04:41,220 --> 00:04:49,440 the fruits of its failure to find mechanisms of disease led to it retaining some of those skills and perspective? 43 00:04:49,440 --> 00:05:01,310 So I think psychiatry has a lot to put back into medicine and help medicine regain a more whole person integrated view and. 44 00:05:01,310 --> 00:05:08,240 The failures of straightfoward reductionist medicine are becoming ever more apparent with a complex ageing population, 45 00:05:08,240 --> 00:05:14,900 with multi morbidity, with unexplained symptoms that cannot be addressed with simple mechanistic medicine. 46 00:05:14,900 --> 00:05:21,230 So it is becoming essential to have the skills of psychiatry mixed back in with general medicine. 47 00:05:21,230 --> 00:05:24,200 And that's becoming widely recognised. 48 00:05:24,200 --> 00:05:33,620 In a sense, completing the picture of a holistic treatment package for patients in hospital, one sometimes shies from the word holistic. 49 00:05:33,620 --> 00:05:38,750 It somehow sounds a little bit flaky, but I think the sense is there a whole patient view? 50 00:05:38,750 --> 00:05:43,820 And one of my favourite quotes from the great physician, William Owsla, 51 00:05:43,820 --> 00:05:49,580 it was a Canadian physician who spent time here in Oxford and wrote the main medical textbook 52 00:05:49,580 --> 00:05:56,060 in the world a little over 100 years ago was that the good physician treats the disease, 53 00:05:56,060 --> 00:05:59,180 but the great physician treats the patient who has the disease. 54 00:05:59,180 --> 00:06:06,130 And I think that's the sentiment that was there in medicine, that we need to bring back a good place to move on. 55 00:06:06,130 --> 00:06:09,590 That's an excellent way to finish that bit. 56 00:06:09,590 --> 00:06:19,100 So let's move on to talking about your trial, a randomised controlled trial into treating depression and those that suffer with cancer. 57 00:06:19,100 --> 00:06:26,840 Maybe you could just begin by telling us what your reasons were for beginning that trial, for wanting to do that trial. 58 00:06:26,840 --> 00:06:39,650 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. 59 00:06:39,650 --> 00:06:45,470 Of course, those very terms are slightly artificial and reflect the split we've just talked about. 60 00:06:45,470 --> 00:06:50,780 But one example of that would be and an example I encountered in my time in medicine 61 00:06:50,780 --> 00:06:56,390 was someone who had a severe condition such as cancer and also had depression. 62 00:06:56,390 --> 00:07:04,490 And my experience in the literature shows that that depression is rarely diagnosed and if it's diagnosed, is rarely adequately treated. 63 00:07:04,490 --> 00:07:12,360 And I was very impressed by the suffering that unrelieved depression caused. 64 00:07:12,360 --> 00:07:17,300 And so was when I first moved to Edinburgh. 65 00:07:17,300 --> 00:07:24,980 I had the opportunity to start doing some work in relation to the cancer centre and thereafter followed some more than 10 years 66 00:07:24,980 --> 00:07:33,560 of work developing and testing a better way of identifying and treating depression in patients attending a cancer centre. 67 00:07:33,560 --> 00:07:37,700 So could you tell us about your trial and. Yes. Well, there was two bits. 68 00:07:37,700 --> 00:07:43,040 The bit that isn't really part of the trial, but it's an essential underpinning is we have to know who is depressed. 69 00:07:43,040 --> 00:07:48,380 And the first problem there is in medicine is that depression is not well detected. 70 00:07:48,380 --> 00:07:53,270 Patients don't want to say doctors don't want to ask. That can be a condition of silence. 71 00:07:53,270 --> 00:08:01,460 And so we implemented a very large scale screening system and depression outpatient in cancer outpatients for depression, 72 00:08:01,460 --> 00:08:06,590 which enabled us to identify which patients are technically more depressed. 73 00:08:06,590 --> 00:08:16,350 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. 74 00:08:16,350 --> 00:08:21,450 So we want to be able to implement an effective treatment. 75 00:08:21,450 --> 00:08:28,020 And here I was very influenced by work in the United States and so-called collaborative care, 76 00:08:28,020 --> 00:08:37,200 which is actually taking the best shot we have of treatments and pushing them together in a system that optimises the patient's care. 77 00:08:37,200 --> 00:08:40,180 So in some ways, there's nothing terribly novel about this. 78 00:08:40,180 --> 00:08:48,480 So what do we know works for depression, antidepressants, some talking treatments like cognitive behavioural therapy and problem Problem-Solving? 79 00:08:48,480 --> 00:08:56,190 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. 80 00:08:56,190 --> 00:09:05,520 It sounds very simple. So we constructed a essentially common sense treatment based on those ingredients. 81 00:09:05,520 --> 00:09:11,100 So in a sense, bringing the the evidence based good quality care to the coalface, to the patients, 82 00:09:11,100 --> 00:09:15,000 rather than making them look for it and often not for not finding it themselves. 83 00:09:15,000 --> 00:09:23,400 So the thing that can't be underestimated here is I think if someone didn't know, they'd assume, well, sure, 84 00:09:23,400 --> 00:09:30,840 the GPS will deliver this treatment or sure, if they're going to a specialist cancer centre, they will get depression treated. 85 00:09:30,840 --> 00:09:39,720 We studied, identified 100 consecutive patients with depression and less than 10 percent were getting any useful treatment. 86 00:09:39,720 --> 00:09:43,680 So the problem isn't that we have to discover a whole new treatment for depression. 87 00:09:43,680 --> 00:09:52,020 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, 88 00:09:52,020 --> 00:09:56,970 which, incidentally, is an issue a lot of other areas of medicine. But I digress. 89 00:09:56,970 --> 00:10:02,970 And what were the reactions of those in cancer services, the professionals working in that cancer services to this trial and where they 90 00:10:02,970 --> 00:10:07,110 pleased for the option of you sort of being there and screening of their patients? 91 00:10:07,110 --> 00:10:16,980 What was the response to to the trial? Well, I think in general, they were very happy for this to go on. 92 00:10:16,980 --> 00:10:25,440 I think that, of course, like any group of doctors, some are wildly enthusiastic and some are more sceptical. 93 00:10:25,440 --> 00:10:35,700 I think oncologists have a very hard job dealing with often incurable illness, certainly giving often distressing treatments. 94 00:10:35,700 --> 00:10:43,170 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, 95 00:10:43,170 --> 00:10:47,640 but feel it's just too much for them to manage on top of everything else. 96 00:10:47,640 --> 00:10:49,890 They lack the skills. They lack the time. 97 00:10:49,890 --> 00:10:58,140 So to have someone come in and set up a system to address this problem is something that that certainly most of them 98 00:10:58,140 --> 00:11:06,860 welcomed because it's it's good to see that they realise it's amazing that they were welcoming in and into the trial. 99 00:11:06,860 --> 00:11:18,470 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. 100 00:11:18,470 --> 00:11:21,930 Well, in the sort of getting you're absolutely right. 101 00:11:21,930 --> 00:11:24,960 And I made it sound far too easy, which, of course, it isn't. 102 00:11:24,960 --> 00:11:34,920 And I should say that we did work in the same cancer centre for some 15 years and colleagues had worked there previously. 103 00:11:34,920 --> 00:11:40,260 And I think that's generally the experience that the default is because of this historical split. 104 00:11:40,260 --> 00:11:48,150 We keep coming back to physicians often see psychiatry as other as alien and don't really know what to make of it. 105 00:11:48,150 --> 00:11:50,280 And they have some wedding fantasies about it. 106 00:11:50,280 --> 00:11:59,190 And like most worrying fantasies, they're best addressed by personal contact with a normal psychiatrist and even better, 107 00:11:59,190 --> 00:12:06,870 seeing some of that patients benefit from their treatments. And I think this applies to most of this area of linking psychiatry and medicine. 108 00:12:06,870 --> 00:12:16,950 Right. It just needs some time, some exposure and being there together, seeing the same patients together and those problems pretty much disappear. 109 00:12:16,950 --> 00:12:23,970 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. 110 00:12:23,970 --> 00:12:30,480 And I should say this paper isn't actually published yet. So I'm going to be a little bit broad brush. 111 00:12:30,480 --> 00:12:44,460 So we recruited to this trial 500 patients attending cancer outpatient clinics who all have depression of a severity called major depression. 112 00:12:44,460 --> 00:12:49,830 In the end, there was a majority of women and the majority of women breast cancer. 113 00:12:49,830 --> 00:12:54,120 And that's we didn't seek to recruit predominantly those kind of patients. 114 00:12:54,120 --> 00:12:57,870 But that's who you pick up. If you screen them, that's another story. 115 00:12:57,870 --> 00:13:07,830 And those patients were randomised to either have their GP told they had depression, they were told to have depression. 116 00:13:07,830 --> 00:13:13,170 Their oncologist was told they had depression and they were all encouraged to get on and do something about it. 117 00:13:13,170 --> 00:13:18,120 So that was one arm that was, if you like, optimised or informed, usual care. 118 00:13:18,120 --> 00:13:20,190 So you might think that should do. 119 00:13:20,190 --> 00:13:27,570 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. 120 00:13:27,570 --> 00:13:31,830 Plus the patients saw nurse for an average of about eight occasions. 121 00:13:31,830 --> 00:13:41,130 That nurse was trained and followed a treatment manual delivering education about depression, helping the patient become active, 122 00:13:41,130 --> 00:13:47,640 helping the patient to problem solve their difficulties and ensuring adherence to antidepressants. 123 00:13:47,640 --> 00:13:55,890 That nurse was closely supervised by a psychiatrist who got given information about the 124 00:13:55,890 --> 00:14:00,850 progress of the patient's depression and about their treatment and made adjustments. 125 00:14:00,850 --> 00:14:03,970 The general practitioners prescribed the antidepressants. Psychiatrists did. 126 00:14:03,970 --> 00:14:10,020 So we communicated with the GP and saying, well, we'd recommend an increase in antidepressants or a change, for example. 127 00:14:10,020 --> 00:14:13,650 So really, you might say we're comparing usual care, 128 00:14:13,650 --> 00:14:19,960 encouraging people to do a bit better with adding something in to what was essentially the same kind of thing. 129 00:14:19,960 --> 00:14:23,820 All right. So you might say, well, you wouldn't expect to make much of a difference with this. 130 00:14:23,820 --> 00:14:30,510 We got results which were so surprising. If we hadn't had about three statisticians working on the trial, 131 00:14:30,510 --> 00:14:38,820 I would have been I would have thought they made a mistake at six months after coming into the trial. 132 00:14:38,820 --> 00:14:48,750 The patients who had that very informed usual care, the percentage who had a really useful improvement in their depression, 133 00:14:48,750 --> 00:14:53,710 a 50 percent drop in score was only was less than 20 percent. 134 00:14:53,710 --> 00:14:58,620 All right. So that means if you go to a cancer centre now, you're screened for depression. 135 00:14:58,620 --> 00:15:01,410 Everyone's told you have depression. The patients told they had depression. 136 00:15:01,410 --> 00:15:07,200 Get treatment you can expect six months later, less than 20 percent will be usefully better. 137 00:15:07,200 --> 00:15:10,980 When he said, well, maybe depression with cancer is very difficult to treat. 138 00:15:10,980 --> 00:15:21,720 So the other on the arm where we put in this additional treatment at six months, more than 60 percent, what had that improvement? 139 00:15:21,720 --> 00:15:27,150 So we actually had an absolute 45 percent difference between the groups of six months. 140 00:15:27,150 --> 00:15:36,120 We measured lots of secondary outcomes, the patient satisfaction with their care, anxiety, pain, fatigue, patient rated quality of life and so on. 141 00:15:36,120 --> 00:15:43,620 And every single one was statistically significant. And those differences were all maintained at the 12 month follow up. 142 00:15:43,620 --> 00:15:56,190 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. 143 00:15:56,190 --> 00:16:03,330 And it really is quite surprising because we didn't do anything that special. 144 00:16:03,330 --> 00:16:11,190 What we did is make sure patients get the treatments that we know work and did that in a very systematic, carefully controlled way. 145 00:16:11,190 --> 00:16:15,570 And really, it's rather an indictment of what usual care is. 146 00:16:15,570 --> 00:16:20,970 Yes, because all those treatments were available potentially to people in usual care. 147 00:16:20,970 --> 00:16:26,790 But the lack of patient education, the lack of proactive monitoring, the lack of insurance, 148 00:16:26,790 --> 00:16:32,430 the treatments were delivered and changed where necessary means you get very poor outcomes. 149 00:16:32,430 --> 00:16:41,490 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 150 00:16:41,490 --> 00:16:47,850 this cohort of patients with unrecognised mental illness to actually to not wait for them to come to us, 151 00:16:47,850 --> 00:16:52,830 but to go and find them in these general medical settings. Yeah, I think there are two challenges. 152 00:16:52,830 --> 00:16:58,680 One is I you know, understandably, because psychiatrists can't see everybody with psychiatric illness, 153 00:16:58,680 --> 00:17:03,660 but the management of depression, of the major depression has largely been given up to primary care. 154 00:17:03,660 --> 00:17:09,060 And the reality is, at least for patients with comorbid physical illness, primary care, that good at it. 155 00:17:09,060 --> 00:17:16,550 All right. The second thing, you're right, these are people who normally, most of whom wouldn't come near a mental health service. 156 00:17:16,550 --> 00:17:18,940 See, you need to go and find them. 157 00:17:18,940 --> 00:17:26,700 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, 158 00:17:26,700 --> 00:17:31,920 the amount of specialist psychiatrist time needed is quite small. 159 00:17:31,920 --> 00:17:37,170 So you couldn't plausibly say all those 250 patients had to be seen by a consultant psychiatrist. 160 00:17:37,170 --> 00:17:45,150 That wouldn't make any sense. But actually having a system where the psychiatrist just provides supervision means it becomes cost effective. 161 00:17:45,150 --> 00:17:52,320 And indeed, we know from the analysis that this was a cost effective treatment costing less than 10000 pounds of Qualys, 162 00:17:52,320 --> 00:17:57,690 which is a long way under the kind of threshold that Nice would say is too expensive. 163 00:17:57,690 --> 00:18:01,710 And another interesting aspect of your trial, and I mentioned it to you before, 164 00:18:01,710 --> 00:18:09,480 was that you chose to use the the cancer specialist nurses for the delivery of some of the talking therapy, 165 00:18:09,480 --> 00:18:17,280 which I thought was a very interesting method that you used to really get fully integrated into that cancer service. 166 00:18:17,280 --> 00:18:20,150 I think one can always be more integrated. 167 00:18:20,150 --> 00:18:31,190 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, 168 00:18:31,190 --> 00:18:36,650 but they also want to see someone who understood cancer and cancer treatments and they were not comfortable 169 00:18:36,650 --> 00:18:43,850 saying just a mental health person had no idea what their cancer treatments and cancer experience have been. 170 00:18:43,850 --> 00:18:53,000 So they felt more comfortable with someone who had both. That did mean we had to provide quite intensive training for the cancer nurses. 171 00:18:53,000 --> 00:18:57,350 But the proof of the pudding is in eating. And it worked well. 172 00:18:57,350 --> 00:19:04,340 Thank you very much for giving us the outline of your trial. So we look forward to reading about that in more detail. 173 00:19:04,340 --> 00:19:09,230 And when it comes out in press, I was just wondering before we finish, Professor Sharp, 174 00:19:09,230 --> 00:19:19,280 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? 175 00:19:19,280 --> 00:19:30,800 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. 176 00:19:30,800 --> 00:19:34,760 And I think there's two main ways that this is working at the minute. 177 00:19:34,760 --> 00:19:43,970 Now, one way is to go into biology research that the neuroscience of psychiatry is linking with neurology 178 00:19:43,970 --> 00:19:50,210 and basic neuroscience and is bringing psychiatry back into medicine and the biological level. 179 00:19:50,210 --> 00:19:55,880 Right. And a lot of people are attracted to that. And it's important work at the clinical level. 180 00:19:55,880 --> 00:20:04,370 There is now very considerable interest with multiple government reports recommending integration as a clinical level. 181 00:20:04,370 --> 00:20:10,760 So integrating psychiatric care with medical care is what psychological medicine is all about. 182 00:20:10,760 --> 00:20:19,400 And I think those two strands are going to be the things that keep psychiatry alive and integrated with the rest of medicine. 183 00:20:19,400 --> 00:20:25,100 And if you're a young medical student or a young doctor who's interested in holistic, 184 00:20:25,100 --> 00:20:29,960 a whole patient medicine, psychological medicine might well be the thing for you. 185 00:20:29,960 --> 00:20:34,250 Thank you. First of all, there's been a actually quite an inspiring interview. 186 00:20:34,250 --> 00:20:39,420 Talk to you about your opinions, your views and and your your your striking results from trials. 187 00:20:39,420 --> 00:20:43,790 So thank you very much for being here today. And thank you, listeners, for tuning in. 188 00:20:43,790 --> 00:20:48,710 Please do listen to my podcast at the Oxford University Psychiatry podcast series. 189 00:20:48,710 --> 00:20:50,160 Thank you. Thank you.