De Londense psychiater Simon Wessely, grondlegger van het (bio)psychosociaal model, blokkeert al jaren biomedisch onderzoek ivm ME/CVS. Hij meent geheel onterecht dat ME/CVS in stand gehouden wordt door irrealistische gedachten van patiënten in verband met hun lichaam, lichamelijke inspanningen en de daaropvolgende inactiviteit. Wessely blijft volharden en blijft zijn onhoudbaar biopsychosochiaal model verdedigen terwijl talrijke biomedische studies duidelijk aantonen dat ME/CVS een invaliderende lichamelijke aandoening is. Wessely plakt een psychisch label op ME/CVS door de aandoening als "medisch onverklaarbaar" te betitelen en CGT (cognitieve gedragstherapie) en GET (graduele oefentherapie) te promoten als therapie. (Cfr. Dit is wat we in België zagen en zien gebeuren in de referentiecentra, vooral in Leuven baseert men zich volledig op de theorie van Wessely). In de U.K. zelf werd Wessely in diskrediet gebracht door het Lagerhuis omwille van frauduleuze praktijken en het totaal gebrek aan wetenschappelijke waarde van zijn werk.
Maar Wessely blijft star volhouden....
Health in mind and body
by dr. S. WESSELY
The physical care of those with major psychiatric disorders is grossly neglected – patients have an average life expectancy at least 10 years less than the rest of the population. But likewise, so is the psychological health of those with physical disorders. It is known that if a person has a heart attack and becomes depressed they are up to three times more likely to die in the next year: that means it is more dangerous to have depression after a heart attack than it is to continue smoking. Looking at hospital attendance, 20 per cent of Accident and Emergency Department admissions are associated with alcohol abuse/dependence; 70 per cent of ‘frequent attenders’ or ‘high users’ of secondary care services have mental health disorders; and around half of all new hospital outpatients have physical symptoms Unaccounted for by physical disease. […]
Physical and mental symptoms
One iconic study from the USA looked at those arriving at outpatient clinics with various symptoms. Sometimes chest pain was explained by heart disease, fatigue by anaemia, or dizziness by inner ear problems, but for the majority there were no simple, clear-cut biomedical explanations for their illness or ill health. Medical education on both sides of the Atlantic teaches our medical students for six years how to manage the first group; sadly those same students spend a good part of their careers then dealing with the second.
A study in King’s College Hospital in London produced very similar results. The majority of those on their first appointment in the acute cardiology clinic did not have an identifiable heart disease. The majority of those seen in gastroenterology did not have Crohn’s disease, and so on. I often tell medical students that if they do not like mental illness they should go into psychiatry. The average consultant psychiatrist will see one or two new patients a week. In a busy chest or cardiology clinic, a consultant will see around 30 new patients a week. Yet between five and 10 of those will have depression, anxiety, etc. So cardiologists see more new patients with psychological disorders than psychiatrists! Physical and psychological symptoms are closely linked. A study of 40,000 people at Camberwell measured the incidence of chronic fatigue and GHQ (a common depression or anxiety). It found a very close relationship. Further, the greater the number of symptoms, the more likely the patient was to develop a mood or anxiety disorder. These symptoms may be just non-specific markers for distress. It is wellknown of course that psychological factors make an important contribution to the outcome of physical disorders. If a doctor wants to know if a patient with rheumatoid arthritis will return to work, he will learn more from inquiring about mood disorder than measuring ESR or adding up the number of swollen joints.
Unexplained symptoms represent a huge burden of costs within the healthcare system.
Yet in order to make the case for more resources, there must be some evidence that it will make a difference. Psychiatrist Khalida Ismail led a major randomised trial at King’s College Hospital in London. The study looked at the impact of psychological treatment to improve the mental health and wellbeing of those with diabetes. Those who received the intervention – it was motivational interviewing – did report better mental health; in fact there was a substantial impact. That is perhaps not surprising. But what caught the attention was that those who received the mental health intervention also achieved better diabetic control.
Another example, Chronic Fatigue Syndrome (CFS), illustrates the gap that lies between physical health/illness on the one hand and mental health/illness on the other. It is a condition or illness with huge morbidity, mainly because it is an illness of economically-active people. CFS is a multi-factorial illness. A person can be at increased risk because of genetics, or because of previous depression, for example. Various infections, including the Epstein Barr virus, definitely precipitate this condition. Yet to understand why some people do not get better as the months and years go by, one has to look at behavioural and psychological factors. The illness is then a complicated mixture of predisposition, precipitation and perpetuation. In terms of treatment we know that antidepressants, diets, vitamins, allergy treatments, etc, do not work. On the other hand, understanding what people think about their illness and how they respond to symptoms, does seem to help. A landmark trial on the management of CFS, known as the PACE Trial, was published recently in The Lancet. It tested four therapies: adaptive pacing therapy (APT), cognitive behavioural therapy (CBT), graded exercise therapy (GET) and standard medical care (SMC). Two treatments, graded exercise and CBT, clearly made a difference, although they certainly were not ‘magic bullets’. For those who appreciate these things, the trial is a thing of beauty, and the results confirm previous smaller studies and follow ups. We now have two treatments that we can recommend with confidence to our patients.
However, the story does not quite end there. Patient groups rejected the trial out of hand, and the internet was abuzz with abuse and allegations. The main reason for this depressing reaction was the stigma that attaches to disorders perceived (rightly or wrongly) to be psychiatric in origin, whatever that means. If one obtained identical results to the PACE trial, but this time with anti-viral drugs, the reaction would have been totally different. This is exactly what did happen when a very small trial of a drug that modulates the immune system (and which has some nasty side effects) was greeted with acclaim from the same sources that tried to discredit the PACE trial, which tested interventions with an impeccable safety record.
Bridging the gap
Policy documents now routinely emphasise the role of mental health in treating physical disorders and the role of physical health in mental wellbeing. So why is there still a gap?
It is partly because of the systems that we have created to deliver healthcare. Separate commissioning of physical and mental health services has proved a disaster in terms of bridging that gap. We now have separate trusts for physical and mental healthcare, with little or no integration or interaction between the two. The general physician is a thing of the past, and it seems as if only the general practitioner still has the ability to bridge mind and body. Our classification systems perpetuate the divide. The separate classifications for
psychiatric and neurological disorders are rendered meaningless by the facts to hand: why for example is schizophrenia or Alzheimer’s listed under psychiatry but not in neurology? The answer is simply historical, and tells us nothing about the causes of either disorder.
However, the gap is being closed. GP-led commissioning promises real improvement.
GPs do not want to send patients on a merry-go-round of specialists; they want the patient with altered bowel habit to be seen on the same day by the gastroenterologist and the psychiatrist, or the 35 year old with chest pain to be seen swiftly by cardiologist and psychologist, and not six months later when it is all too late.
Yet if we move towards a world of patientcentred outcomes, one thing is certain: if we are really interested in how people feel and in their wellbeing, that will require not only
greater investment in mental health services, but also a willingness by the same services to
leave their traditional boundaries and move to where they are needed, alongside their
Bron : The Journal of the Foundation for Science and Technology
Volume 20, Number 7, December 2011 http://www.foundation.org.uk/journal/pdf/fst_20_07.pdf
Reaction from Margaret Williams (ME research UK) on this article : see this link