MORE THAN OUR SHARE OF HAPPINESS
‘The life of man’, famously wrote Thomas Hobbes in 1651 in The Leviathan, ‘is solitary, poor, nasty, brutish and short’. Although this assertion was disputed at length by many subsequently, there seems little doubt that it was a correct description of the life of those committed to most asylums until well into the 20th century. This legacy continues to give psychiatry a depressing image and the time has now come for some to contemplate what may be described as a happiness makeover. Richard Layard, a health economist and Government spokesman in the House of Lords, the curious second chamber of the UK Houses of Parliament where unelected politicians currently hold much more interesting debates than the elected ones next door, has entered the battle as the Happiness Czar. He wants all of us to have a more positive view towards happiness, and regards it as a state not only worthy of attainment but capable of being achieved with the development of extra psychological treatment resources for the population (Reference LayardLayard, 2006).
So perhaps we should join in the happiness makeover and interpret our publications somewhat differently. If we made a start with this issue we could start with the Gilbody blow ‘people get happier with enhanced care for depression, but it costs’ (), followed by ‘no dose–response relationship for happiness with SSRIs’ (Ruhé et al, ), ‘mums’ unhappy eating rubs off on the kids’ (Stein et al, ), ‘if you're happy with your treatment, you'll stay calm’ (Elbogen et al, ), ‘get positive and improve your quality of life after a heart attack’ (Dickens et al, ), and, a looser interpretation than the authors might have chosen, ‘British only happy when manic’ (Mackin et al, ). So perhaps the move to ‘mental health’ from ‘mental illness’ and ‘recovery’ from ‘rehabilitation’ is not just political correctness; it may reverse Beckian cognitive distortion (see our July issue) and give us a genuine uplift that is more than spin.
RESEARCH IN THE DAILY LIVES OF CLINICIANS
All clinicians, irrespective of specialty, are now much better informed than they were a generation ago. They are less idiosyncratic in their practice, they keep abreast of changes by continuing their medical education long after they have finished training, and they embrace online learning and peer review appraisal so that blind spots are exposed and corrected. But are they as involved in research as they used to be? I think not. When Bernard Shaw stated in The Doctor's Dilemma that all professions (not just the medical one) ‘were conspiracies against the laity’ he struck a chord in highlighting the preposterous secrecy that pervaded organisations who believed their status would be undermined by disclosure. My worry in psychiatry is that many practitioners have paraphrased Shaw and regard ‘all research workers as conspirators against the patient’. Research is acceptable to clinicians if it is covert or naturalistic (i.e. does not interfere with individual treatment prejudices) or involves data already collected such as diagnosis (Reference KessingKessing, 2004) or prescriptions (e.g. Reference Helgason, Tomasson and ZoëgaHelgason et al, 2004), but when it comes to interventions that could provide evidence to change practice everyone becomes decidedly coy. Good randomised controlled trials that can provide definitive evidence of efficacy of any intervention are unlikely to do so if they have fewer than 100 in each treatment arm (Reference JohnsonJohnson, 1998). In reviewing all those trials we published in 2005 only four, all drug trials (Reference Bradwejn, Ahokas and SteinBradwejn et al, 2005, n=361 (7.2); Reference Kasper, Stein and LoftKasper et al, 2005, n=358 (8.7); Reference Khanna, Vieta and LyonsKhanna et al, 2005, n=291 (36.4); Reference Vieta, Bourin and SanchezVieta et al, 2005, n=347 (4.6)), satisfied tisfied this requirement. The figures in brackets are the mean number of patients recruited at each centre; these suggest that a tiny fraction of those eligible are taking part. The one exception is the Khanna et al (Reference Khanna, Vieta and Lyons2005) study that has provoked ethical controversy (Srinavasan et al, 2006); this was the only study not involving recruitment in many countries.
So it seems that if we want to do substantial randomised trials, we have to go international, expect poor returns and recruit from many centres. I do not agree. Psychiatrists have to be more receptive to large studies such as the BALANCE trial, not industry supported, that compares different mood stabilisers in the prophylaxis of bipolar affective disorder (Reference Geddes and GoodwinGeddes & Goodwin, 2001). Can clinicians do better? Our service users involved in advising us certainly think so, and their views were reinforced when they heard that of the seven patients recruited to this widely advertised trial in the north-west London area all were recruited by a certain Peter Tyrer in the course of ordinary practice. When the non-participating clinicians ask ‘what's in it for me?’, we can only reply: ‘Better clinical practice. Do you want it or not?’
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