Sunday, 11 February 2018

Tales of Snake Oil, Cures for Depression, Bananas and Bursaries

Snake oil is a preparation that comes from the Chinese water snake. In some parts of the world snake oil is still used as an alternative treatment for arthritis. You can buy it on the internet for £30 - £70 a bottle. In ancient Egypt snake oil was a popular cure for male baldness. However, in this case it had to be mixed with lion, hippopotamus, crocodile and tomcat oils. The reason there is still a market for snake oil is that contains more eicosapentaenoic acid (EPA) than any other source. EPA is an omega-3 fatty acid, something long believed to be effective in treating joint pain, and as a cream, for the treatment of psoriasis and eczema. In more contemporary times, the term ‘snake oil’ has come to refer to any product with questionable or unverifiable quality or benefit.

At first glance, ‘snake oil’ claims can take many forms. Some of these can be quite subtle. Professor David Healy, an expert in psychiatric medications, caused much uproar across the mental health community when he claimed last week that antidepressant use in children and young people might be doing more harm than good. He was speaking at a global health conference in Aberdeen, and drew on his review and analysis of a number of paediatric clinical trials. The prevalence data on mental health problems in children and young people is woefully out of date. What we know is some 10% of children and young people aged between 5 and 16 years have a diagnosable mental health problem. Of these, it is estimated that 0.9% (80,000) will have a depressive illness.

In the general population, antidepressant prescriptions cost the NHS £780,000 a day. I don’t know what proportion of this bill reflects children and young people, but the number of prescriptions for this group has gone up by some 54% since 2005. The National Institute for Health and Care Excellence (NICE) provide guidelines on the effectiveness of medication treatments, and in the case of children and young people, they say antidepressants should, where indicated, be given to them (alongside a range of psychological talking therapies). The only drug recommended for those under the age of 18 is Fluoxetine (better known as Prozac). This has a sound clinical trial evidence base showing that as a treatment for depression, the benefits outweigh the risks. The data would seem to suggest that that this evidence base is not being strictly adhered to. Only 45% of prescriptions for children and young people are for Fluoxetine.

However, in response to Prof Healy, Dr Elaine Lockhart, Chair of the child and adolescent faculty at the Royal College of Psychiatrists in Scotland, noted that antidepressants can be prescribed for a range of problems other than depression. For example, anxiety, OCD, for migraines and other pain related conditions. She noted that current prescribing data does not indicate what the prescriptions are for, so understanding any rise in overall antidepressant prescriptions is made more difficult. Like most approaches to meeting the needs of those living with mental health problems, medication clearly has a place to play, and does so alongside other care interventions. What is agreed however, is that we need to do more in responding to children and young people’s mental health and wellbeing issues.

One of the responses children and young people shouldn’t be exposed to is the so called ‘conversion therapy’. For all kinds of reasons, conversion therapy is absolutely an example of the ‘snake oil’ approach. Conversion therapy is the term for therapy that assumes certain sexual orientations or gender identities are inferior to others, and sets out to change or supress them on that basis. It is an approach that lacks clinical evidence of any kind, and to my mind, is a harmful and totally unethical therapy. So last week I was pleased to see a revised and reinforced memorandum of understanding (MoU) against conversion therapy signed by many of the good folk in NHS England and 12 other professional organisations. The MoU will ensure that those practicing this so called ‘therapy’ will be prosecuted. However, safe-guarding our children who might be experiencing struggles with their sexual identity could become much more difficult, but that is something to explore in another blog.

There is no difficulty with my penultimate ‘snake oil’ story of last week. Apparently the world is facing the extinction of bananas. Bananas are the worlds most exported fruit and the source of nutrients for millions of people. Each year more than £9 billion worth of bananas, primarily of the Cavendish variety, are exported globally. Cavendish bananas are mainly grown to the exclusion of all other bananas. And they have become sick with the so called Panama disease. So far there is no cure. Very soon bananas may no longer be available at your local Tesco (there are other supermarkets). I mention this as there is still a persistent urban myth that eating bananas is a cure for depression.  Bananas contain serotonin. People with depression have been observed to have low levels of serotonin in their brains. Whilst serotonin does help with elevating ones mood (as a neurotransmitter) it can’t reach the brain simply by eating bananas. Our bodies synthesises serotonin through a process that involves the use of Vitamin B6 (which Bananas are also rich in) – however this does not allow for the blood-brain barrier to be crossed.

My ultimate ‘snail oil’ story is the astounding news that last week Jeremy Hunt (Secretary of State for Health) announced the news that from August 2018, postgraduate nurses, midwives and allied health professional students will no longer be exempt from receiving a bursary for tuition fees and maintenance worth some £8000 a year. When similar bursaries were removed from undergraduate nurses, there was a 23% slump in applications to undertake nurse training. With 40,000 nursing vacancies, removing this support would appear to make a mockery of the pledge to fund an extra 5000 student nurse places a year. It simply does not make economic sense. 

I am sure Professor Alan Maynard, professor of health economics would have spoken out against this ‘snake oil’ salesmanship. He sadly died last weekend. He was the ‘founding Father’ of health economics, and someone who commanded great respect for his work and his wisdom. I only met him once, but his impact on my thinking has been long lived.  I am sure if I had asked him about the cost effectiveness of ‘snake oil’ as a cure for arthritis he would have contemplated for a moment and then told me about the benefits of simply taking taking cod liver oil tablets and aspirin. Not only would this probably achieve similar results as ‘snake oil’, but do so at a fraction of the cost.