Terrible 'science' from the Scottish Government

Some recent evaluations of interventions or associations with close ties to the current mental health agenda in Scotland have highlighted the shift away from 'evidence-based policy' to 'policy-based evidence'.

The first was "An Evaluation of wellness planning in self-help and mutual support groups", produced by the Scottish Centre for Social Research, and published in September 2010. Essentially, this was an attempt to determine the benefits from WRAPs (Wellness Recovery Action Plans), which are advocated by the Scottish Government and are tightly integrated with the Recovery model which is driving most aspects of mental health service delivery in the UK and beyond.

The remit for the evaluation was: "...to assess the relevance, impact and effectiveness of Wellness Recovery Action Planning (WRAP) as a tool for self management and wellness planning by individuals with mental health problems from pre-existing and newly-formed groups, where the possibilities for continued mutual support in the development of WRAPs could be explored."

The approach was 'mixed methods', which typically combines qualitative and quantitative methods to address different aspects of the particular research question. Whilst some quantitative information was collected, the bulk of the evaluation relied on qualitative information from interviews and focus groups.

As with most such evaluations of policy, there is a dissociation between the objectives and methods. The purpose of the evaluation included a specific aim to determine the "effectiveness" of WRAPS, but data on whether they make a difference is notably absent. There are lots of anecdotes on how great everything is, but it's when the researchers try to get to grips with some numbers that the problems really start.

Table 2 is shown below. It compares scores on the Recovery Assessment Scale (RAS) and the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) in people before and after their WRAP training:

The authors report that: "...that RAS scores increased in all groups, and WEMWBS scores in all but one group, after the respondents had completed their WRAP training. This suggests that both the facilitators and participants had more positive views in relation to their own sense of recovery and well-being having been trained..."

Also: "...the pre- and post- WRAP training questionnaires were not completed by the same number of people. Any differences between pre- and post- WRAP training scores might, therefore, be due to the fact that people with higher scores completed the post-WRAP training questionnaires."

Indeed. If the authors looked at the table, they might have noticed that when the pre- and post-groups were the same size, the change is not really that great. The numbers in each group are very small, but any changes are likely to be non-significant (i.e. due to chance alone). The only groups that show improvements are those where some people did not return forms. Some groups (e.g. the Tayside Carers Groups 1 and 2) had more respondents in the post-group than existed in the pre-group. This suggests poor handling of data and/ or the possibility that different people were completing forms in the pre- and post groups.

In the groups where data is missing in the post-group, the lower end of the range will often shift up whilst the upper end doesn't move. This suggests that those who had low scores on pre-testing are not included in post-testing. One can suggest this because a change on the WEMWBS score of 10 is improbable given the psychometric properties of the scale, although very little is actually known about its sensitivity to change.

The authors should have known that averaging very small groups is problematic: the average of two people with scores of 2 and 100 on a 100-point scale is 51. However, this score is representative of neither of them. Trying to calculate the mean for such small samples is simply daft, and betrays a degree of statistical ignorance. This doesn't stop the researchers from spinning the poor data: "However, these results do support the very positive views expressed by facilitators and group participants in the main qualitative phase of the study."

The really low quality of the data analysis is indicated by the scores of the facilitators pre- and post-WRAP training. These are shown below (as Table 1):

The authors helpfully point out that scores on the WEMWBS can range from 14-70. It is therefore puzzling how the Pre-WRAP WEMWBS scores range from 76-100 (all above the upper end of the scale), yet still have an average score of 49.4. This is, of course, impossible given the range of scores.

Unfortunately, this is not a new phenomena in Government-commissioned evaluations of its own policy. The quantitative evaluation is handled as if the researchers didn't have a GCSE in maths, and yet all the conclusions are positive. A further example of this will follow.

More papers on the WEMWBS can be found on the links below.

TENNANT, R., FISHWICK, R., PLATT, S., JOSEPH, S. & STEWART-BROWN, S. (2006) Monitoring positive mental health in Scotland: validating the Affectometer 2 scale and developing the Warwick-Edinburgh Mental Well-Being Scale for the UK. Edinburgh, NHS Health Scotland, University of Warwick and University of Edinburgh.

TENNANT, R., HILLER, L., FISHWICK, R., PLATT, S., JOSEPH, S., WEICH, S., PARKINSON, J., SECKER, J. & STEWART-BROWN, S. (2007) The Warwick-Edinburgh Mental Well-being Scale (WEMWBS): development and UK validation. Health and Quality of Life Outcomes, 5, 63.

STEWART-BROWN, S., TENNANT, A., TENNANT, R., PLATT, S., PARKINSON, J. & WEICH, S. (2009) Internal Construct Validity of the Warwick-Edinburgh Mental Well-being Scale (WEMWBS): a Rasch analysis using data from the Scottish Health Education Population Survey. Health and Quality of Life Outcomes, 7, 15.

Psychiatry Ethics Film Festival - Do the films really do justice to their aims?

There's a film festival in Edinburgh running from 26 November to the 28 November. It's called the "Psychiatry Ethics Film Festival".

It raises some questions: "Should individuals with certain mental health problems be placed, against their will, in psychiatric institutions? What are the causes of some of these mental disorders? Do some of the disorders run in families? In other words, is it genetic? Is surgery on the brain of a patient possible? Should it take place again their will?"

All interesting questions, and it will "seek to answer some of these questions while leading post-film debates with an ethics expert.
"

So, what are the films? (links go to the film festival website [FFW], or the Internet Movie Database [IMDB]):

1. The Eighth Day [IMDB]
2. Girl, Interrupted [IMDB]
3. Mental + Sectioned Double Bill [FFW]
4. Stephen Fry: The Secret Life of the Manic Depressive [FFW]
5. The Madness of King George [IMDB]

What's the problem with these films? Do they help us understand the questions raised above?

Well, The Eighth Day is about someone with Down's Syndrome (Georges) and their friendship with a man who is down on his luck (Harry). No problem with that. It's just that we already know that Down's syndrome is genetic. Although Georges is on the run from an institution, it's not really clear that the story is about this. The story is about the development of the friendship between the two characters.
 
Girl, Interrupted is set in an institution...in America...in the 1960s. Of questionable relevance to British psychiatric hospitals in the 21st Century, perhaps. The main character (played by Winona Ryder) gets a diagnosis of  "borderline personality", and the other key protagonist (played by Angelina Jolie) demonstrates a range of rather dissocial personality traits. It's based on a book by Susanna Kaysen and her experiences in a psychiatric hospital in the late 1960s. At the time, she was given diagnoses of "psychoneurotic depressive reaction" and "personality pattern disturbance, mixed type".

It's difficult to know how relevant or informative this film really is. In a review of the book and film in the journal Psychiatric Services, Dr Jeffrey Geller suggests, "historical accuracy about borderline personality disorder is abandoned. At the time Ms. Kaysen was in the hospital, one could not simply take a book of diagnostic criteria off the shelf, as occurs in the film, and read about "borderline personality". The film needs this distortion to make itself whole." It's undoubtedly a Hollywood creation, and perhaps tells us more about the Hollywood portrayal of mental illness than mental illness itself.

The Madness of King George is a strange choice. Admittedly, King George III displays some unusual behaviour. The problem is that there is a possibility that he suffered from one of a range of physical illnesses. One theory is that he had 'variegate porphyria' [Paper Download], a genetic illness which did seem to exist in his family. Another is that he suffered from arsenic poisoning [Paper Download]. Both are rare conditions that are likely to tell us much about the ethical issues affecting psychiatric services today.

Onto Stephen Fry: The Secret Life of the Manic Depressive. Stephen Fry has become the celebrity voice of Bipolar Disorder. The festival website actually calls it 'Manic Depression', an outdated term. However, I'm not entirely convinced that his experience is representative of many people with Bipolar Disorder. His high level of functioning, whilst not a clear exclusion criteria, is rare for many people with bipolar disorder in community mental health teams. Additionally, he appears to be on no medication yet he is told that he has a severe case. To maintain such prolonged media activity and level of functioning with a severe bipolar disorder, yet be on no medication is difficult to reconcile for most psychiatrists who see patients with affective disorders. Again, one wonders how his case can be matched to some of the aims of the film festival.

The only film which would seem to be of real people with real mental illness in contemporary times is Sectioned, which was shown on terrestrial TV some time ago. The other documentary (Mental: A History of the Madhouse) is about the closure of mental asylums in the UK following the Second World War. Yes, it does address mental institutions but it remains to be seen how relevant the experience of people 50 years ago is when trying to address such ethical issues in a completely different Health Service and with an entirely different system of Mental Health legislation.

I suppose that those behind the festival should be credited with not showing One Flew over the Cuckoo's Nest, but this is probably one of the only films which shows psychiatric neurosurgery (albeit lobotomy which hasn't been used for decades). The other film showing psychosurgery was Frances, starring Jessica Lange. This was apparently based on the life of Frances Farmer and was based on the 1978 book 'Shadowland' by William Arnold. All well and good, except that it turns out he made a lot of it up, and Frances Farmer never had psychosurgery.

So, the festival has some laudable aims, but the films all have substantial problems and few actually relate to the questions that the festival is attempting to answer. By raising important questions, but showing what is arguably a poor choice of films, I'm not convinced that the festival is doing much to expand our knowledge...

New Paper on STAR*D - Is all as it seems?

A recent paper commenting on the outcomes from the STAR*D Study (Full paper for download: Pigott, H. E., Leventhal, A. M., Alter, G. S., et al (2010) Efficacy and Effectiveness of Antidepressants: Current Status of Research. Psychotherapy and Psychosomatics, 79(5): 267-279 revisits some of the ground covered by Irving Kirsch but interestingly looks again at the outcomes from STAR*D.

Most people will recall that STAR*D was a large (over 4,000 patients enrolled) and expensive (about $35 million) trial which attempted to determine what the 'real world' outcomes were for four steps of antidepressant therapy (drugs and psychological therapy). It covered a range of different comparisons, and perhaps the 'quickest' overview of what was a complex trial can be found in this paper: Rush, A. J., Trivedi, M. H., Wisniewski, S. R., et al (2006)American Journal of Psychiatry, 163(11): 1905-1917 Acute and Longer-Term Outcomes in Depressed Outpatients Requiring One or Several Treatment Steps: A STAR*D Report. [Link to Journal Website]

A summary of the steps (and to some extent, outcomes) is shown below:

STAR*D used the Quick Inventory of Depressive Symptomatology (16-items) as one of their main outcome measures, and outcomes from each treatment step, using the QIDS-16 were as follows:

• Step 1 = 36.8%
• Step 2 = 30.6%
• Step 3 = 13.7%,
• Step 4 = 13.0% 

The overall [cumulative] remission rate was 67%. This means that overall, two thirds of patients achieved remission. It also means that after four treatment trials, one third had not remitted.

It's important to note that this cumulative remission rate was "hypothetical" in that it assumed no drop-outs. Of course, every trial has drop-outs, and this is what Pigott et al have taken into account. They also make some other criticisms of STAR*D:

1. The use of the QIDS-16 as a primary outcome measure instead of the 30-item scale. The main reason for this was apparently the large number of missing measurements on the latter. However, the QIDS-16 is critiqued by Pigott et al as being used as a 'clinical' measure rather than a 'research' measure throughout the study, and that its use as a study outcome might be unjustified.
2. They also comment on the cut-offs that were used on the Hamilton Rating Scale for Depression (HRSD, or HAM-D). Pigott et al report that 931 patients who should have been excluded because their HRSD score was ≤ 14 (an exclusion criterion for the study, which excludes those with very mild depression - i.e. non-major depression). They argue that this "inflated" the original remission rate for Step 1 from 32.8% to 36.8%.

They go on to present slightly modified remission rates for each step, along with the drop-out rates for each step:

Pigott et al conclude by discussing the fact that remission from major depression is hard to achieve. Perhaps this is not surprising to those who treat depression. Of course, we know that antidepressants aren't as effective for those with milder forms of the illness but antidepressants are probably one of the treatments for depression with the greatest evidence base. STAR*D also included Cognitive Behavioural Therapy (CBT) which is probably the best-evidenced psychological treatment for this population.

Should it really be a surprise that antidepressants don't work for everyone? Hopefully not. However, it is not clear what the authors might be suggesting as an alternative until you get to the 'Conflicts of Interest' section:

H. Edmund Pigott, PhD, and Gregory S. Alter, PhD, are founders of NeuroAdvantage, LLC, a for-profit neurotherapy company. During the past 3 years, Dr. Pigott has consulted for CNS Response, Midwest Center for Stress and Anxiety, and SmartBrain Technologies.

That's right, the authors own their own company, Neuroadvantage, which will sell you (for $995), a device that plays sounds and lights in order to synchronise your brain waves. They claim that it "Helps to Decrease Symptoms of Depression & Anxiety". No wonder that they were keen to weaken the case for drugs and psychological therapies - they have a product which they wish to sell that is targeted at the same market.

As with all such products, "This patented technology is based on over 70 years of research and takes advantage of our mind’s natural tendency to synchronize with pleasant rhythmic stimulation". Not only is the 'technology' old (and therefore established), it links in to natural tendencies.

So keen are the authors/ salesmen to ensure that you consider their product, they provide a link to the paper above (it is free to download) to viewers of the website. This is, arguably, a classic case of 'bait and switch'. There is a very good article on 'bait and switch' available here, but essentially the bait is a treatment that avoids the side effects and apparent ineffectiveness of drugs and therapy, and once lured in, the switch is to unproven therapies with much less evidence.

How much less will be the subject of a subsequent post.

Why are psychiatrists more likely to get into trouble with the NCAS?

The National Clinical Assessment Service (NCAS) was established in 2001 to help the NHS address concerns about the performance of doctors. It was extended to include dentists in 2003. They publish reports on their activity every couple of years or so; the most recent one being published in 2009.

Unfortunately, it seems as though it's difficult to access from outside of the NHS. However, there is a copy here: NCAS Casework: The first eight years. There are some interesting findings.

One is that psychiatrists are over-represented in specialties referred to the NCAS. Between 2001/02 and 2008/09, 541 psychiatrists were assessed out of a total of 4,508 doctors (12%). The majority, 341/ 541 (63%) were consultant psychiatrists.

This might not be that interesting were it not for the fact that more psychiatrists were assessed than might be expected from their overall number of doctors. Psychiatrists make up between 6-7% of the workforce, but contribute 12% of all assessments. This is shown below:

Why might this be? Well, the NCAS has tried to determine the factors that might be contributing to this finding (which is consistent year-on-year). They found that, "The specialties are ranked in order of proportions non-white and qualifying outside the UK (column 2). O&G [Obstetrics and Gynaecology] and psychiatry rank highest (36 per cent and 33 per cent compared with 25 per cent for medical specialties together). They also have the lowest proportions white and UK-qualified (37 per cent and 40 per cent in column 5). Their share of UK-qualified non-white practitioners is below average (column 3) and white non-UK qualified practitioners have an above average share (column 4). Chart 2.1 may therefore be showing, for psychiatrists, the effect of ethnicity and place of qualification alongside specialty."

This appears to suggest that being non-British and qualifying outside of the UK has a bigger effect on psychiatry than other specialties because psychiatry has a higher relative proportion of these groups. They add that, "There is no evidence that non-white UK-qualified practitioners are being referred or excluded disproportionately." I think that it is important to not speculate too much as these are potentially sensitive areas. NCAS are keen to point out that, "NCAS is not trying to produce a determinist explanation of referral patterns".

What about reasons for referral to NCAS? Well, individual specialty data are not available from the report, but the most common reasons for doctors to get into trouble are: "Clinical Difficulties", followed by "Governance/ Safety Issues", followed by "Misconduct". This is shown in the graph below:

Of the clinical difficulties, the most common reasons were: Critical Incident (21%); Diagnosis Skills (20%); Record Keeping (18%); Consultation Skills (18%). Other reasons are broken down by speciality in the table below. Only the figures in bold were found to be statistically significant.

The whole report can be found at the link above.

Deaths by suicide compared to other causes

There's been quite a lot in the media recently about the spate of suicides in Dundee, Scotland; particularly because they occurred in younger people. Many people have been comparing the number of suicides to road deaths (suicides are higher). For example: "Every year in the United Kingdom around 5000 people die by suicide. This is twice the number who die on the roads, and suicide is the commonest cause of death among young people." This was from the British Medical Journal.

However, it's worth looking at this statement in a little more depth to understand what's really going on. At first reading, one might assume that suicide is becoming more common, particularly in young people. This isn't the case, however.

A recent paper looking at trends in suicide rates from 1861-2007 (Thomas, K., & Gunnell, D. (2010). Suicide in England and Wales 1861-2007: a time-trends analysis [In Press - DOI: 10.1093/ije/dyq094]. International Journal of Epidemiology) would indicate that suicide rates in all groups are the lowest they have been for over a hundred years.

Data published by the Department of Health confirms that the suicide rates in all age groups are generally trending downwards, and have been for the last 15 years or so. So why are more people dying by suicide than on the roads?

The simple answer is that over time, the rate of decrease in road deaths is greater than the rate of decrease in suicides. Cars are getting safer, speed cameras might be affecting driving behaviours in high-risk areas, public-health messages on drink-driving might be having an effect, etc. This can be seen in the figure below which uses data from the WHO Health For All (HFA) database; a great (and free) source of population data for European Countries.

The rates are very similar if you correct for changes in population over time (the data are available from National Statistics).


It's a similar situation to deaths from many cancers, which are often reported to be going up. They are going up relative to other causes of death not because they are becoming more common but because fewer people are dying of other causes. A hundred years ago, people were dying of diptheria, typhoid, tuberculosis, and a host of diseases that have been 'tamed' with the advent of vaccinations and modern therapies. If these diseases don't kill you, then you stand a good chance of living long enough to die of cancer.

Hospital SMRs in Scotland

A lot has been made of the publication of Hospital Standardised Mortality Ratios (HSMRs) by the NHS in England and Wales.  These were collated and published by Dr Foster in 2009.

Dr Foster have produced a useful guide to HSMRs here. To quote from the guide:

"The HSMR is a calculation used to monitor death rates in a trust. The HSMR is based on a subset of diagnoses which give rise to 80% of in-hospital deaths. HSMRs are based on the routinely collected administrative data often known as Hospital Episode Statistics (HES), Secondary Uses Service Data (SUS) or Commissioning Datasets (CDS). The HSMR was conceived by Professor Sir Brian Jarman, director of the Dr Foster Unit at Imperial College, London.

Measuring hospital performance is complex. Dr Foster understands that complexity and is clear that HSMRs should not be used in isolation, but rather considered with a basket of other indicators that give a well rounded view of hospital quality and activity."

HSMRs were first used in 2001 and Scotland have just produced their first published set of HSMRs, proudly announcing that "Unexpected deaths fall by six per cent." This is true, to some extent, but let's look at the figures which are available from the Information and Statistics Division (ISD) of NHS Scotland.

The most recent average HSMR is 0.936, which represents a six-percent reduction from the predicted hospital mortality. This figure comes from Apr-Jun 2009, and the comparison is made to the previous period when the rate was 0.992 - this is a reduction of 0.057, or 5.7%.

However, the change from one period to another is not as informative as trends over time. These are shown below:

As you can see, there is a very strange periodicity to the HSMR over time, with peaks during winter, and troughs during summer. Comparing the most recent HSMR with the same period one year ago, the reduction is 1.1% - likely to be insignificant. Quick tip: always choose the greatest differences between time points when you are wanting to look good. I'm pretty sure that the Scottish Government wouldn't have announced in December 2008 that hospital mortality had gone up by 7%!

The reason for this variation is not clear, although there are some possible contributing factors:

1. The increased morbidity in the population during the winter is reflected in increased mortality in those admitted to hospital.
2. The contribution of junior doctor changes is not obvious, but traditionally the changeover times (when new doctors start) were February and August. With changes in training, many doctors are now on 4-month, rather than 6-month rotations, and it isn't clear why doctors starting in February would increase mortality but doctors starting in August wouldn't.

What's also interesting is that this cyclical pattern is not seen in all hospitals, and is marked in others. For example, Arbroath Hospital shows a 100% variation depending on season, suggesting that mortality above the predicted rate doubles at certain times of the year.

Of course, these are new figures for NHS Scotland, and it is possible that there are errors in the data. One would hope that NHS Scotland wouldn't publish the figures unless they were reasonably confident in their reliability.

Finally, if you're interested in the hospitals with the highest HSMRs in the most recent reporting period, look no further. All of the following hospitals have a HSMR higher than the predicted rate. In order to understand that some hospitals may have made significant improvements, the change from baseline (Oct-Dec 2006) is also given. It's important to take the cyclical variations described above into account when interpreting this latter figure.

News of the World on ECT

News of the World (although there's rarely much world news, so it's clearly an ironic title) recently published a feature on the Coronation Street actress Bev Callard's experience of a severe depressive episode during which she received ECT. It was titled: "Frankenstein op saved me from suicide".

It's relatively rare for someone in the public spotlight to talk about their experiences of mental illness; less frequent for them to touch on treatments such as ECT. So, this is to be commended. It's a shame that the paper didn't really take much of an opportunity to provide the information that the average reader might have found helpful. Such as:

1. ECT is not always a "last-resort". Indeed, in this case, it seems as though it was suggested relatively early in a course of treatment.
2. For many people, ECT is offerred for a variety of reasons which include: a) a quick response is needed. This is the case when someone is at high risk of suicide, or they are not eating/ drinking; b) ECT has worked in the past and the person wishes to have it again because they know it works. For some people, ECT can be more effective than drugs, and in most cases will work more quickly. The most common reasons for giving ECT in Scotland are 'Previous Good response' and 'Resistance [to antidepressants]' (Scottish ECT Accreditation Network (SEAN) Annual Report, 2009).
3. Effects on memory are not uncommon, with approximately two-thirds of people experiencing some effect on autobiographical memory for the period in which they're receiving ECT. The vast majority of studies have found that memory returns to normal 2-3 months after a course of ECT, but memories from the period of treatment may always be hazy. However, the majority of people in hospital for severe depression do not report unbroken and clear autobiographical memory anyway.
4. Twelve treatments is the typical maximum number of treatments in a course, although some people might choose to stop after fewer, and other people (those with delayed response and chronic depression) might have more. Like most things, it's a discussion about risk versus benefit. Someone who has had 10 treatments with no benefit and memory problems might choose to stop. Another with partial improvement and few memory problems might choose to continue. In Scotland, the mean number of treatments per course is 7.6 (Scottish ECT Accreditation Network Annual Report, 2009).

The article does reflect some realities about ECT:

1. Most people will experience some sense of improvement after 3-4 treatments.
2. ECT can be very effective. Indeed, it is probably one of the most effective treatments in modern psychiatry. The SEAN Report 2009 indicates that 50% of people experienced a 75-100% improvement in depressive symptoms from baseline to end of treatment. A further 26% experienced a 50-74% improvement. In psychiatry, a 50% improvement in symptoms is usually classified as 'response' (not remission), so in Scotland approximately 75% of people respond to ECT.

Suicides at the FoxConn plant at Longhua in China

There has been much written about the recent suicides at the FoxConn manufacturing plant in Longhua in China. FoxConn is one of the largest electronics companies in the world, making everything from iPods, iPads, iPhones, the Nintendo Wii, Microsoft Xbox 360s, and the Playstation 3.

Conditions on the complex sound far from ideal (see this article from the Shenzen Post).

Apparently, the Longhua site houses 300,000 - 400,000 people and there have been 16 suicide attempts (12 deaths), and 20 people have been stopped before they could attempt suicide. If we round up the timescale to six months, that means there will be 20-30 deaths in one year due to suicide at the plant.

The company have, in the last few weeks, increased wages and attempted to improve conditions on the site. However, what would be the expected number of suicides in such a population?

It's difficult to know what the suicide rate for a similar population in China is, so we will have to extrapolate from UK figures.

1. The age-standardised suicide rate (male and female) is approximately 15 per 100,000 people per year. More details can be found on the ONS website.
2. This means that 15 people will die by suicide for every 100,000 people each year.
3. In a population of 300,000, there will be 15x3=45 suicides.
4. In a six-month period, you would expect there to be 20-25 suicides in 300,000 people.

This means that even though any suicides are troubling and tragic, the number seen at the Longhua plant is slightly less than what one would expect to see by chance alone. Given that the Longhua employees are younger, the expected rate would be even higher than the population rate.

This fact has been explained by Steve Jobs in the last week. If the concern generated improves conditions for workers producing expensive technology then this can only be a good thing, but chance alone would have produced the same rate.

BBC website reports that, "'Green' exercise quickly 'boosts mental health'"

The BBC (and other sites) are reporting a study that apparently claims that "'Green' exercise quickly 'boosts mental health'". The study has been picked up by the US National post, and the UK Daily Mail.

The authors were Jo Barton and Jules Pretty (personal page at University of Essex here) and the study was published in the Environmental Science and Technology journal.

There are some bold claims, such as:

1. "The biggest effect was seen within just five minutes."
2. "A bigger effect was seen with exercise in an area that also contained water - such as a lake or river."

The paper can be found here (Abstract only | subscription required for full paper).

The authors state: "The research used meta-analysis methodology to analyze 10 UK studies involving 1252 participants." It doesn't say that it was a meta-analysis, only that it used the methodology (sic) of meta-analysis. Of course, you can only really meta-analyse studies with a degree of homogeneity and the conclusions one can draw from such reviews depend greatly on the quality of the underlying studies. Poorly-controlled and heterogenous studies with wild estimates of effect sizes don't lend themselves to robust systematic review.

Another alarm bell starts ringing when one reads, "Outcomes were identified through a priori subgroup analyses". Okay, the sub-groups were determined a priori, but subgroup analysis is often used as a way of mining the data for some significant finding. The BMJ has a recent article on the credibility of subgroup analyses.


It's surprising that the study also reported, "Dose responses for both intensity and duration showed large benefits from short engagements in green exercise, and then diminishing but still positive returns." This is counter-intuitive. If exercise is so good, why does it get less effective the more you do of it? I doubt the included studies were looking at elite athletes who may have been overtraining - the authors are reporting that more exercise is less beneficial for most of the reported outcomes (e.g. self-esteem).

It's clear that Jules Pretty is favourably disposed to exercise in green environments (who wouldn't be?), but previous 'reviews' would indicate that reported benefits in different studies are taken at face value, and not critically appraised in the way that they should be. For example, many studies in exercise for depression look at those with mild depressive illness which is, for many people, a self-limiting condition. The fact that someone feels better after a six-week course of exercise may have little to do with the exercise per se, and more to do with the natural course of the illness.

The 2009 Cochrane Review of Exercise for Depression concluded: "Exercise seems to improve depressive symptoms in people with a diagnosis of depression, but when only methodologically robust trials are included, the effect sizes are only moderate and not statistically significant." Essentially, when you exclude poorly-conducted trials, the effects of exercise are not statistically different from those that you would see with chance alone.

The availability of pornography in NHS fertility clinics

An individual by the name of Steve Elibank clearly has a keen interest in this, sending off Freedom of Information requests to NHS organisations requesting information on what material has been purchased, how much it cost, titles, etc. The results can be tracked via What Do They Know?

What do we know so far? (please note the links go to the WDTK site and not the organisation).

1. Tayside NHS Board don't seem to supply anything, so it's bring your own.
2. South London Healthcare NHS Trust do indeed provide purchased material, but have otherwise failed to answer the request in detail.
3. Kings College Hospital NHS Foundation Trust "has not spent any public money on pornographic material." All the material has been provided by "a consultants" (sic) and includes "erotic literature and picture magazines". Titles aren't specified, but the tenacious Mr Elibank has requested further details.
4. Barts and the London NHS Trust have spent £100 in the last 18 months on Playboy and Hustler. I wonder who gets to choose.

Lidocaine brain injections for anxiety...not.

Just under a fortnight ago, the Daily Mail printed an article entitled: "The injection that can cure phobias... unless, of course, you're terrified of needles". In it, the reporter (David Derbyshire, listed as the Environmental Correspondent) suggested that the research, "...could lead to new treatments for phobia." Indeed, the comments section (no longer available on the Daily Mail website) included people who were suggesting that they would sign up for injections to cure their phobias.

The article was reporting a study by Japanese researchers (open access):

Yoshida M, Hirano R. Effects of local anesthesia of the cerebellum on classical fear conditioning in goldfish. Behavioral and Brain Functions. 2010;6(1):20. (Paper here)

The study appeared to be either a replication of a similar study by the same lead author, which involved a number of methods (cooling, ablation) to 'inactivate' the goldfish cerebellum.

Yoshida M, Okamura I, Uematsu K. Involvement of the cerebellum in classical fear conditioning in goldfish. Behavioural Brain Research. 2004;153(1):143-148. (Paper here | Not open access)

In the study, they essentially used an electric shock as the unconditioned stimulus, and light as the conditioned stimulus. In response to the shock, goldfish will naturally exhibit slowing of the heartbeat (bradycardia), and by repeated pairings of the light and the shock, they were able to cause the goldfish to demonstrate bradycardia in response to the light alone. The basic process of classical conditioning is explained at Wikipedia.

Injecting lidocaine into the cerebellum had no effect on the goldfishes response to the first light stimulus nor the electric shock. However, it was found that goldfish with lidocaine in their cerebellums were less able to learn the association between the light and the shock.


So, a superficial glance might suggest that anaesthetising your cerebellum might stop you from getting anxious.

There are some problems with the interpretation of this study demonstrated by the press that picked it up:

1. For many people, a simple phobia might not be so problematic as to warrant injections of local anaesthetic into their cerebellums. Since the cerebellum is essential (in humans) for the coordination and sequencing of complex motor actions, anaesthetising it might result in you being unable to move out of the way of one's feared stimulus. But of course, you will no longer be afraid of it.
2. Classical fear conditioning is not the only learning mechanism involved in the maintenance of phobic responses. In more complex organisims (such as humans), instrumental learning/ operant conditioning also plays a part, and not all phobias have a classical conditioning explanation.
3. There are already effective treatments for most anxiety disorders, and simple phobias. Graded exposure has been around for decades, but due to the emphasis of mental health services on 'severe' mental disorders, many of these simple behavioural treatments have been left out of many people's therapeutic armamentarium.
4. Such a 'treatment' would only prevent the acquisition of a specific association, and there is nothing to suggest that you can wipe out a fear of spiders with an injection that would, of course, be temporary.

I would be surprised if we were seeing lidocaine injections into the brain being available on the NHS at anytime in the near future.