smoking & mental illness

your voice spring 2006 1

Your Voicespring 2006The magazine for members of

Double VictoryGovernment backs down overthe proposed mental health actand acknowledges Rethink’sconcerns on cannabis

pages 8-9

The future care ofmental illness

page 11

2 spring 2006 your voice

cont

ents personally speaking

campaigns

carers

health

benefits

feature

staff diary

news

feature

feature

fundraising

group profile

men’s week

news

obituary

book review

letters

fact file

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Personally speaking...

Rethink is the operating name of the NationalSchizophrenia Fellowship. Registered Charitynumber 271028. Working together to helpeveryone affected by severe mental illness,including schizophrenia, to recover a betterquality of life.

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Changing public attitudes

” Cliff PriorChief Executive, Rethink

There can be few Rethink members who have not seenthe controversy over our pilot campaign to tackle stigma

in Norwich. Along with a large number of events in the cityled by people with severe mental illness and their carers, weran advertising campaigns and local media coverage to raiseawareness and understanding.

One small part of the campaign gained national attention:the unveiling of a statue of Winston Churchill in astraitjacket, to symbolise how people with mental illnessesare nowadays held back by shackles of stigma anddiscrimination, unable to find work or to contribute to society.

The event proved deeply controversial particularly for peoplewho saw the national coverage, but who may not have beenable to see the statue in the context of the local campaign.

Churchill, of course, wrote publicly about his bouts ofprofound depression, which he famously called his ‘blackdog’. To me, he was an even greater hero than most peoplerealise because he achieved all he did whilst coping withsevere depression. But if he was in politics now, howconfident could we be that he would even survive the glareof media attention as an MP, let alone as Prime Minister?Would the stigma and prejudice in society now have stood inhis way, and where would we have been as a country then?

We have apologised to those offended by the statue, andprovided background material about the campaign atwww.rethink.org

In one survey after another, Rethink members and thepeople who use our services put stigma and discriminationamongst the top problems they face and the top prioritiesfor us as a charity to address. We know that stigma isdeeply ingrained. It adds fiercely to the struggle people facein finding jobs, homes, friends, almost every aspect of life.We will not shift the problem without taking strongmeasures, alongside the slower pace of the face to facework which so many members contribute to.

We will be reviewing all parts of the Norwich experience,including the Churchill statue, learning the lessons andtaking stock of the public response. So far the reactionlocally has come out very positive, which may not have beenapparent from the national media coverage. We will study andlearn from every comment received, critical or congratulatory.

Ending stigma will take time and carefulthought. But just as with every othercampaign for civil and human rights, it willalso take courage.


campaigns double victory

Rethink win the Government over cannabis

Rethink has achieved a great victory in its cannabiscampaign, achieving everything that we set out to do.

It has been a hugely successful campaign that hasdelivered 100 per cent of what we asked for only twoyears ago:

• A recognition that cannabis poses a serious risk tomental health

• A Government pledge to invest in new research intothe role of cannabis in causing mental illness

• A Government pledge to launch a massive publiceducation campaign

• A Government recognition that tougher laws that couldcriminalise people with mental health problems is notthe answer

It is unusual to get everything you ask for in anycampaign, particularly one that has such a controversialedge to it – but together we have achieved completesuccess. A huge, big thank you to everyone who hastaken part and supported Rethink’s campaign to get theserious mental health risks posed by cannabisrecognised by Government.

So, how did this all happen?Where did the campaign come from?For many years, Rethink’s members have voiced theirbeliefs about the role which cannabis may play in theonset of mental illness. Rethink has taken theseconcerns seriously and has met with Department ofHealth and Home Office officials and Ministers to voicethese concerns. However, Rethink’s greatest opportunityto change the prevailing views about cannabis came withthe decision to reclassify cannabis.

Reclassification – January 2004In 2001, the Advisory Council on the Misuse of Drugs (aGovernment body) recommended that cannabis bereclassified from a Class B to a Class C drug. The HomeSecretary at the time, David Blunkett, took the council’sadvice and in January 2004, cannabis was reclassifiedfrom to Class C, with an information campaignexplaining this change.

Rethink did extensive media work at the time ofclassification, pointing out research on the link betweencannabis and mental illness and the Government’s failureto warn people about mental health links in theinformation campaign.

The Home Office and Department of Health thenannounced a new joint project to provide informationmaterials to people with mental illness on the issue ofcannabis. Rethink was the only mental health charityasked to advise throughout the project. The Governmentobviously saw Rethink as a key expert on the issue.

We worked with key academic researchers andpsychiatrists in the field, such as Robin Murray and ZerrinAtakan from the Institute of Psychiatry. In December2004, we sponsored a two-day conference at theInstitute entitled ‘Cannabis and mental illness’, the first ofits kind in the world. This work ensured that Rethink waswidely considered one of the ‘experts’ on cannabis.

But our message reached the public too, throughextensive media coverage of the issue – we hadinterviews on radio stations such as BBC Radio 4 andnational newspapers such as The Observer.

Anniversary of reclassification – January 2005As the anniversary of reclassification was approaching,Rethink contacted the Health Select Committee tosuggest an inquiry into the evidence about the risks ofcannabis use. Doug Naysmith MP, a member of thecommittee, confirmed his support for such an inquiry.Our press release got even more coverage than the yearbefore – it was the lead story on BBC breakfast and newsprogrammes, ITV news, Channel 4 news, BBC Radio 4‘Today’ programme and appeared in The Daily Telegraph,The Observer, The Sunday Express, The Sunday Timesand The Independent on Sunday.

As a result, the Department of Health announced areview of the evidence on cannabis – exactly what we hadsaid was needed for over two years. In March 2005, thenew Home Secretary, Charles Clarke, said that he wouldask the Advisory Council on the Misuse of Drugs to lookagain at cannabis, the evidence on mental illness and theissue of classification.

The Advisory Council and the Home Secretary’sdecision – January 2006Rethink contacted the Advisory Council repeatedly,asking to give evidence. We then asked our members towrite and explain their experiences – 27 service users andcarers kindly wrote to us with their views. In September2005, we submitted a comprehensive documentdetailing the academic evidence on cannabis and mentalillness and – crucially – the views and experiencesmembers sent to us and contributed to our website

JANE HARRIS outlines Rethink’stremendous victory in getting theGovernment to listen to its fearsabout cannabis



discussion on cannabis. Later in the month, twomembers of Rethink staff and a service user gave oralevidence to the committee – we were one of only threecharities and the only mental health charity invited to thecommittee to give evidence. This in itself was a majorvictory for Rethink.

On the basis of the views of service users and carerscontacting us and the statistics on usage of cannabis,we argued that cannabis should remain at class C, asusage had not gone up since the classification hadchanged (in fact, it seemed to have gone down slightly).But we said that the Government needed to invest in amajor health education campaign to tell people about itshealth effects. This approach has worked for smoking,so it could work for cannabis too. We also said that moreresearch needed to be funded into the effects ofcannabis and into the experiences of service users andcarers, whose voice is not often heard in this debate.

One member of the council told us later that ourpresentation had been the best of the whole day.Immense thanks must go to the service user whoparticipated – his telling of his story really moved thepanel.

At the beginning of the year, our band of e-campaignerssent emails to the Home Secretary, urging him to investin health education and research rather than a change inthe law.

We also contacted MPs who put down an Early DayMotion (a sort of petition signed by MPs) expressingsupport for Rethink’s campaign.

The Advisory Council’s report was released in January2006. It recommended more research, better healtheducation and for cannabis to stay at class C. The HomeSecretary, Charles Clarke, then announced that theGovernment would stand by the recommendations ofAdvisory Council. After his announcement in the Houseof Commons, Rethink and our recommendations werespecifically mentioned, another great achievement.

In the week before the Home Secretary’s announcement,Rethink received more media coverage – all major TV andradio stations and newspapers covered this issue andmost mentioned Rethink. For example, chief executiveCliff Prior appeared on Newsnight, ITN News and BBC 1One o’clock news; and other staff and membersappeared on Channel 5 news, Radio 4 ‘You and Yours’;Radio 4 ‘PM’, Sky News and Radio Five Live.

Rethink also had coverage in The Guardian, The DailyTelegraph, The Times and the Daily Mirror. So, not only

have we achieved the aims of the campaign, but we havealso increased the public’s and politicians’ awarenessof Rethink.

Of course, we must now make sure that the Governmentcomes up with the necessary funding to achieve itspromises – and we still need help from all of you to makesure that:

• The education campaign is saying the right things tothe right people

• The new research is seeking answers to the rightquestions

• New approaches are developed to help people reduceand stop their cannabis use.

We want Rethink to be involved not only in theraising of this issue, but also in the solutions to it– watch this space!

Many thanks to all those who have helped us with thisamazing campaign victory.

Want more information about our campaign?Contact Jane Harris, Senior Campaigns Officertel: 020 7330 9131 or email [email protected]

Want to get involved in all our campaigns?Even if you don’t have much time, you can help ourcampaigns be more successful. Become an e-campaigner and send emails to decision-makers withRethink messages.

Send an email entitled ‘become e-campaigner’ [email protected].

Are you a service user orcarer with views andexperiences on cannabis?Send them to us so we can publicise them –on our website or in our publications. We willkeep them anonymous if you want us to.

Post them to:Campaigns Department, Rethink, 5th Floor,Royal London House, 22-25 Finsbury Square,London EC2A 1DSor email [email protected]



What’s happened to the Bill?

Plans for a new Mental Health Bill have been droppedafter years of campaigning by Rethink and the Mental

Health Alliance. This is a great victory. The Governmenthad been committed to introducing a new Bill for overseven years. We would like to thank everyone who hascontributed to this success.

But more needs to be done. The Government has nowannounced that it will make a number of amendments tothe current 1983 Mental Health Act instead. It seems thatthe Government wants to rush its new plans rather thantake time to consider how to get the best mental healthlegislation we can. Rethink believes that the new plansmust be subject to a formal consultation like the last Billand to a full pre-legislative scrutiny committee, as werethe old proposals.

The amendments being proposed are:

• Creating ‘supervised community treatment orders’ –people could only be put on these after they had beentreated under section in hospital for at least 28 days.This is a much more restricted kind of communitytreatment than the Government was previouslyproposing. Rethink is still concerned that there shouldbe time limits on these orders, they should berestricted to a very small group of people and shouldonly include conditions on residence and treatment,not on general ‘conduct’. People with mental illnessshould not have their fundamental civil and humanrights restricted permanently when they havecommitted no crime.

• The definition of mental illness will be made muchwider as previously proposed. But there will beexclusions so that people who have a substance useproblem, but do not have a mental illness, cannot betreated under the Act. We think there should beexclusions for political and cultural beliefs as well sothat mental health legislation cannot be used forsocial control.

• Inserting a new condition that ‘appropriate treatment isavailable’ and deleting the current provision thatpeople must have a treatable condition. Rethinkbelieves that the idea of ‘appropriateness’ is too vague.People should not be given treatment unless it givesthem some kind of therapeutic benefit. Detentionwithout therapeutic benefit is not the business of thehealth service.

Sadly, two parts of the old proposals which were positivehave now been dropped. The idea of everyone going to a

Tribunal after 28 days has been rejected. People will notautomatically go to a Tribunal until after six months – thisperiod will be reduced as capacity increases. Rethink toldthe Government continually that there were not sufficientstaff available for a 28 day Tribunal and that greatinvestment would be necessary to achieve this. Thereneed to be clear targets to reduce the six month waitingtime – we can’t assume that this will happen unlesspeople are held to account.

The plan for a legal right to advocacy has also beendropped. The Government says that advocacy will beincreased by other means, that this can be achievedwithout a legal right. Rethink agrees that access toadvocacy can be achieved through other means, but ithas not yet happened and it is not clear how theGovernment is proposing to achieve this. We need aclear programme of work and ringfenced funding foradvocacy if we are ever to move beyond the unacceptablypatchy provision of services we currently have.

Finally, Rethink is very concerned that one of the mainproblems with the 1983 Act is not being addressed bythe Government. Currently, people from black andminority ethnic communities are disproportionately heldunder the Act. A principle of respect for diversity needs tobe added to try and address this horrendous situation.The Government has, however, said that they will conducta Race Equality Impact Assessment on the new proposals– we need to make sure that this is not a rush job.

Please help us get the best possible legislation we can.

Write to your MP!Tell him or her that you want the new proposals to besubject to pre-legislative scrutiny and a formalconsultation. Say that you want a right to advocacy,principles to increase race equality and a therapeuticbenefit condition. Tell your MP about your experiences ofmental health services – you almost certainly know morethan they do!

If you don’t know your MP’s name, find your postcodeand ‘phone 020 7219 4272 or use the websitewww.locata.co.uk/commons/. The address for all MPs is:House of Commons, London SW1P 0AA.

Sign up for the lobby!As soon as a Bill is published, the Mental Health Alliancewill be organising a lobby of Parliament. To make surethat you’re told about it, register with the Alliance co-ordinator, Anna Bird.


carers

Ask friends and family to sign the Alliance petition!The Alliance is also organising a petition. We are reallytrying to show that it’s not just service users, carers andmental health professionals who are opposed to this Bill,but other people too. So please ask your friends andrelatives to sign it.

To do so, send an email with your name, occupation andtown/county of residence to Anna Bird, co-ordinator ofthe Mental Health Alliance ([email protected]). Orsend to Anna Bird, Mental Health Alliance, c/o SCMH,134-138 Borough High Street, London SE1 1LB.

The MHA will hand the petition to the Government in2006 as part of the ongoing campaign on the Bill.

How to convince your friends and family? Tell themthat the Bill is opposed by a number of organisations,including the Royal College of Nursing, the LawSociety and the National Union of Students, as wellas mental health charities and professionalorganisations. It has been called ‘unethical andunworkable’ by a Parliamentary committee. Askpeople to sign up now!

Carers Week

Carers Week 2006 runs from 12th to18th June. It isthe second year that Rethink has been a part of

the consortium that runs Carers Week. This year’stheme for Carers Week is carers’ health, bothphysical and mental health. Carers Week areproducing a leaflet specifically about mental healthand caring.

Why is Rethink involved? Because mental healthcarers need to be in the mainstream of the carersmovement, to make sure that people get the supportand services they need and deserve.

Carers Week is now a huge event, generatinghundreds of pieces of coverage in local media. It isimportant that mental health carers are representedwithin this coverage – it will help to destroy theprejudice, ignorance and fear that surround mentalillness.

We want to help make mental health carers a majorpart of Carers Week in 2006. Please think about whatyou can do to help; perhaps you could:

• Organise an event – see our guide for different options

• Remember to register your event with Carers Week,by going to www.carersweek.org or contactRethink Campaigns for a registration form

• Get some publicity for mental health carers in yourarea, using our press release

• Run a letter-writing campaign locally about healthchecks for carers by the local Primary Care Trust

and information sharing policies from the localMental Health Trust.

Following on from feedback last year from groupsand services, we have produced some mental healthspecific materials to help. We have created:

• A briefing giving facts and figures about carers ofpeople with mental illness, together with letter-writing campaign ideas

• A press release on mental health caring and CarersWeek

• A guide to using the press release

• A list of possible events that you could run, rangingfrom the large scale to less resource intensive

• A guide to running events.

Groups which register with Carers Week will alsoreceive a pack of materials, including a press release.Please use whichever materials you feel are mostappropriate for your event.

To receive a pack of materials to use duringCarers Week please send an email [email protected], phone 0845 456 0455 orwrite to Rethink Campaigns, 5th Floor, RoyalLondon House, 22-25 Finsbury Square, LondonEC2A 1DX.

Let’s make Carers Week 2006 even bigger than itwas for Rethink in 2005! Please do your bit!


royal visit

Princess Anne’s visit to The Archway Centre

A Rethink service celebrated its refurbishment in style –by welcoming HRH The Princess Royal to officially

reopen the centre. Archway community mental healthproject in Walsall was completely rebuilt with funding

from Walsall PCT and Walsall social services and wasofficially reopened on February 22nd after Service ManagerGeoff Warnsby wrote to Buckingham Palace last October.

Speaking about the event, Geoff commented, “I wassurprised, but delighted, when Princess Anne very kindlyaccepted my invitation to reopen Archway. On the day Iinvited Archway members, staff, and representatives ofother external agencies to attend the royal visit. ThePrincess Royal spent an hour talking mainly to serviceusers, and she seemed genuinely interested in what theyhad to say. Everyone has since said that they werepleased that she had been to the centre and was such anice person that she had put everyone at ease.”

Princess Anne also was welcomed by Rethink’s Directorof Public Affairs Paul Farmer, Chair of Trustees BobBanner and the Mayor and Mayoress of Walsall. She wasthen presented with a posy by Archway member Sonja.The Princess spent over an hour in the centre beingshown the impressive modern facilities which include anopen plan living room, quiet room, kitchen and diningroom talking with staff and service users.

Paul Farmer then addressed the audience and thankedthe Princess Royal for her attendance and support;stating that a royal visit was particularly important inhelping to break down the stigma and discrimination

often associated with mental illness. Mr Farmer alsocommented that supporting people with mental illnessand their families is crucial at all stages and that projectslike Archway are instrumental in giving people the chance

to recover the quality of life they want andallowing people to access help in places whichtreat them with dignity and respect.

Whilst officially unveiling a plaque to mark thereopening of Archway, the Princess spokeabout her admiration for the centre’s work andrecognition that modern community mentalhealth day centre’s were crucial to helpingthose with mental health problems on the roadto recovery. She thanked Archway staff for theinvitation and commented on her enjoyment atbeing able to talk to members of the centre.

Before departing, the Princess was invited tosign the centre’s visitors book to record theday’s events. Commenting on the new centreone Archway member said: “I would like tothank Rethink for the new building that they’veprovided for us. They’ve seen our need andprovided even better than that for us. The

design team have provided a lovely open plan main roomfor us. Thank you once again Rethink.”

Archway is open seven days a week for anyoneexperiencing or caring for someone with mental healthproblems. Centre staff work in partnership withindividuals to achieve a personal recovery plan and aim tobuild confidence and self-worth in its members.Archway’s ethos is firmly fixed on providing support andadvice with an emphasis on social inclusion andmeaningfulmembershipinvolvement.Archway hassupported over 200people with severemental illness in thelast two years.

Archway also offerspractical support onissues such ashousing benefits andemployment and can assist in referrals to other mentalhealth services. Services offered include education,therapeutic groups, vocational guidance andcomplementary treatments such as pet therapy.

• Paul Farmer with Princess Anne, Geoff Warnsby and Bob Banner


health

Smoking and mental illness: why?

Since the 1950s it has been widely accepted thatcigarette smoking causes lung cancer. Smoking is

responsible for a huge percentage of preventable deathsworldwide. In the UK, smoking kills over 120,000 peoplea year – 13 people an hour. The manner of deathincludes lung cancer, emphysema, stroke, heart disease,chronic obstructive airways disease – none of which arepleasant ways to die, or to suffer whilst living out anunfinished life. And it doesn’t come cheap: a packet ofcigarettes costs over £5. Yet a vast number of peoplecontinue to ‘take up’ cigarette smoking and continue tosmoke, and individuals who are already establishedsmokers fail time and time again to ‘kick the habit’.WHY? What is there about this drug, nicotine – the activeingredient in cigarettes – that causes otherwise sensible,responsible people to take such foolhardy risks with theirlives and health?

There is now an inverse relationship between smokingand higher levels of education and social class, thoughthis relationship did not exist 60 years ago – in the 1940sand 50s, nearly 80% of men in the UK were smokers,and there was no class distinction. As the associationbetween lung cancer and smoking has become moreobvious and evidence-based, people from higher socialand educational strata have either stopped smoking, ornever started; this trend however has not translateddownwards to the socially and educationally deprived,many of whose number suffer from mental illnesses.

Which brings us to another mystery that surrounds thesmoking enigma – why is it that so many people withmental health problems smoke? Smoking is positivelyassociated with many mental illnesses, includingdepression, bipolar disorder, anxiety disorders andschizophrenia. Cigarette smoking is often described byanxious or depressed smokers as being beneficial in thatit appears to restore concentration and a feeling ofrelaxation. However, it is likely that this is partially a relieffrom nicotine withdrawal in chronic smokers, and notwholly a benefit of nicotine per se.

An overwhelmingly larger proportion of people with amental illness are cigarette smokers; up to 90% of peoplewith schizophrenia and up to 70% of people with otherpsychiatric diagnoses vs 26% of the general population.People with schizophrenia tend to smoke strongercigarettes, and to extract more nicotine from eachcigarette smoked, possibly because they inhale in adifferent manner. Furthermore, there is evidence that themajority of people who do go on to develop a mentalillness are already cigarette smokers, begging thequestion of whether nicotine addiction is a result or even

a cause of mental illness, or, the most likely explanation,that there is a genetic connection between the two.Family members of people with mental illness, whetherthemselves affected or not, are far more likely to smokethan members of unaffected families, which bolsters thetheory of a genetic link between smoking and schizophrenia.

Activation of dopamine receptorsThe answer may be in the brain. Nicotine increasesdopamine transmission via its action on acetylcholinereceptors in the brain. The cholinergic (nicotinic)receptors are usually stimulated by the neurotransmitteracetylcholine. This may produce an excitatory andpleasurable sensation, releasing other neurotransmitterssuch as serotonin, noradrenaline, acetylcholine, moredopamine and beta-endorphins, often described as thebody’s ‘natural opiates’. As the natural progression of acigarette smoking habit is to increase nicotineconsumption, the body is ‘tricked’ into thinking thatmore acetylcholine receptors are needed to cope with theextra doses of ‘acetylcholine’ (nicotine). After a while, thebody adapts by producing more acetylcholine receptors,which in turn tricks the brain and body into thinking itneeds more nicotine, and so on. This actual change inbrain chemistry consequent to repeated nicotine dosingmay be one of the reasons why some people findsmoking cessation so difficult and experience unpleasant‘anticholinergic’ withdrawal symptoms such asrestlessness, difficulty concentrating, constipation andincreased appetite.

The area of the brain called the nucleus accumbens, orthe ‘reward’ or ‘reinforcement’ centre is where the primarydopamine activation occurs when nicotine and otherdrugs of addiction such as opiates (heroin, morphine),stimulants (cocaine, amphetamines) and alcohol (but notcaffeine) are administered. Similar responses areproduced in the brain by all these drugs, and addictionprogresses along a ‘dose-response’ curve – over time,the body needs more of the drug to produce the samepleasurable effects as it did originally; known commonly asbuilding up ‘tolerance’ to the drug; likewise, craving for thedrug becomes stronger over time when it is withheld.

Neutralising antipsychotic medicationConversely, most of the drugs used to treatschizophrenia operate on the opposite principle; that is,they block dopamine receptor activity. Is the reason somany schizophrenic patients smoke that they are trying to‘neutralise’ the effects of their medication? Cigarettesmoking affects the rate at which the body ‘clears’ itselfof some antipsychotic drugs; especially olanzapine and

Smoking is now banned in open spaces in Scotlandand will be banned in the UK next year. In this articleRUTH OHLSEN, Clinical research Nurse from theNational Psychosis Unit, asks the question why dopeople risk their life with nicotine


health

clozapine, and cigarette smokers usually require higherdoses of these medications to achieve the same efficacyas non-smokers. However, clozapine, which is the mosteffective antipsychotic available, may act in a similarmanner to nicotine, activating dopamine receptors inareas of the brain that affect our ability to feel pleasure, thusinducing a feeling of well-being. Patients who have switchedfrom another antipsychotic to clozapine have found it easierto reduce smoking or give it up altogether, maybe becausethey are receiving their ‘reward’ from the clozapine.

The rate of smoking in people with schizophrenia seemsto be associated with the severity and nature of thesymptoms. Although one study showed that smokingseemed to reduce negative symptoms, such as socialwithdrawal and apathy, other studies found that peopleexperiencing positive symptoms of schizophrenia, suchas hallucinations (voices), smoke more heavily than thosewith more negative symptoms.

Sensory gatingA high percentage of people with schizophrenia havesubtle differences in their brains, one of which is knownas the ‘auditory gating deficit’. This phenomenon meansthat people with schizophrenia react more strongly torepeated sounds. On hearing an initial sound – such as aburglar alarm – people with and without schizophreniawill react in a similar manner. However, when the soundis repeated, rather than becoming accustomed to thesound, and reacting less strongly, people withschizophrenia react in the same way as they did uponhearing the original sound or stimulus, and are unable to‘block it out’ selectively, the result being that they feelconstantly ‘bombarded’ by noise. This deficit in the brainis almost certainly genetic, and people with the auditorygating deficit have abnormalities in the Alpha-7 nicotinicreceptor gene. However, smoking a cigarette restores thegating ability for about 15-20 minutes afterwards. Thus, itmight be that smoking is a form of self-medication forpeople with schizophrenia, and smoking cigarettes mayalleviate some of the distress and the distractinginfluence of auditory hallucinations. Increased ability toconcentrate and improvements in memory have also beencited by many smokers as reasons for continuing to smoke.

The cognitive deficits which are a feature ofschizophrenia and, to a lesser extent, bipolar disorderand depression may be partially alleviated (or at leastperceived to be alleviated) by smoking, perhapsaccounting to some extent for the high ratio of smokers:non-smokers in these cohorts.

Reduction of antipsychotic side effectsAnother ‘benefit’ of smoking for people withschizophrenia is that it seems to reduce the side effects

of some antipsychotic drugs. Some older drugs, such ashaloperidol, frequently cause unpleasant side effectssuch as Parkinsonism (mask like face, reducedmovement, limb stiffness) and akathisia (restlessness,shuffling, and inability to relax), as well as a ‘slowingdown’ of thought processes, memory and problems withattention. Smoking may attenuate these side effectsbecause nicotine, being an acetylcholine activator oragonist, releases dopamine in the same areas wherethese drugs block it.

Several studies have shown that improvement occurs inParkinsonian side effects, akathisia and cognitivefunction – especially memory and attention span – after theadministration of nicotine. Similar findings with regard tocognition have been reported in patients with Alzheimer’sdisease and attention-deficit hyperactivity disorder (ADHD).

Smoking is associated with a variety of mental disorders,including anxiety, depression and schizophrenia.Smoking may be perceived as a way of relieving stress,improving concentration, and providing a “reward” byactivating dopamine receptors in the brain. Thedisproportionately high percentage of smokers withschizophrenia might be partially explained by otherfactors including:

• Smoking may alleviate negative symptoms byactivating dopamine receptors

• Smoking restores the sensory gating deficit,decreasing the level of stimulation “bombarding” thebrain and affording some relief from auditoryhallucinations

• Smoking may “neutralise” the effects of antipsychoticmedication

• Smoking may reduce some side effects ofconventional antipsychotic medication and improvecognition in people treated with these drugs.

Although these effects may be perceived as beneficial,there is a pressing need for the development ofcompounds that can be helpful without causing thedevastating morbidity and mortality resulting fromcigarette smoking. Drugs that may selectively activatedopamine and nicotine receptors may provide theanswer, offering the ‘reward’ sought by mentally illsmokers without causing the terrible damage wrought byaddiction to cigarettes.

Suggested readingAllen Carr: Allen Carr’s Easy Way to Stop Smoking (Penguin)Mentally Ill: Smoke a lot: http://mentalhealth.about.com/library/weekly/aa112300a.htmJoan Arehart-Treichel: Smoking and Mental Illness: Which One’s the Chicken?Psychiatric News October 3, 2003 Volume 38 Number 19, Page 34


benefits

Incapacity Benefit reforms

The Government has recently published a Green Papercontaining proposals to reform Incapacity Benefit (IB).

We know that many of our members are worried aboutwhat this could mean for them. It’s important toremember that the changes will only apply to newclaimants of IB. Current claimants of IB will not beaffected, though they may get access to new services.

What’s it all about?The idea is to replace IB with a new benefit, calledEmployment and Support Allowance. If someone wasunable to work and claimed this new benefit, they wouldinitially be put on a ‘holding benefit’ which would pay theequivalent of Job Seeker’s Allowance for up to threemonths. Within this time, they would be given anassessment of their abilities to work and what extrasupport they might need to work. Most people wouldalso be required to attend an interview with a Jobcentreadviser during this period, but advisers would have thediscretion to allow some people not to attend. Theassessment itself is to be re-designed.

After the assessment, people would be put into one oftwo groups. The majority of people would be expected todevise an action plan with a personal adviser. This couldinclude voluntary work, permitted work, going on aCondition Management/NHS Expert Patientsprogramme, JobCentre Plus/external training, meeting anNDDP Job Broker/Disability Employment Adviser, orgetting Cognitive Behavioural Therapy. Their benefit willbe higher than at the assessment stage and higher thanthe current long-term rate of IB. But if they do not abideby the action plan, their benefits can go gradually downto the level of JSA.

The other, smaller group of people will not be expectedto engage in any job preparation activities. They will bepaid a higher level of benefit after the medicalassessment, which will be higher than the current rate ofIB. They will also be able to access support to get backto work if they wish.

If people have fluctuating conditions and their conditiondeteriorates, Job Centre Advisers will be able torecommend that they are moved from the first group tothe second at any time.

A raft of new services, known as the ‘Pathways to Work’programme, will be rolled out across the country. This willmean that people on IB can access support likeCondition Management Programmes, which help peopleto regain confidence and learn to manage their condition.

A £40 per week ‘work credit’ will also be paid to peopleon IB who find jobs.

What does Rethink think?Rethink is concerned that too much pressure will be puton people to find jobs. This could cause stress andanxiety and may even cause people to relapse. This is avery real concern. There is no evidence that people withmental illness should be compelled to find jobs; peoplewill find work when they feel ready to. Forcing people tofind work is like trying to help someone with asthma getfit by strapping them to a running machine.

We are also very concerned about how much Job Centrestaff understand about mental illness. Most only receiveabout a day’s training and this is unlikely to assist serviceusers and carers. Given that 40% of people claiming IBhave a mental illness, we think about 40% of people’straining should be about mental illness.

We also want to ensure that employers’ discrimination ischallenged effectively. Currently, only about 40% ofemployers say that they would employ someone withmental illness – the figure for severe mental illness maybe even lower. Unless this is challenged effectively, howcan people be expected to find work? It’s like asking peopleto go through a locked door, without giving them the key.

What’s Rethink doing?As soon as the proposals were announced, Rethink wasin contact with MPs and members of the House ofLords, to make sure that they knew our views about theissue. Two MPs and one Baroness said that they woulduse information from us in meetings with the Secretary ofState, John Hutton.

We have also organised an e-campaign for people towrite to their MP about the reforms. Our Chief ExecutiveCliff Prior has met repeatedly with ministers and officialsat the Department for Work and Pensions and we haveinvited officials to visit our employment services.

Rethink gave evidence to the Work and PensionsCommittee in the House of Commons at the end ofFebruary, alongside Mind and the Royal College ofPsychiatrists. We talked about the need to get theredesign of the assessment right and involve serviceusers and carers, the importance of addressingemployers’ stigma and giving proper training to JobCentre advisers.

JANE HARRIS explains theproposals on the Government’sGreen Paper regarding incapacitybenefit reforms

continued on page 17


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Future care of the mentally illDuring the early mediaeval period in England thebelief was that those mentally ill who were often thefocus of witch hunting and deemed to be afflicted bydark forces involving demonic possession should notbe the responsibility of the state but of the friendsand relatives of the patient. As we move through the21st century our endeavour must be to transform withsome urgency to a form of mental health care that isdriven by appropriate research principles andchanging demographic values. To date society hasfailed on all accounts to compassionately deal withthese situations. The future health policy initiativesare again struggling to develop and cope with theway forward.

Past echosGregory Zilboorg in 1941 examined the work of a numberof 16th century scholars who produced one of the firstreviews of the care of the mentally ill in England. Thesedistinguished intellectuals were Cornelius Agrippa, DeliaPorta, Cardano, Paracelsus, Lemnius, Reginald Scotusand Johannes Weyer (circa 1486 – 1588). In the mid1960s Ackernecht endorsed Zilboorg’s work by reportingon how important it was that those 16th century scholars

had produced a report that was seen as a progressivevision if not reforming episode of mental health care.Their main academic achievement was to offer aconscientious and thoughtful exploration regardingdemonic possession, current care initiatives, and thefuture treatment of the mentally ill.

Through their pragmatic investigation including suchareas as despair and melancholy these visionaryresearchers made important advances into exposing andexplaining the mind of man. During the 16th century,while demonology and witch-hunts continued, there wereagain those who put forward more enlightened beliefs onthe need for evaluating care issues and clinicalinterventions. One such person was Juan Luis Vives,born in Valencia in 1492, who wrote extensivecommentaries on a wide variety of interventionsconcerning the mentally ill. Juan Luis Vives becameprofessor of humanities at Louvain in 1519 andproduced one of the first notable works on modernpsychology in 1538.

Although not very well known in England he did putforward a strong belief concerning the treatment ofmental distress that we might do well to integrate intosociety today: “Since there is nothing in the world moreexcellent than man, nor in man than his mind, particularattention should be given to the welfare of the mind; andit should be considered a highest service if we eitherrestore the minds of others to sanity or keep them saneand rational ... One ought to feel great compassion for sogreat a disaster to the health of the human mind, and it isof utmost importance that the treatment be such thatinsanity be not nourished and increased, as may resultfrom mocking, exciting or irritating madmen ...”Nearly one hundred years later after the assiduous workof Vives the author Robert Burton in 1621 published TheAnatomy of Melancholy. This book uncovered andechoed the mental bleakness that was to be found inEngland during this period of time. It referred to amelancholic state that often affected the local populationwith feelings of inadequacy and a total lack of energy.

The term Melancholy has been in use since the 17th

century as a collective word for dejection, but in the 20th

century was adopted as a clinical term what we wouldnow call depression. Burton’s 17th century book containsa wide description of Melancholy and lists all the kinds,

• In 1514 the German painter and engraver Albrect Dürermade his most famous engraving, ‘Melencolia’

PAUL SHELLEY is the Associate Editor of theinternatonal journal Psychiatric Nursing Research –here he talks about what the future holds in termsof care for people with mental illness


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causes, symptoms, prognostics and several cures of itsmalaise. The 1632 edition of the book contains a versethat reflects upon the current mental desolation sufferedby men: “But see the Madman rage downright, Withfurious looks, a ghastly sight, Naked in chains bounddoth he lie, And roars amain, he knows not why. Observehim; for as in a glass, Thine angry potraiture it was. Hispicture keep still in thy presence; ‘Twixt him and theethere’s no difference.”

Some 30 years later in 1651 Thomas Hobbes wrote onthe ‘state of nature’ an attempt to explain the principalbuilding blocks of human society, its culture andhumanitarian approach to liberty and equality. Hobbeswrote during some of the most tumultuous times in earlyEnglish history that the life of man was far from exultant.Worst of all he believed that all those living in the 17th

century endured life in a continual state of fear and dweltupon the consequence of a pitiless death. Hobbes’ bleakpolitical statement describes the life of man in a periodnot too well known for its mental health care as being:“solitary, poor, nasty, brutish and short.” Hobbes,disdainful if not cynical view concerning the human racewas not a major revelation about cheerfulness but it didreflect some contemporary issues on the state of society’smelancholic mechanisms. The next 300 years areoccasionally lit up with various people trying to developgood mental health care but very often society would revertto custodial care and institutional incarceration.

Throughout the 19th and 20th centuries many caringmodels and interventions were created with some beingwell publicised while others disappeared into the mists oftime. For example in the 1930s Edna St. Vincent Millayheld the view that the main requisites for the continuinghappiness and well-being of the human race were: (i) ajob; (ii) at least one meal a day for at least the next week;(iii) an opportunity to visit all the countries of the world, toacquaint yourself with the customs and their culture; (iv)freedom in religion, or freedom from all religions, as youprefer; (v) an assurance that no door is closed to you andthat you may climb as high as you can build yourpersonal ladder.

That emotional ladder can be seen as one of thefundamental building blocks of the human race. Itconstantly tries to adjust and cope with various lifestressful events and their subsequent and often poignantreactions. Although life has always been full of precariousactivities and events we lose our sensitive approach tomental health research matters at our peril. These anxietyprovoking events and sometimes fearful activities havemade the public aware and some grow in the belief thatsuch life sorrows, sadness and grief have today for manyincreased beyond human tolerance. These long-lasting

forebodings and the alarming and formidablehopelessness that members of the society experiencehave increased and helped raise some fundamentalquestions on the debate concerning what are our currentapproaches to reviewing mental health policy initiatives.

In the book Madness of Kings Vivian Green reviewsthe historical impact of mental illness and states that:“madness seems like a foreign country and itsinhabitants aliens, either permanent residents ortemporary visitors and as a consequence treated inmore recent centuries as social outcasts”.

Present echosThat quest for 21st century answers began in January2005 when the Mental Health Action Plan for Europeheaded by the World Health Organisation produced apaper called ‘Facing the Challenges, Building Solutions’(EUR/04/50478/6: 2005). This report proposed toanswer some of the European mental health concerns byattempting to formalise through a list of generic aims anda somewhat impassive discourse on current mentalhealth endeavours. Health Ministers and theirrepresentatives attending this conference agreed underthe heading ‘Preamble’ a sentence that categorised thePrimary Aims of mental health as being to: “enhancepeople’s well-being and functioning by focusing on theirstrengths and resources, reinforcing resilience andenhancing protective external factors”.

Would these reports and development initiatives helpguide and formulate the World Health Organisationpolicy? The paper’s Preamble, Scope and Actions are allcongenial and fulfil via government speak the necessarylanguage that utilises the concept of well-being althoughwe are not told what this really means or how we canmeasure it. There are three sentences that give us aninsight into how very poor this paper is on mental healthresearch. In section eight the readers are told that there isa need to have a comprehensive evidence-based mentalhealth policy but there is no reference to any empiricalresearch evidence to this effect. This extremelydisappointing situation was further endorsed (Section 8:sub-section ix), explaining that we should: “designrecruitment and education and training programmes tocreate a sufficient and competent multidisciplinaryworkforce”.

There is very little evidence published that shows us howeffective UK education, recruitment and training is andthis remains the same in Europe and the rest of the worldapart from the pioneering work of a few notable senioracademics and even fewer psychiatric nurses. Mentalhealth nursing practice continues to be ardentlyinfluenced by tradition, unsystematic trial and error, and


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predisposed poor leadership. Bearing in mind that mentalhealth nurses are extremely poor at publishing researcharticles and know that the need for quality care should bebased on the best and most current empirical researchmany nurses fail to attain this principle of care.

Section 8 sub-section xii requires that we should initiateresearch and support evaluation and dissemination ofresearch papers. Under Section 10 sub-section xviii of‘Responsibilities’ the last agenda item suggests that weshould commission research when and whereknowledge or technology is insufficient and disseminatefindings. With a poor track record on undertaking andpublishing nursing data, our current knowledge andtechnological know-how is at best inadequate and atworse stuck in the 1950s. Section 13 sub-section (c) wehave a research heading that is split into two further sub-headings that contain the statement that the authoritiesshould: “establish a network of mental healthcollaborating centres that offer opportunities forinternational partnerships, good quality research and theexchange of researchers. Produce and disseminate thebest available evidence on good practice, taking intoaccount the ethical aspects of mental health”.

This statement is a wish list that hopes that thedissemination of best available evidence on goodpractice is facilitated via osmotic influences. Researchfindings must be published in journals that are read bythose who can use the evidence; however, the number ofpsychiatric nursing research journals across the world isextremely poor and psychiatric nurses in clinical practicedon’t read these journals in any large numbers.

Finally under Section 13 sub-section (d: iv) the paperproposes that service development should: “assist withthe formulation of research policies and questions”. It isincumbent on policy makers that they look at whattheoretical and practical evaluation questions need to beaddressed before health care policies are considered. Theprocess of developing evidence-based nursing practicebegins with a question about a specific nursing problemor situation; it should not start with developing policiesunless there is a hidden agenda.

In conjunction with the above paper on the Mental HealthAction Plan for Europe the World Health Organisationcontinued by producing a further action plan section(EUR/04/50478/7: 2005) again called ‘Facing theChallenges, Building Solutions’. After a very longpreamble and introduction through various sections weare informed in Section 7 that: “It is essential toacknowledge and support people’s right to receive themost effective treatments and interventions…”

Unfortunately, we do not at present have enoughresearch data that could inform us of the most effectivetreatments and interventions, although we have a list ofnursing models that integrate several sciences thatinclude CBT, Psychotherapies, PsychosocialInterventions and medical models. These two papersamount to 18 pages of professional challenges thatshould be addressed between 2005 and 2010. It is onlyin Section 12 of paper 2 that the discourse starts onevaluation of research principles that is perversely shownas an end process rather than a beginning point. ThisSection gives 10 action points and concerns the field ofpsychiatric nursing.

The opening sentence suggests that “considerableprogress is being made in research” although they sayexisting evidence concerning effective good practice isnot known to many professionals. This last sectionreflects the importance of research but fails to create anysense of urgency or even echo our present state of affairsthat shows the scientific data is not there or available toinstigate good universal mental health practice. If youcombine this with no mention of the role or experiencesof the non-statutory and voluntary agencies together withan absence of carers’ concerns – failure of the legalsystem and mental health legislation, financial burdens,drugs, alcohol and vast moral problems concerningstigma – the future of mental health is in dire trouble andthe future health patterns don’t make it any easier.

Future echosAs life expectancy of most individuals continues toimprove, the total number of people experiencing mentalhealth disorders will also increase. Equally and even moreunacceptable is that the number of children showing

Physicians inthe 18th and19th centuriesused crudedevices to treatmental illness, none of which offered any real relief.

The circulating swing, top left, was used to spindepressed patients at high speed. The tranquilisingchair, top right, to calm people with mania. The crib,bottom, was widely used to restrain violent patients


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mental health problems will also significantly grow. Thistrend, already critical, will result in major challenges inmanaging, financing, and delivering treatment servicesfor people who have a mental health problem. From aglobal perspective the scale of the challenge posed bymental illness is enormous. Current data and informationinterrelated with contemporary practical issues just showhow vast that challenge is.

The Diagnostical Statistical Manual (DSM) first used in1952 contained about 100 pages that referred to a list ofabout 60 mental disorders. The latest revised edition ofthe book (DSM-IV 2000) contains about 1000 pages.The next DSM-V is not scheduled for publication until2011. More people appear to be diagnosed from morepsychiatric disorders than ever. In August 2004 the WorldHealth Organisation (WHO) reported that 450 millionpeople worldwide would be affected by mental healthproblems and the European Conference on mental health(January 2005) reported that one in four Europeanswould suffer from a mental illness sometime in their life.Contributing to this sombre situation a vast number ofcountries are currently devoting less than one per cent oftheir total health expenditure on specific mental healthcare. Mental illness including suicide accounts for over

15 per cent of the burden of disease in these countries,that is more than the disease burden caused by allcancers.

Depression was ranked second only to worldwideischaemic heart disease in magnitude of disease burden.The WHO have established a mental health Global ActionProgramme (GAP) that is trying to focus on partnershipsthat would enhance nation states to combat socialstigma, reduce the financial burden of mental disordersand promote mental health care.

GAP reported that disability caused by major depressionwas found to be equivalent to blindness or paraplegia,whereas active psychosis seen in schizophreniaproduces disability equal to quadriplegia. The projectionsshow that with the ageing of the world population andthe conquest of infectious diseases, mental illness willincrease its share of the total global disease burden byalmost half very soon. Major depression is now theleading cause of disability measured by the number ofyears lived with a disabling condition worldwide amongpersons age 5 and older.

With the United Nations reporting global conflictsincreasing five times since the end of World War II theincrease of mental distress is quickly becoming ournemesis. Both internal conflicts, and conflicts that crosscountry borders, result in not only refugee flights but alsotremendous increases in the levels of grief, despair andpersonal anguish. People flee their homelands due tofears of persecution, threats to personal safety and theloss of basic necessities of life. The majority of peopleworldwide suffering from these types of emotionaldistress are very often women and children.

If you include the very recent tragedies of the East AsianTsunami and the Asian Earthquake a massive increase inPost Traumatic Disorder will add to the enormouspsychological effects these people have encountered.The immense challenge facing all of us in promotinggood mental health is passing us by as we sleep walkinto a global catastrophe. As Professor Vives witnessedsome 500 years earlier: “it should be considered ahighest service if we either restore the minds of others tosanity or keep them sane and rational”.

When shall we ever learn? “If men could learn fromhistory, what lessons it might teach us!” Coleridgewrote in 1831, “But passion and party blind our eyesand the light which gives us a lantern on the sternwhich shines only on the waves behind us!”

© Paul Shelley - January 2006

‘Bedlam’, painted in 1735, has sometimes beenthought to be a faithful reflection of conditions insideBethlem, The Hospital of Saint Mary of Bethlehem, aLondon mental hospital commonly known as Bedlam,which sold admission tickets to the public in the 18th

century, becoming a popular tourist attraction.

In this picture by English artist William Hogarth, part ofhis series A Rake’s Progress (1735), two women (seenin the background) tour the hospital, watching thementally ill patients for their amusement. The hospitalbecame notorious for its miserable conditions and crueltreatment of patients.


staff diary

Mention the beautiful north-east coast of NorthernIreland and you will think of the Giant’s Causeway

and the home of Bushmills whiskey. It is also the areawhere Rethink Family Support Worker Richard Lappinworks. Read on to discover how he spends a typical dayworking for Rethink.

It is just gone 8:30am and I take my bag to the car, getin and set off to my first port of call, Ballycastle.Ballycastle is approx 30 minutes drive from home,Portstewart, and takes me along part of the North West200 motorcycle road race circuit to Portrush and alongthe coast past the picturesque Dunluce Castle and thenon to Bushmills, home of the world famous whiskey.From here I head to Ballycastle. My base is an office inthe Dalriada Mental Health Resource Centre, part of theCauseway Health and Social Services Trust. The Trustcovers a wide rural section of North Antrim and EastLondonderry. There is a population of 120,000 in theTrust area, which increases to over 150,000 in summerdue to tourism.

Just before 09:00am – I do the usual things when I getin: check the answer machine, post and emails and havea coffee. I have a Carers Group meeting in the evening soI ring the manager of the venue we are going to use tomake sure all is well. Tonight’s group will be in thePavestone Centre in Coleraine. There are three Groupmeetings each month: one in Coleraine; one inBallycastle; and one in the Glens at Cushendun.

As I am based in a building with the BallycastleCommunity Mental Health Team1 I am able to liaise withthem regarding carers issues and updates. I then call acarer who has left a message enquiring about the service.I tell them what the service has to offer them and arrangea meeting to discuss how I can best support them. Thisis arranged for early next week.

11:30am Carer Visit – I travel from Ballycastle toColeraine to visit a carer. Today, we will discuss theprocess of assisting the person they care for in moving toindependent accommodation. Although this is a positivemove for service user and the family, it also is a situationwhich has many feelings, emotions, and uncertainties. Iam aware that extra support may be needed.

12:30 Lunch – I get the opportunity for a quick sandwichand a coffee in Coleraine before heading to the ColeraineVolunteer Bureau for a meeting of the Disability Forum.

1:00pm Meeting of Disability Forum – – – – – The ColeraineDisability Forum has only recently been set up. There are24 Voluntary and Statutory groups represented so far. Asa committee member I am assisting today to help producethe Aims and Objectives for the organisation in the form of

a Strategy Document. This process has been overseen by aManagement Consultancy Group as part of support fromthe Local Strategic Partnership in Local Government.

The aim is to create a forum that will be proactive in theColeraine area on disability issues. Currently I am the onlyrepresentative from a mental health organisation, buthopefully this will change as we identify more potentialmember organisations in the coming months.

2:00pm ‘Clinic’ at Coleraine Mental Health ResourceCentre – – – – – Every two weeks I hold a ‘clinic’ in each of theMental Health Resource Centres in the Causeway TrustArea. Today I am in Coleraine, but I also hold ‘clinics’ inBallymoney Mental Health Resource Centre and at mybase in Ballycastle. Also there will be a ‘clinic’ in the localPsychiatric Unit, the Ross Thompson Unit at ColeraineArea Hospital.

These ‘clinics’ are an opportunity for me to meet with theCommunity Mental Health Teams, but more importantly Iam accessible to the carers in these areas. I havedeveloped links with the Rural Transport organisationswhich can help provide transport to these venues fromoutlying areas.

5:30pm Dinner – – – – – I head home, which is four miles away,to get a bite to eat and get ready for the evening’s groupmeeting.

7:00pm Carers Group meeting ––––– Each month I facilitatea Carer Group Meeting in three venues. This allowscarers the opportunity to meet have a cup of tea orcoffee, share experiences and get support from peoplewho have been through similar life events. It can also bean opportunity for a guest speaker to attend and discussa specific topic.

Tonight the Rethink Advocacy and Advice Worker for thearea has come along to explain her role and how theservice can be of benefit to carers and those theysupport. This evening two new people attend, who haveboth been referred to the service recently. I also get achance to let the group know about updates withinRethink and tonight I ask their opinion on some draftpolicies which need feedback. I provide copies for themto read and return to me with their comments. This is animportant way to keep the carers informed about thedevelopments within the organisation.

9:30pm Group winds up – – – – – I lock up the venue and headhome to relax after one of the longer days in my calendar.

(Footnotes)1 A multi disciplinary Team made up of Community Psychiatric Nurses,Social Workers and Occupational Therapists.

A day in the life of a family support worker

Rethink’s RICHARD LAPPINtalks about what a typical workingday holds for him


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Rethink Manager receives top sports award

A Rethink Service Manager has been crowned BBCMidlands Disabled Sports Personality of the Year at a

prestigious ceremony in Birmingham.

Neil Smith, Area Services Manager for Rethink EastMidlands, scooped the accolade for his achievements inswimming and was presented with his award at the thirdannual BBC Midlands Sports Personality 2005 byMidlands Today presenter Nick Owen, during theceremony at The National Motorcycle Museum,Birmingham on December 4th.

Neil, who is part of the City of Birmingham SwimmingClub, is based in Leicester and has been with Rethink forfourteen years. The award adds to a growing list ofaccomplishments for Neil: he returned from the WorldCerebral Palsy games held in Connecticut during Julywith four gold medals and a world record time, scoopingthe accolades after winning the 200m Individual Medleyin record breaking time as well as claiming victory in the50m, 100m and 200m freestyle. Following hisachievements there, he was nominated for the BBCaward by the Amateur Swimming Association.

The ceremony was attended by stars of the sportingworld and amongst those present were Denise Lewis andAshes cricketer Ashley Giles. Speaking about hissuccess Neil commented, “I am honoured to have beennominated for the BBC Midlands Disabled Personality ofthe Year and thrilled to have won. I think this awardhighlights that people of all abilities can achieve sportingsuccess and I would particularly like to thank my

colleagues atRethink whohave supportedme in being ableto pursue mypassion forswimming.”

As a result of hisaccomplishments,Neil is down tothe last sixteenapplicants for a documentary due to be filmed in Africa inJanuary for BBC 2. ‘Beyond Boundaries’ will featuretwelve people on a four week journey to cross Namibia byfoot, camel and kayak. If successful, Neil hopes to usethe experience to raise awareness of mental illness anddisability. Additionally, Neil has a number of innovativeawareness raising ideas he is considering for 2006including a channel swim and swimming the UK’s largestthree lakes in 24 hours.

In his spare time, Neil dedicates his energies to helpingthe next generation of swimming stars realise theirpotential and coaches children with varying degrees ofability. He stated, “I feel it’s important to encouragepeople within the sporting world to believe in and followtheir dreams.”

For more information on the awards visit: http://www.bbc.co.uk/birmingham/content/articles/2005/12/05/sports_awards_winners_2005_feature.shtml

National men’s health week

National Men’s Health Week starts on 12 June thisyear. On Wednesday 14 June, the organisers, Men’s

Health Forum, are staging a ground-breaking conference:‘Mind Your Head: Improving the Mental Wellbeing of Menand Boys’. The conference is very timely, especiallybecause of the new duty on public sector organisations topromote gender equality which becomes law in April 2007.

The conference will raise awareness of all the mentalhealth issues that impact on men. It will look at theseissues, however, from a positive standpoint, exploringhow problems can be tackled through gender-sensitivepractice in a wide range of settings and life stages. Theaim is to ensure that each delegate goes away with atleast one working model for their own practice, inspiredby all they have seen and heard.

The Department of Health is sponsoring this conference,along with The Football Association, which hasgenerously made the new Wembley Stadium available toMen’s Health Forum for the day. (Alternative conferencespace has been booked in the event that the stadium isnot completed in time.) NMHW is of increasing interest tohealth and social care workers, and around 500 areexpected to attend this conference.

National Men’s Health Week in the UK is part of a far widercampaign. The theme for Men’s Health Week throughoutEurope is also mental wellbeing and other men’s healthactivities will take place in Australia, Canada and the USA.You can find out more about the conference programme,and register for a place at www.menshealthforum.org.uk

• Neil Smith (left) with Nick Owen


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Hull carers groupco-ordinator steps down

• (from left to right) Rosie Winterton – MP, Andrea Nettleton – OperationsOfficer Hull and East Yorkshire Rethink Carers Service, Barbara Hilding –Co-ordinator Hull and District Rethink Carers Group, and Cliff Prior.

One of the founding members of the Hull and District RethinkCarers Group has stepped down after several years as Group Co-

ordinator. Barbara Hilding has decided to take a back seat and join herpartner, Ian, in a well deserved retirement.

Barbara is well known locally as a passionate advocate for Carersissues and she always does it in her own inimitable style. However,not so well known is her work behind the scenes in supporting Carersunder pressure.

“I know that many of the Hull group’s members have benefited fromher sound advice and her listening ear over the years” said CallyBarker, Manager of Hull and East Yorkshire Rethink Carers Service.“She is always there for people when they are in crisis and she caresdeeply about the well-being of the group as a whole.”

“On a personal level, I will miss Barbara’s support, her frankness, herwarmth and generosity of spirit but of course I’m delighted that she isstaying on as a group member,” said Cally. “I would like to say a hugethank you to her for her hard work and commitment to Rethink andthis Carers Group. She will be a hard act to follow!”

The Green Paper is being consultedon and Rethink is submitting its ownevidence to this. But this campaignis likely to continue for some timeto come.

How you can helpWe need to know about yourexperiences to convince people inGovernment of the current problemswith the system. So please write andtell us about them.

Write to Jane Harris, SeniorCampaigns Officer, 5th Floor, RoyalLondon House, 22-25 FinsburySquare, London EC2A 1DX or [email protected] with:

• Your experience of Job Centrestaff – how much do they knowabout mental health? Please tell usof your experiences, good or bad.

• Your experience of employers –have you or someone you knowbeen affected by stigma?

• Your experience of OccupationalHealth – have you or someone youknow been accepted for a job andthen not been able to take it upbecause of occupational healthconcerns?

Thank you all for your help in thiscampaign.

continued from page 10

Stop press...

Paul Farmer Rethink’sDirector of Public Affairs will

be leaving in April to becomethe new chief executive of Mind.

WE hope to do a more detailedpiece in the next edition ofYour Voice.

Editor


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The genealogy of mental health –a hypothesis concerning mental distressHow do we dig into the past? Can webecome psycho-archaeologists andgenetic geologists of our ownhistories? Is social engineering part ofour psychosocial evolution?

Are the causes of mental ill health or well being geneticor environmental? Are they a result of social conditioningor cultural inheritance? If our ancestors experience arepeated cycle of events do their reactions becomeembedded in the genetic memory of later generations? Ifwe have an on-going response to any given situation arewe reacting to an inherited family memory?

If our ancestors’ traumas were untreated andundiagnosed could stress and anxiety be unconsciouslypassed from one generation to another? Can patterns ofbehaviour develop as defensive reactions to distressingsituations in one generation and become inherited familycharacteristics later down the family line?

If traumatic memories are repressed can they trigger anautomatic psycho-emotional response in futuregenerations? Is there a history gene, which carries thestory of the family and forms the basis of our mental illhealth or well-being? Does this history gene respond in acertain way when certain events are played out in latergenerations? Are illnesses, mental and physical, triggeredthrough a history gene?

Everyone has a history. Whether we choose to recogniseits influence or not – it’s there. It can be present in our livesas a photo, a domestic object, a book, a word, as a pieceof furniture, a building – anything that connects our lives inthe present to a person, situation or event in the past.

Our relationship to that history can evolve slowly overtime, usually influencing our core relationships in life, orerupt suddenly and unexpectedly, as a feeling, a reactionor a mood. This has been described as a pattern. Anyoneand everyone, whether diagnosed or undiagnosed with amental health condition, has a personal historyoriginating from a variety of influences, and based on anumber of sources.

History, usually and generally, belongs to us individuallyand collectively. We share its roots with those who have

experienced similar influences and sources, or we mightremain closed and isolated with a sense that we are theonly person holding on to it. History is exclusively ours ina very individual, personal and unique way.

History is about memoryMemory can be stored as a physical, psychological,emotional or mental reaction, state or condition. This iswhy the discoveries of Freud, Jung and theirdescendants continue to help us understand theconnection between the presence of physical,psychological, emotional and mental symptoms and ourhistory and experience of traumatic and disturbing events.

A group, a family or a community can remembersomething collectively and it may become a story or amyth, but individually we may have a very different takeon it. Our experience or memory of something candiverge quite dramatically and drastically from a collectiveconsensus.

How we react to or interpret memory is our own personalway of understanding and dealing with history and itseffect on us. This can and does translate into behaviour,response, reaction or feeling. A remembered experienceor lost hidden memory produces complex patterns ofresponse or behaviour. They influence our present lives inways that are not always transparent, obvious oracceptable. Almost anything can trigger this responsemechanism.

My own experience of dealing with history and memoryhas been in therapy. I have explored many incidents,among them my reactions to my parents andrelationships within my family. This is probably the mostcommon route that therapy takes, as revealed in themany case histories published over time since Freudbegan his analyses at the end of the nineteenth century.

But for me, therapy did not go back far enough. Themore I looked at my parents’ lives the more I wanted tolook at their parents’ lives. And then beyond that, theirparents’ parents’ lives and so on and so on, back intime. I went back as far as I could in the living memory ofmy family. This has spanned five generations to thebeginning of the 20th.

I have also begun to collect other family profiles acrossthis kind of time frame to see if I can establish evidence

FRAN SINGER, who has hadexperience of mental ill health,discusses her hypothesisconcerning mental distress


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Hypothesis of the history of mental distress – diagram of a processthrough five generations of a family

FIRST GENERATION – A COLLECTIVE FAMILY EXPERIENCE

SECOND GENERATION – REPEATED TRAUMAS: PERSONAL AND COLLECTIVE

THIRD GENERATION – SYMPTOMS RE-MANIFEST: PERSONAL

FOURTH GENERATION – SYMPTOMS PERSIST, DENIAL CONTINUES, ISSUES ADDRESSED LATER

FIFTH GENERATION – SYMPTOMS PERSIST – ISSUES ADDRESSED

High achievers addressing family issues,open to discussion therapy.

Commitment to psychic problem solving,active use of spiritual and holisticpractices, awareness and use of healingdimension.

Physical and emotional healthsymptoms include eating and mood

disorders. Extreme psychosis triggered bydrug abuse. Acceptance of and opennessto healing process including spiritual and

psychic energy and insight.

Teenage girl experiences death of herterminally ill mother alone in South France.Father re-marries within 6 months to amuch younger woman. Girl not allowed tomarry her true love – the brother of the newwife. seen as incest in orthodox law.

1920s - an arranged marriage betweentwo young people who love other peopleand who both want to marry someoneelse. Husband takes the dowry and thengoes away to study. Wife doesn’t knowhow babies are born – she believes throughthe navel

Loss, rejection, separation.persecution, paranoia, fear,anxiety and depression – repeatedand reinforced. Violence, arguments,addiction, manifestation of manicdepressive symptoms, addictive haits formin both parents: abuse of alcoholand nicotine. NO DIAGNOSIS

During the Cold War, a National Pressscandal involves her children named inCommunist activities and peace protests.Holocaust details emerge. Family scandalas wife remarries ‘out’ of the orthodoxcommunity. Woman now sociallyostracised by her family and community

World war 2 begins. Family separates.Mother and children move away fromLondon to avoid bombs. Father leftbehind falls in love with another.

Marriage fails, frequent rows. Motherplans to send children to USA as Naziinvasion looks likely but ship in frontgets sunk by a U-boat.

Family flees persecution from thecossacks, in particular, and arrives inthe East End of London.

1906 First Russian Revolution –a failed uprising against Tsar by variousleft-wing groupings including Marxists,Communists, Social Revolutionariesand Anarchists.

Loss, rejection, separation.persecution, paranoia, fear,

anxiety and depression

Failed or abusive marriages, addiction toalcohol and drugs; various abuses withinrelationships. Holocaust explained anddiscussed.

Children manifest addictive symptoms,have health problems at birth and later,suffer allergies. Their marriage partnershave various social problems andaddictions. All are clever, but rebelliousand victimised; under achieve and neverreach their full potential. Low self esteem.

Loss, rejection, separation.persecution, paranoia, fear,

anxiety and depressionDENIAL

Outcomes include joining a religious cult;first diagnosis of manic depressivepsychosis in family.

Abuse, addiction, depression, separationanxiety, mania, eating disorders. First use of

therapy – individual and family

Children have problematic relationships.All are academically successful but underachieve personally and professionally. Low self esteem.


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of complex patterns of response or behaviour to historyor to memory that have resulted in mental health issuesin later generations.

I dig into the past and look at things rather like anarchaeologist might explore a buried site or a geologistmight scrutinise a piece of rock. This has led me to drawpsychological and emotional history trees where I haverecorded diverse events through the generations.

Personal historiesI’ll give you an example of one family, for instance, where,in the paternal line, an ancestor’s extreme anxiety aboutJack the Ripper’s activities triggered a move fromEdgware to the Midlands; and in the maternal line theTsar of Russia’s pogroms resulted in ancestors’ fleeingfrom Russia to London in 1906. Then during the FirstWorld War – bereavement, shell shock, severe physical illhealth resulting in a fatal illness. Down that family line, threegenerations later, mental health issues began to emerge inthe form of depression, paranoia and delusive thinking.

My hypothesis proposes that the origins of mental andemotional distress can be traced back at least fivegenerations. As in the case above, events took place atthe end of the nineteenth century in Russia, Lincolnshireand the South of France. These are the furthest traceabletraumatic events. There was a mental health diagnosis of

bi-polar affective disorder a hundred years later,manifested as psychosis triggered by a massivehormonal imbalance after birth.

Intrigued by these personal histories I looked moreclosely at mine and others’ psycho-emotionalbiographies and began to draw psycho-emotional familytrees, charting family history lifelines.

Professor Dorothy Rowe has written extensively on thesubject of depression. She promotes the process ofnarrative therapy in which by telling our own story wevalidate our experiences and ourselves. We are constantlyattempting to understand our own place in history andour pathway through our life. Our reaction to history canilluminate many clues to the puzzling web ofpsychosocial behaviour.

I am interested to hear from other readers who areinterested in this way about their family histories. I havebegun collecting anecdotal evidence in the hope that itmay become a more formal piece of research. All materialwould remain the copyright of the author and beanonymous and confidential in line with the strictguidelines on ethics and code of practice respected bythe psychoanalytic profession.

Fran Singer [email protected]

Acute Psychiatric Ward Accreditation System (APWAS) –Carer Representative Required for Steering Group

Research and Training Unit in London approximatelyfour times a year. Non-salaried members of theSteering Group receive payment for their time.

If you are interested in joining this exciting newproject, please contact us for a nomination form:APWAS – The Royal College of Psychiatrists’Research and Training Unit, 4th Floor, StandonHouse, 21 Mansell Street, London E1 8AA

For more information, please visit our website:http://www.rcpsych.ac.uk/cru/ or call MarkBeavon on 020 7977 6647.

The Royal College of Psychiatrists’ Research andTraining Unit is developing a system for accrediting

acute psychiatric wards. The system will be standards-based, will include both self-review and peer-review,and will be developmental, in that it will be applied in away that supports ongoing service improvement.

In order to ensure that APWAS has the widestrelevance and support possible, we are seeking aCarer Representative to join our Steering Group. Thisrepresentative will play a key role in the development ofthe APWAS programme, and will be required to attendmeetings at the Royal College of Psychiatrists’


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John Madden InterviewBelow is an interview with British Director JohnMadden, who has previously directed CaptainCorelli’s Mandolin, Shakespeare in Love andMrs Brown about his new film, Proof.

Proof is a compelling story which stars AnthonyHopkins as a mathematical genius who battledschizophrenia before his death and hisdaughter Catherine’s (played by GwynethPaltrow) struggle to negotiate her Father’s pastand her increasingly uncertain future; howmuch of her Father’s instability – or genius –will she inherit?

Proof was released on February 24th 2006.

Key: JM – John Madden AH – Alita Howe

AH – – – – – Thank you for talking to Rethink; I know you mustbe very busy promoting the film.

JM – – – – – I’m terribly happy to be doing this interview andhappy if the film throws any light on the kind ofexperience and issues that you’re dealing with at Rethink.

AH – – – – – So could you tell me about the film from yourperspective?

JM – – – – – The film is essentially the story of a relationshipbetween a father and daughter. The father is the characterwho’s played by Anthony Hopkins and he is anextravagantly gifted mathematician who has made, earlierin his life, some spectacular advances in mathematicalthought which have revolutionised the field. But, throughthe course of the film, we learn that very early on in hislife he was subject to episodes of instability;schizophrenic episodes I suppose, although that word isnever used in the story. Now a teacher at a university, heincreasingly becomes unable to sustain his career.

The point at which the story commences is theimmediate aftermath of his death.

His wife passed away some time ago and is not reallytalked about in the film but he has two daughters; theelder one has run away from the circumstances and hasnever had a really close relationship with her father buthas justified this behaviour by becoming the provider forthe family. And the younger daughter, who is really thefocus of the whole story, Catherine, who is played byGwyneth Paltrow, has an intensely close relationship withthe father. She has a mathematical gift herself which thefather has fostered and which has tended to exclude theelder sister.

Catherine has taken sole care of the father from her mid-teens and has really sacrificed her own life completely totake care of him and particularly to maintain the illusionthat he is doing meaningful work because he lives for,and loves, his work.

Although you see some extreme behaviour in the film, wedidn’t dwell on episodes of psychosis because wewanted to focus the story on the daughter’s sense thatshe may be descending into the kind of illness that’sengulfed her father. She has lost a sense of her ownboundaries and she really doesn’t know any more whereshe ends and he begins. So really the subject matter of the filmis her notion and her obsession really, as to whether she mightbe experiencing the same illness as her father.

• Director John Madden


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The other part of the film concerns with the relationshipbetween Catherine and a graduate student played byJake Gyllenhall who worships the father and is convincedthat he must have left behind some significant work.Catherine is unconvinced and maintains that he was tooill to have done anything of importance in the last fifteenor twenty years of his life. The story concerns thediscovery of a piece of work, a ‘proof’ which becomesthe central issue.

We didn’t dwell on, in any kind of clinical detail, the exactnature of the father’s illness but what the film does isdramatise and demonstrate the extraordinary closenessbetween the father and the daughter; the mental strainthat the daughter experiences as a result of trying tomaintain the father’s equilibrium and I hope it’s helpfuland moving for people who have to go through or havegone through some of the experiences because I think it’swritten with great accuracy and truth and hopefully playedwith the same. So, I think the film has a lot to offer.

AH – – – – – Did you do any research with anyone with a mentalillness before you were involved in the film?

JM – – – – – I have had experience of those kinds of problemsand I’ve certainly been around people that haveexperienced bi-polar disorder. However, we didn’t do anenormous amount of research into that area because wefelt the film itself really doesn’t focus on the nature of themental illness. I suppose that just as the mathematics inthe story is an off-screen presence; so the mental illnessin the film is an off-screen presence. Therefore, whilst it’ssomething that entirely informs the behaviour of thecharacters in the film, it’s never really visually seen and assuch we didn’t want to get caught up in a clinical reality.

AH – – – – – As the character of Catherine is portrayed as a carerin the film what are your views on the carers and caring?

JM – – – – – Yes, that is the focus of the piece and it’s a role thatI have enormous admiration and sympathy for because Ithink carers famously are the forgotten people and I thinkthat to experience a loss like Catherine, must be anunimaginable pain. I’ve been a carer myself; my motherdied when I was very young; not from mental healthproblems but she certainly suffered from profoundphobias which I remember very clearly and which made avery strong impression on me.

Caring and carers is the subject of this story and I can’timagine somebody watching the film and not being able tounderstand the pain and anxiety which grips Catherinethroughout her father’s illness and after his death. I think thathopefully a profound sense of the love Catherine had for herfather, as well as the pain she had to endure in negotiatingthe extremes of his illness, comes shining through.

AH – – – – – So, did any of the actors do any research intomental illness or carers for the film?

JM – – – – – Again, not in any great depth, and it makes ussound as if we were dabbling in mental illness and weweren’t but I think there is a philosophy to which I

partially subscribe to in that some actors simply want todraw on their own experiences in terms of the materialthe piece presents. We did do some reading and someresearch but had we been doing a detailed study ofmental illness and schizophrenia then we would haveapproached it entirely differently. Anthony Hopkins isfamously averse to intensive research and reading into asubject. However, his experience of mental illness,through acquaintances of his, unquestionably informedsome of his behaviour in the film.

AH – – – – – At Rethink we do a lot of work into the stigmasurrounding mental illness; do you think that this issomething that exists in society and the media?

JM – – – – – I absolutely think it does and one area that occursto me is the very first thing I directed was a play about awoman who suffered a stroke. I did an enormousamount of research into associative brain dysfunctionsfor the project and one thing I remember vividly was thatpeople who had suffered strokes and resultantlypresented unusual behaviour, were often fighting theperception that they were ‘nuts’ or ‘crazy.’ And I think it’strue that people do tend to run a mile from suchbehaviour because they don’t know how to deal with it,they don’t recognise it and they’re frightened of it. So Ithink stigmatisation is a very serious problem andparticularly with mental illnesses; and to some extent thatis part of what is explored in the film; the fear of whatbeing stigmatised actually means.

• Gwyneth Paltrow and Anthony Hopkins in the new film ‘Proof’


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AH – – – – – Do you think that the media are in some wayresponsible, through their coverage of mental health, forfurthering the stigma surrounding mental illness?

JM – – – – – I think that certainly some of the coverage of mentalillness that I’ve seen has tended to be of a more seriousand sympathetic nature and has often illuminatedsomething that one doesn’t necessarily know a lot about.I think that the media could be a source of greatinformation and illumination about a topic such asmental illness and that broadcasters do and should pointpeople towards organisations such as Rethink so thatfurther information can be gleaned and further discussioncan be had which I think is quite crucial. Butunquestionably, stigma does still exist. In my own familyfor example, my Grandfather was one of nine childrenand the ninth child was in a mental asylum from herteens I believe, and was never really spoken about. Andalthough that was in the Victorian era; I think the issue ofstigma and old fashioned notions of asylums is still ahuge problem to be countered.

AH – – – – – Going back to Proof, did your perception of mentalillness, schizophrenia and carers change throughout yourjourney of making the film?

JM – – – – – I think it did in human terms, yes, because it’sobviously my job to imagine myself, and help the actorsimagine themselves, into the circumstances the storydeals with. I can’t ask anybody else to empathise withCatherine’s situation if I don’t understand it myself andso I made it my job and Gwyneth Paltrow made it her jobto understand what the character is going through. Andbecause I think that David Auburn, the writer, has writtensomething very true, I think it does strike a lot of chordswith people who may or may not be in similar situationsbut certainly can imagine being in those situations. Soyes, it has changed me; the whole idea is to empathiseand to imagine yourself into a situation because that’scrucial. I think to bring about a better understanding ofmental health issues you have to encourage people touse their imagination and I hope that is what this film willencourage people to do.

A new study suggests that the most newly-available atypical antipsychotic might be a better

choice than other atypicals if current medication isfailing to control symptoms or is producingintolerable side-effects.

The STAR (Schizophrenia Trial of Aripiprazole) studylooked at what happened to symptoms and sideeffects when 555 people with schizophrenia onmedication that was failing to control symptoms orgiving tolerability problems switched to eitheraripiprazole (Abilify®) or another previouslyunprescribed atypical antipsychotic. After 26 weeks oftreatment, those switched to 10-30mg aripiprazolelost an average 1.3kg of weight, while those in thegroup treated with either 5-20mg/day olanzapine,100-800mg/day quetiapine or 2-8mg/day risperidonegained an average of 2.1kg. Those in the aripiprazolegroup also had better improvements in risk factors forcardiovascular disease, diabetes and the metabolicsyndrome. After 26 weeks, cholesterol andtriglyceride levels fell more in the aripiprazole groupthan in the group treated with other atypicals.

Study leaders said the changes in these risk factorsrepresented a 2-3% reduced risk of developing

coronary heart disease and a 2-3% reduced risk ofdeveloping diabetes for those on aripiprazolecompared to those on the other atypicals. ProfessorRobert Kerwin from the Institute of Psychiatry at theMaudsley Hospital in London said: “Metabolicsyndrome contributes to the risk of diabetes andcardiovascular disease. Many people withschizophrenia already have risk factors such assmoking for these diseases and so it is important tohave a medicine available such as aripiprazole that iseffective, yet may not exacerbate metabolic risk, sothat people with schizophrenia can maintainreasonable function and quality of life.”

The study also looked at patient preference andmeasures of the effectiveness of the atypicalsstudied. Based on a patient preference of medicationscale, 47% of those on aripiprazole rated theirmedication as being “much better” than their priormedication. In those on the other atypicals studied,only 28% said they rated their new medication as“much better”. Those on aripiprazole scored theirmedication higher than those on the other atypicalsbased on a questionnaire looking at symptoms,somnolence (sleepiness), weight gain, prolactinelevation, akathisia, EPS, cognition, energy and mood.

Schizophrenia trial of Aripiprazole


campaigns

The Rethink Anti-discrimination Site pilot ran for thewhole month of March and set out to show that high-

profile, public-facing activity is effective in combatingmental health discrimination.

The campaign was focussed in Norwich and included:

• Paid for advertising on buses, bus stands and radio,plus a single newspaper advert.

• Fundraising asks posted through thousands of letterboxes, supported face-to-face activity on the streetsand online opportunities to donate.

• Media support, targeting local print and broadcastoutlets

• Public activity, stalls, book signings and GP visits,supported by a website.

• Sophisticated evaluation involving lots of interviewswith people in Norwich.

The campaign was not a mental health promotionexercise aimed at raising awareness of personal mentalhealth issues, but an anti-discrimination campaign aimedat raising awareness of how these issues affect peoplewith severe mental illness and changing public attitudes.

It brought together members, people using our servicesand staff from across the region and nationally whoprovided a fantastic energy and presence on the ground.

We certainly raised the profile of the campaign with theunveiling of a statue of former Prime Minister WinstonChurchill, who achieved all that he did while battlingagainst manic depression. We put him in a straitjacket toshow how the “straitjacket of discrimination” holds backhundreds of thousands of people from achieving their fullpotential. It proved controversial – and the evaluation willbe looking at the positive and negative impact it had.

The Norwich campaign is a pilot for an even bigger pieceof work we will be doing in Northern Ireland in January2007. We will use what we learn from evaluating Norwichcampaign to build up our knowledge about what worksin breaking down stigma.

This information will form the basis for an ongoingcampaign challenging central government to provide afully funded, high profile national anti-discriminationcampaign.

Campaigns exist in other areas such as anti-smoking,heart disease and cancer. Mental health campaigns ofthis kind have proven highly successful in other countriessuch as Scotland and New Zealand – we want to buildup the case for demanding one for England.

Norwich was chosen as a pilot area for our campaignbecause it has a strong local identity, it is geographicallydiscrete and it has a healthy media presence. Norwichhas more anti-depressants prescribed per head of

population than anywhere else in Centralor Eastern England – 30% above thenational average. It also has theunenviable position of having high ratesof self-harm and having a higher than anational average suicide rate.

Norwich needed the campaign and weneed to make the very best use of thenew contacts we have made there, aswell as learn the lessons for the future.The full evaluation of the Norwichcampaign should be ready by the end ofMay and will be made widely available.

If you want to find out more, visitwww.rethink.org

• Members of the Norwich campaign team

New pilot scheme aimed to raise awareness


group profile

Clydesdale focus group

A service user led approach to finding out aboutpeople’s experiences of mental health services. This

article is a collaborative venture between members of theClydesdale Centre focus group and a researcher fromKeele University. It describes the work carried out over atwelve-month period by the members of the focus group.

The Clydesdale Mental Health Resource Centre has beenthe group’s focal point for a piece of work that aimed tobring about improvements in mental health services bylistening to service users and acting on their feedback.The Clydesdale Centre is a community Mental HealthResource Centre in Newcastle-under-Lyme, Staffordshire.It provides services to adults living in Newcastle-under-Lyme and Stoke-on-Trent, and offers respite, crisisprevention, and treatment of mental health problems. Akey aim is helping people remain in their own homes andsustain their normal roles in life whilst developing themeans to cope with their difficulties.

At a clinical governance staff team away day in 2003 asuggestion was made to encourage the setting up of aservice user focus group. The hope was that this couldbe a vehicle for service users to express their views aboutlocal mental health services. A focus group wasestablished in April 2004 with a core membership of sixservice users plus two members of staff.

The focus group meets monthly and discusses issuesrelevant to service user care at Clydesdale. One of the firstpieces of work done by the group was developing asurvey that was sent out to all service users of theClydesdale Centre.

“We all knew each other, so it made it easier tosettle into the group. It was explained what thefocus group was about and how the idea cameabout. Then we were asked what areas wethought needed to be looked at from talking toother service users before, and in generalconversation amongst ourselves. So we startedto reel things off. It was surprising what we cameup with… Some things we came up with at thefirst meeting were - crisis support procedure tobe outlined; appointment times to belengthened; awareness of alternative therapies.”(Lisa, a member of the focus group)

After a great deal of work drafting questions andchecking for clarity, a total of 18 questions were agreedon. The questions covered areas from access to

information about condition/diagnosis, access toservices, and access to housing and support – throughto more theoretical questions such as whether the servicewas doing enough to reduce stigma about mental health.Respondents were given a choice of three tick boxes:“Yes”, “No”, and “Don’t know”. Some respondentsadded a fourth response, which was “N/A”. A space wasavailable for comments.

Support to service users to complete the questionnairewas offered by one of the members of the group.760 questionnaires were sent out and a total of 290(38%) were returned. Three key messages from thesurvey were:

• The extent to which service users understood and feltenabled by central aspects of services;

• Service users’ access to appropriate information;

• Levels of support from services.

It is clear that there are some messages for theClydesdale Centre in relation to the key worker system:only 43% of respondents knew who their key worker was,and only 9% knew who would cover in the absence of akey worker. 71% said they were not aware of how tochange their consultant/key worker.

Whether service users have enough information – andtheir experiences about this – was another area that washighlighted. Specific comments indicated that serviceusers felt uninformed in relation to medication anddiagnosis, and fewer than half – 44% – claimed they hadbeen given information about their diagnosis. It might beexpected that these two aspects – having informationabout one’s diagnosis and understanding one’sdiagnosis – would be closely related. However, this wasnot the case: two thirds (66%) of respondents said theydid have an understanding of their diagnosis. Thisdiscrepancy might be explained in other ways. Forexample: service users finding out themselves about theirdiagnosis rather than from health professionals.

Respondents gave conflicting responses about thesupport that services provided. On the one hand anumber of positive comments were made about thesupport received from staff at the Clydesdale Centre. Thisincluded comments about doctors, the crisis team, andstaff in the Centre. However, respondents alsocommented that practical, non-medical support wasoften missing. This included a lack of help in filling informs, and insufficient support when changing to a


information

different area and having to see adifferent health professional.

Another practical concern wasrespondents’ view on housingoptions available to them. Only 33%said they thought there were adequatehousing options for them, 16% saidhousing options were not adequate,and 34% said they didn’t know.

North Staffordshire has a well-established Voluntary Sector with agood spread of organisations thatsupport mental health service users.Whilst statutory mental healthprofessionals may be a first point ofcontact for individuals in crisis, itmay be that more work could bedone to link service users into someof the practical support availablefrom the Voluntary Sector.

Given the high response rate to thesurvey and the useful commentaryand feedback it has provided, itwould seem that a service user ledsurvey is a powerful approach foridentifying issues. The challenge forClydesdale Centre’s staff and serviceusers will be to act on the feedbackthat has been given and bring aboutvisible improvements for service users.

The Clydesdale Centre is due toclose within the next 12 months.Group members are very concernedabout the closure and its implicationsfor all users of this service.

This article was written by SueMolesworth from the ClinicalEffectiveness Support Unit at KeeleUniversity, in conjunction withmembers of the Clydesdale CentreFocus Group.

The Clydesdale Centre FocusGroup would be happy to receiveresponses, comments or feedbackin relation to this article,particularly from groups doingsimilar work. Please email to:[email protected]

What to expect from GPs

The GP contract has recently been reviewed, which has led to mentalhealth becoming far more prominent. Rethink submitted evidence to the

review panel and two of the three issues we mentioned have now beenaddressed in the new contract. This is a great success. This article willexplain what you can expect from your GP now the new contract is in place.

GPs do not have to provide many of the services in the new contract – butmost do because they are paid more to do so. There are two servicesspecifically for people with severe mental illness:

Service 1: An annual healthcheckPeople with severe mental illness should be invited to the surgery every 15months for a healthcheck. This should include a check of physical health –e.g. screening for diabetes and a blood pressure check. Following Rethink’srecommendation, this will now include more health promotional activities –e.g. cholesterol and obesity check, provision of information or referral toservices regarding diet, exercise, drug and alcohol use and smoking.

This is very important as people with severe mental illness currently die 10years younger than others because of physical health problems. Yet thisgroup are offered less health promotional advice. People with severe mentalillness have high rates of smoking and are more likely to experience smoking-relating disorders than other smokers. We need real action to stop this. Inorder for people to receive this health check, they must sign up to be on apractice register. This is not a scary prospect – registers just exist to make iteasier for practices to organise their records. They exist for other healthconditions like diabetes, epilepsy and asthma.

Rethink pointed out to the panel that some people may not agree to go on aregister because they are fearful of what this might mean. The new contractmeans that GPs will get paid for making contact with people who do notattend health checks. This is an important step forward.

Service 2: Keeping a care planPeople with severe mental illness should have a care plan in their records thatexplains their health needs, how they are to be met and what should be donein a crisis. This should include people’s wishes about medication, what theyconsider ‘early warning signs’ and how they wish to be treated in a crisis. Itshould also include the views of relatives and carers, if appropriate. This planshould be reviewed in the regular healthcheck.

There are also new processes for treating people who are newly diagnosedwith depression – GPs must now use an agreed tool if they are to receiveextra money for these consultations. The measures for lithium monitoring arethe same as before. All this adds up to a much better deal for people withsevere mental illness.

Do remember that it’s not just the GP contract that can help you get thetreatment you deserve in primary care. The Disability Discrimination Actapplies to people with mental illness and says that public services like GPsmust make a ‘reasonable adjustment’ to allow people to use their services.This might mean granting a longer appointment or not requiring you to sit ina crowded waiting room for a long period. If there’s an adjustment that youneed, tell your GP about it. It’s your legal right.


news

National men’shealth week

Rethink launches overseas challenges

Overseas challenges have been introduced this yearas a new way of fundraising and raising awareness

for Rethink. You can take part in some of the mostadventurous trips available in far-reaching corners of theworld – and what’s more you don’t need ANY previousexperience.

TrekkingWhether you’re in the deserts of the Sahara or thewilderness of Iceland our local guides will be on hand tomake sure you get the most out of your trip.

18 - 26 August 2006: Iceland TrekWith its striking mix of wild volcanic landscape dottedwith streaming lava fields, icecaps, glaciers, waterfalls,bubbling hot springs and geysers, the stunning Icelandiclandscape is one you will never forget.

4 - 13 Oct 2006: Peru TrekFollow in the steps of the ancient Incas as you trek to thelost city of Macchu Picchu.

CyclingWith our cycle rides bikes are provided, although youcan bring your own if you prefer. All our trips areaccompanied by qualified mechanics with a full rangeof spares.

30 Aug - 3 Sept 2006: London to Paris CycleConnect two of the world’s most chic capital cities as youembark on the challenge of a lifetime for charity.

29 Oct - 10 Nov 2006: Vietnam CycleDiscover this hidden land of bright green paddy fields,rugged mountains and white sandy beaches.

If you are interested in taking part in an overseaschallenge to raise money for Rethink, please contactthe community fundraising department on 0208 5479202 or [email protected]

MBE awarded to group member

Rethink would like to offer its congratulations toRegional Reference Group Member (North West),

Lily Reid, who has been honoured by the Queen inthe New Years Honours List.

Lily has been awarded the MBE for her ‘services to thecommunity’. For over the last thirty years Lily has beenrunning carers and users groups in the Bury area ofLancashire.

Regional Manager Grainne Currie presented Lily with abouquet of flowers congratulating her on her years ofdedication and commitment.

Lily plans to travel to London in May to collect heraward from Buckingham Palace.


obituary

Mrs Kasheen ThompsonJacqueline’s concern about John,and could see her steely resolve, andher determination that she wouldback this courageous man and hiswife come hell or high water. I stillhave her papers for the meeting withher bold, illegible and confidentnotes and comments, including theresolution to make a donation of £10per head for administration costs.

Kasheen immediately embarked onsome intensive letter writing andgained encouraging responses fromvarious people including Churchleaders whom she had volunteeredto approach, such as DonaldCoggan, Archbishop of York, BasilGuy, Bishop of Gloucester, and fanRamsay Bishop of Durham.Meanwhile on a more personal levelJacqueline Pringle wrote to her inAugust1970:

“My own feeling is that just talkingwith new parents in like case orletting them talk to you – is perhapsthe most useful thing we motherscould do”.

The mutual support given at thistime was critical for both families.Both saw that the local groupneeded to be complemented by anational effort. For this reason onOctober 1970, at the request of JohnPringle, Kasheen responded to theinvitation to attend a meeting of MrsBaker and her new group in Bath.Typically Kasheen ducked aninvitation to become the newchairman. My mother backed JohnPringle’s vision of a national bodywith local branches.

Her solid support is disclosed in aletter from John Pringle written onMay 14th 1971. John wrote to mymother and said “ I remember theFortitude in your voice when you toldme about having to go into hospitallast December. And a few linesfurther on:

“I have by no means given up thehope of getting this venture going, butone must face it – that the obstaclesare very formidable”. This was the yeardescribed by David Morphet in TheEarly Years as a low point.

But on November 1st 1972 Johnwrote to Kasheen to say:“I am sure that you are glad that wehave got going at last. It has been along struggle against manydifficulties, and without the generousstimulus and encouragement of theoriginal group, which met in Londonin 1970 to spur me on, I don’t think Icould have kept going through thesetwo difficult years. Thanks foreverything”.

John wrote another long letter onDecember 1st 1972. For the first timeit is on note paper headed:THE SCHIZOPHRENIAFELLOWSHIP.It begins: “I have been awaitinghearing from you with some anxiety,of all the original group you and yourfamily have been most in ourthoughts. I don’t know why thisshould be so except that you havebeen carrying as great burdens asanyone known to us and showinggreat courage”.

The last letter from John was onFebruary 16th 1979. She had writtento him to congratulate him on theOBE. He replied: “You and MrThompson were among the ‘first ofthe few’ as I shall always remember,and now your son David is deeplyinvolved in NSF affairs....”

Kasheen continued to be linked withthe NSF and was a ferociousbehind-the-scenes recruiter. Sheintroduced a number of key playersto the Fellowship – amongst themost significant being Philip Wilmot(Chair NSF and Chair WorldSchizophrenia Society) whom she

The Early Years, the NSF,published in 2002 gives someaccount of the role played byKasheen Thompson in theconception and birth of theNSF in 1970-72. It was abehind the scenes role,because this was her way; buta glimpse of the support shegave to John Pringle, and thesupport she gave over manyyears to the NSF, is to be seenin correspondence from 1970to 1979.

She was an enthusiastic respondentto The Times’ article of May 1970,and in spite of her own difficultiesgave John Pringle unwaveringsupport from the outset. It was onMay 21st 1970 that John Pringlewrote to Kasheen to say that he feltsufficiently encouraged to call asmall private meeting. This was heldin the Wellcome Foundation on July25th that year.

I remember her awareness andsensitivity that day to John Pringle’sanxiety about the meeting, and

KASHEEN THOMPSON was one of the early pioneers of theNational Schizophrenia Fellowship which was to become Rethink.Kasheen’s son, the Rev David Thompson, who was also very muchan early activist talks about the crucial role his mother played inhelping to develop the organisation.


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spotted and encouraged at once –before he was actively involved withthe NSF.

On the twenty-first anniversary of theNSF she was invited to cut the cakeat the celebration. By this time shehad experienced many yearssupporting my father who had had aserious breakdown in his earlytwenties, her son, whose conditioncaused her to respond to JohnPringle’s article, and her belovedgrandson who has struggled withschizoaffective disorder for the bestpart of twenty years. In addition shehad looked after my father‘s elderlyparents in her own small home from

Where would you go if youwanted to find 50 people

interested in volunteering forRethink? Or where could yousign up over 40 new Rethinkmembers in one day? Ashopping centre? A GP’ssurgery? What about a universitycampus?

Rethink in Northern Irelandattended a student ‘WorkExperience and Volunteer Fair’ atQueen’s University in Belfast onWednesday 23rd February 2006and that is what happened! 50people completed volunteerenquiry forms and 46 peoplesigned up there and then tobecome members of Rethink.

Rethink Northern Ireland set upan exhibition stand at the eventwhich was attended by studentsfrom all the faculties andschools ranging frompsychology to aeronauticalengineering to medicine. Over50 organisations took exhibitionspace including many from the

voluntary sector. Rethinkwas represented by ColinMcAlister (CommunicationsTeam Leader), RosemaryMcKeever (Volunteer andQUB student) and MariaCallan (Volunteer and NIManagement Committeemember).

The fair attracted studentswho wanted to broadentheir knowledge and addvaluable experience to theirCVs. Those who visited theRethink stand were eager toknow more about mentalhealth and the outstandingwork Rethink does. Manywere keen to investigate volunteeringwith Rethink.

Many of the students who visited theRethink stand were psychologystudents and Rosemary, apsychology student herself,explained the many benefits Rethinkmembership brought to thoseconsidering such a career path.Maria with her enthusiasm for

including everyone took everyopportunity to encourage peopleto join Rethink and work with usto improve the quality of life ofeveryone affected by mental ill-health. At the end of a hectic butfun day we had raised the profileof Rethink and added many newmembers and volunteers. Welldone to the team!!

Recruiting for Rethink

• Maria Callan and Rosemary McKeever

the age of twenty-one just after herfirst child was born, and her ownmother whom she looked after inthe family home for the best part ofthirty years.

I think she may aptly be called a“caring relative”. Her attitude: “Do notthink what your family can do for you,but what you can do for your family.”She continued to retain a livelyinterest in Rethink until the end ofher long life, and was in touch withthe Cambridge group within the lastfew years.

Kasheen has three sons, Patrick,David and Michael, who survive her.

All three are members andsupporters of Rethink. We areamazed and overjoyed by how farRethink has travelled. It is beyondour wildest dreams.

In her last decade Kasheen wasfinally free from familyresponsibilities, and enjoyed life inHolt in her little flat surrounded byWoodlands, and kept abreast ofworld affairs through a thoroughperusal of The Times. She died atHigh Kelling in the early hours ofFebruary 4th fortified by the words ofJulian of Norwich “All manner ofthings shall be well”.

David Thompson


book review

Depressed, paranoid, schizophrenic, maniac:a sane person’s experience with mental illnessBY MICHELLE CANN

Michelle Cann has written a very powerful book. Thefact that it is all true makes it exceptionally

important. Michelle chronicles her own story of battling amental illness that infiltrated her mind, manipulated herthoughts and rendered her world unrecognisable. It alsotested her faith in God and human nature. Michelle startsthe book by decribing her wonderful childhood and adultyears. Her life was full of music, holidays, swimming,games with two loving parents and her brother. It was thebeginning of a very meaningful spiritual walk, andalthough she would later drift away from God for a shortwhile, it is her faith in God that is all inspiring. She wassuccessful at Academia as well as at sport particularlyswimming, which gave her a life-long interest in exercise,fitness and good nutrition. She qualified with a Bachelorof Arts degree, followed by a Law degree. She then tookup a position with the Bermuda Government in theAttorney-General’s Chambers.

After five years there she joined a private firm for threeyears. Although she was successful in both jobs, therewere signs that some sort of illness was appearing. Shedescribes how she began to feel that people were hostileto her and gossiping about her. Several weeks after sheleft her last job, she felt the line between reality and fantsygradually began to waver and blur; she had no idea thather grasp on reality was slipping. During the early days ofhospitalisation, she had some disordered thoughts thatwere totally different from any that she had beforeentering hospital, preoccupied with the idea that herfamily belonged to some sort of a religious cult, and thatthe reason why she was in the hospital was for de-programming. She also began to question certainindisputable facts; for example, that her family of originwas her true biological family!

After this first illness she changed career and moved acompletely new direction – Mortuary Science, whichwould allow her to become the fourth generation of herfamily to manage their Funeral Business. All went well atthe family business for a couple of months, but she hadanother relapse. During her mania this time she wrote herpsychiatrist a letter which started off saying she wasdiagnosed with schizophrenia in 2002.

She then went on to say that she has since realised thatmental illness “is nothing more than the mind’s way ofprotecting itself from overwhelming pain”. The letter

continued to say “unfortunately my particular situationmay involve such things as incest, attempted murder,tremendous emotional maniplation and severe socialisolation “She then created a test for her abuser to takeand attached it to the letter. She realised later on thatwhat she wrote in the letter was not true. This sort ofparanoia can be very disturbing to relatives and carers ,as they are often blamed by therapists who take them tobe the cause of the problem. Sadly there still remains afew people working in Mental Health, who when theyhear this sort of talk, immediately think there is sometruth in what the client says.

Due to the very different presentation of symptoms in hersecond manic episode, she was re-diagnosed as beingmanic depressive as opposed to schizophrenic,and thenagain she was finally diagnosed as bi-polar. One of thethings that the author found most helpful during herillness was to write down her thoughts, as she wasdescending from the mania. Aside from creating a partialrecord of her thoughts she could refer to later, it had thesame effect on her as organising her physicalpossessions in her hospital bedroom. It allowed her togradually regain order and reason in her mind as themedication took effect. The feeling of having somecontrol over the disease process gave her a great deal ofcomfort because her writing materials were availablewhenever she needed them. Her recovery from hersecond episode was over all much faster and morepainless that the recovery from her first episode.

This book will leave you gasping at times because of itssheer honesty. We should all be grateful to Michelle forsharing such an interesting book with us. She is contentnow to serve a God who has promised to restore theyears that have been stolen from her, and she feels thereis no reason to waste an ounce of energy on regret. So Iend this review on those powerful words, and wouldencourage all users to do the same.

Depressed, paranoid, schizophrenic, maniac:a sane person’s experience with mental illness

by MIichelle Cann

Published by Trafford Publishing (ISBN 1-4120-6845-2)Available online at www.trafford.com/05-1756

MARY NAPIER reviews MichelleCann’s most recent book


events

keep usposted!

Deadline for copy for thenext edition:22nd May 2006

Send your letters to:

Terry Hammond – EditorYour Voice40 Sea ViewNetley AbbeySouthampton SO31 5BQ

Try to restrict the length of your lettersto 150 words maximum. Your Voicereserves the right to edit letters.

18th – 24th AprilNational Depression Weekwww.depressionalliance.org

10th OctoberWorld Mental Health Daywww.wfmh.orgFor further infomation on any of theseevents telephone 0845 456 0455.

Useful websiteswww.ukselfhelp.info/links(the self help section is very good)

www.healthcare-events.co.uk(details of forthcoming conferences)

Victory as Churchill statue is torn downDaily Express Tuesday March 14 2006

Dear Editor I am not offended by this statue but I am offended by what Ihave seen reported in the press. I found nothing degrading in the

photograph and I still see Sir Winston Churchill as the great man he is.

It seems to me that this statue was created to draw attention to the fact hesuffered from this illness. Not to demean him, but to remind people we are allhuman beings, who can suffer from it. It seems to me he stands unbowedeven in straight jacket, and looks out on the world with the strength andcourage we remember him for.

Are we somehow to believe that the appreciation of him as a sufferer ofdepressive illness lessens him? If drawing attention to, or acknowledging, hisillness causes us to view this great man as reduced (and only such reductioncould cause us to view this as degradation) how low must we consider thoseordinary folk who suffer as he did?

Rethink’s error was in overestimating the enlightenment of our communityand its willingness to look at the deeper message. This statue has failed todraw the sympathetic interest of people to the problem of mental illness. Butit has succeeded spectacularly is uncovering peoples’ true attitudes towards it.

Where no insult is intended any perception of such is a mistake on the part ofthose believing so. Is it really likely that an organisation dedicated to helpingthose with mental health problems would deliberately set out to insult them?It appears that selectivity is at work here; certain people have chosen to beinsulted because they can’t make the effort look at the true motives of thosebehind the statue.

‘Insulting, ignorant and appalling’

Is this the true feeling in the House of Commons? Churchill is demeaned andinsulted by this association with the illness he suffered? How does thisattitude reflect when they consider the rest of those who currently suffer? Aperson can only be whole if untainted by mental illness? If those in power areso short sighted and un-enlightened the future does not bode well.

‘Is that not an insult both to his memory and to those with genuine mentalhealth problems’?

I have seen nothing indicating that a genuine sufferer of a mental healthillness was given the opportunity to offer their own opinion; as to whether, ornot, they had been insulted. Is this because they are considered unimportantas a group and incapable of forming a valid opinion? I am highlyunimpressed by the tone of reporting in the press. If it is to be believed thenthey have revealed in themselves, certain highly placed individuals and theHouse of Commons an enduring, negative attitude towards those who suffermental health problems.

If it is indeed a victory it rings hollow to me.

Andrew Wouldham

viewpoint


fact file17• a regular series of features on aspects of mental illness

produced by Rethink’s National Advice Service

Pregnancy and mental health problems

white halo design tel: 024 7631 0779

Pregnancy can be one of the most exciting times for allparents-to-be, but for people with mental illness it can alsobring added concerns. As the body changes throughpregnancy, mental health can be affected in different waysand day-to-day management of symptoms throughmedication may no longer be possible or advisable. This isbecause some types of medication used to treat mentalillness can present a risk to an unborn baby. But you can takesteps to minimise the risk to yourself and to your baby byunderstanding the complexities of pregnancy and mental illness.

Medication and pregnancyResearch shows that women who suffer from a psychoticillness are at an increased risk of relapse during pregnancy,often as a result of suddenly stopping their medication whenthey find out that they are pregnant. Also, severalpsychotropic drugs carry a small risk of birth defects if takenduring pregnancy. But medication accounts for only a smallproportion of the total number of birth abnormalities; it hasbeen shown that people with schizophrenia are more likely tohave minor physical anomalies than the general population,some apparent from birth, others not till later on in life.

If you are taking medication for mental illness and wish tobecome pregnant you should discuss your plans with yourdoctor. If you are on medication and you find out that you arepregnant, you should contact your doctor immediately. Ingeneral, it is desirable to minimise or avoid the use ofmedication during pregnancy and a plan should be drawn upfor you and your doctor to monitor your mental healththroughout the pregnancy.

The Maudsley Prescribing Guidelines (2005) outline somegeneral principles about prescribing and taking medication formental illness during pregnancy:• Doctors should treat with drugs only when absolutely

necessary, where potential benefit outweighs potentialharm – mentally ill women who are pregnant are very likelyto require treatment, especially those who have hadrepeated relapses,

• Prospective parents should be fully involved in alldiscussions regarding the pregnancy,

• Women with mental health problems should consider therisk of relapse if thinking about stopping treatment – havinga relapse as a result of stopping treatment may result inhaving to take a higher dose than would otherwise havebeen necessary,

• It’s best to avoid, where possible, using drugs in the firstthree months of pregnancy – this is the time when thebaby’s major organs are being formed,

• Use established drugs at the lowest effective dose,• Avoid multiple drug treatments (polypharmacy) where

possible,• Parents-to-be should try to make full use of available

screening procedures during the pregnancy,• The baby should be monitored after birth in order to check

for any signs of withdrawal effects,• All decisions should be accurately documented by the

medical team.

Antipsychotics –The older antipsychotics (typicals) aregenerally thought to have a very small risk of causingmalformations in the unborn baby. Evidence from researchinto the more modern atypicals is still being collected, althoughOlanzapine is widely used in the UK.

Antidepressants – Treatment with antidepressant drugs forwomen who develop depression during pregnancy should onlybe used when psychological management techniques havenot worked.

The older ‘tricyclic’ antidepressants have been widely used formany years without any apparent negative effects on theunborn baby, although some babies of mothers who haveused these drugs in the last three months can show signs ofwithdrawal effects after birth.

The more modern SSRIs also appear not to be linked withcausing abnormalities when used during pregnancy.

But MAOIs should be avoided in pregnancy because of asuspected increase in the risk of congenital malformations, andthe risk of increasing blood pressure to dangerously high levels.

Mood stabilisers – The risk to women with bi-polar disorderof relapsing before or after birth is very high if drug basedtreatment is stopped abruptly, so they are likely to be advisednot to stop their treatment. For women who have had a longperiod of stability and are planning a family, it may be possibleto stop treatment before conception and for at least the firstthree months. This should be discussed by the parents-to-beand their doctor.

No mood stabiliser is safe – Lithium has an association tocardiac malfunction although this is low (1 in 1000),

Valproate, which has the most known links to foetalabnormalities, carbamazepine and combinations of moodstabilisers should be avoided if possible.

After the birthThere is an increased risk of new mothers developingdepression, or having a new psychiatric episode within threemonths of birth – 10% of pregnant women will go on todevelop a depressive illness. This risk is highest for women withbi-polar disorder. Ideally women should not be separated fromtheir babies during hospitalisation. Special mother and baby unitsor designated beds on maternity wards are the recommendedoptions for new mothers with mental health problems.

If you are worried you are at risk of this you could discuss whatyou would like to happen in such events with your doctor.

Breastfeeding whilst on medicationIf you are planning to breastfeed you should be aware thatsmall amounts of some medications pass into breast milk. Thepotential benefits and risks of breastfeeding your baby whiletaking psychotropic medication should be discussed with yourdoctor, who should also be able to let you know the specificsrelated to the particular medication(s) you are taking.

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