Head of Mental Health at The Scottish Government,
Directorate for Health and Social Care Integration Mental Health and Protection of Rights Division
T: 0131-244 3749
26 September 2013
I said I would write to you with a summary of our meeting on 19 September.
This was a wide-ranging meeting although the initial focus of your engagement over recent months has been on dementia.
We covered your concerns on what you see as the risks around over-diagnosis of dementia and the over-medicalization of memory loss in old age. As discussed the Scottish Government’s shift of emphasis from early to timely diagnosis is quite a subtle and nuanced one reflecting the balance of clinical and other opinion in favour of the latter. The essential principles – reflected in our strategic focus on post-diagnostic support embodied in the HEAT target – are that, as you know, people benefit from an accurate and timely diagnosis and there can be significant advantages in getting the diagnosis at the stage of the illness (early on) when they can get optimum benefit from post-diagnostic support to adjust to the diagnosis (both psychologically and practically), connect better and navigate through services and plan for and make active and informed decisions on future care. We recognise that there are some challenges around early diagnosis in that diagnosing some dementias are difficult in the early stages.
You also shared some concerns you have about the potential ethical issues around diagnosis and the roll-out of post-diagnostic support in areas such as consent and confidentiality. More broadly you are strongly of the view, as we are, that responding to memory loss and dementia should be informed by a holistic, person-centred and human rights-based approach. This is exactly the approach taken in developing and implementing not only the post-diagnostic HEAT target – which adopts a comprehensive, person-centred model, supported by the roll-out of national training and awareness not only to front-line staff but also to operational and strategic managers – but also the dementia standards and the Promoting Excellence framework.
In dementia and other areas you expressed your on-going concerns about the risk, as you see it, of disproportionate influence of pharmaceutical companies in inculcating and sustaining a clinical culture where there are risks of over-diagnosis and where drug treatments are over-prescribed. You argue that greater transparency is needed regarding the relationships between such companies and individual clinicians and practices.
We had some discussion on the prescribing of anti-depressants. I explained that although our national target on reducing anti-depressant prescribing had been superseded on our target on increasing access to psychological therapies as a main lever for change and improvement, implementing the anti-depressant target in Scotland had been an immensely valuable process and helped us learn more about the issues involved than many other parts of the world.
We have good evidence of the appropriateness of clinical practice in this area. The study “ Newly initiated anti-depressant treatment in Scotland: a database study” (Christopher Burton & Colin Simpson, Centre for Population Health Sciences, University of Edinburgh) found that their “data suggest better adherence to treatment [in Scotland] than in three recent reports using comparable routine care data from England, Spain and the USA” . In addition, John Gillies, the Royal College of General Practitioners Chair has said: “As the stigma attached to mental health has declined, more patients raise problems such as depression with their GPs. There is good evidence that GPs assess and treat depression appropriately. Good prescribing practice often means treating patients at a therapeutic dose for longer to avoid a recurrence. This explains much of the rise in prescribing”.
Our over-riding principles are that people with mental illness should expect the same standard of care as people with physical illness and should receive medication if they need it. While we ensure those who need medication continue to receive it, we are also committed to improving access to alternatives, such as psychological therapies, that increase choice and best accommodate patient preference.
Thank you for taking the time to meet with me. Please let me know if at any time you wish to or have the time to get involved in or contribute to dementia work streams being taken forward as part of implementing the 2013-16 strategy. I know you have already contributed your views on our work with stakeholders to develop a national commitment to reduce the prescribing of inappropriate psychoactive medications in the treatment of dementia.