Response to a Petition Against the NICE guidelines

Okay so I’m going to acknowledge that this blog post might be a little divisive. But if I look around at our society right now, most issues regarding health are. This is probably more of an opinion piece than many of my posts, which I do research (yes, I read scientific journal articles to make sure I get the facts as straight as possible for all of you). I did a post (and a podcast episode) about the guidelines that came from NICE in the UK regarding the treatment of chronic pain awhile back. These guidelines were controversial within the medical community itself because, well, they recommend against the use of pain medications due to a lack of evidence that they are effective AND that many of them can be addictive. Doctors, of course, like to prescribe medications.

Image from: https://www.rcplondon.ac.uk/news/first-evidence-based-nice-guidance-diagnosis-monitoring-and-management-asthma

The recommendations for the treatment were: (1) exercise, (2) acupuncture, (3) cognitive behavioural therapy, (4) acceptance and commitment therapy, and (5) anti-depressants. I recently saw a post on Instagram that linked a petition against these guidelines. The reasoning behind the petition was that it makes it harder for people to get the treatment (i.e., medications) that they need to manage their chronic pain. Much like doctors, most patients also feel like medications are the way to go (which is a fairly western version of pain management – check out the podcast episode with Dr. Richard Harris for an East meets West version of pain management that tends to work better). Now, I’m not saying that pain medication doesn’t work for anyone ever. And I don’t think that’s what they guidelines are saying either. They are saying that the evidence-base isn’t strong for most of those medications, but it is strong for these alternative treatments. The other argument in the petition is that the alternative treatments are expensive and not covered by insurance. I’m going to break each of these arguments down a bit further.

Me during a hike this summer.

So first, whether or not people will still be able to access pain medications. Regardless of these guidelines I find it very hard to believe that most Western doctors will stop prescribing pain medications. Like I mentioned earlier, most doctors were upset by the guidelines in the first place. Also, doctors are trained to prescribe medications, they aren’t trained (literally almost no training) on prescribing alternative treatments. It’s more than likely they’ll go with what they know. They might though be more willing to recommend alternatives as adjunct treatments. This is actually what my rheumatologist did. She recommended that in addition to the medications she prescribed, I seek out alternative treatments such as physiotherapy and naturopathy (and I did and they were helpful). I get why people are upset about the guidelines, especially if they mostly rely on medications. The guidelines do state that for some conditions (mostly CRPS) pain medications do work best (it’s best just to read all the guidelines – AND all the hyperlinks that give fuller explanations yourself – available here).

Image from: https://www.shutterstock.com/search/no+medication

The second point that alternative treatments are expensive, is true and not true at the same time. Exercise is technically free. I exercise at home – both cardio (walking) and strength training (body weight) and have spent $0 on it since the pandemic started (I did go to the gym before that). But a lot of people with chronic pain are hesitant about exercising (check out the podcast episode with Dr. Frank Nahn). Acupuncture can be a bit pricey depending on where you live, but it is sometimes covered by insurance. I had insurance through work that covered my naturopath, who did acupuncture, for up to $500 a year. That’s about 6 sessions. I’m not saying it’s always covered, but it might be. CBT and ACT, the two psychotherapies listed are along the same lines as acupuncture. They might be covered or they might not be. In the province (Canada) that I live, it is covered up to a certain amount by provincial insurance, or short-term therapy is also covered by the provincial government. There are also self-help versions of these available at bookstores and online. Finally, anti-depressants, again may be covered by extended health insurance if you have that. Also, wouldn’t a better petition to be to try and get governments (or insurance companies) to cover these services for chronic pain and chronic illness patients? Just a suggestion…

As a therapist who went into the field to help people with chronic pain and illness (and their co-occurring mental health issues I decided to primarily use ACT with my clients due to its large evidence base).

I guess what I’m saying is that if you dislike the guidelines because you only rely on medication but also haven’t tried or even looked into these alternatives, then it makes sense that you’d be upset. I would be too! I started using some of these alternatives (exercise, acupuncture, CBT/ACT) long before these guidelines came out and I saw how much they improved my well-being, well over and beyond what my medication has ever done. I also find it interesting that I often see posted online people complaining that their medications aren’t really helping. It’s easy to have some cognitive dissonance here. We want to believe medications will solve all our problems even when we’re acknowledging that they’re not. I’m doubtful that I’ll change too many minds with this post, but my hope is that we at least get thinking about using both holistic approaches (like in NICE’s guidelines) and are medication together so that we can get the best results.

Okay, that is all for this week. Keep making the most of it everyone!

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Treating Depression

Depression is one of the most common mental health problems (right up there with anxiety). It also commonly co-occurs with chronic illnesses. If you’re feeling depressed, or have been diagnosed with Major Depressive Disorder, it’s really important you are treating it in some form. As a therapist-in-training, I see many clients with depression – some with both depression and anxiety, some with perinatal depression, some with depression and chronic illness – and there are a lot of evidence-based treatments out there. It’s really important to know that you don’t have to suffer alone. So I thought this week, we’d talk about some common treatments, and some up-and-coming ones for depression. I also have an entire podcast episode dedicated to depression and chronic illness this week, which you can access here.

This week’s podcast.

For chronic illness, depression most frequently occurs in people with Alzheimer’s, autoimmune diseases of all sorts, cancer, coronary heart disease, diabetes, epilepsy, HIV/AIDS, hypothyroidism, and Parkinson’s. I got into the criteria for major depressive disorder in the podcast episode, so definitely check that out for more information. When it comes to treating depression, the two most common routes are anti-depressant medications and psychotherapy. Anti-depressants most commonly come in the form of SSRIs (selective serotonin reuptake inhibitors) that alter our brain chemistry because it is implicated in depression (our brains are not the only thing that is implicated though). There is a lot of research that supports anti-depressants in treating depression, though research also shows that it works as well as a placebo. In other words, if you believe it will help it will. Now don’t get me wrong, I fully support someone taking medication (unless you’re pregnant or breast-feeding and can’t – thus why I see many perinatal moms in my practice), however what a lot of people find is that just taking medication isn’t enough to see significant improvements in their symptoms, and many people don’t want to rely on medication forever.

Depression affects about 20% of the population in their lifetime.

That’s where option 2 comes in: psychotherapy. As a student, I see about 10 clients a week plus I co-facilitate a group for 2 hours a week. There is a lot of research that supports the use of psychotherapy. My podcast episode on anxiety, which you can access here, breaks down how much your therapist and you each contribute to your outcomes in therapy, which is important to know. As for what type of therapy, there are many to choose from and they all have good outcomes. CBT (cognitive-behavioural therapy) and it’s third-wave counterparts (DBT, ACT, SFT, etc) are the most common. Typically this involves a combination of talk therapy, where you tell your therapist about your thoughts and feelings, and then the therapist giving you some things to try out in session that you can also practice between sessions (some people call it “homework” but I don’t like that term). Another option for therapy is psychodynamic, which involves talk therapy plus the therapist often makes interpretations. And then there are the therapies that rely mostly on talk, utilizing the therapeutic relationship, such as person-centred, existential, etc. All of these can help and are something I highly recommend. There is also evidence that different lengths of therapy are beneficial as well, from one session of drop-in counselling to short-term (10-20 sessions) of CBT or long-term (more than 20 sessions) of person-centred therapy.

Our thoughts and feelings can be like quicksand. Our natural tendency is to struggle, but that only makes us sink deeper in. The actual way to get out of real quick sand: be a still and flat as possible and let yourself float to the surface.

If you are in immediate crisis because of self-harm, abuse, trauma, and suicidal thoughts/plans, then please contact your local help line. I’ve put some numbers in the show notes for my podcast on depression. A quick Google search can help you find them in your country. If you don’t like talking on the phone, there are some organization that offer texting services. I volunteered for Kids Help Phone in Canada which had switched to primarily a texting hotline since many young people prefer to text. You are strong for reaching out because it is not easy to.

Canada.

In terms of other treatments, a few are available for treatment-resistant and severe depression. Electroconvulsive therapy (ECT), which used to be called “shock therapy” can be helpful for people with severe depression, though there are some potential harmful side effects, and psychiatrists don’t commonly use this unless necessary. Transcranial Magnetic Stimulation (TMS) is another option for treatment-resistant depression where magnetic pulses stimulate the nerves in your brain. Newly approved in Canada (and how I got the idea for this post) is the use of Ketamine for treatment-resistant depression. Ketamine is a dissociative drug that has a lot of research supporting its use for depression. It activates your glutamate, dopamine and serotonin receptors in your brain. It takes effect much quicker than anti-depressants and has shown to decrease suicidal ideation. So far research shows no long-term side-effects, though because it is a psychedelic drug, there is the chance of substance dependency.

Great video for anxiety and depression.

Whether or not you have chronic illness, if you have depression there is hope for recovery, and lots of options available. Talk to your GP, your psychiatrist, a psychotherapist or whomever else is or could be part of your mental health care team. That way, you can keep making the most of it.