“If it wasn’t for Open Dialogue I wouldn’t be here now. This time last year, I was suicidal. I had totally lost faith in the mental-health services; I felt I’d been put in the ‘too difficult’ box.”
Suzanne Chapman has been in and out of the mental-health system since attempting suicide twice in her early twenties. Now 49, she’s had every treatment for depression and bipolar disorder: medication, therapy, ECT. For long periods of her life, the drugs worked.
But three years ago, she hit her worst crisis: a bout of depression that made her unable to function. “On Christmas Day, my daughter gave me a potato to peel and I just stared at it. I had no idea what to do with it. I had no strength; I would just lie on the settee or shuffle about the house. I wasn’t coherent, I wasn’t sleeping, I’d lost three stone. I felt so dark, so alone, so worthless.” None of the drugs that had helped in the past made much difference. Suzanne had to give up her job as an administrator and her husband, Simon, a police officer, took three months off to look after her. The couple have two daughters, aged 27 and 25, and a two-year-old granddaughter.
By the time Suzanne was offered an experimental treatment called Open Dialogue last October, she was desperate. It’s a pioneering approach that enables patients and their families to develop their own route to recovery. After just three sessions, Suzanne’s husband noticed a “miraculous” improvement; he now says, “I’ve got my wife back.” Suzanne accepts that she will never be free of depression, but says it’s now firmly under control.
Open Dialogue is currently being piloted in four NHS trusts. It could revolutionise mental-health care in the UK, according to its champions, who include Suzanne’s psychiatrist, Russell Razzaque. The North East London Foundation Trust, where he works, has just given the go-ahead for an Open Dialogue-based service for patients referred from anywhere in the country, starting next May.
Open Dialogue is primarily for people who are suffering a mental-health crisis such as suicide or psychosis – 1.8 million of them in the UK last year. They badly need help: a damning report from the Care Quality Commission in June found that the current system is struggling to cope with mental-health crises, with 42 per cent of patients not getting the help they need. A campaign launched last month calls for an increase in funding for mental-health services and parity with physical health.
The Open Dialogue approach was first developed in Finland in the 1980s, which at the time had one of the worst incidences of schizophrenia in Europe. There are now well-established services in Berlin and New York, where state investment in four respite centres that practise Open Dialogue has been doubled to $100m (£66m). Services are also springing up in Italy, Poland and Scandinavia.
What’s most impressive about Open Dialogue is its success with even the most intractable mental illnesses, where current systems of care too often fail, or offer only short-term respite. Results over the past 30 years from Finland sound impressive: 74 per cent of patients experiencing psychosis are back at work within two years, compared with just 9 per cent in the UK. Crucially, relapse rates are far lower than here: after an average of two years’ treatment, most patients don’t need to come back – ever. Here, a mental-health diagnosis can feel like a life sentence.
Open Dialogue’s key principles are: people are seen within 24 hours of becoming unwell; and all meetings with the psychiatric team are held at home, or wherever the patient finds most helpful. Significant others in the patient’s life – family members, or trained peer-support workers – are engaged in meetings from the word go.
Health news in pictures
Health news in pictures
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The majority of antidepressants are ineffective and may be unsafe, for children and teenager with major depression, experts have warned. In what is the most comprehensive comparison of 14 commonly prescribed antidepressant drugs to date, researchers found that only one brand was more effective at relieving symptoms of depression than a placebo. Another popular drug, venlafaxine, was shown increase the risk users engaging in suicidal thoughts and attempts at suicide
RoschetzkyIstockPhoto / Getty
2/25 'Universal cancer vaccine’ breakthrough claimed by experts
Scientists have taken a “very positive step” towards creating a universal vaccine against cancer that makes the body’s immune system attack tumours as if they were a virus, experts have said. Writing in Nature, an international team of researchers described how they had taken pieces of cancer’s genetic RNA code, put them into tiny nanoparticles of fat and then injected the mixture into the bloodstreams of three patients in the advanced stages of the disease. The patients' immune systems responded by producing "killer" T-cells designed to attack cancer. The vaccine was also found to be effective in fighting “aggressively growing” tumours in mice, according to researchers, who were led by Professor Ugur Sahin from Johannes Gutenberg University in Germany
3/25 Green tea could be used to treat brain issues caused by Down’s Syndrome
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6/25 Dementia patients left without painkillers and handcuffed to bed
Dementia patients experience a ‘shocking’ variation in the quality of hospital care they receive across England, a charity has warned. Staff using excessive force and not giving dementia patients the correct pain medication were among the findings outlined in a new report by The Alzheimer’s Society, to coincide with the launch of Fix Dementia Care campaign
7/25 Cancer risk 'increased' by drinking more than one glass of wine or pint of beer per day
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8/25 Vaping 'no better' than smoking regular cigarettes
Vaping could be “no better” than smoking regular cigarettes and may be linked to cancer, scientists have found. The study which showed that vapour from e-cigarettes can damage or kill human cells was publsihed as the devices are to be rolled out by UK public health officials as an aid to quit smoking from 2016. An estimated 2.6 million people in the UK currently use e-cigarettes
9/25 Rat-bite fever
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10/25 Taking antidepressants in pregnancy ‘could double the risk of autism in toddlers’
Taking antidepressants during pregnancy could almost double the risk of a child being diagnosed with autism in the first years of life, a major study of nearly 150,000 pregnancies has suggested. Researchers have found a link between women in the later stages of pregnancy who were prescribed one of the most common types of antidepressant drugs, and autism diagnosed in children under seven years of age
11/25 Warning over Calpol
Parents have been warned that giving children paracetamol-based medicines such as Calpol and Disprol too often could lead to serious health issues later in life. Leading paediatrician and professor of general paediatrics at University College London, Alastair Sutcliffe, said parents were overusing paracetamol to treat mild fevers. As a result, the risk of developing asthma, as well as kidney, heart and liver damage is heightened
12/25 Fat loss from pancreas 'can reverse' effects of type-2 diabetes
Less than half a teaspoon of fat is all that it takes to turn someone into a type-2 diabetic according to a study that could overturn conventional wisdom on a disease affecting nearly 3 million people in Britain. Researchers have found it is not so much the overall body fat that is important in determining the onset of type-2 diabetes but the small amount of fat deposited in the pancreas, the endocrine organ responsible for insulin production
13/25 Potatoes reduce risk of stomach cancer
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15/25 Sugar tax
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A potentially “phenomenal” scientific breakthrough has offered fresh hope to cancer patients rendered infertile by chemotherapy. For the first time, researchers managed to restore ovaries in mice affected by chemotherapy so that they were able to have offspring. The scientists now plan to begin clinical trials to see if the technique, which involves the use of stem cells, will also work in humans by using umbilical cord material and possibly stem cells taken from human embryos, if regulators agree
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18/25 Health apps approved by NHS 'may put users at risk of identity theft'
Experts have warned that some apps do not adequately protect personal information
19/25 A watchdog has said that care visits must last longer
The National Institute for Health and Care Excellence (Nice) said home help visits of less than 30 minutes were not acceptable unless part of a wider package of support
20/25 Pendle in Lancashire tops list of five most anxious places to live in the UK
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21/25 Ketamine could be used as anti-depressant
Researchers at the University of Auckland said monitoring the effects of the drug on the brain has revealed neural pathways that could aid the development of fast-acting medications. Ketamine is a synthetic compound used as an off anaesthetic and analgesic drug, but is commonly used illegally as a hallucinogenic party drug. Dr Suresh Muthukumaraswamy, a senior researcher at the university and a member of the institution’s Centre for Brain Research, used the latest technology in brain imaging to investigate what mechanisms ketamine uses to be active in the human brain
22/25 A prosthetic hand that lets people actually feel through
The technology lets paralysed people feel actual sensations when touching objects — including light taps on the mechanical finger — and could be a huge breakthrough for prosthetics, according to its makers. The tool was used to let a 28-year-old man who has been paralysed for more than a decade. While prosthetics have previously been able to be controlled directly from the brain, it is the first time that signals have been successfully sent the other way
23/25 The biggest cause of early death in the world is what you eat
Unhealthy eating has been named as the most common cause of premature death around the globe, new data has revealed. A poor diet – which involves eating too few vegetables, fruits, nuts and grains and too much red meat, salt and sugar - was shown to be a bigger killer than smoking and alcohol
24/25 Scientists develop blood test that estimates how quickly people age
Scientists believe it could be used to predict a person’s risk of developing Alzheimer’s disease as well as the “youthfulness” of donated organs for transplant operations. The test measures the vitality of certain genes which the researchers believe is an accurate indication of a person’s “biological age”, which may be younger or older than their actual chronological age
25/25 Aspirin could help boost therapies that fight cancer
The latest therapies that fight cancer could work better when combined with aspirin, research has suggested. Scientists from the Francis Crick Institute in London say the anti-inflammatory pain killer suppresses a cancer molecule that allows tumours to evade the body’s immune defences. Laboratory tests have shown that skin, breast and bowel cancer cells often generate large amounts of this molecule, called prostaglandin E2 (PGE2). But Aspirin is one of a family of drugs that sends messages to the brain to block production of PGE2 and this means cancer cells can be attacked by the body’s natural defences
What service users appreciate most is that they always see the same people. Annie Jeffrey, whose son took his own life last year after suffering from psychosis for five years, and relapsing several times, explains why this is so important: “Many service users say they feel like a parcel passed from one team to another: community services, in-patient services, crisis teams, psychiatric liaison… The number of times I went to meetings with my son to see a team of people we’d never seen before and we would never see again. How are you supposed to start talking to someone you don’t know? My son just felt that he wasn’t listened to.”
What also sets Open Dialogue apart from standard treatment is that discussion about patients takes place in front of them, in what are called “reflections” between members of the team; this adds to the sense of control.
For Suzanne, this was a turning point. After just a couple of sessions, she found herself talking about traumatic events and emotions she’d kept bottled up for 30 years. She explains: “The ‘reflection’ gives you a different perspective and makes you see how other people view your situation. In the past, I was always frightened that what I said would be judged. I was so afraid of talking about my past, and how dark I actually felt, for fear they’d call an ambulance to take me away. So I went into denial.
“Open Dialogue is totally different to any kind of therapy I’ve had before. At first, I didn’t know what to expect, but it helped that the psychiatrist and nurse were on my territory. I could always ask them to leave.”
Open Dialogue is not anti-medication. Treatment, from drugs to different kinds of therapy, is agreed by everyone at the meeting. Suzanne currently takes a mood stabiliser plus diazepam if her anxiety gets overwhelming. But whereas the mainstay of standard treatment is usually medication, the mainstay of Open Dialogue is talking. Dr Razzaque explains: “In normal treatment you explore what has led to the crisis, but then the response is usually to prescribe medication. Whereas with Open Dialogue the service user takes the driving seat in understanding what are the factors that have led them to be the way they are. That’s a very healing thing.”
It’s not immediately obvious what it is about Open Dialogue that makes people open up. Clearly, seeing the same team builds trust. Longer sessions help, too. In the early days, Suzanne met Dr Razzaque three times a week, and meetings lasted as long as three hours, whereas in the old system, appointments with her psychiatrist were 15 minutes to an hour. Therapy sessions were limited to six or eight – not enough to establish trust, she says.
But there’s something else which encourages patients to open up: mindfulness. Every member of the team, from psychiatrists to support workers, practises it. Dr Razzaque explains: “This is not about teaching service users mindfulness. This is about clinicians practising mindfulness themselves. It’s very stressful to be in meetings where we really give patients the space to explore their emotional difficulties. So clinicians need some emotional training themselves – such as mindfulness – to enable them to facilitate that environment.”
Annie Jeffrey, who started training to be an Open Dialogue support worker after her son’s death, agrees: “I’ve found it very hard to listen to people being very emotional because you always want to make people feel all right, don’t you? But you learn to sit with that, instead of trying to shut all that emotion down. And service users say how helpful that is.”
But surely the big stumbling block is that 90-minute meetings several times a week are totally unrealistic for our cash-strapped, overstretched mental-health services. In some areas, doctors are struggling to meet National Institute for Health and Care Excellence standards of seeing patients within 14 days, never mind 24 hours.
Critics also stress the need for more robust evidence before ploughing precious NHS funds into expanding an experimental service. Evaluation will inevitably take time. A multi-centre research trial conducted by University College London will publish its results in 2020.
Dr Razzaque insists that Open Dialogue doesn’t have to place an extra burden on staff. He also argues that in the long term, it won’t cost more than previous initiatives to improve mental-health services, such as training swathes of cognitive behavioural therapists. This is partly because of the low relapse rates: once patients have been discharged, the majority don’t need to use services again. Dr Razzaque adds: “The frequency of meetings is the same as it would be normally in the initial period: over two years, meetings average out at just one a month; over five years, it’s once every two months. Putting intensive, highly focused support in that early time of crisis enables people long term to graduate from services altogether.” µ
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