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 日本でも報道されることのあるHonor killingSeppuku、何が違うのだろうと思う。




Good health is born of a good society. Little wonder that we’re suffering


Deaths registered in England and Wales: 2015


The British are in the midst of a critical health epidemic. In the 12 months to June 2016, the number of deaths jumped by the biggest absolute and relative amount since 1940 – a rise of 52,400. And this appears not solely to be an effect of a growing and ageing population, since the increase is spread across age groups. (Deaths rose by 12% among those aged 90 and over; 10% for 85-89; 7% for 80-84; 5% for 75-70; and 3% for those aged 55-74.) This is unprecedented in peacetime .

The jump, unreported in national media, is not entirely a surprise. Death rates have been rising slightly since 2010, reversing what was a steady fall since the 1970s. This is part of a general decline in health and wellbeing over the same period. The Office for National Statistics’ survey of wellbeing reports that the numbers who are self-reporting satisfaction with their health has consistently declined since 2010. The “happiness index” recorded its lowest ever level in March 2016.



Happiness depends on health and friends, not money, says new study

Happiness study 'lets austerity off the hook', psychologists claim

Mental illness and poverty: you can't tackle one without the other

Origins of happiness: Evidence and policy implications


 日本同様、この冬、イギリスでもノロ・ヴァイルスが猛威を振るっている。予防喚起の報道記事に寄せられる読者からのコメントを読むと、暗澹たる気持ちになる。何でもかんでも皮肉らなければ気が済まないイギリス人の負の気質が全開。先月、イギリス人の友人達とランチをともにしたとき、健康の話題もでて、建設的な意見を言えないイギリス人全般への印象を、「Many British people show their incapacity to be serious when they have to be serious」といったら、場が一気に静まった。





Beer and Philosophy: Engagement Japanese Style

By Bridget Grenville-Cleave

In the UK business community there is a growing interest in the topic of employee engagement, sparked by a government-commissioned report in 2009, Engaging for Success: Enhancing Performance through Employee Engagement. In November 2012 the report’s authors, David MacLeod and Nita Clarke, established a group called Engage for Success (EfS) which describes itself as a “movement committed to the idea that there is a better way to work, a better way to enable personal growth, organizational growth and ultimately growth for Britain by releasing more of the capability and potential of people at work.”

Anything linked to higher performance, productivity and profit (and making companies more recession proof) is going to interest business leaders. Not surprisingly, how to engage staff in the workplace is making waves in many organizations big and small. It’s also becoming an important topic in positive psychology (for example see the work of Wilmar Schaufeli at the University of Utrecht or the chapters devoted to employee engagement in the Oxford Handbook of Positive Psychology and Work).

But are we over-intellectualizing engagement?

As is the case with many management-related topics, much has been written about employee engagement by various gurus, consultants and HR practitioners which isn’t necessarily evidence-based. A recent discussion in the EfS LinkedIn Group started with the question, “Are we intellectualizing employee engagement too much?” Perhaps, it was suggested, it’s a management capability that some managers ‘get’ because they’re naturals at people-related stuff. And maybe there are other managers who just don’t get it, no matter how compelling the business case?

The question was prompted (not entirely tongue-in-cheek I believe) by a BBC article about the turnaround of Japanese Airlines Company (JAL), which had filed for bankruptcy in 2008 with debts of $25bn, yet by 2012, was back in profit and relisted on the Tokyo Stock Exchange. How had it re-engaged employees and achieved this remarkable turnaround in such a short space of time?

JAL’s remarkable recovery, it seems, is to a great extent attributable to the actions of its Chairman, Kazuo Inamori, who was appointed in late 2009. Leaving aside the fact that, had JAL been a Western company, Inamori would never have got the job on account of his age (80 years old) and lack of aviation experience (prior to joining JAL, he had precisely none), I’m not sure his management techniques would have been endorsed by many Western leaders either. According to several news reports, what Inamori did to re-engage employees and lead JAL back into the black was to insist on compulsory philosophy sessions for all staff, washed down with free beer.

I was so intrigued by this story that I wanted to delve a bit deeper. Having recently stumbled on Honda’s connection with positive psychology, I hoped Kazuo Inamori’s business philosophy might yield some positive psychology gems too.

In a section on his website entitled ‘philosophy keywords’ Inamori outlines his approach to running a business with employee happiness at its heart. Although he doesn’t use positive psychology language, there is a great deal which is based on its principles, for example:

Passion and Meaning

In a section called ‘aim high’, Inamori talks about the need for passion, keeping energy levels high, and having a cause at work to elevate us. Whilst not referring explicitly to flow or strengths, this section captures the essence of performing meaningful work, which we now know is linked to increased well-being.

Optimism and Pessimism

For effective business planning he recommends the following: “Conceive optimistically, plan pessimistically, and execute optimistically“. According to Inamori, it’s essential that we master the ability to switch viewpoints, from optimism to pessimism, and back again to optimism. I really liked this advice; it reminded me of Philip Zimbardo and Ilona Boniwell’s research into time perspectives which suggests that a balanced time perspective (the ability to move between future, past and present orientations) is linked to greater well-being.

Leading a Wonderful Life

In a section on elevating our minds, Inamori suggests the following behaviors:

Having an open mind
Being humble, thankful and cheerful
Acting with a loving, sincere, and harmonious heart

Again, although there’s no overt reference to positive psychology, what springs to mind are the VIA character strengths of open-mindedness, humility, gratitude, optimism and love.

It All Comes Down to Employee Happiness

In an interview earlier this year Inamori told the Wall Street Journal:

When I first came to JAL, I told executives that we have to state the management’s philosophy and share that with everyone at the company. I also told them we don’t need many statements. One thing we need to say is that the management’s goal is to pursue the happiness of all employees, both physically and mentally…That was what it all came down to.

It wasn’t for shareholders, and it wasn’t for executives. It was for all the employees working at the company. We put that at the very beginning of our philosophy statement. ‘This is your company, and its goal is to make all of you happy.’

To share the idea that the company’s goal is to make all employees happy is a prerequisite, before sharing any other ideas. The whole philosophy wouldn’t work without this prerequisite.

Going back to the Engage for Success question about whether we’re over-intellectualizing employee engagement, positive psychology’s answer is definitely ‘no’. Although positive psychology didn’t exist as a science for the larger part of Kazuo Inamori’s career, the roots of much of what he recommends can be found in its research and evidence base.

I’ve no idea how many of the UK’s business leaders will read Inamori’s management philosophy, ask their managers to study it or apply it to their companies, but they probably should. They might opt for handing out free bottles of beer though. Despite some considerable time searching, I’m afraid we still don’t know what brand he supplied.

 面白い試みだと思って読み始めたけど、僕にはとてもぬるい内容に思える。日本理解の参考になるとは感じられない。それに、著者自身のリサーチが全く欠落しているので、どうしてこれを書きたかったのかが見えない。心理学関連の論文やエッセイで「research and evidence base」がでてくると、統計で得られたのであろう数字と推測を一般論として「事実」とする姿勢には詭弁を感じる。




 9月初旬、アメリカ人フェミニスト(らしいです)のNoami Wolfさんの最新の著作、「Vagina」がイギリスでも発売になり、主にガーディアン紙が大騒ぎになりました。

Naomi Wolf: 'Neural wiring explained vaginal v clitoral orgasms. Not culture. Not Freud'

Vagina by Naomi Wolf – digested read

Naomi Wolf's book Vagina: self-help marketed as feminism


 で、この本の直後に、ガーディアン、さらにテレグラフやタイムズも大喜びで取り上げたのは、アメリカ発の映画でした。壮年期後半に差し掛かったセックスレスの夫婦をメリル・ストリープとトミィ・リー・ジョーンズが演じる「Hope Springs」。イギリスではかなりヒットしたようです。


It’s not too late to save our marriage

The bedroom blues


 で、ここからが本題。特にウォルフ女史の本のレヴューや批判のコラムを読んでいるとき、Vagina やPenis等の単語がたくさんでてきました。口にしようが、頭の中でこれらの単語を思い浮かべようが、何ら思うことはありませんでした。単に、体の一部にしかすぎないので。
 しかしながら、これらの単語を日本語に訳してみると、ちょっと違った感情がわいてくるのを感じました。で、ネイティヴ・スピーカーにとって、Vagina とかPenisって、もちろん公の場で大声で言う言葉ではないですが、口にするのがはばかれる感覚があるのかを回りの友人たちに尋ねてみました。

 友人と言っても、心理関係、カウンセリングに携わっている人が多いので、皆一様に、「Vagina、Penis は基本、Technical termsだから」。テクニカル・タームズを日本語にすると、技術用語。
 友人たちから言われたことで一つ面白く感じたのは、language dissociation。言葉の無関連性とでも言うのか。同じ事象を表す言語でも、その事象と言葉の関連性を知らなければ、無意味でしかない、ということ。このことを言われたときに思い出したのは、フランスでの経験。パリのサン・ジェルマン地域に、「」というそばをメインにした日本料理のレストランがあります。





My dear boy, please don’t put a label on me - don’t make me a category before you get to know me!




 彼が最もpissed offした批判は、「セクシャル・マイノリティ」と称される人たちから寄せられたそうです。それは、「あなたはゲイではないから、エイズの蔓延については本当のことはかけない」、というもの。僕の想像ですが、アーヴィングが怒ったのは、「ヘテロ・セクシャル」というラベルをアーヴィングに貼付けることによってゲイの人たちは彼らの視点を狭めている、ということではないかと。
 アーヴィングが彼の憤りを語る前に言ったのは、「Label would narrow you」。僕は、この点は、ラベルを貼る側も貼られる側も同じだと感じます。日本だけではないと思いますが、日本の例を。




Laura Jane Grace: 'So I'm a transsexual and this is what's happening'

 かなり長いですが、ジェンダー、結婚、家族という枠組みに関心がある人にはmust readのインタヴューだと思います。読者からのコメントを読むと、イギリスでもこのようなジェンダーにかかわることへの理解は混乱している印象を持ちます。



I happen to be a homosexual.


I happen to be a man.

I happen to be a woman.

I happen to be a Japanese.

I happen to be a British.

I happen to be a heterosexual.


 ジョン・アーヴィングが言った、「Label would narrow you」の本質が彼の思考のどこにあるのかは判りません。ラベルを貼る側、貼られることを甘んじている側、ラベルを自ら主張することで外から隔絶する人たち、そしてそのラベルをもてはやすだけのメディアは、人々が持つ可能性を見失い、視野を狭めているだけなのではと感じます。



Mental Health in Primary Care 2

Mental Health Policy: No health without mental health
Mental health has become a core part of primary care in the UK. However, this central role has only recently been recognised through policy imperatives around the new mental health workforce and opportunities to re-examine how mental health services can be constructed and organised in primary care (Lester and Glasby, P.75, 2010).

In 2011, the UK government made their latest policy of mental health: No health without mental health. The core strategy of this demonstrates a set of “shared objectives to improve mental health outcomes for individuals and the population as a whole”. The six shared objectives are as follows:

More people will have good mental health
More people with mental health problems will recover
More people with mental health problems will have good physical health
More people will have a positive experience of care and support
Fewer people will suffer avoidable harm
Fewer people will experience stigma and discrimination
(DoH, P. 6, 2011a)

According to the government, this new approach means a different approach to direction setting: developing strategies to achieve outcomes. Outcomes strategies focus on how practitioners on the front line can best be supported to deliver what matters to service users within an ethos that maintains dignity and respect (DoH, P. 11, 2011a). In line with the discussion of how the quality of mental health in primary care is improved, what changes the third object, More people with mental health problems will have good physical health, is expected to make is focused on.

As we have already explored, society has improved its awareness of how physical health affects mental health and vice versa. The government has also recognised the relationship as it presents some of the data; having a mental health problem increases the risk of physical ill health and depression increases the risk of mortality by 50% and doubles the risk of coronary heart disease in adults (DoH, P. 23, 2011a). Since about 90% of people with mental health problems are now managed entirely in primary care, ensuring that all people have access to effective primary health care is fundamental to improving the recognition and management of mental health problems (DoH, P. 33, 2011b).

In order to realise the government’s mental health strategy in primary care, improving the skills of primary care staff to enable them to recognise mental health problems earlier and to deliver appropriate treatments in a primary care setting is recommended by the National Institute of Health and Clinical Excellence (NICE) guidelines (DoH, PP.33-34, 2011b). In addition, different types of treatments, such as psychological therapies, in primary care are considered. Psychological therapies have been shown to improve outcomes for people of all ages with long-term physical conditions and mental health problems (DoH, P.61, 2011b). The expansion of psychological therapies has become a government priority, which should make psychological treatment more easily accessible in primary care (RCPSYCH and RCGP, P. 80, 2009). This clear understanding reflects an understanding that investing in mental health has a pay-off through physical health (CEP, P. 7, 2006).

While some GPs show their interest in developing a therapy capacity within their practice, the majority welcome the provision of a psychological treatment outside the practice, to which they can refer their patients (CEP, P. 9, 2006). Partly because of this situation, the government is accelerating a programme for people to have more access to psychological therapies in primary care.
This plan is not new as NHS proposed a plan a decade ago that one thousand new graduate primary care mental health workers would be employed to help GPs manage and treat common mental health problems in all age groups (DoH, 2000, cited in Lester and Glasby, P.70, 2010).

The current programme is called the Improving Access to Psychological Therapies (IAPT) programme and aims to improve delivery of talking treatments to service users with mental health problems (RCPSYCH and RCGP, P. 7, 2009). The policies and details of the programme are;

The IAPT programme began in October 2007 when the government announced annual investment rising to £173m by 2010/11 to fund the roll-out of evidence-based psychological therapy services across England for people experiencing depression and anxiety disorders. The treatments offered are those approved by NICE for treating common mental health problems (NHS, P. 4, 2011b).

Investing around £400 million over the four years to 2014/15 enables every adult that requires it should have access to psychological therapies to treat depression (DoH, P. 2, 2011c).

More people with long-term physical health conditions, medically unexplained symptoms or severe mental illness are routinely offered evidence-based psychological treatments when appropriate, as part of personalised care planning (DoH, P.4, 2011c).

The IAPT programme was created to offer patients a realistic and routine first-line treatment for depression and anxiety disorders, combined where appropriate with medication – which had traditionally often been the only treatment available. The programme was first targeted at people of working age. The economic case on which it was based showed that providing therapy could benefit not only the individual but also the nation, by helping people come off sick pay and benefits and stay in or return to work (DoH, P.5, 2011c).

It is based on a ratio of around 40 therapists serving a population of 250,000 (DoH, P. 13, 2011c).

In the next section, we will explain how IAPT works in primary care setting by introducing its two pilot sites, and then discuss what IAPT can further offer to the society.

How IAPT works in primary care
Psychological, or ‘Talking’, therapy is a broad term covering a range of therapeutic approaches; they involve talking, questioning and listening to understand, manage and treat people’s problems. (NHS, P.19, 2007). A meta-analysis on psychological treatment finds that the psychological treatment of depression is effective in primary care patients. (Cuijpers et al, 2009). Thus, for the government, the Improving Access to Psychological Therapies (IAPT) programme is the main focus on the delivery of psychological therapies as part of a primary care setting.

The IAPT programme is at the heart of the Government’s drive to give greater access to, and choice of, talking therapies to those who would benefit from them and aims to implement NICE Guidance for people with depression. The government calculates that one in six working adults, who are current targets patients group, at any one time are suffering from clinical depression. In the first phase of the programme, two demonstration sites were established in Doncaster and Newham with funding to provide increased availability of cognitive-behaviour therapy-based (CBT) services to those in the community who need them. The services opened in late summer 2006 (CEP, 2008; NHS, P.4 & P.8, 2007).

By September 2007, the number of the patients who attended at least two sessions at both demonstration sites were 1654 at Doncaster and 249 at Newham. Both sites achieved good recovery rates (52%) for people who had depression and/or an anxiety disorder for more than 6 months. Another finding which can be highlighted is to offer patients a self-referral route to psychological therapies in primary care setting. GPs act as a “gate keeper” to specialist treatment services. However, concern that a GP only access system may disadvantage some individuals with mental health problems led the Newham Demonstration site to experiment with self-referral (Clark et al, 2009).
Although the rate of the self-referral at Doncaster was less than 1 %, 21% of the patients at Newham accessed to the treatment were as self-referral (CEP, P. 30, 2008). In addition, providing a self-referral route appears to enable the service to access disabled individuals in the community who are not well served by existing GP only referral systems routes (CEP, P. 2, 2008).

Another notable result is that the two demonstration sites succeeded in helping people off sick pay and benefits so that they could stay in or return to work (DoH, P.5, 2011c). As a worked example, IAPT programme delivers efficiency and possible cash savings to local NHS of an estimated £1,060 on average for each additional person who recovers from depression or anxiety disorder (NHS, P. 2011a).

There are some points about how the IAPT will be developed for the society. Firstly, the current target patients group is working-age people with common mental illness, such as depression and anxiety disorder, but the government is to extend the programme for people with severe mental illness (DoH, P. 16, 2011c). In addition to this group, the government is also to include people with long-term physical health conditions, such as diabetes, cardiovascular disease or chronic obstructive pulmonary disease. The reason is that these people often have comorbid mental health conditions, but they are rarely referred for psychological interventions, despite good evidence that such management of mental health problems can reduce their need for GP appointments (DoH, P. 19, 2011c).

Secondly, the point of who delivers appropriate psychological therapies in primary care should carefully be assessed. In line with the efficiency of CBT, Haby et al (2006) raise an issue. Although they find CBT effective when offered by a psychologist, they are not clear whether psychiatrists, social workers, nurses, general practitioners or other professional groups can achieve the same efficacy. The British government say that the IAPT programme requires a total of 6,000 new IAPT High Intensity and Psychological Wellbeing Practitioners (PWP) workers (NHS, P.18, 2011b) for full coverage across the NHS. The training programme which they propose may better be updated in regular timing in order to keep the quality of the service to the society in primary care setting.

As demonstrated, both government and society have improved their understandings of how mental and physical health affect each other. Their awareness has also motivated primary care staff, for instance GPs, to provide appropriate treatment for mental illness as well as physical health problems. In addition, the government has keenly implemented the specific programmes to ensure the depressed can have more easy access to get psychological treatments in primary care setting. Needless to say, however, GPs are not trained as psychological therapists while the therapists in the programme cannot treat physical health problems. It is a vital point for us to know from whom we can have necessary treatment for either mental or physical health problems in a primary care setting.
(4349 words)

The Centre for Economic Performance’s Mental Health Policy Group (2006): The Depression Report

The Centre for Economic Performance’s Mental Health Policy Group (2008): Improving Access to Psychological Therapy: Initial Evaluation of the Two Demonstration Sites

Clark, D.M., Layard, R., Smithies, R., Richards, D.A., Suckling, R. and Wright, B. (2009): Improving access to psychological therapy: Initial evaluation of two UK demonstration sites. Behaviour Research and Therapy, Vol. 47, 910-920

Cuijpers, P., van Straten, A., van Schaik, A. and Andersson, G. (2009): Psychological Treatment of depression in primary care: a meta-analysis. British Journal of General Practice, February, e51-e60

DoH (2000): a plan for investment, a plan for reform cited from Mental Health Policy and Practice by Lester and Glasby (2010)

DoH (2011a): No health without mental health: A cross-government mental health outcomes strategy for people of all ages

DoH (2011b): No health without mental health: Delivering better mental health outcomes for people of all ages
DoH (2011c): Talking therapies: A four-year plan of action

Haby, M.M., Donnelly, M., Corry, J., Vos, T. (2006): Cognitive behavioural therapy for depression, panic disorder and generalized anxiety disorder: a meta-regression of factors that may predict outcome. Australian and New ZealandJournal of Psychiatry 40, 9-19

Lester, H. and Glasby, J. Mental Health Policy and Practice second edition (2010) Palgrave Macmillan, Hampshire, UK

NHS (2007): Commissioning a brighter future

NHS (2011a): Commissioning Talking Therapies for 2011/12

NHS (2011b): Guidance for Commissioning IAPT Training 2011/12 – 2014/15

The Royal College of General Practitioners (2005): Mental Health and Primary Care

The Royal College of Psychiatrists and Academy of Medical Royal Colleges (2010): No Health without Mental Health: the supporting evidence

The Royal College of Psychiatrists and the Royal College of General Practitioners (2009): The management of patients with physical and psychological problems in primary care: a practical guide

Pilgrim, D. Key Concept in Mental Health second edition (2010) Sage, London, UK

Running On Empty report (2005)

Schreuders, B., van Marwijk, H., Smit, J., Rijmen, F., Stalman, W. and van Oppen, P. (2007): Primary care patients with mental health problems: outcome of a randomised clinical trial. British Journal of General Practice, November, 886-891

Mental Health in Primary Care 1



Relating your discussion to recent and relevant policy, critically discuss the relationship between mental and physical health care and the way in which primary care services can respond to wider issues of mental illness in local populations.

As mental health issues become less stigmatised in our everyday life and society than before, our society shows a clearer understanding of what issues in mental illness we have to tackle to improve the quality of the treatment for those who suffer from mental disorders. Indeed, treatments for people with mental illness, such as depression and anxiety disorder, have been frequently updated by the government. Nonetheless, there are always continuing debates about the most suitable treatment for the depressed in primary care to be provided and how primary care staff should handle mental health problems while they also care for physical health problems.
The aim of this report is, therefore, to discuss how mental health and physical health affect each other while to identify what impact depression, as one of the common mental health in the UK primary care, causes on our society. Then, with an evaluation of a recent mental health policy, we will assess the sort of treatment for the depressed is offered in primary care setting.

The term ‘depression’ refers to a wide range of mental health problems characterised by low mood, loss of interest and enjoyment in ordinary things and experiences, and a range of associated emotional, cognitive, physical and behavioural symptoms (RCPSYCH and RCGP, P. 40, 2009). At a global level, depression is forecast to be the second most common cause of ‘disability’ by 2020 (Lester and Glasby, P.3, 2010), and depression is the most common mental health problem that doctors diagnose at primary care in the UK (RCPSYCH and RCGP, P.40, 2009). Accelerated by society’s improving attitudes towards mental illness (it is now less stigmatised and we talk about it more openly), the British government’s mental health policy has regularly been updated and developed. It seems that both society’s and people’s understandings of mental illness, such as depression and anxiety disorder, have become clearer and more compassionate than before.

In addition, since the National service framework for mental health: modern standard and service model was issued in 1999 (according to Lester and Glasby [P. 41, 2010] this is the first document in mental health to set a common agenda for local agencies), the quality of effective services for people with mental illness in the UK has been changing and has improved. For instance, better mental health care in primary care setting has been provided and consistent advice and help for people with mental health needs, including primary care services for “individuals with severe mental illness” (Lester and Glasby, P.41, 2010), has been provided and improved.

However, with our new more accurate understanding of mental illness, our society has also become aware of the serious impact caused by mental illness; our understanding of the seriousness of this impact has become clearer and the impact has increased. Although issued in 2006, The Depression Report warns that the total loss of output due to depression is “some £12 billion a year”. In other words, the more people suffer from depression, the less our society flourishes. Mental health effects both our well-being and our economic prosperity.

Furthermore, there are now more discussions focusing in particular on how depression affects physical health. One recent report shows that there is a high prevalence of major depression in people with chronic medical conditions with associated increases in the use of health services, lost productivity and functional disability (RCPSYCH and RCGP, P.42, 2009). Another report concludes: depression itself is a risk factor for physical illness and major depression doubles one’s lifetime risk of developing type 2 diabetes. Depression has also been proven to be a risk factor for the development of heart disease (RCPSYCH and AMRC, PP.9-10, 2010). The UK government is also aware of this point: depression is associated with a 50% increased mortality and doubles the risk of coronary heart disease. Having two or more long-term physical conditions increases the risk of depression seven-fold (DoH, PP. 33-34, 2011b). However, there is an opposing view on the relationship between physical health and mental health: people with chronic medical illness, compared to those without, have an increased risk of depression (RCPSYCH and AMRC, P.9, 2010). In the next sections, we will explore how mental and physical health affect each other and the impact they both exert on in primary care.

Mental health/ Physical health
Approximately one quarter of people with physical illness develop mental health problems as a consequence of the stress of their physical condition (RCPSYCH and AMRC, P. 9, 2010). Since illness is a threat to self, all illnesses have a “psychological impact” (RCPSYCH and RCGP, P.16, 2009) although its outcome can be different among people. If illness is a threat to self-identity, most individuals will be stressed by their symptoms and how they respond can influence the outcome either way. (RCPSYCH and RCGP, P.18, 2009). In other words, a person’s physical health status predicts their mental health and vice versa (Pilgrim, P.50, 2010). In the latest Mental Health policy, No health without mental health, the government clearly demonstrates an awareness that mental health and physical health affect each other: mental health problems such as depression are much more common in people with physical illness. Having both physical and mental health problems delays recovery from both (DoH, P. 23, 2011a).

Here are some figures which display the relationship between mental health and physical health.

Approximately 20% of patients have clinically significant depression at the time of diagnostic cardiac catheterisation.
Depression increases the risk of developing coronary heart disease (CHD) and of adverse outcomes among those who already have CHD (RCPSYCH and AMRC, P.25, 2010).

Depression may be a risk factor for type 2 diabetes; in several prospective studies, depression predates the onset of type 2 diabetes by many years. Depression and depressive symptoms are associated with poorer glycaemic control, diabetes complications and increased risk of death (RCPSYCH and AMRC, P.26, 2010).
Severity of diabetic symptoms is more strongly associated with depressed mood than with glycosylated haemoglobin levels (RCPSYCH and RCGP, P.43, 2009).

These data support the government’s view that both the development of mental health problems and the results are associated with poorer physical health (DoH, P. 9, 2011b).

As discussed above, the awareness of the important relationship between mental and physical health seems to have strengthened in primary care setting. In reality, however, there are still some discrepancies in the clinical setting. According to the joint report issued by two health professionals institutions, most people with chronic illness now receive a regular review of their physical condition by their GP, but psychological status is often neglected despite the fact that all patients with chronic illness should receive a regular review of their physical, psychological, social and spiritual needs (RCPSYCH and RCGP, P.34, 2009).

If we wish to narrow the gap, there are a couple of situations to be considered. For instance, although depression is common in physical illness, particularly in chronic illnesses, mental health services are “separated from physical health services with separate commissioning processes, targets and service boundaries” (RCPSYCH and RCGP, P.7, 2009). In addition, primary care is charged with providing care for common mental health problems and contributing to health promotion, but there is a “lack of clarity about who should lead on the care of those” (RCPSYCH and AMRC, P.17, 2010) with mental health problems.

Another report finds that when a chronic physical disease is found to be present, there is the risk that attention will shift to this disease and the depression may be overlooked (RCPSYCH and AMRC, P.11, 2010). This may be due to prioritisation of physical health problems, perceived lack of expertise among GPs, or reluctance by patients to engage in mental health services. For instance, this causes a situation that the majority of depressed CHD patients do not receive adequate treatment for their depression (RCPSYCH and AMRC, P.26, 2010).

In order to improve the situation that both mental health and physical health are treated as a whole in primary care setting, a criticism which also seems to be a helpful opinion should be considered:

Many mental health care practitioners have little training in how to manage physical care, the rates of physical assessments of those under care are poor and the monitoring of physical health and health education is generally unsatisfactory. This situation results from the fact that healthcare services are often fragmented and un-coordinated, with both clinicians and those under care, unaware of available and appropriate resources (Running On Empty, P.11, 2005).

It is important for health care professionals to understand how mental health can affect overall physical health and vice versa (Running On Empty, P. 19, 2005).

Primary Care
Before we explore the government recent mental health policy, it is useful to understand what role the UK primary care plays in the society. By summarising their description from Mental Health Policy and Practice (Lester and Glasby, 2010), primary care in the UK generally offers rapid access for routine and crisis care in a low-stigma setting. A key strength of the primary care is open access where the patient is seen as part of a complex network of family, friends, work and social life. Because different patients display and talk about their own unique problems, primary care has developed sophisticated ways of working with the uncertainty and complexity of its environment. The front line staff of primary care services are GPs, practice nurses, district nurses, health visitors, practice managers, administrative staff (Lester and Glasby, PP.55-75, 2010).

Recently, primary care has been asked to play another role that provides and increasingly commissions good quality mental health services since most people with mental health issue are seen and treated within this setting (Lester and Glasby, P.13-14, 2010). Primary care in commissioning services has come to meet the needs of local people who are experiencing the common mental health problems of depression and anxiety disorders (NHS, P.1, 2011a).

The need to address patients’ psychological welfare has clearly been recognised in primary care and many people now present to GPs with physical symptoms that often have an underlying psychological component. (RCPSYCH and RCGP, P.6, 2009). As well as their physical needs, primary care has been important for people with mental health problems. There are two reasons; first, over 90% of them will be in contact with their GP or other primary health care worker. Second, only 10% of such patients are referred on to specialist mental health services. Consequently, most people with mental health problems only receive a primary care response (Pilgrim, P.77, 2010).

The need to increase the recognition and treatment of depression in the community through the development of guidelines for depression (Lester and Glasby, P.65, 2010) has been one of the main issues which the UK primary care has been tackling. As a result, at present 2¾ million patients come to GP surgeries each year with depression or anxiety (CEP, P.10, 2006). In the average GP surgery in the UK around one in four people consulting a doctor will be significantly distressed psychologically as defined by validated instrumental measures and systematic clinical assessment (RCPSYCH and RCGP, P.18, 2009). Another report shows that 90 per cent of people with mental health problems are cared for entirely in primary care (RCPSYCH and AMRC, P.17, 2010).

As secondary mental health services focus more and more on severe mental illness, primary care mental health teams and GPs are faced not only with service users with mild or acute psychological issues, but also those with long-standing problems and chronic difficulties. Primary care services are best placed to provide a comprehensive and integrated service for individuals with both physical and mental health problems, providing there is sufficient skill base among the staff and resources to manage these kinds of problems (RCPSYCH and RCGP, P. 76, 2009).

Despite the above, some new issues have recently emerged. First, primary care is the gateway to specialist services but because of limited capacity in the latter, non-specialist staff are often left to manage complex cases (Pilgrim, P.78, 2010). Second, healthcare professionals working in primary care are well placed to understand the relationship between physical health problems and mental health (DoH, P.33, 2011b), but mental health problems are particularly hard to detect when there is an overlap of symptoms (RCPSYCH and AMRC, P.11, 2010) unless the staff are provided training to improve their understanding of the relationship between mental health and physical health. In addition, clinical barriers, such as short appointment times, a lack of knowledge about depression and treatment, or a lack of time to talk to the patient about these issues can also prevent detection of mental illness (RCPSYCH and AMRC, P.11, 2010).
Health professionals express their further concern how mental health problems are not satisfyingly treated in primary care setting;

Some healthcare professionals may not think to enquire about psychological symptoms, or may feel uncomfortable doing so. Even if the symptoms of depression are discussed, practitioners might regard depression and anxiety as understandable reactions to being physically unwell. As such, the patient’s symptoms are normalised and the practitioner might not realise the mental health problem could be treatable (RCPSYCH and AMRC, P.11, 2010).

What GPs do for the depressed in primary care
In the recent British mental health policy context, primary care has been charged with improving services to people with mental health problems in two ways. First, primary care practitioners are now expected to ensure consistent advice and help to people with mental health problems. Second, all patients should have their mental health needs assessed (Pilgrim, P.78, 2010). Therefore, GPs are now seen to play a key role in helping patients to cope with physical illness and “facilitating a natural psychological adjustment” (RCPSYCH and AMRC, P.17, 2010). The majority of people with serious mental illness and with common mental health problems are now registered with a GP while only approximately 10 per cent of people with a mental health are seen by secondary care mental health specialists (Lester and Glasby, P.65, 2010). Mental health issues are the second most common reason for consultations in primary care. GPs in England spend on average approximately 30 per cent of their time on mental health problems (Lester and Glasby, P.65, 2010).

Although they are responsible for most people with mental health problems within primary setting (Pilgrim, P.78, 2010), GPs are criticised for their lack of mental health knowledge and the low achievement in treating depression. For GPs, consultations with patients who have health problems related to anxiety and depression frequently pose a challenge for which there are two main reasons. Firstly, limited time is available: patients with these issues take up more time during a consultation and attend more frequently than other patients, often with vague reasons for their visit. Secondly, the implementation of treatment is often complicated (Schreuders et al, 2007).

This situation echoes a result of a survey. According to Lester and Glasby (P.67, 2010), only one third of GPs have had mental health training in the last five years, while 10 per cent have expressed concerns about their training or skills needs in mental health. Hence, GPs are, in general, less likely to make a diagnosis of depression when people present with physical symptoms (RCPSYCH and RCGP, P. 44, 2009).

In addition, GPs may need to be careful not to over-diagnose depression. In UK general practice, particularly since the advent of once-daily antidepressant medication, there is a growing tendency to use a diagnosis of depression as an apparently handy means of finding one’s way out of consultations that doctors find difficult to resolve (RCPSYCH and RCGP, P. 45, 2009). GPs vary a great deal in their likelihood of making a diagnosis of depression. This is partly related to the way they approach mental health as a clinical problem. In other words, GPs are more likely to make a diagnosis when they feel comfortable about treating depression (RCPSYCH and RCGP, P.43, 2009).

Because poor primary mental health care has the potential to do harm (RCGP, P.5, 2005), it is vital that GPs increase their ability to identify and diagnose cases of depression and anxiety (CEP, P. 9, 2006). GPs are recommended to ask their patients routinely about their mood, particularly those with serious or chronic illness. Many individuals in primary care present with physical symptoms for which it is difficult to establish an underlying cause. Some patients are reluctant to talk about their mental health symptoms and, even within lower-stigma setting of primary care, are worried about the effects of divulging symptoms of mental illness (Lester and Glasby, P.67, 2010). It is important that GPs adopt a balanced perspective and consider physical, psychological and social factors and their interaction (RCPSYCH and RCGP, P. 31, 2009).

The core of a GP’s role is to help patients make sense of often paradoxical symptoms in the context of their whole life story. Listening and helping patients to reflect can often be more relevant than having correct answers. When the system is welcoming and the clinicians have both the skills and time available, general practice is ideally placed to work with patients with mental health problems; (RCGP, P.5, 2005). If GPs improve the quality of their attitudes towards and knowledge about mental health issues, GPs can enable all patients to “help themselves contribute to society, and its understanding of mental health” (RCGP, P.9, 2005) by using mental health in primary care setting.
In the next section, what the latest mental health policy directed by the UK government proposes to improve the quality of the care for the depressed provided in primary care setting will be discussed.





Talking therapies: A four-year plan of action

 これは、2007年から始まった、Improving Access to Psychological Therapies (IAPT)という心理カウンセリングを第一医療現場でもっと活用するというプロジェクトの、2010年から4年間の取り組みをまとめたもの。

The Depression Report



No Health without Mental Health



The management of patients with physical and psychological problems in primary care: a practical guide



Tenerife beheading suspect had been treated in UK and released





'Do not cry': a nurse's blog brings comfort to Japan's tsunami survivors



 4月上旬、精神医療のプロフェッショナルではないのですが、旧ユーゴ・スラヴィア分割に伴う紛争後のクロアチアで、人道支援のNGO立ち上げに携わった男性による「Psychosocial intervention, war torn zone and PTSD」という短いレクチャアがありました。

PTSD is a normal reaction to abnormal situation.

In Croatia, psychologists and psychiatrists wanted to label people as suffering from PTSD, instead of providing social & psychological supports.

As a result of being labeled by psychologists, psychiatrists and even politicians, the people were divided, which they did not expect, ie a group of the people was provided support, but the other not.

Without careful consideration, questioning the victims will only affect the reality of what PTSD should be.


 先週、クリニカル・サイコロジストの大御所、Dr Dorothy Roweの特別講義がもうけられました。昨年の秋のはこちらに:

 でも、精神医療、そしてカウンセリングの場で、言葉の重要性を忘れてはいけない。例えば、現在では、「I am now feeling depressed because I forgot to take my umbrella today」のようにとてもカジュアルに使う。
 雨が降ってきたのに傘がないことをdepressといえるかもしれない。でも、クリニカルの現場から見ればそれはunhappyというべきではないか。Unhappy does not mean being depressed, being depression is not unhappiness.


Our language creates reality. Be aware of the importance of language.


Treat a patient/ client as a human being. Do not assume what you can see is not the same what your patient/ client is seeing.


Do you like yourself?
Do you care of yourself?
Do you value yourself?
How do you judge yourself?
How did this happen? Why did this happen?


Thinking about the importance of what you are listening for? Why is it important to your patient, not to you? By Dorothy Rowe.




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