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INSIDE HEALTH – Programme 9.

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TX:Ìý 13.03.18Ìý 2100–2130

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PRESENTER:Ìý MARK PORTER

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PRODUCER:Ìý FIONA HILL

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Porter

Coming up over the next half hour:Ìý Middle ear implants – the new technology filling the gap between conventional hearing aids and cochlear implants. ÌýWe meet the youngest person in the UK – at just three years old – to have benefited. ÌýAnd her mother will never forget the day it was turned on.

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Clip

Her eyes widened, her mouth dropped, she was looking around, like, and obviously we were at St Thomas’ so we walked on the South Bank afterwards and it’s really windy and she was covering her ears, saying whooaa the wind, the wind.

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Porter

And we return to antidepressants, Margaret McCartney’s been examining the evidence behind recent claims that they are not as easy to stop taking as many patients are told.

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But first, recovering from a heart attack, and a worrying audit by the British Heart Foundation that reveals around 70,000 people a year in the UK are missing out on potentially lifesaving and life changing cardiac rehabilitation therapy.Ìý Joining a rehab programme after you have had a heart attack can reduce your risk of dying over the next year by as much as a fifth, and cardiac rehab is now part of the routine NHS care, yet half of all those eligible still don’t take up the offer. ÌýWhy?

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To find out we joined a session in the gym at Charing Cross Hospital in London.

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David

My name’s David, I’m 49 years old and I’m a technical sales manager for a software company.Ìý Felt a bit light-headed when I was exercising, because my father had died quite early on from a heart related issue and I was quite overweight, I went to see my doctor.Ìý I was referred to hospital where they put me on the treadmill and after about 10 minutes they found there was a little blip in the ECG.Ìý So, I was referred on.Ìý Had an angiogram and they decided that I had a coronary artery disease, so they put two stents in to widen the artery out.Ìý And I found this quite disturbing, mentally, as a process, so I went through a bit of an anxiety and depression curve to start with.Ìý And then about three or four weeks after the angiogram I came to my first appointment at the cardiac rehab, where they assessed my weight, my fitness and talked to me about the programme of eight weeks monitored exercise they put me through.Ìý And also, I’ve been having some sessions with one of the clinical psychologists here, who has been sort of helping manage that anxiety.

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Doherty

Medication’s important and taken as it’s prescribed.Ìý But that aside the ability to control your own destiny comes through your lifestyle.

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Porter

Patrick Doherty is Professor of Cardiovascular Health at York University and lead author for the recent national audit of cardiac rehab.

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Doherty

The stent is a really good thing but in essence it doesn’t deal with the systemic problem and this is a holistic problem for the human.Ìý Any time you present with a heart attack at the age of 66, which is the average age people are presenting, you may also have respiratory disease, you might have a stroke, you could be controlling cancer, it’s a multi-faceted approach and the best way to manage that is through lifestyle.Ìý There’s no one tablet that’s going to deal with all those multi-morbidities.

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Porter

But people are scared aren’t they, they worry that doing too much is going to put them back in hospital with another heart attack.

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Doherty

Yes, there’s a real mixed message out there in terms of exercise – yes it’s good for you but you’ve got to be very careful about starting exercise, particularly if you’re a novice to exercise.Ìý And one of the things we’ve learnt from our patients is a large majority of them have spent most of their lives not being exercise people, which may explain why they’ve come to a heart attack earlier than some others.Ìý But the likelihood of having a cardiac event during cardiac related exercise is one non-fatal event for every 116,000 hours of exercise – that’s incredible.Ìý So, in other words it’s one of the safest forms of exercise imaginable is cardiac rehab and that’s because it has a warm up, it has a moderated main part and it has a cool down.

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Cardiac rehab actuality

…and again the idea is just to gradually bring this heart rate down nice and slowly…

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Porter

Senior physical activity specialist Nigel Harris is taking today’s class at Charing Cross, along with senior cardiac rehab nurse Judith Edwards.

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Edwards

At the moment there’s about 12 people in the class and they are people who are recovering from a variety of health conditions.Ìý They’re just giving themselves a round of applause.

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Cardiac rehab actuality

…just take a walk around the room, have a little walk around.Ìý If you need a drink help yourself to water…

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Harris

We have classes once a week for about two hours and about 50 minutes of that – 50 – is the exercise bit and that includes a warm up at the beginning, the main bit of the exercise in the middle and then the cool down at the end.Ìý But we get them to do the circuit that they do in the class at home twice a week.

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Francisco

My name is Francisco, I’m 50 years old.Ìý Two years ago, I went on holiday, back home, and had a heart attack.Ìý I spent two weeks in hospital and then I came back here and went to see the doctor.Ìý They say he do the operation.Ìý I lost the contact with people and since I come here the class I feel more stronger and get better much quicker.

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Harris

I think for some patients definitely confidence is a big thing for them, so when they come to the programme they’re very unsure about how much they should be doing, how much is good for their hearts.Ìý So, part of coming along and exercising is to empower them to take control of their exercise and physical activity.

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Porter

Do we know what’s happening to the hearts of people who are going through rehab?

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Doherty

There’s multiple mechanisms at play.Ìý One of them is that if you exercise more and you’re physically active and you control your diet you’re more likely to control your weight, so you tackle one of the big risk factors.Ìý Your blood pressure will come down.Ìý In terms of cholesterol again there’s evidence that exercise will maintain, if not reduce, your cholesterol, which is very important.Ìý But there’s also a really important mechanism through regular exercise at a particular intensity.Ìý As you get above moderate exertion and you can sustain it for a period of time if you do that your vascular system and your muscles will start to adapt and very subtle things that happen is the ability of the inner lining of your heart to start to perform a bit better and the inner lining of your arteries also perform better by exchanging the chemicals, exchange across the barriers much, much more efficiently.Ìý And your muscles, with training, are able to kind of pull more oxygen out from your blood to utilise more effectively and they do that much more efficiently than they did before.Ìý So, lots and lots of actually pathological reversal in terms of cardiovascular disease.

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Edwards

There’s a lot of misconceptions around heart disease.Ìý Of course, the big one is once you’ve had a heart attack you can never have sex again.Ìý So, we look at those sorts of issues, which are recurring problems or that people feel that they’ll never be able to exercise to the level that they could before and for most people that’s untrue and we would hope that actually they’ll be doing more exercise.

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Cardio rehab actuality

Keep those feet gently marking…

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Doherty

Rehabilitation when done well doesn’t do things to people, it enables people to manage themselves.Ìý So, by the end of a rehabilitation programme we’re always very confident that these patients will be able to exercise anywhere in the world, in any setting, safely.

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Porter

What’s the evidence behind rehab?Ìý I suspect that no one rehab programme’s quite the same as another, so are they quite difficult to compare?

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Doherty

Yes, across the globe there’s various kind of permutations of what rehab is but we do have very sophisticated high level medical reviews by the Cochrane research groups, from all sorts of trials, over 63 clinical trials in the cardiac rehab area for the conventional cardiac patient showing a 26% reduction in cardiovascular death.Ìý And very importantly, a 30 plus reduction in unplanned hospital readmissions.Ìý Really important for the NHS but also important for patients because if you’re having unnecessary hospital admissions that is a poor quality service.Ìý We have evidence that if clinicians do encourage patients to attend rehab they will more likely attend but there’s a huge amount of referral that is made but the problem with rehabilitation at the moment is about 30% of patients drop off from referral to the actual start of rehabilitation.

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Porter

And what do we know about those people who are dropping off?

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Doherty

They differ quite substantially from the people who actually take up rehabilitation as a whole.Ìý And one of the clear areas of concern is in women who have had a heart attack where there’s a greater deficit in terms of the number of people who are referred to actually take up rehabilitation.

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Edwards

I think that women probably find the concept of exercising in a gym might be off-putting and they don’t feel particularly comfortable.Ìý So, what we find here is that once we can get the women to the class there isn’t a big drop-out rate, so they do tend to stay once they’re here.

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Cardiac rehab actuality

If you feel really comfortable, you want to go with the higher level, you can add in a hand to the knee…

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Harris

The version of rehab that’s offered not just in the UK but globally tends to be biased to a model that is about group-based exercise, it’s dominated by males, there’s more males have heart attacks than females.Ìý And as a consequence of that there’ll always be more males at a programme than females.Ìý And so there’s evidence suggesting that there’s much more that can be done in tailoring programmes to the needs of females going forward.

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Porter

What about the impact of deprivation – is this a social group issue as well in terms of uptake?

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Harris

Yeah and it’s overwhelming clear that areas of greater social deprivation have the poorer uptake to these services.Ìý But there is a sense in the research and in some government thinking that we have hard to reach groups and they often blame the patient and say this patient group is hard to reach.Ìý I don’t share that view.Ìý I think sometimes the offer is so unattractive that people wouldn’t take it anyway.Ìý And I think what we have to do is stop blaming the patient and start thinking about new and innovative ways to offer cardiac rehab to make them much more attractive.Ìý That involves home programmes, community-based programmes, online programmes – these are all innovations that are happening in the modern era and we should be looking to capitalise on those initiatives.

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David

Every time I left the house I was scared that there was something going on with my heart.Ìý Every little ache and pain I was worried that there was something going on with my heart.Ìý Now, because I’ve been able to really work hard in a monitored safe environment, I’m now back at work like normal, now weighing less than I have done in the last 15 years, I feel a lot fitter, I feel psychologically like I’m back to normal or actually even in maybe a better place than I was before this started.

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Porter

David, who obviously sees the value in the programme run at Charing Cross by Nigel Harris and Judith Edwards and thanks to Professor Patrick Doherty. ÌýUseful links to more information on cardiac rehab are on the Inside Health page of the Radio 4 website.

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Antidepressants have been in the news a lot recently following research published last month confirming they work well and suggesting they might be underused, a story we covered here on Inside Health. ÌýAnd since then there has been something of a spat over side effects, in particular, withdrawal reactions, with some questioning the official line that most people have no problem stopping them when they have recovered.

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Here is a flavour of the debate from the Today programme at the weekend. ÌýGP, Dr Clare Gerada, is medical director of the NHS Practitioners Health Programme, which supports doctors and dentists with mental health concerns.

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Gerada

About a third of patients get withdrawal symptoms when they stop antidepressants.Ìý And for that third the majority of those symptoms will be things like a resurgence of anxiety, anxiety symptoms, some sleep disturbance and some people feel flu-like symptoms.Ìý Most of those will go in about two weeks, some might last for two months.Ìý A few patients might get withdrawal symptoms that might last many months.

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Porter

But John Read, Professor of Clinical Psychology at the University of East London, thinks that is an underestimate and, along with 30 other signatories, has formally complained to the Royal College of Psychiatrists about its position that withdrawal effects are short-lived in most patients. This is what he told Today.

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Read

Talking about figures as high as 60%, people experiencing withdrawal symptoms.Ìý In the largest survey, direct consumer survey, ever conducted 29% said they experienced drugs as addictive.

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Porter

So, who is right? ÌýWell Margaret McCartney is in our Glasgow studio and has been looking at the evidence.Ìý Margaret, this is an ongoing debate.

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McCartney

It is and actually there have been reports in the literature of people describing withdrawal side effects as far back as the late 1950s with the older fashioned antidepressants – things like imipramine being reported in the literature to cause side effects upon stopping.Ìý And really been it’s on since there.Ìý But what is striking from the literature is the lack of really high quality long term studies looking into this phenomenon and I really worry that we are missing some of the detail that would help people make much better decisions about what to do with their antidepressant prescription.

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Porter

So, what’s your take on the situation?Ìý I mean here we had Clare Gerada saying this isn’t that big a problem and John Read saying it’s potentially a much, much bigger problem – who’s right or are they both right in their own way?

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McCartney

Well I think there are arguments to be made on both sides.Ìý I think that Clare Gerada has a very good point – and conflict of interest as I do know Clare, we both sit on the council of the Royal College of GPs, though obviously I speak in a completely independent capacity here.Ìý There have been studies done that would indicate that yes about a third of people will have some kind of symptoms coming off.Ìý But the problem is that a lot of the literature has fairly short-term views of what coming off antidepressants means.Ìý So, they just follow people up, for example, two months, is a fairly typical amount of time.Ìý Which means that we miss the tale, the few people, that seem to have persistent symptoms for much longer.Ìý There is no doubt that abrupt discontinuation gives people lots of symptoms and there have been lots of trials done where people had a placebo substitution for a few days within a packet of pills and they didn’t know which were the placebos and they reported when they felt unwell and it coincided exactly with when those placebo tablets were taken.Ìý There’s no doubt about that.Ìý What we’re much less certain about is when people are having managed decreases in doses with the intention of coming off, what kind of symptoms to expect in how many people and over how long.Ìý Certainly, many people will experience some side effects, a few will experience ongoing side effects but we really lack high quality trials to tell us how many of those people are overall.

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Porter

John Read there mentioned direct to consumer surveys.Ìý Now the surveys tend to be dismissed by a lot of researchers but do you think we should take them more seriously in this context?

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McCartney

Well definitely, I mean I think if people are telling you that they’re having symptoms you should listen to those people and take their symptoms very seriously.Ìý But what you need to do next is use that as a door into studying it more vigorously and looking to see can we find patterns, what’s going on.Ìý The problem with any survey is that you have to be sure what population you’re studying, so if you’re only studying people with problems that’s really useful because you can get lots of information and data from them but it perhaps doesn’t give a flavour of what to expect for someone who’s thinking about going on to antidepressants in the first place.Ìý They might want to know what are my chances of having persistent problems coming off these.Ìý And surveys might not give you that information but they might give you other very important and useful information.

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Porter

The accusation here was that the Royal College of Psychiatrists were perhaps underestimating the impact of withdrawal effects, do you think that’s a fair accusation, given the dearth of good evidence that’s out there?

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McCartney

Well I think what’s clear is antidepressants also do help some people.Ìý They certainly do have a role to play and I wanted want to see them being dismissed, I think they’ve got a place in the toolbox.Ìý But I suppose what I worry about is that there’s so much emphasis put on them that we forget about all the other things that we have to offer.Ìý The many societal impacts that there are on our mental health, the many environmental factors that can cause problems and the psychological treatments that we know are really good.Ìý So, I think they’ve all got a role to play and what we should really be aiming for I think is better quality information and better resources so that people have got a good choice to make and they’re not just stymied into making one choice for medication when they’d maybe prefer psychological treatment but they can get one treatment immediately but they’ve got to wait three or four months for the psychological appointment to come through.

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Porter

And what about this term addictive, it’s an evocative term isn’t it, because conventional wisdom has it that antidepressants are not addictive?

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McCartney

Yes, and I think when we hear the word addiction we tend to think of things like alcohol or cocaine or tobacco, things that you get hooked on.Ìý But the other definitions of addiction I think bear looking at.Ìý So, for example, people will often describe a feeling of intoxication with an addictive substance, they’ll describe a craving for it, they’ll describe the need for an increased dose to get the same effect and ultimately describing it impacting on their life so that they can no longer function because of it.Ìý Now I don’t think that the use of antidepressants for people in the UK comes into those categories, I don’t see that kind of craving behaviour, I don’t see that of people wanting to increase their dose to get some kind of a hit or high from it, that doesn’t seem to apply at all.Ìý If you’re saying is it difficult to come off of antidepressants, for many people it can be and that’s why I think we need much better research about how to do things in a managed way.Ìý Lots of medications are difficult to come off of for all kinds of different reasons.Ìý So, we’ve talked before on the programme about proton pump inhibitors – lansoprazole and omeprazole – and the kind of rebound effect that can come back if you stop them quickly.Ìý So, there’s room for nuance in here and I think it’s really important to be able to talk about the side effects and the withdrawal or discontinuation syndromes honestly but I think we also have to make sure we’re giving people high quality information because these drugs do help some people.

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Porter

Do you think we’ve historically been too dismissive of the difficulties for some people when it comes to stopping their medication?

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McCartney

I do and I also think we have a big problem with reporting side effects more broadly.Ìý And we’ve talked before in the programme about the yellow card system and just to flag it up, it’s a really great thing, anyone can notify the Medicines and Healthcare Regulatory Authority about a suspected side effect through their website at the Yellow Card website or through a Yellow Card at their doctors, it’s in the back of our prescribing bible – the British National Formulary.Ìý So, I think we’ve all got a duty and a responsibility to report any side effects that we think are occurring.Ìý And certainly, it was the Yellow Card reports that did contribute towards flagging up the issues with coming off of antidepressants to start off with way back in the 1960s.

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Porter

Thank you, Margaret.

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Well there may be an ongoing argument about how difficult it is to stop antidepressant therapy but there is widespread agreement that it pays to reduce treatment slowly, typically tapering it over weeks for people who have been taking antidepressants for months, and over months for those who have been taking them for years.

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Now, to some pioneering technology that is transforming the life of people who can’t hear.

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We are all familiar with hearing aids, which are basically amplifiers that boost volume in a failing ear.

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And you may have heard of cochlear implants which, in people who are too deaf for aids, can be used to bypass much of ear and send signals directly into the inner part that sends sounds to the brain.

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But I bet you’ve never heard of middle ear implants, which are now being offered to people whose hearing loss sits between these two extremes, or who can’t wear a conventional hearing aid because their ear has not developed properly.

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ENT Surgeons at Guy’s and St Thomas’ Hospital in London – Professor Dan Jiang and Harry Powell – have performed a middle ear implant on the UK’s youngest ever patient, Charlotte Wright, who was just three when she had the pioneering treatment.

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It’s a real breakthrough and surgeon Harry Powell told me many more children could potentially benefit from the procedure.

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Powell

One in six or seven thousand children per year in the UK, which is about a 150 children in the UK, are born with a condition called microtia and/or atresia and it means that the outer ear, which is usually formed in utero doesn’t form correctly.Ìý And often in conjunction that you have what’s called an atresia where the ear canal itself doesn’t develop, so they haven’t got a normal ear canal.Ìý And the consequences of that are they may well have a functioning inner ear, so the cochlear may be normal, but sound cannot get to that cochlear.

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Porter

So, for these children the aim is to get sound past the damaged or malformed parts of the outer ear and through to the inner ear or cochlear as soon as possible.Ìý The earlier you operate the sooner the auditory pathways are stimulated catching the developing brain at a stage when it’s more malleable or plastic.

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Powell

At Guy’s and St Thomas’ we’re slightly pushing the boundaries, it’s something that we are starting to do in children that are younger and younger.Ìý And that’s because based on that same information for cochlear implants effectively we know that doing this earlier is going to be more beneficial for children, especially in terms of their ability to then localise sound and manage better in noisy environments.

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Wright

I’m Sophie Wright, I’m Charlotte’s mother.Ìý When Charlotte was born we knew right away there would be possibly something wrong with her hearing because she has microtia, which is the outer ear isn’t developed on one side.Ìý So, we were a little bit worried at that point.

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Charlotte

I just call it little ear because it’s little.

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Wright

Little ear and big ear.Ìý Once she started talking we could really hear that there was definitely a problem because no one really understood what she was saying.

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Charlotte

I remember when I was three and I was watching the Lion King and I told mummy that I couldn’t hear anything.

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Porter

So, people who have a middle ear implant they have the normal inner ear working fine, it’s just the outer part that collects the sound that’s gone wrong.

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Powell

Precisely, they may have a problem with the outer ear canal that in fact it may either not be present if it’s a congenital problem that they were born with or they may have a problem with the transmission of sound either through the ear canal to the middle ear or there’s a problem with the middle ear and the little hearing bones that transmit sound through the middle ear and we therefore harness the natural mechanism one way or the other to attach a tiny little device to one of those hearing bones that then takes the sound into the working cochlear.

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Porter

Can you explain what the implant looks like, what it consists of?

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Powell
Yes, so there’s actually two components.Ìý There’s an external component, which is an auditory processor, which pick up sound.Ìý The part that we implant under the skin behind the ear has a magnet which enables it to connect to the outer part and then there’s some electronics which basically decode the signals that are taken from the outside and they turn those signals into tiny little vibrations.Ìý And there’s a little active component which is smaller than a grain of rice and that active bit vibrates.Ìý That piece is clipped to one of the ossicles, so one of the little hearing bones, and that vibration then drives the sound, it amplifies the natural acoustic hearing and takes sound into the inner ear.Ìý

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Porter

Charlotte had developed glue ear on her good side – or big ear, as she calls it – as a result she was really struggling to hear when her parents opted for the implant.

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Charlotte

I was very brave.

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Wright

She was really excited about having the operation.Ìý She went – is it hospital day – yeah.Ìý So she was really excited, so that was nice to be so positive, obviously we were scared out of our wits but pretended to be all excited too, so that was fine.Ìý So, the operation we were told was going to take four to five hours but not to clock watch, but it took seven and a half to eight, so that was really nerve-wracking because obviously we didn’t know what was going on, the nurses didn’t know what was going on so that was kind of scary.

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Charlotte

And I had hospital pyjamas.

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Wright

You did.

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Porter

Ten weeks after the operation the device was turned on and the difference for Charlotte was instantaneous.

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Wright

Her eyes widened, her mouth dropped, she was looking around.Ìý And obviously we were at St Thomas’ so we walked on the South Bank afterwards and it’s really windy and she was covering her ears saying – Whoooa the wind, the wind.Ìý I remember she heard a bird and she didn’t know what it was, she was like what’s that, lots of birds.

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Charlotte

I heard quite a lot of things.Ìý When I was young I couldn’t even hear a single sound.

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Wright

Yeah, so the receiver’s just here on the side of her head and it slips on with a magnet and it’s…

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Charlotte

There’s a magnet in my head.

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Wright

There is a magnet in your head.

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Jenkins

My name’s Marcia Jenkins, I’m a clinical scientist that works here in the Hearing Implant team at St Thomas’ and I’ve been working with Charlotte now for ooh about two years.Ìý Today is Charlotte’s annual review, so she’s now had her middle ear implant for a whole year.Ìý We’re doing a variety of tests to see where she’s at – that’s hearing tests as well as language tests.Ìý And also speech perception tests as well.Ìý So, we’re going to do…

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Charlotte

…music now.

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Jenkins

We’ll do music afterwards because first of all we’re just going to do some games, you’re going to play with Sandra for a little bit.Ìý Do you want to come over and see what games she’s got for you?

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Driver

Hi I’m Sandra Driver, speech and language therapist and work here in the Hearing Implant team.Ìý So, we’ve got a wooden boat and – because Charlotte’s a bit older now she can wait and listen for the sound and when she hears the sound we’ve got some little wooden men, then she has to put them in the boat each time she hears a noise.

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So, we’re going to wait…

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Porter

Marcia will never forget the moment when Charlotte’s implant was first turned on.

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Jenkins

It was really amazing actually because she did actually say – I can hear.Ìý She had stereo sound and she just really loved it from the start.Ìý

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Charlotte

Thank you.

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Jenkins

So, with her device she coped with about two decibels more noise than what she did without the device.Ìý Two decibels is quite significant in those situations, so yeah that’s good.Ìý Really, really good.

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Porter

Charlotte’s now five and today they’re trying a new challenge.Ìý She’s in front of a computer facing a 180-degree curving wall of speakers.Ìý She has to listen and find the right square on a console by following an instruction.Ìý The instruction starts off loud and then gets quieter and she has to discriminate it from background sounds that mimic the sort of noisy environments she will have to cope with in the real world.Ìý And she’s doing very well.

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Jenkins

Charlotte will be the youngest child that we’ve run through this.Ìý We don’t really know how she’s going to go but we’re just trying to represent what the world is like out there, the fact that it’s not a very quiet place, it’s a very noisy place.

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Actuality

Just have a guess if you don’t know.

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Touch the screen to finish.Ìý Okay, excellent, good work.

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That was tough, wasn’t it.

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I was scribbling and moving my finger and sometimes I got it wrong because as it gone lower I couldn’t really hear it that well.

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Porter

And what sort of response would you expect in someone like Charlotte, I mean can she hear normally?

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Powell

Yes, she’s had a remarkable response but actually that’s what we would expect.Ìý She’s lost count of the number of things that she now hears better than she used to.Ìý So, it really is very, very rewarding.Ìý The world of ear surgery, in terms of the implantable hearing technology, is just going to completely continue to expand.Ìý Yeah, it’s very, very exciting.

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Charlotte

Sing a rainbow, sing a rainbow, sing a rainbow, along with me.

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Porter

A very gutsy, Charlotte, ending on a song.

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And there is more information about her type of implant on the Inside Health page of the Radio 4 website, where you can also sign up for our weekly podcast so you need never miss an episode again.

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Just time to tell you about our next programme when I will be looking at scans used in the diagnosis of dementia. ÌýHow good are we at differentiating between a normal ageing brain and one that is showing signs of more sinister deterioration? ÌýJoin me next week to find out.

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ENDS