Why medicine makes us feel worse

By Sheena Meredith

Yesterday's headlines warning of risks attached to continuing use of beta-blockers to treat high blood pressure will have alarmed a good proportion of the estimated two million patients affected, as well as the thousands of people taking these drugs for other conditions. The huge media interest is a measure of the importance we attach to drug safety; but it also highlights wider issues about our attitudes to risk and disease prevention.

The reports were based on the latest conclusions of the National Institute for Health and Clinical Excellence (Nice) that beta-blockers should no longer be routinely prescribed as initial treatment for high blood pressure. Yesterday, patients were advised not to panic and to wait until their next GP appointment. When switching to other drugs, beta-blocker doses should be reduced gradually, so patients should certainly not stop taking them without consulting their doctor.

However, it is also usual in the face of such news for GPs to experience a flood of worried callers, understandably so in the face of headlines screaming "stroke risk" and claiming that the drugs increased the risk of heart attacks and diabetes as well.

Nice reviewed its recommendations ahead of schedule in the light of results of a major study, the Anglo-Scandinavian Cardiac Outcomes Trial, dubbed "Ascot". This actually compared just one beta-blocker, atenolol, combined with a thiazide diuretic (both older drugs), with a newer drug combination - and some experts have queried how much the results can be generalised to other beta-blockers. Notably, neither the Nice guidelines nor the Ascot results state that beta-blockers increase the risk of stroke and heart attack, rather that they are less effective in preventing them than other drug combinations.

Instead, patients should first be prescribed diuretics, ACE inhibitors or calcium channel blockers or some combination thereof. Beta-blockers are still recommended in some situations, such as younger or potentially pregnant patients. Although the Ascot study results were published in the Lancet last September, doctors were advised to await the Nice report before changing their prescribing practices.

In fact, prescribing for hypertension has already moved away from beta-blockers – the two million taking them for high blood pressure represent only about a third of the total number of treated patients. Beta-blockers form only one plank of a variety of drugs recommended in previous Nice – guidelines, published only in 2004. Both Nice and the British Hypertension Society recommend treating blood pressure at levels that embrace an estimated 40 per cent of the adult population. High blood pressure is notoriously under-diagnosed and under – treated, but already results in about 900 million prescriptions a year that represent 15 per cent of the primary care drugs budget.

The financial cost is worth it: treating high blood pressure reduces the risks of the awesome consequences that may follow, including heart attacks, strokes, kidney disease and sudden death. The latest Nice assessment included a cost-analysis: although switching from beta-blockers to other recommended drugs could cost the NHS £58-4 million per year, the estimated saving just from not having to treat all those extra heart attacks and strokes is £221-9 million.

However, with such a high proportion of the population on treatment, we may need to consider additional consequences, including alarm as a result of being confronted over the morning papers with headlines about a drug one is taking.

Furthermore, drugs for high blood pressure are only part of the overall picture. Nice recommendations earlier this year increased the number of adults deemed to need statin treatment to reduce high cholesterol levels to more than five million – 14 per cent of the adult population. If Britain were to adopt American thresholds for treatment, the proportion would be even higher. Notably, another branch of the Ascot study also recommended that people with high blood pressure and other risk factors should receive statins irrespective of their cholesterol levels.

Some experts are beginning to worry that turning a risk factor -such as high blood pressure – into a disease also has unanticipated effects. As the British Medical Journal noted, preventive medicine makes us miserable – the higher a population's exposure to modern medicine, the lower do its people tend to self-rate their health and wellbeing. People in poor parts of India have much lower expectations of healthcare and do not live as long as Americans -but they feel a lot less ill.

Two thirds of the British population is now on some form of long-term medication whose aim is to treat or prevent illness or to enhance wellbeing. Attempts to give us longer and healthier lives have, to an extent, succeeded in the medicalised West. However, as London GP Dr Iona Heath argued in the BMJ, those lives may be increasingly dominated by feelings of illness and fear, as yesterday's headlines exemplify.

We are increasingly good at measuring and setting targets for blood pressure and cholesterol levels, as well as for what the healthcare industry deems lifestyle factors – diet, weight, alcohol and smoking. We are less good at balancing the positive effects of all this measuring, medicalising and nagging against all their possible harms.

There are no targets for optimum levels of wellbeing or, come to that, of acceptable rates of worry, or guilt, or even of drug-related complications. Should our healthcare aims, as a society, just seek to prolong life, or should we also aim to enhance its quality – or at least not reduce it to the extent of turning a majority of the population into patients? Would our overall wellbeing be improved more by, say, reducing (or abolishing) the waiting list for hip replacements, or speeding up cataract operations, or improving treatment for children with depression?

Yesterday's announcement about beta-blockers certainly does not warrant panic. It could usefully generate a little more debate about whether it is indeed healthy for such a high proportion of the population to be on medication, and to consider itself sick.

The Daily Telegraph

Thursday, June 29, 2006