Stress and pregnancy, CBT for insomnia, Cluster headache, Smoking and mental health

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Dr Mark Porter finds out why insomnia can often go untreated by the NHS despite there being a treatment that not only works but also doesn't involve drugs. There are nearly 11 million prescriptions for sleeping tablets in the UK every year but their effect isn't long lasting and people can find it hard to come off the tablets. Cognitive behavioural therapy has consistently been shown to be very effective at improving sleep in the long term but few people have access to it. Mark is joined by Colin Espie, professor of Sleep Medicine at the University of Oxford, and by professor Kevin Morgan, director of the Clinical Sleep Research Unit at Loughborough University, to discuss why insomnia is so neglected, and to talk about the success of methods to deliver CBT online using mobile and web technology.

Also in the programme, Mark talks to Peter Goadsby, professor of neurology at King's College Hospital London, to find out what cluster headaches are, why they're so painful and why they can occur when the clocks change. He also meets Ann McNeil, professor of tobacco addiction at the Institute of Psychiatry, to bust the myth that smoking helps bust stress.

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28 minutes

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Wed 26 Mar 2014 15:30

Programme Transcript - Inside Health

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THE ATTACHED TRANSCRIPT WAS TYPED FROM A RECORDING AND NOT COPIED FROM AN ORIGINAL SCRIPT.  BECAUSE OF THE RISK OF MISHEARING AND THE DIFFICULTY IN SOME CASES OF IDENTIFYING INDIVIDUAL SPEAKERS, THE BBC CANNOT VOUCH FOR ITS COMPLETE ACCURACY.

 

 

INSIDE HEALTH

           

Programme 10.

 

TX:  25.03.14  2100-2130

 

PRESENTER:  MARK PORTER

 

PRODUCER:  ERIKA WRIGHT

 

 

Porter

Coming up today:  Alternatives to sleeping pills – I will be speaking to the sleep expert behind a new online service offering cognitive behavioural therapy, CBT, to people with insomnia.  Tobacco and stress – we explode the myth that smoking helps your nerves.  And unusual headaches triggered by next weekend’s changing of the clocks. You may never have heard of cluster headache, but if you are unlucky enough to have ever had one, it’s unlikely you will have forgotten the pain.

 

Clip

I see patients again and again with cluster headache and they will tell you they just haven’t had a worse experience and I’ll get them to trot out all the delivery of a child or appendicitis, anything you can think of these people have had.  In the generality of things they’re terrible pains, so you’ve got to give them something for the pain.

 

Porter

More on cluster headache later.

 

But first - Inside Health’s resident sceptic Dr Margaret McCartney has been taking a closer look at some of the health stories making the headlines. What’s caught your eye Margaret?

 

McCartney

Well there’s two interesting stories, one in the last couple of days basically claiming that meditation will improve your chances of becoming pregnant and the other story I thought was of interest was that sleep is supposedly now something that doctors should be prescribing far more of.

 

Porter

Well tell us about the stress one.

 

McCartney

Yeah, so this one was a study – an American study – looking at 501 couples in America who were trying to get pregnant and the headlines were very much along the lines that yoga and meditation can boost the chance of pregnancy, which is actually not what the study found or was even looking at.  But it was quite an interesting study nevertheless.

 

Porter

What did the study actually find then because the suggestion from that headline is that if you stay calm and relaxed that it’ll increase your chances of getting pregnant?

 

McCartney

Yeah and that’s a bit nonsensical really.  So the study looked at two different saliva markers for stress, supposed stress, which were cortisal and alpha amylase, which are two hormones that are meant to be related to stress in the body.  And they found that salivary alpha amylase levels were related to not getting pregnant, so the higher the level was the less chance there was of getting pregnant.  However, it was actually only a very small difference and the cortisal hormone showed no difference at all.  I mean lots of things can increase stress hormones in the body, not just mental stress but also physical stress.

 

Porter

Okay, so the assumption from the trial you could come away saying look stress is bad for fertility, it can reduce your chances of conception.  So what the press have then done is said well therefore relaxation and yoga et al must be good for it?

 

McCartney

Well I would actually want to put this in context with lots of other studies that have come back and said well actually there isn’t any relationship between the stress levels that women report, which this study didn’t actually look at, and what actually happens to pregnancy outcomes.  And what I really wouldn’t want to happen is for women who are trying to get pregnant to then start blaming themselves for being stressed and not getting pregnant quicker – that would be the opposite of what I would want to happen.

 

Porter

This is a sort of typical vicious circle isn’t it, where you’re trying to conceive and then you worry about your inability to conceive and therefore it makes you less likely to conceive.  But you’re saying there isn’t a lot of science behind that?

 

McCartney

No there’s lots of other studies that actually haven’t found an association between women’s reported stress levels and their ability to get pregnant.  And what I suppose I’m a bit also concerned about is that we start focusing on stress as a big issue here when actually the big factors that impact on fertility are greater age, smoking and obesity – so there are three other factors that are perhaps a bit better able to control than our stress levels anyway.

 

Porter

What about sleep?

 

McCartney

It’s really interesting because sleep is one of those things that I think people complain really bitterly about when they’re not getting any and we doctors often feel quite impotent with what we have to offer.  Now the research narrative that was published in the Lancet is really interesting, it looks at what we know about sleep in association with illnesses and basically there’s a lot of stuff out there that’s pointing towards a link between a lack of sleep or poor quality sleep and your risk of developing certain conditions, such as high blood pressure, obesity and a tendency towards diabetes.  And the question is is the sleep disruption causing those factors or is it actually the other way about.

 

Porter

The researchers behind the study were reported in the press as saying that actually the quote was look doctors should be prescribing better sleep to their patients, in the same way that we would take steps about encouraging people to lose weight etc.

 

McCartney

Yeah and I think that’s the kind of thing that has going in the back of my neck, we do not want to get into a 1960 situation where doctors are prescribing tamazepan, sleeping tablets, like sweeties.  We know they’re addictive and they don’t do us any good, that would not be a good solution.

 

Porter

Well herein lies one of the issues isn’t it because you and I, if we want to help patients sleep, practically - there are a number of things we can – but practically the one that most doctors resort to is the prescribing pad.

 

McCartney

Absolutely because we can do it straight away whereas we know that cognitive behavioural therapy, which works pretty well, is actually only available if you’re prepared to go on a waiting list and very often when someone’s coming in to see the doctor they’re in crisis, their sleep isn’t very good, it’s not very optimistic to be saying to someone okay it’ll be four or six or eight weeks before you get an appointment.

 

Porter

But you, as a GP, I mean you work at the other end of the country from me you’d agree that we don’t manage sleep well as it is at the moment.

 

McCartney

At the moment I think it’s plain that we don’t have a huge amount of brilliant interventions to offer.

 

Porter

Indeed, thank you Margaret.  Well here to debate how we should be treating insomnia are two world experts on the subject.

 

Colin Espie is Professor of Sleep Medicine at the University of Oxford and the founder of a new online service offering CBT for insomnia, and Kevin Morgan is Professor of Psychology and Director of the Clinical Sleep Research Unit at Loughborough University.

 

Morgan

People’s understanding of sleep is very low and that cultural failure to understand sleep is recognisable in clinical practice.  Secondly, it’s very interesting that while there are plenty of sleep conditions that do have advocacy groups, that do have champions, insomnia doesn’t.  And the absence of champions is terribly detrimental to the effective treatment, public treatment, of conditions like insomnia.  And thirdly, it’s not owned by any clinical specialty, no particular specialty within our own health service or in health services generally feel that insomnia is their business.  So sleep related breathing disorders they’re well taken care of but insomnia disorders are less well taken care of and that’s a great disadvantage because within the health service, as within most healthcare services, ownership requires a kind of championship role which generally drives the research and clinical agenda.

 

Espie

I think Kevin’s absolutely right that the lack of a champion means it’s not being promoted enough as a disorder.  So I think in actual practice GPs are mostly dealing with insomnia and they generally have only the option of prescribing sleeping pills, that’s all that’s really available to them.  Sleep is the primary investment that everyone makes in their health and wellbeing, if you don’t sleep you have no consciousness, if you don’t sleep you don’t have any quality of life.  So this is why it is so important that when people have disturbed sleep that we do something constructive to help them other than simply offer them pills.

 

Porter

How effective is a sleeping tablet likely to be if someone’s been taking them for months or possibly years – do we know that?

 

Morgan

Ineffective – these are drugs of tolerance, so we have abundant data that shows that when consumed relatively continuously, that’s to say weekly for over a year, the profile of a person consuming sleeping tablets is no different from an untreated person with chronic insomnia.

 

Porter

Colin, you’ve brought a new product to market sleepio, can you explain what it is and why you decided to introduce it?

 

Espie

One of the big challenges for using an effective technique like cognitive behavioural therapy, which really addresses the key problems in insomnia – that is a racing mind and the inability that people have to get into a good sleep pattern – the big problem with this is that usually CBT involves face to face therapy and there are challenges in getting the number of people who have got problems with insomnia to see a therapist.  So what we have done in sleepio is we’ve harnessed web and mobile technology to develop an engaging experience which mimics, if you like, the clinical setting because sleepio’s delivered by an animated therapist, but also helps to deliver the ingredients of CBT in a supportive way at home.

 

Porter

I had a look at the programme, so it’s £50 or thereabouts for a full course, and it’s six sessions – what actually goes on in those sessions, what does cognitive behavioural therapy mean?

 

Espie

Well cognitive behavioural therapy addresses several zones if you like – your lifestyle and your home environment, which are, if you like, the context in which sleep occurs.  Try and make your bedroom environment as sleep friendly as possible and your lifestyle as pro-sleepish as possible.  Its foundations are really dealing with cognition – the racing mind, thoughts the intervene by helping you to put the day to rest before you go to bed, to know how to deal with intrusive thoughts that tend to upset you during the night and to stop you trying to sleep – and that’s a real enemy of sleep – and then to establish a new behavioural pattern.  So, for example, if we were to think of a child who wasn’t sleeping well we’d be fairly confident that by getting them relaxed, content, not worried about being awake in their room, that nature would then take its course and we’d get them into a pattern.  And essentially CBT does the same for adults and it helps to remove even entrenched problems.

 

Porter

Kevin, what sort of evidence do we have for CBT in general?

 

Morgan

The evidence again is abundant, I mean the summary of the evidence would suggest that up to five hours of CBT will deliver lasting benefits for up to 80% of treated patients, lasting benefits and some of these benefits actually improve over time.  So the issue here is service delivery – it’s how can we get the therapy to the patients who require it.

 

Porter

Well I can tell you as somebody who tries to get access to therapy from the other end and tries to get people to see people like you and it is very, very difficult, I think in the last two or three years I’ve managed to get face to face CBT for just two or three of my patients at Bristol and that was a bit of a struggle.

 

Morgan

And this is where things like online therapies can be very helpful.  I suppose if we pan back and look at the whole scenario what we have here is the opportunity to develop a culture of what is now called self-help, whether it comes from a therapist guided self-help in that manner or whether it comes from the internet, the culture here is actually transferring therapeutic skills from those who have the expertise to patients themselves.  And I think there’s another point to be made here – most complaints of insomnia, most of them arise in the context of other illnesses and disorders.  And it stands to reason that if we can transfer these skills directly to patients effectively then we ought also to be able to transfer these skills to those people who are already encountering patients and meeting them, so that they can deliver them too.

 

Porter

Colin Espie, we might have good evidence that CBT can help most people with insomnia but does it matter how it’s delivered?  We’ve got good evidence for face to face, do we have good evidence that it works online as well?

 

Espie

So we’ve tested this therapy in the same way that drugs come to the market, if you like, which is testing them against the placebo effect, so I think we’ve fairly rigorous evidence that this therapy is effective for the treatment of insomnia.  And I think the real insight here is to use digital technology to transform our approach to healthcare by helping people who are not actually very good at changing their behaviour generally to actually change it for the good and using tools like their mobile phone and your computer as an aid to therapy.

 

Porter

Kevin, would you expect it to make any difference how the CBT is delivered, as long as it follows the same sort of format?

 

Morgan

The evidence is growing that CBT is a robust therapy, that if you deliver it as an online engaging therapy using ubiquitous technologies or if you deliver it in booklet form and certainly if you deliver it in group or individual therapy it will deliver results.  The issue is about just how strong those results sometimes are but nevertheless this is a robust therapy.  And we too have been developing online products working with our local service providers.

 

Porter

This is a service for the NHS?

 

Morgan

This is a service for the NHS, designed specifically to be delivered in a context of what’s called guided self-help, this is where a service like in England an IAP service, those are the services that are improving access to psychological therapies that have been running in England for several years now, these are basically psychological therapy services to which all patients have access directly through primary care.

 

Porter

And how far down the line are you with your work?

 

Morgan

We’re running what are called usability trials at the moment, we’ve completed a package, we’ve completed the platform from which it runs, all we’re doing now is making sure that patients engage with it, that they understand the instructions that they’re given and they stick with it in a way that reflects a kind of understanding of what we’re trying to achieve here.

 

Porter

And do you think that introducing something like this will encourage a service to build up around it?

 

Morgan

The very first point is to encourage services to recognise the need even to address insomnia.  And we know also that insomnia doesn’t just affect people’s sleep it affects their lives, it’s serious.  So if we can convince the services that this is a condition which merits treatment for which there are endless benefits downstream then we can then start negotiating how this treatment ought to be delivered.

 

Porter

Professors Kevin Morgan and Colin Espie.  And you will find links on CBT for insomnia on the Inside Health page of the Radio 4 website.  Where you will also find details on how to listen to the programme again, download our podcast, and get in touch with us.

 

Dorothy, who lives in New Zealand and listens via the podcast, e-mailed to ask for more information about cluster headache, a condition she has recently developed. And I think I know just the man to ask, and by coincidence Dorothy, he is originally from your part of the world.

 

Peter Goadsby is Professor of Neurology and Director of the National Institute for Health Research facility at King’s College Hospital in London.

 

Goadsby

Typically it happens in clusters, so the patient will start having attacks of headache that will occur at a particular time of the year, so they might have them come on around the change in clock in spring or in autumn, when the clocks change and the distribution of daylight changes.  And they will have one or two or sometimes up to eight discrete attacks of headache per day that will last an hour or two, they’ll be strictly one sided and that will go on for six, eight, 10 weeks and then it will stop.  And they’ll be perfectly well until the following year at about the same time when exactly the same thing happens.  So it’s cluster – it’s this clustering at a particular time that gave it the name.

 

Porter

Does it always affect the same side and why is it one sided anyway?

 

Goadsby

The structure in the brain that’s involved is one sided, so we think that there’s some mechanism whereby these systems are talking across the midline and one becomes dominant.  It can swap sides, it usually does it between bouts, very rarely it can swap sides within a bout, and swapping sides within a bout is something that makes you have a little pause for thought.

 

Porter

In terms of the diagnosis?

 

Goadsby

Yeah.

 

Porter

And you talk about this occurring with the clocks changing, are there any other changes in somebody’s routine that might precipitate these sorts of episodes?

 

Goadsby

No the actual precipitation of the bouts is very much linked to what’s called circannual rhythms, you know I think if we understood more about hibernation mechanisms, for example, we might understand a lot more about cluster headache.  But it’s very typical around the clock changes or for some patients it’s around the solstices, so around mid-winter or around mid-summer.  It’s remarkable the exposure to light issue.

 

Porter

You’d be thinking that with a story that clear that this would be a diagnosis that would be relatively easy to make.

 

Goadsby

You could say that, however, let’s stand back for a second – what else happens?  Well one of the classical symptoms that happens are what’s called cranial autonomic features, and that’s eye watering, redness, nasal congestion, stuffiness, the eye will look a little bit swollen.  Now if that happens around spring when the flowers are blooming and you get headache and feel a bit sniffly and you look a little bit like you’ve got an allergy and you go to the doctor and you tell them the story at first blush you could be forgiven for thinking well it’s just seasonal, it’s a seasonal allergy and that’s one of the things that happens.  One of the other things that happens is it very often focuses very much either around the eye or just in the upper jaw.  So if you’ve got a pain that’s coming and it’s really severe – and cluster headache is the worst pain, patients will tell you, it’s the worst pain they’ve ever had, it’s really severe here in the upper jaw – dentists might think that was something he would do and a dentist will do something.  So I think that it’s always easy in hindsight but at the coalface it can be a bit tricky.

 

Porter

Let’s start with what we do when someone comes in and they’re a week or two into their cluster, what can we do for them immediately?

 

Goadsby

There are two groups about – there are the people who you know already, they’ve been through a bout before, the diagnosis is safe and you go and look at what you can do in the short term.  So the first thing is to get them pain relief.  And there are two things that are really very good for the pain, the first one is the triptans, the sumatriptan, given as an injection or the less effective in the population, a little bit slower in onset are the sprays, so the sumatriptan spray or the zolmitriptan spray, but they’re all proven – all the things I’ve just said are proven in randomised placebo controlled trials, so properly done.

 

Porter

And these are modern migraine medicines that we would use?

 

Goadsby

They are exactly.  So in that sense if you give a person the migraine medicine it’s not so bad although usually we use in practice the tablets.  And the tablets are next to useless and there are some good studies to show they don’t work, so that’s one of the reasons not to do that.

 

Porter

So it’s injection or sprays in this case?

 

Goadsby

It’s injection or sprays.  And then the other thing which works in cluster, for which there’s no evidence in migraine, is oxygen, 100% oxygen, mask covered over so they get proper concentration, 12-15 litres per minute.  A really good study that we did several years ago against air because it’s very easy to blind, to show that oxygen works, very effective treatment and very safe and very straightforward to use.

 

Porter

So what do we think is actually going on in the brain – if oxygen’s helping, what does that suggest to you?

 

Goadsby

That wasn’t terribly well understood until the last perhaps year or so when we’ve been starting to address how oxygen might work.  There are nerve cells in the brain stem, so it’s the bottom part of the brain, just above the spinal cord, that are sensitive to oxygen and that will turn off in experimental situations.  So we’ve started to nail down the nerve cells in the brain that are – seem to be the senses of this oxygen response.  It used to be thought it was a vessel constriction thing but there’s actually no evidence for that.

 

Porter

So do we know – I mean can we by scanning people’s brains when they’re having these attacks, can we learn exactly what’s happening, what changes in the brain to cause this pain?

 

Goadsby

We have a pretty good idea about – one of the sort of advantages, you might say, of having a really well defined one sided horrible pain for an hour or so is that if you scan it and you compare it to someone who doesn’t have any pain at all you get a very sharp difference.  And so we showed several years ago with the work that was funded by the Wellcome Trust activation in a deep part of the brain, just behind the hypothalamus, and it’s an area where a structure called the suprachiasmatic nucleus, the clock which is sensitive to light sits.  And when we found this it was like Ching! – that makes a whole lot of sense.

 

Porter

Let’s assume we manage to provide relief in the short term, the next question coming from my patient is going to be well if this is going to happen to me twice a year doctor I want to have something that’s going to stop it happening, do we have any preventative medication in the same way that we might use preventative medication in people who are getting regular migraines?

 

Goadsby

Yes we have preventives – the best of them is a drug called verapamil, typically used in blood pressure, it’s used at very special cluster headache doses, so you would recognise that in blood pressure you might use 120 or 240 milligrams a day, that would be considered pretty good, in cluster headache you may have to run up to 960 milligrams a day, which will make most people blanche when you say it.  That said it can be extraordinarily effective at turning the attacks off.  It has no preventive effect before the bout – if you actually continue taking it between the bouts it has less effect, so a crucial thing is to only take it during the bout.  We also showed that about 20% of patients on it will have some abnormality on their ECG, so it’s really important anyone starting on verapamil gets an ECG beforehand and a little thing…

 

Porter

Verapamil affects the heart.

 

Goadsby

It does, it affects something called the PR interval which is how the heart keeps its rhythm up, it’s really important that that gets checked about 10 days after a dose change to make sure the heart doesn’t get slowed up.

 

Porter

What’s the natural history of this – if I’m getting this problem – is the outlook good or am I going to have them forever?

 

Goadsby

Well it’s good and it’s not good.  The natural history is for the bout length to get longer, so six, eight up to 10, then 12 then sometimes three months but the inter-bout intervals to get longer.  So as time goes on a patient will miss a year and they’ll think wow Christmas and then the following year it comes back.  So the natural history is for that process to continue – bouts get longer, inter-bout intervals get much longer.  So the longest inter-bout interval I’ve seen was 18 years and that was in someone who was 96 who kindly came along because he thought I’d be interested and he was quite right.  And if he’d died at 95 you would have said the disorder had gone and he came to see me at 96.  So the great thing is that there will be really really long breaks and every time a cluster patient is in a long bout the light at the end of the tunnel is that the break afterwards is going to be great.

 

Porter

Professor Peter Goadsby.  And you will find even more information on cluster headaches if you feel you need it, on the Inside Health page of the Radio 4 website.

 

Now I am sure that I don’t need to spell out the myriad physical hazards of smoking. But what about the impact on your mental health?

 

Smokers will often tell you that they find the habit relaxing, and that it helps them cope with stress - a view generally supported by those who live with them.

 

Little wonder then, that so many people with mental health issues smoke. But the latest research suggests they are mistaken and that far from helping to ease daily angst smoking actually makes matters worse.

 

Ann McNeil is Professor of Tobacco Addiction at the Institute of Psychiatry, King’s College London.

 

McNeil

Many smokers will say they smoke in order to calm down, to feel less anxious, it helps them get through the day but this is a myth because what tends to happen is that smokers, once they’ve been for about half an hour or an hour without smoking they start to feel withdrawal from nicotine and that can make them a bit edgy, a bit irritable, a bit angry, anxious and then when they smoke that calms them down again, so they miss attribute their feelings to the cigarette has helped them to calm down, whereas in actual fact the cigarette is just helping them with their nicotine withdrawal.

 

Porter

But that’s quite a widely held misperception isn’t it, not just amongst smokers themselves, I mean it’s a sort of cliché that when something happens you reach for a cigarette and it calms you down?

 

McNeil

Yes even non-smokers and some non-smokers will even encourage their partner or whatever to have a cigarette to help them to calm down.  So it’s important to try to unpick this and see what is going on and that’s why we were interested in looking at the relationship between stopping smoking and then what happens to people’s mental health when they do stop.

 

Porter

And this misperception isn’t just held by the friends and relatives of an individual but also by – widely by healthcare professionals too.

 

McNeil

Yes unfortunately that is the case.  So for people with mental health problems we haven’t had any success at reducing their smoking over the last couple of decades, so smoking has been coming down in the general population, it’s now about one in five people who smoke but something’s been happening for people with mental health problems – their smoking has stayed relatively stable.  And you – they are approximately double the rate, so about 40%, but in people with serious mental illness that can go up to 60 or 70% of people who smoke.  I mean people with mental health problems die many, many years earlier than people who don’t have mental health problems.  They don’t often die because of their mental health problems they often die because of coronary heart disease, cancers, all the things caused by smoking.  So really we have a duty to ensure that we offer smokers with mental health problems the same advice and treatment that we’re offering to people without, otherwise we’re just going to increase the health inequalities that these people are suffering from.

 

Porter

How much do we know about the interaction between smoking and the sort of medicines, the drugs that we use to treat mental health issues, could there be any impact through that pathway?

 

McNeil

Well I think this is a really interesting question because I think there are a problem a number of factors.  One thing that we do know is that smoking affects similar parts of the brain that are affected by their mental illness.  We also know that smokers metabolise those antipsychotic drugs much more quickly than non-smokers do.  And some of those antipsychotic drugs have quite nasty side effects, so they have to take more of the antipsychotic drugs, when they stop smoking they take less, so that’s a real benefit which I don’t think we’ve talked about.  But I think one of the main problems that’s been deterring these smokers from stopping is the attitude of people around them who have believed up till now that their mental health problems would get worse and deteriorate if they stop smoking and what this study seems to suggest is that that won’t happen and they may see an improvement in their mental health.

 

Porter

Of course the other problem from the healthcare professionals’ point of view is you’re often dealing with people, particularly at the more severe end of the spectrum, who can have recurrent problems and if they’re well and they’re coping and they’re at work and everything’s going well for them the last thing you want to do is upset the apple cart and there’s this perception that by getting them to stop smoking you might just do that.  Is there any evidence to support that?

 

McNeil
No evidence at all that people’s mental health problems will be exacerbated when they stop smoking.  And the problem is for many smokers they wait till the right time but there’s never really a right time to stop smoking, you just have to do it and do it as soon as you can.  But what I wouldn’t want to be giving a message to people is that they shouldn’t be using other forms of nicotine replacement therapies because they do help people to get over the psychological withdrawal when they don’t have their cigarettes.  So I’d be very much encouraging people to use other sources of nicotine during the period when they’re trying to stop smoking and then in the longer run they can think about reducing their nicotine intake.

 

Porter

Professor Ann McNeil talking to me at the Institute of Psychiatry and there is a link to her research showing that giving up smoking is good for your mental wellbeing on our website.

 

Just time to tell you about next week’s programme when I will be finding out more about care of the dying and new guidance that will soon replace the controversial Liverpool Care Pathway. And we respond to your requests for a more detailed look at what determines gender and why it might not always be obvious whether a new born baby is a girl or a boy.

 

ENDS