Tuesday , September 27 2022

In medicine, 'social prescribing' is catching on despite lack of evidence


There was a time when the medical strategy of social prescribing was seen as a folksy gimmick, in which a doctor would have to fill out a prescription with a garden order, or maybe a friend of a friend .

It made sense. These activities are associated with improved health, and for some, pursuing them can ease their troubles while also relieving pressure on over-burdened family doctors.

Now, the gimmick has gone mainstream. The British health system, where the strategy originated, recently adopted as a key government policy, and the last year has seen a steep rise in social prescribing in Canada as well.

This is the practice of medically prescribing non-medical treatments to improve social determinants of health, such as loneliness, despair, and poverty. Common examples of recommendations include those for exercise, social interaction, walking, gardening, cooking in groups, or taking up artistic hobbies such as painting or knitting.

Since November, for example, Quebec doctors have been able to prescribe visits to the Montreal Museum of Fine Arts.

The Royal Ontario Museum in Toronto is likewise about to launch a pilot program in January, offering free admission with a social worker, a healthcare or community professional.

The strategy is backed by theory widely seen as logical and intuitively attractive, especially for older people and the so-called worried well. Less serious ailments such as mild depression and some digestive and metabolism problems are known to respond well to exercise, for example. Social isolation is also a powerful determinant of health.

However, there is still no strong evidence of social prescribing's effectiveness, partly because studies have been small, anecdotal, qualitative and poorly designed. Some studies have shown no effect at all. But, some have found improvements in self-confidence, weight loss, emotional well-being, and other factors that affect health.

Janet Brandling, a health researcher based at the University of the West of England, Bristol, described this evidentiary uncertainty in the British Journal of General Practice. "Is it yet another unwanted role to be foisted onto (general practitioners), or a welcome path away from the medicalisation of society?"

Health care funders have adopted the strategy even in advance of widespread acceptance. In Britain, a large-scale monitoring system was recently launched to gauge the effects of social prescriptions, both in objective measures such as blood chemistry or weight, and in the subjective measures such as social connectedness.

British Prime Minister Theresa May has called this a "loneliness strategy" and "a vital first step in a national mission to end in loneliness in our lifetimes." To that end, Health Secretary Matthew Hancock has supported a serious increase in social prescribing as a way to take off the heavily burdened public health service, even going so far to say social prescribing "can be better for patients than medicine."

In September, Sadiq Khan, the mayor of London, included a social prescribing as part of a strategy that aims to help doctors who are in for non-medical problems.

In Ontario, the Alliance for Healthier Communities, recently launched a program to similarly measure the use and effectiveness of the social prescribing strategy.

"People can be their own best resource for their health and wellbeing, when they are connected to each other and the right services," said Kate Mulligan, director of policy and communications at the Alliance for Healthier Communities, said in a statement. "Social prescribing changes our lens from seeing individuals as patients with conditions, to understand them as people with gifts."

Nearly all patients had a history of mental health problems and were "frequent attenders" at doctors offices. Many had chronic conditions, such as irritable bowel syndrome, fibromyalgia, or chronic fatigue. Most were female, and a common thread was limited benefit from medical interventions.

A 2017 U.K. BMC Open found social prescribing "engendered feelings of control and self-confidence, reduced social isolation and had a positive impact on health-related behaviors including weight loss, healthier eating and increased physical activity." BMJ surveyed 15 other studies and found most were small, poorly designed, with a high risk of bias, lack of controls, and short on follow-up. However, the article conceded that: "Despite the clear methodological shortcomings, most evaluations presented positive conclusions."

Another study from the U.K. 's Center for Reviews and Dissemination has found no significant reduction in mental depression, although not anxiety.

"Many trends begin as great, well-intentioned ideas," Ranit Mishori, a professor of family medicine at Georgetown University School of Medicine, wrote in the Washington Post. "Before we begin proselytizing, we need to make sure that the resources are there, that we, as physicians, are well trained in how to push a change without causing any harm."

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