Friday 28 December 2007


2008 will hopefully be a fine year in the blogsphere.

Although sadly Maple Leaf Medic has stopped blogging, Dr Brown has returned with patient experiences and keen insight in equal measure, Mousethinks waxes lyrical with thought provoking clinical contacts, Cal's accounts remain as stimulating and entertaining as ever, Milk & 2 Sugars is back from her soujourn after exams and thankfully continues to deliver her antipodean perspective and humour as does Polly with The Girl giving more medical student perspectives.

It's a shame that The Psychiatrist Blog remains silent since even those not enthusiastic 'bout it would say it generated stimulating and animated discussion. Shiny Happy Person continues to write 'bout psychiatry far better than I ever could, succinctly conveying what I'd spend pages waffling over, giving a pithy and somehow more real account of both postgraduate medical training and of psychiatric clinical practice that's always engaging to read.

What with retired nurses and the vibrant Mental Nurse site keeping me both pondering and entertained, there's a lot to look forward to reading through 2008.

What I'm really looking forward to is the illuminating discourse from Zarathustra (gah, the link's old, he's not still a student) 'bout the text Al Azif penned by Abdul Alhazred. A true treatise on sanity, hmmm! ;-)

Wednesday 26 December 2007


Just 365 sleeps to go then we get to do it all again :-)

Tuesday 18 December 2007


I work with older adults 'cept when I'm on call.

A couple weeks ago, when on call and covering everything, I had to deal with "a problem" that an acute admission ward was having with a chap in his 20's who was psychotic. He'd no past episodes. He was a non-smoker. Deluded, grandiose, assertive, thought disordered and at risk (having driven his van in to a neighbour's house) and drug/alcohol free, the nursing staff were perturbed that he was awake at night, shouting and resisting personal care (like a bath, earler that evening). When one nurse forced him back in to his bedroom, and the bloke swung at the nurse, they called me to review things.

When I saw him he was pretty calm with me over the hour I talked with him, and pretty reasonable and accepting of options explored.

He felt awake, he wasn't sleepy, he never went to be at 11.00pm normally even when well, he didn't want to lie down when he wasn't remotely tired.

The admitting team had him on 20mg olanzapine (the maximum dose), 4mg lorazepam (the maximum dose) and 7.5mg zopiclone (the maximum dose).

Maximum BNF doses make me ponder. Is it that the drugs are the wrong answer? Is it that drugs are the right answer but we've chosen the wrong drugs? Is it that the drugs aren't being given? Is it that the pharmacodynamics require more than one drug to be given? Is it that patient factors (how their body handles medication) means higher doses need to be given? Is it something that patient's doing (e.g. smoking cigarettes affects olanzapine's dose a lot, effectively halving it) that affects the dose?

It struck me that high dose antipsychotics didn't seem justified even though it's what the nursing staff sought. I'm not one to leave nursing staff to get battered, but I really believed that this chap could be managed with skilled nursing care and the medication he was on. We got an extra nurse on to the ward (she wanted the extra shift for cash before Christmas anyway ;-) ) and helped with reality orientation, distraction and de-escalating arousal/distress better than more antipsychotics could. There were no more assaults and no documented episodes of hostility or aggression.

A week later and the team say he's doing well. His sleep pattern is normal. His psychosis is resolving. Thank goodness he's not established on hefty doses of more drugs (since invariably that's then seen as what's cured him, so that's evidence to stay on them all for ages).

Happen it's because I'm an old age psychiatrist (and often am at BNF limits but seldom exceed BNF limits), but ramping up doses of high dose antipsychotics increasingly fills me with ill ease. When discussed at a case conference I was struck that I was in the minority, most colleagues taking a different view. It's a funny old world.

Thursday 13 December 2007

Social Care

It's not often that I recommend that a patient is detained under the Mental Health Act 1983, but this week I had cause to do just that. That makes 3 patients detained this year, not bad for a full time Consultant Psychiatrist and less than my colleagues, but I'm still conscious that it's loss of liberty and choice for 3 people at a distressing time in their lives.

This week it was a gentleman who's thoroughly confused but has never been seen by mental health services. He's been living in squalour for months. Social services visited him, he declined help, they left him. This seems frankly criminal, given the state he was in. His fridge didn't work and had only rotten food that was composting down in it. Milk bottles were full of solid milk. Items on the floor were shredded by rodents. Dead mice and mice droppings littered the rooms and stairs. Urine and faeces was soaked in to him, his clothes, his furniture. He was unkempt, unwashed for months, had debris stuck to him and his clothing and smelt of the urine and faeces that he'd been generating and sitting in for months. Broken glass was on his lawn, porch and stairs. He had no heating and we discovered the reason his fridge wasn't working and he was sitting in gloom was because he had no electricity. Now I know I'm just a medic and not a trained Social Worker, but this does seem a curiously suboptimal state of social wellbeing to leave a chap in.

I've no idea if he's toxic through infection or if he's cancer that's metastasised to his brain (he's had cancer in the past that was cut out but he never attended follow up), if he's nutritional deficits (I can't imagine he hasn't, though) or if he's dementing. So he's now on my ward, detained under section 2, a month after social services visited his home then left him in this state.

I don't believe a Social Worker could necessarily have prevented his confusion but they could have organised the social care he needed and deserved.

Much badness.

Wednesday 12 December 2007


Again I shamelessly take themes that you, gentle readers, generate yourselves rather than having creativity myself. Again I'm caught by Disillusioned's comments about differences in service provision arising within the same Trust.

So I had a rummage around the stats and, what do you know, Disillusioned is right.

Within our Trust the General Adult services are pretty hit and miss. Some folk get a decent service, many don't. I could wax lyrical about why this is, but it'd be futile and consume me with despair which really isn't in the spirit of the Christmas season!

Within my own corner, Older Adults, my sector is seen to be working well. I've had my annual appraisal last week with a Director from another hospital and he reckoned All Was Good. I've presented at conferences how our team works, since it's seen as A Good Thing. Our Trust likes it and has had me doing teaching and roped in to meetings 'bout it all. In truth, it's all about the team (not me) so it's curious that I get to say my spiel when it's the team as a whole doing the work.

But it got me comparing my team with others. And there is indeed a lack of parity. My team has less qualified and less unqualified staff than any other team. It's the smallest. Other teams, that are larger, have broadly the same amount of work to do (referral rates and sector populations being comparable). In all teams no new patient has to wait more than 10 days to be seen, in our team referrals are all usually seen within the week. Access time aside, from referral with memory problems to receiving your first prescription for a cognitive enhancer, my team gives fastest access, a couple teams are similar but somewhat longer, one team has a delay of almost 2 months longer.

Interesting to see that folk in the same patch with more staff and the same amount of work have a less responsive service.

Now how the heck is this tactfully taken forward?

Monday 10 December 2007

No work

Disillusioned kindly posted comments 'bout Day Hospital but then interestingly mentioned how staff sickness meant that the work didn't get done.

This got me thinking.

If a Consultant Psychiatrist is off sick for a short time (a few day), any routine work isn't done but any urgent work is covered by colleagues, being absorbed in to their working week. If off for any length of time, a locum is brought in to fill the post and do the work. Although I've not had a day off sick this year, nor have others I work with, I think that it's understandable that if I am off sick, 'phoning in that morning to say I'm on my death bed, then the clinic list for that day would have to be cancelled. Given that the work isn't done by anyone else then has to be done when I return to work, on top of everything else, it's usually easier to soldier on and do the work rather than take time out one week then have 2 weeks' work to do the next. But anyway, short term sickness will occasionally occur and will occasionally impact on appointments.

For nursing staff, the story's the same for short term sickness too. If colleagues are off for a short time then urgent stuff is dealt with and some it's understood that appointments for that day may need to be cancelled. Going through all activity since April 2008, we've actually not had to do this terribly often, since either other CPNs* or I have done the visits instead. Thus, we can count on one hand the number of patients who've had cancellations through sickness. We don't like to mess patients around so if we can sort it out we rather would do, then we're up to date and the patient's had the input we'd all felt was needed.

Long term sickness is different, though. I've little sympathy or understanding for why long term sickness should affect patient visits and support at all, since it's long term (so plans can be made to address this).

Disillusioned said that staff off long term do have impact on support. Needs identified and planned for within the Care Programme Approach (CPA) should, obviously, be met. The whole point of it is that you're looking at needs and planning medical, social and nursing care to address these needs.

For a service to have folk, with CPA evidencing the service provision nececssary for their health, to then fail to deliver, seems wholly inexcusable. Okay, if through short term sickness I'd concede as above that the odd visit may not happen, but for people to just do nothing is unbelievable. It's embarrassing.

In what other area could someone be off work, have patients in need of support, and still no support is given and no work gets done?

* Apologies to anyone who's a Integrated Developed Independent Outreach Team (IDIOT) nurse and not a CPN, but I can't get my head around new jargon for new jargon's sake ;-)

Wednesday 5 December 2007

Clinical Research

Commonly I'm asked to help manage Behavioural and Psychological Symptoms of Dementia (BPSD).

Usually this involves stopping medication that's making things worse and changing the environment to reduce ambiguity and distress then psychoeducation to guide carers on what to expect, how to de-escalate distress and what interventions can be effective to minimise disturbed behavioural repetoires without compromising personal care.

For example, a wife recently struggled to bath her dementing husband because he assertively resisted each time she tried. Removing unnecessary medication made him much more content more of the time anyway, then guidance with her meant she'd cracked it and was able to use a mix of ongoing reality orientation and reassaurance to bath him without any problems.

Still, for some folk, medication for BPSD is useful. I don't like older antipsychotics, I won't sedate anyone to "make things more manageable" and I'll only use medication as part of the process of care (rather than being seen as the solution itself). At best, medication then is something that helps the patient and carers manage behavioural disturbance better, allowing the patient to engage with the carer in the techniques they can use. Medication, then, is just a tiny part of the solution, helping the carer do the high quality dementia care we teach and advocate.

With that in mind, it's not often I find myself using olanzapine or risperidone in the treatment of BPSD. Just a couple times a year, that I can recall. But there's a snag.

The UK Medicines and Healthcare products Regulatory Agency (MHRA) said that they shouldn't be used.

Letters in the British Medical Journal criticised the authority/strength of direction, saying these drugs shouldn't be used, since they're clinically helpful and risks were low.

A more objective observational study didn't find the level of risk and concern the MHRA described concluding, "Perhaps the best we can say is that on the basis of this good observational study, the risk of increased strokes from atypical antipsychotics in dementia is less than the trials indicate."

The MHRA say that background risk of stroke is about 1% a year in this patient group. Patients on olanzapine or risperidone have an annual risk of about 3%. Many of the strokes are small (and arising in people with a degree of vascular dementia already).

The MHRA conceded that it's not likely to be a problem with these specific drugs, it's just that there's evidence about them. So alternatives aren't known to be any safer.

These patients with dementia and behavioural disturbance often can't and don't have capacity to give valid consent to treatment with a difficult risk/benefit ratio to consider. As the medics in the BMJ wrote, who is advocating that they should get the care they need and deserve?

Studies tell us about general risks and trends and effects. They don't tell us about our specific patient in front of us. Curtailing clinical freedom so the individual's care is overly influenecd by "average" statistical trial outcomes is harmful.

Much badness.

Tuesday 4 December 2007

Day Hospital

Should we have one?

The case against is compelling.

Our day hospital has oodles of staff treating very few of my patients. Not much bang for our buck. If the staff were in a Community Mental Health Team they'd be seeing about 4 to 5 times as many folk.

What does a Day Hospital do that a CMHT and social service day centres and EMI nursing homes can't do, if NHS staff visit and work within them?

Wednesday 28 November 2007

Severe Depression

A few patients have had almost identical problems over the last couple days.

One gentleman is typical of the issues. He's 86, retired and widowed (for 13 years, now, and is on sertraline 100mg to help with this). He lives alone in a property he's happy in, in the locale he's lived in all his life. Family live 2 hours away but drive to see him every week or so and 'phone daily. He's no local friends and doesn't use local amenities such as cafes, church, libraries, theatre, support groups or whatever.

Physically, time's taken it's toll and he's got a few complaints (heart pain, gastric reflux, joint pains) none of which are now serious but all of which erode his resolve and ability to cope. His joint pains are so signifiant that, despite joint replacement, he remains on morphine tablets to address the intensity of his pain (which is at manageable levels of discomfort now, most of the time). Non-pharmacological interventions have also been tried. Like many folk, it's impossible to get better symptom reduction without either major risks or unacceptable side effects, so his physical health is pretty much as optimal as things can get.

He keeps busy through the day, mostly doing DIY in his home (that's very well maintained) and has done fantastic paintings in oils that he's rightly proud of, displaying in his front room.

He's no major stresses. He's financially comfortable, no debts (ever), he's no family worries, no relationship difficulties, no problems with neighbours, no neighbourhood difficulties, no practical heating/lighting/home difficulties, no legal issues, there's nobody struggling with their health, no worries about self care or acitivities of daily living, in fact there are no clear stressors or precipitants/perpetuating factors affecting his mood at all.

But, he's low in mood. Not all the time, when he's distracted he's fine, but when he's on his own (as he invariably is) his thoughts surface, with notions that he's nothing left to live for, he's a burden to his family and life's empty now his wife's gone.

He's always been a private man, he's never sought help from anyone, he refuses to let us tell his family how he's faring and only has been seen by us over the last 2 days when his GP referred him after finding him in floods of tears (but discolsing no problems or risks).

He described how he wakes in the early hours of the night, feeling grim. I can imagine him lying in the darkness, in total silence, with just his thoughts strirring, feelings of hopelessness consuming him. Sometimes he gets up to distract himself, turning on the television, sometimes he simply lies there wishing to be dead. Often he thinks he should be dead. He's pondered different modes, seriously, and considered which owould be unacceptable and which he could do. Two days ago he ground up all his morphine tablets and went to sleep, awoke to take the powder and kill himself but thankfully couldn't find it. It's positive that he told me about his suicidal thoughts and intent when he'd not felt able to tell his GP, I suppose. He's nothing to live for, feels his family would be relieved if he killed himself (there's no evidence of this, they seem to dote over him) and he couldn't accept there'd be ripples with enormous guilt if he did.

He's put his affairs in order and signed his home over to his family. He has no plans for the future.

A patient who is male, elderly, somewhat physically unwell, in chronic pain, feeling he's a burden, feeling suicidal (with active suicidal ideation), feels hopeless and worthless, is planning the mode of death and has tried to act on this. He's not volunteered any symptoms to his family, GP or other services and hasn't sought help.

He's adamant he doesn't want to be in hospital.

Dismal for his first contact with mental health services, the first time he opens up and discloses his thoughts and feelings, to result in compulsory hospital admission . . .

Tuesday 20 November 2007


Having found this, which I thought hugely amusing, I found David Armand also did this. It's just a typical day's work for a clinical psychologist :

Monday 19 November 2007

Primary Care

Mr Angry explains his recent experience with Primary Care. It's worth sharing :


Tuesday 13 November 2007

The circus comes to town!

All Educational Supervisors (i.e. all Consultant Psychiatrists) in our wee corner of the world were summoned to learn about Workplace Based Assessments, last week. Although it kicked off in 2005 with PMETB (the Postgraduate Medical Education and Training Board) the behemoth of change rumbles over us, crushing past success and introducing change. Because, erm . . . change is good. I'm told. So it goes.

"Roll up, roll up, come see the greatest show on Earth!" We sat dutifully whilst clever folk told us about Why It Had To Be and flirted with selling the whole thing to us. No matter what magic and words were woven, this trick didn't work. To say the reception was "frosty" is rather like saying the void of deep space is "a tad chilly."

"See, see how friendly and enticing this is! Gasp at the splendor of it all! Why, it's even in colour, don't you know!" We then were directed (erm, I think they called it something more pleasing like instructed, though, or mentored, p'raps) in the use the plethora of Workplace Based Assessment forms that our otherwise sensible College is foisting 'pon us.

"Watch them perform! Come, come see the clowns!" Oodles of Consultants, who've all been training juinor doctors for many years, watched. All had just been indoctrinated (erm, mentored, facilitated, coached, did they say?) in Workplace Based Assessment then immediately we were given videos of trainee/trainer interviews to rate. Excellent, then, cutting to the chase. Let's just crack on and do that then, so we can get our trainees through the myriad of hoops they've now to jump through. "Jumping through hoops, high how can they go? Oooh, watch them skip and dance! What a performance, what a show!"

Our ringleader whipped us in to shape, working us in a score of small groups, scoring the performance of the trainees in the videos. We get through a few videos, a few different mini-ACE and Case-based Discussion. "Did they frolic, cavort and entertain? Did they leap to the hoops, only to fall? What scores, what ratings one and all?" We compared scores. A score of 4 is a pass, meeting the necessary standard. 5 or 6 is great (above standard and mastery). 1 to 3 is a fail, below standard. In one video we all watched the room scored the trainee from 1 to 5. Some failed the trainee as the worst ever, some passed her as above standard. This pattern unfolded itself again and again. We all watched the same video, had the same training and used the same scales at the same time (and discussed it in small groups so no one voice generated extremes). Yet there was huge variation in whether the candidate would pass (well) or fail (catastrophically). Not just a few voices in each camp, either, with most in the middle . . . there really was huge spread. So it goes.

"Ah, what mirth, what merry japes, 't is but practice, after all" And, in point of fact, it's the clinical practice of the whole next generation of doctors that's being flippantly fiddled with. Doctors who will be treating me. Treating my kith and kin. So it goes.

I've tried to register with the Healthcare Assessment and Training (HcAT) website who say they've sent me details to log on, but they lie. So since all forms are online I can't do any assessments with my trainee. None what so ever. So it goes.

Am I the only one who feels that form and theatre and checklists wholly eclipses merit and content? We live in interesting times. Junior doctor training has been modernised. So it goes.

Saturday 10 November 2007

Text Messages

A chap broke up with his partner of 3 to 4 months.

They started sending increasingly acrimonious text messages to one another.

Laughing with his brother he said, "this'll wind her up!" and texted her saying he'd go to the woods and kill himself.

She 'phones the police saying she's had 40 texts from him that day and he was suicidal. Police find him late afternoon and detain him under section 136 of the Mental Health Act 1983 and drag him to my hospital. Where he's laughing and smiling and well. Obviously so.

It's hours before an Approved Social Worker (ASW) could visit since they were busy with other distraught folk.

At almost midnight, the ASW arrives so she and I assess him. After a few minutes it's clear he's neither suicidal nor ill. Being zealous I spend an hour and check everything and find him to be absolutely fine and well, far better than most folk are, in truth! Cheerful, happy with his life (and new partner), no stresses, physically well, great relationships with family, no worries about anything and looking incredibly well.

The moral of the tale : Don't text folk saying you're suicidal as a joke, or police will detain you for an evening/night (with risks of it all going pear shaped after that "just in case"). Even after break ups, play nice :-)

Thursday 8 November 2007


I've a gentleman with dementia. Properly, he's got ICD-10 F00.12 Alzheimer's disease, late onset, severe.

He couldn't manage at home, had support, progressed, had respite care and now is in permanent care within an EMI Residential Home.

He is happy.

Within the meaning of the Mental Capacity Act 2005, with regard to decisions on his placement and future care, he's an incapacitated adult.

I have seen him many times at this care home, he always has been settled, cared for and content. My nursing colleagues see him and find him equally well. An Occupational Therapist assessed him. A Physiotherapist has looked at his mobility of late, as it's deteriorated. A Dietician saw him 2 weeks ago to give advice on dietetic input. A Modern Matron from the PCT saw him recently to look at pressure care and prevention of sacral sores (which he's never had, but he's increasingly sedentary). His GP reviews him episodically to consider physical health concerns (episodic joint pain and cramps, mostly). An external Independent Mental Capacity Advocate (IMCA) reviewed care and felt it would be in his best interests to remain in that care home receiving the care he was receiving.

His mental health has been stable, he's on no medication at all and hasn't needed any.

The EMI Residential care home has had two unannounced visits from the regulatory body CSCI this year and found to be absolutely fine. With so many professionals going in, often unannounced when we're in the area, we've also found everything to be fine. Scrutiny of the care plans show care to be fine. No families or residents have complaints/issues.

So, my patient's in a good care home receiving good care that oodles of professionals over a many months consistently see to be the case.

The home feels they may have to serve notice on him. They do not want to, they feel great warmth for him and enjoy caring for him (which they do well). They're very patient centred, if he has sleep disruption (as he does) and wants a bath at 2.00am (as he did) then he has one. When he was offered food at meal times but declined then was hungry later on he ate pizza just before midnight. They're sensitive to his care and are very accomodating.

My patient has 2 daughters. One thinks he's getting great care. She told me today that every time she visits dad,"He's happy, and that's the most important thing." She thinks he's well cared for. She wants him to stay there.

Another daughter wants him moved. She has no formal mental illness diagnosed but in the couple years I've (endlessly) seen her I'd wager good coin she's got a personality disorder. Maybe this is kinder than her sister who says she's a "vile woman" who's been "thinking of herself all her life" and "is wicked."

This daughter concedes that all major care is delivered (he is fed, washed, toileted, mobilised and so on) but that the quality of care falls short of what she wants. So she harasses staff. Daily. And generates prolific pages of complaints. Endlessly.

Protection of Vulnerable Adults (POVA) was initiated but hasn't had helpful outcomes since the daughter's malign influence hasn't been sufficient to enable police or agencies to be involved. The POVA meeting recognised she lied and mislead people and misrepresented people's views.

My patient's happy. He's happy to stay there. The care home want him to stay there. The professionals feel he's best placed there. The independent IMCA feels he should stay there. One daughter wants him to stay there. The other daughter (who's the nearest relative) makes it untenable for the staff to look after him (and has moved him 3 times already).

The evidence base is that if he were to move at this stage in his illness he'll be dead within 12 months.

Is there any lawful way we can prevent the nearest relative from visiting her father when she's impacting so negatively on the home that her father's best interests are not being served?

Tuesday 6 November 2007


The Healthcare Commission reviewed, scrutinised, harrassed and sussed out what was happening in our Trust. It's allowed, though, as they're the "healthcare watchdog" so I can't complain.

What's interesting is the result. You see, we're "Excellent."

What does that mean? I didn't know either. I looked it up. There was a lot to read through. For mental health the summary is :

Meeting Core Standards.
"Fully met."
Our Trust, "was meeting all of the core standards set by Government."

Existing National Targets.
"Fully met."
Our Trust, "performed consistently well for this assessment."

New National Targets.
Our Trust, "performed well beyond the minimum requirements and the reasonable expectations for this assessment."

We knew we were in the top few Mental Health Trusts prior to this but it's good to see that outside forces, looking for fault, reckon we're pretty alright too :-)


I started to reply to a post over at Mental Nurse but had to stop. It was becoming a rant and I rather feel it's bad form to go somewhat off topic and to rant on someone else's site. So instead I've shamelessly nicked the theme and can wax lyrical at length, as is my wont. At length, hmmmm. I do "at length" well enough, I do "brevity" appallingly badly. As my nursing colleagues tell me, flawed though I am that at least I'm self aware :-) After a manager wanted to highlight some good practice in our service I've been charged to talk at a conference in a couple weeks time for a total of 15 minutes. 15 minutes?! An impossible task, reinforcing views that managers are out of touch with clinicians and heartless ;-)

Back on topic . . . therapeutic relationships.

The point, well made, is that outcomes of therapeutic interventions is uncontestably associated with the quality of the therapeutic relationship. For some folk in some situations this isn't true. A mother with a newborn baby who has crashing postnatal depression needs to be well, and quickly, evidence is ECT is more effective than medication or talking therapies and has better outcomes than pills, talk or watchful waiting (and less side effects, and half the deaths that tablet treatment results in). As one cheeky colleague has told me sometimes bedside manner counts for nigh on naught and what you want is to be found within the National Grid.

But, for most folk, most of the time, the form of the clinical interaction adds benefits in addition (or even more so) than the content of the clinical event. Psychodynamic psychotherapists would be more extreme, saying their interaction is almost everything.

The content matters too, but as has been said, a clinician with a great relationship doing anything can be useful to most people. A clinician with appalling relationships with their patients doing the "best" intervention is useless to most of their patients. Patients have no trust in the diagnosis, no belief in the formulation, no confidance in the intervention, no conviction they will improve and see no credibility in the interaction.

How the relationship between a doctor and a patient is framed matters, Primary Care are good at looking at this, with Michael Balint's view of "the doctor is the drug" being oh so true.

In 2003 we were told about New Ways of Working for all by NIMHE. In 2005 the Department of Health told us all about New Ways of Working for psychiatrists. More recently CSIP have told us about New Ways of Working. I believe I do a lot of the New Ways of Working malarky already (as do managers, it seems, as they want me to talk for 15 minutes about it).

But really, there's not a whole heap of new stuff to do, is there? I think we used to have it right. So in my corner, at least, we can have medics and nurses and PAMs and clerical staff and managers all working towards patients getting excellent care (we do, the Healthcare Commission says so) with clinicians having the time and space to form meaningful, useful therapeutic relationships.

Wednesday 31 October 2007

Composition of the MDT

We've been having discussions, of late.

I thought it'd be pistols at dawn, but it's been the typical reasoned and affable banter that thankfully seems to pervade our neck of the woods. The issue has been, who should we have in the Community Mental Health Teams (CMHT) as they expand?

Now, everyone has an opinion, with most folk are suggesting some or more of their discipline. Apart from me, since although we're below Royal College recommendations for Consultant Psychiatrist numbers given our patient populations, in truth we've enough medical time to get the work done well so I can't really justify arguing for more.

Within each CMHT at the moment we've got 1.8 to 3 qualified nurses (all at band 6 or band 7 with many having CBT and non-medical prescribing training), 1 Support Time Recovery worker, 1 social worker, 0.5 occupational therapist, 0.2 OT technical instructor and 1 Consultant Psychiatrist (potentially with some Staff Grade and ST1 junior doctor support but in practice they're supranumerary and there just for training). One team has 0.2 of a pharmacist. We've access to a Nurse Consultant and to psychology who work more widely than just with the CMHTs. We've sessional input from a physiotherapist. We've service level agreements for dietetic and Speech Therapy input.

As activity rises and we've extra cash to invest in the community, what should we invest in?

The crunch is that every discipline can contribute something useful, there's no startling unmet need we have to address, instead we're rather looking at improving quality of care further (even though the Healthcare Commission again rated us as Excellent, yay!) and generating extra capacity for the future.

My gut instinct is that a Community Psychiatric Nurse (CPN, erm, or whatever they fashionably call themselves now) wins almost each and every time but the physios and OTs and pharmacists clearly want to expand their corner with psychology jumping up and down too. All add something useful but with rationed resources we need "the biggest bang for the buck" which principally is quality of care rather than purely volume of activity (since currently we've sufficient resources to see and sort all referrals, with no wait beyond 10 days).

In such a community team, would you have any views on what should be prioritised?

Tuesday 30 October 2007


I saw a gentleman with, apparently, dementia.

He had prostatism.

He had a stroke so his mobility wasn't great.

It transpires that he's actually got Normal Pressure Hydrocephalus (NPH) and I've referred him on to neurosurgeons to try and cure him.

What was embarassing was the "classic" trio of dementia, gait disturbance and urinary incontinence were manifestly present, but I'd missed the significance of the symptoms since I'd thought they were prostate and stroke disease.

Most folk with dementia don't get a CT or MRI scan since it doesn't change management. I did scan him, for no good reason other than it seemed "a bit odd," I'm so glad the clever radiologist chappies commented on the changes suggesting NPH since I'd not have considered it, otherwise.

Scary when good fortune rather than good clinical acumen gets the patient the right care . . .

Monday 29 October 2007


I've stoically maintained medical content in my blogging with no sorties solely in to my personal or family life, no memes or lists and no film reviews or the like.

For no good reason other than I like her blog and I'm curiously inclined to acquiesce to older lady's polite requests, I'm running with Elaine's tag about books. Too, I am rather fond of books.

4 childhood books
The Lion, the Witch and the Wardrobe. My father read the whole Narnia series to me and, to this day, I remember being snuggled in bed with wondrously fanciful bedtime stories. The Queen, the Turkish Delight, Aslan, it's all compelling stuff. Only now, with an adult's perspective, do I get how unfair it is that a bloke can be a treacherous traitor but be forgiven, but the lass who errs didn't get to enter paradise.
Winnie-the-Pooh. Again, excellent tales I loved as a child and as an adult. I've shared them with my kids, too. And I liked the child friendly introduction to poetry that AA Milne wrote.
Swallows and Amazons. My father had a full set of all Arther Ransome's series, original hardback first editions, that I'd read and be thoroughly absorbed in for hours on end. Better still, we spent Summer holidays in the Lake District with family every year so I really did get to swim in Lake Windermere and my father'd row us around to the small islands that were used in the novels.
Dune. I read it thinking I was all grown up and reading proper literature (I know, I know, but that was the least of my clangers) and hated it, failing to grasp the plot. I reread it after seeing the film and loved it. The scope of it suddenly became clear . . . the great Houses, the Spacing Guild with the monopoly it held, the genetic manipulation, the feuds, the Fremen's values, the challenge of a desert world, the massive political machinations that all made sense.

4 authors I will read again and again
Terry Pratchett. Trudi Canavan is popular at the moment, Iain Banks and Gibson and Asimov and Lovecraft entertain me with SciFi, Sergei Lukyanenko's Watch trilogy had me up for nights reading obsessively, but from all the SciFi and fantasy authors Pratchett is the one I probably read over and over again the most. The plots are variable with some great and some weaker but the characters and humour see it through, for me, such that I've always read the novel for the plot and pleasure then reread them and invariably got more out of it.
Bill Bryson. A bit like Michael Moore, you couldn't stand to hear what he's got to say day in day out, but Bryson's style appeals to me and his research is at least somewhat involved even when it's not wholly impartial. Still, the combination of good writing, interestingly researched with personal context grounding it all makes his texts easy to dip in and out of time and time again.
Paulo Coelho. The Zahir did little for me, the Witch of Portobello did more, The Alchemist was fantastic. Each time I read it I get more out of it.
Kurt Vonnegut. He challenges and muddles and intrigues me without pushing me too far away to lose me. My favourite, Slaughterhouse Five, I love even though I still don't really grasp it. The whole impact and futility and barbarism of the bombing of Dresden really has impact without being gratuitous or detached with morally reprehensible claims, it's all the more shocking impact for simply and elegantly describing it as it was. The anti war theme is so well crafted, with none of the usual zeal or extreme positioning. I get more from it each time I read it.

4 authors I will never read again
Stephen Fry. I'm lying on this, just 'cause I'm sulking. He's a genius and I own most everything he's written. Days after Moab is my Washpot was on the shelves I got my copy only to find his autobiography stopped at late adolescence. Robbed, I was! Patiently waiting for Serendipity is my Linen Basket, or whatever sequel it will be, nothing has been forthcoming. But this lovers tiff will pass, all will be forgiven, when the next book's penned . . .
Emily Brontë. Although I try so hard to read some 'proper' literature episodically, I just couldn't win, here. I tried Wuthering Heights twice this Summer and just couldn't get in to it. Kate Bush lead me to believe it would be windswept moors and exciting romance and passion transcending death. No. It's anachronistic English text 'bout two households mundane interactions with just three brief forrays to the moors in the whole book. Gah!
JRR Tolkein. I've read so much so many times that I'm all Hobbited out. And no matter what anyone says, The Silmarillion is rubbish.
Will Self. I've been engrossed by most anything he has to say when I've seen him on TV or being interviewed on the radio. Erudite, loquatious, insightful, I thought I'd dabble in his books and enjoy How the Dead Live. It was ghastly, one of the few books I've not been able to finish. Ho hum.

The first 4 books on my to be read list
The Picture of Dorian Gray. I started this in the late 80's but never finished it 'cause I broke up with my partner at the time and she nicked off with it! Some day I'll get around to finishing it, I'm quite fond of Wilde.
The Works of Algernon Charles Swinburne. From Alice Cooper's Poison I found my way to Swinbune's Dolores, our Lady of Pain. I've never really devoted enough time to many of his poems and, some day, will make time to muse over them.
The Collected Poems of Rupert Brooke. Again, I've read many of Brooke's poems, which is odd as he's the only war poet I'm taken with. Again I found him by accident, after hearing Pink Floyd's The Gunner's Dream I was taken by the line "in the space between the Heavens and the corner of some foreign field, I had a dream." Chatting to more learned friends I learnt that "The corner of some foreign field" was a line from Rupert Brooke's The Soldier. I read more but it's years since I read much of Brooke, he's another poet I really should devote more time to.
Nigella Express. I do a lot of the cooking in the house, my wife reckons I need to learn more snappy, quickly produced meals. We've bought Nigella's latest book, it's on my list of Things To Look At.

The 4 books I would take to a desert island
Dune since it captivates me each and every time I read it.
A Bible to help sustain faith.
Slaughterhouse Five as it's the book I've bought most times (having lost and given away more times than I care to remember).
Collected works of Shakespeare since I like a few of his plays and I love most of his sonnetts so this'd absorb me for ages. Too, it's good to have something soft, strong and thoroughly absorbent that can also be used usefully with kindling.

The last lines of one of my favourite books
The House at Pooh Corner, In Which Christopher Robin and Pooh Come to an Enchanted Place, and We Leave Them There.

Two folk I'd tag to do the same, if they'd wish to, would be Cal and Dr Brown.

Friday 26 October 2007


In mental health we're all pretty familiar with working within a multidisciplinary team (MDT) which generally is A Good Thing.

Our patients have input from medical, nursing, social work, pharmacy, occupational therapy and CBT directly from our team with additional access to physiotherapy and psychology from the service. We've good links for dietetic, epileptic, continence, diabetic and stroke rehab input.

Thus when we see a patient we're usually in a position to do something effective, as a team. Too, we support one another with both clinical advice and through stress and strife.

In my junior doctor training when sitting through a Forensic Psychiatry lecture (in the days when we were thankfully allowed to be spoon fed in lectures) the content became increasingly macabre, including blood splattered rooms and body parts. When the lecturer was challenged by one gentle soul that this was gratuitous and unnecessary for the teaching he replied with wisdom. "Psychiatry is about misery. If you don't like it, you're in the wrong field."

Much of psychiatry is, I suppose, "about misery" as he meant it. People who are well and satisfied and happy and coping won't have much involvement with mental health services. Although I think "misery" is over stating it, most patients and families are experiencing marked distress. Since we're not in a position to cure most folk, we're mostly in the business of helping people make sense of and cope with their situations better.

For folk working in this field, dealing with people in distressing hour after hour, day after day, can be invigorating (as so much good is done) or demoralising (as few folk are cured and the morbidity never seems to end). In places where mental health services are upbeat, motivated, zealous, patient centred, compassionate and healthy (Law 4 : The patient is the one with the disease) the difference is the team.

A supportive and open MDT than has good team dynamics makes a world of difference to the culture we work in and therefore the type of work we do and indeed the details of the way we work.

Curiously, days go by without me seeing another Consultant colleague, weeks go by without me chatting to one. They're there when I'm worrying I'm having a blonde moment and need to bounce an idea off them, but by and large the MDT challenges and supports me such that practice is as it should be.

Now that's an interesting position for me to reflect upon, when senior nurse practitioners working collaboratively with medics help generate such a dynamic.

Friday 19 October 2007

Soulful Psychiatry

My team practices pretty eclectic psychiatry.

This week alone we've worked in people's homes, on the streets as we've gone for walks, in a garden centre, in a cafe, in a pub and on one lady's garden path. Heck, 3 patients were even seen in an out-patient clinic :-)

All of this was purposeful. Whether it was one lady's anxiety and phobia necessitating walking to her garden's gate and being there 'til distress diminished, or a social phobia and sitting in a cafe with the hustle and bustle or wanting to get back "to normal" after a bereavement and bimble about looking for bedding plants, we're in the business of alleviating distress and working with patient's problems in a way that fits with them. Everyone's different, after all.

Too, medication's just part of the solution. Seeing a bereaved gentleman at his home with his son yesterday evening the nurse and I were struck by his progress over the last few weeks which I attribute wholly to the support (and CBT principles) his community nurse* proffered.

The medication he has of olanzapine 5mg (used as a treatment for his bipolar disorder in the past and his son's at present) was reintroduced when sleep got worse (down to 2 to 3 hours), Activities of Daily Living became increasingly impaired, anxiety rose (so he'd not leave the house) and thoughts became more disturbed with negative ruminations. A month on and things hadn't changed but he then was less chaotic in his thoughts and could work with the nurse to effect practical behavioural change and spend hours with her doing this work.

Which is good, because he's now dramatically better.

But what got him better, to my mind, was the nursing input and the medication. The medication afforded enough resilience, cohesion and alleviation of distress to engage in the somewhat cognitive and mostly behavioural work, the medication wasn't a cure and didn't effect the change itself.

Working with people at their pace, introducing nursing when there's a window of opportinuty and they're ready for it, use of medication at the lowest doses, treatment in the community at the most suitable location, work with the patient and family, use of different modalities as interventions, as I started off saying I'd like to think we're a team with a pretty eclectic approach.

I was dipping in to Bob's blog and reading about Soulful Psychiatry. The language used by Dr Roberts sounds appealing. I'm not sure who Dr Roberts is, she's not listed as a medic. Some themes espoused sound appealing. The antipsychiatry and antidrugs does not sound appealing. As Bob himselves says, he's spent ages on in-patient wards and now his mix of medication and removing stress has thankfully kept him well for ages. What are your thoughts on talk of things like Soulful Psychiatry? So much mumbo jumbo? Dangerous anti-psychaitry propaganda that's increasing the stigma of psychiatry? Maligning mental health care making it less accessible by people who could benefit from it? Or it it useful in highlighting elements that can be introduced in to main stream mental health clinical practice?

* I used to call them CPNs (Community Psychiatric Nurses) but nowadays there's a vogue for them to be CMHNs (Community Mental Health Nurses) for reasons I can't quite fathom, so I largely eschew.

Tuesday 16 October 2007


I really really shouldn't do this, but it amused me too much.

I'd say I'm sorry, but clearly I'm not sorry enough not to do it, so I s'pose it wouldn't count.

Jokes I heard today 'bout orthopaedic surgeons I simply have to share :

Q. What does an orthopaedic surgeon call the heart.
A. A soft tissue organ for pumping cefuroxime around the body.

Q. What do you call 2 orthopaedic surgeons reading an ECG.
A. A double blind trial.

Now, tell me honestly that you're not grinning :-)

Sunday 14 October 2007

Doing Nothing

A touch facetious (since it's rare I see a patient without generating a management plan with at least half a dozen interventions even if they're all nursing or psychoeducation), but I'm indulging myself.

As a junior doctor, when called by staff to a patient it was always because something needed "doing". Put in a venflon, write a drug card, inject iv antibiotics, assess a rash, tell them they're dying, consent them for a procedure, defib their VF, whatever.

It's taken some time to step back and gain perspective, from "doing".

An anaesthetic Pain Consultant was saying of orthopaedic surgical collegues, "when you're holding a hammer, everything looks like a nail." I think it's a delightful turn of phrase she used to mean that when you're used to offering surgery, undertaking surgery, working in a surgical unit and seeing surgical referrals, you tend to think/do just surgery.

She p'raps was being overly harsh since most clinicians evolve a more balanced perspective over time, realising they can't "do" their thing all the time and often stepping back to do no harm and not meddle is the best course of action.

Training at the moment is focussed on Direct Observation of Procedures and "doing" which is important. But maybe Dr Basch had it right.

Maybe the trick of it is Law 13, to do as much nothing as possible.

Friday 12 October 2007

Stopping Medication

Just to tease my favouritist blogging GP, commenting on Secondary Care stopping medication that with hindsight is inappropriate . . .

. . . I was referred a lady with Behavioural and Psychological Symptoms of Dementia. She bit, kicked and punched care staff in her nursing home. She pushed other residents out of the way, causing a fracture in one old lady.

After initiating galantamine and promazine, she improved. A week later on review there was no hostility (not even verbal hostility) and all was well. A month passed. The home was happy. Her husband was happy.

She had a review by her GP who halved her promazine from 4 times a day down to 2 times a day (just morning and night). I know this because the GP 'phoned me to ask for a prompt review this week since she's now screaming like a banshee and flailing at folk with her walking stick through the afternoon and evening when she's no longer receiving her promazine.

Sometimes, just sometimes, us mental health folk do get it right and it's best not to rock the boat :-)

Thursday 11 October 2007

Parkinson's Disease

I've looked at a young chap (well, 66, so young to my mind) who unfortunately has Parkinson's Disease (PD). He's under the care of a physician who's been grappling with his PD but found the psychotic features tricky to manage, so asked for my views.

In PD there're regions of the brain where there is not enough dopamine. Result : my chap's rigid, literally unable to initiate movement and struggling to initiate speech and action. Medication is given to boost dopamine, helping improve the symptoms of his PD so he can play pool, read his paper, walk to the shops with his wife. Much better.

An unhappy side effect of the treatment is that the neuropsychiatric sequelae of PD become more prominent. That's to say, he has hallucinations and delusions. He awoke to see animals on his bed at 3.00am and had to get up, causing difficulties on the ward. This was compounded by his conviction that his wife had died and he had to get to her (so attempted to climb out of a window to leave the ward). Charging round a geriatric ward at 3.00am and making escapes unsettles staff, hence a referral to me.

I can start using an effective antipsychotic to help with his hallucinations and delusions. These types of medicine effectively reduce dopamine levels in the brain, improving his mental health. Result : his psychotic experiences (the hallucinations and delusions) improve but the dopamine antagonism works against his PD medication and his PD gets worse.

One antipsychotic, quetiapine, can work well . . . I've tried this but it's sedating him excessively so isn't an option.

Clozapine can also help, but is also very sedating (and can stop your body making blood cells to fight off infection, which kills you, and rarely you can get serious heart damage, which kills you). You need frequent (initially weekly) blood tests while you take clozapine and then ongoing blood tests at regular intervals since it's so hairy. Given his sensitivity to sedation I don't see him tolerating clozapine but it can be tried.

He's too unwell to be able to communicate preferences or discuss treatment options meaningfully and proffer valid consent. His wife obviously can't consent for him but I sought her opinion and she's keen for me to do "what ever is best" for him.

So what to do?

Either he's physically locked in (as his PD is bad) and mentally better (as his psychotic symptoms are managed). Or he's physically well and active (as his PD is well managed) and mentally unwell (with intense intrusive psychotic symptoms).

Any thoughts?

Monday 8 October 2007


The media have a major role in colouring our world. Are our streets safe, are libraries being valued, do we have accessible parks and outdoor recreational areas? I can answer such questions easily myself, yet my answers will shift by what the media says. I experience streets all the time, I read voraciously, I'm outdoors every week. Yet the feel for these issues is changed by the sustained voice of the media.

Any media has to have a voice or it ceases to exist. As such, material that is subjective comment rather than reported news is thrust at us endlessly through every medium possible.

This constant barrage of "news" gives texture to our experiences and does shift how we see our world, beyond our experiential learning.

How safe we feel is largely beyond our control (since principally it's other people who would make it unsafe). Because it's beyond just us we do rely on media stories to normalise how safe/unsafe our world currently is.

Mental illness is seldom seen in a positive light.

Much of our society will experience mental illness (about 1 in 4 of us in our lifetime will, depending which study you believe). 1 in 4. So it's common. Very very common. So common as to be unremarkable and normal and acceptable. Why isn't it accepted?

Media portray elements of major mental illness such as hearing voices as serious and risky. We know it usually isn't. Marius Romme's famous TV broadcast in the Netherlands in 1985 on prime time TV turned the tables momentarily, when some 400 people 'phoned in saying they heard voices but many (about 38%) functioned productively in the community. Many people with hallucinations have no contact with and are unknown to mental health services.

So why is mental illness seen so badly, with such stigma?

I'd go with this quote :

"The function of the press in society is to inform, but its role in society is to make money."
- A J Liebling

Sunday 7 October 2007


The Mental Health Act 1983 is, obviously, the law. It's a "statutory instrument" that contains provision to detain people with mental health problems and unmet needs in hospital (even though they don't wish to be there). There's a Code of Practice that tells us how we're to use the MHA 1983.

A couple points are worthy of mention.


When I was a trainee doctor, we'd get shredded for talking of "sectioning" someone. We were instead to speak of "detaining someone under section blah" which at the time seemed pedantic thought control. One Royal College examiner said he'd failed a candidate for such talk. With hindsight it's sitting increasingly well with me, but p'raps I'm simply becoming more pedantic as time marches on. Being less glib and more professional is important, though.

Being detained

I've never detained anyone. Well, technically not. I've made medical recommendations. Approved Social Workers have made applications to hospital managers for a patient to be detained. Hospital Managers have agreed to detain the patient in their hospital.


It shouldn't be.

Nurses have to be the patient's advocate, the NMC says so. Curiously, the GMC doesn't have anything like that directing doctors but most of us do feel we have such a role. As such, when we're advocating that a patient has a right to get the help they need and deserve it's useful to be part of the decision making process rather than be painted wholly as the prison warden. We don't detain people, we make recommendations for their care then social workers and hospital managers detain them if that's necessary. As such we can continue to focus on their care. A seemingly tiny point, but such things shift the culture and philosophy of mental health units from paternalistic/abusive to collaborative/clinically driven.

Anyway, I'm a civilian. Should I be locking people up?

Least restrictive setting

We've got to manage patients in the least restrictive setting. Hospital in-patient care should be for folk who have needs that can only be addressed through hospital care and increasingly these are far and few between . . . what can be done in a hospital that teams can't do in the community? There are assessments and interventions, of course. But typically it's rare that there's specific work that a hospital admission does that couldn't be done in the community (which is self evident, given that 1/4 of the population will at some point in their lives experience mental illness, but so few reach Secondary Care services let alone in-patient admission).

Hands up who thinks detaining people is just about hospitals? A not uncommon scenario for me is of someone with dementia who's been diagnosed and treatment's been optomised but they can't manage in the community despite having lots of support. One elderly lady this Summer became more confused at night, thinking since it was light that 9.00pm was 9.00am. She was helped to bed at 8.00pm by home care and would then rise to wander around the street through the night - living on a busy main road made this particularly unsafe. She'd been active at night for many months, it got worse, what were we to do? She was adamant that she wanted to stay at home.

Section 7 of the MHA 1983 lets the local Social Services authority force someone to reside at a specific address (e.g. you now live at Care Home X). As this is then the law, if they leave police are obliged to return them to this property. They're also compelled to attend out-patient clinics, any medical reviews and even non-medical meetings such as job centre attendance, going to a specific place of work, or having to attend specific evening classes as well as having no choice where they live.

All this seems pretty heavy, doesn't it? What I find more perturbing is that the protection patients have within the MHA 1983 are pretty good. The Mental Capacity Act 2005 is far more widely reaching (e.g. allowing community treatment orders against the patient's wishes) but has none of the scrutiny, no need for 2 doctors/doctors with specialist training and experience, no rights of appeal to hospital managers and a Mental Health Review Tribunal and no review dates. Scary.

Thursday 4 October 2007


Working with patients is, mostly, straightforward. It's what I've been trained to do, for years. Working with managers is, mostly, straightforward. Again there's training but mostly it's because our manager is ace. Working with nurses is, mostly, straightforward. My teams are fantastic and genuinely work collaboratively with me. Working with students is, mostly, straightforward. They are usually inquisitive, bright young things full of enthusiasm and keen to engage in training opportunities.

Powers that be are making my life less straight forward.

I do a fair bit of teaching. I do all the medical student teaching and, unlike colleagues with Staff Grades, I've always had a "training grade" junior doctor and rigorously undertake formal weekly supervision and informal teaching.

This is largely for the love of it, and to help our next generation of medics, since there's no additional resources for the time invested and just as the junior doctor's getting up to speed they leave . . . hence the enthusiasm for stable Staff Grade doctors in many camps.

Now I am becoming stuck.

To get around possible inconsistancies in training (which I've yet to find any evidence for) and to make training shorter and cheaper (where evidence tragically is legion) we've now got Workplace-Based Assessments to do.

We objectively assess trainees in blah. To prevent favouritism and prevent rubbish/dangerous doctors becoming Consultants and prevent untrained doctors progressing this necessitates a series of assessments that I am to do with my trainee.

I have read what I can but am still none the wiser.

For years I've had structured RITA assessments for SpR's and almost identical start/mid/end point appraisals with SHO's but now that's jettisoned in favour of these new fangled workplace whatnots that nobody's written or spoken to me about. Neither informed about nor trained in this, what am I to do?

I am stuck.

Tuesday 2 October 2007


I have a few beds on an "organic assessment" ward where patients with dementia can be assessed and treated.

Few patients are admitted.

The diagnosis of dementia is made in the community, the treatment is implemented in the community, why should a patient need hospital in-patient care for their memory problems?

They don't.

They're not admitted through memory problems, such folk would be placed in urgent respite care within a specialist (charmingly classified as EMI, Elderly Mentally Infirm) care home.

So who is admitted?

Usually it's folk with dementia who have behavioural disturbance. What is behavioural disturbance in my world? Mostly it's someone who, through their impaired concentration, memory, information processing and temprement misconstrues circumstances and acts aggressively.

You're sitting down minding your own business. Someone you don't know looms over you and starts undressing you. What would you do? Most of us would resist, and resist pretty assertively. Folk with severe dementia can't appreciate the hands on personal care so even if told they're being undressed to get in to a bath as their top is being taken off, a few minutes later will have forgotten and wonder why some strange folk are hauling their trousers off. Sensory ambiguity and misperceptions (seeing curtains blowing in the wind then thinking they're moving 'cause an intruder is there in their room), commensurate increases in paranoia, it's unsurprising that such an individual is feisty when a carer discreetly pads in to their room in the night to check they're alright.

Most folk with severe dementia are impaired but are fine to be around. Some folk will be aggressive and although it's not acceptable it is often understandable (when you start to think of their experiences from their impaired perspective). I don't like care home staff being battered. Such folk are admitted to my "organic assessment" beds.

They have Behavioural and Psychological Symptoms of Dementia (BPSD).

Despite comiing from an EMI Nursing Home, most (in fact, a review of the last 4 years shows all of them) are then are discharged back to an EMI Nursing Home. What magic do we work?


Medication is optomised but in fairness the Care Home team and I will have done this well before they were admitted, anyway. Stopping medication that could aggravate symptoms, starting and titrating helpful medication, we've fiddled with the chemistry in the community and it's still unmanageable in the EMI Nursing Home, so in they come to the ward.

Occasionally I find a medical condition exacerbating their distress and disturbed behaviour, occasionally I find a change of medication that I'd not explored in the community and initiate in hospital with benefit . . . but mostly I have, in truth, little to offer.

Nursing care

Nurses do it all. They assess what the patient finds distressing, what provokes distress of confrontation and what is helpful. Some distressed folk need their hands held, eye contact, calm speech, soothing touch, close proximity and reassaurance and all this support and reality orientation can keep them in the here and now, coping. Other folk find this claustrophobic and intense and intrusive and are wound up big time, favouring space and solitude and a desire to pace, pace, pace endlessly around the garden or ward (that's a huge circular building, for this purpose).

As well as gleaning what winds patients up and what is helpful, nurses then can implement an informed behavioural approach sympathetic to the person's presentation. Having sussed out how they can get dressed or bathed or fed without provoking hostility this is done each and every day, establishing a routine and habituating behaviour.


After a few weeks behaviour settles. The person's stable and then we're able to be discharge them to a care home.

What's worked?

So many folk are full of praise for what I've done to "help their mum" or "get their old dad back" or "stop Mr X battering my staff" and, no matter how many times I tell folk, they continue to say this. But it isn't me. It's the nurses. Not nurses doing doctor's roles. Not nurses doing extended roles. It's highly skilled nurses doing highly skilled nursing.

Thursday 27 September 2007


An update on my lady who's been having sex.

Although we've directed him not to, the man who's been whisking her off to his place for nights of intimacy continues to do so.

Yesterday she turned up at her day centre. Staff were concerned. They 'phoned to say she was smelly and found he'd packed her off wearing no knickers and she had semen dripping from her. Worse, she had extensive bruising on her upper legs and perineum.

Police have finally agreed to look in to this . . .

Wednesday 26 September 2007

Mental Health

Mousie has kindly shared thoughts in comments here that an explanation of good mental health services was necessary.

I work in a mental health Trust that delivers, I believe, good mental health care. I've an appraisal in a couple months (a subject to blog about at another time) and part of the information gathering that managers undertake for this, generating an entire lever arch file full of objective evidence, shows exactly what I do and what the sector I work in as a whole is like.

- In the last 12 months every urgent referral from a GP has been seen within 4 hours.
- In the last 12 months every routine referral from a GP has been seen within 10 days.
- My access time for my next out patient clinic slot is under one week.
- In the last 12 months every patient of mine needing a hospital bed has been admitted immediately (with no wait time from blocked beds).
- In the last 12 months every routine liaison referral from medical/surgical wards has been dealt with within 5 days (some within an hour, most by the next day).
- In the last 12 months the number of patient clinics cancelled at short notice (defined as within 6 weeks of their appointment) : 0
- Average number of professionals involved : 3 (eyeballing it it's averaging a community nurse and me for most folk, with a social worker or occupational therapist or support worker or psychologist or memory clinic nurse too).
- In the last 12 months every patient discharged has had a letter written by me with summary including a diagnosis and risks and medication and interventions and follow up completed and signed before the patient leaves the ward, to be mailed to the GP.
- In the last 12 months every patient discharged has had a full discharge letter sent to the GP within 2 weeks.
- In the last 12 months every patient needing Mental Health Act 1983 assessment has been seen by me within 2 hours of the request (and only 2 of my patients have been detained).
- I've had letters of gratitude and praise, which of course is always welcome.
- I've had no complaints (verbal or written) about me or the service which in mental health seems amazing.
- Our Primary Care Trust gave extra cash to us this year (to offset the 2.5% "efficiency saving" the DoH forces on every hospital every year) because the PCT loves us. They let me prescribe what I want and aren't trying to limit drugs even when NICE are.
- meeting with GPs in the sector, they're strangely enthusiastic about our service and haven't had any axes to grind.

So everyone is seen within 2 weeks (urgent problems are seen that day), everyone can access a Consultant within 1 week (urgent problems are seen that day), all communication is prompt and there's good support from GPs and the PCT. The wards are new, every patient has their own room with ensuite, their own space and privacy.

It's not magical, it's just the sort of service I'd want for me, or my nearest and dearest. So that's the service we try and deliver. After all, who pitches up to work wanting to give a bad service? It's more satisfying for us this way as well as being responsive for our patients.

It's just to say that it is possible to have what I'd see as good mental health provision in the NHS.

Private Practice

I have never worked in private practice and have no intention to do so. When my wife needed to see an orthopaedic surgeon a few years ago we waited 18 months to see one on the NHS. I like the NHS and think when it gets it right it can be fantastic. It's nice when it all just works.

I've nothing against private healthcare, I just am sufficiently naieve and idealistic to see the NHS as the laudable preferred option.

What piques me is the pervasive whispering that episodically surfaces, insinuating itself into speech and media stories, that "going private" is, of course, going for a better service.

It isn't.

It's going for a different service.

I worked with an SHO (ST2 junior doctor in new speak) who moonlighted and covered a huge private hospital for a huge city on nights and weekends. Maybe he still does. He was the resident medical officer. He was the medic on the site. When ever there was a need for medical care, he did it (as he was the only one there).

When I was "on call" working on NHS medical wards I'd spend hours on Coronary Care and on the Haematology ward and covering scarily ill patients, but my medical Registrar and her Senior Registrar would do scary things (like cardiac pacing). It would happen almost instantly, we'd get bleeped, we'd dash to Coronary Care, we'd get pacing wires and run them in to the person's heart, fiddle with dials to capture pacing, exciting but scary stuff. I'm so glad there were House Officers, Registrars and Senior Registrars as well as my good self. Once we were busy through the night and at 8.00am the Cardiology Consulant arrived to meet us in Coronary Care. When his patient had (another) cardiac arrest the Consultant let us crack on and manage the event . . . the "junior" medical staff were much more familiar with such emergencies than the senior Consultant staff, thankfully the Consultant wasn't too proud to show that. An NHS hospital. Lots of staff, all doing lots of emergency work (we worked like Egyptian slaves) so got pretty proficient at what we did. If I had a heart attack and arrested, I'd want that sort of team managing me.

Cut to a private hospital. There's a SHO/ST2 junior doctor there. He's an SHO in psychiatry. He's never even seen cardiac pacing. He vaguely remembers how to resuscitate someone since he's got to attend an update every year or so, but it's not somthing he's seen or done for years. As a psychiatrist his knowledge of surgical and medical problems is modest. He was the only doctor in that hospital.

Now, in the private hospital, the surgery was done by a Consultant not by a trainee junior doctor. The food was excellent. The rooms were sumptuous. Flat screen TVs on the walls. Great selections of books and magazines.

Routine and elective care was excellent.

But in an emergency, would I rather be in an NHS hospital with a horde of experienced junior/senior trainees who could capably sort the problem out, or would I rather be in a private hospital with a psychiatrist who could ask me how I feel about it?

Tuesday 25 September 2007


Who should do psychiatry?

A mature and sensible anaesthetist (she was a physiologist before training to be a medic) believes that psychiatry is just very complicated neurology. If you're a proponent of biomedical psychiatry it becomes quite a compelling argument.

A psychiatrist who taught me when I was a junior doctor believes that many psychiatric conditions, like severe depression, are too serious to leave to psychiatrists to treat. Although truly biopsychsocial in outlook, the "bio" bit was important enough for him to feel that "social psychiatrists" focussing on psychosocial problems were mistreating many of their patients by ignoring pathological neuroendocrine biological processes. "In 10 years time," he said, "physicians will be the ones treating depression, not psychiatrists . . . it's too serious a condition for us to play with."

Taking this views on, who should treat them? Their points both suggest that "sitting down and talking about it" is wrong and a more active management is warranted. And in many ways they're right.

We know that depression is bad.

The consequences of depression are serious. We know research shows that being stressed for protracted periods of time is damaging since the hormones released aren't meant to be sustained at high levels for any length of time. A "fight or flight" response is great if a lion is chasing you but to have surges of catecholamines like adrenaline is, we know, neurotoxic.

This means each and every day that someone's being there, fraught and frazzled, stressed and depressed, they're poisoning their brain and killing off brain cells. Much badness.

The original comments referred to this, meaning that patients deserved prompt and effective treatment to address the neuroendocrine elements of their distress. They felt that depression was too serious an illness for "social psychiatry" to treat and physicians (or maybe neurologists) should be treating such folk. My mentor said this over 10 years ago; his vision hasn't come to pass.

I think this is a good thing.

I believe that good mental health services can address the biochemical elements of illness expediently but, critically, can generate a holistic and cohesive careplan that's broader (and better) than simply getting the right drugs prescribed at the right time.

Wednesday 19 September 2007


I've said earlier this week that a key trait in mental health work is an interest in the patient's experience. It's from this that we can sleuth out both meaning and management plans.

Often it's assumed we're in the business of making people "normal" or curing "pathology" which are goals largley abandoned long ago in favour of helping people understand and cope with their experiences.

What's important then shifts so the emphasis is not to be reaching stratospheric doses of multiple psychotropics simply to abolish one specific symptom.

Imagine we've a patient who was in their kitchen hears footsteps walking upstairs when nobody's there. They also smell aftershave when no man's been in their house for ages. At night they feel someone lying next to them.

Auditory, olfactory and haptic hallucinations, mostly in clear consciousness (I'll concede feeling a body in bed with you could be a hypnagogic or hypnopompic experience as they drift in or out of sleep). Not illusions, not misperceptions whilst in a dreamy oneiroid state, these is crisp fully formed hallucinations.

Solid evidence of psychosis?

Not necessarily. I remember reading a paper from 1971 by a GP in Wales who looked back at 293 bereaved patients seen near the end of a life long career in General Practice and found that hallucinations were common. 46.7% experienced the presence of their departed spouse at some point, 13.3% had auditory hallucinations and 2.7% had tactile hallucinations such as feeling a loved one still in bed next to them, for example. In 1985 another paper found 61% of the 52 widowers they interviewed experienced hallucinations.

Hallucinations are typically seen as the hallmark of major mental illness. These papers and a wealth of evidence suggests that hallucinations can arise in folk who are not mentally ill. It's not simply the presence or absence of psychopathology that's key (even important psychopathology like hallucinations). Even in specialist mental health work what's key is the patient's narrative, their experience and the context.

Citations :
1) Dewi Rees W: British Medical Journal, 1971 Oct 2; 4 (5778): 37-41
2) Olson PR, Suddeth JA, Peterson PJ, Egelhoff C: J Am Geriatr Soc. 1985 Aug;33(8):543-7

PS : Isn't it great that good quality enduring research, informing and educating psychiatrists decades later, was done by a rural GP in Wales?

Tuesday 18 September 2007


Rarely (about once a year or so) one of my patients needs Electro Convulsive Therapy (ECT). It's a contentious topic to some folk that I'll whitter about another time. When folk have ECT they're asleep. An anaesthetist (a doctor with decades of training and experience) gives them an anaesthetic, they drift off, they have ECT for however many seconds then they wake up and life's getting better for them.

This preamble is simply to introduce what anaesthetists (the gasmen) do since this is the funniest thing I've seen for ages and simply has to be shared :


Psychiatrists talk about sex a lot, apprently, so it's about time it was blogged.

The Mental Capacity Act 2005 has had explanation on it's implementation through the Code of Practice which presents helpful guidance.

I have a lady who has dementia. She enjoyed frequent intimate relations with a longstanding friend who has had a turn for the worse and been admitted to hospital. When his name is mentioned her face lights up.

Since he was admitted months ago, another man has started seeing my patient who is an affable old dear and opens her door to anyone. He has started having intimate relations with her. She has repeatedly told nursing staff she doesn't like him but then on other occasions is confused and is more ambivalent. When his name is mentioned she recoils. Her daughter is mortified the man who her mum hardly knows has no relationship with mum except for sex and wants the man to go away and never see mum again.

Within the meaning of the Mental Capacity Act 2005 she is an incapacitated adult. She can not consent to sex. The Code of Practice says in 1.10 that there are ". . . specific decisions which can never be made . . . by family members, carers, professionals, attorneys or the Court of Protection." The subsequent list includes, "consenting to have sexual relations."

She can not consent to having sexual relations and the Mental Capacity Act 2005 makes it clear that nobody can consent on her behalf.

Is it that incapacitated adults can't have sex? Can the issue be ignored? Is it that a man, having sex with a woman without consent, should be charged as a sex offender?

Monday 17 September 2007


I recently was talking to junior doctors about career options. They've been sharply curtailed and the freedom to explore specialities as active doctors in one speciality (rather than as a more passive student) has largely been lost. Speaking with one doctor it dawned on me how much even early clinical contact can have formative influences that resonate with how I work now.

My first clinical attachment as a 2nd year medical student was General Surgery. I loved being on the wards and seeing patients and finally getting "stuck in" to proper medicine.

The quirks (having to illicit Boas sign on a ward round), the theatre of it all (ward rounds with an entourage whirling around the deific Consultant at the epicentre), the needles (learning to take take blood and cannulating) . . .

. . . the patients were the thing, though. Finally doing history taking and examining folk, being proper medics, then clever folk sussing out what was going on, it was being a part of magic!

For me, over time I loved the patient work up on the wards, the sleuthing out why a patient had jaundice, then what could be done to sort it.

Sadly, the "sorting it" didn't interest me. Surgery as a speciality was great, 'cept I didn't enjoy the cutting which kind of wrote it off for me :-)

Still, that attachment was fantastic both for teaching a wealth of skills and for learning from surgical folk who were interested in their patients. At variance with the sterotype back then, good modern surgeons would delight that even way back then there were surgical teams that valued undergraduate medical education and were essentially patient centred (but never would have called it that). The patient focus stayed with me, drawing me to train as a GP before back to hospital medicine and mental health.

What was my conclusion with my trainee? It was that the sum of my training and experiences means that for me the heart of good medicine and the quiddity* of psychiatry is a genuine interest in the patient narrative.

* A great word I really must try and use more :-)

Edit : Milk & Two Sugars just blogged about surgical training this morning, too. Snap! Her more lucid medical student perspective is here.

Thursday 13 September 2007

Deliberate Self Harm

We know Deliberate Self Harm (DSH) is common. One study talking to over 350 interested parties found about 1 in 15 children doing it from age 12 upwards. Other studies quote up to 1 in 7 in certain subgroups. So it matters. We know DSH invariably is nothing to do with suicide. We know that in younger folk (12 to early 20's) it's usually concealed (e.g. cutting arms then hiding the cuts under clothes) and is not about overt attention seeking.

Some groups seem at higher risk than others.

The National Institute of Health and Clinical Excellence has guidelines about this.

One key issue is that the self harm is a way for the young person to cope. They've often no better way to cope, which is why they cut. Stopping the cutting is stopping them coping. Thus, guidance is (sensibly) directed at looking at the causes of the DSH and addressing these rather than simply abolishing the self harm behaviour.

All well and good.

But, the crunch . . . just how do you explain to a terrified parent that we're going to accept their 19 year old teenager is still cutting themselves?

We'll offer alternatives (many distraction techniques work brilliantly) and CBT (which has established benefits after just a couple sessions) and medication (lorazepam can give similar relief that cutting does and works quickly to de-escalate distress) to try and reduce cutting and we'll give advice on cutting safely, but it's the loneliness and college pressure he's put himself under that needs sorting out then (invariably) the DSH diminishes and stops.

A difficult management plan to sell . . .

Wednesday 12 September 2007


I've spoken with a gentleman who's been to another planet, visited Heaven and divined the future. Through "revealed truth" this will be shared. He's seen that I shall write a book which will bring great rejoicing. On this other planet he visits he has great standing and has been promoted to the top of four tiers.

Travel to a far off planet where you have import, a future of happiness and rejoicings, it's not a bad way to journey.

If only his travels hadn't also led him down a rather more mundane route, crashing his car and abandoning it in oncoming traffic . . .

Monday 10 September 2007

Primary Care

Most poor mental health isn't anything to do with illness and disease and being sick.

Most mental health is to do with feeling rubbish, transiently, as life's given you a good kicking.

The severe problems (psychotic breakdowns) are few compared to the large number of folk with difficulty coping for a while (but not quite having an anxiety disorder or depressive disorder or whatever).

Thus, as we all know, most mental health work happens in the community and mostly in Primary Care.

It's of interest to me, then, that today it's reported that the Government is keen to whip GPs back in to working nights and weekends.

Will this generate better patient care?

Friday 7 September 2007


There is no "me" in "team" unless you're dyslexic or a savant. Modernising Medical Careers and New Ways of Working threatens to undermine a lot of established good practice.

I work with several teams. There's one team, for example, consisting of two nurses, a social worker, a bit of an occupational therapist, a support worker, part of a secretary and me. We all spend a lot of time in the same office.

But what is teamwork? What's the difference between collaborative work, parallel working and genuinely working as a multi-disciplinary team?

Thursday 6 September 2007


Our Directorate is fine, all our patients are seen within 2 weeks, patients and GPs love us, outcomes are consistantly above average and we've run without finincial overspend for over a decade. All is good.

And then . . .

. . . 10.00am, meeting with hospital managers and a number of Directors explain the "vision" for our Trust.

I have of late, but wherefore I know not, lost all my mirth and indeed it goes so heavily with my disposition that this goodly frame the earth seems to me a sterile promotory.

Being British

I often have doubts over a word's appearance and fret over the spelling or meaning of a word that seemed right but looks dodgy when typed out. Thankfully there are online dictionaries, huzzah.

Recently I was tempted to use the word "gaol" in one discussion, but typed out it looked odd and I wondered if I was being a tad too anachronistic and if the American "jail" or the term "prison" would be better. I learnt that "jail" and "gaol" are synonymous but that "prison" has a different meaning.

What tickled me was one online dictionary's definitions of "gaol" that simply has to be shared.

Rummage around here and read down to find what presumably an American has written 'bout British folk using the term "gaol" :

see jail, you tea-sodden football hooligan.

Online Etymology Dictionary, © 2001 Douglas Harper

Tea-sodden, well, quite possibly :-)

Wednesday 5 September 2007


Psychiatrists diagnose mental health problems.

We have been trained to sift through symptoms and signs in order to ellucidate relevant psychopathology and ascribe significance to this, then weigh the constellation of relevant symptoms and signs and intensity and duration to generate a robust diagnosis.

One comment from my ST1 doctor (Specialist Trainee year 1 doctor, what used to be an SHO) stirred my thoughts. He's just finished his Foundation training which included a stint in GP land.

He was surprised at the diagnostic rigour in psychiatry.

A lot of diagnosis in Primary Care is based on clinical impression formed from history, examination and occasionally relevant investigations to confirm or refute a diagnosis. Many diagnoses are formulations made with the best evidence available before the GP, which can be a bit thin. Diagnosis of, say, Irritable Bowel Syndrome or a Chronic Fatigue Syndrome can be difficult to make in a robust fashion. Even before diagnosis, symptoms can be hard to quantify (such as dysmenorrhoea that means different things to different people).

My junior doctor was surprised that in Primary Care most GPs diagnosed problems intuitively through each consultation, seemingly at whim. Psychiatric diagnoses are determined within the World Health Organisation's International Classification of Diseases, 10th Edition, ICD-10.

In psychiatry we need to tick many boxes before we can say, "This patient has a diagnosis of F33.11 Recurrent depressive disorder, current episode moderate, with somatic syndrome."

It was interesting to see a young doctor realise that determining diagnosis of mental health problems is oft times more considered and robust than diagnosis of physical health problems.

We're not just musing and making stuff up!