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.