Monday 31 March 2008

Interesting lives

This morning I spoke with folk and, as usual, was struck by the rich tapestry of life.

One patient has had a fascinating career working in bomb disposal. Not a vocation for the faint hearted.

One patient has an engaging and encyclopaedic knowledge of greyhounds. Breeding, racing, everything.

One patient knows incredible amounts about tapestry and needlework. She returned from France where she travelled, alone, to visit a convent where some nuns could teach her a particular style and stitch.

People have such interesting lives, some days you're shaken in to realising it's a real privilege to share this.

Saturday 22 March 2008


Over the last month two GPs have referred their patients to me "on diazepam" for their anxiety.

Both ladies have been on diazepam for anxiety for decades.

Both ladies had stable mental health on diazepam, with no panic attacks, no reduction of Activities of Daily Living or constricted behavioural repetoire, no altered symptoms or presentation, no distress.

Both ladies had no side effects on their diazepam.

Both ladies had the option of other ways of coping presented to them, neither sought to do so. Whatever I suggested was politely declined, they were quite happy staying on their diazepam, thank you kindly.

Both ladies were averaging diazepam 2mg twice a day. Neither was getting more, I went through their boxes of tablets at their homes, counted how many they'd got, counted when they were dispensed, knew when the repeat prescriptions were due and it all matched up. Compliance with prescribed medication was spot on.

Both ladies had a diagnosis of "anxiety" made decades ago on what, to me, seemed somewhat spurious grounds. But I accept that medical notes are just notes, so the true situation isn't always well captured. Both ladies were started on diazepam, it worked, nobody's revisited the diagnosis or treatment and they've remained on it for decades.

Both ladies believe their diazepam does them good, keeps them well, causes no problems and they're both desperately keen to continue on it. Both felt that without out it they'd "be terrible" and become very unwell very quickly. Doctors have said so, which is why they take their medication so meticulously. Both truly believe they've a need for this medication. Both firmly believe this medication is powerfully potent in maintaining their wellbeing thus without it they believe, with great certainty, that they'll be vastly worse.

Tricky one, this. If it was 5mg of diazepam four times a day I'd have issues with it, but 2mg bd is a very modest dose. Pharmacologically, it's a dose you don't get hooked on. So they're not chemically dependent on the benzodiazepine and, in fact, it could be stopped. Psychologically they're both strongly wedded to the notion that diazepam = health and no diazepam = illness. Decades of experiential learning ahs proved this to them, they've continued on diazepam and been well, so there you go, it has to work.

Neither wanted help in anxiety management (not having been anxious for decades). Neither really knew why they had to see me at all. Having discussed options we all agreed there wasn't any need for them to see me again, but I'd be happy to do so if they wanted to. They left with open appointments, so can book in to see me without a referral, and I wrote back to their GPs saying that all seemed well. Both GPs were happy with things being reviewed and the decision being to continue.

Does make me wonder, though, whether medication of dubious benefit should be continued, even if it's safe and cheap and seemingly effective, just to please the patient and make life easier for medics. Because, objectively, there's no reason for the medication to be continued and a drug free trial makes good pharmacological sense.

Of course, the two ladies would resist this vociferously, but they can't prescribe so the decision's ultimately not theirs to take.

Turning a blind eye to diazepam 2mg bd, is that acceptable or is that an anthema to Evidence Based Medicine and the thin end of the wedge of poor practice?

Monday 10 March 2008


I met with a GP rather early (because most GPs in my neighbourhood start work at some ungodly hour) to look at the care of a gentleman with dementia. If you're one for diagnostic labels, he's got F00.12 Dementia in Alzheimer's disease, late onset, severe.

On first appearences, he's muddled but manageable. He's not leaving the house, not posing risks to others outside, not wandering in front of traffic, he's fed and watered and cared for by his wife. Speaking with him he says all's fine and can't understand why my nurses and I visit him, or why we dragged his GP there on this occasion.

The truth of it is that the cost of keeping him at home is high. Arguably too high. His wife is going under, big time. He's disoriented so seeks reassaurance. All the time. Really, all the time, such that he follows her everywhere, even to the toilet. She's scared since at night he comes to shout at her, distraught, so she's had to buy a lock for her bedroom door. Her reassaurance doesn't work now, he just gets frustrated and angry and can't understand why things aren't as he recalls/believes they should be.

She's in floods of tears most of the day. She's not clinically depressed, she's just in an untenable situation where she's no longer valued or respected but, despite endless devotion, is shouted at and abused. She gets almost no sleep.

We know this because we visit her and I've been seeing her and her husband for some 4 years now. Their GP knows because I keep in touch with her and she visits them, mostly to support the wife. We're supporting his wife in letting go and choosing a care home for him.

When the government finishes shafting GPs and we've polyclinics in Tescos instead, will the medic or nurse practitioner see this couple at home over time, too? Will they do home visits at all? If they do visit him at home, not having met him or known him before, would they just take at face value what is seen or would they spend an hour unpicking it all then work with me and visit over time to see the system as a whole (physical health, mental health, disturbed behaviour, care for him, cost to the wife) or would they focus just on their patient? Focussing just on their patient, the wife would go under, he'd be placed in emergency respite care (so would be in a care home neither he nor his wife chose) and she'd feel tremendous guilt at having failed.

I've feelings of disquiet . . .

Thursday 6 March 2008

Humble Pie

I am sceptical about the benefits of aromatherapy. I am not anti-complimentary therapy. Just as I am sceptical about the benefits of some drugs, the effect of some injections and the validity of a lot of cardiac surgery, so I am sceptical about aromatherapy.

You smell stuff and get better. Huh?

Some sites are nauseating in their juxtaposition of soft fluffy cuddly safeness and hard longterm pseudoscience. Would you trust this salesman? I wouldn't. Some content just riles me too much.

Several of our band 3 and band 4 staff have undertaken aromatherapy and massage courses. They've been undertaking aromatherapy and hand massage with patients who have dementia. A proportion of patients have behavioural and psychological symptoms of dementia (BPSD). As they're increasingly distraught and disoriented they find it harder to engage with the nursing staff. Confrontational and unhelpful behaviour can escalate. Medication is used to help them regain control to engage in the reality orientation processes with nursing staff. This gives me audit data showing the prevalence of lorazepam use prn (as needed) for BPSD on that day unit.
Staff didn't change. The band 3 and band 4 staff started to do aromatherapy hand massages and burn basil and whatnots. Incidence of BPSD reduced. Prevalence of lorazepam use prn reduced.

Maybe it does work on the limbic system, improving things for a wee while. Maybe it's a placebo effect. I don't know. But it seems to be useful for some of my patients, some of the time, with no significant treatment emergent adverse events.

Wednesday 5 March 2008

Approved Clinicians

The new Mental Health Act legislation makes for interesting reading, to folk working in mental health. It allows nurses (and others) to hold Approved Clinician (AC) status. Being an AC means they can be the Responsible Clinician (RC) for a detained patient, instead of a psychiatrist being the Responsible Medical Officer (RMO). Most psychiatrists will have AC status so can still be RCs come October, but not all psychiatrists will automatically convert to having AC status. The change opens up the option of nurse lead units where psychiatrists have a much more modest role and aren't directly either involved or responsible for detained patients' care.

Tainted Halo asked, "I'm very interested to see how doctors embrace this new world freedom?! . . . what do the learned shrinks think they'll do with it?"

In my corner, we're having none of it.


Well, frankly, we're in the happy position of not needing to. Looking after detained in-patients isn't an onerous duty for us. We're in an urban setting so have benefits of covering a relatively small, tight geographical patch. We've easy access to psychiatrists, section 12 approved doctors and Approved Social Workers. We've frequent review of patients on the ward which is multidisciplinary. The reviews are frequent so they can be small (i.e. just a couple of people meet with the patient each time, rather than a room full of folk to face). As such there's frequent (daily to weekly weekly) input from medical, nursing, occupational therapy, pharmacist, social work and physiotherapy staff.

Recent presentations by CSIP and the DoH explained that change wasn't necessary in units such as ours. Fantastic to hear that for once central agencies aren't advocating change for changes sake.

Since we're able to have our cake and eat it, offering detained patients input from a wide range of professionals all working together, all seems well. The Healthcare Commission have been very happy with our mode and standards of care. We've not had issues from the MHAC either, who are oh so very rigorous. Since our patients, commissioners, carers, Healthcare Commission and MHAC are happy with what we're providing, as are we, we're able to say we've considered other service models but for now ours addresses patients' needs.

If it ain't broke, don't fix it.