Tuesday 26 May 2009


I trained as a GP, after going to med school. I sought the continuity of care, of looking after folk over the long haul, rather than fiddling for a day then passing them on. I sought the clinical freedom to work as I felt best within my own practice, rather than as I was told to do by hospital managers. I sought work that was biomedical and psychosocial, that was complex and meaningful.

Through this, I found myself spending rather a lot of time in care homes. Most lunch times, in fact. I liked it. Meant I rarely got lunch (a habit that persists to this day) but meant that I could while away time with elderly folk, talking through what was meaningful to them (notionally the "patient agenda") and what was meaningful to me (reviewing their chronic health problems and drug regimens) whilst passing the time of day with what was invariably engaging conversation with interesting folk.

I knew I wanted to work with older adults early on.

Oh, the child health surveillance clinics were good enough. I enjoyed my paediatric SHO job, and obsterics as an SHO and in Primary Care. But rather than kids or young adults, it's always been the older adults I've gravitated towards. So often they ask for nothing, you want to give them everything.

I knew I wanted to be a psychiatrist before I'd even finished my VTS. Somehow I managed to get through all my psychiatry training with just 12 weeks of pure General Adult psychiatry (of which hospital induction, annual leave and study leave wiped out over half of it). I've nothing against General Adult psych, it's just not for me, I knew it never would be, so I didn't want to do it as an SHO. I didn't do any, after being an SHO. I knew I sought to work with Older Adults, so for me it was old age psychiatry all the way. Oh, I did my CAMHS and forensic and rehab and a few specialist posts as an SHO, but thought I may as well focus on what was useful to me rather than fiddle with working age adult psychiatry when I knew my enthusiasm lay elsewhere.

Overall I'm very grateful for all the training posts I've had. Life in A&E and in Primary Care teaches you a lot about triage, consultations, decision making and safety netting. Every post I've had has given me useful training that's shaped me into the clinician I now am. Even though I'm not a physician, there're translatable skills gleaned from that post.

I'm in the habit of visiting all GPs in my patch. Some don't want to meet and over years the only contact we've had is through letters. Some want to but are too busy to. Mostly, though, meeting GPs is a good thing that's welcomed. Firstly so we can wrangle over how we can collectively iron out any wrangles. Secondly so we can share news on patient care (what the guidance released in March 2009 says about schizophrenia, how we should manage vascular dementia vs what stroke outreach do, how acetylcholinesterase inhibitors and memantine's used locally). Thirdy so we can form better relationships, with fewer barriers and more common sense.

One problem GPs have is what's happening in care homes. Out of hours, when struggling, especially if poorly staffed, care homes call the out of hours doctors. The doctors are presented with skewed information by the care home, of an unmanageable patient in profound distress who's generating risk to themselves and to others so needs something doing right away. Dementia typically progresses over months and doesn't typically get worse over minutes/hours - if they were settled at 4.00pm why are they now unsettled at 7.00pm? Their dementia's not warranting hospital in-patient care, suddenly, so what can the on-call doctors do? The deterioration could be delirium, so could be managed medically in Primary or Secondary Care. Usually the care home's just after some medication "to calm them down." The on-call GP has few options. The on-call GP invariably isn't in a position to effect changes in care plans generating person centred dementia care that addresses the causes and consequences of the person's presentation with nonpharmacological strategies. You need to know the staff, the care home, the environment, the patient, the resources and the context before you have a hope of that. The on-call GP is left with the stark choice of effectively do nothing or prescribe a tranquilliser, most often the antipsychotic, haloperidol. The care home reports a need for this to continue so it's added to a repeat prescription at low dose.

A local "audit" by the PCT has shown that invariably it isn't reviewed. The sampling wasn't perfect so I went through all care homes in my patch and reviewed every MARS and it was true - most psychotropics were initiated in Primary Care and most weren't reviewed. Was it audit? What was the gold standard being espoused, what was the GP and Consultant Psychiatrist's variance from this? No, it wasn't formal clinical audit. More a PCT survey, really. But the PCT pharmacist has at least got the discussion going. Scared the willies out of me, for a start.

Lots of elderly incapacitated folk, on psychotropic meds, without review.

Over the last year or two the amount of psychotropic medication used in care homes has plummeted. Care homes know that I'll pop in promptly, as will our CPNs, so there's little excuse for hassling a GP out of hours for mental health problems. Although I regularly go through every care home, it's a time consuming business. Most folk in care homes aren't known to our Trust. To suss out what's going on, why they're on medication, what the effect of the medication is, isn't straightforward. A lot of unpicking to be done. Usually the care home manager sits with a CPN and me as we review all their residents, sometimes it's the RMN if it's a nursing home, but someone has to be there to explain the consequences of medication and presentation of their residents. It's a good learning opportunity for all parties, too. Thus, as well as popping in to sort specific patient problems, we also review the drug regimen and mental health of all residents in care homes, which takes roughly 6 months to do. With current resourcing, that means we review everyone in a care home in my patch twice each year. Could be better, could be worse, I guess.

Usually we stop the medication and review this. Mostly they're better off the drugs.

Milo has suggested that, "I don't think that there are many psychiatrists out there (i haven't been able to find any!) who would not be judgmental towards someone who has paranoid schizophrenia and chooses not to take anti-psychotic medication!"

Dementia, schizophrenia, depression, anxiety . . . if you're taking medication there should be rational prescribing practice. I'm not judgmental towards someone not taking medication. I think GPs and Consultants simply need to evidence sound, rational prescribing.

Increasingly I'm of the view that Voltaire had the truth of it in saying, "The art of medicine consists in amusing the patient while nature cures the disease." Medication has a place. A very important place. Mental illness can be ghastly and can cause permanent structural damage. Medication therefore matters. Whether palliation, whether prophylaxis, whether effecting a cure, medication can be key in reducing/removing symptom burden and ensuring restoration of decent mental health. But it's often just part of the answer, a way to improve things so that "the proper treatment" can then work. And when the non drug treatment's working, often the medication's withdrawl is then useful.

I guess all this is a long way of saying I'd challenge Milo's view. I think mental health is better at reviewing patient's medication, offering choices and considering rational prescribing practice. I do think we fiddle less.

Sunday 24 May 2009


After twelve years of therapy my psychiatrist said something that brought tears to my eyes. He said, ‘No hablo ingles.’

Sunday 17 May 2009


I've a lady who has a mood disorder who I've been seeing for a few years, now. As time's ticked by, she's also developed dementia. She recently had an acute admission, onto a medical ward that's busy, rather like this.

Staff are largely well meaning but care's not as you'd wish since the wards don't have enough staff to optimally support the patients' needs.

This was rather brought home when, last week, I was in their hospital seeing other folk but had heard my lady with dementia had been admitted. I popped on to her ward, to see how she was being cared for and to let the ward team know what support we'd be able to put in place on discharge. I saw her, she didn't look good. She was thirsty. She was very thirsty.

Her bedside looked like this. I've not moved a thing, this is exactly as I found it :

This was all well outside of her reach.

5 drinks, if you count them. There was water there from the morning. Orange juice that came with lunch. Then coffee. Then a dietary supplement. Finally, some more water from the afternoon.

5 drinks, all on the tray of a lady with dementia, all still there for hours and not drunk as drink after drink is added.

She was discharged back home that afternoon, on antibiotics for her exacerbation of COPD, where she's getting a couple hours of home care and 2 visits a day from daughters to support her. Tragically, this episodic care 4 to 6 times a day results in far better care for her than being on an in-patient unit where there are staff there continuously, 24 hours a day.

As Nurse Anne says, something's very wrong on our acute medical wards . . .

Sunday 10 May 2009

Care Planning

Yesterday I described a lady who had schizophrenia, but had been managing fairly well.

She had emerging deficits and had historically reacted to command hallucinations and delusional ideation that, to a modest degree, adversely affected her (e.g. in employment opportunities, where to live, who to be around and in personal relationships) but, since she could talk to so many friends psychically, she'd always got by well enough. Effectively, she'd her own support network.

Calling 999 and presenting with breathlessness unsettles me. When I did my time in GP land, before jumping over to mental health, we'd reflect in Balint groups. Oddly, I've no reflective practice or peer support now I'm doing more complex and risky and distressing work in mental health, but that's another story and I digress. Again. When reflecting, one of the recurring questions was, "Why now?"
Most people pitching up in Primary Care weren't there with true emergencies. So the dry, pink, itchy skin rash you've had on and off at times for 6 months or so, why'd you come to see me about it today? Why not yesterday? Why not next week? The headaches you've had and put down to stress, for 2 years or so, what brought you to consult me, "just to get things checked out," right now? That indigestion you've managed for a couple months with over the counter antacids, what brought you to discuss your fears of stomach cancer now, in this moment?

Timing matters. To a degree it's pragmatism. It's about when we can get time off work, when an appointment's available. But more often it's about what we want. We want reassaurance since things haven't settled down as swiftly as we'd wish. We want an intervention early on, just in case we need to stop something getting worse. We're now worried enough to make changes or do something about it, so consult. A friend died with similar symptoms, giving us impetus to act. The media say that a condition we think we might have now has a miraculous treatment. Our family's worried and nags us into going because the symptoms grumble on and they're worried it's something sinister.

We're creatures of purpose. We don't take time out to fret over things, make an active decision to seek help, 'phone for that, take time out of our week, travel, wait, talk, be examined, discuss ideas, consider investigations, weigh treatments, arrange follow up, travel to chemists, wait, pay for pills and do all the other gubbins that seeing a medic involves, just on whim.

Shall I read a novel in the park as the cherry blossom cascades down around me, shall I whimsically whisk my wife off to a fantastic new restaurant, shall I weigh up the merits of a rather splendid 24 year old Port Ellen vs a bottle of Shiraz I've been gifted and partake of the winner, shall I lavish time on my children who're enthused with a new playground, or shall I go to the doctor and discuss indigestion I've had on and off for a few months?

To seek medical advice, even when free at the point of delivery, we need something that's motivated us to do it then, at that point in time, at that moment, rather than do whatever else we'd otherwise wish to do. There's no cash cost, but there's always an opportunity cost.

For a lady to be silent 'bout her mental wellbeing for 30 years then now choose to urgently disclose what's going on, in rich and exhaustive detail, surely is relevant.

The experiences had mostly been positive, now she's having more unpleasant thoughts about conspiracies and her role in surveillance. She's being told what to do more. They're affecting her physically, once causing pain and recently making her breathless.

Symptom burden seems perhaps to be increasing.

She's sought contact with mental health services after so long, having feared psychiatry for decades. There are no high risks. There're no risks that are serious/significant but unlikely or are moderate but likely to arise, to either herself or property or others.

She's adamant she ain't taking tablets, so medication's not an option. We talked through different medication options, considering what could help her feel more in control of her thoughts and feel more resilient, what could help her feel more relaxed and less distraught, affording her more fortitude, but she was firm in her view that medication simply wasn't going to happen.

Diagnostically her symptoms, negative impact (on career, residence, social behaviour, relationships) and mental state undeniably attract a diagnosis of F20.0 paranoid schizophrenia. It's not a diagnosis I often make, but if I could share all details it'd be evident that it's really not contentious.

A nurse (band 6 on an acute medical ward) felt she was mentally ill. The nurse is correct. She has a mental disorder, within the meaning of the Mental Health Act 1983.
The nurse felt she was psychotic. The nurse is correct. She has hallucinations and delusions and lacks insight into the nature of these and, critically, into the impact and consequences of these.
The nurse felt she needed mental health input. The nurse is correct. She has had increased symptoms which recently have been more distressing and wanted to talk to a psychiatrist and wanted to share her narrative at length, at this point in time. She's not known to us so the nurse felt her mental health and risks, "needed monitoring."
The nurse felt she needed medication. I'd say the nurse was wrong, here. Medication might help some symptoms some of the time, but abolishing all psychopathology would surely be a futile and unhelpful endeavour. The amount of medication necessary would no doubt be stratospheric. The fact she's refusing means she'd need detaining under the Mental Health Act 1983 so medication would be undertaken as a depot administered under Part IV of the Act. Not the best way to forge a therapeutic relationship, for certain. Probably not the best way to manage her mental health, either. The nurse disagreed, vehemently. "You're saying she's ill, she's got schizophrenia, she's hallucinating and deluded, she's hearing voices telling her to do stuff, she's got things making her feel pain and become breathless, she's wasting ambulance time and she's been in A&E and a medical bed when she's not ill, so we can't let her go and not treat her!" She went on to state how my lady's mentally ill, we don't know anything about her, she's refusing treatment, so we need to "section" her.

Talking glibly of "section her" was what finally did it for me. Pedantic, I know, but one of my many foibles is we don't "section" people, I make recommendations for detention and treatment. We don't do punishment, we do therapy, we do care. The glib presumption that somehow I can lock folk up on whim and stick needles in 'em as, "a section," always, always riles me. A lot.

I documented the interview at length, since it had been a lengthy consultation and she was such an interesting soul. I concluded that she was psychiatrically fit for discharge. She went home that afternoon.

I'm seeing her next week, at her home, so she doesn't feel threatened and doesn't need to come to a hospital. I'm sure there'll be no change in risk. I'm sure there's little benefit from ongoing surveillance. I'm sure she'll again decline social support, CPN input, out-patient follow up, CBT, day hospital, psychological work, in-patient admission and our functional community group that's just a couple minutes up the road from her. I'm sure she'll want no drug treatment. But maybe Balint had it right. Maybe sometimes the doctor's the drug.

Saturday 9 May 2009


I recently saw a lady who medics asked me to assess on their ward. She'd been brought in breathless but had been checked out and all was well. That's to say, serious things (like a heart attack) had been excluded, no cause for her breathlessness was found, but since it got better she was medically fit for discharge. She'd nociceptive pain that seemed pleuritic to me and was a touch alkalotic for my liking, but by the time I got to see her I couldn't hear anything odd in her lungs, her CXR was clear, haematological and biochemical indices were all normal (but her ABG hadn't been repeated). It could have been anxiety. It probably was. It could be pleuritic pain and consequent suboptimal ventilation and respiratory alkalosis from rapid short shallow breaths blowing off her CO2 but, in truth, I think the medics had it right and she'd been anxious.

What surprised me was that they sought an urgent consultation because as the discharge facilitator said, "She's mad as a sack of rats." Challenging stigma. Ace.

The lady told me, at length, about her voices. She hadn't told anyone about them for 30 years. Last time she mentioned them they locked her up and gave her ECT. Coercive psychiatry that did her no good. She was rightly wary of mental health services after that less than helpful contact.

I don't know why she said to ward staff she wanted to talk with someone about her voices, or why she opened up to me after 30 years of silence, but she'd clearly a desire to narrate her life story and what changes voices had made. They'd told her who to marry. Where to live. Which countries to go to. They'd hidden behind her eyes, spying for Stalin (which was when she piped up about them and had ECT in England as a young woman).

Mostly the voices talked with her about politics, current affairs and gossip. She really enjoyed them, she didn't believe she was ill and certainly didn't either want help or want the voices to go away. They talked to her, constantly. She said, several times, that they were real people who could talk to her psychically and were her friends. Better still, they could make her feel things. One had made her breathless (causing her admission) but mostly they made her feel good things. Every evening she has an overwhleming feeling of warmth, as if held, and is suffused with a feeling of being loved, "as if you look in to your mother's smiling eyes." It sounded beautiful.

She manages everything at home. She's been living like this for ages. Decades.

She has auditory hallucinations talking to her.
She has auditory hallucinations talking about her.
She has mood incongruent delusions of government conspiracies unfolding through presences utilising surveillance and telepathy within her head.
She has made acts, to touch things.
She has made feelings, usually they're positive.
She has made impulses, usually thoughts of travel.
She has thought insertion.
She has thought withdrawl.
She has thought broadcast.
She has had these for decades, she described hearing voices since she was an 11 year old child.
Maybe you like to consider Schneider's First Rank symptoms. Maybe you like Andrew Sims models of throught disorder (a man I met in my training, and even when he explained it to me I still couldn't get it). I tend to favour Nancy Andreasen's definitions of thought disorder. But however you like to assess, formulate and structure things, it's clear she's psychotic.

She had sufficient symptom and signs to attract a diagnosis F20.0 paranoid schizophrenia.

But, she's well. She's had no contact with mental health services for decades, she sees herself as well, she's scared witless of hospitals and psychiatrists (no idea why she spoke to me for an age), she's adamant that she will accept no medication (having had ghastly experiences of it, and since she sees herself as well) and avoids seeing her GP unless she feels she absolutely has to.

What should I have done?