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.


Lady Pippa Jemima Fortesque Smyth said...

I guess part Milo's problem (and those like him/her) is that 'refusal' to take medication is viewed as a symptom of the illness. It may not be seen as a rational decision because the person labelled 'schizophrenic' is, if actively unwell, regarded as not rational.

As someone who has experiences of depression, anxiety and who may or may not 'be' borderline, I find that clinicians do listen to me and do respect my decisions. That's because I have not been diagnosed as 'psychotic' and am clearly intelligent, educated and generally rational. Milo may well have a point.

In addition, who would want the responsibility of not medicating a person with a severe and enduring mental illness with all of the risks that that entails....I can see the headlines. I'm not arguing that this is a valid reason for prescribing, just pointing out that this may be a factor...also known as a** covering.

Milo said...

oh my God! I am so humbled to be mentioned in a blog. I need to go and read this post word by word... I am gonna come back soon.

The Shrink said...

Milo, you're mentioned in a good way, stirring thoughts and discussion that's got me reflecting on practice.

A good thing! :)

Milo said...

Thank you. I am grateful for anyone who has the wisdom to understand this. i took my clozapine religiously for six years. It made a difference, i knew it and i needed to take it. I don't think that i would be here today writing this if i hadn't received help in the past. i am not anti-drugs nor am i anti-psychiatry. then came a time when i realized i wanted to do more with my life. it was an extremely sedating drug in my case and i just couldn't show up for my lectures (or i would turn up, but fall sleep waking up hours later in some politics lesson!). i brought it up with my psychiatrist. he threatened me with involuntary detention. i just couldn't figure it out any more. the sense of hopelessness was sooo overwhelming. it wasn't much fun...
thanks again for this post.

Lady Pippa Jemima Fortesque Smyth said...

I also think that some clinical staff underestimate by a long way the impact of side effects on the person taking them. In your case Milo, I think that it would have been appropriate to look for a drug that was less sedating rather than threaten you with detention. Saying that you don't want to take drug A is not the same as saying that you don't want to take any drugs.
I have a life threatening heart condition, I knew when I took a particular antidepressant that it increased the heart irregularities I have. One of my GPs was sceptical until I showed them the clinical evidence (found online) that this drug (an ssri) causes arrythmias in some people. I was also diagnosed with the sudden death syndrome that I have having been told by a cardiologist that I had nothing more than anxiety! I have had to become an expert patient to protect myself. Fortunately I've a background in nursing and am a graduate with a degree in psychology. Like you Milo, I'm not anti-medical science; its saved my life, but people have to be educated and have to ask questions....

Anonymous said...

Spot on. Having worked as a GP out of hours I know how tough the care home visits can be. Like you say the most common reason is a request from the staff to 'settle the patient down'. And the on-call GP's have zero access to the patient's case notes, which makes an informed decision very difficult.

Luckily night time sedation is becoming a less popular option in care homes. Although sometimes it is simply unavoidable.

But which drug to use? I got flamed once for prescribing 0.5mg of haloperidol to a distressed patient with dementia who'd had his room changed to across the hall which had left him sleepless and unsettled. The psychiatric team felt I had made a grave mistake.

"You should have used quetiapine!" was their arguement.

Lady Pippa Jemima Fortesque Smyth said...

You mean you somehow missed the compulsory module on fortune telling and mind reading during your training? Maybe the psychiatric team could have used their psychokinetic powers to prescribe and administer the 'right' drug that night.

I'm sure that if you had known why you should have prescribed that particular drug you would have done.

What's really important is the ability to ask questions and to learn...why quietiapine and not haloperidol?

And also do they prescribe cheeryupapine to depressed people? (Couldn't resist - childish I know)

Anonymous said...

hello... hapi blogging... have a nice day! just visiting here....

f said...

Hope you're enjoying a really good holiday?
I know of a carer who says she has been left 'high and dry' by everyone, in trying to find out why her mother with vascular dementia and hallucinations has dizzy spells and sees 'a haze' in front of her eyes such that she cannot go out alone and this has been for 6 months now.
It does raise the question of who has been consulted,what medication taken etc.but the carer does say no-one can explain.
Grateful for any comments from you and your readers.
Have a good break but don't stay away too long - always thoughtprovoking,edifying and uplifting blog and comments.

Fiona said...

Hi I am the carer kindly referred to by 'F' earlier. We have seen a neurologist who said her dizziness wasn't connected to her cervical spondulitis. Mum has been on simvastatin (taking a break recently to see if dizziness & hallucinations reduces, no). Aricept made her more dizzy but has gone back on it because the hallucinations are so ghastly. I would appreciate any suggestions. Thanks.