Tuesday 9 November 2010


Another rant, I'm afraid.

First a confession. I have a fondness for Social Workers. They're oft times maligned and criticised for doing too much (bundling elderly folk into care homes, ripping families apart) or too little (neglecting elderly folk in houses going to wrack and ruin, leaving kids in chaotic households) and it's rarely recognised that their job is mostly about making difficult judgements. In our corner a lot of routine work is done by Assessment Officers, the Social Workers do the harder stuff where qualified staff forming professional opinions are necessary.

The Social Worker in our team is brilliant. Utterly, utterly brilliant. I'd truthfully rather do without my junior doctor than do without my Social Worker, since what she does and how she does it makes such a massive difference to how care's delivered. Social Worker not an Assessment Officer 'cause she makes her own mind up about things and forms her own opinion, so half the time is telling me what to do/what needs to be done.

The Social Workers in area teams have a lot of work to do. An awful lot of work. The organisation and support is nothing like that which we enjoy within our Trust. They're not in the same office as nurses and a Consultant and team leader, they're very much out on a limb. When they're chided for acting and chided for not acting, shaky confidence and a desire to check out a plan of action is understandable. Some of them are good. Some of them, frankly, are not. But the world they work in is not easy.

I've had 3 referrals recently from local authority Social Workers for cases which they said were complicated.

They weren't.

On face value, with the problem in front of us, it was all very simple indeed.

It's easy to make things more complicated than they need to be. It's easy to present something as complicated when it's not. Simple things, when understanding the details behind simplicity, can become hellishly complicated. But what we're faced with, what's right in front of us, need not be complicated.

Hot stuff. It's simple. When my youngest child was a toddler she accidentally learnt from a hot radiator what hot meant. Something being hot is a simple concept. A one year old grasped it, appreciating what "Hot!" shouted to her as she advanced towards something then meant. A demented lady can ask for a nice hot cup of tea and we know what she means by that, without it being tepid or scalding her. Stuff that's hot is, therefore, on face value, simple. Behind it it's complicated. What is heat? I guess you'd start waffling about the total kinetic energy of a system, generation of heat then transfer varying on the specific heat capacity of the different objects, conductance/convection/radiation and so on. The sun's hot, that's evident and simple. Why the sun's hot is not simple.

Social Workers took what was in front of them and simple, started drawing in the whys and what ifs and made it much more complicated than it was. In each case a vulnerable adult could not stay alone at home. The risks were clear. The risks were sustained. The risks could not be mitigated. In all 3 cases the risks had been realised so weren't just potential/hypothetical risks. The risks generated adverse outcomes for the 3 people. The 3 adults all were incapacitated adults without donnee, deputy or advance decisions (as, invariably, is always the case, still).

I was perplexed.

Why were these cases being brought to my door? No mental health diagnosis or treatment or intervention would effect meaningful change. The Social Worker had done the work and was telling me the person couldn't manage at home, it was a complex case, could I sort stuff out. There was nothing to sort out. The 3 people needed emergency respite care, managing their needs within a care home and discussion with the patient, family, GP and carers to determine placement long term within the MCA 2005 Best Interests framework.

We have this conversation often, they knew it's what I'd say. They know dementia, they knew I have no pill that could magic up a different outcome. They didn't want a Mental Health Act 1983 assessment. They didn't want a different diagnostic formulation. They didn't want an FP10 for some wondrous treatment. They didn't want ongoing input or care from me/from mental health services.

They just needed support that the decision they were making to move someone from their home, after decades of lived experiences there, of that being part of their life and their life being within that house, that what they were doing was okay, was alright, was the decent thing to do for the person who had no voice.

Although they justify Consultant Psychiatrist input through saying it's complicated, sadly it isn't. It's very simple. It's just also very very hard to do, alone.

Wednesday 3 November 2010


Is it wrong to want to slap someone? There's a dark cloud.

There's an irrational, unwanted, non EBM collusion that in older adults you prescribe medication by, "starting low and going slow."

No, I don't really know what that means, either. It was never taught to me in pharmacology lectures at medical school. Nobody in conferences speaks of subtherapeutic prescribing, unless you're in a homeopathy class, presumably. And then, well, frankly it's just water so dose becomes singularly uninteresting to me.

But for proper drugs, doesn't an effective dose matter?

Really, in all the pharamcological and therapeutics conferences, CPD events, reading and training I don't hear folk saying, "Take the patient research, the evidence based medicine, the product SPC and of course just ignore it all . . . halve the starting dose to well below what the BNF has as a minimum, keep 'em on that subtherapetic dose for ages and then maybe titrate up to the minimum dose months later . . . since boy and girls, we much start low and go slow."


Older adults with mental health problems are vulnerable adults. I'd absolutely advocate minimum therapeutic doses, if medication's indicated at all. Most of the time medication's not got a major role to play. When it is used, it's therefore important that it's used effectively and that it works.

Depression is serious. An older adult, being depressed, is harmful. Evidence shows permanent neuronal cell death arising from depression, so each day depressed is a day that a little bit more brain dies.

We know that a metaanalysis of antidepressants confirmed that the drugs aren't any more effective than placebo in mild, moderate or severe depression, with benefits only being realised in very severe depression (as described here). If an older adult is clinically depressed, either it's mild/moderate/severe and arguably medication's seldom used, or it's very severe and medication's used effectively. It's hard to argue to use medication ineffectively.

Why do some folk, who are otherwise sensible and rational and effective doctors, therefore prescribe subtherapeutic doses of antidepressants which don't work (surprise, surprise) then refer them, perplexed, to my door, time and time again? I know why it is, because I asked them. It's because they're harrowed by drug reps whittering on about "start low and go slow" in older adults. Bastards. It means my patients are getting shabby care for no good reason, what so ever, but Big Pharma has lots of FP10s which have to be dished out for months "because you have to go slow" before then the meaningful prescribing can start.

Why should anyone with depression, which is severe enough to need medication, be on citalopram 10mg once a day? The BNF has the minimum starting dose as 20mg once a day. It kindly guides us into evaluating at 3-4 weeks to titrate up to 40mg and kindly specifies that in folk over 65, 40mg is the maximum dose. Brilliant. Crystal clear. For folk over 65, you're on 20mg od and if after 3 to 4 weeks you need more, you're on 40mg od. Why oh why are 10mg or 30mg prescribed, then? Drug rep waffle seems to be cited as the only cause, and worryingly is more powerful in effecting change in practice than the crystal clear/precise BNF is in directing appropriate prescribing.


Olanzapine also is used in timid doses. I don't want high dose presribing, this year my appraisal portfolio evidences just 2 patients under my care received above BNF doses of medication at any time. I'm not after high dose use. I just don't want subtherapeutic or irrational use. Olanzapine's blood level is roughly halved in smokers, with many of my older adults in the deprived areas I cover being smokers. Yet there's a zeal for homeopathic starting doses, which are continued ineffectively for months, to "start low and go slow."

Whoever it is, in 2010, that's going around and poisoning doctors' minds away from evidence based medicine, pharmaokinetics/pharmacodynamics, product testing and the licence/Summary of Product Characteristics and BNF prescribing details, they're harming patient care. Those folk whittering on about this "start low go slow" notion, I want their evidence base or I want to slap them. Or reporting them to APBI may placate me and rid us of such pernicious counsel. There's a dark cloud, but there's a silver lining.

Monday 1 November 2010


Walking through the hospital grounds this morning, beneath bright sunshine, the grounds are a riot of colour. Trees shifting through golds, browns, yellows and vibrant reds.

I love Autumn.