Communication

Communication skills are important. We're sociable beings and reach out to communicate from the day we're born. One gentleman was explaining, fervently, that he does not need to pay his telephone bill 'cause he never uses it. He only speaks with the dead (he is a medium) or to people far away by telepathy.

He communicates with neighbours, his wife, the rich and famous and healthcare professionals through his mind. He sees this as a rich and desirable source of support, they're endlessly referred to as his, "telepathic friends."

Communiating with the dead or those geographically distant, he asserted he "never uses a kiosk" so didn't believe he should pay his 'phone bill.

He uses his mind. He thinks his messages. In his view, it's not good to talk.

Stairway to Heaven

I was due to see a patient who I've known for a long time, she was due in out-patient clinic but did not attend. My secretary checked on the patient administration system and found out she had unfortunately passed away.

It was with sadness that I saw the message, in bold, that the patient was deceased.

Next to this was also the comment, "Transport not required."

I guess she can now find her own way, to where she's going. With thoughts of fondness, and knowing her impish humour, that brought me a smile. Happen PAS is right and she's found her own stairway to heaven.

Detention

Walking across the hospital grounds I overheard a couple talking as they returned to the ward.

He was saying to her how grateful he was that his Consultant Psychiatrist, ". . . had sectioned me that night, getting me into hospital," because he felt, "I right needed to, if I didn't I'd have been pissed and in [a nearby large city] and right violent."

The psychiatrist in me thought, how wonderful, he got the right care when acutely unwell and now has insight. But then I also thought, what a shame his Consultant Psychiatrist hasn't heard that and, probably, will never know. I also thought how great it was that he could reflect on it and freely talk through how being "sectioned" was a positive thing for him.

Although a formal Advance Decision can only define what treatment can't be given, he could craft an advance directive framing how he'd like future care to be orchestrated, which has no legal power but at least gives a steer as to his preferences, should the situation arise again. It could either be a discrete statement or part of a wellness recovery action plan (WRAP).

I was mildly piqued by the glib "being sectioned" phrase, but that's because in my training that was seen to be a cardinal sin. Detention under the MHA 1983 is a formal, serious business and "I'd section" a patient was seen as a careless, casual, trite comment at variance with the import and formality of the act. We were also scolded over how inaccurate that is, since doctors can't detain patients, we only make recommendations which ASW/now AMHPs choose to accept or decline, with hospital managers receipting the paperwork and then they formally detain the patient. But that's a personal foible I've hung on to, and labour over with my trainees, so in the cold light of day I'll concede that I shouldn't really be piqued that a patient talks of "being sectioned" instead of "being formally detained under the Mental Health Act 1983."

That was my moment of pondering today . . . hearing a patient's comment, thinking of the positive, thinking of his possible futures, thinking of the terminology used and thinking how he was expressing being grateful for the care he'd received.

Odd how but a few moments of snatched conversation can stir thoughts!

Generosity

I'm interested in how we think, in what internal and external processes impact 'pon how we see ourselves, how we value ourselves, how we perceive ourselves to be. A positive sense of self is important. TED talks are often engaging, this one on generosity (and social change, challenging poverty, altruism, philanthropy and business) is worth shamelessly snaffling and displaying here :

Sasha Dichter: The Generosity Experiment from TED Blog on Vimeo.

Humour

I saw a young patient who has had obsessional ideation for some time, but it's now well managed. They still have to arrange towels in order, folded just so, arranged by colour and shade in a certain order. They still have to have the groceries and tins in certain places, with the labels facing a certain way.

But there's no more checking, no more repetition, no more repeated routines intruding unhelpfully for hours a day. She has a sharp and witty sense of humour and an enormous sense of living a life full of joy.

I saw her today with a junior doctor, with a view to discharging her. She was explaining to the junior doctor that she has CDO. He asked what that was. "It's just like OCD, except the letters are in the right alphabetical order, just like they should be."

Priceless!

Insight

We used to assess and document insight a lot, routinely for every patient. It's become more of a trivial afterthought now (and rightly so) with more appropriate and sophisticated consideration of decision/situation specific capacity replacing the concept of insight being present/absent.

I was musing this over with an AMHP as we discussed what insight means, how it's been mis-used in the past in tribunals as a proxy to not being capacitated, how it's seldom relevant now. She raised this because in all her time in the multidisciplinary team it dawned on her that she's never heard us discuss insight. She saw this as a good thing and I'd agree. Insight as a concept has been of enormous import and done rightly is fine, equally it has historically oft times been a shorthand that's too superficial/medical to have the utility it needs. Patients' formulation of their experiences, understanding of needs, engagement with informal family/friends/support and formal health/social servcies can be framed in terms of insight but invariably is better considered in terms of understanding and capacity.

Having chewed the cud with an AMHP and stirred thoughts on the concept of insight at length, I moved on half an hour later and to my shame, I lacked insight.

I met with our Trust's Chief Executive. I do so fairly often. Our Chief Executive is an agreeable, competent, grounded and incredibly sensible soul. I'll frequently meet the Chief Executive and talk through stuff over coffee. Or email stuff that merits Board level consideration. Or the Chief Executive will come see me, which happened yesterday.

Because our Chief Executive is so approachable and engaged with Consultants, I rather fear I've done them a disservice.

I'd always thought the Chief Executive to be influential. I was naive. The Chief Executive has great influence over a great many things, but it's finite and in some ways is actually quite narrow. I'd not really appreciated the constraints that Monitor and CQC and SHA and DoH and others shackle the Chief Executive with. The Chief Executive has responsibility but Executive Directors have their own portfolios and they, not the Chief Executive, sort those. After deciding how things shall be, the Chief Executive then has tiers of managers whose Chinese whispers distort the detail and implementation of the intentions, horribly. Can the Chief Executive direct me to prescribe Mrs Smith olanzapine 5mg velotab at night? No. That's a clinical not a managerial decision, the Chief Executive has no direct influence on what clinicians do in their work.

National drivers constraining the Chief Executive's options. Local commissioners directing the Chief Executive's choices. Tiers of managers running with the Chief Executive's wishes yet effecting implementation (or not) their own way. Managerial decisions' boundary with clinical decision making (and no direct managerial influence in this). Good grief. I'd not really thought through what a grim position it is to hold, having all the responsibility yet with much less opportunity to effect detailed sophisticated systemic change than I'd considered. Worse, I erroneously presumed that the Chief Executive is boss and can sort everything. Most folk do.

I lacked insight into the situation.

Time to remedy this.

Lithium

How many older adults present, after retirement, for the first time with schizophrenia? Almost none. How many older adults present, in later life, with mood swings which are so significant that they need long term management with interventions which include a mood stabiliser? I don't know. But there aren't that many folk presenting in later life with major mood swings for the first time.

Why's this in my thoughts? It's because a number of folk, who have had significant mood swings (by which I mean, they've literally tried to kill folk, being consumed with rage or jealousy and felt righteous in their actions) have been referred to my door. And, to a one, all of them have asked for lithium.

Why?

Has there been a campaign about it? Is there new good press about it, somewhere? Has some celebrity trash mag carped on 'bout how it cured someone of mood changes? Enquiring minds need to know!

My patients had mood problems arising mostly from stroke damage within their limbic system and/or frontal lobes so they'd lost the bits to experience, regulate and control mood as effectively as they used to. In one patient lithium's had major benefit, resulting in a move from a very restrictive care setting back in to mainstream care services. In two others it's improved interactions and quality of life appreciably (that is, other than through speech, there's no expressed hostility) with both patients and their families feeling it's been transformational.

I'm not really sure why lithium should be so miraculous, especially when the problem's mostly structural brain change rather than purely chemical pathology (to which chemical solutions, like lithium, can be brilliant).

Still, they're better. That's good. It just puzzles me why they sought out lithium, why they were right to do so and why it's been so curiously helpful!

Extremes

When articulating a point of view, increasingly I find myself being more extreme. Usually I'm seeking a view somewhere in the middle ground, but to shake the inertia in the system and effect any substantial change that's sufficient, invariably I'm having to shift from this tempered position to one of a more extreme position, to illustrate dramatically a striking comparison or extreme position in order to make a point/have a point understood and appreciated.

When I recently read a quote, it very much resonated with me.

"We know what happens to people who stay in the middle of the road. They get run down."
- Aneurin Bevan, 1953

Within the NHS, which is brilliant at what it does well, management process seems increasingly to benefit from more extreme views that help clarify the need/importance/consequences. Those staying in the middle of the road are steam rollered over. Sadly, more balanced and moderate views simply seem to be lost in the drone of organisational noise and chaos and process.

Ho hum.

Medicine

We go in to a vocational career, such as medicine, for many reasons.

Here are 10 reasons why we fair well in a job.

Sometimes I read articles that are unwelcome, I sigh, but I let it go and move on. This pernicious utterance is one such lamentable article. Would you give medication to/stick needles in a woman who's just walked off the street?

She writes that she said, "But this is an emergency." There seems to be little unmet clinical needs that are urgent/immediate that need attention. Oh I'm not unsympathetic, I'm also mindful that health is a state of physical, social and mental wellbeing. Getting to work and crack on with global journalism is important to her. What piques me is her contention that NHS resources should be deployed to assuage her inconvenience, rather than prioritising resources according to clinical need. If both can be done (and often they can) then you can generate a responsive, patient centred service that meets clinical needs well. But to strop 'cause a GP you're not registered with won't instantly attend to non-urgent care aggrieves me, it's perhaps a desired expectation but it simply not reasonable to demand this.

For her to then generalise this and contend in her headline, "The caring professions? They just don't seem to care at all," well that's just provocative and vexatious. She didn't get what she wanted and is having a strop, unwelcome though this is I shan't lose sleep over this since medical care wasn't poor, it simply was her organisation was and her expectations were unreasonable.

Professor Sir Bruce Keogh, on the other hand, has worried me more. I've been in a couple of conferences with him and each time he's spoken of innovation and quality and laudable evolution of NHS services, but the medical role in this has been scant. By scant, I mean absent. As the Medical Director for the NHS, this dismays me.

The GMC revalidation plans will have massive impact on medical workforce. CQUINS, QUIPP, CRES, SHA Clinical Pathways and Foundation Trusts all impact on us a lot already, the amount of data collection and form filling is vast. I was incredulous to find the computer entry on seeing a patient is now 3 hours in our Trust, it takes one hour to see a patient. We spend three times as long doing form filling as clinical care. That's all patient contact stuff, that's excluding meetings and policy generation and supporting activities. The NHS informatics systems are not supporting clinical care, they're dominating. Did nurses become nurses to spend an hour seeing a patient then a whole afternoon tippity tapping away at a computer? And they say it's my patients who are mad . . .

Then we've NICE guidance, DOH guidance, Royal College guidance, Trust strategies and policies and protocols and standard operating procedures, Monitor, CQC standards, NHS LA standards and we've to evidence we're compliant with such.

Now our local commissioning consortia wants data on what we do (not activity data, which we already give the PCT each month, but new data on what outcomes we achieve, too). The APC and Medicines Management Committee want data on pharmacological interventions, in great detail. Who gets the drugs, who doesn't, how are patients assessed, how is consent considered, what reviews are in place, how is local Shared Care used, can we demonstrate adherence to care pathways.

So many sources add so much administrative procedural activity to our day. For really rather dubious benefit, much of the time. It's planned that the GMC revalidation will need doctors to evidence their outcomes, mapped on to the 12 Good Medical Practice domains. Their outcomes. Not the team's, or Trust's or GP Surgery's performance/outcomes, but the individual doctor's practice. Needless to say, we don't currently collect data on an individual doctor's performance and outcomes in all 12 domains. We do it, but we look at teams and systems.

The NHS managment costs have escalated stratospherically from about 5% to about 25% with more managers generating more management activity which necessitates more infrastructure and support, so it's a self perpetuating beast that grows and grows. A bit like a neoplasm.

What I'd hoped for from our NHS Medical Director was a bit of sanity, common sense, perspective. A bit of hope that some of the 10 helpful factors I linked to previously of Little hassles, Perception of fair pay, Achievement, Feedback, Complexity and variety, Control, Organisational support, Work-home overflow, Honeymoons and hangovers and being Easily pleased could have been touched on.

More, when talking of quality and innovation and modernisation and change, I wanted to hear that we'd be liberated with greater freedom and less constraint, we'd not be on our knees with yet more process.

Ho hum.

Cured

Picture an elderly gentleman, living on his own, in his own flat, for 10 years.

He's been a recluse, family bringing him all his groceries, the dentist visiting him there, he's literally not been out of the property for a decade. He had lived in gloom (the curtains always had to be closed). Then his GP (who's not been able to see him for years) refers him to me, worried he might have dementia since he's not functioning and he's become paranoid and feels the man above him is wafting smoke at him, he's being watched by people, neighbours try and set him on fire, they're tampering with his water. He now feels afraid in his own home.

He agrees to stay with family, crossing his doorway for the first time in so many years. In their home he's no better. Pictures talk to him. The pets are telepathic. The family are variously helping him, or poisoning him, so he lashes out with a walking stick.

He was unwell. He needed an antipsychotic to make him better. This was done. He recovered. He's now relaxed, happy, sociable and active. He's no longer housebound, he goes to shops and the seaside with family. He was going to go back to his flat but he's such a great sense of humour and so fun and so good with the grandchildren the family have moved him permanently into their home, which he's delighted about.

He wasn't acutely paranoid. He's been unwell for at least a decade. He's been appropriately referred, treated and most of all supported by family, and now he's well. Cured. From housebound and antisocial and afraid, sitting in the gloom, he's now happy and well. He doesn't have dementia. He's had no acute illness at all. He's simply been mentally unwell for over a decade and now he's had the combination of care he needed to help him. He's cured. It's not often I get to say that.

Patient Safety

We have been told (by the General Medical Council) how doctors' revalidation will improve patient safety, back in October 2010.

The sagely Jobbing Doctor muses over whether nurses' revalidation/governance will tighten up, querying what the fallout will be, here.

It truly isn't a cynical comment, it's simply an observation, that I really can't see how revalidation will make any difference to patient safety. Post-Shipman we've had rigorous annual appraisals, taking literally days to do each time. And Consultant peers looking at our cases for Case Based Discussions. And Peer Groups (which should have happened anyway) actually happening, looking at our learning objectives and what we're doing/what we've done. I really can't say patient safety's any different.

Realistically, how would you spot someone like Shipman? We frequently have very different outcomes with different clinicians. A real example from my training : one surgeon wants low mortality rates and only operates on those who will have good outcomes, leaving most to no active treatment/palliative care, so those with moderately advanced cancer are denied surgery and go on to die. But those he operates on do very well and his perioperative death rate was incredibly low, since he only operated on those with early cancers and decent health. Another surgeon would try his hand at even the most desparate cases, figuring that death was inevitable and pretty immediate if he didn't. Many (indeed most) of his patients did very well, but some of course died soon after surgery. His perisurgical death rate was stratospherically higher. But understandaly so. He was still the better surgeon (and arguably the better clinician). Mortality rates alone are just numbers, we need context and understanding of the patient population, the interventions, others involved in care, comparative data with others, understanding of norms and bell curves and variability, it's not simple to speak with a doctor and dichotomously allocate them in to a "safe" box or "murdering" box.

What it boils down to is, usually, over a coffee, hoping to trip up the bad apples through slipping in a question such as, "Well Bob that about covers things. Oh, by the way, d'you have any urges or are you planning on murdering large cohorts of your patient population, within the next year?"

It's as good as governance systems would seem to be . . .

Cash

I've finally accepted the truth of it. Personalised Budgets were constructed with willfully malign glee and, clearly, are naught but the machinations of the devil, made real.

I can not begin to rant over the hideous, hideous consequences 'pon vulnerable folk with dementia that the change to Personalised Budgets has inflicted.

Access to care is now beyond grim.

General Practice

I was out at a local Chinese restaurant with Mrs Shrink, after a fatality within the oven in our kitchen wrote off a nutitious evening meal, 'less your idea of nutritious involves burnt unidentifiable charcoal clumps.

Out we went. We ordered lots of nibbly things. Very nice they were, too.

The owner kept looking at me. I couldn't think why. He came over to thank me for treating his daughter, in the 1990's sometime, when I was working out in GP land. Apparently I'd diagnosed her skin condition correctly as eczema, I'd given her the right creams and oils and she'd been cured.

He remembered that. He remembered me and what I'd done for his child. Patients do that, with GPs. The current NHS changes invite discourse on what GPs do that's important, what GPs do that's delegable, what GPs do that can be displaced to other services. This contact stirred thoughts that, frankly, that's all missing the point. The gentleman approached me 2 decades on to offer his gratitude because that consultation and care within General Practice had rich meaning to him. It mattered. And that's the bottom line . . . what GPs do makes a difference to peoples' lives, is valued and deeply meaningful.

Suicide

Back from holiday and there's always mountains of stuff to sort. Busy busy busy. But the nuisances and inconveniences pale against that adversity that some patients endure. A number of patients presented with different backgrounds causing the same presentation and experience of wishing to die in an active intentional elective manner. Indulge me in merging details of several patients into one vignette.

A patient's got severe COPD and is breathless just sitting around doing nothing. He's got lungs full of coal dust. He's got knackered joints all over, he struggles to mobilise at all now. He's scalded himself, dropping cups of tea on himself through arthritic and somewhat numb hands (his GP reckons past machine use has caused vibration white finger). He's long standing angina, blood pressure and mild heart failure, he's getting older and renal function's starting to decline too but a recent diagnosis of Parkinson's Disease clinched it.

He described how he reckoned he'll get iller, frailer, more dependant, physically and mentally deteriorate and explained he'll die, "buggered, a cabbage." Those were his words. Grim. He'd been a proud man, proud of his working class roots and life, grafting to earn everything and asking nothing from anybody. When he came into hospital he'd not even allowed his family to look after his dog, he asks nothing and puts nobody out. Except inadvertently a social worker, who sorted kennels.

He feels it's not right for him to lose his dignity and independance, he's wishing to end it all before it comes to that. He's not awfully cheerful but he's not clinically depressed. Specifically, he's not mentally disordered (within the meaning of the MHA 1983) and he's a capacitated adult (within the meaning of the MCA 2005). His psychological wellbeing's not cheery, but there's no frank psychiatric condition to attend to. Mental wellbeing's supported, protective factors are explored, support's considered that may engender more hope and help him endure over the longer term. Or maybe it won't.

Killing himself won't be a happy ending for me. Or for his family. But it may be the ending he wants and needs, in the way and time he chooses. I don't want it to happen, but it's not my choice. I can't have a happy ending every time . . .

Antipsychotics in Dementia

Dementia is a gruesome disease.

It robs you of your dearest memories, your personality and sense of self, your vocabulary and communication, function and what you can do, and life. Unlike cancer, there's no drug or surgery or intervention that we have which can prolong life/delay death by even one day.

Broadly dementia is said to cause both cognitive problems (changes in memory and thinking) and non-cognitive problems (behavioural and psychological symptoms of dementia, BPSD).

Cognitive changes can be managed, fairly successfully, most of the time. Non-drug strategies (practical support, carer interactions and psychological interventions) make a huge difference. I'm not amazingly sold on Cognitive Stimulation Therapy as the bees knees (that NICE advocate in their clinical guideline CG 42), but a host of simple practical suggestions can help non-demented and demented folk alike, like these. Acetylcholinesterase inhibitors have significant benefits to most folk with Alzheimer's Disease (and related dementias) most of the time. We can't stop cognitive change over time, but we can manage the symptoms of it and the impact of it, fairly well, most of the time.

What's much more problematic is managing the non-cognitive BPSD part. Wandering without purpose day and night, mood changes and frustrations with anxiety or utter unconsolable despair, shrieking and screaming in public, disinhibition trying to kiss strangers and masterbating in public, suspicion of partners/carers with consequent hostility and violence. Much harder to manage than cognitive changes such as forgetting a hairdresser's appointment.

Our weekly carers' support group rarely focuses on cognitive problems, mostly it's BPSD that takes carers to their knees, it's BPSD that they need help managing. Without the intensity of the BPSD they miraculously could (and usually do) cope well in truly dismal circumstances.

Delusions, with paranoid persecutory thoughts, mood disturbance and seemingly irrational beliefs, how can these be managed?

In America the FDA have said, "Antipsychotics are not indicated for the treatment of dementia-related psychosis."

This can be harsh.

You can have psychosis, this can torment the patient and torment the carer, you've antipsychotics to treat the psychosis but you don't. Kind of galls me, that.

The reasoning behind the FDA's reticence to entertain antipsychotic medication in dementia care is sound. It's not homeopathy, it's proper medicine that has proper benefits but also proper risks/side effects (like ramping up risks of a stroke in the next year by 2%). The medications can cause significant harm.

Originally work was mostly focussed on risperidone and olanzapine since there was sufficient research to evidence consequences of use in dementia care (both good and bad), with such medication evidencing great benefit as well as great risk. Subsequent research shows older adults in care homes experience similar risk from which ever antipsychotic drug you use. They all have side effects and can cause harm, it's just some are more likely to cause a heart attack, others more likely a stroke, but the over all risks are pretty comparable.

Knowing that the medication has a modest risk:benefit ratio and can cause significant harm, such medications need to be carefully considered and used judiciuously. Careful consideration of what the issue being treated is, what the target symptoms are, what the level of symptom burden is before treatment, what it is after introducing medication and is there objective gain through the medication's use? The time necessary and sophistication of assessment, reasoning/rational prescribing practice, carer input/management of frequently incapacitated adults (with respect to the treatment decision and valid consent), initiation, titration and evaluation of medication is usually outwith the scope of Primary Care or acute hospitals and sits better within mental health services for older people.

With that in mind, and seeing the grim consequences for patients and carers of not treating BPSD and dementia related psychosis, I'm increasingly aligning with this view, ". . . that antipsychotics may be justified using a palliative model."

Evidence Based Medicine (EBM) informs the discussion but to then elect to use antipsychotic medication, for some patients, some of the time, that somehow feels much more humane.

Horse Riding

I've had a number of folk who I've seen who ride horses. That wasn't the reason for referral to my door, it's a benign enough past time and not a behaviour that generally merits treatment. Although I recall an A&E Consultant lecturing on how there were more accidents per mile when horse riding than when motor racing. Her point of contention was that horses were more perilous than Formula One racing and children/young adults jaunting along on a hack was oft times seen in far too cavalier a manner.

There're some reasons p'raps to support a ride in the great outdoors. Leave the urban sprawl and, where I work, we're blessed by verdent landscapes pretty much on our doorstep. Getting out and about can be therapeutic.

Kaplan's work in 1995 (The restorative benefits of nature: Toward an integrative framework. Journal of Environmental Psychology, 15, 169-182) was progressed in 2005, with consideration of such restorative environments. This has been advanced in 2008 with exploration of natural versus urban environments and consequences of this upon cognition.

Being outdoors and exposed to nature seems to be good for our brains.

The evidence of exercise on cognition and neurogenesis is compelling. Growing new brain cells as we get older, what's not to like?! So I should enthuse over folk striding out to be at one with nature.

I'm contracted to do really rather varied work. Unfortunately a number of folk I've worked with have had significant riding accidents. One teenager smashed up her pelvis spectacularly, changing overnight her opportunities and possible futures, as mobility and fertility are eclipsed in a blink. A number of back injuries, necessitating referral on for surgical intervention. Large numbers of exacerbation of existing painful backs. I fear the A&E Consultant had the truth of it, horses are not without their risks.

What's been surprising is the role of psychological therapy, physiotherapy and pharmacotherapy when combined. Looking at acceptance (and mindfulness, with mostly a CBT model) whilst also optimising function, looking at nociceptive/neuropathic analgesics and attending to mood disorder has yielded pretty good outcomes. Well, both evidenced functional outcomes and patient questionnaires post discharge suggest outcomes are good, which is heartening.

Through this, duloxetine seems to have been helpful. It's licensed for the treatment of diabetic neuropathy in the UK, and fibromyalgia in the USA, so is a reasonable treatment for pain. It's also licensed for the management of major depressive disorder and generalised anxiety disorder. Depression is a straight 60mg dose, so no titration or adjustments, meaning you know you're on the perfect dose from day one. Neuropathy may need titration from 60mg to 120mg, so is simple to manage too. Treating low mood, anxiety and pain, with a once a day drug, with just 2 strengths of dose so it's straightforward to get patients on the optimal dose, I guess it's unsurprising we're seeing decent outcomes. It's not miraculous. Often it doesn't work. But for some folk, some of the time, it's really been a rather helpful adjunct to their care.

Improvement

I've a gentleman who lived in a flat, alone, for a decade. What was curious was that he never left it. His son did all his shopping for him. His GP and dentist managed him through home visits. He'd elected to be housebound. We never knew him, then.

He moved in with his son because his son couldn't keep visiting all the time. He was was confused. He thought he had paid tens of thousands for a penthouse to be built for him. He heard spirits talking to him, from animals. He spoke to photographs of the children, because they spoke with him. Voices told him bad things. He felt worried, suspicious, afraid, insecure. He took no medication because his GP, who he saw in the living room every day, told him not to. He ate little since he knew his son was poisoning his food. He never bathed because the water was tainted and would hurt his skin, transforming it. His son thought all this was odd, asked for help, we became involved.

His son and a community psychiatric nurse invested endless hours with him. He was started on olanzapine velotabs which he took haphazardly, but then reliably. 5mg initially, then 10mg once a day. He got better.

He's now well, happy, laughing and engaged with his son and family. He's been to the shops, to town, to appointments with his son.

From being tormented and housebound to being happy and active.

A good result.

Shambling

I was reading through a lot of guidance today that's been published by the National Institute of Health and Clinical Excellence (NICE) since I've been drawn into doing some work on quality standards and care pathways and stuff. It's not an organisation directly controlled by the government, but it's funded by it. Sort of independent, but sort of State organised.

I've issues with guidance, since it's easily given too much authority and seen as the best and only "evidence" and direction. When mis-used in this manner it's worse than having no guidance at all and actively undermines both appropriate commissioning/resourcing of services and undermines patient centred care.

When used well, as something to consider and actively follow or consciously discount for valid patient factors/reasons, NICE guidance is a very useful resource.

Taking it simply for what it is, of informed opinion, so one credible point of view, it's got a very useful place.

It's quite a formal organisation. Proper. Seemly.

In the USA they have formal health bodies, like the Centre for Disease Control (CDC). In their guidance for emergency preparation and readiness they've issued govenrment guidance on what to do in a Zombie Apocalypse.

Geeeenius!

Confusion

I saw a lady last year, referred to me for assessment and management of her dementia. She was confused, her Addenbrookes Cognitive Examination (ACE-R) was poor, her functional level had declined (with constricted activities of daily living).

Poor memory, confusion, reduced functional level and poor ADLs, with a poor ACE-R, it all stacked up as significant congitive decline. She'd had low mood, too, which her GP had sensibly treated with an antidepressant (citalopram) for an appropriate length of time.

Her history, presentation and depression rating scales didn't suggest depression, so either her citalopram was working or she wasn't depressed. After a conversation with her GP, who had started citalopram because her family felt she wasn't coping and thought she was depressed, we stopped her citalopram.

A month or so later and her confusion had resolved, her mental state was stable, with no significant cognitive impairment and no mood disorder. I saw her recently. Her ACE-R is normal. Her CT brain scan, again, was normal. Critically, her functional level was normal.

History, evidenced functional level, mental state, cognitive testing and serial brain imaging finds her to be well, with no features to attract a diagnosis of dementia or major mood disorder.

It's not often we get to cure someone of their cognitive deficits so completely, it's heartening that withdrawl of citalopram really did enable a pick up your bed and walk moment!

NHS Review

I was reading the weekend papers with Mrs Shrink. Whilst she was musing over a lass who's gone all gaga, I was taken by the front page news, "NHS review chief: health reforms are unworkable."

Prof Steve Field, chairman of the "listening exercise" that David Cameron's called him in to do and review the proposals, seems to have told it like it is.

The final report's due out at the end of the month.

The conclusions he voices are that the reforms will be destabilising, undermine key services in hospitals, break up the NHS, close beacon national services, GPs aren't expert/don't have the skills to do all the commissioning that's proposed for them, NHS training doctors (and absorbing the costs) with private providers not bearing costs is unfair . .

. . . I was amazed. Really. I'd never expected such sense to be publically voiced by an influential person in an influential body. More, it was then articulately presented as front page news within the mainstream media. Amazing.

Read it. It's fairly short. To my mind, it's right on the money. More, finally it's someone with balls telling it like it is.

Hurrah!

Leave

I'm back after a bit of a holiday. Lots of people have enjoyed a break through the glorious sunshine we've been enjoying. I'm mindful when emails bounced back with "Out of office" messages, or when trying to sort out meetings, just how many people are away at the moment.

With annual leave, study leave and mandatory training, a few months a year are taken out of everyone's working year before Bank Holidays, compassionate leave, carer's leave, sabbaticals, maternity or paternity leave or sickness are counted.

At any one time, over one thousand staff are on some sort of leave and are not in the workplace. A thousand. That's a lot of work not getting done, each and every day.

What piques my curiosity is how everything ticks along quite nicely despite this. If front line clinical staff are away, we feel the pressure very quickly indeed. So much so we plan leave in obsessively meticulous detail specifically so there's usually only one team member away at most in each clinical team.

What of the non-clinical teams? Porters, domestic staff, estates/gardeners and catering are conspicuous by their absence. That still doesn't maker a huge dent in the 1000 staff who'll have been off today. What does is the support services, the finance and IT and HR and corporate services, the management structures. There'll have been hundreds of such staff out of the workplace today.

I wonder how many people noticed . . .

Complementary Medicine

I can't recall who linked this YouTube video, it wasn't found by me. I chanced upon it on a blog which, to my shame, I can't recall. My wife thinks I read too many blogs. Meh.

Anyway, watch this :



"I'm like a rabbit suddenly trapped in the blinding headlights of vacuous crap."

Brilliant.

Art. Allegedly.

My wife persuaded me to see some art she was interested in. An effort for the poor lass, since my interest in culture seldom exceeds the remits of what's grown within a petri dish.

I'm no culture vulture and find my mind's attention when glancing at most modern art is roughly equivalent to my mind's attention when glancing at rows of bin bags in the supermaket. Which to choose? The work of but a moment, then time to move on. Unless it's Hunt, Millais or Rossetti. She effortlessly talked me to seeing Liverpool's pre-Raphaelite originals then impishly whooshed me along to the Tate Modern which regrettably lived up to my every expectation.

A few weekends ago we romped through London's museums and galleries, where I was pleasantly surprised, but she also fancied a trip to Yorkshire Sculpture Park to see some Henry Moore whatnots set out in the countryside. It looks interesting but what really got me was they'd the most weird Jaume Plensa creations.

Apologies for the images, they looked a lot sharper on my mobile 'phone!





Eerie, unnerving and unsettling, the glowing statues set in darkened rooms really were very powerful. Placing words like "Amnesia" and the like all over, to externalise what's usually internal, was lost on me and just seemed a bit naff, but the size, shape, structure, luminosity of it all was striking, with real impact.

Diagnostic Formulation

The acute medical ward referred a patient to me, for urgent assessment.

The patient had been perfectly well until 2 weeks ago when she experienced left sided weakness and slurred speech that she and her husband have been very worried about. She'd become confused. The medical team referred her to me "with dementia" to sort it all out.

She's had a stroke.

The history, clinical course, clinical examination and structural brain imaging yield a diagnosis of a stroke.

She was perfectly well a fortnight ago. She does not have dementia.

The medical team (well to be fair, a junior doctor on the medical team) assert otherwise. She thinks I'm being unhelpful, not curing this woman or taking over her care "to manage her dementia." I explain she's not got dementia. The junior doctor continues to assert that she does.

I'd love to do this :

Care Pathways

I've been throwing in my 2p worth to discussions 'bout how care pathways could be constructed. I was invited on whim. Folk thought I may know what was happening, what best practice guidance is and what could work. All that is true. They also thought that the discussions could then generate a care pathway so patients could receive services according to their oft repeated mantra of, "the right care, in the right place, at the right time, by the right person."

Mmmm.

One small example was that of vascular dementia. People have poor blood supply to the brain, as time ticks by. In the UK, furring up of the arteries starts at an early age (with post mortem studies of road traffic accidents finding atheroma in children as young as 11 years old) so it's no surprise that decades on with common conditions such as hypertension and diabetes that, in the UK context of atheroma/shabby cardiovascular health, we've an older adult population that has shabby blood supply to the brain.

Chronic (long term) ischaemic changes emerge, with consequent changes in brain function. Or a furred blood vessel makes lots of blood clots (the high pressure as blood squeezes through a furred up narrow tube causes cracks on the furred atheromatous plaque, which causes lots of blood clotting to happen, these blood clots then whiz off and cause strokes). Acute (short term, immediate) ischaemic changes emerge, with changes in brain function.

The top and bottom of it is that folk have small or large strokes, gradually or suddenly. Unlike strokes causing slurred speech or muscle weakness, the strokes are in other bits of the brain and can cause memory problems, mood problems, changed personality, confusion and difficulty in making decisions. Vascular dementia.

Who is the expert at dealing with vascular damage? Maybe it's a neurologist Consultant, with expertise in strokes. Maybe it's a Consultant physician, with expertise in cholesterol levels, blood pressure, anticoagulation and managing hypertension/diabetes etc. Vascular Surgeons have a role in de-furring blood vessels (with carotid endarterectomy and the like) but rarely seem to coordinate vascular care more broadly. I think GPs with their context, longditudinal knowledge of their patient, broad understanding and consideration of multifactorial elements and most usefully their application of common sense not protocol/commissioned activities, GPs could have a key role to play (but locally a vocal vociferous few don't want to be involved at all, so none will be). A Consultant Psychiatrist arguably has a modest role in this; if you've had a stroke, nobody seems to think the right care pathway is refer to mental health services who ask you how you feel about it.

Locally most people with memory changes come to psychiatry. It may scream vascular damage, CT scans may evidence vascular damage and no atrophy, it still comes to my door.

Our commissioners chide me for seeing vascular patients, it's the responsibility of the acute Trust they claim, they're paid to do this work. Seeing the wrong patients means I can't do the work and see the patients the commissioners want me to.

Can all my GPs take a referral where there's a history of memory changes, assess whether it's clinically significant or not, exclude delirium, exclude mood disorder/physical health problems/medication impacting upon cognition, assess cognition to formally diagnose dementia and then determine the dementia subtype, to then refer neurodegenerative dementias to me and vascular dementias to the acute Trust? With the best will in the world, no, they're not all in a position to progress assessment, diagnosis and subtyping to then refer appropriately.

The commissioners found this frustrating news to hear. Too much truth. The "challenges" were too real.

Time passed. Nothing's changed. We still have no explicit (let alone resourced) dementia care pathway in our locality for these patients. It doesn't really matter, they all come to our service and get the right assessment and advice. It's frustrating we get chided for this, though. And we've no resources for this. With NHS changes and profit, especially when making a profit by healthcare organisations is legally required and they can be up on charges if they don't use all means to do so, whether patient care will still be a priority that well meaning organisations (that aren't funded or required to deliver on) still helpfully do is a more salient concern . . .

Crisis Team

I've had to work with a Crisis Team nurse, who was not Charlie Fairhead.

She was, in point of fact, a singularly unhelpful soul who would neither see a patient, nor give them advice, nor arrange any support what so ever.

Time for me to take deep breaths. Count to 10. Self medicate with alcohol, stat.

Drugs

I've been seeing a patient for some time, withdrawing their benzodiazepines with them. Mentally well all his life, the patient had felt anxious and when he retired, then widowed, had declined talking therapies and sought medication to help. His GP is a sensible soul but over time and by accident and through locums whilst on holiday ended up with a patient being prescribed and taking very hefty doses of two benzodiazepines and wanting more.

The drugs weren't working any more. On mornings and after coming down off the drugs' peak effects, he was restless and irritable and more anxious. He'd started falling. Alcohol intake was modest (a couple glasses of wine a week) with normal liver function.

I had never seen the patient before being involved this time. I had not started the benzodiazepines. Our PCT has commissioned neither drug and alcohol services nor my corner to manage iatrogenic addiction (ie the doctor caused it), feeling if one doctor's caused dependence through their prescribing, they need to sort it out. I'm no expert at substance misuse at all. The patient had no wish to see me to reduce benzodiazepines, quite the opposite, he wanted more.

I've massive sympathy for the patient and for the GP. Both were trying to do their best at the original point in time, managing the few poor choices they felt were laid out before them. The GP wrote an excellent detailed helpful referral letter to me, asking if I could sort it all out. She's a good GP. She's helpful. We both collude in working to do what's best for her patients despite the local policies and care pathways and frameworks and shared care arrangements; she's sensible in ignorning most of the bureaucracy and instead we just crack on with what's best. I might prescribe when it should sit within her budget. She might prescribe when it hasn't been the exact blah months needed for a shared care to start. She's a good clinician and she works hard, very hard, to support her patients as best she can.

When she wrote saying she'd messed up and got herself into a tricky position, she knew I wasn't a drug and alcohol expert, but she felt stuck and uneasy, well as said within Jerry Maguire she had me at "hello" and I couldn't leave her to flounder.

The patient loves his GP, thinks his GP is ace. I've been involved for many months and soon will be discharging the patient, benzodiazepine free. The patient suffers my visits and has a less than favourable view of what I've done. He understands why, but it's not what he wanted. But as he 'fesses up, he was addicted. I won't need to see him again, hopefully. His GP hopefully will be seeing him for many years.

Even if it's not my mess, not my work, not my problem, sometimes it's better for the GP to be the good guy and me to be the bad guy.

I wonder if the new NHS commissioning and structures will facilitate helpful working arrangement . . .

Blame

A banker, a Daily Mail reader and a Benefit Claimant are sat round a table, and there are 12 biscuits.

The banker immediately takes 11 and whispers to the Daily Mail reader, "Be careful, that Benefit Claimant is after your biscuit."

Policy is a direction and framework we consider (and should strongly consider) in deciding our clinical practice.

But policy supports clinical practice. Clinical practice doesn't support policy. We do what's right, we don't do what's written down. That's why qualified staff take clinical decisions instead of unqualified staff delivering what the policy says with no decison making at all.

Pyjamas in Bananas has pointed out the flaws of trying to support and use policy documents.

Part of me, rather impishly, wonders how much I should follow policy guidance. NICE guidance should apply to about 3/4 of the population the guidance is generated for. The routine, standard care should typically be in accord with NICE guidance, but for 1/4 of patients specific bespoke custom care is likely to be more appropriate.

As a specialist within Secondary Care services, I'm seeing a patient population that almost by definition don't fit typical routine care pathways that GP and non-medical mental health colleagues progress. When something's unusual or complex, that's typically when it's brought to my door.

On that basis, if NICE guidance applies to 75% of patients, and over 75% are managed in Primary Care or within NICE guidance by nurse lead services in Secondary Care, I'm seeing a portion of all the remaining 25% who sit outside NICE guidance.

Shouldn't 100% of my workload by complex/atypical stuff meaning I'm never adhering to standard policy or guidance or protocol? As I said, it's an impish thought, but I have shared with my Chief Exec that I fear I'm far too compliant with guidance and need to be more maveric and eschew such constraints on my clinical freedom, nigh on 100% of the time. Food for thought . . .

Case Based Discussion

We tell patients the truth. How much is valid consent, how much is coercion?

This is a theme that case based discussion threw up with my colleagues and me. I was pleased, I'd not expected case based discussion to be at all useful. On exploring, with a peer group, how a Consultant managed random in-patient episodes, reviewing the notes and talking it through, a significant difference in approach emerged.

One school of thought was that patients deserve the truth, patients need an honest account of what professional advice a Consultant is offering. More, patients also need to know the consequences of their choice, if it's to be making a considered and valid decision, so patients need to be aware of outcomes from choices. Consultants in this camp will tell patients something along the lines, "We're both agreeing that you're not as well as we'd both wish, we're seeing you're behaving in a way that's unhelpful to you and those you care about, we know being in hospital is helpful for you and over a few weeks has worked every time before, I strongly believe you need to be in hospital, now."
The patient declines the offer of support within an in-patient unit and then is told, "If you're not wishing to come in informally, I'll need to look at a Mental Health Act assessment and admission under section 2."
It was strongly argued that not to tell the patient this was unfair, since valid consent and joint guidance from the BMA and Law Society in 2004 requires that the patient needed to know the consequences of not accepting the proposed treatment.

The other school of thought was that patients deserve the truth and an honest account but this related to the immediate issue. Whether their choices could then perhaps lead to discharge or perhaps to compulsory admission or maybe to consideration of a depot or whatever is a future consideration and shouldn't excessively influence the decision in the here and now.
It was suggested you'd have the same identical conversation but if after you recommended hospital admission your patient declines, you'd walk away and discuss it with the MDT and an AMHP rather than suggest compulsory denention.
It was strongly argued that as well as essentially making a threat, however tactfully delivered, it was inappropriate to offer informal admission then in the same breath say that if you don't come informally, formal admission will be sought, because there's then undue pressure. The same joint guidance from the BMA and Law Society in 2004 reequire that valid consent is made with "free choice" to curtailing choice to "do this, or I'll make it happen" is a less than free choice.

Mostly the argumements and points of view expressed by the Consultants weren't medicolegal or clinical, but essentially were ethical.

Is it better to be totally honest and let patients know the consequences of their decisions? Is it better to offer the choice and then if patients choose to decline, to then approach the MDT/AMHP to discount informal admission and revisit options?

I was firmly in the second camp, I've never to my recollection said to a patient that I'm offering informal admission and if it's declined I'm coming back with pink papers, an AMHP, a GP and an ambulance (with or without police, to convey) since that to my mind could be perceived as somewhat coercive. The argument was that I'd then be admitting people under a section of the MHA 1983 more often than they otherwise needed to be. I typically have just a couple of section 2 admissions a year, I've only made recommendations and managed my patients under section 3 twice in my career to date, so my use of both section 2 and section 3 is lower than colleagues within my peer group.

Different points of view, with different Consultants giving different answers. Usually you ask half a dozen Consultant Psychiatrists a question and you get half a dozen different answers. Unusually we had agreement with just 2 camps and recognition that the opposing camp had valid views but maintaining strong views that their camp was the best way to practice.

I was surprised by how useful the case based discussion was. I'd expected a tedious hour. The open exploration of implications of different approaches to practice, reflection on how we worked and discussion of alternate view points was stimulating and genuinely useful.

A pleasant surprise.

Lifestyle Advice

Kudos to Dr Zorro for an article that's a bit hard to swallow.

Advice

One of my patients with dementia has a son in a low secure forensic unit. I met the son to share news on how his mother's faring, wanting to maintain the family involvement in mum's care now she's becoming increasingly confused. The son's Consultant Psychiatrist felt I should share the news episodically (rather than other family members talking with him) so it could be done sensitively without de-stabilising the son's mental wellbeing.

I've mixed views on that.

Okay, I'm used to breaking bad news. Telling someone they have dementia, and what that will do to them, is hardly a cheery act. I share news and discussion and seek input into formulation and decision making from patients and families every day. Speaking with a son about his monther's deterioration, about current options, about future considerations, without causing excessive upset, that I'm happy to do.

But don't his brothers and sister know him far better, aren't they just as capable/more capable to talk with him about their mother and from the options currently considered to then collectively form a coherent family concensus on suggestions of how care could be?

Anyway, I talk with the family and all's affably agreed, on this occasion, with fairly clear views of what's the best way medication options and residence and care package for their mother.

Whilst talking this through with the son, we discussed antipsychotic medication and how this had been tried but was unhelpful in his mother's care, so had been withdrawn. The side effects were significant, the benefit slight, so the decision was simple enough. The son, though, was ineterested. He was on similar medication, being given antipsychotic medication daily, which he felt was causing adverse side effects.

He wanted to discuss his medication, his experiences of how it felt, his side effects, his options for other drugs. I'm not his psychiatrist, I really can't do that. But I can't just ignore him. I ended up sharing my views on what some people find the benefits to be, what side effects could be related to medication, but ultimately it's between him and his own psychiatrist to make sense of how medication supports his care. I wrote to his Consultant Psychiatrist about what we'd discussed (both of his family and incidentally the concerns he'd disclosed on his medication) so hopefully everyone's informed on all issues.

Although there to support his mother's care, it seems fair for a Consultant Psychiatrist not to direct care/give an opinion but to proffer a little information, when asked to do so. Odd that boundaries of care are so explicit that it feels a little racy to do so!

Covert Medication

Do we use this enough?

At the moment I've no patients who are receiving medication covertly. I have lots of patients who have a mental disorder, within the meaning of the ammended Mental Health Act 1983. I have lots of patients who have an impairment of, or a disturbance in the functioning of, the mind or brain, as set out within section 2(1) of the Mental Capacity Act 2005. In fact all of my patient can fit in to one of the categories of mental disorder/impairment/disturbance of mind/brain.

It was put to me that since all my patients are mentally unwell, if they stop taking medication, can't they be made to take medication? Well no, no they all can't. But it got me thinking that yes, some of the could, but I don't force this. This led to me being chided for not treating vulnerable patients who couldn't make valid choices on treatment.

If you're in a care home or hospital, say, and you have dementia, you probably are fine to make valid decisions on medication you're offered/continue to take. But you might struggle to make valid decisions on medication as dementia progresses or when you have a UTI, chest infection, constipation, pain, dehydration or other cause for acute confusion that makes your thinking worse.

What happens then?

Usually medication's offered to you, even though you're confused and can't give/withhold valid consent on the use of medication. If you accept it, you keep receiving it. If you refuse it, you're allowed to and it's documented as declined and you don't get medication. So whether you receive medication or not isn't based on clinical decision making, it's based on how stroppy you seem and how much nurses/care assistants respond to this. In acute wards it's also about pressures on qualified nurses' time which is now so pressured that even if staff wanted to sit down and explain/support a confused patient with medication, they don't have the 20 to 30 minutes that might take.

The pharmacist and manager givig me grief over this were reckoning that this arbitary giving/not giving medication on how compliant/stroppy a patient is seen to be isn't good. It should be on clinical evidence. If someone is confused and can't give (or withhold) valid consent, they're managed under the Mental Capacity Act 2005 framework and medication can be given when this is in their best interests. Rather than not giving it, the least restrictive means should be used. Instead of section 3 and depot antipsychotic given under Part IV of the MHA 1983, wouldn't orodispersible olanzapine in their tea be a much better option?

I rarely advocate for covert medication to be used. Maybe I'm wrong.

Transition

I work with a lot of people.

Or more accurately, as I'm oft times reminded, I meet with a lot of people and they do a lot of work.

One area of work is prescribing. I'm a doctor, doctors have expertise in this area. Psychiatric drugs are contentious, I'm a psychiatrist so can inform on reasoned, evidence based rational prescribing practice. This means I'm often asked to attend Local Authority or PCT or APC meetings to talk through how medication should/shouldn't be used.

This has contributed to significant improvements.

Patients can access any class of drug without constraints placed upon prescribers, rather than being totally protocol driven our patients can access drugs at any stage of illness (so we can freely prescribe outwith NICE guidance), our use of contentious drugs (such as antipsychotics in dementia) is audited and is seen to be good, use of medication in care homes has dropped markedly with rich mental health staff input instead, Local Authority has funded use of support workers/day care to reduce carer stress (and reduce medication through staff input as a viable alternative), GPs 'phone me up for advice or drop a short letter with all the details as well as making formal referrals for input.

Over the last few years things have got a lot better in my corner, with much better medicines management.

A recent PCT meeting I was invited to caused concern. The folk advancing all the work to progress sensible care were no longer in post, within either the Local Authority or the PCT. With the writing on the wall for PCTs, everyone's leaving, sharpish. With Local Authority not able to cut front line Assessment Officers/Social Workers unless they're not needed (and they are!) it's managers/decision makers who're being lost.

But in this state of flux, work that's been gently but purposefully progressing for the last few years now comes to a hiatus.

In this brave new world of austerity and GP consortia, will it all get better, once again?

Anxiety

We've had this and this paper look at antidepressant medication use in mild depression.

Yesterday we had updated guidance on the use of medication in the management of anxiety. NICE guidance now is that, "GPs should not offer benzodiazepines or antipsychotics to patients presenting with generalised anxiety disorder (GAD)," the one page summary is here.

Will that mean their drugs budget comes over to me, so I can treat them then? :P

Overheard

A patient has great understanding of other people. She's worked in the hospitality industry so has worked with large numbers of people all her life. She's often been a kindly ear to those with troubled needs.

Recently she's needed a bit of help.

On discussing how she's an incredibly resourceful soul with plenty of ideas for others' problems, so has the tools in her toolbox to manage with a helpful steer, she smirked at me and told me, "It's easier to look into a goldfish bowl than to be in one."

Insight and genius, all in one.

Depression's Not Common

Clinical depression's not common, to my mind.

Unhappiness is very common. Unhappiness is an emotion, not an illness.

A little bit of unhappiness, or a lot of it, is a varying intensity of one normal human emotion, so even intense unhappiness is but part of life's rich tapestry and unwelcome though it may be, it's not an illness or a disorder.

Although I'm not a slave to diagnostic checklists, they certainly have a place and shape my thinking. On discussing someone's experiences the details, the nuance, the context, they matter. On considering someone's mental state, eliciting psychopathology and ascribing significance to it/formulating it in other ways and discounting it matters. History taking and mental state examination are clinical activites, not check lists and tick boxes, so there's always room for inclusion of folk and diagnosis of depression for people who don't present with a perfect list for the diagnosis to be textbook.

With this caveat that diagnosis is clinical, contextual and will at times vary from diagnostic lists, I'd concede that most of the time diagnosis falls within accepted frameworks. My training and practice is using the World Health Organisation's International Classification of Diseases, 10th Revision (ICD-10).

It's very useful. It's not just determining what a diagnosis is, it also determines what a diagnosis isn't. For example, "alcoholic" and "alcoholism" aren't in there so aren't and can never be formal diagnostic labels I make. Using the ICD-10 framework engenders a more transparent, consistent, reasoned process to formulation and diagnosis which I find helpful.

Low mood is very very common. Endogenous functional clinical depression arising through abnormal serotin/neurochemistry balance, much less so.

Does this distinction matter?

People with clinical depression have abnormal brain chemistry, this causes illness which has physical and psychological symptoms and signs. By inference, the chemical pathology causing this upset can benefit from chemical solutions (antidepressants). Clinical practice illustrates this, clinically depressed patients do get better on antidepressants.

People may also have low mood because their situation's ghastly and gets them down. If you're down because you're lonely or hungry or in severe chronic pain or you're dying or your loved one's dying or you're abused then is your intense unhappiness clinical depression, caused by chemical illness, so will happiness come in a tablet? Unfortunately not.

People may have low mood through organic syndromes. Stroke damage within the base of the brain or poor blood supply causing ischaemic damage within the diencephalon damages the limbic system, the mood centre in the brain. I've patients who have had cheery dispositions, had stroke damage, are depressed and it's through structural organic brain damage caused by the stroke. Antidepressants have little place.

If unhappiness is sometimes situational and sometimes through structural brain changes, then how do we pick up those unhappy folk who have clinical depression? This matters since such folk with severe clinical depression usually profit from antidepressant drug therapy.

What are the ICD-10 diagnostic criteria?

You need to be depressed for 2 weeks. Being depressed for a few days, then being okay, isn't enough.

You need to be depressed in most situations, most of the time. If you're low for the whole day, but you're okay when your kids visit and take you out to the pub for Sunday lunch, that's not clinical depression. Neurochemistry doesn't rapidly shift as you change from one room to another, so shifting from alone in your house to company in a pub suggests a more reactive/situational cause for unhappiness, or loneliness, rather than being consistent with the chemical illness of clinical depression.

Okay, you've someone with low mood, they've had low mood for 2 weeks, their mood's persistent and pervasive, isn't that just them being unhappy? Yes, it is. To be clinical depression you need to have a number of features :
· Depressed mood that is definitely abnormal for the person, present most of the day, almost every day, largely uninfluenced by circumstances, sustained for at least 2 weeks
· Loss of interest or pleasure in activities
· Decreased energy or increased fatiguability
· Loss of confidence or self esteem
· Unreasonable feelings of self-reproach or excessive and inappropriate guilt
· Recurrent thoughts of death or suicide, or suicidal behaviour
· Diminished ability to think or concentrate
· Changes in psychomotor activity (with agitation or retardation)
· Sleep disturbance
· Change in appetite (decrease or increase) with corresponding weight change

How many of the features correlates with severity :

Mild depressive episode :
"Two or three symptoms are usually present. The patient is usually distressed by these but will probably be able to continue most activities."

Moderate depressive episode :
"Four or more symptoms are usually present. The patient is likely to have great difficulty in continuing with ordinary activities."

Severe depressive episode :
"Eight or more symptoms must be present. Symptoms are marked and distressing, suicidal thoughts and acts are common and a number of ‘somatic’ symptoms are usually present."

The additional somatic symptoms that usually are present would consist of :
· Loss of interest or pleasure in activities
· Reduced emotional response
· Waking in the morning 2 or more hours before the usual time
· Depressed mood is worse in the morning
· Objective evidence of psychomotor retardation or agitation (reported/remarked on by another person)
· Marked loss of appetite
· Weight loss (5% or more of body weight in the last month)
Marked loss of libido

This is important, I believe, because if we diagnose clinical depression when it isn't then people get the wrong treatment. We know from last year's JAMA paper that antidepressants work no better than placebo in mild, moderate or severe depression and only are shown to work better than placebo in very severe depression. We know from a paper in this month's British Journal of Psychiatry that, still, antidepressants don't work in mild depression. Okay okay, studies show us averages and trends, individual patients may respond brilliantly to antidepressants despite have mild or moderate depression, but on average response is the same with antidepressant or placebo.

If we need 2, 4 or 8 core features of depression, and typically there're also some of the 7 somatic features of depression, to my mind that's getting to a much more specific (and smaller) group than all people who have intense low mood.

It's also a harder way to work. If we equate intense low mood with depression, so refer for psychological therapy and start an antidepressant, then everything's done and is easy. If we're sleuthing out who has a depression that's reactive/situational, who has a depression that's organic/structural and who has a depression that's endogenous/chemical, that's a more involved assessment. Worse, if only the last group generally profit from an antidepressant, we're then having to help people with ghastly low mood, suicidality and feelings of not coping through support that doesn't typically include antidepressants. We have to do more than just offer a prescription and refer to a psytchologist.

Harder work, both in assessment and interventions, but to my mind increasingly it's looking untenable to work in any other way.

Being Left Alone

I work with a number of senior, experienced specialist practitioners who, in addition to the perk of getting to pay the NMC a little more each year, also are non-medical prescribers.

Like every Trust, we have a large number of policies, strategies, frameworks, pathways and protocols that are seen as telling staff what to do. Who likes this? I know of no clinical colleague who embraces such policy documentation with joy and enthusiasm. Some colleagues vociferously oppose it as curtailing clinical freedom and, in maveric piques, go against it all.

People don't generally like being told what to do, how to do it, when to do it and what format they have to use.

There's no policy documentation on how non-medical prescribers have to document their prescribing activity. As part of medicines management within our corner, I reviewed it. All of it. There was rather a lot of it. They'd extensive documentation of their Continuing Professional Development, tidily presented in a folder, with the activity and supervision and time taken. They'd evidenced letters to the GP and referrer for all prescriptions, with copies of all of these. They'd detailed the discussions before prescribing, with every case I picked up specifically detailing what had been discussed between them, the patient/carer and a Consultant Psychiatrist. Letters had details of all prescribing, including the specific prescription number of the script. They'd a photocopy of all prescriptions.

I thought it'd be a lot of work for them. It looked fantastic. It wasn't a lot of work, or time, they'd been incredibly efficiant. They simply detailed a one line record of CPD in their folder as it happened. They succinctly summarised prescribing in a couple paragraphs to the GP for each script. They used the copier in the office to keep a copy of all prescriptions, so it was just a few moments to do that. There was little time invested in to it, yet their audit trail of non-medical prescribing activity wasn't just okay, it was flawless.

It's good to see.

It supports what I believe, so is something that stuck in my mind. If folk are told what to do, it's oft times seen as a nuisance and hassle. Leave a nurse (all the non-medical prescribers were nurses) to just crack on and do it herself, without any direction, without any manager, without any Modern Matron, and they're utterly brilliant at sorting stuff themselves.

Now, if I can just persuade folk to leave clinicians alone more of the time . . .

Quote

I took my children to see Megamind recently. Great fun it was, too. One line from it made me laugh out loud at the time then resonated again with me when I saw someone today.

After making a mistake, but both wanting to save face and keep a positive sense of self, Megamind 'apologised' by saying, "You were right. I was . . . less right."

Brilliant :P

Liaison Work

Acute hospital wards often stuggle with psychiatric problems. Medical and surgical colleagues frequently refer patients with depression who are miserable but not clincially depressed and are not ill. I used to think it odd, doctors (who all trained in some psychiatry as undergraduates) can't usually suss out if someone's ill or not.

I used to think that colleagues should be able to undertake a decent history, examination, ask about informant/contextual history and put together some sort of formulation. Partly through training, partly through prejudice, partly through not being their core business/not routine, and mostly because working on acute wards is now described as beyond grim, even competent colleagues with a will to do so struggle to make sense of psychiatric dimensions to their medical/surgical patients.

If history, assessment and formulation aren't undertaken in a systematic, thoughtful, involved manner then how can care planning be person centred and be effective? Largely it can't.

This generates more difficulties because the culture forced on clinicians through current pressures precludes better ways of working. Nurses know that is someone is wandering around or shouting or pulling drips out or pushing buttons on other patients' syringe drivers that usually drugs makes it worse.

Of course they do. We have no "anti wandering" or "anti shouting" or "anti fiddling" drugs, those are behaviours they're not illnesses. What's sought is abolishing symptoms, without attending to the primary cause of these presentations.

It's ingrained, though, so nursing staff are disempowered/under resourced in managing one to one patient care, call medical staff since it's unsafe and problematic, medics feel they can't do anything but prescribe. What do they prescribe? Usually they prescribe the drugs that don't work/make it worse. If used correctly, as well as usually doing little beneficial and lots that's harmful, the appropriate use of the drug also needs extensive ECG and blood monitoring that ties up even more nursing time, which could otherwise have been used in direct patient care to manage the behavioural disturbance.

There's a bit of an inconsistency, though. On the one hand the acute hospitals generally want a chemical solution, and nothing else, to manage behavioural disturbance. On the other hand, their care pathways for this are very different from most any other care pathway they'd generate.

The Dobbing Doctor explained his hospital has a "Rapid Tranquillisation Protocol" and asked what drug would be better.

A protocol on the administration of a drug to treat a behaviour. Is there an "Inhaled Breathing Protocol" giving the procedure for nebulised n-saline in obstructive airways disease or RSV/croup and the like? Is there a "Bolus Steroid Protocol" for injection of steroids in COPD? No, there's no "Bolus Steroid" protocol but there is a "Rapid Tranquillisation" protocol. Why? Why have a protocol for one class of drugs, major tranquillisers, but for most every other protocol it's about the disease state/care pathway? They have Stroke Pathways, COPD pathways, MI pathways but no delirium/acute confusional state pathway. Instead there's a drug protocol for "rapid tranquillisation."

This is less than ideal since we know medication has a tiny role to play, so if it's the only role your hospital offers in such patients' care then, frankly, patients aren't going to get the right care. Last September's update on National Dementia Strategy outcomes and Banerjee's Time for Action report reiterate the best practice guidance that non-pharmacological approaches must be tried first.

The reality is, they work.

I work with older adults. All my in-patients are ill, with major mental health problems. Almost all of them have physical comorbidity too, such as infections, contributing to their acute deterioration necessitating hospital in-patient care. Most are pretty elderly and pretty frail. Despite being confused, ill, unsettled and presenting with challenging behaviour, use of medication is modest. My last patient with hypomanic features arising through stroke damage was managed and discharged on no psychiatric medication. I've never used our equivallent of the "Rapid Tranquillisation" policy on any of my in-patients patients, ever.

If the frail, elderly, ill, most mentally and behaviourally challening in-patients can be managed with little/no psychiatric medication, it suggests that less mentally ill patients within acute hospitals also should be manegeable without drugs. Which is what best practice guidance, Royal Colleges, patient advocate groups and DoH reports say.

The crunch, of course, is that the environment and nursing ratios need to be fit for purpose. Nurse Anne reckons, ". . . that years of intense research have shown that the maximum number even the best nurse can take and not make mistakes is 4-6 on a general floor." She described how when things went well, "I worked a late shift on a 25 bed ward and there was 4 of us staff nurses and 2 care assistants for the ward." Our wards do have such staffing levels, with one qualified nurse per 4 to 6 patients, plus support workers, plus ward physio time and OT time and ward social worker time.

Rationally, if they're not psychotic, or having abnormal dopamine excess needing pharmacological treatment, why is an antipsychotic indicated?

The right environment and the right staffing obviates the need for antipsychotic medication, most of the time. I reckon that's one for the Ghost of Christmas Future to sort out . . .

Haloperidol

A post from my liaison psychiatry work, with musings on haloperidol. I'm not a huge fan of haloperidol.

It has been used by different countries as a drug of torture. Even in both low and moderate therapeutic doses it can cause akathisia.

But quite apart from being a drug with rather unpleasant side effects, more than unpleasant symptoms it can be quite harmful. In older adults with dementia, use of haloperidol is associated with increased risk of death, ramping up risk over the 10 weeks or so on average it was used for by about 60% to 70%. That's less than ideal.
It also explains how it triples your risks of strokes. Nice.

It's a drug with unpleasant side effect profile, it's dangerous, but what about practicalities of its use? Unfortunately it's a tricky drug to use correctly.

The Summary of Product Characteristics (SPC) reminds us that, "Cases of sudden death have been reported . . ." and that it has significant risks if you've heart problems. By significant risks, it's not that the drug has cautions and careful considerations to weigh up, no, it's that it's contra-indicated and should not be used. When is it explicitly contra-indicated, in black and white? When you have :
- clinically significant cardiac disorders
- recent acute myocardial infarction (heart attack)
- uncompensated heart failure
- arrhythmias treated with class IA and III antiarrhythmic medicinal products
- QTc interval prolongation
- history of ventricular arrhythmia
- history of torsades de pointes
- clinically significant bradycardia
- second or third degree heart block
- uncorrected hypokalaemia

Quite a list with pretty common problems, like heart attacks and heart failure, precluding the use of haloperidol.

If a physician is going to prescribe, what do they need to evidence in their records? The SPC directs that, "The risk-benefit of haloperidol treatment should be fully assessed before treatment is commenced," detailing how, including heart monitoring with 12 lead ECGs.

ECGs "particularly during the initial phase of treatment."
"Baseline ECG is recommended prior to treatment in all patients, especially in the elderly . . . during therapy, the need for ECG monitoring (e.g. at dose escalation) should be assessed on an individual basis."

"Periodic electrolyte monitoring is recommended, especially for patients taking diuretics, or during intercurrent illness," so older adults on water tablets or who are ill should have electrolyte monitoring, which by definition is pretty much all patients in acute general hospital beds (because they'll have intercurrent illness).

What does this mean? It means you've a drug with significant side effects, significant risks, marked increase in strokes and death, that shouldn't be used in patients with many common cardiac problems, it needs frequent blood monitoring for electrolytes, an ECG before starting and repeating an ECG on changing dose.

Odd, then, that on medical and surgical wards in the acute Trust it's widely used. Used on acute hospital wards, I can't say it's an intervention I'd wish for myself, or for my nearest and dearest . . .

Decision making

Towards the end of last year I generated a number of letters purely explaining decision making.

One was to a patient's wife, one to a GP and one to a clinical team on a general hospital's orthopaedic ward.

In all 3 cases the patient had been jointly seen by a CPN and me, investigations done, a diagnosis made, explanations given and appropriate management put in to place. But in all 3 cases there was a desire by another party, not the patient, to have more information. The theme was "why" with a desire to know why management was suggested as it was.

Now in all 3 cases the request for more information was polite and inquistive, rather than a forthright demand for explanations, so I'm more than happy to oblige. Sharing reasoning can only be a good thing. The original assessments and letters were extensive; typed up they were a minimum of 5 pages each. The management plans at the end were explicit and numbered, with from 7 to 11 action points in each case. With so much information, it's no surprise that folk want to know a little more about details of specific bits of this.

The wife sought to know why her husband's dementia medication was being withdrawn. The severity of his dementia, the side effects he was experiencing, the risks he'd shown (with ECG changes and collapses), the changes over time on the medication with no benefit seen by us or his wife, the diagnosis (he came to me on medication for Alzheimer's dementia but clearly has vascular dementia, which kind of accounts for why the drugs haven't worked) made decisions on the use of the medication pretty clear cut. Since he's off it he's fantastically better, his mood's settled/undistraught, his thinking's better with less preoccupation and his presentation's better with more successful acceptance of interventions, support and reassurance from his wife. But on stopping his medication his wife, not unreasonably, worried about this and sought more information. She explained how I'd spent an hour reviewing her husband with her, but only 10 minutes talking about medication. She's right, that's pretty much how time was spent. "Only" 10 minutes on why medication's not helpful is to my mind a reasonable amount of time to spend on sharing reasons and understanding, but a carer's mind is a whirl when a Consultant's questioning and investigating and formulating and changing stuff, so it's no surprise she mulled it over then wanted more information. It was no trouble to write to her, my secretary copying and pasting from the GP letter on file, detailing the 11 factors we'd considered that concluded in withdrawl of medication being appropriate. On subsequent review she's been very happy with it all.

The GP and surgical team both sought to know why his patient wasn't getting antidementia medication. It's a GP I know well and with her patient this had been explained but the patient's husband had turned up to the GP with lots of stuff clipped from papers and printed from the internet. The GP wasn't clear on how it all fitted with the current best practice and whether we'd considered relevant factors. On going through the notes it was clear we had, with over half a dozen specific statements about prescribing decisions in one letter alone and almost a dozen factors specified that influenced decisions on the patient's needs and consequent care planning. I liked this one, it was a chance to share with a colleague the reasoning behind prescribing decisions, the evidence base supporting this and the patient factors that impacted upon this. The GP gained understanding around how developing abnormal heart rhythm impacts on risk of medication causing serious harm. Similarly with the ward team.

I guess that like most clinicians, I favour spending most of my time speaking with patients and improving things with them. But sometimes it's also satisfying to have gentle challenge, stirring thoughts on decision making, to organise a response that articulates the contexts and evidence and findings and formulations and risks and degree of benefits and consequences, then share how these have been weighed up and how conclusions have been made.

All 3 times it was joint work with a CPN and others so the responses had effectively a case conference before responses were generated and this open discussion of how we worked and what we did is healthy for our team, reflecting on how we've worked.

So although I favour clinican contact and wouldn't want to navel gaze all the time, having gentle challenge/inquisitiveness to stir reflection of decision making is welcome and, to my mind, keeps us sharp in looking at how we work.