After starting to touch on the important difference between low mood that we all get through being human and experiencing emotion, compared to clinical depression, Lucy's comments got me thinking.
She posed 3 sensible questions about probity :
1) How straight talking are you allowed to be?
2) Have you told her that you are unwilling to prescribe medication because she is not clinically depressed, and that the reason she is unhappy is her situation (which only she can change)?
3) Are you 'allowed' to say things like this to patients?
How It Shalt Be
How to start? Well, let's see what our regulatory body, the General Medical Council have to say on this. This is important since basically the GMC get to say, "This Is How It Shalt Be, Or Mighty Shalt Be Mine Displeasure." They say, "Patients need good doctors. Good doctors make the care of their patients their first concern: they are competent, keep their knowledge and skills up to date, establish and maintain good relationships with patients and colleagues, are honest and trustworthy, and act with integrity."
Honest.
So, to be a good doctor in the GMC's eyes, I have to be honest.
What if that's too hard, what if I didn't care about being a good doctor, I just want to be a good enough doctor, keep my head down and scrape by? Well in addition to the guidance on being a good doctor, the GMC also direct what the duties of a doctor are. These are neither optional nor negotiable.
Their publication, "Good Medical Practice" in 2006 says what must be done and what should be done by doctors.
"To justify that trust you must show respect for human life and you must: Be honest and open and act with integrity."
Right then, good doctors have to be open and honest, but so do bad doctors. Failure to do so is at variance with the GMCs direction on how doctors must conduct themselves.
Giving Information
That GMC document also states that I must, "Give patients the information they want or need in a way they can understand."
That's effectively two interesting clauses, there :
"Give patients the information they want in a way they can understand."
"Give patients the information they need in a way they can understand."
This is a must. Another directive that's neither optional nor negotiable. As a doctor I have to give my patients information that they want or they need. Therein lies the rub; there may well be situations where patients are being told what they need, which it not even close to being what they want.
Given that I must, "Make the care of your patient your first concern," I do it sensibly and professionally.
Sharing news as a process, not just as one event
When I trained as a GP I was lucky enough to work with excellent GPs who were passionate about good palliative care. I spent time in a hospice, too. Communication and sharing bad news was done very well.
Depending on who you believe, about 1 in 5 causes of dementia is thought to be due to Lewy Body disease. I think it's less but that's for another time. Patients with Lewy Body disease have a rough time, their carers have an equally rough time. Average duration from diagnosis to death : 3.5 years. If they're presenting later in the illness, obviously it's much shorter. When I first meet and diagnose someone with Lewy Body dementia, I don't paint things in such stark terms. The "honest" bit has to be tempered with some common sense. I don't duck it, if asked I'll share what I can, but on the first occasion when I give the diagnosis (which they almost all already know involves losing their memory, then abilities, then probably personality, then death) there's a place for support and explanation without adding excessive doom and gloom. As the condition progresses I talk through the different stages, the implications and what can be done so there is honesty and explicit discussion, but I do this over time. Will, undertaking two Lasting Power of Attorneys, driving, dentition, Council Tax, resuscitation if they have a cardiac arrest, end stage palliative care, lots is talked through. But not all in one go.
Sharing bad news is, in my experience, best done as a process. When I first get a referral I know little, I meet a patient and I'll introduce myself then explain why I believe we're meeting, clarifying something such as, "We're here because you went to your GP thinking you had memory problems."
After seeing them I'll have a feel for what's likely to be the case. I'll plan the biochemical, haematological and neuropsychological investigations to be undertaken and slant explanation accordingly, along lines of "memory problems" if delirium or treatable elements seem most likely, or raise the word "dementia" if it's seeming that that's the case.
When results are back, I'll continue to slant description in terms of what I think is going on, along with dropping in some comment on severity (mild, moderate, severe) since the neuropsych assessment will let me now quantify that. Usually I'll have a very good idea what's going on by now so I'll spell that out, such as, "I'm prepared to be surprised, but it does look as if it's likely to be dementia which has been caused by your high blood pressure, diabetes and frequent strokes."
After any radiological or radioisoptopic investigations we can then meet up and I can say, "Given the account you described, the course over the last blah months, the blood tests, the memory assessments and the imaging we did, the cause of your memory problems is blah." And then I go in to my spiel, then they have half an hour to ask questions, then at follow up they get to ask for further information.
To me, this process of being open at each stage makes the last stage effortless since you're simply confirming what you've already been honestly sharing with them over time already. Psychotherapists would say that I am, "socialising them to the idea," so it's not a shock when we have the final definitive discussion, sharing a diagnosis.
Answers
To answer Lucy's questions :
1) The GMC state that I have to be straight talking, but not ruthlessly so
2) I did explain why medication was not appropriate (which she'd already deduced but continued to hope wasn't the case)
3) I'm "allowed" to say whatever I wish, but I'm required to be professional and "make the care of [my] patient [my] first concern."
Monday, 25 February 2008
Wednesday, 20 February 2008
Being happy
I reviwed a lady with F33.4 Recurrent depressive disorder, currently in remission.
She is unhappy. She in not clinically depressed. Real life is unpleasant so she feels saddened. A normal human emotion to a normal situation. I've no pill for this scenario, either.
It's difficult. Some clever philosopher who's name escapes me reckoned there are only 3 outcomes to choose for any problem :
- you address it, solving it
- you accept it, then live with it
- you don't accept it, then walk away from the situation
In a simplistic, reductionist way it's true, how else would you manage any situation?
With this in mind, I counsel her in all 3 areas. I make suggestions and look at solutions; she's not keen to make pragmatic change. She's not keen to look at accepting her situation; she wants to feel happy. She won't leave her abusive husband, her home of 20-odd years or her nearby difficult/thieving grandchildren to walk away from the stresses to live with her daughter, on the coast.
She wants to be in the same situation, with the same stresses, making no changes, but feel happy. She's well, she's not depressed, she's active. We agree there are no outward signs I'd see differently if she were happy (i.e. she's going to bingo, she's going shopping, she's knitting for family, she bakes for the local church), her mood's not changing her bahviour or limiting her one iota. It's just, the joy of life's not quite there any more and she's like it back, through a pill, please.
I can treat depression, most of the time. But gifting bliss is beyond me. I am not a stand up comic, a clown, or a Butlins red coat. Making people happy is not my job. So why do I sometimes feel it should be?
She is unhappy. She in not clinically depressed. Real life is unpleasant so she feels saddened. A normal human emotion to a normal situation. I've no pill for this scenario, either.
It's difficult. Some clever philosopher who's name escapes me reckoned there are only 3 outcomes to choose for any problem :
- you address it, solving it
- you accept it, then live with it
- you don't accept it, then walk away from the situation
In a simplistic, reductionist way it's true, how else would you manage any situation?
With this in mind, I counsel her in all 3 areas. I make suggestions and look at solutions; she's not keen to make pragmatic change. She's not keen to look at accepting her situation; she wants to feel happy. She won't leave her abusive husband, her home of 20-odd years or her nearby difficult/thieving grandchildren to walk away from the stresses to live with her daughter, on the coast.
She wants to be in the same situation, with the same stresses, making no changes, but feel happy. She's well, she's not depressed, she's active. We agree there are no outward signs I'd see differently if she were happy (i.e. she's going to bingo, she's going shopping, she's knitting for family, she bakes for the local church), her mood's not changing her bahviour or limiting her one iota. It's just, the joy of life's not quite there any more and she's like it back, through a pill, please.
I can treat depression, most of the time. But gifting bliss is beyond me. I am not a stand up comic, a clown, or a Butlins red coat. Making people happy is not my job. So why do I sometimes feel it should be?
Monday, 18 February 2008
Caring families
It's good, when of venerable years and in our dotage, that family care for us.
I saw a new patient. I like to see folk at home at least once but on this occasion I saw him in out-patient clinic, through his choice. His GP had referred him with depression.
What was the gentleman's tale? He'd been widowed for a decade and was quite used to living on his own. He'd become more frail, couldn't walk as far as he used to, couldn't manage all the shopping and proffited from additional support. His son and daughter-in-law offered to look after him. He relocated from "down South" to my neck of the woods, moving in to his son/daughter-in-law's home which was difficult. He doesn't like moving. He's got to know the local church, so feels connected and a part of the church once more, which is good for him. He knows some of the folk in his locale now, passing the time of day if he seems them in the streets or corner shops, which is good for him. He spends time talking with his son, when they're alone, his son listens, which is good for him.
He doesn't get on with his daughter-in-law now and when she's in the same room as his son, his son sides with her and hardly talks with him. He says she's heartless and unforgiving, but who knows what the truth is. Not me, for sure.
He's not lonely. He's low in mood. He's got poor sleep, initial insomnia, broken sleep, early morning wakening, diurnal variation in mood, loss of appetite, loss of weight, loss of energy, loss of motivation, no hope or optomism for the future, feels worthless and devalued and frequently (daily) has passive suicidal thoughts and feelings (i.e. wishes he'd go to sleep and die, but isn't planning on actively killing himself). He's a quiet, stoical and almost regal gentleman, open and honest but wan and faded, he looks resigned and beaten.
Why? Well, his daughter-in-law is kicking him out of the house. This is the precipitent for his low mood. I don't have a pill to cure this problem.
Worse, I've feelings of disquiet . . . couldn't she have made this clear before he sold his home down South, or before she'd got a new bathroom with the profits, or before she'd bought the new car and conservatory with it?
I saw a new patient. I like to see folk at home at least once but on this occasion I saw him in out-patient clinic, through his choice. His GP had referred him with depression.
What was the gentleman's tale? He'd been widowed for a decade and was quite used to living on his own. He'd become more frail, couldn't walk as far as he used to, couldn't manage all the shopping and proffited from additional support. His son and daughter-in-law offered to look after him. He relocated from "down South" to my neck of the woods, moving in to his son/daughter-in-law's home which was difficult. He doesn't like moving. He's got to know the local church, so feels connected and a part of the church once more, which is good for him. He knows some of the folk in his locale now, passing the time of day if he seems them in the streets or corner shops, which is good for him. He spends time talking with his son, when they're alone, his son listens, which is good for him.
He doesn't get on with his daughter-in-law now and when she's in the same room as his son, his son sides with her and hardly talks with him. He says she's heartless and unforgiving, but who knows what the truth is. Not me, for sure.
He's not lonely. He's low in mood. He's got poor sleep, initial insomnia, broken sleep, early morning wakening, diurnal variation in mood, loss of appetite, loss of weight, loss of energy, loss of motivation, no hope or optomism for the future, feels worthless and devalued and frequently (daily) has passive suicidal thoughts and feelings (i.e. wishes he'd go to sleep and die, but isn't planning on actively killing himself). He's a quiet, stoical and almost regal gentleman, open and honest but wan and faded, he looks resigned and beaten.
Why? Well, his daughter-in-law is kicking him out of the house. This is the precipitent for his low mood. I don't have a pill to cure this problem.
Worse, I've feelings of disquiet . . . couldn't she have made this clear before he sold his home down South, or before she'd got a new bathroom with the profits, or before she'd bought the new car and conservatory with it?
Wednesday, 13 February 2008
MVA
My junior doctor started last week and, today, starts on his placement.
What's he been up to over the last 7 days, then? He's been indoctrinated or inducted or instructed or something in to the Trust. Finally he's arrived, bright eyed and bushy tailed, ready to learn something about mental health work with older adults.
What did he do yesterday? Why, he did his Managing Violence and Aggression (MVA) training. What was this? He said it was mostly about running away but then there was lots of tustling around with holds and stuff that he's already forgotten as it all got quite confusing.
Medics tend to have a more cavalier attitude to this since, in truth, it's not common for patients to assult us. Fair or not, the last 2 occasions I know of when a patient seriously assaulted a psychiatrist they both ended up detained in a high security forensic hospital for the long haul . . .
. . . it's rather the opposite with in-patient nursing colleagues, sadly, since they are assaulted more often. Our incident forms show it's rare for community nurses in our corner to be assaulted. In-patient staff are open to assault when delivering personal care. Although not acceptable it is understandable - helping a confused patient undress for a bath when the patient can't appreciate why amounts to them experiencing someone tearing their clothes off them, thus they react to fend this off. Good dementia care means repeated reality orientation (speaking to the patient throughout the process rather than just explaining before care's undertaken and assuming 90 seconds later they're still retaining that) and de-escalation of risk.
So in fairness a good organic assessment ward for older adults will have patients who can be challenging to nurse if it's not care planned for and resourced adequately. I'd see this as key - high staffing levels of qualified mental health nurses are key to managing Behavioural and Psychological Symptoms of Dementia (BPSD) and reducing risk to staff and other patients.
At present none of my in-patients are on an antipsychotic at all, not even prn. It's been tried but hasn't been successful so was stopped. The management is wholly about skilled nursing care. In the last year, several patients have been admitted from EMI nursing homes as unmanageable through violence. Medication changes were tried in the community. All have been placed from the ward back into the community after admission and receipt of this skilled nursing care.
For nurses to generate stability and reduce risk without use of oodles of medication, in my corner, necessitates good staffing ratios and the right environment. Without this, the evidence shows nurses get battered.
It's frustrating. Done well, with lots of staff, units are successful with excellent patient care, turning folk from unsettled/unmanageable to content/manageable. Done badly, with poor staffing levels, units are unsuccessful, don't effect change, staff turnover is high and assaults are commonplace.
Now if only I could persuade the local acute Trust to buy in to this, so their staff aren't getting battered all the time whilst trying to care for delirious and demented folk with medical needs . . .
What's he been up to over the last 7 days, then? He's been indoctrinated or inducted or instructed or something in to the Trust. Finally he's arrived, bright eyed and bushy tailed, ready to learn something about mental health work with older adults.
What did he do yesterday? Why, he did his Managing Violence and Aggression (MVA) training. What was this? He said it was mostly about running away but then there was lots of tustling around with holds and stuff that he's already forgotten as it all got quite confusing.
Medics tend to have a more cavalier attitude to this since, in truth, it's not common for patients to assult us. Fair or not, the last 2 occasions I know of when a patient seriously assaulted a psychiatrist they both ended up detained in a high security forensic hospital for the long haul . . .
. . . it's rather the opposite with in-patient nursing colleagues, sadly, since they are assaulted more often. Our incident forms show it's rare for community nurses in our corner to be assaulted. In-patient staff are open to assault when delivering personal care. Although not acceptable it is understandable - helping a confused patient undress for a bath when the patient can't appreciate why amounts to them experiencing someone tearing their clothes off them, thus they react to fend this off. Good dementia care means repeated reality orientation (speaking to the patient throughout the process rather than just explaining before care's undertaken and assuming 90 seconds later they're still retaining that) and de-escalation of risk.
So in fairness a good organic assessment ward for older adults will have patients who can be challenging to nurse if it's not care planned for and resourced adequately. I'd see this as key - high staffing levels of qualified mental health nurses are key to managing Behavioural and Psychological Symptoms of Dementia (BPSD) and reducing risk to staff and other patients.
At present none of my in-patients are on an antipsychotic at all, not even prn. It's been tried but hasn't been successful so was stopped. The management is wholly about skilled nursing care. In the last year, several patients have been admitted from EMI nursing homes as unmanageable through violence. Medication changes were tried in the community. All have been placed from the ward back into the community after admission and receipt of this skilled nursing care.
For nurses to generate stability and reduce risk without use of oodles of medication, in my corner, necessitates good staffing ratios and the right environment. Without this, the evidence shows nurses get battered.
It's frustrating. Done well, with lots of staff, units are successful with excellent patient care, turning folk from unsettled/unmanageable to content/manageable. Done badly, with poor staffing levels, units are unsuccessful, don't effect change, staff turnover is high and assaults are commonplace.
Now if only I could persuade the local acute Trust to buy in to this, so their staff aren't getting battered all the time whilst trying to care for delirious and demented folk with medical needs . . .
Monday, 11 February 2008
Subjective Comment
There used to be a habit of documenting personal comments in medical notes.
Pick up any letter from 20 years ago and it will invariably start with :
"Thank you for asking me to see this delightful 57 year old retired lady who presents with . . . "
"Thank you for referring this disgruntled 84 year old married lady who presents with . . . "
"Thank you for asking me to see this difficult 36 year old divorced teacher who presents with . . . "
"I reviewed this charming 71 year old widowed gentleman who presents with . . . "
And so forth.
In General Practice, such details were commonplace in correspondence. When training in psychiatry, the vogue was to purge such details from all letters, censorship that still intrudes in to my consciousness today.
This struck me when, this morning, I reviewed a lady's care with nursing, social work and occupational therapy staff. We'd found her to be perfectly normal, her care home found her problematic so had asked her GP to refer her on to me.
The GP's referral letter asked us to see, " . . . this stubborn lady."
Through my background indoctrination of objective, factual correspondence this piqued me, initially. My, that's a rather judgemental comment, no? She's not firm, she's not assertive, no, she's stubborn. That rather colours perceptions of her, doesn't it?
On meeting her, her daughter and the home carers (in a regular nursing home, not an EMI unit) things became clearer. She's in her room a lot of the time because she favours her own company. She happily attends for meals and medication and the like, she just prefers not to socialise all the time with the other residents. Physically she's reasonably well, mobility's poor after a fractured hip (and surgery that's been undertaken a couple times to sort this, unsuccessfully) but otherwise is pretty well. She's a very warm lady, you can't help but smile and be charmed by her ways. Despite what the staff say about her, she's very likeable.
She does indeed like things her way. She wants to be on her own but then buzzes for nurses to attend to her needs. Nurses want her sitting in the day room so they can sort her needs more conveniently for them, rather than going to her room. Too, they're worried she's not showing compliance with the "social stimulation" they need to document they do. She wants none of that, thank you very much. Her daughter says she's always been like this, they had a major falling out 'cause she's been so opinionated and assertive in determining what she wanted and how she wanted it.
She wasn't depressed. She wasn't anxious. She wasn't demented. She was perfectly well.
Her GP had the truth of it. She is, indeed, simply a stubborn lady. It was the right information to share, it was succinct, it was meaningful and useful in the assessment (knowing she's always been like this, rather than labelling her with some random psychiatric diagnosis to explain her current behaviour).
In future I'll just reframe subjective comment as "premorbid personality" and welcome it. It's got meaning and it helps patient care.
Pick up any letter from 20 years ago and it will invariably start with :
"Thank you for asking me to see this delightful 57 year old retired lady who presents with . . . "
"Thank you for referring this disgruntled 84 year old married lady who presents with . . . "
"Thank you for asking me to see this difficult 36 year old divorced teacher who presents with . . . "
"I reviewed this charming 71 year old widowed gentleman who presents with . . . "
And so forth.
In General Practice, such details were commonplace in correspondence. When training in psychiatry, the vogue was to purge such details from all letters, censorship that still intrudes in to my consciousness today.
This struck me when, this morning, I reviewed a lady's care with nursing, social work and occupational therapy staff. We'd found her to be perfectly normal, her care home found her problematic so had asked her GP to refer her on to me.
The GP's referral letter asked us to see, " . . . this stubborn lady."
Through my background indoctrination of objective, factual correspondence this piqued me, initially. My, that's a rather judgemental comment, no? She's not firm, she's not assertive, no, she's stubborn. That rather colours perceptions of her, doesn't it?
On meeting her, her daughter and the home carers (in a regular nursing home, not an EMI unit) things became clearer. She's in her room a lot of the time because she favours her own company. She happily attends for meals and medication and the like, she just prefers not to socialise all the time with the other residents. Physically she's reasonably well, mobility's poor after a fractured hip (and surgery that's been undertaken a couple times to sort this, unsuccessfully) but otherwise is pretty well. She's a very warm lady, you can't help but smile and be charmed by her ways. Despite what the staff say about her, she's very likeable.
She does indeed like things her way. She wants to be on her own but then buzzes for nurses to attend to her needs. Nurses want her sitting in the day room so they can sort her needs more conveniently for them, rather than going to her room. Too, they're worried she's not showing compliance with the "social stimulation" they need to document they do. She wants none of that, thank you very much. Her daughter says she's always been like this, they had a major falling out 'cause she's been so opinionated and assertive in determining what she wanted and how she wanted it.
She wasn't depressed. She wasn't anxious. She wasn't demented. She was perfectly well.
Her GP had the truth of it. She is, indeed, simply a stubborn lady. It was the right information to share, it was succinct, it was meaningful and useful in the assessment (knowing she's always been like this, rather than labelling her with some random psychiatric diagnosis to explain her current behaviour).
In future I'll just reframe subjective comment as "premorbid personality" and welcome it. It's got meaning and it helps patient care.
Thursday, 7 February 2008
ECT
On talking of ECT treatment, Mandy asked about use of ECT in the elderly, specifically with regards to side effects.
I'm not particularly pro or anti ECT, any more than I'm pro or anti tablets or pro or anti psychological therapies. Any intervention has potential benefits, risks and side effects. The issue is simply one of offering a choice of the right therapies for the right problem at the right time.
If you had free choice of treatment, rather than the NHS where you can only choose from what's offered to you, what do informed patients choose? The USA shows us this. In America, where patients have informed consent (i.e. are told all the risks and benefits of all options) and through private health care can pay for the treatment of their choice (or go see another shrink who'll take their cash and do it for them), how much ECT is used? Answer : twice as much as in the UK.
The latest DoH data suggests we're undertaking about 4266 sessions of ECT a month in the UK, about 140 a day. From their stats, most (84%) is undertaken with consent.
Why do Americans prefer ECT when given a free choice? Because in a few situations it's a safer and better treatment than alternatives. Bottom line : people can get better much quicker, with fewer side effects than other treatments.
That sounds great, so why's it not used more? Because it's only a few situations where it's the treatment of choice. Severe mood disorders, rare subtypes of schizophrenia and post natal depression are pretty much the only good reasons. Most people with depression don't benefit from ECT, it's only severe depression and depression with marked physical symptoms (the "somatic syndrome" bit) that responds well to ECT.
How is ECT given? You lie down, you have an anaesthetic injection, you go to sleep for about 2 minutes. In that time two handles are put on your head, a charge is delivered and you have a fit. Fit is over stating things. The anaesthetic stops you having a fit, in modern ECT. 5 years ago I timed ECT by watching how long someone fitted for. Nowadays I see nothing as we don't physically move, being anaesthetised and relaxed. Now we look at EEG (brain wave monitoring) to monitor the seizure since the person's relaxed, but typically it lasts 25 seconds or so. A minute later you come round, have a cup of tea and a biscuit and all's done.
Risks? It's been shown to half the incidence of death, compared to tablet/talking therapy treatment. So tablets/talk is twice as risky as ECT for severely depressed folk. Safer than other alternatives, then.
What of long term risks to mind and memory? Some people have no change at all, so have their ECT, are right as rain and go home (having out-patient ECT). Most people are more confused after ECT, for a short while. Some papers show no change to memory over the long term (i.e. after 12 months, memory's the same as before ECT). This paper also confirmed that older patients regained their memory better than younger patients, ECT is often better tolerated and more useful in older adults. Imporantly, everyday memory isn't changed.
This all sounds rather positive. Doesn't ECT cause permanent memory change? Tricky. Maybe yes, maybe no, if it does so it's a rare event (which trials haven't been able to tease out). The problem is that being severely depressed affects our memory, long term. So you can see memory and cognitive changes in folk with severe depression whether they do or don't have ECT. Because depression causes memory change, this makes it really tricky to work out how much ECT adds to the chance of this happening.
What of people in the know, would I want ECT? The Royal College of Psychiatrists surveyed us all, asking us that. If severely depressed, almost every psychiatrist said they'd want ECT. Those who didn't were Child & Adolescent psychiatrists and Psychotherapy psychiatrists who never saw ECT so hadn't formed the opinion on it.
So, if cautiously used for the right folk, I see ECT as a useful thing that may have risks (but the evidence base and clinical experience happily both confirm it's much safer than medication and safer than doing nothing). Serious long term risks (like memory loss) are rare.
Of the thousands of unwell patients in my corner each year, how many do I feel should be offered ECT as the best treatment? Not many. Last year it was just two folk in my whole sector who had ECT.
I'm not particularly pro or anti ECT, any more than I'm pro or anti tablets or pro or anti psychological therapies. Any intervention has potential benefits, risks and side effects. The issue is simply one of offering a choice of the right therapies for the right problem at the right time.
If you had free choice of treatment, rather than the NHS where you can only choose from what's offered to you, what do informed patients choose? The USA shows us this. In America, where patients have informed consent (i.e. are told all the risks and benefits of all options) and through private health care can pay for the treatment of their choice (or go see another shrink who'll take their cash and do it for them), how much ECT is used? Answer : twice as much as in the UK.
The latest DoH data suggests we're undertaking about 4266 sessions of ECT a month in the UK, about 140 a day. From their stats, most (84%) is undertaken with consent.
Why do Americans prefer ECT when given a free choice? Because in a few situations it's a safer and better treatment than alternatives. Bottom line : people can get better much quicker, with fewer side effects than other treatments.
That sounds great, so why's it not used more? Because it's only a few situations where it's the treatment of choice. Severe mood disorders, rare subtypes of schizophrenia and post natal depression are pretty much the only good reasons. Most people with depression don't benefit from ECT, it's only severe depression and depression with marked physical symptoms (the "somatic syndrome" bit) that responds well to ECT.
How is ECT given? You lie down, you have an anaesthetic injection, you go to sleep for about 2 minutes. In that time two handles are put on your head, a charge is delivered and you have a fit. Fit is over stating things. The anaesthetic stops you having a fit, in modern ECT. 5 years ago I timed ECT by watching how long someone fitted for. Nowadays I see nothing as we don't physically move, being anaesthetised and relaxed. Now we look at EEG (brain wave monitoring) to monitor the seizure since the person's relaxed, but typically it lasts 25 seconds or so. A minute later you come round, have a cup of tea and a biscuit and all's done.
Risks? It's been shown to half the incidence of death, compared to tablet/talking therapy treatment. So tablets/talk is twice as risky as ECT for severely depressed folk. Safer than other alternatives, then.
What of long term risks to mind and memory? Some people have no change at all, so have their ECT, are right as rain and go home (having out-patient ECT). Most people are more confused after ECT, for a short while. Some papers show no change to memory over the long term (i.e. after 12 months, memory's the same as before ECT). This paper also confirmed that older patients regained their memory better than younger patients, ECT is often better tolerated and more useful in older adults. Imporantly, everyday memory isn't changed.
This all sounds rather positive. Doesn't ECT cause permanent memory change? Tricky. Maybe yes, maybe no, if it does so it's a rare event (which trials haven't been able to tease out). The problem is that being severely depressed affects our memory, long term. So you can see memory and cognitive changes in folk with severe depression whether they do or don't have ECT. Because depression causes memory change, this makes it really tricky to work out how much ECT adds to the chance of this happening.
What of people in the know, would I want ECT? The Royal College of Psychiatrists surveyed us all, asking us that. If severely depressed, almost every psychiatrist said they'd want ECT. Those who didn't were Child & Adolescent psychiatrists and Psychotherapy psychiatrists who never saw ECT so hadn't formed the opinion on it.
So, if cautiously used for the right folk, I see ECT as a useful thing that may have risks (but the evidence base and clinical experience happily both confirm it's much safer than medication and safer than doing nothing). Serious long term risks (like memory loss) are rare.
Of the thousands of unwell patients in my corner each year, how many do I feel should be offered ECT as the best treatment? Not many. Last year it was just two folk in my whole sector who had ECT.
Wednesday, 6 February 2008
Flexibility
Today I saw a lady with Parkinson's disease, visual hallucinations and confusion. She wasn't delirious, she'd been like this for a goodly while and her GP had excluded causes of an acute confusional state (and kindly sent me all results of relevant investigations). Her husband (and 3 children who visit in turn daily) care for her very well indeed. On looking at things with her I saw her problems as almost all biomedical, arising through Lewy Body dementia and benefiting from medication. Out comes the FP10, she gets a prescription.
Today I saw a lady who was always anxious, always worrying, had done all her life. She's fretting over her grandchildrens' health and over how appropriate it is for them to go on holiday to "for'n parts" now. On looking at things with her I saw her problems as almost psychosocial (and psychological not psychiatric).
Today I saw a lady who's anxious and worried but only when alone. With family or friends all is well. On looking at things with her I saw her problems as almost all social, with loneliness being the paramount issue (which she volunteered and agreed was the case).
Today I saw a gentleman who's anxious and worried much of the time against a background of word finding difficulties and poor recognition. He's not readily consoled by friends or carers (he's in 24 hour care now, in a good EMI Residential Home). History, clinical course, mental state and imaging studies confirm he's got vascular dementia. His mood symptoms are caused by structural damage to his limbic system. On looking at things with him I saw his problems as almost all physical (caused by strokes wiping out the bits of his brain necessary for moods to be normal), with no cure and role for medication at the moment.
There's often talk about different models in mental health.
I think the only credible approach is to have no one model. I flit from one sort of formulation to another, I think we have to if we're striving to be patient centred.
Biological, physical, psychological, social, systemic and environmental factors all affect all of our lives. When mental health is impaired, it's only by looking in different ways with different folk that we can focus on what's best for them, at that time.
Today I saw a lady who was always anxious, always worrying, had done all her life. She's fretting over her grandchildrens' health and over how appropriate it is for them to go on holiday to "for'n parts" now. On looking at things with her I saw her problems as almost psychosocial (and psychological not psychiatric).
Today I saw a lady who's anxious and worried but only when alone. With family or friends all is well. On looking at things with her I saw her problems as almost all social, with loneliness being the paramount issue (which she volunteered and agreed was the case).
Today I saw a gentleman who's anxious and worried much of the time against a background of word finding difficulties and poor recognition. He's not readily consoled by friends or carers (he's in 24 hour care now, in a good EMI Residential Home). History, clinical course, mental state and imaging studies confirm he's got vascular dementia. His mood symptoms are caused by structural damage to his limbic system. On looking at things with him I saw his problems as almost all physical (caused by strokes wiping out the bits of his brain necessary for moods to be normal), with no cure and role for medication at the moment.
There's often talk about different models in mental health.
I think the only credible approach is to have no one model. I flit from one sort of formulation to another, I think we have to if we're striving to be patient centred.
Biological, physical, psychological, social, systemic and environmental factors all affect all of our lives. When mental health is impaired, it's only by looking in different ways with different folk that we can focus on what's best for them, at that time.
Tuesday, 5 February 2008
"Missing you"
I spoke with a lady today, in her late 70's, who I've been seeing for a few years now.
She suffers with several painful conditions, a fair bit of infirmity, a lifelong legacy of self doubt and anxiety, she'd lost her confidence and is troubled by F41.1 Generalised anxiety disorder. Has been for many many years.
I've seen her in out-patient clinic regularly (but not that frequently) over the last three or four years, once I offered her in-patient care when things were fraught after her husband died, episodically I meet with her in the day hospital, but overall I must confess it's the case that, as better folk than I convey, the doctor's the drug.
Decades with others have shown, and after rocking the boat I've realised too, that all that really helps her is seeing someone, and time's shown that someone has to be a psychiatrist, to review things and chew the cud with her once in a while. So over the last few years I see her every 3 months or so, it takes half an hour of my time and keeps her well. She now feels she's coping, she's going out, she's shopping, she enjoys time with others.
On getting folk well I'm invariably discharging them from regular follow up and offering open appointments, partly so I'm seeing folk who need seeing, partly so folk can then see me when they want to (rather than after an arbitary time I choose), but there are probably some half dozen patients who I'm seeing 4 times a year to simply see them. It's what they ask for, the GPs love it as it's stopped them visiting their GP frequently, it's the best thing I can think of that contains their ill ease and keeps them well.
So after 20 minutes of reviewing how she's been over the last copule months, what's gone well, what's been trying, what's changed, she spoke of her late husband and how when she get's home she'll apologise.
"Apologise for what?" I asked.
"For being late, getting back," she said, smiling weakly. "I always do it. Whenever I get home, I speak to him, still. I tell him when I'm going to sleep, too."
I could have hugged her, then.
It was so endearing, he lives on with her, her relationship endures with him despite his death, in a healthy and charming fashion that she lives each and every day. It's not just GPs who are fortunate men :-)
She suffers with several painful conditions, a fair bit of infirmity, a lifelong legacy of self doubt and anxiety, she'd lost her confidence and is troubled by F41.1 Generalised anxiety disorder. Has been for many many years.
I've seen her in out-patient clinic regularly (but not that frequently) over the last three or four years, once I offered her in-patient care when things were fraught after her husband died, episodically I meet with her in the day hospital, but overall I must confess it's the case that, as better folk than I convey, the doctor's the drug.
Decades with others have shown, and after rocking the boat I've realised too, that all that really helps her is seeing someone, and time's shown that someone has to be a psychiatrist, to review things and chew the cud with her once in a while. So over the last few years I see her every 3 months or so, it takes half an hour of my time and keeps her well. She now feels she's coping, she's going out, she's shopping, she enjoys time with others.
On getting folk well I'm invariably discharging them from regular follow up and offering open appointments, partly so I'm seeing folk who need seeing, partly so folk can then see me when they want to (rather than after an arbitary time I choose), but there are probably some half dozen patients who I'm seeing 4 times a year to simply see them. It's what they ask for, the GPs love it as it's stopped them visiting their GP frequently, it's the best thing I can think of that contains their ill ease and keeps them well.
So after 20 minutes of reviewing how she's been over the last copule months, what's gone well, what's been trying, what's changed, she spoke of her late husband and how when she get's home she'll apologise.
"Apologise for what?" I asked.
"For being late, getting back," she said, smiling weakly. "I always do it. Whenever I get home, I speak to him, still. I tell him when I'm going to sleep, too."
I could have hugged her, then.
It was so endearing, he lives on with her, her relationship endures with him despite his death, in a healthy and charming fashion that she lives each and every day. It's not just GPs who are fortunate men :-)
Friday, 1 February 2008
Treatment
There's a presumption that patients have a right to treatment.
There's a duty of care that mental health folk have to patients.
There're laws passed (statutory instruments) that give us the tools to undertake this care.
All well and good, most of the time. But what if it's taken to extremes? Who should be treated, and how much, for how long? At best it's quirky and autocratic care, at it's worst it's paternalistic and tyrannical health care. Gets you thinking, this does, when patients crop up with unmet clinical needs that could be treated.
Let's take a lady and call her Alice. Alice is elderly and depressed. She's often had bouts of depression in the past so has a diagnosis of F33.2 Recurrent depressive disorder, current episode severe, without psychotic symptoms. She was unable to look after herself well, feeling weary and disinterested in "stuff to deal with" to get through a day, wasn't eating anything but gingernut biscuits and wasn't drinking much fluid at all. She smoked over 100 cigarettes in a day (usually it's less than 20) and was too demotivated to go and get more so was withdrawing from nicotine abruptly, too. Life's bleak, she'd rather go to sleep and not wake up. She's no energy, no hope, no joy, no quality sleep, no feeling refreshed, no motivation. She feels utterly worthless and a nuisance to everyone.
2 months ago she was right as rain.
In the past when this has happened she's had ECT, been cured, gone home and stayed well for between 10 to 22 months before another depressive episode occurs.
She refuses people coming in to her home to help. It's started anyway, but she doesn't let them in. She refuses hospital admission and is fading away fast. She's admitted under section 3 of the Mental Health Act 1983 for treatment of her underlying mental disorder, depression.
She refuses medication and historically has poor concordance with prescribed medication on discharge, with the only antidepressants in her flat on this occasion being 4 months out of date and untouched.
She's said in the past that she doesn't want ECT again.
Through her depression she's got marked bradyphrenia, depressive cognitions, cognitive distortions and abberant ideation. She's not frankly psychotic, but her thought process are disturbed through her depression so, within the meaning of the Mental Capacity Act 2005, she has imparied function of her mind and is an incapacitated adult (with respect to the decision to determine current treatment such as ECT).
This time, what should happen?
It's not even up for discussion as the law stands; she should have ECT :
- she has a mental disorder
- we have a duty of care
- she has been detained under the Mental Health Act 1983 for the treatment of this mental disorder
- statistically we know ECT is the treatment of choice (better outcomes than tablets, swifter resolution of symptoms, safer with half the mortality of antidepressants) and specifically we know it works very well for her, very quickly, such that's she's well and functioning independently for a year or two even off all medication. So the clinical intervention of choice, for her, at this stage, is ECT
- she refuses ECT and has, in writing, an Advance Decision refusing ECT treatment. But ECT can be given under Part IV of the Mental Health Act 1983 under section 62 then with a Second Opinion doctor agreeing under section 58, so we've a statutory instrument allowing us to deliver the care she needs.
- ECT is given, she gets better after 4 sessions (two weeks) but has 2 more sessions to consolidate the treatment course, she's regraded and discharged and is well
Outcome : a lady got the care she needed when she was unwell and vulnerable and was cured, for a while at least.
As an aside, having taken advice on this, if her Consultant Psychiatrist didn't give her ECT he'd be open to claims of medical negligence (having a duty of care, admitting her for treatment, having a statutory instrument to use to deliver the treatment but then electing not to do this and thus not providing her with the care she needs and deserves). Like it or not, that's the law as it stands today in England.
I'm totally for people with insight making rational decisions about their current and future care. Some people can very sensibly and very thoughtfully describe why they will or won't buy in to treatments offered to them and make a choice on this. Whether I agree or disagree with that choice then, generally, is irrelevant . . . I'm bound to accept their wishes.
The revisions to the Mental Health Act 1983 are making things slightly different. In the future, if you've an Advance Decision to refuse treatment (including ECT treatment) andf that Advance Decision is undertaken in accordance with the Mental Capacity Act 2005, it'll be legally binding. The Mental Health Act 1983 can't then be used to deliver ECT even if the person's incapacitated with regards to this decision.
I wonder what this will mean for Alice.
There's a duty of care that mental health folk have to patients.
There're laws passed (statutory instruments) that give us the tools to undertake this care.
All well and good, most of the time. But what if it's taken to extremes? Who should be treated, and how much, for how long? At best it's quirky and autocratic care, at it's worst it's paternalistic and tyrannical health care. Gets you thinking, this does, when patients crop up with unmet clinical needs that could be treated.
Let's take a lady and call her Alice. Alice is elderly and depressed. She's often had bouts of depression in the past so has a diagnosis of F33.2 Recurrent depressive disorder, current episode severe, without psychotic symptoms. She was unable to look after herself well, feeling weary and disinterested in "stuff to deal with" to get through a day, wasn't eating anything but gingernut biscuits and wasn't drinking much fluid at all. She smoked over 100 cigarettes in a day (usually it's less than 20) and was too demotivated to go and get more so was withdrawing from nicotine abruptly, too. Life's bleak, she'd rather go to sleep and not wake up. She's no energy, no hope, no joy, no quality sleep, no feeling refreshed, no motivation. She feels utterly worthless and a nuisance to everyone.
2 months ago she was right as rain.
In the past when this has happened she's had ECT, been cured, gone home and stayed well for between 10 to 22 months before another depressive episode occurs.
She refuses people coming in to her home to help. It's started anyway, but she doesn't let them in. She refuses hospital admission and is fading away fast. She's admitted under section 3 of the Mental Health Act 1983 for treatment of her underlying mental disorder, depression.
She refuses medication and historically has poor concordance with prescribed medication on discharge, with the only antidepressants in her flat on this occasion being 4 months out of date and untouched.
She's said in the past that she doesn't want ECT again.
Through her depression she's got marked bradyphrenia, depressive cognitions, cognitive distortions and abberant ideation. She's not frankly psychotic, but her thought process are disturbed through her depression so, within the meaning of the Mental Capacity Act 2005, she has imparied function of her mind and is an incapacitated adult (with respect to the decision to determine current treatment such as ECT).
This time, what should happen?
It's not even up for discussion as the law stands; she should have ECT :
- she has a mental disorder
- we have a duty of care
- she has been detained under the Mental Health Act 1983 for the treatment of this mental disorder
- statistically we know ECT is the treatment of choice (better outcomes than tablets, swifter resolution of symptoms, safer with half the mortality of antidepressants) and specifically we know it works very well for her, very quickly, such that's she's well and functioning independently for a year or two even off all medication. So the clinical intervention of choice, for her, at this stage, is ECT
- she refuses ECT and has, in writing, an Advance Decision refusing ECT treatment. But ECT can be given under Part IV of the Mental Health Act 1983 under section 62 then with a Second Opinion doctor agreeing under section 58, so we've a statutory instrument allowing us to deliver the care she needs.
- ECT is given, she gets better after 4 sessions (two weeks) but has 2 more sessions to consolidate the treatment course, she's regraded and discharged and is well
Outcome : a lady got the care she needed when she was unwell and vulnerable and was cured, for a while at least.
As an aside, having taken advice on this, if her Consultant Psychiatrist didn't give her ECT he'd be open to claims of medical negligence (having a duty of care, admitting her for treatment, having a statutory instrument to use to deliver the treatment but then electing not to do this and thus not providing her with the care she needs and deserves). Like it or not, that's the law as it stands today in England.
I'm totally for people with insight making rational decisions about their current and future care. Some people can very sensibly and very thoughtfully describe why they will or won't buy in to treatments offered to them and make a choice on this. Whether I agree or disagree with that choice then, generally, is irrelevant . . . I'm bound to accept their wishes.
The revisions to the Mental Health Act 1983 are making things slightly different. In the future, if you've an Advance Decision to refuse treatment (including ECT treatment) andf that Advance Decision is undertaken in accordance with the Mental Capacity Act 2005, it'll be legally binding. The Mental Health Act 1983 can't then be used to deliver ECT even if the person's incapacitated with regards to this decision.
I wonder what this will mean for Alice.
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