Composition of the MDT

We've been having discussions, of late.

I thought it'd be pistols at dawn, but it's been the typical reasoned and affable banter that thankfully seems to pervade our neck of the woods. The issue has been, who should we have in the Community Mental Health Teams (CMHT) as they expand?

Now, everyone has an opinion, with most folk are suggesting some or more of their discipline. Apart from me, since although we're below Royal College recommendations for Consultant Psychiatrist numbers given our patient populations, in truth we've enough medical time to get the work done well so I can't really justify arguing for more.

Within each CMHT at the moment we've got 1.8 to 3 qualified nurses (all at band 6 or band 7 with many having CBT and non-medical prescribing training), 1 Support Time Recovery worker, 1 social worker, 0.5 occupational therapist, 0.2 OT technical instructor and 1 Consultant Psychiatrist (potentially with some Staff Grade and ST1 junior doctor support but in practice they're supranumerary and there just for training). One team has 0.2 of a pharmacist. We've access to a Nurse Consultant and to psychology who work more widely than just with the CMHTs. We've sessional input from a physiotherapist. We've service level agreements for dietetic and Speech Therapy input.

As activity rises and we've extra cash to invest in the community, what should we invest in?

The crunch is that every discipline can contribute something useful, there's no startling unmet need we have to address, instead we're rather looking at improving quality of care further (even though the Healthcare Commission again rated us as Excellent, yay!) and generating extra capacity for the future.

My gut instinct is that a Community Psychiatric Nurse (CPN, erm, or whatever they fashionably call themselves now) wins almost each and every time but the physios and OTs and pharmacists clearly want to expand their corner with psychology jumping up and down too. All add something useful but with rationed resources we need "the biggest bang for the buck" which principally is quality of care rather than purely volume of activity (since currently we've sufficient resources to see and sort all referrals, with no wait beyond 10 days).

In such a community team, would you have any views on what should be prioritised?

Dementia

I saw a gentleman with, apparently, dementia.

He had prostatism.

He had a stroke so his mobility wasn't great.

It transpires that he's actually got Normal Pressure Hydrocephalus (NPH) and I've referred him on to neurosurgeons to try and cure him.

What was embarassing was the "classic" trio of dementia, gait disturbance and urinary incontinence were manifestly present, but I'd missed the significance of the symptoms since I'd thought they were prostate and stroke disease.

Most folk with dementia don't get a CT or MRI scan since it doesn't change management. I did scan him, for no good reason other than it seemed "a bit odd," I'm so glad the clever radiologist chappies commented on the changes suggesting NPH since I'd not have considered it, otherwise.

Scary when good fortune rather than good clinical acumen gets the patient the right care . . .

Books

I've stoically maintained medical content in my blogging with no sorties solely in to my personal or family life, no memes or lists and no film reviews or the like.

For no good reason other than I like her blog and I'm curiously inclined to acquiesce to older lady's polite requests, I'm running with Elaine's tag about books. Too, I am rather fond of books.

4 childhood books
The Lion, the Witch and the Wardrobe. My father read the whole Narnia series to me and, to this day, I remember being snuggled in bed with wondrously fanciful bedtime stories. The Queen, the Turkish Delight, Aslan, it's all compelling stuff. Only now, with an adult's perspective, do I get how unfair it is that a bloke can be a treacherous traitor but be forgiven, but the lass who errs didn't get to enter paradise.
Winnie-the-Pooh. Again, excellent tales I loved as a child and as an adult. I've shared them with my kids, too. And I liked the child friendly introduction to poetry that AA Milne wrote.
Swallows and Amazons. My father had a full set of all Arther Ransome's series, original hardback first editions, that I'd read and be thoroughly absorbed in for hours on end. Better still, we spent Summer holidays in the Lake District with family every year so I really did get to swim in Lake Windermere and my father'd row us around to the small islands that were used in the novels.
Dune. I read it thinking I was all grown up and reading proper literature (I know, I know, but that was the least of my clangers) and hated it, failing to grasp the plot. I reread it after seeing the film and loved it. The scope of it suddenly became clear . . . the great Houses, the Spacing Guild with the monopoly it held, the genetic manipulation, the feuds, the Fremen's values, the challenge of a desert world, the massive political machinations that all made sense.

4 authors I will read again and again
Terry Pratchett. Trudi Canavan is popular at the moment, Iain Banks and Gibson and Asimov and Lovecraft entertain me with SciFi, Sergei Lukyanenko's Watch trilogy had me up for nights reading obsessively, but from all the SciFi and fantasy authors Pratchett is the one I probably read over and over again the most. The plots are variable with some great and some weaker but the characters and humour see it through, for me, such that I've always read the novel for the plot and pleasure then reread them and invariably got more out of it.
Bill Bryson. A bit like Michael Moore, you couldn't stand to hear what he's got to say day in day out, but Bryson's style appeals to me and his research is at least somewhat involved even when it's not wholly impartial. Still, the combination of good writing, interestingly researched with personal context grounding it all makes his texts easy to dip in and out of time and time again.
Paulo Coelho. The Zahir did little for me, the Witch of Portobello did more, The Alchemist was fantastic. Each time I read it I get more out of it.
Kurt Vonnegut. He challenges and muddles and intrigues me without pushing me too far away to lose me. My favourite, Slaughterhouse Five, I love even though I still don't really grasp it. The whole impact and futility and barbarism of the bombing of Dresden really has impact without being gratuitous or detached with morally reprehensible claims, it's all the more shocking impact for simply and elegantly describing it as it was. The anti war theme is so well crafted, with none of the usual zeal or extreme positioning. I get more from it each time I read it.

4 authors I will never read again
Stephen Fry. I'm lying on this, just 'cause I'm sulking. He's a genius and I own most everything he's written. Days after Moab is my Washpot was on the shelves I got my copy only to find his autobiography stopped at late adolescence. Robbed, I was! Patiently waiting for Serendipity is my Linen Basket, or whatever sequel it will be, nothing has been forthcoming. But this lovers tiff will pass, all will be forgiven, when the next book's penned . . .
Emily Brontë. Although I try so hard to read some 'proper' literature episodically, I just couldn't win, here. I tried Wuthering Heights twice this Summer and just couldn't get in to it. Kate Bush lead me to believe it would be windswept moors and exciting romance and passion transcending death. No. It's anachronistic English text 'bout two households mundane interactions with just three brief forrays to the moors in the whole book. Gah!
JRR Tolkein. I've read so much so many times that I'm all Hobbited out. And no matter what anyone says, The Silmarillion is rubbish.
Will Self. I've been engrossed by most anything he has to say when I've seen him on TV or being interviewed on the radio. Erudite, loquatious, insightful, I thought I'd dabble in his books and enjoy How the Dead Live. It was ghastly, one of the few books I've not been able to finish. Ho hum.

The first 4 books on my to be read list
The Picture of Dorian Gray. I started this in the late 80's but never finished it 'cause I broke up with my partner at the time and she nicked off with it! Some day I'll get around to finishing it, I'm quite fond of Wilde.
The Works of Algernon Charles Swinburne. From Alice Cooper's Poison I found my way to Swinbune's Dolores, our Lady of Pain. I've never really devoted enough time to many of his poems and, some day, will make time to muse over them.
The Collected Poems of Rupert Brooke. Again, I've read many of Brooke's poems, which is odd as he's the only war poet I'm taken with. Again I found him by accident, after hearing Pink Floyd's The Gunner's Dream I was taken by the line "in the space between the Heavens and the corner of some foreign field, I had a dream." Chatting to more learned friends I learnt that "The corner of some foreign field" was a line from Rupert Brooke's The Soldier. I read more but it's years since I read much of Brooke, he's another poet I really should devote more time to.
Nigella Express. I do a lot of the cooking in the house, my wife reckons I need to learn more snappy, quickly produced meals. We've bought Nigella's latest book, it's on my list of Things To Look At.

The 4 books I would take to a desert island
Dune since it captivates me each and every time I read it.
A Bible to help sustain faith.
Slaughterhouse Five as it's the book I've bought most times (having lost and given away more times than I care to remember).
Collected works of Shakespeare since I like a few of his plays and I love most of his sonnetts so this'd absorb me for ages. Too, it's good to have something soft, strong and thoroughly absorbent that can also be used usefully with kindling.

The last lines of one of my favourite books
The House at Pooh Corner, In Which Christopher Robin and Pooh Come to an Enchanted Place, and We Leave Them There.


Two folk I'd tag to do the same, if they'd wish to, would be Cal and Dr Brown.

MDT

In mental health we're all pretty familiar with working within a multidisciplinary team (MDT) which generally is A Good Thing.

Our patients have input from medical, nursing, social work, pharmacy, occupational therapy and CBT directly from our team with additional access to physiotherapy and psychology from the service. We've good links for dietetic, epileptic, continence, diabetic and stroke rehab input.

Thus when we see a patient we're usually in a position to do something effective, as a team. Too, we support one another with both clinical advice and through stress and strife.

In my junior doctor training when sitting through a Forensic Psychiatry lecture (in the days when we were thankfully allowed to be spoon fed in lectures) the content became increasingly macabre, including blood splattered rooms and body parts. When the lecturer was challenged by one gentle soul that this was gratuitous and unnecessary for the teaching he replied with wisdom. "Psychiatry is about misery. If you don't like it, you're in the wrong field."

Much of psychiatry is, I suppose, "about misery" as he meant it. People who are well and satisfied and happy and coping won't have much involvement with mental health services. Although I think "misery" is over stating it, most patients and families are experiencing marked distress. Since we're not in a position to cure most folk, we're mostly in the business of helping people make sense of and cope with their situations better.

For folk working in this field, dealing with people in distressing hour after hour, day after day, can be invigorating (as so much good is done) or demoralising (as few folk are cured and the morbidity never seems to end). In places where mental health services are upbeat, motivated, zealous, patient centred, compassionate and healthy (Law 4 : The patient is the one with the disease) the difference is the team.

A supportive and open MDT than has good team dynamics makes a world of difference to the culture we work in and therefore the type of work we do and indeed the details of the way we work.

Curiously, days go by without me seeing another Consultant colleague, weeks go by without me chatting to one. They're there when I'm worrying I'm having a blonde moment and need to bounce an idea off them, but by and large the MDT challenges and supports me such that practice is as it should be.

Now that's an interesting position for me to reflect upon, when senior nurse practitioners working collaboratively with medics help generate such a dynamic.

Soulful Psychiatry

My team practices pretty eclectic psychiatry.

This week alone we've worked in people's homes, on the streets as we've gone for walks, in a garden centre, in a cafe, in a pub and on one lady's garden path. Heck, 3 patients were even seen in an out-patient clinic :-)

All of this was purposeful. Whether it was one lady's anxiety and phobia necessitating walking to her garden's gate and being there 'til distress diminished, or a social phobia and sitting in a cafe with the hustle and bustle or wanting to get back "to normal" after a bereavement and bimble about looking for bedding plants, we're in the business of alleviating distress and working with patient's problems in a way that fits with them. Everyone's different, after all.

Too, medication's just part of the solution. Seeing a bereaved gentleman at his home with his son yesterday evening the nurse and I were struck by his progress over the last few weeks which I attribute wholly to the support (and CBT principles) his community nurse* proffered.

The medication he has of olanzapine 5mg (used as a treatment for his bipolar disorder in the past and his son's at present) was reintroduced when sleep got worse (down to 2 to 3 hours), Activities of Daily Living became increasingly impaired, anxiety rose (so he'd not leave the house) and thoughts became more disturbed with negative ruminations. A month on and things hadn't changed but he then was less chaotic in his thoughts and could work with the nurse to effect practical behavioural change and spend hours with her doing this work.

Which is good, because he's now dramatically better.

But what got him better, to my mind, was the nursing input and the medication. The medication afforded enough resilience, cohesion and alleviation of distress to engage in the somewhat cognitive and mostly behavioural work, the medication wasn't a cure and didn't effect the change itself.

Working with people at their pace, introducing nursing when there's a window of opportinuty and they're ready for it, use of medication at the lowest doses, treatment in the community at the most suitable location, work with the patient and family, use of different modalities as interventions, as I started off saying I'd like to think we're a team with a pretty eclectic approach.

I was dipping in to Bob's blog and reading about Soulful Psychiatry. The language used by Dr Roberts sounds appealing. I'm not sure who Dr Roberts is, she's not listed as a medic. Some themes espoused sound appealing. The antipsychiatry and antidrugs does not sound appealing. As Bob himselves says, he's spent ages on in-patient wards and now his mix of medication and removing stress has thankfully kept him well for ages. What are your thoughts on talk of things like Soulful Psychiatry? So much mumbo jumbo? Dangerous anti-psychaitry propaganda that's increasing the stigma of psychiatry? Maligning mental health care making it less accessible by people who could benefit from it? Or it it useful in highlighting elements that can be introduced in to main stream mental health clinical practice?


* I used to call them CPNs (Community Psychiatric Nurses) but nowadays there's a vogue for them to be CMHNs (Community Mental Health Nurses) for reasons I can't quite fathom, so I largely eschew.

Orthopaedics

I really really shouldn't do this, but it amused me too much.

I'd say I'm sorry, but clearly I'm not sorry enough not to do it, so I s'pose it wouldn't count.

Jokes I heard today 'bout orthopaedic surgeons I simply have to share :

Q. What does an orthopaedic surgeon call the heart.
A. A soft tissue organ for pumping cefuroxime around the body.

Q. What do you call 2 orthopaedic surgeons reading an ECG.
A. A double blind trial.

Now, tell me honestly that you're not grinning :-)

Doing Nothing

A touch facetious (since it's rare I see a patient without generating a management plan with at least half a dozen interventions even if they're all nursing or psychoeducation), but I'm indulging myself.

As a junior doctor, when called by staff to a patient it was always because something needed "doing". Put in a venflon, write a drug card, inject iv antibiotics, assess a rash, tell them they're dying, consent them for a procedure, defib their VF, whatever.

It's taken some time to step back and gain perspective, from "doing".

An anaesthetic Pain Consultant was saying of orthopaedic surgical collegues, "when you're holding a hammer, everything looks like a nail." I think it's a delightful turn of phrase she used to mean that when you're used to offering surgery, undertaking surgery, working in a surgical unit and seeing surgical referrals, you tend to think/do just surgery.

She p'raps was being overly harsh since most clinicians evolve a more balanced perspective over time, realising they can't "do" their thing all the time and often stepping back to do no harm and not meddle is the best course of action.

Training at the moment is focussed on Direct Observation of Procedures and "doing" which is important. But maybe Dr Basch had it right.

Maybe the trick of it is Law 13, to do as much nothing as possible.

Stopping Medication

Just to tease my favouritist blogging GP, commenting on Secondary Care stopping medication that with hindsight is inappropriate . . .

. . . I was referred a lady with Behavioural and Psychological Symptoms of Dementia. She bit, kicked and punched care staff in her nursing home. She pushed other residents out of the way, causing a fracture in one old lady.

After initiating galantamine and promazine, she improved. A week later on review there was no hostility (not even verbal hostility) and all was well. A month passed. The home was happy. Her husband was happy.

She had a review by her GP who halved her promazine from 4 times a day down to 2 times a day (just morning and night). I know this because the GP 'phoned me to ask for a prompt review this week since she's now screaming like a banshee and flailing at folk with her walking stick through the afternoon and evening when she's no longer receiving her promazine.

Sometimes, just sometimes, us mental health folk do get it right and it's best not to rock the boat :-)

Parkinson's Disease

I've looked at a young chap (well, 66, so young to my mind) who unfortunately has Parkinson's Disease (PD). He's under the care of a physician who's been grappling with his PD but found the psychotic features tricky to manage, so asked for my views.

In PD there're regions of the brain where there is not enough dopamine. Result : my chap's rigid, literally unable to initiate movement and struggling to initiate speech and action. Medication is given to boost dopamine, helping improve the symptoms of his PD so he can play pool, read his paper, walk to the shops with his wife. Much better.

An unhappy side effect of the treatment is that the neuropsychiatric sequelae of PD become more prominent. That's to say, he has hallucinations and delusions. He awoke to see animals on his bed at 3.00am and had to get up, causing difficulties on the ward. This was compounded by his conviction that his wife had died and he had to get to her (so attempted to climb out of a window to leave the ward). Charging round a geriatric ward at 3.00am and making escapes unsettles staff, hence a referral to me.

I can start using an effective antipsychotic to help with his hallucinations and delusions. These types of medicine effectively reduce dopamine levels in the brain, improving his mental health. Result : his psychotic experiences (the hallucinations and delusions) improve but the dopamine antagonism works against his PD medication and his PD gets worse.

One antipsychotic, quetiapine, can work well . . . I've tried this but it's sedating him excessively so isn't an option.

Clozapine can also help, but is also very sedating (and can stop your body making blood cells to fight off infection, which kills you, and rarely you can get serious heart damage, which kills you). You need frequent (initially weekly) blood tests while you take clozapine and then ongoing blood tests at regular intervals since it's so hairy. Given his sensitivity to sedation I don't see him tolerating clozapine but it can be tried.

He's too unwell to be able to communicate preferences or discuss treatment options meaningfully and proffer valid consent. His wife obviously can't consent for him but I sought her opinion and she's keen for me to do "what ever is best" for him.

So what to do?

Either he's physically locked in (as his PD is bad) and mentally better (as his psychotic symptoms are managed). Or he's physically well and active (as his PD is well managed) and mentally unwell (with intense intrusive psychotic symptoms).

Any thoughts?

Stigma

The media have a major role in colouring our world. Are our streets safe, are libraries being valued, do we have accessible parks and outdoor recreational areas? I can answer such questions easily myself, yet my answers will shift by what the media says. I experience streets all the time, I read voraciously, I'm outdoors every week. Yet the feel for these issues is changed by the sustained voice of the media.

Any media has to have a voice or it ceases to exist. As such, material that is subjective comment rather than reported news is thrust at us endlessly through every medium possible.

This constant barrage of "news" gives texture to our experiences and does shift how we see our world, beyond our experiential learning.

How safe we feel is largely beyond our control (since principally it's other people who would make it unsafe). Because it's beyond just us we do rely on media stories to normalise how safe/unsafe our world currently is.

Mental illness is seldom seen in a positive light.

Much of our society will experience mental illness (about 1 in 4 of us in our lifetime will, depending which study you believe). 1 in 4. So it's common. Very very common. So common as to be unremarkable and normal and acceptable. Why isn't it accepted?

Media portray elements of major mental illness such as hearing voices as serious and risky. We know it usually isn't. Marius Romme's famous TV broadcast in the Netherlands in 1985 on prime time TV turned the tables momentarily, when some 400 people 'phoned in saying they heard voices but many (about 38%) functioned productively in the community. Many people with hallucinations have no contact with and are unknown to mental health services.

So why is mental illness seen so badly, with such stigma?

I'd go with this quote :

"The function of the press in society is to inform, but its role in society is to make money."
- A J Liebling