Lifestyle

Care Pathways

I saw a patient with dementia. He was wandering on evenings, couldn't manage his money any more, couldn't sort food for himself and couldn't maintain his property adequately.

He was seen by a CMHT nurse and myself. Assessment was clear. CT imaging confirmed atrophic change. A diagnosis of a neurodegenerative dementia, almost certainly Alzheimer's disease, was made. He had 16 interventions made on his care plan including Council Tax exemption, advice to sort out two LPAs, getting his will sorted, a monitored dosage system, reducing meds, benefits check, three Home Care visits a day, DVLA notification and selling his car, Social Work follow up to review care schedules, nurse visits to family for carer education and support, telecare for a pendant alarm and to alert family if he's opening doors after 10.00pm, an FP10 for galantamine, ongoing follow up for review, day Memory Therapy Services for CST, follow up with me for titration/review of Rx, advice to him/his family on local Alzheimer's Society resources. Usually we provide decent care for folk with dementia, a regional report has us as a beacon service. All well and good.

I saw a patient with dementia. He was wandering on evenings, couldn't manage his money any more, couldn't sort food for himself and couldn't maintain his property adequately.

He was seen by a CMHT nurse and myself. Assessment was clear. CT imaging confirmed vascular damage. A diagnosis of a vascular damage was made. The care pathway is then refer to Primary Care to manage, who can refer to neurology and stroke outreach if necessary (who have no social work and no community services, at all). He had 2 interventions on his care plan, basic advice given and discharge to Primary Care.

Somehow, for both people to have the same sort of experiences, yielding the same consequent deficits, but profoundly different support, stirs disquiet . . .

Zarathustra's musings

Well, he has me intrigued!

Being recognised

I don't live in the locale I work within so don't often see folk out of work. Although last time our team went out and I was rather the worse for drink I did meet a few patients' relatives who came to chatter with me, but they could hardly stand up either, so I don't think much embarrasment was held by either party. Phew.

Got me thinking how some time ago I did meet an elderly patient, when I'd popped out to the shops at lunchtime to buy a sandwich. I was in the shop, in the queue, when a patient marched over and very loudly shouted out, "Ooooh, hello doctor!" and came over to give me a tight hug. I said hello and 'cause we were in a busy place didn't really want to ask her anything personal so simply opened with a polite and genuine enquiry, since she's a friendly chatty woman who the whole team hold a lot of warmth and affection towards, asking whether she was enjoying the great weather we were enjoying, that day.

She then shouted out, she has such an incredibly loud voice, that she wasn't doing too badly at all and had just had her hair done, having to get out of the house 'cause she'd seen childrens' faces in her walls leering at her and voices from her smoke alarms telling her that her (dead) husband's, "A mean fuck who should burn and die."

I stood in silence, aghast, pondering how to respond. Everyone paused, the world stopped. The shop stared at me, waiting for the doctor to deal with the crazy lady.

You could see everyone around her taking a few steps back. For some perverse reason, that really irritated me. She shouted at me, "Ah, but I don't bother with that today." She paused and grinned at me and told me the same thing she tells me each and every time. "It's my schizophrenia!" She's always been a straight talker with me and my, do I love her for that.

I couldn't do anything but laugh, hug her back and loudly say something along the lines of, "Well it's cracking that it's not upsetting you today, you're feeling bright and cheery, and all's well with the world!" Maybe it was the utterly banal chatter we shared and the manifest lack of concern I showed. Probably it was the total lack of worry and the gesture of hugging her. Who knows. The shop let out a collective sigh, folk realised they weren't about to be axed, the world turned again.

She probably did more there to challenge views of schizophrenia and stigma than I ever could.

Acute Wards

I do work on medical and surgical wards, covering liaison psychiatry for older adults in the acute hospital.

Things ain't great.

Medication is accidentally omitted (oddly, never reported to the NPSA despite their alert on this issue).

People are left lying in urine.

People are left unfed.

This happens every day.

Rather than plan person centred care, Wellness Recovery Action Plans, sophisticated dementia care and the like, basics need to improve. They're not poor because the wards are poor. The nurses and HCAs aren't turning up to work full of wickedness, intending to do a bad day's work. The crunch is that they're understaffed.

As an outsider seeing this, and not someone they can sack, it's been easy for me to raise this with their management structure. Which I did. They took note of the serious concerns raised, the unacceptable standards of care, care at variance with national guidance and the risk generated for their Trust through suboptimal care. Excellent. So what's happened?

They now have Modern Matrons charged to make it better, but they've no resources (at all, no extra time, no teaching time, no money, no staff, nothing). But because it's such an important issue, the Modern Matrons must ensure that Dementia Champions are trained. They don't have a view on what these Champions will do, but the Trust needs to have some, so staff have to be removed from the ward for training (but there's neither cover nor a training budget for this training). Failure will therefore be a ward level failure, with the managers having given strategic direction and solutions. Hmmm.

How will the Trust be sure that things are in place? Nurses will check. Except the senior nurses, who 2 years ago were seeing patients, now don't. They now "support the governance framework" through checking things on clipboards are ticked off and done. This drives them to distraction, they're band 8 nurses, not band 3 clerical support, but that's what the Trust requires of them. Tick, tick, tick.

So when there's a clinical problem, the solution was remove nursing time from the ward and remove senior nurses to do surveys/tick boxes, compounding the problem of a lack of hands on ward time.

My, how my colleagues in the acute Trust live in interesting times.

More on medication

Drugs have a really important role to play in mental health care. They can cure people. They can make symptoms disappear. They can keep people well for years, when without them their lives are in bits. I've seen this time and time again, with patients feeling they're doing well on medication and feeling/showing they're doing badly without.

Maybe it's because of this that use and review of drugs matters. It's not a simple "drugs are good" message. Medication is good, for some people, some of the time.

How do we know who it's good for? We don't. We guess. It's an informed guess, but it's still a guess. Sometimes it's pretty clear that medication can have a useful role to play (i.e. it is "indicated") but that's different from knowing it's going to work and should be continued.

How often does a patient continue medication over the long term? It's not meant as a rhetorical question. Really, I'm inviting you to speculate. In the teams that I lead and I'm the only doctor in them, so all prescribing decisions come through me, we have in the ballpark of 5000 direct face to face patient contacts/year. 96 a week. How many patients, each week, have medication put on repeat prescription? Take a moment and have a guess.

We did an audit on oral medication use over the last 3 months and it surprised me. It excluded depot antipsychotic injection, which is long term medication so I'll 'fess up that there are 5 patients on long term depot. But apart from these 5 folk who wish to continue on depot, how many of the 96 contacts/week result in repeat prescriptions of medication?

The thing with drugs is it's not all about just one thing. The indication needs to be right and as the posts below describe, "depression" isn't good enough. Nor's "clinical depression" or even a DSM-IV "Major Depressive Disorder" diagnosis. Because management is guided by accurate formulation. Presence or absence of somatic symptoms has major implications for whether an alerting (help get up from bed, have some energy) or sedating (help stop worrying and get some rest and restorative sleep) and on use of medications over time. Psychological factors and social factors impact on psychological and practical interventions.

Meaningful assessment takes some time. Quite a lot of time.

From this, if medication potentially has a part to play, it's offered and started and doses are fiddled with and it's reviewed. If it's not working it's stopped. If it is working and side effects/risks are absent/tolerable it's continued. It's continued by the GP, so all longer term management is prescribed through Primary Care.

Which takes me back to the audit. Rather than just a short term intervention that our service prescribes and I'm involved with through assessment/medication use/review, the number of patients having repeat prescription from the GP was audited. All activity for 3 months was reviewed. Many, many patients had trials of medication. Often it was stopped. Often it was fiddled with by me, so I kept prescribing since doses and drug combinations were constantly changeing.

So how many did pass back to the GP for longer term prescribing of a stable medication dose regimen?

Of the roughly 96 patient contacts/week, 1.92 patients/week had a repeat prescription. It's not that many. We spend so much time prescribing and fiddling with drugs and reviewing drugs, it's only on review of the big picture that we see that drugs aren't a major longterm feature for most.

That surprised me.

Blood

I learnt something new today.

I do most days, mostly from nurses, but on this occasion it was after our monthly team CPD (continuing professional development) meeting. We'd rattled through a discussion of recent papers and how they should affect our practice, we noted the bias of one review and chewed over how we were doing with NICE guidance. We discussed depot olanzapine's evidence of what the pharmaceutical company report as a "post injection syndrome" and how everyone else calls it "a coma" and how this seemed bad.

It was noted that I brought a number of abstracts from British and US journals but nursing colleagues didn't. Yet they're very interested in the 10 minute discussion of each paper, grabbing the headline messages and learning points, with their "care pathways" having changed for the better over time through considering new research and reviewing what we do. A number of articles and papers have been published by us over the last year. If nurses embrace new research (in a balanced and critical way) then adopt the good bits, why aren't they sharing lots of papers at our monthly meeting?

It's all down to what's valued. Consultant Psychiatrists have time set aside each week for CPD. Nurses do not. Nurses are told what to adopt and articulate how they're not given time to provide even basic nursing care. I wonder how many nurses have time for CPD in their week? Do any have time to browse web sites, muse over abstracts, download papers and read through NICE, DoH and other advice, guidance and direction? I know of no nurses who do.

So for a hour a month we do it ourselves, rattling through a couple papers (no more than 10 minutes on each, just to distill what the issue was, what the paper shows us, the weaknesses of the paper and how we then could use it in our work) and any new guidance and obstacles to good practice.

At least this means we've a fighting chance of spotting quackery that's increasingly peddled in more mainstream literature. Like this, which I learnt of today. Live Blood Analysis (LBA). You take a spot of patients blood, both you and the patient just look at it on a big screen for 2 hours, you see stuff move and decide what this means. Such as, "Look at those moving, they must be alive, you have parasites in your blood, take this herbal medication that's expensive but look at your blood, it's so worth it."

A Dr Rubin looked at this and found no papers on LBA in the scientific literature. None. Yet there were 2.5 million hits on Google. Interesting. Someone's advertising and making a lot of money from this LBA thingy. So, does LBA work? Is the scientific community elitist and simply ignoring a helpful diagnostic intervention? Actually, no. It's pseudoscience and doesn't work.

That's a helpful paper. I've learnt today of a new entity, Live Blood Analysis, and learnt of rigorous review of LBA which found it to be so much stuff and nonsense. Which is worth knowing.

Should I charitably tag this post as "Complimentary Therapy" or should I generate a new tag of "Fraud" I wonder . . .

Homeopathy

A number of people, indeed most, will look at options of self management, which is a good thing. Some will be desparate and try things which have little benefit. But hey, what's to lose. Some will be even more desparate and try things that have little benefit but cost money. Hmmm.

Complementary Therapy has had bad press, because much of it that is useful is understated (since it's obvious and now mainstream rather than "complementary" to maintstream practice) so it's the more extreme claims that are pushed. Which invariably aren't valid.

The bottom line is that sensible people try stuff and find it doesn't work very well.

"Herbal medicine has been around for thousands of years, indeed it has, and then we tested it all and then the stuff that worked became 'medicine' and the rest of it is just a nice bowl of soup and some pot pouri."

"Well, science knows it doesn't know everything, otherwise it'd stop."

"I'm sorry if you're into homeopathy; it's water! How often does it need to be said, it's just water!" and, "The great thing about homeopathy is you can't overdose on it. Well you could fucking drown!"

Not very politially correct at all, but pretty darn amusing :

More drugs!

Although an American publication this year alluded to the message, "Drugs, just say no!" as discussed below, there's new news.

The British Medical Journal last month published a clinical review paper on, "Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants."

What did it show us?

It showed us 3 things.


1) We're prescribing more antidepressants.

They assume this is because people are prescribed them for longer (because that's what they found, so they're right). The assumption is flawed, though. We prescribe more antidepressants in the UK and USA than we did in 1993 because over the last 17 years prescribing practice has changed.

People with generalised anxiety disorder, adjustment disorder, post traumatic stress disorder and somatoform disorders used to get pretty rubbish drugs. If you had such a problem, with "neurotic" and not "psychotic" problems, and weren't clinically depressed, you often didn't get an antidepressant or antipsychotic (since you're not depressed or psychotic) so got an anxiolytic. Diazepam. Or another benzodiazepine of choice. They were liked because they worked and melted away distress well. Then, years on, problems emerged and subsequently "antidepressant" medication is commonly used in the management of anxiety states. Anxiety states often endure, hence such medication's needed for a long, long time.

Use of antidepressant medication's gone up not necessarily through changes in management of depression, but because "neurotic" disorders are managed with such medication now, instead of dishing out nothing or benzodiazepines.


2) If you continue on medication, you do better

Relapse rates are lower. Antidepressants drugs reduce the rate of relapse, significantly. Hurrah!

The drugs also cause side effects which are common (e.g. at best 24% and at worst 80% of people on antidepressants developed sexual dysfunction).

Stay on the drugs, but get side effects most of the time. Hmmmm.

How many do you need to treat to prevent relapse? They looked at that, too. 4. So for every 4 patients you keep on an antidepressant long term, 3 get no benefit and 1 won't experience a relapse they otherwise would. 3 have no benefit but all the side effects, 1 has benefit and side effects. Hmmmm.


3) The title lies

"Long term treatment of depression with selective serotonin reuptake inhibitors and newer antidepressants" is misleading. It suggests that the paper is about people with depression being on antidepressants long term and although most have serious/unpleasant side effects and for 75% it won't help, for 25% it will be beneficial.

Sadly not.

To their enormous credit, the authors do 'fess up to this. This is because the published papers have significant bias. Rather than taking people with depression, half having antidepressants and half having placebo, then seeing how they do over time (a randomised controlled trial), the studies reviewed were "discontinuation trials." This means that the (usually drug company sponsored) research involved getting a group of people with depression and giving them an antidepressant. Any who didn't respond are then excluded. So of your 100 depressed patients, it may well be that half got better anyway and a third didn't benefit from the drug, so only 10 patients progress through to the trial. What the "discontinuation" bit means is that the researchers then discontinue the antidepressant medication in half the people it's helping and swap them onto placebo.

So a more accurate take on this very good and detailed systematic review of 31 trials, mainly/all discontinuation trials, is :

"In patients with depression, who respond well to an antidepressant, continuing the antidepressant over a longer time (e.g. 12 months) can reduce risk of relapse for 1 in 4 patients."

It's not quite as catchy a headline, though.

Meh, maybe the drugs still don't work quite as well as we'd wish, or as pharmaceutical companies would lead us to believe. But at least if I've patients with chemical clinical depression, who respond to an antidepressant, and have a relapse, then this paper supports the ongoing use of an antidepressant over the longer teerm (over years). And that this works well, halving the risk of relapse. That's good news. It's certainly something folk will welcome, who've shown clearly that the antidepressants work well for them, as robust evidence that it's worth continuing and shouldn't be taken off them!

Antidepressants

Drugs work. They do. They can be very, very helpful indeed.

But as Richard Ashcroft of The Verve penned, regarding the effect of drugs on his father dying of cancer when he was 11 years old, "and I hope you’re thinking of me, as you lay down inside, now the drugs don’t work, they just make you worse, but I know I’ll see your face again."

We think drugs work well. But for an 11 year old boy, reality hit hard, seeing his dad die and drugs fail to change things.

Drugs work, but drugs aren't miraculous.

Having a discussion on this is always contentious. There are two wholly valid reasons for this. Firstly the statistical evidence can be challenged/critiqued/appraised. Secondly experiential learning (of having drugs and being cured/being worse) gives valid and wholly accurate evidence that they're brilliant/harmful. These two sources of information, aggregate trial data of large numbers and single patient therapeutic trials with an n of 1 both give different perspectives and facts, both supporting enthusiastic use/reticence to use antidepressant drugs.

DeeDee's comment stirred my thoughts on this, again.

Like any meaningful, complicated, multifactorial issue, in or out of health care, a dichotomous "this is good" or "this is bad" doesn't really work. Much as it's cozy and comfortable for a newspaper to publish that antidepressants are great and patients are missing out through not being properly treated, or antidepressants aren't wonderful and patients have shabby care through doctors dishing them out inappropriately, the truth is more complicated. Newspaper headlines can't be complicated. Many newspaper articles need to be timely, snappy and simple so can't be complicated. Complicated health issues (with personal and socioeconomic consequences) aren't easily discussed or debated in mainstream media. The issues are left to wither. So it goes.

If I was to be horribly reductionist and come down with a quick and easy message my thoughts'd be that antidepressants can work well as part of a package of care for some people some of the time so the message would be, "Use antidepressants appropriately and get it right!"

Which isn't massively helpful.

The crux of it is that it's incredibly useful for individual patients, as DeeDee describes. Or it's unhelpful/harmful for individual patients, as others describe.

Beyond patient numbers, we get the same pattern. Drug companies have had to evidence efficacy (that the drugs work) to get a marketting authorisation to sell their antidepressants. Clinical trial data shows that the drugs work in clinical trials. Out of clinical trials, in the really real world, a study this year published in the Journal of the American Medical Association showed that antidepressants work no better than placebo in mild, moderate and severe depression (with benefit emerging just through very severe depression).

This means if you're a GP seeing someone with mild, moderate or severe depression you're informed that, statistically, prescribing an antidepressant for the patient sat in front of you will have as much effect as prescribing placebo. Yet, clinically, some patients respond brilliantly.

It's a flaw of evidence based medicine that effects which are uncommon but highly significant for a small number of people get diluted/lost in the trial data. Trials aren't usually sufficiently powered to evidence statistical significance through rare but highly meaningful events. This is even more true in looking at clinical effectiveness of treatments (i.e. how it works in real clinical practice) rather than trials of efficacy (rigid clinical trials with strict patient inclusion/exclusion criteria).

In the really real world, outside clinical trials, people have low mood. A lot. Most people with low mood do not meet ICD-10 diagnostic criteria for clinical depression. Most people with low mood do not have a somatic syndrome, common in chemical (functional, endogenous) mood disorder. For most people, chemical solutions (of antidepressant medication) therefore has little benefit. Which is what patient and trial evidence, and clinical experience, shows us.

Yet, for people with chemical mood disorders, psychosocial interventions have some but modest utility and chemical treatments (or treatments effecting chemical changes in the brain, like ECT) can work brilliantly.

Antidepressants therefore have a very important and very valuable role to play, but in a very defined subgroup of people who have a mood problem. Of all those with mood difficulties, those with endogenous chemical depression do well. Those with reactive depression, feeling depressed because of events, responding (as most of us would) with depressed mood to a depressing situation, are low in mood through their situation not their brain chemistry, so plying medication 'pon them unsurprisingly effects little benefit.

Gets you thinking.

If appropriate and successful drug treatment hinges on accurate diagnosis and subtyping of diagnosis (it's pretty robustly evidenced and understood that chemical functional mental illnessness of ICD-10 recurrent mood disorders and bipolar disorders merit antidepressants) then is it fair to ask GPs to do this?

In older adults it's even more complicated. Loss of health, role, mobility, opportunity, income, friends and family is common in older adults we see. There's often been a lot of adversity. If life's not peachy, should folk be feeling peachy? Then, as well as loss events, there're cognitive changes. In neurodegenerative dementia like Alzheimer's Disease the limbic system, controlling mood, is always affected before memory is. Everyone with Alzheimer's Disease has brain damage affecting their mood area of the brain so frustration, irritability, low mood and changeable mood is common, before even accounting for the changes in their life that dementia causes. Teasing out if older adults have a mood disorder that's sufficient to attract an ICD-10 diagnosis of clinical depression isn't quick and easy. Determining if medication has a role to play is complex.

Our APC and PCT's been wrestling with this. Clinical care is one consideration. Cost of the drugs is another. So the question last month was, "Is it fair to ask GPs to initiate antidepressant medication, or should this always be undertaken within specialist care?"

I'm sure nobody will be bold enough to answer it.