psychiatry

Random stuff

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After many years, things are being taken out of cup-boards and off shelves, turned inside out and properly looked at. Dusty books, clothes, folders, boxes and sachets. Some familiar fragrances are escaping and some old scenes are playing out on the screen of the mind. Bits of stuff slipping out of other stuff and falling to the ground with a clink. Some stuff that was believed to be misplaced is being placed. Some that was believed to be forgotten is being revisited.

Sample 1

A nappy pin. Special feature – A white safety cap to prevent accidental opening up while the baby has his cloth nappy on. Commonly used in India and other developing countries. Original owner: Baby Saagar.

Sample 2

A business card. Special feature – Simplicity. An invitation to music and joy. Original owner: Saagar.

Sample 3

A Crisis Plan. Special features – Not worth two pennies. Highly ineffective. Not accompanied by a conversation. No detail. Not individualised. Not created in partnership with the patient. Not an alive document. Does not mention anything more than ‘self-harm’. Doesn’t tell us what ‘Crisis’ looks like. Doesn’t identify any helpful distractions, activities, friends or family. Doesn’t appear to know the patient, for example, a key fact – does this person have a key worker? Does not express any understanding or compassion.

Commonly used in developed countries.

Oops! The name of the GP surgery is visible. It doesn’t matter. It closed down years ago. We were it’s last few unlucky patients. Owner: Saagar Naresh (1994-2014).

(Resource: Safety Planning is essential to safety: https://stayingsafe.net/home)

Home

Treatment versus Care

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It was a clean, warm and open space with well-designed floral furniture in pastel blues and greens. It had plenty of natural light and pots of healthy looking plants thoughtfully dotted around the floor. The artwork on the walls was selected by someone who knew their stuff. It would be hard to guess that this was the entrance to the New Hampshire Hospital. which provides acute inpatient psychiatric services for all age groups.

As I was guided through the facility, I was enamoured by a lush beautiful big greenhouse, two well-stocked libraries, a massive gym for staff and patients, 3 cafés, an outdoor patio and play area for kids, a vegetable patch, a healthy colourful aquarium on wheels, loads of Halloween decorations all around, an art workshop and cooking class in progress, television screens, a chapel, a small shop, a pool table, a ping-pong table, lots of board games and cheerful group therapy, treatment and visitor’s rooms.

Each kid had a room to himself or herself with nice bed-linen of their choice. 2 adults often shared a room. The age groups were appropriately separated. The youngest patient there was 6 years old and the oldest a septuagenarian. The nurse’s station was not a demarcated area. It was part of the ward layout. Social workers, occupational therapists, doctors and nurses didn’t wear any uniforms. They were dressed in everyday clothes. Everyone spoke softly and the atmosphere was relaxed and caring.

The most impressive part of the service was the presence of an Aftercare Liaison officer. It is well known that patients are at the highest risk within 30 days of discharge from inpatient services or Emergency department. (Ref: Luxton, June and Comtois 2013) They concluded that repeated follow-up contacts appear to reduce suicidal behaviour.

Aside from following up on these patients, the Aftercare Liaison Officer has the following roles before the patient is discharged:

  1. Speaks, listens and connects to each child and adolescent patient. Educates them and their support system about warning signs of suicide, triggers, risk factors, protective factors and restriction of means of self-injury.
  2. Draws up a detailed Safety Plan with them and their carers.
  3. Helps them identify sources of social support (trusted adults) and develop personal resources through open conversations.
  4. Interface with other professional agencies (eg. for DBT) and community services that will help dilute their identity as a person diagnosed with a Mental Illness. For example, they match their interests to activities such as therapeutic horsemanship, a running group or a Mountain Teen Project.
  5. Engage their parents, families and friends and anyone they would like to involve.
  6. Use technology if possible – MY3App.

I don’t think we have this service in the UK. I know we don’t.

The one thing that is most important to me and worth living for is … to continually express my love for Saagar and help other parents do the same for their kids.

you is kind. you is smart. you is important.

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My laptop claims to have at least 8 films on it but for some strange reason, on a train from Birmingham to London, it agreed to play just one, called, ‘The Help’. It’s about the writing of a book compiling the stories of African American maids working in white households in Jackson, Mississippi in the early 1960s. A book about an open ugly secret. About the courage of a few to start talking about it as a mark of protest. About the collective impact of small actions in bringing about big changes.

Yesterday was World Mental Health day and the UK became the first country in the world to announce a minister for Suicide Prevention. The day before yesterday, I learnt that Health Education England are very keen to put measures in place to prevent suicides within medical practitioners. Having been a part of the Suicide Prevention Community for the last 4 years, the one profession that is most conspicuous by its absence is Psychiatrists.

At 2 different meetings, I happened to meet 2 different Consultant Psychiatrists. On hearing Saagar’s story, one of them said he was very sorry but ‘this has been happening for 30 years’. I went blank. I just looked at him. I wonder what the public’s reaction would be if a surgeon would publicly admit that his surgical team has been making the same errors, that have been costing people their lives for 30 years. Yes. These are systemic errors. They are difficult to tackle. But, even today, youngsters like Saagar are dying because of lack of leadership within the specialty of Psychiatry, like they have been for the past 30 years.

The other, extremely prominent and respected Consultant Psychiatrist completely rubbished Mindfulness, Yoga and Meditation, without having tried any of them. He said that all these interventions have side effects. He believed that a Psychiatrist is only meant to attend to the most extreme cases. Their role comes into play only after these 5 have been called upon – parents, schools, GPs, CAMHS and Talking therapies. I am sure he knows that many youngsters die while on the waiting list, without ever getting to see a proper Psychiatrist, once. I am also sure he knows the side effects of psychiatric medications that are offered generously to all and sundry by non-psychiatrists. Lastly, I am sure he also knows how unsupported the GPs feel when faced with patients who are severely mentally unwell due to slow and inefficient response from the secondary services. And, I am sure it’s all down to poor funding. The same excuse that we’ve had for decades gone by and will have for decades to come. How about some imaginative leadership?

As parents, let’s start by saying to our kids in words and actions –
‘You is kind. You is smart. You is important.’
To me, I say – ‘I is kind. I is smart. I is important.’
You could too.

Day 886

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“More people are being detained by police under the Mental Health Act as Psychiatric services struggle to cope” says Jacqui Wise in the cover story of the British Medical Journal of 18th March 2017.

Statistics tell us that deaths in custody are up by 21%.
Self-inflicted deaths are up by 13%.
In the female estate, the number has doubled from 4 to 8 in this 12 month period.
Self-harm incidents up by 26%.
Individuals self-harming up 23%
Assaults up by 34%.
Assaults on staff up 43%.
Natural cause deaths up 17%, explained by the ageing population.
5 apparent homicides, down from 7 in the same period of the previous year

Could there be a co-relation between the facts stated in the first and the second paragraph?

“The police to an extent have always been used as an emergency mental health service” says Michael Brown, a police inspector. He adds that police receive little formal training in managing patients with mental health problems. “A highly agitated person may be experiencing Serotonin Syndrome due to the mismanagement of their antidepressant medications. The signs are subtle and most police officers won’t be able to pick up on that. We need to have a proper debate about the role of the police in this area.”

Ref:

Safety in Custody Statistics 2016: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/562897/safety-in-custody-bulletin.pdf#page=6
Blog about Mental health and the Criminal Justice system:
https://mentalhealthcop.wordpress.com/
Serotonin Syndrome:
https://patient.info/doctor/serotonin-syndrome

Day 811

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Her Voice – a short story

‘I hear her. Her voice is in my head’ says Joe.
“How long has the voice been there?” asks the trainee psychiatrist.
‘Since I was 12.’
“And you are now 18.”
‘Yes.’
“Is it really upsetting for you?”
‘Yes. Distressing. I feel terrible.’
“What does the voice say?”
‘Different things. Often cries desperately.’
“How often does this happen?”
‘At least 3-4 times every day. It’s painful.’
“Hmmm. Let me speak to my senior and come back to you in a few minutes.”

A few minutes later.

“We think you might have Schizophrenia. Let’s start you on Quetiapine and see how it goes.”
‘Okay.’

Joe waits at the pharmacy to collect his medication. A trainee nurse is also waiting there to collect some meds for a patient on the ward. They talk. He tells her why he’s there. She asks him who is ‘she’? Whose voice does he hear?

‘She is my little sister. When we were kids we shared a bedroom. At night, my mum’s boy friend would come into our room and trouble my little sister behind a curtain. She cried. I could hear her but I was powerless. I could hear her then. I can hear her now.’

‘Do you think these pills will work?’

Day 795

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As I read this piece of research, I could see Saagar and me reflected in it. It rang true. It gave me a deeper understanding about myself, my humanity and the precious fragility of our closest relationships. This qualitative research by Prof Christabel Owens et al tries to understand the needs of concerned family members and friends that can better equip them to intervene when their loved one is suicidal or in distress. It focuses on micro-social systems, like families or a group of friends as opposed to macro systems like nations and societies. (http://www.bmj.com/content/343/bmj.d5801)
Microsociology is the study of thoughts, feelings, moods, behaviours and forms of language that serve to maintain or threaten bonds between individuals.

Life is lived in small units – husband and wife, mother and son, boy-friend and girl-friend and so on. This is the level at which suicidal crises unfold and are managed, very often without any help from clinical services.

Family members and friends are the real frontline of suicide prevention but little is known about what goes on in these settings. A series of narrative interviews with the next of kin of 14 young people lost by suicide were analysed : What did they see and hear? What did they think was happening? What actions did they take and why? What additional knowledge, skills and support would have been useful?

Findings:

  1. Warning signs were rarely clear at the time. For example, one dad of a 19 year old boy said,“He had a teddy bear hanging from a light cord in his bed room.” In retrospect, the signs were clear but at the time, they were offset by countersigns or were difficult to decipher, open to a range of interpretations.
  2. Significant others engaged in normalizing and legitimizing their behavior. For example, a mother of a 29 years old man said, ”A few times he rang me in the early hours of the morning absolutely piddled out of his head and he’d be gabbling on but I couldn’t understand a word he was saying because he was drunk. I’d say, “Look, I’ll come and see you tomorrow and we’ll talk about it then.” I’d go there and nothing would get said and he’d seem alright.” In almost all cases, more weight was given to countersigns. The boundaries of normality were stretched to accommodate a loved one so as to avoid ‘pathologising’ or labeling them as that may be perceived as rejection.
  3. Fear (of loss) prevented them from saying or doing anything that might have prevented tragedy. For example, the partner of a 26 years old woman said, “I was trying to find the right words to persuade her to go to the GP. It’s bloody difficult and I was afraid she’d react badly. The situation was delicate and I had an awful lot to loose. And I ended up loosing it anyway.”

The article concluded that these are highly complex decisions. Due to a deep emotional involvement, we often cannot think and act in a rational manner. These findings are now being used to devise emotionally informed suicide prevention efforts, as opposed to cognitive ones which are most commonly used. These methods will help people like you and me to acknowledge and overcome our fears and act appropriately.

So far this leaflet had emerged as a result of this study:

Click to access UoA2_leaflet.pdf