Posts Tagged ‘psychiatry’

Psychiatry: the dos and don’ts of assessing major depression in diabetes

Evidentia - 6th August 2010 3:10 pm

It is increasingly recognised that depression constitutes a significant long-term complication of diabetes and is associated with debilitating rates of reduced quality of life, poor self care, reduced life expectancy and increased healthcare costs.

The lifetime risk of suffering major depression is up to three times higher in patients with diabetes compared with the general population. In a session dedicated to the clinical management of depressive symptoms in patients with predominantly Type 2 diabetes, Dr Jim Bolton from London discussed the means of assessing depression in this patient group and highlighted some common clues and pitfalls.

Read more.

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How to redesign mental health services - a summary

By Mike Broad - 2nd July 2010 9:13 am

The Royal College of Psychiatrists has made 17 new recommendations for the redesign of mental health services. The paper, Looking Ahead: Future development of UK mental health services, involved the views of more than 50 psychiatrists, psychologists and allied professionals.

Here’s a summary:

Community mental health teams

The relationship between community teams and specialist teams should be examined with a view to rebalancing their roles, and the model of an enlarged CMHT should be further explored.

A whole-system comparison of the different models of mental healthcare, for example service lines and enlarged CMHTs, should be carried out urgently, with adequate resources made available for this comparison to be made.

The comparison should aim to furnish the mental health sector with high-quality data on interventions and outcomes of the various prevailing approaches.

Consultant expertise at the beginning of the pathway

Consultants’ expertise should be used in complex assessment and management, rapid review of those in crisis, and advice to multidisciplinary teams and staff working in primary care.

Services should be organised in such a way that appropriate expertise is available to ensure that the ongoing assessment of service users’ needs is a routine aspect of the care they receive.

Research should be carried out into the clinical effectiveness and cost-effectiveness of primary care psychiatry services in the UK.

Standardised outcomes

Changes to one part of the care pathway can have unintended effects on the whole system. It is therefore imperative that whole-system comparisons of the different models of mental health service provision are carried out.

These different systems should also be evaluated, using a common system of data collection and outcome measures relevant to commissioners, clinicians, service users and carers.

The Royal College of Psychiatrists and other professional bodies should undertake this work.

Investing to save through the development of family mental healthcare

The majority of serious mental health problems among working-age adults begin early in life and cause disability when those affected would normally be at their most productive. Furthermore, some illnesses cluster in certain families.

Research should be carried out to evaluate the clinical effectiveness and cost-effectiveness of family-oriented mental healthcare jointly coordinated by adult mental health services and child and adolescent mental health services, and family-oriented mental healthcare delivered through family psychiatry services.

Out-of-area treatments

Commissioners and local authorities should - as a matter of urgency - review their systems and invest expenditure currently used to fund unnecessary out-of-area treatments into the local mental health economy (and specifically into rehabilitation services provided by the statutory and voluntary sector).

Mental health of older people

Equitable access to services across different populations (such as Black and minority ethnic groups) was identified as important throughout the enquiry.

Commissioners and providers must ensure that people over 65 also have equitable access to the full range of age-appropriate and non-discriminatory mental health services required to meet their needs. Comprehensive specialist older people’s mental health services are an essential part of meeting need across the lifespan and must be available in all commissioning areas.

In-patient care

In-patient services are a fundamental part of the whole care system. Different models of in-patient care, including assessment wards, the integration of crisis teams with wards and crisis houses, and other alternatives to admission or facilitation of discharge must be evaluated thoroughly.

Research should also be carried out to evaluate discharge procedures.

Statutory and voluntary sector partnerships

The use of partnerships or compacts between statutory and voluntary sector agencies to develop the availability and quality of step-down services from secondary and primary care should be increased.

Housing

Greater partnership working is required between health services, social services and the voluntary sector to facilitate timely and safe step-down accommodation. Services should employ suitably experienced staff to liaise with local housing departments regarding discharge, and contact should be made within days of patient admission.

Employment and mental health

Organisations with a workforce over a certain size should be required to report annually on their 13 mental health at work policy, as part of their report on health and safety at work.

This would be an inexpensive, non-prescriptive process, which is nevertheless legally required, that would encourage employers to reflect on the mental welfare of their employees.

Substance misuse

Mental health services should remove dual diagnosis/substance misuse as an exclusion criterion and ensure that staff are trained in substance misuse issues.

Given the high rates of substance misuse among people with mental health problems, denying them access to services only further excludes vulnerable members of society and deprives them of potentially beneficial treatment.

Relationship between physical and mental health

Action is required to ensure that the link between physical and mental health is addressed by all health services.

A renewed emphasis on liaison psychiatry and psychology services is required, including consultant-led services that aim to reduce acute medical and surgical bed occupancy and acute attendances of individuals with unexplained physical symptoms.

Psychological therapies

Access to evidence-based psychological interventions/therapies is required at all points along the care pathway, and should be needs-led; within five years there should be the same availability of psychological therapies as evidence-based medical interventions.

The enquiry heard that the employment of peer support workers is both a cost-effective and recovery-oriented method for providing personalised support and assistance to people using mental health services, and an approach that can reduce admissions to hospital and shorten length of hospital stay.

Piloting and evaluation of the clinical effectiveness and cost-effectiveness of the use of peer support workers in mental health services should be carried out in the UK.

Commenting on the recommendations, Prof Dinesh Bhugra, president of the Royal College of Psychiatrists, said: “We know there is growing pressure on NHS services to cut costs and do more work for less money. Although the college is opposed to disproportionate or harmful cuts to mental health services, we are aware that efficiency savings do need to be found.

“Our enquiry explored ways of creating efficiencies and improving productivity through redesigning services and care pathways, making better use of consultant expertise, the need for standardised outcome measures in mental health, and the need for more family-based mental health services.”

Read the full report.

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RCPsych must reconsider examination decision

By Dr Waqqas Khokhar, CT3 trainee - 19th January 2010 9:33 am

A grave injustice has been inflicted on psychiatric trainees - particularly the staff and associate specialist group - by its own royal college. The Royal College of Psychiatrists (RCPsych) has seen fit to invalidate a pass in MRCPsych Part 1 retrospectively.

Under the old system, the exams were divided into Parts 1 and 2. Each part had a written and a clinical component. But, the RCPsych changed its exams to three written papers followed by a clinical assessment of skills and competencies examination (CASC).

In this system, a pass in paper 1 and 2 can be banked forever. However, after passing paper 3 of the exam, you get four chances at CASC. If you fail to pass it within an allocated timeframe, you are expected to re-sit paper 3 and then the cycle continues.

Part of the process was that the college set a validity period for those who hold a pass in Part I of the previous format. The college decided that a pass in Part I will be expired, and will not count towards completing the membership exams, by July 2010.

The trainees were not aware or informed that this could be the case when they sat for this exam. The regulations of the previous format of the exam (to the best of our knowledge) did not state a number on attempts or period of validity.

Part I candidates had to endure the stress of sitting the OSCE exam, which took a lot of effort and competence. This is now going to be discarded, and candidates are disadvantaged by the above decision. What makes it worse is the fact that the college decided to consider a pass in papers 1 and 2 permanent in the new exam system.

This has been a source of great distress for many trainees and SAS doctors who feel cheated and abused at the hands of their own college. What a waste of time and money for them.

The specialty of psychiatry is already experiencing the consequences of the MMC debacle. Recruitment and retention problems in this already battered specialty are surfacing and this decision will further aggravate the problem as many people are considering working abroad. Countries like Australia and Canada are already actively recruiting experienced psychiatrists from the UK.

A group of trainee and SAS psychiatrists have recently set up an e-petition calling for the RCPsych to reconsider its decision. It’s been signed by 200 doctors and I urge readers to put their names towards helping our cause.

We are even considering a legal challenge. It’s time the college listened to its trainees and SAS doctors whose careers are being compromised.

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“Protect mental health services in downturn”

By Mike Broad - 14th November 2009 9:00 am

Slash and burn cuts to mental health services will only worsen the effects of the recession on people’s health, academics have warned.

A report, called Mental Health and the Economic Downturn, says mental health services are particularly vulnerable to cuts because they are not paid through the same national tariff system the rest of the NHS and there are few metrics for measuring quality of value for money.

The study, by the London School of Economics, Mental Health Network and Royal College of Psychiatrists, argues the case for supporting such services claiming mental health issues are likely to increase as the downturn continues.

Increased debt problems, family breakdown and job losses all contribute to the problem.

The report outlines the key mental health challenges for the NHS, such as keeping people in work, improving early intervention and public health strategies.

It calls for a cross-government strategy for developing better mental well-being for the whole population, and new initiatives that will save the public purse elsewhere in the system, such as mental health diversion schemes for those in the criminal justice system.

Research should also be a priority in order to better understand the effectiveness of some types of interventions to prioritise investment.

The report also calls for a raft of ‘efficiencies’, from the operational to workforce and care pathways, warning that it needs “careful planning to ensure changes bring about efficiencies and patient benefits, rather than unintended consequences”.

For wider system efficiencies “new offers to primary care, addressing physical healthcare costs through mental health intervention, psychological therapies and joined-up working may lead to savings”.

Steve Shrubb, director of the Mental Health Network, said: “In the past, we have tended to react to reduced spending by cutting services across the board. We know such ‘slash and burn’ tactics will not work.

“We have to see this spending squeeze as an opportunity to look again at how we offer support and, with clinicians and managers working together, develop services that are not only better for patients but also better value for taxpayers.”

Professor Dinesh Bhugra, president of the Royal College of Psychiatrists, said: “It’s all too easy in times of economic hardship for commissioners and providers of services to see short-term cuts as the solution. However, such action would be grossly short-sighted and would undoubtedly deliver long-term pain.

“During these times of economic downturn, it’s vital that careful investment is made in mental health services and prevention programmes.”

 

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Making equality a reality in mental health services

Dr Dave Anderson, chair of the Royal College of Psychiatrists’ Faculty of Old Age Psychiatry - 31st October 2009 9:05 pm

It was welcome news when health secretary Andy Burnham announced last week that the NHS, under the new Equality Bill, will have to comply with age discrimination rules by 2012. There is no question that age discrimination exists in the NHS, and the bill - along with New Horizons - is an important step by the government in tackling discrimination.

But the problem cannot be addressed through national action alone. We are in desperate need of local change. Unless services are commissioned, configured and developed locally to better meet the need of older people, discrimination will continue.

The ageing population has been described by researchers as a demographic tsunami, and is the biggest challenge facing health and social care services today. Yet investment and development in mental health services has explicitly excluded older people.

The figures speak for themselves. For every 1 million older people with depression, 850,000 receive no treatment whatsoever. While 50% of younger adults with depression are referred to mental health services, only 6% of older people will receive a referral. And in a recent report by the Healthcare Commission, a service audit found that of 1,300 referrals for psychological therapy only 49 were for people over the age of 65.

There is no justifiable reason why an older person with the same need as a younger person is denied equitable mental health care, yet that is the current position. Earlier this month, the Royal College of Psychiatrists’ Faculty of Old Age Psychiatry launched a new position statement: Age Discrimination in mental health services: making equality a reality.

The statement and accompanying evidence document show how tens of thousands of older people are missing out on vital support and risking serious deterioration in their mental health purely because of arbitrary age limits.

Access to mental health services has traditionally been configured by age. Although having administrative benefits by creating clear accountability of services, this approach may be considered discriminatory, such as when a person attending any specialist mental health service is required to transfer to an older people’s service purely because they have reached the age of 65. In doing so, they can lose benefits of the relationships they’ve formed with those services and be disadvantaged. People over 65 may also be denied access to services available to younger people, such as 24-hour crisis resolution and home treatment services.

The college’s Faculty of Old Age Psychiatry believes all mental health services should be available to people on the basis of need, not age, and is calling on local services to abolish the arbitrary age limit. We know that local change can make a difference and we have gathered some excellent examples. For example, in 2006, following reconfiguration of services in Doncaster, a specialist older people’s mental healthcare home liaison team was established to deliver person-centred care and training to local registered care homes. In the first year, the team received 460 referrals and admissions to hospital reduced by 75%.

And in West Suffolk, the crisis resolution home treatment team for working-age adults was extended in 2006 to include people aged over 65. The number of older people admitted to hospital fell by 31% without any loss of patient or carer satisfaction.

But we also need to remember that people’s needs change as they progress through the life cycle. In moving towards equality for older people, we must guarantee their needs are addressed by mental health services specially designed to meet them. If this doesn’t happen, age discrimination will continue in another guise.

Our position statement clearly states the actions required at a local and national level. These actions include an urgent need to provide access to crisis home treatment, early diagnosis and intervention, care home liaison, general hospital liaison and access to psychological therapies.

The statement’s launch at the House of Commons was attended by 18 Parliamentarians, including shadow minister for mental health Anne Milton MP. It’s notoriously difficult to persuade busy Parliamentarians to find space in their diaries to attend such events, so we were enormously encouraged that so many came along. Just maybe, it’s a sign that ministers are starting to listen - and are prepared to give older people’s mental health services the attention they so desperately need.

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RCPsych supports excellence through new awards

By Professor Dinesh Bhugra, president of the Royal College of Psychiatrists - 16th October 2009 10:50 am

Psychiatry can get a bad press. Too often, the media focuses on the rare occasions when things go wrong within mental health services and ignores all the excellent work being carried out by psychiatrists and other mental health professionals every single day.

I felt very strongly that the Royal College of Psychiatrists should take a lead in recognising excellence in psychiatry and mental health and so, when I began my presidency in July 2008, I vowed to start an annual RCPsych Awards ceremony.

Unsure what to expect in the first year, we were delighted to receive hundreds of entries - all of an incredibly high standard. Earlier this month, 300 guests gathered at the Royal Society of Medicine to hear about the winners of the nine RCPsych Awards categories. The judging panel looked for teams and individuals who went beyond general standards of good practice to provide truly exceptional services for service users and carers.

Medical experts have multi-faceted roles. Nominees in the individual Awards categories needed to demonstrate their skills as a professional, communicator, collaborator, advocate, scholar, researcher and manager, as well as excellent leadership, responsibility and accountability skills.

Teams needed to demonstrate excellence in delivery, innovation, effective use of resources, improvement in service user, carer and GP satisfaction, and progress in the development of clinical outcomes.

The ceremony was hosted by writer and broadcaster Libby Purves, who spoke of her very personal reasons for wanting to be involved. Three years ago, Libby lost her son to suicide, after his long battle with depression. But despite this tragedy, Libby said her family’s encounters with mental health services had been positive and paid tribute to what she described as the unique blend of scientific and intuitive skills offered by psychiatrists.

Dr Ian Harwood, a CT2 at Cambridge and Peterborough NHS Foundation Trust, and Dr Susham Gupta, a fourth-year specialist registrar at Central and North West London NHS Foundation Trust, won the Core Psychiatric Trainee of the Year and Advanced Psychiatric Trainee of the Year awards respectively. Both trainees demonstrated exceptional levels of achievement far beyond that expected of their grade.

Outstanding multi-disciplinary team working was showcased by the winners of the Psychiatric Team of the Year Award - The Bridge Substance Misuse Service in Solihull - and the Mental Health Service Provider of the Year Award - Oxleas NHS Foundation Trust. Oxleas enjoyed a double celebration when medical director Dr Ify Okocha took the prize for Medical Manager of the Year.

The Psychiatric Academic of the Year award was presented to Michael Sharpe, Professor of Psychological Medicine at the University of Edinburgh and honorary consultant psychiatrist to the Edinburgh Hospitals, for his dedication to enhancing psychiatry’s relevance and reputation amongst medical colleagues, and mentoring the next generation of psychiatrists.

Dr Phil Timms, of South London and Maudsley NHS Foundation Trust, was named Public Educator of the Year for producing accessible, evidence-based mental health information leaflets for the public.

Service users and carers voted Dr David Fearnley as their Psychiatrist of the Year, for making a positive impact to service user and carer well-being and encouraging change in the development of mental health policy. He has been a consultant forensic psychiatrist at Ashworth General Hospital for eight years, and is also medical director and deputy chief executive of Mersey Care NHS Trust.

Lastly, care services minister Phil Hope presented the prestigious Lifetime Achievement Award to Professor Sir David Goldberg in recognition of his mastery of the discipline, unparalleled research and teaching skills, and wise ambassadorship on behalf of patients and psychiatry. Sir David’s influence on psychiatry extends far beyond his own generation and will endure long into the future.

On behalf of the College, I want to congratulate all this year’s winners and shortlisted nominees. I can promise that next year’s Awards will be even bigger and better. Nominations for the RCPsych Awards 2010 will open in December. I encourage you to spread the word among your psychiatric colleagues, and encourage the individuals, teams and organisations that you believe are making a real contribution to mental health services to apply.

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Psychiatrists demand action on anorexia websites

The Independent - 18th September 2009 5:24 pm

Urgent action is needed to tackle the soaring number of websites encouraging adolescent girls to starve themselves, doctors said today. The proliferation of “pro-ana” and “pro-mia” websites, which promote anorexia and bulimia, is encouraging growing numbers of young women to wage war on their bodies. 

The websites support anorexia as a lifestyle choice rather than a medical disorder. They include messages such as, “I am starting a four-week fast today. Anyone want to join me?” They contain advice on how to get through the pain of extreme hunger after eating a yoghurt a day, or how to hide extreme weight-loss from parents or doctors. Some use pictures of excessively thin models as “thinspiration” for self-starvation.

One million people in the UK suffer from eating disorders, commonest in teenage girls. More than one in 10 girls look at pro-eating disorder websites repeatedly, the Royal College of Psychiatrists says. In a paper today, the college calls on the government to do more to protect vulnerable women. They said the UK Council for Child Internet Safety, set up last year, should specifically target pro-eating disorder websites in its monitoring and educational activities.

Professor Ulrike Schmidt, chair of the College’s Eating Disorders Section, said: “This is not a rare problem; it affects a significant number of schoolchildren. Studies have shown that girls who looked at these sites had low self-esteem, felt bad about their bodies and were miserable. Patients in eating disorders units spend up to 20 hours a week looking at [the websites]. There is a vulnerable group of women who are being sucked into this.”

Read more at The Independent.

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Improve mental health services for BME elderly

By Mike Broad - 26th August 2009 10:43 am

Little progress has been made in improving mental health services for black and minority ethnic (BME) older people over the last eight years, a report claims.

The report, by the Royal College of Psychiatrists, proposes new projects to evaluate the effectiveness of professional interpretation services and new ways of providing information to BME older people.

It also calls for funding to develop diagnostic tools for dementia and depression in languages spoken by BME older people that can be administered by an English-speaking mental health practitioner with the aid of a professional interpreter.

Progress in developing and improving services “has been slow”, the report says, since the college’s original report in 2001.

Report author Professor Ajit Shah said: “With a growing BME elderly population, the time is now right to build on previous work to further develop culturally appropriate and sensitive mental health services for older people from BME groups.”

Over the last decade, the mental health of BME groups has become a more significant issue. In 2001, estimates put the proportion of BME older people over the age of 65 at 8.2% of the total population in England and Wales - up from just 3% in 1991.

Research suggests dementia and depression are as common, or more common, in older people from BME groups in the UK than among older white British people. BME older people, however, continue to have poor access to mental health services.

Dr Dave Anderson, chair of the Royal College of Psychiatrists’ faculty of old age psychiatry, added: “With an ageing population the numbers of people with mental health problems is rising rapidly. It is vital to improve access to specialist older people’s mental health services equipped to meet the needs of this neglected group of older people. 

“By 2030 there will be twice as many people over age 65 as there will be teenagers. The time has come to actually deliver equality.”

The report also calls on the college to set up a new working group to address this neglected area.

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New thinking on psychiatry jobs crisis

By Mike Broad - 8th June 2009 8:00 am

Summer schools, societies and celebrities are being used to tackle the recruitment crisis in psychiatry.

The specialty is struggling to recruit UK-trained graduates. The proportion of UK nationals among the graduates sitting the college’s membership examinations has fallen from about 20% in the last decade to under 6% for one paper last year.

Prof Rob Howard, the college’s dean, said: “Psychiatry is an immensely unpopular career choice among UK graduates. Most think it’s weird and different from the rest of medicine.”

Prof Howard said psychiatrists have failed to connect with undergraduates through clinical teaching and the speciality doesn’t have enough presence within the foundation programme.

Changing how medical graduates perceive the specialty is priority for the college and a hot topic of debate at last week’s annual conference. For undergraduates, the college has created psychiatry societies in medical schools – with currently 800 members – linked up with newsletters and events.

It’s also trying to develop a programme of 15 summer schools a year, and launches its first at the Institute of Psychiatry, in London, in July. There were 97 applications for 30 places.

For foundation programme trainees, the college would like to see longer, four month placements in psychiatry. And Prof Howard wants to create more opportunities for trainees to experience psychiatry through combined placements with other specialties, for example orthopaedics.

Even celebrities are being called on to help recruit. Stephen Fry recently twittered “his readers” – reportedly half a million – on behalf of the college. He said: “Just had dinner at the Royal College of Psychiatrists. Real recruitment crisis. Come on med students - choose psychiatry! So needed.”

Prof Howard said that while vacancies were being successfully filled by overseas doctors, he was concerned that they could encounter communication problems and miss cultural nuances.  

“The overseas doctors are all appointable,” he said. “But it is not good enough to fill jobs with just apppointable people. It’s not fair on patients and families – they deserve better.”

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