There's a lot of it about

More evidence in the last week of the prevalence of mental health problems in general hospitals. This time it’s a report from the Agency for Healthcare Research and Quality (AHRQ) in the USA who describe hospital care for adults age 18 and older with mental health or substance abuse problems who were treated for those conditions in community (as opposed to speciality) hospitals in 2004. These are the most numerous hospitals in the USA (about 5000 institutions) – they are non Federal general hospitals but exclude speciality psychiatric or substance abuse treatment facilities.

A number of interesting facts and figures.

• Most psychiatric care occurs in the general hospitals, that is 44 million days of care to patients with mental health and substance abuse disorders compared to 27 million days of care in psychiatric facilities.

• Hospital stays for adults with only secondary MHSA diagnoses* were 20 percent longer than adults with no MHSA diagnosis (5.4 versus 4.5 days).

• Adults with only secondary MHSA diagnoses were the most likely to be admitted through the ED (63.6 percent). They were 1.4 times more likely to be admitted through the ED than those with no MHSA diagnosis (45.0 percent) and 1.3 times more likely than those with only a principal MHSA diagnosis (50.7 percent).

• The costs of stays with only secondary MHSA diagnoses were slightly less than stays with no MHSA diagnosis ($8,500 versus $8,900).

• Care for adults with only secondary MHSA diagnoses accounted for roughly 18 percent of hospital stays and total hospital costs and 20 percent of all days in the hospital.

• The top four secondary diagnoses were mood disorders, substance abuse disorders, schizophrenia and other psychoses (surprisingly) and delirium. No mention of somatoform disorders.

*Secondary MHSA disorders are people diagnosed with a principle non mental health diagnosis (for example myocardial infarction) but also have a secondary mental health diagnosis.

So to summarise about 1:6 admissions to community hospitals in the USA also have a mental health disorder, which costs slightly less to treat than those without a mental health disorder but they have a 20% longer admission. Presumably they don’t have increased costs because the increased length of stay is due to placement issues? The reassuring thing is that this confirms previous work that about 1:5 people admitted to hospital also have a mental health or substance abuse problem – there’s a lot of it about.

The fundamental attribution error or why patients get blamed for their problems

One of the things I notice working in acute mental health services is the tendency some teams have for blaming patients for their problems. This usually takes three forms. Firstly patients are said to have a “personality disorder” – a bit like having blue eyes it can’t be changed. Secondly that their substance abuse stops them being treated and lastly that they don’t turn up to appointments. Therefore the patients are really to blame for not getting better. However this view of patients is based on a well recognised fallacy in reasoning called the fundamental attribution error. This is based on experimental studies that have repeatedly demonstrated that as humans we attribute much more weight to “personality” factors that to environmental factors in explaining people’s behaviour. In fact the main determinant of people’s behaviour seems to be external environmental factors rather than “personality”.

The classic experiment that demonstrated this was described in 1967 by Jones and Harris. Subjects listened to pro- and anti-Fidel Castro speeches (it just had to be the USA….). Subjects were asked to rate the pro-Castro attitudes of the speakers. When the subjects believed that the speakers freely chose the positions they took (for or against Castro), they naturally rated the people who spoke in favour of Castro as having a more positive attitude toward Castro. However when the subjects were told that the speaker's positions were determined by a coin toss, they still rated speakers who spoke in favour of Castro as having a more positive attitude towards Castro than those who spoke against him. The subjects were unable to see the speakers as mere debaters performing a task chosen for them by circumstance; they could not refrain from attributing some disposition of sincerity to the speakers.

A further demonstration of the impact of environment on people’s behaviour (as opposed to personality) is shown by Philip Zimbardo’s classic experiments in August 1971 looking at the behaviour of “normal college students” put in to the roles of guards and prisoners. Some guards turned into sadists, despite knowing that the “prisoners” had done nothing wrong and the experiment had to be stopped after six days. "Many of the normal, healthy mock prisoners suffered such intense emotional stress reactions that they had to be released in a matter of days; most of the other prisoners acted like zombies totally obeying the demeaning orders of the guards; the distress of the prisoners was caused by their sense of powerlessness induced by the guards who began acting in cruel, dehumanizing and even sadistic ways. The study was terminated prematurely because it was getting out of control in the extent of degrading actions being perpetrated by the guards against the prisoners - all of whom had been normal, healthy, ordinary young college students less than a week before." (Zimbardo has just written a book “The Lucifer Effect: Understanding how good people turn evil” which makes links between this phenomena and such abuses as the torture that occurred in Abu Ghraib).

So in clinical practice I've become wary of blaming the patient for their problems – their behaviour is far more likely to be due to their environment than their “personality”. But of course understanding their environment requires time and interest to enquire about. Something that may be lacking in acute clinical practice.

References

Jones, E. E. & Harris, V. A. (1967). The attribution of attitudes. Journal of Experimental Social Psychology 3, 1–24

Zimbardo P. The Lucifer Effect: Understanding how good people turn evil. Random House. 2007 ISBN-10: 1400064112

The Health and Disabilty Commisioner’s report on the tragic death of a 50 year old man in Wellington Hospital makes interesting reading for Liaison Psychiatrists. The report focuses on the behaviour of the doctors and nurses concerned and the systemic problems that allowed them to happen. What is interesting is that the family were far more concerned about the attitude of staff to their brother who had a bipolar disorder and had recently been treated with risperidone for hypomania.

[Mr A] was an unassuming and gentle person, painfully aware of the views generally held by society towards mental-health consumers and the treatment that often resulted. The injustice and unfairness of this situation made him very sad, and after more than thirty years in the mental health system it was something he had become resigned to. During his stay in Wellington Hospital, [Mr A] told us on several occasions not to get a nurse or make a fuss as it would ‘just make them angry’. ...”

Our belief, based on own experience at this time and strengthened by your report, is that [Mr A’s] inability to co-operate, due to his deteriorating condition, led to him being labelled as a ‘non-compliant’ patient. That label, along with his history of mental health issues, led to a situation where many of the medical professionals involved in [Mr A’s] case seem to have down-graded the level of care they provided, based on their own prejudice and as a punitive measure against him for being ‘non-complaint’.

They felt that this was a reason why his agitation was minimised and he received a low priority. This doesn’t really come across in the expert comments which really just focus on what was recorded in the notes rather than interviews with the people concerned. This is a weakness in the report in that the way it is done makes it hard to say anything about attitudes.

Support for the culture of stigmatising patients with a mental health history comes from the DHB internal review, which comments on the need to “review smoke free policy to consider the needs of mental health patients in general inpatient areas”. Presumably this review won’t include patients who are not “mental health” patients (whoever they are). As one of the experts writes “this is to miss the point, it is not only ‘mental health’ patients who suffer while in hospital but any heavily addicted patient needs to have their needs addressed”.

The discussion on smoking is interesting. The issue was that the man was going through acute nicotine withdrawal for which he didn’t receive any effective treatment. (Presumably this wouldn’t be allowed to happen if he’d been withdrawing from alcohol). He wasn’t allowed to smoke on hospital premises and only received nicotine patches. His family brought in a nicotine inhaler in an attempt to control his withdrawal. The evidence appears to be that nicotine gum and inhalers are equally good at controlling acute withdrawal symptoms (DARE review).

According to the nurse expert there is an exemption in the 1990 Smoke Free Environment Act that allows hospitals to permit smoking in incapacitated patients. I couldn’t find it in the Act – anyone know where it is? Clearly according to this report there needs to be some flexibility in the management of incapacitated patients with a nicotine addiction in hospital.

On using electronic notes in medicine

This week I saw a patient with a complicated medical history. To find out what this was I spent part of the consultation turned towards a computer trying to find the most recent electronic discharge summary from the surgical team. I managed to do this and then spent 30 minutes after the one hour appointment typing the notes into the computer.

This illustrates some of the advantages and disadvantages of using electronic notes. First they improve communication – there is no doubt about this and I would never want to go back to pen and paper notes. It is so much easier to find out what is happening to people – just log onto the nearest computer and there are all the notes. Clinically I work in an organisation which provides mental health care to 450,000 people - so the provision of care is complex involving different clinical teams and many different people. Having the narrative notes from all these people in one place available from any computer is great. However there are significant downsides.

Firstly you need to find a computer to log onto. They are not always available at places where patients are seen. Secondly there is the additional time spent typing in notes. With pen and paper notes I used to make notes when I was talking to patients. The advantage was that they were instantaneous and it was easy to capture verbatim comments. Now I have to set aside time to type in notes – usually about one hour per clinic which translates into one less new patient each week. For the organisation I work in this represents terrible value for money, I must be one of the best paid yet least efficient typists in the organisation. Then there are the physical effects of all this extra typing – I have for the first time developed an overuse syndrome in my wrist and several other colleagues are nursing sore backs. Another problem with electronic notes is that not all parts of the health service use them – I still need to track down paper notes on people seeing other physicians. This doesn’t exactly encourage joined up health care and emphasises the split between mind and body.

Lastly there is the effect electronic notes have on “dumbing down” health care. The problem is that the electronic notes are not blank screens. There are numerous forms to complete from assessment forms to risk and hazard forms. What this does is that it encourages a checklist approach to assessment so that the emphasis is on completing the forms rather than finding out what is important for the patient. Every assessment is the same no matter what the patient needs and it is a “good” assessment if all the boxes on the electronic forms are completed. The ability of health workers to prioritise needs and to understand why this person has this problem at this particular time is damaged. Also there is an emphasis on risk and “hazard” rather than needs. This is often simplistic so that assessment of risk emphasises predicting whether people are at high, medium or low risk of violence/self harm. Unfortunately it is clear that clinicians prediction of who is going to kill themselves is no better than chance and probably not worth doing, after all most people who commit suicide are low risk. The purpose of risk assessment is identifying modifiable risk factors rather than some vague prediction of the future. So health care is dumbed down – just fill in the forms and that is fine no matter what they mean.

So would I return to pen and paper notes – no. Can electronic notes be improved. Yes – find another way of entering the data rather then getting expensively trained clinicians to be typists; decrease the number of forms and make them more flexible as well as training in how to keep notes; and get the whole organisation to use the same system. Then the goal of joined up health care and better communication in a complex system will be one step closer.