Pacific Thoughts

2010-03-15T04:40:00.000-07:00

I saw an interesting patient recently who presented to a medical ward with tiredness and an inability to walk. The case made me think firstly about unusual presentations of disorders and secondly the problem of inadequately trained staff doing assessments outside their field of expertise. The patient was in her 40's and had had a gastric bypass operation seven years ago. She complained of bilateral numbness in her upper thighs, forearms and hands; poor concentration and memory; blurred vision; tearfulness and worry that she may have had a stroke. The doctors and nurses on the ward "could not find anything organic" and were more impressed with the "drama" around her behviour when they visited which they used to support their diagnosis of "psychiatric". Blood tests showed a significant macrocytosis, a very low folate and abnormal liver function tests. On interview the most striking thing was her cognitive dysfunction with disorientation in time and place scoring 18 out of 30 on the mini mental state examination. My diagnosis was of an unusual presentation of Wernicke's encephalopathy and the treatment injections of thiamine after blood tests for vitamin B1 and B6.

The second issue was that this patient had been seen by two community mental health nurses two days previously who had discharged her from their service with a diagnosis of mild anxiety and depression - completely missing the point of the referral and the cognitive problems. What to do about this? I wouldn't expect the nurses to diagnose Wernicke's but would expect them to understand the point of the referral (can't discharge this patient) and not to miss the cognitive deficits. What I'm going to do is to provide them with feedback and also talk to the manager of the service about the community team seeing people in hospital and at least discussing the presentation with a liaison psychiatrist.

Why do some people get help for mental health problems and some don’t

2009-02-13T14:33:00.001-08:00

It has always intrigued me why some people get help for mental health problems and some don’t. What seems clear is that it is only partly related to need or severity of problems. A recent paper (Receiving treatment for common mental disorders
Verhaak, P. F., et al Gen Hosp Psychiatry 2009; 31: 46-55) sheds some light on this issue by looking at 743 people from a sample of GP attendees (attending for any reason) with anxiety or depression in the Netherlands. Only just over half of them had received any treatment in the last six months from their GP and about one in seven had received treatment from mental health services. You were more likely to get treatment from your GP if you were younger (just odds ratio 0.96); thought they communicated well (odds ratio 1.64); and recognised you had a mental health problem (odds ratio 7.43)(not surprisingly). Treatment in secondary care was associated with confidence in professional help (odds ratio 1.73) and number of diagnoses (odds ratio 1.47) with no relationship to the severity of anxiety or depressive symptoms.

This emphasises that accessing GP help is dependent on people being mental health literate and recognising that what they are experiencing could be due to a mental disorder. This study only looked at characteristics of the patients and not that of the services they were trying to access. As treatment involves at least two parties this seems to me an important omission which no doubt will be addressed in future studies.

2008-11-24T14:53:00.000-08:00

Tragic death on camera in Miami

The death by overdose of a 19 year old Abraham Bigg on camera watched by thousands of people on the internet is tragic. Commentary about this has focused either that it was online and people actually encouraged him to carry through with his act (sic) or that "internet causes suicide". Just to put this in context there are over 30,000 suicides in the USA every year - so what was different about this death? People have very different views about people who want to die. Historically the view that people who want to "self murder" are bad people who should be condemned has been prominent. This is clearly what a lot of people watching this thought. More recently thinking of suicide as a medical probleem has generated several useful ways of thinking about suicide prevention including effectively treating mental illness. What hasn't been emphasised is that Mr. Bigg had a bipolar disorder the adequate treatment of which represents an important opportunity for suicide prevention. This however is not a sexy headline - especially when compared with internet causes suicide. The other thing to note here is that clearly Mr. Bigg was ambivalent about death - otherwise he wouldn't have killed himself in a way which also offered the chance of someone saving him. Mr. Bigg's exposure by web cam to a potentially vast audience was both an expression of anger and hope. It is a truism that if someone is talking to you about suicide they are ambiivalent and at least part of them wants to live.

South Korea tackles record suicide rate

2008-09-01T01:34:00.000-07:00

South Korea has the highest suicide rate in the 30 OECD countries (24.7/100,000) followed by Hungary (21/100,000) and Japan (19.5) – this compares with New Zealand on 11.9/100,000 (OECD Health report 2008; figures from 2005). Now it seems the South Korean government is doing something about it. According to The Korea Times the government is coming up with a strategy that involves “that focuses on strengthening the social and economic safety net for those in the low-income bracket and the aged…. seeking to establish more screen doors at subway stations to prevent people from committing suicide by jumping in front of trains…regulating purchases of poison pesticides … and Web sites encouraging suicide are also considered a major target.” Curiously no mention at all of the role of mental health services or primary care in suicide prevention. The strategy will be announced on world suicide day on September 10th – hope they’ve looked at the ways other countries are doing it.

Drugs and suicide?

2008-09-01T00:46:00.000-07:00

A sign of things to come. The FDA in the USA is now considering the case of various drugs prescribed for “physical illness” in causing an increase in suicides. The two drugs reported to be in the spotlight are Singulair (Montelukast sodium) an asthma medication and Neurontin Gabapentin). The report describes two people who committed suicide whilst on these drugs – and that really is the difficulty. Providing any evidence for a connection between the prescription of these drugs and suicide is going to be hard to do as suicide is such a relatively rare outcome – even in people taking antidepressants it is a rare outcome and hard to prove a connection. One solution proposed is to set up a monitoring system for all new drugs to look at suicidal thoughts – however thinking about suicide is a wobbly old construct which is quite complex and doesn’t usually lead to any actions. It certainly is not the same as thinking about death (something it is often confused with in teenagers). However at least this shows that yet again thinking about physical and mental problems as separate is not a particularly helpful thing to do.

Cancer and depression

2008-08-19T06:16:00.001-07:00

clipped from content4.clipmarks.com

Depression in people with cancer is not "normal"

2008-08-19T06:08:00.000-07:00

A recent study reported widely (although not referenced) has shown that feeling significantly depressed occurred in 8% of a sample of 2900 people with cancer in the UK compared to 2.6% in the general population. The study was done by the Psychological Medicine Research group at the University of Edinburgh. It builds on ten years of major work in this area including their recent Lancet RCT which used problem solving therapy (amongst other interventions) in depressed people (Strong, V., Waters, R., Hibberd, C., Murray, G. D., Wall, L., McHugh, G. L., Walker, A., & Sharpe, M. 2008,"Management of depression for people with cancer (SMaRT oncology 1): a randomised trial",The Lancet - Vol. 372, Issue 9632, 5 July 2008, Pages 40-48).

The fact that depression is common in people with cancer is not on the face of it that surprising. When bad things happen to people they grieve for what they have lost - which includes going through a period of depression. Maybe what is more surprising is that 92% of people reported not feeling significantly depressed. In liaison psychiatry one of the major day to day issues is the problem of other health professions not recognising significant depression because it is "understandable" or normal. One take home message from this study is that even when bad things happen most people do not get depressed and feeling that they would be better off dead is not a normal and "understandable" reaction.

Awful care in the Emergency Room

2008-07-25T20:13:00.000-07:00

A terrible story from the US about the death of a 49 year old woman with "psychiatric problems" who had been waiting for a bed for over 24 hours in an Emergency Room of a New York hospital. She collapsed from a pulmonary embolism and lay on the floor for nearly an hour whilst other patients and hospital staff looked on without doing anything (sic). What makes this news is that it was captured on tape that has been broadcast around the world. While some commentators have written about what an awful thing it is to have to wait, sometime for days, for a hospital bed to become available that somehow misses the point. (Although it is interesting how the financial incentives in the US encourage hospitals to keep well insured patients as in-patients and the poor or uninsured in emergency departments). What is striking to me is the complete lack of professionalism and care of any of the staff involved. Staff just looked at the woman and walked away! The lack of professionalism is reinforced by the fact that after the event the notes were altered by staff, (what were they thinking of and how stupid when the tape showed they were lying...) to make it appear as though the woman had been consistently observed and the collapse was responded to promptly. So far seven people including the head of psychiatry have been sacked. Interestingly the media reponse to this has been to portray the woman not as "someone to blame" or as "someone not worthy of attention" but as someone who lived a rich life who was unfortunate to have suffered a mental illness - a refreshing change. Be interesting to know how the media got hold of the tape and if the story would have made news without these pictures.

There's a lot of it about

2007-05-27T01:38:00.000-07:00

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.

2007-05-13T01:16:00.000-07:00

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

2007-04-13T03:28:00.000-07:00

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.

2007-01-13T12:59:00.000-08:00

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.