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.
Ithas 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.
Monday 24 November 2008
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 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.
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.
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.
I'm a psychiatrist in Auckland New Zealand. I work at the University of Auckland teaching psychiatry and researching about suicide, psychotherapy and somatoform disorders. Clinically I work two days a week as a liaison psychiatrist providing a psychiatric service to a general hospital. Or to put it another way I'm a professional writer with an interest in mental illness and biography.
The content of these blogs is mainly concerned with writing, clinical topics, the interface between medicine and psychiatry, politics, journalism and whatever else grabs my attention.
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