Open Dialogue: reflections on the model and the evidence

You can’t work in mental health services for too long without hearing about Open Dialogue.

There certainly aren’t a shortage of bold claims about the model of care used to treat psychosis in a small pocket of Finland, for example, as the Open Dialogue UK website states:

‘They have the best documented outcomes in the Western World. For example, around 75% of those experiencing psychosis have returned to work or study within 2 years and only around 20% are still taking antipsychotic medication at 2 year follow-up’.

And as a well-publicised play inspired by the model suggests, there is a rumour that they have actually eradicated schizophrenia in Western Lapland. These are substantial claims – so substantial that a seriously hard objective look at both their model and the evidence for its success is required to verify them. I wasn’t able to find such an interrogative assessment online, so I thought I’d write one myself.

My aim is to contribute to a transparent, honest discussion about what the effective parts of Open Dialogue might be, and how confident we can be of that. There has been a lot of fervour about this approach, but we also need an impartial examination of the facts. Please do leave comments underneath the post.

I want to make a disclaimer straight away: Yes, I am a psychiatrist, but no, I am neither a particular fan of medication nor a particular hater of talking therapy. I try to appraise the evidence for both objectively. What I am not a fan of is a treatment of any kind being pushed harder than the evidence base should permit. Our patients deserve treatments that have been rigorously proven to work, whatever they may be.

The model

Open Dialogue has been the standard psychiatric model in Western Lapland since the mid-1990s. In short, it sounds very much like a cross between a crisis team and intensive family therapy. When a referral comes in, whoever answers the phone is responsible for organising the subsequent care for that patient. The care involves a series of meetings at the patient’s home, at which 2 or 3 therapists as well as anyone else who is important in the patient’s life come together to share their experience of the crisis, develop an understanding of it and work out a plan. The team try to leave their assumptions and professional models at the door, and there is an added focus on avoiding ‘neuroleptic’ medication (antipsychotics) for as long as possible.

 

Their practice has 7 tenets:

1) On receiving a referral the first meeting with the patient should take place within 24 hours.
2) The social network of the patient should be invited to take part in the meetings from the outset and for as long as necessary.
3) The treatment should be adapted to the needs of the individual patient and their family, using the most suitable methods.
4) Mental health services will guarantee that certain people will take responsibility for the patient and organise a team that will make decisions with the patient and family about all aspects of treatment.
5) Psychological continuity is guaranteed; staff from different teams will be invited to participate as required.
6) A sense of security should be promoted by tolerating uncertainty, which mobilises the resources of the patient and family.
7) The team should focus on creating a dialogue between everyone in the meetings to create a new language for experiences previously unspoken.

 

There’s no denying it – all these principles are laudable. However, the most interesting thing that struck me about them is that we already value most of them in NHS mental health services, but struggle due to poor resourcing. They aren’t exclusive to the Open Dialogue model.

Seeing every patient in crisis within 24 hours? We’d love to do that. But in reality the more likely scene is of a nurse quietly holding back the tears of frustration as the duty phone won’t stop ringing. The NICE quality standards instruct that newly psychotic patients should be seen within 14 days and even’s that’s difficult to achieve. The Open Dialogue team clearly have enough staff and resources to be able to see people quickly, which may be an important part of why they do so well, but there’s nothing novel about the idea of early intervention.

Likewise, tailoring the treatment to the specific needs of the patient, taking their wishes and the wishes of their family into account, is also something we try hard to do, and would do better if we were simply properly resourced. Again, the NICE quality standards highlight family interventions, employment, education and support for carers and CBTp (as well as medication) as a range of choices which should add up to patient-centred care.

Similarly, continuity of care as a patient progresses through the system is a well-recognised aim for mental health professionals the world over. Sadly, the fragmentation of NHS mental health services has made this noticeably harder to achieve.

So, many facets of the Open Dialogue model are general qualities of a good service, qualities which could be achieved by improving the current systems we have rather than bringing in a whole new way of working.

However, some of the other facets of Open Dialogue are quite unique to their model. I think the aim to maintain a non-judgmental approach and foster a shared language between the patient and their family has great merit. I’m not keen on forcing people to take a certain narrative for their distress, and if they can find a way of understanding themselves that keeps them safe and well, then great. However, I do have reservations that this is suitable for all patients. Especially where I work in London, perhaps more so than in Lapland, we see an awful lot of extremely psychotic people. People whose mental states are an acute and serious risk to themselves or others, people whose experiences are plainly so extreme that to deny their pathological nature and take immediate action would be irresponsible.

This all links into the related discussion on whether psychosis is something we should be mainly trying to find meaning in, or remove. It’s not at all unusual to see a patient improve from their psychosis and come to the opinion that their psychotic beliefs were all absolute nonsense and they’re relieved to have had them medicated away instead of mused over. I wonder how Open Dialogue would address those patients.

Another issue would be that we see a lot of people who are so psychotic that they cannot engage in a series of meetings, either because they are unable or unwilling to talk, often with marked hostility or confusion. Also, many of our patients either lack any semblance of social network or possess one that actually contributes to their illness. Many would simply refuse to consent to the process, valuing their confidentiality, because they are individualists. The question mark over the cultural generalisability of Open Dialogue is huge.

Finally, I do find it hard to accept a model whose prior aim is to avoid antipsychotic medication for as long as possible. Whether you personally love them or hate them, there is a huge amount of evidence that especially in the early stages of psychosis antipsychotics are tremendously helpful for reducing symptoms and therefore distress. Their research papers (see below for links) note that at least historically they have tried to use only benzodiazepines for the first 3 weeks of treatment. This is a curious plan, as benzodiazepines expose patients to all kinds of side effects (oversedation, falls, paradoxical reactions) without any of the positives of antipsychotics.

The evidence

As I said earlier, some huge claims have been made about Open Dialogue. They are essentially stating that schizophrenia, an illness that for hundreds of years no treatment (including many other talking therapies) has failed to adequately improve has been eradicated simply by a different method of talking. We owe it to our patients to examine these claims carefully.

I chose only to read the quantitative research into Open Dialogue, for the simple reason that only quantitative research could provide evidence for these claims. Furthermore, if we’re going to spend public money on Open Dialogue, quantitative research is the only thing that will prove that it works better than alternative options.

I need to say from the outset, I found the evidence base to be thin. Very, very thin. Whereas a single drug needs to be tested on hundred if not thousands of people to get anywhere near the marketplace, the amount of patients that Open Dialogue has been given to in quantitative studies appears to total 64, and the studies are of poor methodological quality.

The first study of interest is Seikkula et al. (2011a), which compares outcomes of Open Dialogue psychosis patients during two periods (1994-97 and 2003-05) with outcomes for psychosis patients seen by the team before they used the Open Dialogue model (1992-93). During this pre-Open Dialogue period the team still had a non-medication focus and the system of treatment had already been reorganised towards a needs-focused approach, but the specific Open Dialogue model had not been fully implemented. Seikkula et al. (2006) uses identical data but uses only the earlier Open Dialogue group.

The number of patients in each group was low – 46, 18 and 36 respectively – limited further by exclusions, including 9 from the Open Dialogue group that ended up with 18 patients, because patients refused to participate, could not be reached or follow-up or had died. There was no significant difference between the groups over the 2 year follow up period concerning:
• The number of patients given antipsychotics (26-50% started them across groups)
• The number of relapses (less than 30% in all groups)
• Employment status (62-78% studying or working across groups)
The mean Brief Psychiatric Rating Scale (BPRS) scores of patients in the 1994-97 group were significantly lower after 2 years than those in the 1992-3 group (30 vs 24), but this effect had disappeared by 5 years and the 2003-05 group showed no significant difference to the control at either point. More than 80% of patients in each group were free of psychotic symptoms at 2 year follow-up, but again, there was no significant difference between the Open Dialogue groups and the control. The amount of days patients spent in hospital was different between groups, with the control group (25 days) being worse than the 1994-97 group (9 days) and 2003-05 group (14 days).

So this study is the source of the statistics in the introductory quote, but overall, what these results make clear is that Open Dialogue is actually no better than the model that went before it, the simple needs-focused approach. The unusually good outcomes reported in the area must be due to factors other than the switch in model. Could it be that the team, who are dedicated, cohesive and not burnt out, get good results whatever the specifics of their model? Could it be that the area, a highly atypical one compared to the UK, has less of the stressors associated with emerging psychosis? Could it possibly be that all the patients who are going to do badly simply don’t seek out the local service or don’t engage with it, biasing their sample? And lets’ not forget that a third of the 2003-05 sample were excluded – are they very unwell?

Another paper which seems to be the source of so many large claims about Open Dialogue is Seikkula et al. (2003). As far as I can tell, this is the only time that the results of an Open Dialogue team have been compared to those of a different team. The paper uses the same Open Dialogue group from 1994-97 and the same pre-Open Dialogue comparison group from 1992-93 but adds in another comparison group – one from a neighbouring Finnish community that weren’t using Open Dialogue. They investigate the outcomes of only the patients in each group with schizophrenia, not other psychotic disorders, as only that subgroup of patients was comparable in demographics across treatment arms. This raises immediate questions – are the neighbouring community’s patients older, more unemployed, less married? In any case, the resultant groups are absolutely tiny – just 14 patients in the neighbouring community control, versus a barely better 22 and 23 in the Open Dialogue groups.

The results show that the Open Dialogue patients were in a much better state that the control group after 2 years. Only 6 out of 23 patients had relapsed compared to 10 out of 14 in the control group, 15 out of 23 were working or studying versus 3 out of 14 in the control group, and 8 of 23 had needed antipsychotics at some point compared to all 14 in the control group. Days spent in hospital were fewer in the Open Dialogue group, but interestingly BPRS scores weren’t significantly different between the groups (25 vs 27).

The limitation of this study are eye-popping. Anything as minor as the psychiatrist in the control group having a very paternal style of practice (i.e. favouring medication and longer stays in hospital) could have biased the whole thing. Heck, there could be a crack den or a genetically unfortunate family in the control area that skewed the results. The sample sizes are tiny and a group of 14 people is in no way an adequate representation of ‘treatment as usual’ in the rest of mental health services. The Open Dialogue team seemed to keep their patients off medication, out of hospital and in work but their actual levels of psychosis – the BPRS scores – weren’t any different, so are they treating psychosis or just providing awesome social support?

The final study of note is Seikkula et al (2011b). In this study, the notes of every patient aged 15-44 who presented to mental health services in Western Lapland between 1984 and 1994 are examined, the patients are retrospectively diagnosed based on those notes, and the relative rates of diagnoses between two groups (1985-89 and 1989-94) are compared to see if the rates of schizophrenia dropped after Open Dialogue was brought in. The paper states that a comparison between pre- and post-1990 was chosen as family therapy programmes began in the area in 1989. This seems to reconcile poorly with the previous papers that used the 1992-3 group as the ‘pre Open Dialogue’ group, effectively admitting that the 1992-93 group is very similar to Open Dialogue proper.

The authors found that the mean annual incidence of schizophrenia fell from 25 to 10 between the 1985-89 and 1990-94 groups. The fewest cases diagnosed in any one year was 3, in 1994. Brief reactive psychoses rose from 1 to 7 cases per year. The paper also notes that there were no patients staying longer than a year in hospital after 1992. It is from this paper, it seems, that the claim that schizophrenia has been eradicated has emerged. The authors hypothesise that so many of the local population must have been involved with their family meetings that the beneficial psychological effects may have spread, actually preventing new cases of schizophrenia emerging in the first place.

Sadly, there are several more mundane possibilities. The local economic climate may have picked up, or illicit drugs might have been better controlled. The professionals who originally saw the patients, working for a service that is so enthusiastic about reducing psychosis, may have been selective in their note taking at the time, leaving out or not fully exploring key psychotic symptoms. After all, the difference between a ‘psychotic episode’ and ‘schizophrenia’ is only a clinician’s judgement of how soon the psychosis ended. Furthermore, retrospectively diagnosing patients from their notes isn’t exactly accurate and using old notes to establish a regional incidence rate isn’t close to watertight. The claim that the Open Dialogue model has disseminated amongst the local populus, creating a psychosis-resilient social environment, is a huge one and there is no reason to believe it without intense further study. There’s not even a lot of evidence that individual interventions like medication and CBT work for people at ultra-high risk of psychosis, so it’s a real long shot hypothesis.

 

Summary

My thoughts on Open Dialogue can be summed up in two themes:

Firstly, their model is admirable, but many facets of it, like continuity of care and timeliness in intervention, have been recognised as key components of good care for many decades. The reason we struggle to achieve them in the NHS is because we’re so short on resources, not because we lack the Open Dialogue model. Other facets of the model are more unique but there are huge issues around their generalisablity on social, cultural and individual levels.

Secondly, the evidence which suggests that Open Dialogue works better than any other treatment is slim to none. We have no idea if it’s the general facets of the model that cause improvements (if there are any), or more specific aspects of the dialogical approach. If we’re going to make significant investments in the model in this country, using public money, we need to have more convincing data. A multi-centre UK trial is in the offing and I look forward to the results with an objective eye.

How can technology affect the doctor-patient relationship?

Medicine is good friends with technology. From electronic blood pressure cuffs to fMRI scanners and robot surgeons, technological innovation has improved investigation, diagnosis and treatment. But what effect could all this bright, shiny equipment have on the most central of medical processes, particularly in psychiatry – the doctor-patient relationship?

When I asked the good people of Twitter for their opinions, two responses were far more common than others:

1) It depends who the technology is designed to help, and who helps design it
2) I wish my consultant would stop using their mobile phone during my appointments

Though the exasperated second point suggests that a piece of new kit could never do anything but get in the way of an essentially human interaction, thankfully it’s the first point which is likely to be the more fruitful answer. Some technologies can help.

Doctor-patient relationship

Take Optimism, for example. It’s a very user-friendly app which allows patients to input data about their symptoms, triggers and other personal criteria on a daily basis. It plots out graphs of this data, allowing trends to evolve – trends which could be useful to look at in clinic. Another digital tool, Buddy, goes one step further. It sends patients text messages asking them how their day has been and to input mood data, and also reminds them of their appointments. That data is available to their therapist, who can get to know the patient quicker and tailor sessions specifically.Featured image

Research is broadening these ideas. The AMoSS study, running in Oxford, is using portable devices to record movement, quality of sleep and physiological measurements like blood pressure as well as mood, to create a data set that could be useful come appointment time. GPS trackers are also being trialled to correlate the position of a patient with where they feel worse – meaning they can be advised on where to steer clear of, and even warned of a potential relapse – hopefully strengthening the trust in the clinician.

In fact, simply using text messages by themselves, without an accompanying app interface, can strengthen the doctor-patient relationship. I currently work in a day hospital for people with borderline personality disorder, the duty service of which frequently uses text messages to stay in contact with patients. It can be just the type of attachment system our patients need – available, but never too close.

However, as we can all attest to, technology isn’t always designed with the interests of the patient in mind. Before the rise of computers and ‘paper-free’ work environments, did we really spend as long as we do now filling in questionably useful forms? Risk assessments, child risk assessments, diagnosis tabs, medication tabs, clustering assessments, HONOS assessments…not to mention the bizarre and absurd repetition of printing, faxing and scanning that soaks up hours each week – hours we could be spending more valuably with the patient.

Computer-patient relationship

So it’s all about who the technology is designed to help. But could we push the question further – could technology even replace the doctor-patient relationship?

We already commonly use a computer as a medium for human interaction. The increasing sophistication of online communities like Big White Wall, which allow patients to rely on each other, are an invaluable option for advice and emotional support. And many of us will have heard of Avatar Therapy, a novel modality for helping people take control of their auditory hallucinations by talking to an on-screen avatar puppeted by a human therapist.Featured image

And fully computerised therapists are on their way. Online CBT programmes like MoodGym and interactive variants, including those with videos like AI-Therapy, are very popular. Though these programmes are simplistic, other computers are getting better and better at identifying emotions in facial expressions. And even more are passing the Turing Test – fooling humans into thinking that they’re talking to a real person. When combined, the mix of therapy skills, intelligent sensing of emotions and believably human output can be astounding. In fact, research has shown that during a therapy session with a computer avatar ‘therapist’, people will disclose significantly more personal information and show more emotion when they’re told that the avatar was totally driven by code (which it was), compared to if they’re told that there’s a real person pulling the strings. Could the computer-patient relationship come to be the doctor-patient relationship without embarrassment hindering useful discussion?Featured image

Profession-patient relationship

We can push the question further in another way – how has technology helped the profession-patient relationship? From my own experience, Twitter has brought me closer to what is important to patients, to the difficulties they face outside of the clinic room, and sometimes, thickening my skin, to what they really think of doctors. Hopefully in return I have been able to give back a balanced, informative, inquisitive and personal face – something I know we often lack. And there are far more prominent psychiatrists than me on Twitter. Having the likes of Simon Wessely and Dinesh Bhugra accessible to anyone who asks a reasonable question is an amazing thing, which can only improve how people think of us.

On a broader scale, television has developed the power to help or hurt the profession-patient relationship in equally powerful measure. Though honest series like Bedlam hopefully made people more attuned to the real us, last year’s Channel 5 series Inside Broadmoor, complete with haunted house music, was less conducive to good feeling.

So there we have it. There is no halting the rise of technology in its influence of the doctor-patient and profession-patient relationships. Who knows where we might be in 20 or 50 years – will there be time for even a handshake amongst all the apps, graphs, texts and tweets? Will human professionals even be required for some patients? As long as we continually remind ourselves of one thing, the future seems to be full of potential – when designing technology for use in mental health services, we have to ask ourselves – who are we doing this for?

My thoughts on there being ‘no stigma’ around mental illness

Last Sunday, the Observer published a piece by Elizabeth Day which appeared to claim that stigma around mental illness no longer existed.

She certainly didn’t sugar the pill.

“I don’t view mental illness as a scary, strange thing or as a form of weakness. Do you? I doubt it.”

“…bandying around the term “stigma” in reference to mental illness is unhelpful…can’t we just ditch the word?”

“…let’s stop saying there’s a stigma attached to it.”

Unsurprisingly, this went down like a sack of lead balloons with the mental health community. Amongst the fervent criticism was a typically evocative piece by Charlotte Walker.

And who can fail to understand the outrage? Research persistently shows that around 90% of people with a mental illness experience the effects of stigma.

However, in a follow-up piece published on her own blog today, Day tries to clarify her ideas. I’ll assume she’s being genuine in this and not resorting to tactical repositioning. She starts by stating that the real message of her piece was that mental illness is no longer a taboo subject (though the word ‘taboo’ is used once and ‘stigma’ is used eight times). She then goes on to assert that she would never deny that people with mental health problems still experience discrimination, but stigma, something different, is largely a thing of the past.

She reminds us of the definitions of stigma that she used in the original piece:

“…a Greek term that referred to the marking – by cutting or burning – of socially undesirable types such as criminals, slaves or traitors.

and

“…the phenomenon whereby an individual with an attribute which is deeply discredited by his/her society is rejected as a result of the attribute”.

It is here, for me, that the confusion and uproar has arisen. Day’s definition of stigma and the way she interprets it, as well as her obvious lack of appreciation of the prevalence of what others see as stigma are both askew with reality.

Day appears to believe that stigma simply denotes the process of society highlighting an intrinsic, internal flaw in someone (though her chosen definitions do not make that clear):

My issue with the term “stigma” is that it makes the condition itself a negative thing. It places the responsibility for bearing it with the person who has depression. It makes depression the mark of an outcast, of a tattooed outsider, rejected by the wider society.

However, we know that stigma it is a rather different beast to that. The now generally accepted conceptualisation of stigma is Thornicroft’s suggestion that it encompasses problems of knowledge (ignorance), attitudes (prejudice) and behaviour (discrimination, which Day sees as something altogether separate) – all of which are external to the person with mental illness. Though the results of stigma can be felt horrendously, the stigma itself comes from someone else and is inflicted upon a sufferer.

And even if we do work with her more narrow definition of stigma as a process whereby people are laden with blame for their conditions, it’s hardly as if society’s image of mental illness is as unblemished as she thinks it is.

“I simply don’t think the majority of right-thinking people believe [that mentally ill people are bad] anymore.”

Though in science and philosophy (areas which Day may be more familiar with than severe mental illness) we may have moved past the notion of mental illness being worthy of moral judgement or reason for scorn, the real world is sadly still rife with punishment and abuse simply for being unwell.
Moreover, appropriating the term stigma for her own ends (whether knowingly or not) was to steal a word belonging to a group of people for whom it  means something powerful and meaningful, who use it to understand their experiences with depth, pain and hopefully strength. This semantic hijacking is disrespectful. Providing a dictionary definition of stigma to justify it does nothing to negate that.

A final thought – whatever the cause of the misunderstanding, wherever the fault lies, there was a certain word missing in Day’s follow-up, a word that can have such healing power – sorry.

Why A+E fees are a despicable idea

With the average time patients spend in A+E rising and ambulances left queuing up outside for hours, it’s no wonder we’re trying to think of ways to ease the deluge of emergency presentations to hospital.

But one particularly bad idea keeps coming back time and time again – the idea of charging people who turn up with ‘inappropriate’ problems.

This morning it was the turn of the Northern Ireland health minister to float the proposal, targeting people who ‘abuse’ the system by having the temerity to turn up under the influence of drugs or alcohol. England is no stranger to the suggestion either.

I want to list the main reasons why this idea is at best misguided and at worst malicious.

Firstly and most importantly any fee for attending A+E, or any health care service for that matter, is a tax on the sick. The NHS was built on the founding principles that health is a right not a privilege and that no one should have to pay one penny more in sickness than would have had to in health. Sickness and disease are burdens to be accepted and borne by society, not cast onto unfortunate individuals.

Some might say that only charging people who ‘abuse’ the system or ‘bring their illnesses on themselves’ abrogates this moral duty. But I don’t think such a group is either easy to define or deserving of such spite.

So many of the patients I see labelled ‘timewasters’ are in reality the most deserving of care. They often have complex social, emotional and medical needs as well as substance misuse problems over which they have very little control. Society has frequently failed outright in providing them education, a safe and happy childhood, housing, employment and a stable emotional life, but instead of holistic intervention and understanding we are now suggesting charging them for seeking help in the only way we ever taught them – with desperation. Such a policy demonstrates nothing but the most basic misunderstanding of our most vulnerable patients.

Furthermore, how many illnesses which people ‘bring on themselves’ are we more than happy to treat for free? A broken leg from a skiing accident gets you top notch free orthopaedic care, even though you knew it could happen when you booked the holiday. Smoking for 20 years gives you COPD but there’s still an NHS bed for you if you need it when the winter chest infection season starts. But if you’re difficult to emotionally relate to, you keep coming back and have difficulty following advice, all of a sudden it’s your own fault and you should learn your lesson.

No one turns up to A+E for fun. We need to address the problems of difficult patients more thoroughly, not bat them away with a fine for being so bothersome.

There are numerous secondary reasons why charging people for medical services is counterproductive. People who are genuinely unwell will decide not to turn up for fear of it being labelled inappropriate or expensive, as the US know only too well.

The cost of implementing a system to charge so-called ‘abusers’ of healthcare would in all likelihood cost far more than it would earn, especially bearing in mind the track record of NHS IT projects, and almost by definition would target the very people who are least able to pay the charges anyway. Many also fear it would also represent the thin end of the wedge towards universal charges – something I wouldn’t put past this government.

All in all, a frighteningly frequent proposal which shows just how badly some people understand our more challenging patients and just how little they really want to help them. I hope I never see it suggested again, though I’m completely sure I will.

Dangerous Debates

I like a good public debate, especially when it comes to mental health. I’ve been to a fair few, like the Maudsley Debate on CBT for psychosis, and even spoken at one myself, on the value of diagnosis in psychiatry.

Debates are often called for, much anticipated, and generally held up to be an uncontaminated source of truth and progress in heated times.

I wonder though, whether they’re the universal answer that they’re cracked up to be. I’d never argue against issues being discussed informally on smaller platforms like Twitter, but hosting an official and well publicised event on a grand stage seems to hold quite a propensity to make the issue at hand even less clear.

Firstly, the motion sometimes isn’t fair. I was rather piqued to read the introduction to a debate due to happen in November at the Royal Geographic Society, at which speakers will argue for and against the motion that ‘Psychiatrists and the Pharmaceutical Industry are to Blame for the Current ‘Epidemic’ of Mental Disorders’. It’s a straw man – the assumption has been made that there is an epidemic of psychiatric diagnosing (when in fact, mental health services are too busy to see even the sickest patients enough and are being cut further) and someone is to blame.

The rest of the blurb is obnoxiously biased too, for example ‘Drug pushers. We tend to associate them with the bleak underworld of criminality. But some would argue that there’s another class of drug pushers, just as unscrupulous, who work in the highly respectable fields of psychiatry and the pharmaceutical industry.’

Sir Simon Wessely, speaking against the motion, is one of the best public orators I’ve ever seen but he’s starting from a phenomenally biased position. Unless the motion and backdrop are fair and balanced, a debate can turn into a pointless inquisition and show trial serving only to reinforce the skewed presumptions of the people who set the motion.

Secondly, I just don’t think that some topics are suitable for public debate, either because of the nature of the question or the state of the current answer to that question.

Public debates are not objective. They are rhetorical sniping contests won not by people with the best and most useful answers but by the people who convince the audience, who are themselves hugely biased already, using charisma, ethos, selective information and verbal trickery. The recent demand in a broadsheet newspaper by the so-called ‘Council for Evidence Based Psychiatry’ for a public debate on the harms of psychiatric medication was in my view completely ridiculous – there is no way a complex, lengthy and highly statistical issue like that should be thrown to a few angry academics in front of microphones.

In some cases too, simply having the debate lends credence to one side of the argument that it doesn’t deserve. We wouldn’t have a public debate on vaccination and autism, because we know well enough already what the answer is and we don’t want to give the other side more credit than it deserves. I suppose you could call it meta-debate. Far be it from me to ascribe that to any topic in mental health, but Nick Clegg didn’t seem to fair too well against Nigel Farage. It was over before it even started – Farage had proven that his views were apparently worthy of airtime. The fact he outdid Clegg with panache too was an added bonus for him. The sensible, grown up politicians steered clear of the no-win situation.

To finish, we shouldn’t mistake the result of a debate for closure on an issue either, which seems to be a nagging recent trend. If we can’t make our minds up about an issue after decades of research then there’s no way we’ll get there in one evening.

At the end of the day we just need to remember what a public debate is – a few highly biased people talking in a highly biased way to a highly biased audience about an often highly biased motion. They can be fun, exciting and stimulating, but they run the risk of distorting an argument even further and they certainly aren’t an absolute truth.

Overshadowing

Earlier this week I had a rare moment of cognitive lucidity and tweeted that sometimes the main role of the psychiatrist is to conclude that the problem isn’t psychiatric.

I had two broad and frequently occurring scenarios from clinical reality in mind.

The first is when the patient’s difficulties are far better conceptualised as temporary interpersonal strife or harmless eccentricities. Staff might not be getting on well with a patient, or might be struggling to figure out why they act the way they do. All that is needed in those cases is not a diagnosis or ‘treatment’ but reassurance and perhaps a few pointers on how to understand them better.

But the second scenario in which concluding that the problem is not psychiatric is even more important – when the problem could well be ‘organic’. In these situations,  it could be lifesaving.

It’s a common story. If someone without a history of mental illness goes to A+E with chest pain, confusion or any other worrying symptom, the list of tests and referrals is often generous and sometimes completely exhaustive. The doctors are keen not to miss that rare disease or that subtle sign of a hidden disaster to come. But if someone with a mental illness turns up at A+E with exactly the same symptoms, the amount of investigations that get done is sometimes the bare minimum, if any at all. The vast majority of doctors I’ve worked with are phenomenally caring, holistic and entirely free of this kind of error, but the times when it does happen are hard to forget.

In fact, as I’ve seen many times, the investigation of new symptoms will progress as normal until the very moment when the history of mental health problems is uncovered or when psychiatry show up to help. And then the tests stop.

This potentially deadly phenomenon is the result of what we call ‘diagnostic overshadowing’. Any new symptom that a person with a mental health problem complains of will automatically be put down to the mental health problem. I can understand how it happens. Doctors tend to unconsciously use pattern recognition to figure out which disease or illness a constellation of symptoms is due to, and with such a large confounding factor of a severe mental illness clouding this unconscious process the urge to ascribe the new symptom to the pre-existing problem is logically hard to resist. But sometimes, doctors can stick to this bias despite overwhelming evidence to the contrary. In her book The Centre Cannot Hold Elyn Saks describes turning up to A+E with the worst headache of her life. Despite her friends insisting that this wasn’t part of her usual schizophrenic illness, she was sent home. She was having a subarachnoid haemorrhage.

There are many reasons why the life expectancy of people with severe mental illness is decades shorter than those without. On average they smoke and use drugs more, engage with GPs less, are less able to identify worrying symptoms in themselves, eat less well and do less exercise. But I can’t believe that diagnostic overshadowing is any less significant than any one of those.

But unlike many risk factors for earlier death, diagnostic overshadowing is within the control of health professionals – so how can we fix it?

Firstly,  healthcare professionals in other specialities need greater literacy in mental health. Hopefully, this is happening already. From August there will be a  rise in the amount of psychiatry rotations for newly qualified doctors, so they can learn more about caring for patients with severe mental illness and how to discern what’s mental from ‘organic’. In time, this should reduce the number of calls psychiatrists get from other doctors who don’t know where to start with a patient with a mental health problem as they ‘aren’t trained to deal with this’.

The divisive phrase ‘medically clear’ is no help in this. Before transfer to a psychiatric hospital a patient often has to be declared ‘medically clear’, as if medical and mental are different things, furthering the divide between us. But psychiatrists are doctors who are trained in treating organic disease, and every doctor should be able to do a little psychiatry. We all did placements at medical school. Also, as I’ve discussed before, I don’t think separating psychiatric institutions from other medical instituations either geographically, pragmatically or conceptually is doing the health of our patients any good. It breeds ignorance and therefore error on both sides.

Secondly, we need to listen to patients and their families better (whatever I write about, that always seems to be a conclusion). They need more help to speak up and make their concerns heard, for example from advocacy services or care co-ordinators who actually have the time to attend clinics with them. When they say something isn’t right and isn’t part of their mental illness, we need to believe them and investigate appropriately.

Lastly, liaison psychiatry services are vital in facilitating this and I was glad to see the release of a joint report by a series of medical colleges not long ago recommending a service in every A+E.

I know there are many personal and professional experiences of this topic out there, and I’d be keen to hear them.

 

Shouldn’t mental health units be part of general hospitals?

I’ve been working in liaison psychiatry for the last six months. For those of you who haven’t heard of it before, it’s the branch of psychiatry that see patients who are in hospital with physical health problems. Some hospitals have a dedicated liaison department, some have a team that only visit if they’re called, some have no service at all.

There’s a very instructive video about the speciality by CNWL NHS Trust available here.

Anyway, I’ve enjoyed my job, and think that every hospital should have a liaison psychiatry service – but I got to wondering, why should we need to liaise in the first place? Why should every speciality except psychiatry have their patients under one roof, with psychiatry visiting from outside to help out, while people with mental health problems are usually admitted to separate hospitals often miles away?

I tweeted about it:

Having mental health wards as part of general hospitals is something that already happens in other countries. There appear to be positives and negatives to it.

On the plus side, patients would get a higher quality of physical health care. So many patients who have a mental health problem also have physical health problems, and many need treatment for both simultaneously. Sometimes the cause of the mental health problem is a physical health problem. Being seen by doctors from a range of specialities would be easy; so would getting all the relevant tests. It would be a far better situation than currently, when patients who are unlucky enough to have both a mental and a physical health problem are often shuttled back and forth between hospitals in a time consuming, inefficient, untherapeutic and potentially risky game of musical beds.

Furthemore, some might argue that having mental health units as part of general hospitals might lower the stigma of being admitted. I’ve met so many patients who were quite happy to come into a general hospital but not into a mental health hospital, just because of the negative connotations. Having mental health patients and indeed psychiatrists mixing in the general hospital environment might serve to demonstrate that we are deserving of respect and equality and do not live up to our distorted stereotypes.

On the negative side, perhaps it would reinforce what some feel is already too ‘medical’ a model. Maybe having our mental health hospitals physically separate from general hospitals enables, or at least encourages, us to treats our patients less like disease-bearing entities and more like people. Personally I’m not sure I agree though. I don’t see why a mental health ward placed on a general hospital site couldn’t still have a holistic, non-biological ethos, and I’m not sure our mental health units are even slightly holistic currently as a result of being separate. In fact, I might argue the opposite – that by isolating mental health units, we stagnate in comparison to our forward-thinking relatives in other specialities, hide away our deficits and struggles and encourage insular practice.

So those are my initial thoughts, but there is so much left to be said. What do you think?

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