Brain/mind: a false divide

Every so often I’m reminded of a conversation I had some time ago with a researcher (who shall remain nameless) who wasn’t too keen on psychiatry. I want to reflect on that discussion to examine the fallacy of the brain-mind divide and how it’s just not possible to partition away emotions as something the medical model shouldn’t be dealing with.

Doctors are quite within their rights to treat brain diseases, this man said. Problems with moving your arms and legs, physical sensation or balance are all perfectly suitable ailments to see a neurologist with. But emotions and the mind are different things entirely. For a doctor to go interfering with those would be quackery.

So I asked him – what did he make of the fact that people with Parkinson’s disease suffer more frequently with depression than the background population? This sadness was understandable psychologically, he said, as a result of being ill. And he seemed quite satisfied with that. The emotions were not brain symptoms but something separate.

But people with Parkinson’s disease, I replied, get depressed more often than people with equally distressing and disabling diseases which don’t involve the brain tissue, like rheumatoid arthritis. Surely the brain being affected by disease must be changing the emotions of the patients? Where on earth are emotions from if not the brain?

Eventually he retreated at this point, conceding pretty reluctantly that brain diseases could affect emotions and therefore these emotions could be treated by doctors. But never, he was firm, should they be conceptualised using the medical model when there is no sign of brain disease. If there’s no organic disease for the neurologists to treat, then no one should go treating emotions – a seemingly convenient divide.

But is that really so simple a segregation? Let’s take an example – epilepsy. People with epilepsy are three times more likely than the background population to have a psychotic episode. So by the rule of treating emotions when there’s a brain disease present, we can go ahead and treat. But hold on – using simple maths, a third of those people would have had a psychotic episode anyway, just like the background population do. And there’s no way of telling which third they are. So what do we do, treat them all or treat none of them as medical symptoms? Or guess?

The same argument can be applied countless times to other scenarios. People who use cannabis are about twice likely to become psychotic than the background population, but that means around a third to a half of people who smoke cannabis who become psychotic would have become psychotic anyway. Who do we treat as genuine organic drug-induced reactions and who do we say are just having ‘non-medical emotions’? Should we draw a line at one spliff a day, one spliff a week, maybe one spliff a year…?

People given steroids for tumours or inflammation can become manic. I’ve seen it many times. But by simple probabilities we know some of them would have become manic anyway, because of the stress of the illness. There’s just no way of telling which are which.

People with multiple sclerosis have a 50-50 chance of being depressed at some point, compared to a variable but lower number for people without the disease. Should we call it disease-related depression if there are only one or two tiny plaques on the brain scan, or not? Where is that divide now?

This all boils down to a simple point. If something is a symptom in the presence of an obvious brain disease, it’s still a symptom if there is no obvious brain disease. It is valid to conceptualise depression, mania, and psychosis in medical terms because there is no convenient dividing line between “brain disease-caused” and “non-brain disease-caused”. In the end, all emotion comes from the brain whether something worrying shows up on a scan or not. Furthermore, the thought of denying people effective medical help for their highly distressing emotions unless they have evidence of a coarse brain disease is actually pretty perverse.

But this is not to say that emotions should be treated like cold, hard neurological signs like loss of sensation or power in your limbs. Every medical discipline has their tools of treatment – surgeons their scalpels, dermatologists their creams, public health doctors their policies, medics their tablets – each catered to their relevant illnesses. We can still use social and psychological treatments to relieve and limit symptoms whilst calling them just that.

Likewise, just because something is a symptom doesn’t mean it has to be treated. Not every cough is a chest infection, not every knee twinge needs a joint replacement. So not every low spell needs a tablet and not every bizarre thought needs a section.

As for the man who I was talking to, I’m not sure he agreed with me. He told me frustratedly that “fine, you can believe in the brain, and I’ll believe in the hand”, and strode off. He never did explain what he meant.

‘In case of crisis, go to A+E’

A+E can be an intensely frustrating place for mental health patients in crisis. Having recently finished another set of night shifts in the department, I thought it might be a good time to discuss why visits there seem to be so unsatisfying.

When I asked people for their experiences on social media, some did have very positive memories – but many others couldn’t have been less pleased with the treatment they received. Their responses were very useful in the writing of this blog and I’ve included some of their illuminating tweets throughout.

It seems that a lot of the time, these bad experiences were generated by a fundamental mismatch between what A+Es are designed to provide and what patients in mental health crisis actually need.

I’ve worked in A+E as a general medical doctor. The modern vision of an emergency department, especially following the implementation of the 4 hour breach target, is of a fast-paced and well-oiled machine designed to treat people quickly and move them on. The most urgent of procedures are carried out in the department (setting broken bones, resuscitation, stitching up cuts) but the onus is very much on getting the patients out.

Now, there are several ways in which A+E can be very useful to mental health patients using this style of working:

Ruling out a physical cause for your symptoms. Is this ‘psychosis’ actually an encephalitis, a thyroiditis or a brain tumour? Especially for patients presenting for the first time, performing a thorough batch of tests is essential. In my experience we hugely under-investigate psychiatric symptoms and probably miss quite a lot of treatable disease.

Providing a brief place of safety. Though many patients should undoubtedly go to 136 suites, there are certainly also a subgroup for whom A+E is appropriate. Acutely,  grossly intoxicated people who express a fleeting wish to harm themselves, for example, can be physically monitored and sleep off the risky thoughts.

Treatment for self harm and overdose. Having easy access to efficient medical help for these problems is a vital part of mental health care.

Getting an urgent prescription. It’s hardly ideal, but if you desperately need more of your tablets in the middle of the night, A+E is the only place to go.

Being the gateway to an emergency admission. Community and home treatment teams, in a perfect world, should be spotting and dealing with potential admissions during the day, but for the genuinely unpredictable emergencies, A+E can get you into psychiatric hospital – if there’s a bed.

But these positives struggle to cancel out the fact that the atmosphere and structure of A+E departments are directly at odds with perhaps the most important thing mental health patients actually visit the department for:

Emotional support during a crisis.

A+E departments are necessarily busy, noisy and impersonal. Because they’re used to caring for people on the edge of death and disaster all day, they’re built to ensure the emergency medical care is given efficiently – at the cost of ‘optional’ extras like complete privacy and tranquillity. Patients frequently overhear their names and conditions discussed in cold medical terms just outside their cubicle, detracting further from any sense of warmth.

The medical and nursing staff, used to taking bullet-point histories to exclude life-threatening disease and working long, exhausting shifts, don’t find it easy to suddenly switch into calm, reflective, empathic mode when someone comes in with self harm or another mental health problem. In fact sometimes their tiredness, mixed with a lack of mental health training, can even boil over into blaming the person for coming in.

The environment isn’t easy for mental health professionals either. As much as we want to help patients who turn up in the depths of despair in the middle of the night, it’s difficult to give them what they need. We often don’t know their history very well, it’s hard to form a rapport with someone you’ve just met, and we have a long list of other patients who need to be seen urgently too. That’s even if there’s a liaison psychiatry service – many hospitals still don’t even have one, meaning patients have to sit around in the department to see the team they need.

The opposite can happen too. The four hour target pressures departments to get people out quickly, when what patients in mental health crisis need is the exact opposite – somewhere to feel relaxed without any threat of rejection.

All in all, the lack of services on offer in A+E can lead to a complete disillusionment with the prospect of going there. So many patients tell me that despite the fact that patients are often told to go there, they are then simply told to ‘go home’, ‘take these tablets’ or ‘see their care team in the morning’. It can feel dismissive – but what else can A+Es offer? The things they’re good at – heroic lifesaving procedures, CPR, broken bones – isn’t any use to them with these problems.

It doesn’t help that often we put ‘in case of crisis, go to A+E’ on crisis plans. We need more appropriate places for people in mental health crisis to go. Drop in centres and crisis houses are far more suitable environments, but are just the type of services that get cut when the going gets tough – which it has. We need to prove that they’re good at making people feel better, deal well with crises and are therefore worth recommissioning. Going to a place where people are highly experienced in mental health and know you well, instead to A+E to see a random, bleary-eyed doctor, perhaps with little mental health training at four in the morning, shouldn’t be difficult to sell as a more therapeutic option.

Furthermore, to really get to the heart of this problem, we need to think systemically. Better staffed and funded community teams, social services and psychological therapy services could prevent crises before they even happen. By the time the patient gets to A+E, the horse has already bolted.

The Crisis Care Concordat highlights many of these problems, but I won’t be the first to reserve judgement until the money to fund the improvement appears and change genuinely starts to happen. Until then, unfortunately, for many people it’s A+E or nowhere.

Sectioned for a bed: results of our RCPsych survey of trainee psychiatrists

Some aspects of the crisis in mental health care, like the 1,700 bed closures and 101% ward occupancy rates, have been relatively easy to estimate. But worrying practices associated with the strain on resources, like patients being sent home in the absence of a bed or being sectioned to secure one, have been far harder to quantify – until now.

The Royal College of Psychiatrists Trainees Committee has surveyed all junior doctors working in psychiatry in the UK for their experiences over the last 6 months. These doctors are fully exposed to the problems, having an unrivalled view of care from 9am to 5pm and often making decisions about admitting or sectioning patients themselves when consultants are at home in the evenings and at weekends.

576 such doctors responded, and what they told us was deeply concerning.

Over 70% had experienced difficulty finding an appropriate bed for a patient. In child and adolescent services (CAMHS), that number was 83%. Sadly these findings weren’t unexpected, but the rates of various practices associated with the scarcity of beds certainly were.

A shocking 37% told us that a colleague’s decision to section a patient under the Mental Health Act had been influenced by the likelihood of finding a bed – perhaps that by doing so it would legally force the provision of a potentially otherwise unavailable bed. 18% were even willing to tell us that their own decisions had been influenced in such a way. A Health Select Committee report published to widespread concern last summer suggested that patients had been deprived of their liberty to secure a bed in isolated cases, but the true rate seems to be far greater.

Doctors usually use the Mental Health Act as a last resort for patients who desperately need hospital care but are so unwell that they refuse. Now they are presumably beginning to use it increasingly often for patients who aren’t actively refusing an admission, because it’s their last remaining option to make sure very unwell people get the care they need. And it’s no wonder they have to do so, when 24% reported that a bed manager had told them that beds were closed to all patients except those under section. Again, a policy of desperation in the face of pitifully limited resources.

Even if a bed is somehow found, it could be absurdly far away. 80% of respondents had been forced to send a patient outside the boundaries of their trust, with over a quarter sending a patient over 100 miles away. In CAMHS, this was a heart breaking 37%. Unsurprisingly, such transfers were reported to be detrimental to care. Dragging a mentally exhausted, fragile and often acutely distressed person away from their families is not a form of care I recognise – especially if that person is a child.

As an alternative to being exiled hundreds of miles, three out of ten doctors had seen a patient admitted to a ward but without a bed, presumably leaving them to sleep on a sofa. One in five reported that they’d admitted people to beds belonging to patients on periods of trial leave – at least giving a temporary fix. But when the original owner of the bed comes back, as they often do, out comes the sofa again.

After a decade in medicine the only circumstances in which I have known patients to be admitted to hospital without an official bed have been whilst volunteering in the developing world and in UK mental health.

Still, a sofa may be better than sending a critically ill patient home because no bed can be found. An alarming 28% admitted to doing that. The rate in CAMHS was even higher at 37%. If just one paediatrician reported that they’d sent a sick child with asthma or appendicitis home simply because there wasn’t a bed, the reaction would be swift and scathing. But if the child has a mental health problem, their suffering appears not to warrant the same level of concern.

It would be easy to conclude that the answer to this nightmare is additional beds. That would certainly help, as would providing emergency support to forestall the plans to close more beds in some places, but the cause of this crisis is more pervasive. A chronic institutional bias against mental health has suffocated the funding of our speciality in every area. Community teams have seen their funding plateau in the face of a 13% increase in referrals despite the fact that a recent report suggested that for every £1 invested in early intervention we could save £15 in later hospital admission costs.

As reassuring as it is to read the recent Closing the Gap and Crisis Care Concordat policies, only a clear, urgent and substantial pledge of extra funding will convince mental health professionals that things are about to get any better. Despite the heartening rhetoric, such funding has not been forthcoming.

In fact, following February’s NHS England announcement that mental health services would ironically be subject to greater tariff cuts than our counterparts in acute services, Professor Dame Sue Bailey suggested that the frankly dangerous levels of under-resourcing might lead us to become the next Mid Staffs.

Based on these stats, I would go further. What will it take for us to admit that we’re already there?

The full results of the survey can be found here.
The results of the survey specific to CAMHS can be found here.

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