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.

 

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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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