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Mental health patients are being 'detained in all but name'

Posted on January 31, 2013 at 4:40 AM Comments comments (97)
The Care Quality Commission finds mental health patients denied information, and staff inadequately trained
Guardian article by Chris Campbell published on 30th of January

More people are being sectioned under the Mental Health Act and too many of those detained are subjected to unnecessary restrictions and get too little help to recover, the NHS watchdog reports today.The Care Quality Commission's (CQC) annual report into the working of the Mental Health Act 1983 (MHA) paints a picture of some pockets of excellent practice, where patients are treated with dignity and respect. But it also highlights concerns that "some hospitals have allowed cultures to develop where control and containment are prioritised over treatment and care".

David Behan, the CQC's chief executive, says: "Our report has found too many instances where people have been restricted inappropriately. It is unacceptable for the current situation to continue."In total, 48,631 people were detained in hospital to receive mental health treatment in England in 2011–12 – 5% more than the year before. Another 4,220 people became subject to a community treatment order – up 10%. A further 16,000 people voluntarily admitted themselves for treatment.

The CQC based its findings on visiting 1,546 wards, talking to 4,569 detained patients and checking more than 4,500 detention documents. Its findings include that on one in five visits – "an unacceptably high number" – MHA commissioners (inspectors) found that people who were in hospital voluntarily "might be detained in all but name". Although such patients are supposedly able to leave any time, "in 88 out of 481 visits there were no signs on locked doors that explained to voluntary patients how they could leave the ward".

The CQC is worried about staff being inadequately trained in how to correctly restrain those exhibiting disturbed or violent behaviour and wants safeguards improved. Some staff at a learning disability unit had not had refresher training for two or three years, despite the high number of such incidents in their unit.

On one ward, two patients who had become very disturbed were restrained by police using a Taser gun, according to the report. The CQC also found "two further examples of patients who were Tasered while being transferred in detention". Taser use within hospital premises "is of great concern" and raises questions about staff numbers, it said.

Of the 4,576 patient records checked by the CQC, 4% "showed irregularities that called the legality of the detention into question [which] means that more than 180 patients may have been unlawfully detained".

Paul Farmer, the chief executive of the mental health charity Mind, voiced concern that "people's basic human rights are being infringed at a time when they are likely to be at their most vulnerable". He says the overall rise in detentions and community treatment orders is "very worrying" and "is symptomatic of problems elsewhere in mental health services". According to Farmer, better access to talking therapies, or well-resourced crisis-care services that can respond to a person's individual needs, can help prevent a situation escalating until compulsion appears to be the only option. "Yet we know from extensive research that mental health services are failing in all these areas," he says.

For Paul Jenkins, chief executive of Rethink Mental Illness, the report shows that "the system has become too focused on managing risk, at the expense of quality care and treatment". The NHS is wasting money because some patients are being "needlessly detained in very expensive settings", which is "unfair and potentially damaging to the individual", he says. Mental health needs to undertake "a fundamental shift" and put less into secure care and more into early intervention services, to stop people becoming acutely unwell, he adds.

The CQC is also concerned that mental health services are under growing pressure, with wards overcrowded, staff overworked and too few community services. In some places, patients are being discharged too early, or without enough support. The watchdog is also worried that despite many initiatives, such as improvements outlined in the coalition's mental health strategy and a mandate to the NHS Commissioning Board, which legally requires the board to pursue the objectives of putting mental health on a par with physical health, there is still "a significant gap between the realities CQC is observing in practice and the ambitions of the national mental health policy". Its report concludes: "Practice in some areas ... is a far cry from the policy vision."

There are no things, only relationships

Posted on January 15, 2013 at 2:37 PM Comments comments (89)
Ian McGilchrist gives a lecture at Schumacher. Watch here. 

Free New York Times archived articles on mental health

Posted on November 22, 2012 at 8:24 AM Comments comments (99)

A proposal to classify happiness as a psychiatric disorder

Posted on November 21, 2012 at 5:09 AM Comments comments (2)
Here's a very funny also strangely spooky scientific satire by Richard Bentall, who makes a tongue-in-cheek proposal that happiness be classified as a psychiatric disorder. Or at least I think it is tongue-in-cheek. He might be serious. (Read it here)

Bentall's argument is seductive, wildly entertaining but also strangely spooky because it shows how seemingly impecable logical sequencing of arguments can nevertheless lead to an absurd conclusion. It simply turns all arguments for considering aspects of mental life symptoms of psychiatric disorders on their head. 

Bentall is obviously having a justified dig at the proliferation of psychiatric disorders, and whether there's anything there at all to prevent all human emotions being conceived as abnormal. Bentall proves that one certainly can rake up the arguments to do so and how useful to the task are conceptually vague concepts such as "normality" and "function". 

Childhood adversity affects brain function. Guardian science article

Posted on November 20, 2012 at 5:53 PM Comments comments (95)
Childhood adversity affects adult brain and body functions, researchers find. Poverty can impair working memory while physical abuse can raise risk of cardiovascular disease, scientists claim.

By Alok Jha, science correspondent (The Guardian, 16th of October, 2012)

Growing up in a low socioeconomic background can impair working memory as an adult and affect the size of different parts of the brain, researchers say. Photograph: Jeff J Mitchell/Getty ImagesAdversity in early childhood – in the form of anything from poverty to physical abuse – has measurable changes in the function of the brain and body well into adulthood, according to researchers.

Growing up in worse socioeconomic circumstances can impair working memory as an adult and affect the size of different parts of the brain, while abuse can lead to a higher risk of developing cardiovascular disease in later life, they report.

In a series of presentations at the annual meeting of the Society of Neuroscience in New Orleans on Tuesday, scientists reported on work studying critical periods of development for the brain. 

Eric Pakulak, at the University of Oregon, found that people who grew up in homes with a lower socioeconomic status had greater deficits in working memory, compared with those from wealthier homes, even when he controlled for the participants' education.Working memory, Pakulak said, was broadly associated with general intelligence. "As a four- or five-year-old, if you have very good attention and regulations skills, it's a foundational skill that would spill over into other areas of cognition – if you're trying to learn your letters, or to read, or learning numbers or math or a musical instrument. When you're learning a musical instrument, you're really training attention."He asked 72 adults to complete a test of working memory, where they had to remember the final words from a series of sentences. 

On average, adults from lower socioeconomic backgrounds could remember two words whereas those from more wealthy backgrounds, on average, got up to four words.Suzanne Houston, of the University of Southern California, showed that the size of different parts of the brain could be affected by growing up in different homes. "We found higher parent education, smaller amygdala. The higher the income, the larger the hippocampus."The overall size of brain regions was not of primary significance, she said, but the fact they were measurably different would allow scientists to tease out what sorts of differing environmental factors might be affecting the brain development of children from different backgrounds.Understanding environment can also help scientists to modify it. 

Pakulak said his work had informed the development of teaching courses that could, by working with parents and pre-school children from lower socioeconomic status backgrounds, improve aspects of parents' behaviour and reduce their stress, as well as improving children's behaviour and cognition within weeks."Most powerfully, we've shown that, after eight weeks, children in our intervention training group show the same [result for] brain function for selective attention that their higher [socioeconomic backgrounds] peers show," Pakulak said.

Layla Banihashemi, of the University of Pittsburgh, focused on the enduring effects of physical abuse in childhood. She found that adults who suffered physical abuse as children had greater increases in blood pressure when they engaged in stressful tasks as adults. Overall, she said, this would put them at greater risk of developing cardiovascular disease.

She asked 155 healthy adults, who were 40 years old on average, to complete a childhood trauma questionnaire, a standard way of assessing the level of physical abuse someone may have suffered as a child. "As physical abuse scores increased from none to moderate to severe levels, we saw significant increases in the change in blood pressure in response to stress," said Banihashemi.The mean arterial blood pressure in people who had suffered no abuse during childhood changed by 2.73mmHg, from a baseline of around 90mmHg, when they were stressed in Banihashemi's experiment. In the low abuse group, the average change was 4.71mmHg, and moderate or severe abuse in childhood elicited an average change of 5.45 mmHg. "People that have these heightened blood pressure responses, in magnitude and duration, are more at risk at developing cardiovascular disease," she said.

Banihashemi added that most of the participants in her study were not in the severely abused category. "They are primarily within the minimal range – I think this is unique because it indicates that even minimal to moderate levels of abuse can influence stress responses of the brain and body."Andrea Danese, a clinical lecturer in child and adolescent psychiatry at King's College London's Institute of Psychiatry, said the series of studies addressed important questions in the understanding of how childhood experiences shape adult lives.

Pakulak's work, he said, was particularly interesting because it showed how it was possible to remediate the consequences of a lack of opportunity early in life. "These changes might support upward social mobility and improve family environment across generations."He added that replication of developmental studies would be crucial in working out which effects are real and which are not. "A key limitation is that human studies linking early experiences to later brain, psychological, or health outcomes are observational in nature," he said. "For ethical and practical reasons, researchers can seldom actively manipulate children's experiences and more often have to passively observe differences in experiences and relate them to certain outcomes.

"However, because different experiences or vulnerabilities – poverty, insufficient stimulation, maltreatment, parental mental illness, low IQ – often occur together in the same children, it is challenging to confidently point to the effects of one specific experience without its active manipulation."

Previous meta-analyses have shown that being sexually or emotionally abused as a child can affect the development of a part of the brain that controls memory and the regulation of emotions. In addition, people with a history of abuse or maltreatment during childhood are twice as likely to have recurrent episodes of depression in adulthood. These individuals are also less likely to respond well to psychological or drug-based treatments.

Suicide prevention polemic

Posted on November 19, 2012 at 9:08 AM Comments comments (0)
To follow up on my earlier posts on suicide, I three more contributions to the polemic whether suicide is preventable or not. Two were published in the October 1994 of the BMJ, before the Department of Health published its prevention strategy plans. 

Greg Wilkinson contribution to the debate is that better treatment of mental illness is a more appropriate aim. It is "difficult to resist the conclusion that suicide is not morally wrong" and that "suicide may be rational". Although we understand better the suicide risk factors (such as a diagnosis of mental illness including severe depression, Bipolar Affective Disorder, schizophrenia, personality disorder, PTSD, previous suicide attempts, gender etc) we are still finding it difficult to predict suicide. The reasons may be that suicide intent is not constant, many people with whom we associate high risk factors do not commit suicide, and "when an event is as rare as suicide even a predictive factor with high specificity and sensitivity includes too many false positives for practical purposes". 

Wilkinson believes that our resources should be concentrated on treating clients with mental illness "properly".

H. G. Morgan in response argues that prevention is possible if doctors are taught how. Whilst we cannot prevent all suicides, we should try to avoid those suicidal deaths that might be avoided. Morgan believes that this does occur, and yet we may not be able to quantify this effect because the patient lives. In other words it is easier to count the failures to prevent suicide than the success in facilitating someone staying alive. 

Morgan also argues that those who are suicidal remain ambivalent until the end, and that we need to support the part of the patient that wants to live. He also urges us to hold onto the hope that even the worst circumstances can change for the better. The distressed cause to survivors may be "disabling for many years". Risk factors are invaluable tools and all mental health practitioners can be trained to incorporate them in their practice. 

The third article comes from the Psychiatric Times, and raises the question whether there is enough evidence that psychopharmacology (drugs) can help prevent suicide. Leonardo Tondo (et. al) focus on Lithium, a drug used to treat Bipolar Affective Disorder and other psychotropic drugs.

Reviewing the available research Tondo has found that the potential anti-suicidal effect of psychotropic drugs is "strikingly limited" and that in particular there is inconclusive evidence that antidepressants help prevent suicides. Lithium however seems to have a stronger evidence base as many studies support the impression that risk of suicide and suicide attempt is far lower during treatment with this drug. "Neurobiological mechanisms that might be involved in apparent anti-suicidal effects of lithium include decreased impulsivity and hostile or aggressive behavior that may be mediated by enhanced functioning of the central serotonin system." Interestingly though, suicide risk is also lowered significantly when the patient is treated with a placebo. 

The study concludes that "altered suicide risk may be obtained with some modern antipsychotic and anticonvulsant drugs commonly used to treat patients whose illnesses include suicidal ideation. However, such applications, and even use of lithium, require further systematic study for both positive and possible adverse effects on suicidal behaviours."




Psychosis: the facts so far

Posted on November 15, 2012 at 4:47 AM Comments comments (1)
From the 2012 Schizophrenia Commission report (subtitles added by me): 

"Nowadays, about 45% of people who receive a diagnosis of schizophrenia recover after one or more episodes, but about 20% show unremitting symptoms and disability and the remaining 35% show a mixed pattern with varying periods of remission and relapse (Barbato, 1998). 

Contributing factors

There is no single cause but rather a range of factors combine to push an individual into psychosis. Genes contribute to vulnerability (Kim et al, 2011; Rees et al, 2011) and children who are born premature or suffer oxygen starvation at birth also have a higher risk. 

Heavy abuse of drugs such as amphetamines and cannabis is increasingly considered to be important (Di Forti et al, 2009; Casadio et al, 2011). 

A range of early socio-psychological adversities such as separation from a parent, being a migrant, growing up in a city, or being persistently bullied or abused, all increase risk of psychosis. Similarly, adverse life events and trauma can precipitate the illness. 

Dopamine

All the factors that increase risk of psychosis ultimately impact on brain dopamine levels (Di Forti et al,2007). For example, not only do recreational drugs increase dopamine levels but so does stress. High brain dopamine levels then lead a person to experience unusual perceptions and give excessive importance or “salience” to commonplace events (Van Os and Kapur, 2009). When people have such overwhelmingly strange experiences they try and find some explanation and this may lead them into delusional thinking.

Until recently it was thought that there was a clear distinction between people who had psychosis and the general population. However, numerous surveys have shown that up to 15% of the general population will experience hearing voices at some point in their life and 15-20% have regular paranoid thoughts (Tien, 1991; Freeman and Garety, 2006). 

There is therefore a continuum between those who have no psychotic symptoms and a sizable minority who have mild symptoms that cause them no trouble. A smaller proportion of these people are distressed by their symptoms and consult mental health services and are considered as having psychosis: many of those who are most distressed and disabled by their symptoms meet the conventional criteria for schizophrenia. Schizophrenia has blurred borders not only with normality but especially with bipolar disorder and with depression. 

Diagnosis

This overlap is the reason why people may be given different diagnoses by different clinicians. Because of the dissatisfaction with the present system of categorical diagnosis, there have been repeated attempts to find an alternative. One is a system based on four symptom dimensions: psychotic symptoms (hallucinations and delusions); affective dysregulation (depression, mania and anxiety); negative symptoms (lack of motivation and withdrawal) and cognitive difficulties (Van Os et al, 2010)."

Failed care for sufferers of Schizophrenia

Posted on November 15, 2012 at 4:33 AM Comments comments (98)
In 2011 Rethink Mental Illness set up an independent commission led by Professor Robin Murray, to look into how the needs of people diagnosed with schizophrenia are serviced in secondary care. They interviewed both experts in the field and people who have lived with this illness. Tere were 2500 respondents to an online survey. 


Some 220.000 people in England are diagnosed with Schizophrenia. These people are cared by a system that the independent commission found was "broken and demoralised" and "does not deliver the quality of treatment that is needed for people to recover".

Some of the problems identified by the commission:
  • the wards are anti-therapeutic and frightening places
  • nurses are overwhelmed
  • medication is prioritised at the expense of psychological interventions
  • not having a say in choice of psychiatrist
  • families of sufferers have to battle for basic services
  • poor access to general practitioners and general hospital care
  • a fragmentation of services which prevents people from continuing to be treated by the professionals they trust
  • Early Intervention in Psychosis services are being cut

The commission also heard that "good care delivered by kind, compassionate practitioners can make all the difference.(...) Time and time again we heard of a transformation whereby an apparently downward course was reversed by a nurse, doctor, peer or therapist who tool the time to listen and understand."

Some facts about severe mental illness
  • sufferers die 15-20 years earlier than non-clinical population
  • the NHS currently spends £11.8 billion a year on treatment
  • compulsory treatment is on the rise. Levels of coercion increase every year
  • only 1 in 10 get access to psychological therapies
  • carers (family members) are not treated as partners and are not receiving support

Physical illness increases the risk of mental illness

Posted on November 12, 2012 at 10:15 AM Comments comments (2)
According to an article in the Times: "Doctors must give equal priority to mental cases"  the new NHS mandate will be to place mental health care at the heart of its new framework. The Centre for Mental Health produced a report (read it here in full), which highlights the prevalance of mental health illness among people with physical health conditions (two to three times higher than in the general non-clinical population, as well as the fact that medical staff are routinely over-looking this aspect of their patients care, or are simply not inclined to see it having a crucial influence over the patient's recovery rates.  

The Centre for Mental Health wants to see more liaison psychiatrists involved in the overall assessment and care management of patients. 

I have selected below a few paragraphs from the report. I have included subtitles and italics to highlight the most striking statements. 

"Physical health and mental health are inextricably linked. Poor physical health is a major risk factor  for poor mental health, and equally, poor mental health is a major risk for poor physical health. 

Despite this pervasive interplay, NHS services for mental and physical health are largely  commissioned, funded and provided in separate compartments. A heavy price is paid for this lack of integration in terms of poorer health outcomes for patients and in greatly increased costs of care to the taxpayer. 

The better management of co-morbid physical and mental health conditions probably offers more scope for contributing to the Quality, Innovation, Productivity and Prevention (QIPP) agenda of better health at lower cost than any other activity in the 
NHS."

Co-morbidity
"A recent review of the evidence on co-morbidities indicates that people with long-term physical health conditions, who together account for around 70% of all expenditure in the NHS, are two to three times more likely than the general population to experience mental health problems such as depression, anxiety or dementia (Naylor et al., 2012). In total, this amounts to some 4.6 million people in England with co-morbid physical and mental health problems.The prevalence of mental and physical health co-morbidities is particularly high among patients in general and acute hospitals. 

One reason for this is that a significant number of patients develop a health problem during their stay in hospital, in addition to those who are admitted with an existing condition. Another is the very high proportion of older people in the inpatient population."

Undetected mental health issues
"Many cases of mental illness among hospital patients go undetected by acute clinical staff. Estimates of detection rates vary between studies but are commonly put at around 50%, and may be even lower for some conditions such as delirium. There are various reasons for this. The presence of physical illness may make the detection of mental health problems more difficult. Hospital staff often have little training or expertise in the identification of mental health conditions. They may understandably focus attention on the primary health condition for which a patient has been admitted. And they may feel that a degree of mental distress is a natural reaction to illness and hospitalisation even though this may conceal more serious problems."

Poor health outcomes
"Co-morbid mental health problems lead to much poorer health outcomes for people with physical health conditions. For example, mortality rates for individuals with co-morbid asthma and depression are twice as high as among people with asthma on its own (Walters et al., 2011). Similarly, people with chronic heart failure are eight times more likely to die within 30 months if they also have depression (Junger et al., 2005). There is also evidence that co-morbid mental health problems can have a greater effect on the functional status and quality of life of people with long-term physical conditions than the severity of their physical illness (Yohannes et al., 2010; de Jonge et al., 2006), and that quality of life for those with co-morbid mental and physical health problems is considerably worse than among people with two or more physical health problems (Moussavi et al., 2007)."

Medically unexplained symptoms
"Medically unexplained symptoms are surprisingly common. For example, they account for about 50% of all first attendances at outpatient departments in general hospitals (Nimnuan et al., 2001), and patients with medically unexplained symptoms may be among the most frequent and intensive users of health services in both primary and secondary care settings. Medically unexplained symptoms are not covered in the cost estimates given in Naylor et al., but a separate study published in 2010 indicates that the overall cost to the NHS of medically unexplained symptoms is nearly £3 billion a year (Bermingham et al., 2010)."

Older patients
"Detection rates for mental health conditions among older patients are typically very low. For example, one study found that delirium was missed in up to two-thirds of cases (Inouye, 1994), while a meta-analysis of studies of depression in older medical patients showed a median detection rate of just 10% (Cole & Bellavance, 1997). And even when problems are identified, the treatment provided by clinical staff in acute hospitals is often sub-optimal, including over-use of psychotropic medication in the management of dementia and delirium (Holmes et al., 2003) and failure to provide anti-depressants for the majority of depressed older patients (Holmes & House, 2000). Psychological interventions are very rarely used."