This chapter is based on a chapter of the same name which I wrote with Maggie Bloom, barrister, Hardwicke Chambers, for Clinical Negligence, 4th edition, ed. Powers, Harris and Barton, London: Tottel 2008.
I am most grateful to my co-author and the editors and publishers for permission to use this material.
INTRODUCTION
The interaction between the law and psychiatry has always been
complex. The present chapter attempts to cover those aspects of
psychiatric practice most relevant to the clinical negligence
practitioner:
(1) development and present state of psychiatric services; (2) classification of psychiatric disorders; (3) Treatments for psychiatric disorders; (4) Mental Health Acts 1983 and 2007; (5) Common areas of psychiatric negligence; (6) Relation between complaints process and negligence; (7) Group litigation; (8) Mental Capacity Act 2005; and (9) Psychiatric injury/nervous shock.
THE NATURE OF PSYCHIATRY
Much ink could be spilt on an attempt to define psychiatry, but in an article about negligence it seems more sensible to concentrate on
psychiatric services. For present purposes, psychiatric services are
taken as those specialist services, mainly in secondary care, for
patients with mental health problems, to which they are (usually)
referred by their GP, or some other agency. Psychiatric conditions also
form, of course, a substantial part of the workload of general
practice, and they also occur in all departments of the general
hospital. Independent healthcare providers and non-governmental
organisations also figure increasingly. These important additional
aspects of psychiatric services will be discussed further below.
Current mental health care provision
It is natural to a psychiatrist to start a chapter about psychiatric
negligence by writing about hospitals. But psychiatric services are no
longer synonymous with psychiatric hospitals or beds. Psychiatric
services are now predominantly delivered outside hospitals. For
example, an episode of illness which formerly would have led to
inpatient admission may now very well be dealt with ‘in the community’,
by a Crisis and Home Treatment Team. However, starting with some
description of psychiatric hospitals is probably still appropriate, as
the more seriously affected patients, whose care is presumably most
likely give rise to allegations of negligence, will likely still have
substantial portions of that care delivered in hospital.
History of mental health care provision
It is impossible to understand the present configuration of mental
health services, and the way in which they are developing, without some
historical background. Controversy about imperfections in mental health
care service provision is in fact nothing new. In the 18th and early
19th century, there was concern over the lack of provision for ‘pauper
lunatics’, who were seen as inappropriately accommodated and
maltreated, for example in jails or workhouses. There was also a series
of scandals concerning the treatment of better off patients in the
private ‘madhouses’ of the day, regarding poor treatment or
misappropriation of property or other abuses.
(See Gill D
B ‘A commission of lunacy, mad doctors, and happy hunting’ (1993) BMJ
307(6919): 1603–1606 for an account of a well-observed fictional
episode befalling Surtees’s Mr Jorrocks.)
A series of
Lunacy Acts to regulate such matters followed, but these pale beside
the astonishing outbreak of sustained social conscience which produced
the Asylum Movement of the 19th Century.
Each county
had its own asylum, mostly built by public subscription in the 19th
century. In other words, they were largely paid for by individual
charitable gifts from local inhabitants, motivated at least in part by
peer pressure, that is, a desire to ensure that provision for the
mentally ill in their area was as good as that in other counties. These
asylums dominated the development of psychiatric services for the next
150 years or more. As the then Minister of Health, Enoch Powell,
famously put it as late as 1961,
‘There
they stand, isolated, majestic, imperious, brooded over by the gigantic
water-tower and chimney combined, rising unmistakable and daunting out
of the countryside – the asylums which our forefathers built with such
immense solidity to express the notions of their day.’
However,
he also, in the same speech, foretold correctly – though this is less
often quoted – that ‘the institutions themselves are doomed’.
In the early years of the asylums, there was therapeutic optimism,
through the medium of work (and religion) (and music: Elgar was the Bandmaster at Powicke Hospital, near Worcester).
One downside, however, was
the implanting of a presumption in our culture that, if someone
developed mental health problems, that necessarily meant that he had to
go – or be taken – to a hospital, likely distant and strange. This
presumption is only now in the last 20 years or so being challenged by
the idea that persons with such problems could, indeed should, be
looked after at or near home if possible.
The asylums
are now almost all closed (at any rate in England and Wales, though
some cling on in Scotland, Ireland and the dominions). These were
substantial buildings, typically with large farms, on which the
patients did actual work, as a real form of occupational therapy. This
probably benefited their wellbeing in many cases. At their height, they
had huge numbers of beds, but a series of scandals in the 1960s and
1970s, in combination with the then fashionable ‘anti-psychiatry’
movement, hastened a secular decline in bed numbers which had been in
train since the Second World War.
The first step, from
about the 1950s, in the move away from the asylums was the provision of
outpatient services. At the time, unbelievable as it may now seem, it
was a new departure for psychiatrists to practice outside their
hospitals. Inpatient bed use remained heavy, and individual stays often
protracted.
From the 1960s and 1970s, the main further
development was the provision of psychiatric services, including
inpatient wards, on the same site as District General Hospitals. This
tended to mean in local towns, rather than in the countryside where the
asylums usually were. This has been later followed by the development
of Community Mental Health Services, with staff working outside
hospitals, that is ‘in the community’.
The process of
asylum closure gathered pace. But a number of well-publicised cases
gave rise to concern about whether patients, especially long-stay
patients who might have lived in the hospital for many years, were
being adequately provided for outside. There were legitimate concerns
about whether a patient being moved from a large hospital to
accommodation outside would have the care and facilities necessary, and
traditionalists did look back with nostalgia to the better aspects of
the old system. The fact of the matter however is that the vast
majority of patients were resettled adequately and, when asked,
preferred their new circumstances.
Although asylums
were provided largely from individual charity for the benefit of
patients, they had been taken over by the NHS in 1948. Unfortunately,
the capital from the sale of these by now very valuable assets was not
ringfenced, and went neither to the original founders, nor to
specifically psychiatric services, but disappeared into state coffers.
As an elderly Macmillan said about the public utilities, psychiatric patients have had their family silver sold, but did not benefit financially from the
proceeds.
NHS mental health services
Most mental health problems are minor and self-limiting, and are dealt
with in primary care, but if they are protracted or severe the patient
may be referred to specialist mental health services. The main
providers of mental health care remain NHS trusts. Most are separate
from acute hospital trusts, though some ‘unitary trusts’ do exist.
In many cases, mental health trusts have amalgamated with those parts
of local authority social services which have historically also dealt
with mental health patients, through the provision of social workers
and other facilities. Often, the local authority’s social care
responsibilities are delegated to the resulting Trust, which may be
styled a ‘Partnership Trust’.
A typical mental health
Trust will have an adult psychiatric inpatient unit or units, usually
with separate wards for the elderly. It will run a number of Community
Mental Health Teams, each covering a defined patch, based on the
patient’s address or registered GP. There will be other resources, such
as Day Centres or Day Hospitals, though the details of provision vary
greatly from area to area.
The provision of services in
the community is constantly changing; the influence of central planning
seems to have increased over the past 10 years. The ideas of the
Sainsbury Centre for Mental Health have been influential.
The development of specialised teams has been encouraged – these include:
(1) Assertive Outreach,
who have smaller case loads, specifically looking after patients, who
tend to drop out of follow up, and therefore have worse outcomes, to
try to improve their care and keep them out of hospital (so-called
revolving door syndrome).
(2) Crisis and home treatment,
whose remit is to look after patients, who are becoming acutely unwell,
so as to try to prevent inpatient admission, or promote early
discharge. They will use a package of measures such as frequent home
visits, supervised administration of medication, promotion of
attendance at day hospital, etc.
(3) Early intervention,
whose remit is to identify younger patients in the early or so-called
prodromal phase of the development of serious mental illness such as
schizophrenia, and through intensive treatment to try to prevent these
patients going on to develop the full-blown illness.
(4) Eating disorder, specialising in patients with anorexia, bulimia.
(5) Forensic psychiatry,
offering a variety of services, including assessment of individual
patients, caring for a caseload of their own, and prison inreach, court
diversion, etc
(6) Child and adolescent, offering an almost entirely community-based service, working closely with paediatrics and schools.
(7) Learning disability, again, these days almost entirely community-based, accessing a variety of resources including day centres and workshops.
Each
of these teams will be multidisciplinary: it will include a consultant
psychiatrist, either on a full-time or sessional basis, a psychiatric
junior doctor, administrative support, and a mixture of predominantly
community psychiatric nurses and social workers, usually also with some
input from occupational therapy and psychology.
At
the time of writing, the vogue for these multiple teams seems to be
starting to pass. They have all been formed, of course, out of
‘existing resources’, and the view seems to be gaining ground that
there could be efficiency savings or ‘economies of scale’ in
re-combining some of these teams.
‘Foundation Trusts’
have greater autonomy, and may bid for work outside their existing
boundaries. Their budget from government is more protected, but they
have limited borrowing powers and are thus, at any rate at present,
dissimilar from commercial businesses.
Non-NHS mental health services
Many other types of body also provide mental health services, including:
(1) hospitals and clinics in the independent sector, for-profit and otherwise; and
(2) charities and other NGOs, for example providing day centres.
It is likely that political changes will lead to further changes in
how services are provided. In future, organisations other than NHS
Trusts, whether commercial or not-for-profit, may contract with
purchasers (currently known as Primary Care Trusts, or PCTs) to provide
clinical services. (It is of course already very common for
non-clinical services (catering, cleaning, etc) to be contracted out.)
These changes seem likely to proceed more quickly in England, than in
Scotland, Wales and Northern Ireland.
Complexity may be
the order of the day in future; for example, a service might say NHS
‘on the tin’ but be provided by a private company or NGO under
contract. It is likely to be important for purchasers and providers of
services to have measurable standards, and mechanisms for ensuring that
they are maintained.
Structural problems in current mental health services
The post-asylum era has been associated with long-term shortage of
resources in mental health services, which continues to date. Bed
closures have continued, and bed numbers have probably now gone below
an optimum level. It is common for bed occupancy to exceed 100 per cent
in the NHS, and spillover into non-NHS beds is common.
This all leads to acute psychiatry having to be practiced in highly
pressured circumstances, with pressure from administrators to avoid
admissions and ‘leave beds’ (the bed of a patient who has been sent
home for a period of leave to see how he does prior to discharge)
having to be used. It is in such circumstances that adverse outcomes
are more likely. These organisational factors, as well as clinical
error, will need to be assessed and taken into account in any
investigation thereof.
Responsibilities of organisations providing services
Before moving on to matters concerning the clinical care of individual
patients, where possible negligence by a health professional may be at
issue, it is important to remember that organisations also have to meet
standards. For example:
(1) access to services – the NHS Act
and other legislation and regulations may give a patient rights to care
from NHS and social services; and
(2) various ‘watchdogs’
supervise health and social care providers, including CHI, the
Commission for Health Improvement, and the Mental Health Act
Commission.
The reported performance of an organisation according to such yardsticks could be relevant to a negligence claim.
ORGANISATION OF PSYCHIATRY, TRAINING OF PSYCHIATRISTS, FIELDS OF PRACTICE
When the last edition of Clinical Negligence was published, the training of
psychiatrists was firmly in control of psychiatrists themselves,
through the Royal College of Psychiatrists, and the specialty retained
considerable power in the organisation and administration of mental
health services. For good or ill, psychiatrists have lost power in both
areas.
Government has established the Postgraduate
Medical Education and Training Board (PMETB), to oversee training and
the issuing of Certificates of Completion of Specialist Training. This
has led to concerns that Government’s need to ensure a sufficient
number of trained consultants has caused the standard of training to be
watered down. It is clear that consultants are now being appointed
whose length and breadth of training is less than was previously the
case.
For UK medical graduates, the main route to
specialist training in psychiatry continues to consist of doing junior
training positions in the speciality, combined with studying for the
membership of the Royal College of Psychiatrists, the recognised
postgraduate diploma in the specialty. This is followed by competitive
interview for a position as a specialist registrar, which, after
approximately three years, subject to assessment, leads to eligibility
to be appointed as a consultant psychiatrist.
The names
of the positions have changed; previously, pre-MRCPsych trainees were
predominantly senior house officers (SHOs), and post-MRCPsych trainees
on programmes of specialist training were known as senior registrars.
Nowadays, they are denoted, more cumbersomely, ST1-3, for SHOs, and
ST4-6, for senior registrars. (‘ST’ means specialty trainee, and the
numbers refer to the years of training).
Other routes
to consultant appointment have opened up. Psychiatrists from EU
countries who can demonstrate eligibility to consultant appointment in
their country of origin are now eligible for NHS consultant
appointments, and many such appointments, notably of colleagues from
Eastern Europe, have in fact been made. Also, it has been made possible
for psychiatrists who have worked for some years at senior but
sub-consultant levels, such as Associate Specialist, to apply to PMETB
for a Certificate of Eligibility for Specialist Registration; if they
can demonstrate appropriate experience and training, they may be
awarded the Certificate, which permits application for Consultant posts.
Overall, therefore, since the last edition of Clinical Negligence, there has
been an increase in the number of NHS consultant psychiatrists;
training has changed to be shorter and more focussed on the needs of
the NHS, but has inevitably been diluted somewhat. Some middle-grade UK
psychiatrists and some European colleagues, who have not followed the
traditional MRCPscyh training route, have nevertheless been made
eligible to consultant appointment. Secular decline in the authority of
the consultant within organisations has continued.
Every patient in the NHS would previously have had a consultant
psychiatrist at least nominally in charge of his care. This will still
apply if he is an inpatient or attending outpatients, even if he is
only seeing a trainee (ST1-6, speciality trainee covering the grades
formerly known as SHOs and Registrars) or a non-training sub-consultant
grade (these are permanent positions, Staff Grade and Associate
Specialist, the latter the more senior). However, patients may these
days be seen by CMHT members only, and not seen by (or their case even
discussed with) a psychiatrist.
The GMC has issued
guidance on working with teams, which says, broadly speaking, that the
consultant is not responsible for adverse outcomes in patients seen
only by other non-medical members of his team.
SPECIALISMS WITHIN PSYCHIATRY
The College recognises the following specialist areas:
(1) academic; (2) addictions; (3) child and adolescent psychiatry; (4) forensic psychiatry; (5) general and community psychiatry; (6) liaison psychiatry; (7) psychiatry of learning disability; (8) psychiatry of old age; (9) psychotherapy; and (10) rehabilitation and social psychiatry.
The
largest speciality is general adult psychiatry; often appointments may
be with a ‘special interest’, for example, half general adult and half
liaison.
REVALIDATION AND RELICENSING
Partly in response to the crimes of Harold Shipman, the Department of
Health, with the Royal College of Psychiatrists and NHS Trusts, has put
in place processes to try to check that doctors in post are up-to-date
and safe. Originally, this was planned to lead to ‘revalidation’ to
continue practice, or not, as the case might be. Revalidation seems to
have been dropped, at least for the time being, but the process
continues. It has three parts:
(1) a programme of Continuous
Professional Development (CPD), which requires psychiatrists to
maintain, develop and remedy any deficits in their knowledge and skills
relevant to their professional work;
(2) job planning; and
(3) appraisal.
Continuous Professional Development (CPD)
is the responsibility of the individual consultant. He must meet with
his peers and agree a Personal Development Programme (PDP), which is
registered with the Royal College of Psychiatrists, and which sets
specific learning targets for the year. At the end of the year, the
completed plan is submitted to the College on a self certification
basis, though random checks are carried out to make sure that the
information, for example about courses attended, is accurate.
Job planning
involves agreeing a timetable and objectives with the NHS Trust; it is
carried out with the consultant’s medical manager (Lead Clinician or
Medical Director, the precise terms vary) in the form of an annual
meeting. It represents the NHS’s input into the process.
Appraisal
is the final link in this chain. If the consultant has an agreed job
plan, and his PDP is up-to-date, he can have an interview with an
approved Appraiser from his Trust, as a result of which he is regarded
as having been appraised.
It seems doubtful whether
this somewhat toothless process would stop another Shipman, who
apparently had many unsolicited thank you letters from patients.
However, it is to be hoped that the process will help identify
struggling colleagues at an early stage.
CLASSIFICATION OF PSYCHIATRIC DISORDERS
In psychiatry, it is unusual for there to be a single, well-understood
cause of illness. There are a few exceptions, for example Alzheimer’s
Disease, which is caused by physical degeneration of specific cells in
the brain, leading to dementia, and Down’s Syndrome, where the person
is born with three copies of chromosome 21, instead of two, leading to
learning disability.
In the vast majority of mental
disorders, however, there is no single clear cause. Even in the
examples given, the precise mechanism whereby the physical or chemical
abnormality gives rise to the clinical features is not completely
understood. It follows therefore, that classification of mental
disorder cannot be based on cause alone. Current international systems
of classifying psychiatric illness such as DSM or ICD (see below)
recognise this. They are essentially descriptive, and do not make
assumptions about the presumed causes of the various illnesses. They
are the cumulative result of many years of research and observation,
and refinement through successive editions. They represent the
collective opinions of experts about how the various categories within
them can best be codified so as to fit as closely as possible the
observed patient data.
DSM stands for Diagnostic and
Statistical Manual of Mental Disorders – Fourth Edition, known as
DSM-IV, of the American Psychiatric Association. ICD stands for
International Classification of Diseases, 10th Revision, known as
ICD10. It is produced by the World Health Organisation, and is the
official classification for the rest of the world, including the UK
NHS. ICD10 is free online at
http://www.who.int/classifications/apps/icd/icd10online/. DSM IV is
available by subscription only, though unofficial versions do exist on
the internet.
DSM vs ICD
Until the publication of DSMIII in 1980, US psychiatry, as previously
indicated, was heavily influenced by Freudian and other psychoanalytic
theories. Although of continuing interest to many, these theories are
now agreed to be without scientific basis. DSM since then has ‘caught
up’ with ICD in eschewing theory in favour of observation. It has
gained in influence relative to ICD, possibly outstripping it in
certain aspects, such as its multiaxial system (see below). DSM has
also brought to prominence now-familiar terms such as ‘major
depression’ and ‘PTSD’. Unlike ICD, which has just one ‘axis’ on which
to code for mental disorder, DSM has 5 axes.
(1) Axis I:
mental illnesses, an illness being defined as a state of impaired
health with a clear onset following a period of normal function.
(2)
Axis II: for recording (in the jargon, ‘coding’) the presence or
absence of personality disorder(s) and learning disability (the latter
was formerly called mental handicap or retardation); here, the
abnormalities are permanent, and are apparent from adolescence or
earlier.
(3) Axis III: Physical health problems.
(4) Axis
IV: Psychosocial and Environmental Problems ‘is for reporting
psychosocial and environmental stressors that may affect the diagnosis,
treatment, and prognosis of mental disorders.’
(5) Axis V:
Global Assessment of Functioning Scale ‘is for reporting the
clinician's judgement of the individual's overall level of functioning
and carrying out activities of daily living. This information is useful
in planning treatment and measuring its impact, and in predicting
outcome.’
Both classifications are regarded as valid
for UK use. The ICD is the official classification for the UK NHS. It
would not be generally accepted that one was better than the other for
medicolegal purposes.
Caveats concerning DSM and ICD
These systems are guides only, describing ‘conditions coming to the
attention of psychiatrists’. They are designed to summarise the
assessment of the clinician, and to improve research and communication.
They were not designed specifically for medicolegal use. They are not
intended for lay use; they are not ‘cookbooks’, which dispense with the
need for the psychiatric expert, any more than a collection of law
books makes the services of a lawyer unnecessary. Thus, ICD and DSM are
only properly used when they are interpreted by the seasoned clinician
in the light of experience and expertise.
‘Best
estimates’ rather than immutable scientific truths, there are
differences between DSM and ICD, and between successive editions. They
are ultimately no more than continually developing consensus statements
of committees of researchers, but nevertheless do form a useful summary
of the ‘state of the art’. Real patients seldom fit with complete
neatness into the categories; indeed, patients may have more than one
diagnosis, as the categories are not mutually exclusive.
Psychosis vs neurosis
Psychosis vs neurosis is another key concept in understanding the classification systems.
Psychosis
In psychosis (eg, schizophrenia), the patient has lost touch with
reality. They experience delusions (unshakeable false beliefs) and/or
unreal perceptions (eg, hallucinations such as hearing voices when
no-one is around). The connections between their thoughts may be
disrupted (‘formal thought disorder’). This is a severe illness, and
approximates to the lay idea of ‘madness’. The patient does not realise
that they are unwell (‘lacks insight’). Psychosis due to mental illness
is sometimes termed ‘functional’, to distinguish it from ‘organic’
psychosis, which refers to psychotic states due to defined physical
factors, such as drug intoxication or withdrawal (eg, delirium tremens
in the case of alcohol). ‘Psychosis’ and ‘psychotic’ are still
‘respectable’ terms, widely used in clinical practice and in the ICD
and DSM.
Neurosis
Neurosis, by contrast, is generally a less severe and much more common
state. The patient is free from delusions and hallucinations – they
know that their worries or depressive thoughts, for example, are
excessive for the reality of the circumstances, and therefore recognise
them as irrational. The vast majority of cases of anxiety and
depression are of this type.
Use of terms such as
‘neurotic’ or ‘neurotic depression’ is less frequent because of the
pejorative connotations the word has accquired in lay use. (This is a
frequent occurrence in psychiatry; ‘paranoid’ is the latest escapee
from the textbooks to the street. Even ‘lunatic’ was originally a
technical term.) Accordingly, the word neurotic or neurosis would not
be used frequently in clinical or medicolegal practice. The distinction
between psychotic and non-psychotic states remains vitally important,
however, but normally, the presence of psychosis will be made clear.
The word ‘neurosis’ still occurs in the ICD, though not the DSM, as
part of the rather unwieldy title ‘Neurotic, stress-related and
somatoform disorders’.
Available therapies
Modern psychiatry make use of a range of treatments, most of which are
reasonably well-founded in evidence. As usual, the evidence base is
stronger for specific types of medication or psychological treatment,
rather than for broader questions of service delivery such as hospital
admission.
Medication
Medication is probably the mainstay of psychiatric treatment, not
because it is the only effective treatment, but it is the most readily
available; non-drug treatments typically depend on the involvement of
highly trained staff, who are usually in short supply and may not be
available, especially at short notice. Psychiatric medications can be
grouped together under the term ‘neuroleptics’, although it is less
used these days. The main types are set out below.
Antidepressants
Antidepressants are probably the most widely prescribed, especially in
general practice. Probably the best known is Prozac, the trade name for
fluoxetine, which was one of the first SSRI antidepressant drugs
available. Such drugs have been very widely prescribed, and have made
enormous sums for the manufacturers. Concern has been expressed (see
below) that side-effects from SSRIs (such as agitation in the early
stages of treatment, with possible increase in risk of suicide) have
been downplayed by the drugs companies, and also that the heavy
involvement of the companies in psychiatric research may have led to
changes in the way psychiatric practice has developed. This may have
amounted to a moving of the goalposts in favour of more frequent
diagnosis of depression, and consequent promotion of prescription of
antidepressant medication.
Tricyclic antidepressant
drugs, the ‘previous generation’ before the SSRIs, remain available.
They are probably more effective, especially in severe cases, but at
the disadvantage of being potentially toxic in overdose. Obviously,
this is a potential cause for concern if they are being prescribed to
patients with a risk of suicide (and all patients in mental health
services have an elevated risk of suicide, compared with that of the
general population). However, a patient determined upon suicide has a
variety of other easily available methods, for example, purchase of
paracetamol from a shop. Prescribing tricyclics is not in itself,
therefore, contra-indicated in patients with, for example, severe
depression. It will be appropriate if the drug is considered as the
best one for the condition being treated, and if it is combined with
appropriate risk assessment.
Now little used, the
monoamine oxidase inhibitors or MAOIs are a group of powerful
antidepressants, which have an unusual dietary restriction, namely that
the patient has to avoid an eclectic group of foodstuffs including
yeast, cheese, broad bean pods and Chianti. These have in common that
they contain tyramine, which can cause high blood pressure, if combined
with MAOIs. If unchecked, this could proceed to the patient having a
stroke. Although the risks are actually very low, these unusual matters
invariably worry patients, and MAOIs are underused as a result, which
is regrettable as they are sometimes effective when other drugs have
failed.
Major tranquillisers
Also known as antipsychotics, major tranquillisers, as the name
suggests, are mainly used in psychosis, for example schizophrenia,
paranoid psychosis, mania and psychotic depression. The first
generation of these drugs, typified by chlorpromazine and haloperidol,
produced some astonishing improvements in long institutionalised
patients when they were first introduced in the 1950s, to the extent of
allowing many of these patients to leave hospital. At this stage, they
tended to be used in low doses.Subsequently, there was a tendency to
try the use these of these drugs in higher doses, in the remaining
patients who had not responded; there was little further improvement,
even on very excessively high doses, which tended to produce
side-effects such as weight gain and Parkinson like states
(extrapyramidal side effects). This is how the older antipsychotics got
their bad reputation.
However, they remain an excellent treatment in moderate doses, when they often produce few side-effects.
More modern, and much more expensive antipsychotic drugs, the
so-called ‘atypicals’, such as olanzepine and risperidone, are widely
prescribed; initially, as with all new drugs, they were thought to have
few or no side-effects, but 10 years on, the adverse effects are
becoming clearer, particularly weight gain and diabetes, and risk of
stroke in the elderly.
Antipsychotic drugs are
available in long acting injection form, so called ‘depot’ medication,
which is very useful for patients who are not reliable at taking
tablets (poor ‘compliance’ or, to use a more recent word,
‘concordance’).
Anticholinergic drugs
Anticholinergic drugs such as procyclidine are helpful in combating Parkinsonism due to antipsychotic drugs.
Mood stabilisers
Mood stabilisers such as lithium and a variety of anticonvulsants
drugs including carbamazepine and valproate are used in bipolar
affective disorder (formerly known as manic depressive psychosis),
where, if taken regularly, they reduce the severity and frequency and
duration of episodes of mood disorder. Problems surrounding lithium
treatment are covered in more detail below: the level of the drug in
the blood needs to be monitored by regular blood tests, as also do
thyroid and kidney function. Lithium has a bad name for adverse
effects, particularly kidney damage, mainly because of historical use
in high doses with poor monitoring; negligence cases have arisen for
this. In modern use, with proper monitoring and more moderate doses,
adverse effects are rare.
Anticonvulsants
Anticonvulsants (especially in women of child bearing age) such as
carbamazepine and valproate are widely used as alternatives to lithium
in bipolar disorder; carbamazepine has its own side effects, notably
blood and liver problems, and also requires blood monitoring. Valproate
is probably the most widely used drug for this indication in the US. It
does not usually need blood monitoring. These drugs raise the risk of
malformations in the foetus, which is discussed below.
Minor tranquillisers
Minor tranquillisers, such as the benzodiazepines, the best known of
which is diazepam (trade name Valium), are less frequently prescribed
these days because of the risk of addiction (see below). (Alternatives
for patients requiring short-term medication treatment for agitation or
insomnia include small doses of antihistamines.)
Stimulants
Stimulants are used to treat the controversial condition ‘attention
deficit hyperactivity disorder’, ADHD, in children. They are intended
for short-term use as part of a multidisciplinary treatment programme,
but because of shortages of resources in child and adolescent mental
health services, there is frequently pressure from various parties,
including schools, to prescribe for long periods. The best known drug
is Ritalin, the trade name for methylphenidate, which is a kind of mild
amphetamine. They are not currently licensed for this indication for
use in adults in the UK.
It seems to the authors that
there is something intrinsically contradictory in the use of stimulant
drugs to treat a condition defined by overactivity. The ‘condition’ may
well be partly due to changes in children's lifestyles, in particular,
reduction in physical exercise, and the increasing use of television,
videos, computers, computer games etc. These drugs are being heavily
promoted, on both sides of the Atlantic, and it is possible that future
years will see re-examination of the basis for their widespread
prescription not only in medical circles, but also possibly in legal
ones.
Acetyl cholinesterase inhibitors
Acetyl cholinesterase inhibitors are used in Alzheimer's disease and
other kinds of dementia. There has been controversy about their
availability in some circumstances in some parts of the UK, but not
England. They can to some extent slow disease progression, and help
delay need for institutional care.
Psychological treatments
Psychological treatments are popular with patients, and also
fashionable; a government minister, Lord Layard, went so far as to
propose mass availability of cognitive behaviour therapy (CBT), the
most favoured form currently, in dedicated ‘psychological treatment
centres’, though it is presently unclear whether, or to what extent,
this is going to be implemented, though pilot schemes of Improving
Access to Psychiological Treatment (IAPT) are underway. IAPT may
encourage the employment of “graduate workers”, typically psychology
graduates, who are given basic training in CBT, especially computerised
CBT (see below), and employed in Enhanced Primary Care Mental Health
Teams.
A great deal of counselling is done in primary
care, and although there is little hard evidence of clinical
effectiveness, it is popular with patients, who see it as preferable to
‘drugging the problem’. In fact, most such mild problems would probably
resolve with the passage of time in any case. For significant degrees
of anxiety and depression, the evidence is that medication combined
with psychological treatment is superior to either alone.
Cognitive behavioural therapy is a form of psychological treatment,
which has evidence of effectiveness across a range of mental health
problems. The treatment combines cognitive therapy and behavioural
therapy. Cognitive therapy is based on the idea that repeated patterns
of thinking can influence mood, and that organised efforts to change
thought patterns can improve mood. Behavioural therapy is based on the
idea that increasing activity can improve confidence and reduce
symptoms, for example, ‘getting back on the horse’, if one has had a
fall. CBT for depression, therefore, might involve half a dozen
individual sessions with a therapist, starting with the development of
a shared understanding of the current problems, setting goals for
therapy, and their achievement progressively through thought exercises
and activity scheduling, progress being monitored by the keeping of
written records.
Such systemised therapy is obviously
well adapted to the use of the written word, and schemes of ‘books on
prescription,’ sometimes dignified with the name of bibliotherapy, are
widespread and seem acceptable to patients. Computerised therapy is
also increasingly available. Other forms of therapy such as the
traditional psychoanalytic therapy, deriving from the work of Freud and
successors, are now, generally regarded as not evidence-based, and are
accordingly less and less available in the NHS.
Occupational therapy
Occupational therapy has a long history, and when it was in the form
of real work was likely helpful to many patients. Occupational
therapists have followed patients out of the hospitals into the
community mental health teams, where they often run groups, for example
to help patients with self-esteem or assertiveness, and help
particularly in rehabilitation back into employment.
IMPORTANT DISCLAIMER This website is provided in good faith for general information only, based on Dr Gill's understanding of psychiatry in the UK. It does not represent the views of any organisation with which he has a relationship. It is not to be taken as advice or opinion on any specific case or issue whatsoever. In particular, material provided about the method of assessment in medicolegal cases or about any other matters is not to be taken out of context. Opinion expressed by Dr. Gill in an individual medicolegal case and method of assessment may adhere to or depart from the material on this website entirely according to his professional judgement. Nothing on this website forms part of his terms and conditions for medicolegal work, let alone part of his reports. Nor does Dr. Gill holds himself out as an authority on these matters. Other views undoubtedly exist on most if not all matters covered, which may be just as valid as his. No liability is accepted for any use of this website, or for any error or omission. By using the site, you agree to these terms. The text partly derives from Outline of Psychiatry, a textbook originated by Dr Jenny Barroclough, later prepared jointly, and the most recent edition by Dr Gill.
