This post is about exploring the DSM and how the axes are currently used with a proposal for a new way of using the DSM in determining need for health care interventions. I may be out of sync with other places internationally that have already taken this pathway - or similar - but I’ve not seen anything thus far to lead me to think so. Let me know.

Multi-axial system

The DSM-IV organizes each psychiatric diagnosis into five levels (axes) relating to different aspects of disorder or disability:

• Axis I: clinical disorders, including major mental disorders, as well as developmental and learning disorders
• Axis II: underlying pervasive or personality conditions, as well as mental retardation
• Axis III: Acute medical conditions and physical disorders.
• Axis IV: psychosocial and environmental factors contributing to the disorder
• Axis V: Global Assessment of Functioning or Children’s Global Assessment Scale for children under the age of 18. (on a scale from 100 to 1)

The Global Assessment of Functioning (GAF) is a numeric scale (0 through 100) used by mental health clinicians and doctors to rate the social, occupational and psychological functioning of adults. The scale is presented and described in the DSM-IV-TR on page 32. Children and adolescents under the age of 18 are evaluated on the Children’s Global Assessment Scale, or C-GAS.

There’s a debate on Shrink’s page where he rightly questions:

What’s mental illness? At what stage do we say that problems aren’t necessitating input from specialist professional services?

Traditionally, presence of an Axis I diagnosis has been the primary indicator - if someone has a diagnosable MH condition services are usually compelled by social policy to intervene at some level, even if only to ‘monitor’. This is quite prejudicial and is fuelled by the continuing misrepresentation of just how far MH contributes to aberrant behaviour.

Tho level of service is generally always associated with how this impacts on the persons life; this is exactly what the GAF targets - how someone is ‘coping’ with life.

Kennedy has developed an assessment of Axis v GAF which covers:

1) Psychological Impairment
2) Social Skills
3) Violence
4) ADL-Occupational Skills
5) Substance Abuse
6) Medical Impairment
7) Ancillary Impairment

I’ll admit I’ve no more than a passing knowledge of the Kennedy GAF or any other similar GAF assessment models (eg Camberwells Assessment of Need; DWP Personal Capability Assessment); but if ‘a’ GAF tool is comprehensive enough, and inter-rater reliability can be optimised - surely a GAF is a better indicator of when MH services should intervene (coercively or otherwise) and/or to what extent; rather than an Axis I, II or III which are only indicators on treatment pathways and do not particularly demonstrate how compromised someone may be with that condition?

And if we’re going to deprive someone of their liberty under MHA Law on ‘probability’, surely that assessment of probability ought be as robust and reliable as possible, represent the reality of the situation and not rely on speculative argument determined primarily by the presence or absence of a single condition?

Following on from Z’s discussions on Anger Management in kids; NY Times has breakthrough news on how to help kids adjust - it suggests not punishing them for bad behaviour but reward them for good behaviour. Astonishing.

The problem may not be the kids so much as the way parents define discipline. Childhood health experts say many parents think discipline means meting out punishment. But often the punishments parents use end up reinforcing the bad behavior instead of correcting it. Surprisingly, the most effective discipline typically doesn’t involve any punishment at all, but instead focuses on positive reinforcement when children are being good.

They also highlight in Training Young Brains to Behave; how we can

.. err… encourage children to have better self control at an early age by concentrating on brain activities that develop the executive functions of the pre-frontal cortex around the 2 year old mark.

Some children’s brains adapt quickly, while others’ take time — and, as a result, classmates, friends and adults are interrupted for years along the way. But just as biology shapes behavior, so behavior can accelerate biology. And a small group of educational and cognitive scientists now say that mental exercises of a certain kind can teach children to become more self-possessed at earlier ages, reducing stress levels at home and improving their experience in school. Researchers can test this ability, which they call executive function, and they say it is more strongly associated with school success than I.Q.

.. and probably more psychopathy than empathy.

Moving on… it get’s better… schizophrenia and depression is now linked to middle east terrorism … but Down Syndrome people remain cuddly and are no longer vilified.

Psychiatric case files of two female suicide bombers who killed nearly 100 people in Baghdad this month show that they suffered from depression and schizophrenia but do not contain information indicating they had Down syndrome, American officials said Wednesday.

[I feel like I should apologise for drawing attention to this article and may in fact edit the link to direct to the BNP instead.]

Finally from the Numpty Yanks Times, in an attempt to exonerate them - I find an article that looks at the over-medicalisation of normal sadness:

Let’s say a patient walks into my office and says he’s been feeling down for the past three weeks. A month ago, his fiancée left him for another man, and he feels there’s no point in going on. He has not been sleeping well, his appetite is poor and he has lost interest in nearly all of his usual activities. Should I give him a diagnosis of clinical depression?

In their recent book “The Loss of Sadness” (Oxford, 2007), Allan V. Horwitz and Jerome C. Wakefield assert that for thousands of years, symptoms of sadness that were “with cause” were separated from those that were “without cause.” Only the latter were viewed as mental disorders.

With the advent of modern diagnostic criteria, these authors argue, doctors were directed to ignore the context of the patient’s complaints and focus only on symptoms — poor appetite, insomnia, low energy, hopelessness and so on. The current criteria for major depression, they say, largely fail to distinguish between “abnormal” reactions caused by “internal dysfunction” and “normal sadness” brought on by external circumstances. And they blame vested interests — doctors, researchers, pharmaceutical companies — for fostering this bloated concept of depression.

The argument could not be put better. Alas, Dr Ronald Pies MD (is that Ronald “Pies” MacDonald - a new venture?), closes with:

Until solid research persuades me otherwise, I will most likely see people like my jilted patient as clinically depressed, not just “normally sad” — and I will provide him with whatever psychiatric treatment he needs to feel better.

I was going to add a list of contra-indicating research about how anti-depressants often raise the chance of suicide and self harm between 2% - 4% especially in children and young people in the first weeks of use - but eh, what’s the point?

Moving on to news closer to home - my home that is -

They claim they were not warned by the psychiatrist who prescribed the antidepressant that it carried an increased risk — between 2 per cent and 4 per cent — of causing suicidal thoughts and self-harm in children and young people in the first weeks of use.

Crucially, they were not told their daughter would require close monitoring because of this risk. They were also not informed that the drug is not recommended for treatment of depression in children by either Australia’s drug monitoring agency, the Therapeutic Goods Administration, or the drug company Pfizer, which markets Zoloft in Australia. And they were not given a copy of the consumer medicine information leaflet that is supposed to detail these issues when they bought the drug.

However, as they later learned, even if they had got a copy of the leaflet, it would not have told them much of this anyway.

Yay - it’s not just UK MH patients who are not informed on medications then. The girl in this post lived through her overdose. The authorities therefore thought there was no need to report it as a potential adverse reaction. Drug companies always seem to get away with it.

In other Aussie news;

FOUR criminal charges against Pan Pharmaceuticals founder Jim Selim were dropped yesterday but the company was later fined $10 million for 53 offences related to altering the ingredients of therapeutic drugs it exported to Vietnam.

In April 2003, Pan, worth more than $300 million, collapsed after the TGA suspended Pan’s licence and issued the recall of all Pan’s products, the largest recall in the world. Earlier that year, consumers had reported hallucinations and severe illness after taking the Pan-manufactured travel sickness drug Travacalm.

I think it was advertised under the slogan : “The trips are better with Travacalm”.

In another Aussie story that must have come as a huge surprise -

Assisted suicide advocate takes her own life

The story is actually a very sad indictment against the criminal treatment of those who support euthanasia which highlights an increasing need to support open and accessible real discussions on the issue.

VOLUNTARY euthanasia advocate Caren Jenning has taken her own life to avoid dying in jail.

The 75-year-old, who had cancer, was three months ago convicted of being an accessory before the act of manslaughter over the death of dementia sufferer Graeme Wylie.

Jenning’s crime? She was the “drug-mule” who bought the Nembutal in Mexico and illegally into Australia.

A statement released by euthanasia advocacy group Exit International said Jenning “died peacefully from an overdose of the barbiturate Nembutal”, the banned sedative she obtained from Mexico for Wylie’s partner, Shirley Justins.

Friend and fellow euthanasia campaigner Phillip Nitschke, who discussed Jenning’s decision with her over a “final dinner” last week, said she saw no alternative.

“She knew that if she did get a custodial sentence, she couldn’t just nip home and end her life,” Dr Nitschke said. “She said over and over: ‘I am not going to die in prison’.”

Justins, 59, was found guilty of manslaughter for killing Wylie, 71, after claiming his death in 2006 was an assisted suicide.

The manslaughter charge appears to have been made simply because “Justins was found to have killed her de facto husband without establishing whether he was capable of choosing to die”.

Both were facing up to 25 years in jail.

Prosecutors had argued that his death was motivated by greed. Wylie changed his will a week before his death, leaving most of his $2.4 million estate to Justins.

So he has capacity to change his will - but not to end his life? Pah.

Finally from Oz, this interesting advance in the disease-modifying treatment of dementia:

“We believe that as you age, the brain’s ability to control the concentration of zinc and copper fatigues,” Bush says. “You get an abnormal interaction, a build-up of zinc and copper in the synapses, the connection between nerve cells, and it causes beta-amyloid to accumulate and become toxic.”

The result is an abnormal beta-amyloid complex that forms the plaques so characteristic of Alzheimer’s disease.

Bush and colleagues have therefore taken the approach of trying to remove the zinc and copper ions from the abnormal beta-amyloid, using a compound they’ve called PBT2 after the Australian company involved in its development, Prana Biotechnology, which Bush helped found in 1997.

This compound has the ability to seek out the abnormal beta-amyloid, with its unwanted baggage of zinc and copper.

“The drug manages to selectively find this abnormal complex and helps to pull the zinc and copper off the beta-amyloid,” Bush says. “The zinc and copper then returns to the tissue and the beta-amyloid clears — it gets moved away completely and destroyed.”

ok.. so what super news has the UK got?

A swimmer has been banned from his local pool because of his unusual goggles.

Roland Grimm, in his late 60s, said: “I’m very upset because it seems mad. I’ve used these goggles in more than 100 pools and no one else has ever complained. After you’ve been swimming for 40 years all over the world you know what works best for you and what’s safe.”

Gary Dark, manager of the leisure centre in Swiss Cottage, northwest London, said the goggles were a health and safety risk because the glass was not shatter-proof and the nosepiece could cause breathing difficulties.

I’m not so sure it’s the goggles mate, or just the paedophillic look it gives you.

Six in ten (63%) of community psychiatric patients said this year they definitely had trust and confidence in their psychiatrist. This is up from 59% in 2004.

One in ten (9%) of community patients said they had no trust and confidence in their psychiatrist.

And 82% of community patients say their psychiatrist definitely treats them with “dignity and respect”. This is up from 79% from 2004. Only 3% said their psychiatrist did not.

CPNs also fare rather well

The survey reported that 86% of patients said they were definitely treated with respect and dignity by their community psychiatric nurse. Two per cent said they were not.

But on issues to do with out of hours access and information on medication, community services got the “could do better”. You can find the full survey here.

What is it about medication? This finding - that patients don’t feel they are given enough information - comes up time and time again in survey after survey. Is it that service providers feel that if they give too much information, patients will be more reluctant to take the magic tablets? Or is it that there is some aspect - qualitative or otherwise - of taking medication that just isn’t addressed in a bog-standard leaflet?

What do people think? Are you currently taking meds and are you happy with the information you were given, or did they miss out something vital? Are you dishing out/monitoring medication? What information do you regularly give the people you expect to take the meds? This is an area of nursing practice that nurses carry out all the time, and yet I feel it’s perhaps the one we think about (and know about) least.

Here in my part of Oz, mentally ill offenders can only have leave approved by the MHRT. When a person breaks the law in the context of a mental illness, it’s no longer a clinical decision as to whether someone is suitable for leave and all leave conditions are determined (increased, decreased or remain the same) by the MHRT at 6 monthly meetings.

Recent news has us once again reacting for our Risk Assessment calculator (that should say ‘reaching ‘ but oddly it doesn’t). Darren Harkin, a 21 year old who was resident of a low secure unit has been charged with the rape of a 14 year old girl after absconding. Darren is reported to have Autistic Spectrum Disorder. Not specifically a ‘mental illness’ - more of a mental disorder - but “he’s not normal” so he must be a mentalist.

Before I continue, a word of sympathy to the victim of this event; an event that no one disputes should not have happened. Though this posting may be somewhat anti-reactionist, I do not wish to minimise the nature of the events that have taken place.

The case highlights failures in a system which is backed up by an investigation carried out by reporter Nicola Stanbridge. The Today programme found that at least 94 patients escaped from medium and low secure psychiatric hospitals, or while under the escort of hospital staff last year.

Good work Nicola.

In response to the inevitable headlines, Louis Appleby has written a rather splendid piece in the Gunirada which reviews his interview on The Today Programme bashing stigmatism and reactionism [is that a word?]

In my interview I tried to explain how in mental health, unlike prisons, we have to strike a balance between care and security – against a tide of interruptions, hostile questions and incredulous asides, all the things that are so entertaining when they happen to someone else. What listeners would have concluded from the ensuing row is hard to tell. My nine-year-old said later, “I heard you on the radio arguing with that man.” Then he added, “Like you always do.”

Which somewhat differs from the Times Online report citing Uncle Louis as stating:

England’s director of mental health care today called for tougher standards for secure hospitals after it emerged that at least 116 mentally ill criminals escaped last year, more than 20 times the rate of escapes by offenders held in prison.

What appears to be the case, and this is the interesting part - is that Harkin was subject to a Restriction Order (s41 MHA) or similar.

In court, Judge Nicholas Cooke QC asked how Darren Harkin had managed to meet Home Office criteria to be housed in a low secure unit, having absconded three times from his medium secure unit and displayed destructive and aggressive behaviour

So if anyone wants to know how Harkin managed to get to being housed in a low secure unit - it’s because the Home Office said he could be. Of course, circumstances change and he may well have become more at risk. However, there are already many protocols in place for management of such offenders and, I really hope this do not lead to another level of counter-therapeutic security scrutiny and supervision.

In fact - isn’t it about time that the justice services picked up the supervision and monitoring role of managing “mentally ill” offenders in the community and stop this prejudicial treatment of the staff charged with their care? Mental health professionals are not trained to do anything that impedes the patient’s progress; we are by definition trained to do the opposite.

Further resources can be found here here and the full BMJ in iPaper for - here.

Scientists are exploring the use of psychedelic drugs such as LSD to treat a range of ailments from depression to cluster headaches and obsessive compulsive disorder.

In the Swiss trial eight subjects will receive a dose of 200 microgrammes of LSD. This is enough to induce a powerful psychedelic experience and is comparable to what would be found in an “acid tab” bought from a street drug dealer. A further four subjects will receive a dose of 20 microgrammes. Every participant will know they have received some LSD, but neither the subjects nor the researchers observing them will know for certain who received the full dose. During the course of therapy researchers will assess the patients’ anxiety levels, quality of life and pain levels.

I wonder what indemnity they asked for from the subjects against any claims for intractable mental instability?

Unless of course there is sufficient proof that it doesn’t cause such problems?

Andrew Feldmár writes also in the Gurniad:

I can only hope that if new research with psychedelics proceeds in a responsible, careful and creative manner, the powers that be can begin to support and foster further research into this fascinating realm. I was 27 when I first tasted this incredible substance called LSD. Now I am 68 and for the last two years have been persona non grata in the US, because a border guard Googled my name, and found an article I wrote many years ago on entheogen-assisted psychotherapy.

That article has an interesting anecdote of his LSD experiences:

The first time is unlike any other time. Zenon [his psychology supervisor] gave me 900 micrograms and the surprise of my life. He made himself comfortable, read a book, occasionally glanced at me, but otherwise he left me to my own devices and no words were exchanged. At one point he gave me a single stem of hyacinth to hold in my hands. I felt he had entrusted me with a fragile treasure, and I wasn’t sure I could do well by it. The strangest experience that day was what I would now call mind-interlock: although Zenon had taken no mind-altering drug, I read his mind, I became he, I knew everything he knew. I knew how he felt about his wife, I knew how he held his penis when he stood at a urinal, I knew what he thought about what he was reading. I experienced intense and embarrassing intimacy. Zenon seemed unaware that I was tapping into his soul. After some days, during which my embarrassment persisted, I asked Zenon about some of my more innocuous insights. He confirmed them all to be true, and felt short-changed because he had made no inroads into my mind. He had become transparent while I had remained opaque. I felt shy and uncomfortable to be so entwined with my thesis supervisor: I was loving him through knowing him. I had no critical thoughts, and felt deeper and deeper levels of acceptance.

This is the closest way I have ever found to describe “being off your tits”.

And In other news:

Random sex with strangers increases your happiness.

Nicotine and Alcohol linked to reduction in obesity; and:

Killing people who annoy you linked to a reduction in global stress levels.

A new vision for mental health is a discussion paper from seven national mental health organisations intended to provoke a debate on the best direction for future mental health policy.

The government’s ten-year plan - the National Service Framework (NSF) for Mental Health - will come to an end, signalling a new era. Important policy choices must be made to ensure both that its achievements are built upon and its shortcomings tackled.

Seven leading national mental health organisations have come together as the Future Vision Coalition to outline their proposals for a substantial shift in policy during the next ten years.

These organisations are: the Association of Directors of Adult Social Services; the Mental Health Foundation; Mind; Rethink; Sainsbury Centre for Mental Health; Together; and the NHS Confederation’s Mental Health Network. [pasted from here]

We agree that the underlying aims of future mental health policy must be to:

• overcome persistent barriers to social inclusion that continue to affect those with experience of mental health problems
• improve the whole-life outcomes of those with experience of mental health problems
• improve whole-population mental health.

This will not be easy to achieve, since attitudes have been ingrained over many decades of use, and because medical models of mental health problems have long dominated the debate about the appropriate focus for policy. However, we suggest ways in which we think the vision can be realised.

For the full vision, read the launch press release and the paper below.

Download a New Vision for Mental Health discussion paper (504 KB) [pdf]

The idea is to set a scenario and debate the issues it throws up - I explicitly invite “service users” to also jump in and stir the ethical stew-pot as well as our regular contributors.

#1 is around confidentiality (and risk).

Joe was diagnosed with schizophrenia secondary to drug use some 4 years ago. He’s been in hospital voluntarily on 3 brief occasions (4 - 8 weeks) - once as a social issue when he lost his flat and decompensated; twice for breakthrough symptom management that resulted in medication changes. Currently he’s on Olanzapine 10mg nocte and Risperdal Consta 25mg every 2 weeks. He sees the psychiatrist at outpatients every 3 months and the CPN fortnightly. His next psychiatrist appointment is in 5 weeks.

He has a history of criminal behaviour relating to his drug use (several ‘possessions’ and break & enter convictions) but nothing indicating a history of violence towards others. He has no family living near by, has several acquaintances though no close supportive friends but has been assisted by the local advocacy services on previous occasions. He is currently unemployed and receives DLA and also irregularly attends a day centre facility about two or three times a week.

As a community mental health nurse you visit with him at his home for regular review when he reports an increase in the presence of positive symptoms of schizophrenia. He discloses “voices” that have been telling them to “put the world right again” and thoughts of being “the chosen one”.

Your enquiry as to what this means exactly is replied to with ambivalent statements of “You know - just set the record straight; bring some justice”. Joe does not seem anxious or concerned about his current presentation and identifies no specific ‘plan’ to these thoughts.

You suggest Joe might benefit from an earlier psychiatrist review but he insists he doesn’t think it’s necessary. Then he says “I’d rather you didn’t tell the doctor cos he always messes with my medication and I hate that”.

What are the immediate patient considerations?

What decisions does the community nurse have to make?

What evidence is there to support any clinical decisions?

Estradiol is good for reducing symptoms of schizophrenia in women. A study of 102 female patients in a RCT (not sure single or double blind) published in the Archives of General Psychiatry showed clinically significant reduction in PANSS measurements.

The study seems ok; but only 102 subjects and over 28 days means more research is needed. It’s not a new theory but one that has been progressed by active demonstration with this new study.

Some links are here: PsychCentral; Science Daily; Medscape; Live Science.

It’s hoped they can create a drug version without the same known side effects of hormonal treatment and eventually trial on men also.

I sincerely hope this offers a treatment option - anything is better than nothing - but I’m getting a serious flashback to the future about this one.

As some of you may have guessed by now I am currently reading a book on “Social construction” or social constructivism or constructionism by Ian Hacking called the “Social Construction of What?”. At the risk of boring certain members of the audience even further (audience what audience?). I want to give a resume of Chapter 5 (pp 100 – 125) entitled “Madness: Biological or Constructed” and maybe draw a few conclusions of my own.

There are many controversial diagnosis in psychiatry (Intermittent explosive disorder, ADHD and conduct disorder in children, Sexual addiction and personality disorder in adults) where it is suspected the medical profession is medicalizing certain aspects of behaviour that until recently were considered deviant, naughty, normal or criminal but which are now seen as an illness in need of treatment. There are also cases of diagnoses that have gone the other way (homosexuality and moral imbecility) have all dropped out of current usage and are no longer considered illnesses.

Some mental illnesses are described as transient, they show up at a specific moments in time and place and then mysteriously disappear. Examples include hysteria in 19th century France, Multiple personality disorder in 20th century America and Anorexia which can according to Hacking can be quite local in its history and at the time of writing was particularly virulent in Argentina of all places.

But is there a sense in which mental illness is “constructed” or is it “real” and if mental illness is real what do we mean by real? Hilary Putnam had this to say about reality:

“ (there is a ) Common philosophical error of supposing that reality must refer to a single super thing, instead of looking at the ways we endlessly renegotiate - and are forced to renegotiate – our notions of reality as our language and our life develops”

So is there a sense in which reality is constructed and the dichotomy between what is considered real and constructed a false one in this case? “Socially constructed” and “real” do appear to be at odds with each other. Psychiatry is a part of medicine which views itself as a branch of the natural sciences dealing in “real” things not stuff which has been socially constructed or made up by social workers. Psychiatry sees schizophrenia at its heart as a biochemical/ neurological/ genetic disorder but a minority of critics think that the disorder itself has been socially constructed. Is there a way of reconciling these apparently incompatible views? Hacking thinks there is.

Hacking describes interactive, indifferent and natural classifications or kinds of things. He believes the idea of an indifferent kind of thing can be adapted to resolve the differences between the biological and constructionist camps. Hacking defines an indifferent kind as one that does not interact directly with its environment but is not entirely passive either. Electrons are indifferent to the idea of electrons and do not interact with the concept of what it is to be an electron and so remain unchanged by the concept. Electrons are there fore a natural kind of thing because they have no agency and act as a philosopher would say under description. Likewise the diagnosis of schizophrenia is indifferent to what it means to be a schizophrenic but a schizophrenic on the other hand is conscious of what it is to be schizophrenic and is changed by that diagnosis. Schizophrenics when allied with others who have the same diagnosis (Schizophrenia fellowships and interest groups) are able to influence the diagnosis which in turn changes how the diagnosis is viewed by those so diagnosed. There is in effect an active dialogue between the diagnosis and the diagnosed which evolves over time. A similar dialogue may be occurring between notions of what an electron is thought to be by scientists and how it is thought to behave in the laboratory but this has nothing to do with any independent thought or action carried out by electrons.

The word “kind” was first used in this context by JS Mill and William Whewell and was used to describe the way in which the thing or group being classified interacts with the classification and vice versa. The interaction between kinds and their classifications can be strong or weak in nature and occurs through a looping effect described above in relation to how a diagnosis of schizophrenia changes the individual and is turn changed by the individual. The social sciences (sociology, anthropology, psychology?, Psychiatry?) have for a long time tried to emulate the natural sciences (physics, chemistry, biology, medicine) to identify “true or natural kinds” that is kinds which are fixed and have an objective reality and nowhere is this more clearly demonstrated in Psychiatry than in the research to discover a neuro-chemical basis for schizophrenia.

Indifference does not necessarily imply a fixed and passive response. Schizophrenia may not interact with the idea of schizophrenia but schizophrenics interact with the business of psychiatry and with the psychiatrists who are attempting to treat the condition (or are they treating the individual?). When philosophers talk about natural kinds the indifferent nature of the kind in question is in a technical sense taken for granted, but natural also implies a fixed and passive quality that is not necessarily implied by indifferent. Things classified as natural are not aware of being so classified and do not interact with their classification but schizophrenics do react with their classification or diagnosis so schizophrenia, as it affects the individual, should according to Hacking, be seen as an indifferent rather than as a natural kind.

The targets for the natural sciences are relatively stationary; the targets for psychiatry (literally and figuratively) are, owing to the looping effect, not. The term Schizophrenia was first coined in 1908 by Eugen Bleuler but descriptions of schizophrenia like symptoms are to be found in the Egyprian Ebers Papyrus (BC 2000) and in ancient Greeks and Roman texts which describe symptoms of psychosis but not in a way that would satisfy a modern diagnosis of schizophrenia. However there is a widespread conviction in the psychiatric profession that like America, the condition was always there and waiting to be discovered and will continue to be with us as long as there are people around unluckily enough to be so afflicted. In the constructionist camp disorders like schizophrenia are interactive and essentially man made, in the biological camp they are fixed and timeless. Hacking thinks there is a middle ground by describing mental illnesses like schizophrenia as indifferent.

N.B. Hacking is describing the condition schizophrenia as it affects the individual as an indifferent kind he is not describing those diagnosed with schizophrenia as indifferent to their condition.

Now there’s a whole heap of debate on coercion and understanding the difference between a patient electing an informed choice as opposed to one who simply doesn’t see themselves as ill. However, I have a niggling question about this state of denial that others may be able to shed considered thought or experience on.

In the case of someone who denies the existence of a mental illness, is it ever found to pervade to the denial of other illnesses, particularly new found medical ones?

I’m not sure I’ve ever come across anything that reports on this phenomena. Lots on why patients won’t take their psych drugs or engage in psychosocial therapy - but nothing that establishes any real construct theory on the nature and extent of this ‘lack of insight’ phenomena.

I raise this primarily in light of a particular case of a man with schizophrenia who has since developed diabetes. He has not adjusted to this new condition well and requires much motivation to follow a decent diet. However, he doesn’t deny he has the condition, engages in glucose testing and takes his medication (tho is passively accepting of all other meds anyhow).

His insight into his shizophrenia is limited (ie - he reports experiences of voices and recognises them as why the doctors say he has schizophrenia  - but does not accept his fixed delusional beliefs as being odd or delusional or how these increase risk associated with his index offence of stalking a woman).

Surely, as he lacks insight, it would be logical to assume he wouldn’t accept his medical diagnosis either?

If this is not so - then why not so?

Any experiences of how patients are accepting of medical diagnoses - whilst denying the presence of mental illness phenomena/significance?

However, during my surfing I also stumbled across this Personnel Today HR website and was [expletives deleted] to read this insightful article. I make no apologies for posting in full - it has to be read to be believed. Incidentally, the site welcomes comments so feel free.

Mental health: Off message - No trace of nuts

22 May 2008 10:03

Warning: any member of the kneejerk brigade should have their hammers at the ready, and should begin tapping their patellas furiously in preparation for getting really, leg-twitchingly annoyed, for we are about to enter into dangerous territory. Into the mouth of madness, as it were.

How many workplaces across the UK display the cheery sign ‘You don’t have to be mad to work here but it helps’?

Yet when it comes to talking about mental ill health, people find the subject too difficult to tackle - either preferring to ignore the subject for as long as possible, or taking the moral high ground and pontificating furiously about the need to confront the issue in a caring and sharing kind of way.

Taboo

Mental ill health is undoubtedly something that most people will have some experience of at one time or another - either personally, or as a witness - and is, therefore, one of the few things that most people would be qualified to discuss.

But, by and large, we choose not to. And employers seem more reticent than the average person, with only 5% of them acknowledging that members of the workforce have any such problems.

However, the Shaw Trust rightly argues that employers need to wake up to the fact that many people in their workforce will have some form of mental breakdown at some time. And the recent House of Lords ruling that an employer has to pay compensation for failing to spot an employee’s suicidal tendencies suggests that employers should take the matter seriously.

But the TUC’s recent call for employers to encourage job applications from people with mental health difficulties and to urge individuals to disclose any mental health problems they may have (PersonnelToday.com, 16 May) shows that it has only the most tenuous grip on reality.

No clues

It suggests that organisations should abandon their fears about employing people with known mental health conditions, yet apart from some generalised information about how to spot symptoms of mental distress, gives few clues to help managers actually deal with the problem.

According to the TUC work-related stress accounts for over a third of all new incidences of ill health, and each case of stress-related ill health leads to an average of 30.9 working days lost. It says this equates to 12.8 million working days being lost to stress, depression and anxiety every year. Stress, it must be stressed - unlike ‘pressure’, which can be a positive motivating force - leads to mental ill health.

Costly failure

According to Tim Cooper, managing director of the Shaw Trust the failure to manage mental health in the workplace costs the UK economy as much as £9bn in salaries alone, not including the impact on productivity (Personnel Today ITALS, 22 April).

And figures form the Office for National Statistics show that at least one in four employees experiences stress, anxiety, and other forms of mental ill health (Personneltoday.com, 1 February).

Ok.. so far it’s not so bad….. however… it continues….

The workplace is full of delusional individuals getting by and going up the ladder despite their obvious shortcomings. And as people have a tendency to employ people who are like themselves, that already provides an open door to a fresh supply of people with depression, anxiety and the like.

Sit up and take notice

So just getting employers to be aware of the problem in their midst would be a good start. For instance, it is arguable that anyone who chooses to work more than 40 hours a week clearly has a disorder of the frontal cortex.

The Health and Safety Executive helpfully provides a list of mental health symptoms for managers to spot impending trouble.

The most common signs of of anxiety are palpitations, headache, back ache, breathing difficulties, feeling on edge, worrying excessively and panic attacks. And when it comes to out-and-out depression, symptoms include inability to concentrate, impaired sleep, bouts of crying, poor appetite and general fatigue.

Typically stereotypical uneducated stupidity… yet, there’s more…. emphasis added…

A role for OH

Clearly, investing in an occupational health service would be a good starting point. And if so many of us are suffering with mental health problems, surely it would be a dereliction of duty for any organisation anywhere to knowingly court even more mentally distressed individuals who might pose a danger to existing members of staff - not to mention members of the public or other people being served by the organisation? That way madness lies.

And better still…. emphasis still added

Any discriminating employer would aim to give jobs to the people best qualified to do them. Sadly, but correctly, that would rule out people who would struggle to cope due to some mental frailty.

And unfortunately, there really is no business case for employing someone with mental health difficulties. Unless, of course, you know differently.

If you’d care to let him know differently…

Tony Pettengell (About this Author)

Timothy Pinkston was detained in a psychiatric hospital at the time and therefore I would presume “clinically insane” or whatever the term is. I can’t understand how they could send him to jail for something he said while he was officially mad and safely locked up in a psychiatric hospital.

I wondered if you guys could enlighten me how things would pan out if there were a similar incident in a UK psychiatric hospital. The case raises lots of issues but there are four main areas that concern me.

1) Personal responsibility while under the influence of alcohol

Up here in Smalltown, Scotland it is fairly common for people to threaten to kill each other when drunk. The usual scenario is two guys arguing in a pub and as one is ejected, he shouts, ”This isn’t over mate. I’m gonna get you. YOU’RE DEAD!”. Occasionally it’s all forgotten about the next day, sometimes there is a permanent rift between them and at worst a punch-up at a later date. The thing is, drunken threats are rarely taken seriously here, but I accept that may not be the case in all cultures.

Anyway, what is the situation in a psychiatric unit when someone is drunk, are they considered responsible for their actions? If I am admitted totally pissed and I get stroppy and start threatening people, am I likely to be charged? What if, as an inpatient, I become violent and punch a nurse, will I be charged?

2) Personal responsibility while under section

Can patients be held responsible for their actions whilst detained in hospital against their will? If I am violent whilst detained in hospital would you ever call the police? Similarly, if I am detained in hospital and during a restraint I threaten to kill you when I get out, can I be charged?

How do you judge the seriousness and potential consequences of each threat and avoid reporting thousands of people to the police?

3) Nurses responsibility and breaching confidentiality

At what point is it OK to disclose something a patient has said to you while under your care? If I tell you I smoke hash, I don’t expect you to call the police. If I tell you I plan to send hate mail to my neighbour, do you inform any external agencies? If I say that I plan to murder someone what would you do? Do you pass the buck to a colleague? What do you do if your manager poo poos your concerns and tells you to drop it? How do you actually respond?

4) Terrorist threat

What if I am not violent or threatening but whilst under your care, disclose extreme personal views on politics which lead you to suspect I may be a threat to national security, how do you respond?

Do have any set protocols or guidelines for these situations or is it left to your discretion? I appreciate I have asked loads of questions but I’m guessing there may be an all encompassing statement that covers most of the issues here.

(P.S. You may have may guessed that I’m a bit paranoid at the moment.)

And on who’s authority is he getting a DIY SOS makeover?

Well for a start, I think Nick Knowles might be happy to be involved. He’s just condemned Reality TV shows for mocking the mentally ill… but that’s a whole other thread.

However, more illustriously, none less then the incumbent president of the Royal College of Psychiatrists, Professor Dinesh Bhugra had this to say:

Britain’s most eminent psychiatrist has launched a powerful attack on the state of Britain’s acute psychiatric care system, saying many inpatient units are unsafe, overcrowded and uninhabitable, adding: ‘I would not use them, and neither would I let any of my relatives do so.’ <ref>

So what does the great Bhugra have to say? With the advent of the Darzi reform specifically highlighting Mental Health as the Cinderella service we’ve always know, I’m pretty sure he’s about to take the goverment to task. Isn’t he?

‘Some acute psychiatric inpatient ward conditions are absolutely unacceptable,’ he told The Observer. ‘They are uninhabitable. The system often leaves patients feeling lost and abandoned. I predict the situation will become worse in coming years.’

Ooops.. sounds like he’s predicting he’ll ruin it even more? I’m sure he meant to add… “..unless we do something“?

“But what?” I hear you both cry….

Bhugra is calling on the government to introduce a compulsory kitemark system of accreditation for all acute, inpatient psychiatric wards: ‘Until there is a compulsory kitemarking scheme, my prediction is that, as overcrowding increases, funding becomes more stretched and morale of patients and staff fall, overall conditions are likely to continue to deteriorate.’

Bloody great idea! Lets have some standards and accredit wards that reach those standards. Why didn’t anyone think of that before? Probably because we already have standards; be they generally unwritten ones, and having written ones doesn’t make better managers or produce extra funds.

Tho it does help to train the managers on where to put the money and what to address…. just think of a Tesco’s shelf-stacker filling holes in shelves with tins - how would they know where to fill if they didn’t have a manager saying “there’s a hole in tinned tomatoes on aisle 3″; and if they didn’t tell the stock room workers to tell him when they were running out of tinned tomatoes then surely we’d have a huge tinned tomato crisis. What the shelf-stackers don’t realise is in his office, the shop manager has a list that goes…

- check tomato tins are filled

- check there are spares out back

- check sweetcorn tins are filled

- check there are spares out back

The Darzi reform says change comes from bottom up - not top down. But when government determine that the last lot of extra funding it afforded mental health should be spent on community services it kinda ties your hands to improving in-patient services.

But is it acceptable to allow this sort of thing to continue?

‘I arrived at the mixed ward one evening with a letter from my GP which explained that because I was a survivor of rape and sexual abuse, I was very scared of being in a unit with men. Despite this, the nurses said it was too late to show me around or even indicate where the bathroom was or where to get breakfast in the morning.

‘I found it hard to even persuade them to give me fresh bandages to cover the wounds I’d given myself from self-harming. There was very little individual interaction. Nurses communicated in one-word screams: ‘breakfast!’, ‘dinner!’, ‘medication!’

‘The male patients walked around with their genitals hanging out of their ill-fitting pyjamas and, when one man deliberately exposed himself to me in the dining room and I complained to a nurse, he replied: ‘What do you expect? This is a psychiatric ward.’ When I told one of the female staff members that the ward scared me, she admitted it scared her too.

Modern matrons (did they ever really happen in the AMHUs?) can certainly make a difference, given the authority, to the functional and professional practices of a unit. As Darzi said:

Nurses play a vital role in the NHS: they will always be at the heart of shaping patient experience and delivering care.

I’d love to see substantial funds injected for a one off overhaul of in-patient services but rather than waste huge amounts of money on business consultations and steering committees to lead audit and monitoring to set government kitemarks standards or accreditations processes - why can’t we just let sensible non-governmental organisations such as the Bright Charity take their Star Wards ideas forward? It’s not bloody brain science and they’re likely to do more good for the dollar than some suit with a clipboard.