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?

Pulse reviews the guidelines which saves me reading anything.

NICE has ruled out use of antipsychotic drugs in patients with attention-deficit hyperactivity disorder, after evidence linking them with stroke, diabetes and parkinsonism.

Instead, it recommends, patients should be treated with methylphenidate, atomoxetine and dexamfetamine.

So NICE are still recommending drug treatment.

The brief guide according to Pulse:

- Determine the severity of behavioural and/or attention problems suggestive of ADHD and how they affect the child and their parents
- Consider watchful waiting for up to 10 weeks, or offering referral for a formal diagnosis of ADHD
- If the problems persist refer to a paediatrician, child psychiatrist or specialist child and mental health services
- Consider prescribing methylphenyidate, atomoxetine and dexamfetamine as drug treatment under shared care arrangements only
- Do not use antipsychotics for patients with ADHD

Great summary - succinct and direct. But what the guidance actually says is:

1.5.2.1
Drug treatment is not indicated as the first-line treatment for all school-age children and young people with ADHD. It should be reserved for those with severe symptoms and impairment or for those with moderate levels of impairment who have refused non-drug interventions, or whose symptoms have not responded sufficiently to parent-training/education programmes or group psychological treatment.

Drug therapy is only recommended for those with severe cases of ADHD.

In school-age children and young people with severe ADHD, drug treatment should be offered as the first-line treatment. Parents should also be offered a group-based parent-training/ education programme.
• Drug treatment for children and young people with ADHD should always form part of a comprehensive treatment plan that includes psychological, behavioural and educational advice and interventions.
• When a decision has been made to treat children or young people with ADHD with drugs, healthcare professionals should consider:
− methylphenidate for ADHD without significant comorbidity
− methylphenidate for ADHD with comorbid conduct disorder
− methylphenidate or atomoxetine when tics, Tourette’s syndrome, anxiety disorder, stimulant misuse or risk of stimulant diversion are present
− atomoxetine if methylphenidate has been tried and has been ineffective at the maximum tolerated dose, or the child or young person is intolerant to low or moderate doses of methylphenidate.

[pp11]

Ok, I read some of it.

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.

Joe has consented to trial Clozapine. He has undergone all the tests, titration and monitoring is progressing without incident and is now at day 12. He’s receiving 50mg in the morning and 200mg a night and progress seems to be looking good.

Friday night (it’s always Friday?) Joe tells you he doesn’t want the tablets any more so you call the duty registrar who doesn’t usually work your unit and he visits yet is also unable to persuade Joe to continue. Saturday Joe remains adamantly the same.

However, on Sunday night, and after spending a long time talking with one of the Nursing Assistants, Joe presents and says he’s decided to keep taking the tablets as he doesn’t want to go back to how he was.

You phone another registrar who says “Well, there’s still a prescription for it so continue with the prescribed dose of 200mg from tonight.

As a nurse, what must you raise with the registrar and how might you (respectfully) advise them?

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.

When the phlebotomist arrives the next day, you collect up the forms and take them along to the clinic room. As you peruse them to see who needs what doing - you note the following tests have been ordered on Joe’s form:

FBC; U+Es; Hepatitis; serum HIV*

What should you do?

[*: FBC = Full blood count and U+E= urea and electrolytes - which are the normal routine bloods and show generally how the body is functioning; Hepatitis and serum HIV are tests for specific chronic contagious diseases]

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]

In a bizarre and unprecedented feat of organisation, my university has put up a timetable for the first term of the second year. So, on the 14^th November, the university is going to teach me how to give an intramuscular (IM) injection. I assume by this they are going to teach us the correct technique, as opposed to those we have been observing and ignorantly emulating on the wards thus far. But it has got me thinking and possibly even, dare I say it, reflecting…

My first IM was quite unremarkable really, despite shaking so hard I nearly injected my thumb with zuclopenthixol decanoate. The opportunity to do one hadn’t arisen during my first placement, therefore I felt somewhat similar to how I had when I was 16, and positive that I was the only virgin left in my school because everyone else had (allegedly) ‘done the deed’. Embarrassed, impatient and terrified at the same time. It could have been worse though, the other student I was there with hadn’t done any yet either, and won’t now get the chance to before the first placement in second year…on an acute ward.

So, my mentor went through the technique with me, made sure I had read up on what I was doing and administering, then told me to get on with it. Luckily the patient had been having this particular depot for over 20 years, and had had hundreds of terrified students prodding at her buttocks looking for just the right spot to shove a big needle in.

Being a bit of a swot (in the irritating definition, not the strengths/weaknesses analysis twaddle) I had researched my technique, and considered the dorso versus ventrogluteal sites. Of course, when it came to it, I stuck it where my mentor told me to, given that she had never heard of the ventro site and was unlikely to allow her student to just take a (well intentioned) punt at it.

The thing I remember most was how bloody long it took to get the stuff out of the needle and into the backside. I actually had backache when I emerged, blinking, from my crouched position. I was assured that it always takes that long, and the patient very kindly gave me a “twenty out of ten” for my technique. In fact, the experience was very positive. The only concern I had was on hearing that the patient had been admitted to hospital the next morning; I think it’s safe to say I nearly crapped myself, in fact. But I’m reassured that the two things were unrelated, and was just unlucky that my first ever depot patient went into multiple organ failure shortly afterwards. (Last I heard she was shouting abuse at the doctors and singing loudly at 4am, so I imagine discharge is imminent).

I am looking forward to the practical session at uni then, just to see if there was anything I should have done differently. There also appears to be a special section devoted to Risperdal Consta; possibly this is the Trust’s way of ensuring its new nurses don’t accidentally bugger up a £150-a-shot injection.

Now that would be embarrassing

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.

I have to say, I have only read the one article about it and not looked any deeper, but incase anyone missed it it’s here.

A NEW drug capable of halting Alzheimer’s disease in its tracks was hailed yesterday as a “hugely exciting” development in the battle against the devastating condition.

The drug, developed and tested on patients in Scotland, slows down the progression of Alzheimer’s by as much as 81 per cent.

While the Telegraph highlights:

Thousands of mental health patients go missing from wards

The sectioned patients either escaped from wards, went missing during authorised leave or failed to return to hospital when they should have, a critical report by the Healthcare Commission found.

During six months in 2007, patients detained under the Mental Health Act went missing on 2,745 occasions for a total of 8,870 nights

The Independent writes specifically about how unsafe such wards are.

Despite increased spending of £1.2bn in real terms on adult mental health services since 2002, one in four of England’s 10,000 mental hospital beds is in a trust rated as “weak”, which, says the commission, “does not meet the minimum requirements and reasonable expectations of patients and public”.

There was previous discussion (originally discussing the waste of the ology and iatry in mental health) which developed into suggesting we should be focusing more on the actual wards rather than splitting neurons; but I’m not about to revive it.

So, back to the report. What does it tell us? Apparently it reports that:

Overall, eight trusts were rated as “excellent” (accounting for 843 beds – 9%), 20 as “good” (2,808 beds – 28%), 30 as “fair” (3,985 beds – 40%) and 11 as “weak” (2,249 beds – 23%).

Hmm… so what does this mean?

On the four key criteria against which we assessed performance, our findings were:

• No trust was scored excellent on all four of the key criteria, suggesting there is room for improvement for all service providers.
• Almost two-fifths (39%) were scored weak on involving service users and carers – this was the area with the highest proportion of weak scores.
• Around one in every nine trusts was scored weak on the criteria for providing individualised whole person care and for ensuring safety.
• No trust was scored excellent for the effectiveness of the acute care pathway, although fewer trusts were scored weak here compared with the other three criteria.

Rather than discuss the results of this report, I’d like to talk about “reports”. How do they do them and what do they really mean?

Well for this one…

[w]e used a combination of national and bespoke data as part of a rigorous assessment process, and our findings fed into our annual health check of trusts’ performance.

So of course, I had to look up ‘bespoke data analysis‘ - and took a look at some of the indicators they used - and decided I’d just leave it there and let someone else write about it instead.

But its come at an interesting time for me because, all the way down here - were going through our Accreditation process.

As an aside, the Aussies were a bit smarter than the UK (sorry to tell you OSB!) and when it came to evaluating services, the Australian Medical Association and Australian Hospitals Association jumped in with self-regulatory policy before federal government did [1]. This means they evaluate what they choose to, how they choose to, in the manner they choose to.

The ACHS proudly states on it’s website:

What is accreditation?

Accreditation is the status obtained by an organisation after a successful third party external evaluation by a recognised body to assess whether an organisation meets applicable pre-determined and published standards

And declares:

Is the ACHS accreditation process similar to an audit?

No. The focus of ACHS accreditation programs is to provide a framework for continuous improvement. ACHS accreditation is not quality assurance, or ticking the boxes and staying at the same level of performance. It is about establishing a structure and processes that allow quality and safety to proliferate

So there you have it; it’s a ticking box audit.

Which explains why everyone at work is frantically ensuring every patient’s file has a sticky label on it and that all errors are crossed through and initialed by the author and the care plans are signed by staff and patient.

It does go further into detail (probably using a bespoke data analysis machine) on some aspects but essentially, as long as it says you did it - it means you did it - and THAT’S A QUALITY IMPROVEMENT!

There’s nothing wrong with standards but two things that always bothered me with benchmarking, audit, evaluation and quality improvement is - why do we benchmark the same things every year if this is a quality improvement thing? And why do we only do it 3 months before we’re (not) being audited and what use is it when, for the most part, it’s faked?

I’d guess a fair bit of this UK HCC report was ‘faked’ too.

Table 21: Bespoke data collection submission & return rates

Questionnaire for acute inpatient leads: 99%

Questionnaire for ward managers
(completed for each relevant ward): 99%

Questionnaire for service user groups
(completed for each relevant ward) : 100%

Audit of care records (completed for a
sample of 50 care records): 100%

I’d also guess it was pretty important, eh? Pity the standards most failed to achieve weren’t as important.

We assessed all of the 69 NHS trusts that provided mental health acute inpatient services during 2006/2007. These trusts registered 554 acute mental health wards within the scope of the review, providing a total of 9,885 beds.

So why the title document, document document?

Well, most benchmarking indicators rely on not seeing what is done or the assessing its quality - but looking through the records to see if it says it was done. In this review, there were several thousand clinical files audited. So if you want to improve your scores - be sure to spend even more time in the office documenting thoroughly and in the right way just exactly what is was you did today; though I believe such audits generally tell us we’re good at administration - rather than mental health care.

By the way - the report actually concludes - inner city care is of a lesser quality than rural.

I wonder how much it cost for that report? And why didn’t anyone listen to the last 20 reports on inadequate inner city care standards?

[1] Palmer, G. & Short, D (2000) Health Care & Public Policy 3rd Ed. Macmillan Pub.

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?

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.