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The Psychiatric Eye Formerly, The London Division Newsletter 05/07/2015 Edition 4 Editorial Welcome to the fourth edition of the newsletter. In this edition we focus on the physical healthcare of our patients. It is now well recognised that patients with mental illness have an increased risk of physical health problems. The need to monitor the health of patients, particularly those on antipsychotic medication, has been highly publicised, and there is now an abundance of guidelines and standards that are physical disorders and therefore one should not be ignored at the expense of the other; Dr Cohen talks about unrealistic expectations of the ward doctor and of assuming the role of a GP without the training; Dr Young discusses how to work more effectively with primary care to achieve shared goals and Dr Ali reviews whether health checks lead to better outcomes. In addition. we have our “The physical health care of psychiatric patients - the elephant in the room” aimed at improving practice. Has there indeed been progress in meeting the physical health needs of our patients or do we continue to encounter challenges, particularly at the interface with primary care and other medical specialties? regular features, which includes Face Time with Linda Gask about her views on physical health monitoring, as well as a new section called “Round Up” that summarises discussions from the London Division meeting. Happy reading! We have contributions from Dr Davies who argues that it is the role of psychiatrists to consider the interacting nature of mental and Zaubia & Afia Improving the lives of people with mental illness Editorial Staff: Afia Ali Zaubia Alyas Karyn Ayre Rowena Carter Lydia Bocko Stephanie Young MESSAGE FROM THE CHAIR Can we conceptualise existence of the texture or the phenotype of a vegetable separately from its nutritional value or its genotype? It sounds unnatural. Similarly the idea of separation of the physical from the psychiatric and psychological of a human being is like trying to separate the brain from the mind. It is not possible, just so because it is not natural. In the last decade there has been evidence building up how the emotional aspects of the growing up experience affect the structural development of the young brain that is still forming its neuronal connections which ultimately determine its anatomy. Psychiatry is a medical science, which endeavours to study the basics of the structure and the functions of the human brain; functions including the physiology as well as the mental functions. Mental functions in turn include the core cognitive functions e.g. memory and praxis, but also the executive functions like abstract thinking and judgement. Then, of course, the emotions are also included in the realm of psychiatry, based in certain regions of the brain like hippocampus and amygdala. Hence, we as medical professionals that are to understand the functions and the mal-functions of the brain and treat the disorders, must encompass the bridge between the brain and the mind wholesomely. Some developments that have not been helpful in this respect are separation of the psychiatric services from the general hospitals. This may in turn have something to do with what I call as ‘over-MDTisation’ of psychiatry. If we are to retain our very important role of the healers of the brain-mind spectrum, we must make active attempts to rectify these problems. Psychiatric services, particularly community based services, tend to over-rely on GPs for physical health monitoring of their patients.This adds to the split of the person who has come to us for treatment in an unnatural manner. I would think our training programs require some review, in order to enhance the focus on the mind-brain spectrum. We would need to add more of neurology and psychotherapy to our core training of psychiatry, so that any current un-natural gap between the brain [physical] and the mind [psychiatric] can be bridged effectively. Happy reading! Dr Shakeel Ahmad IMAGINE Teifion Davies Imagine. One morning your favourite newspaper has the headline, “Police officers take decision to combat crime”. On your way to work you see tabloid headlines proclaiming, “Fire-fighters pledge to fight fires” and “Teachers agree to teach”. Your reaction might be surprise, or even annoyance. What have they been doing until now these police officers, firefighters and teachers? ‘Fire-fighters pledge to fight fires’ Surely, these are the jobs they are paid for, their roles in society or their personal vocations. So, what would be your response to another headline that hits closer to home: “Doctors consider treating illness”? And, more importantly, what reaction would you expect from the public and our favourite tabloids? Extraordinary? Yet this is precisely the situation in which we find ourselves: doctors who are considering treating people who are ill. What makes this most remarkable is that, as psychiatrists, we are not saying that we do treat patients who are ill, nor that we have decided to do so, but that we are considering doing so. To show just how seriously we take this, we've told everyone else what they should do about it (1). As a doctor, you might ask how this perplexing situation came about, and what we should do about it. There are several reasons for our current ambivalence on the role of psychiatrists in diagnosing and treating illnesses in our patients, but two deserve special mention. Both are illusory distinctions concerning identity (cf. the Buddhist parable of the blind men and the elephant(2)): the identity of the psychiatrist as “doctor”, and the identity of illness as physical or mental. Perhaps when psychiatry emerged as a medical specialty and separated from general medicine there was a need to carve out a distinct identity for its practitioners. Psychiatry laid claim to certain domains and skills that we lionized as “mental”, and eschewed others, shying away from its medical roots. While this might have buttressed the foundations of an emerging specialty, it had the paradoxical effect of giving other medical practitioners a licence to demean psychiatric disorders (summed up in the despicable “diagnosis of exclusion” after which a patient could be dispatched to the nether regions of the psychiatric ward). ‘Primum non nocere’ Primum non nocere. Psychiatry’s self-imposed separateness has not swept stigma aside, but added to it (3). Early in their education, students learn to regard the psychiatric history as different from anything else in their experience of medicine. It is not: the psychiatric history is a comprehensive medical history; it is the model not the exception. Psychiatry has diversified into worthy areas that, surely, someone should cover, but again with paradoxical effects (4). We are all aware of the adverse impact on medical students’ career choices, and recruitment into the specialty, with many recruits placing psychiatry low in their preferences (5). Physical and mental disorders are not separate but interacting concepts, they are merely differing perspectives on a single entity: disease or, when experienced by an individual or viewed by a society, illness. Each socalled physical disease has implicit and sometimes explicit features that can be described as mental states (pain is probably the most obvious example, but mood and affect are perhaps more ubiquitous). Equally, each mental illness or disease is realized (6) in a physical being whose unique anatomy and physiology permit generation of mental states that are capable of referencing the past, the present and the future. This is not trite biological reductionism, nor a squabble between psychobabble and biobabble (7). It is a failure to see the whole patient. Doctors gain respect, achieve status, and receive rewards. As doctors, if that is what we are, we cannot concern ourselves with one aspect of illness and overlook others. The purpose of psychiatry, surely, is to be the medical discipline that encompasses all. Teifion Davies PhD FRCPsych Visiting Senior Lecturer in Psychiatry, KCL Institute of Psychiatry Psychology & Neuroscience. Specialist advisor on CASC development at the Royal College of Psychiatrists. [email protected] 1. Parity of esteem working group (2013). Whole-person care: from rhetoric to reality. Achieving parity between mental and physical health. Occasional paper OP88. RCPsych. https://www.rcpsych.ac.uk/pdf/OP88.pdf 2. Buddhist Canon Udana 68-69: Parable of the blind men and the elephant. 3. Literature on stigmatization of psychiatric patients and psychiatrists is vast. An interview with Professor David Goldbloom, chair of the Mental Health Commission of Canada, is an amusing summary. http://www.macleans.ca/culture/books/drgoldbloom-am-i-crazy/ 4. Goldacre MJ et al. (2013). Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009. British Journal of Psychiatry, 202: 228-234. 5. Davies T. (2013). Recruitment into psychiatry: quantitative myths and qualitative challenges. British Journal of Psychiatry, 202: 163-165. 6. Searle JR (1983). Intentionality. An essay in the philosophy of mind. Cambridge University Press. 7. Scull A. (2015). Madness in civilization: from the Bible to Freud, from the madhouse to modern medicine. Thames & Hudson. A RECIPE FOR STRADDLING MENTAL & PHYSICAL HEALTH CARE Sophie Gascoigne Cohen To bring or not to bring one’s stethoscope to work on the first day as a psychiatry trainee is one of many, albeit clichéd questions, faced by those stopping over the threshold from so called ‘physical’ to ‘mental’ healthcare training. ‘.…sense of trepidation’ Needless to say that I brought mine in along with a pen torch, an Oxford Handbook and a sense of trepidation that the physical health of my patients was potentially more problematic first hand than their mental wellbeing. After all, there was an SpR and a consultant plus experienced nursing staff and pharmacists to seek advice from regarding all things ‘psychiatric’. For all things ‘physical’, it felt like there was a CT1 in psychiatry and a phone. Coming from Australia, where public psychiatric units are commonly colocated on tertiary hospital sites, it took time to become accustomed to the separation between some NHS mental health and acute trusts. It struck me as peculiar, verging on Cartesian, that we treat patients for mental illness in one trust but order bloods and x-rays and arrange medical follow-up in another, that may be miles away. We work in A&E and on the medical wards in mental health liaison teams but don’t automatically have the right for IT access to view online prescriptions or pathology or imaging results in the acute trust. The very structure we work in with these patients are in seems to divide their mental and physical health care. Fortunately, there is a public health push to link them back together to augment both. Mental health versus acute trust divide A ‘medical clearance’ is necessary to enter a psychiatric unit from A&E or the community. I have heard colleagues question the semantics of this safety net in A&E; they claim that we are doctors as well and therefore the patient isn’t ‘medically cleared’ as we have not yet seen them. Perhaps they feel clinically more confident or maybe they are frustrated that ‘medical’ doesn’t encompass psychiatry, even though they have a ‘medical degree’. There is neither room nor need to debate in depth the rigor of emergency medical clearances nor its semantics. They are inarguably a critical safety net for psychiatric ward admissions. Unfortunately, with discharge targets in pressurised A&Es, many trainees will have stories of patients who still needed CTBs or delirium screens or simply alcohol withdrawal regimens written up. So, the medical hat remains in situ as we follow these patients along to the wards. For me at least, on the ward and beyond, it feels like there are somewhat confusing expectations of us as psychiatry trainees and future consultants regarding the degree to which we are meant to manage the physical health care of our patients. We are embarking on psychiatry training, and yet are rightly expected to maintain a degree of general medical competence. The questions remain to what extent and up to what stage in our careers is this requisite or realistic? In Australia prior to 2012, one could start psychiatry training with only FY1 experience. I remember a tutor advising me it didn’t matter if I did 1 or 2 years of medicine first as I would’ve forgotten everything by the time I was a consultant anyway. I disregarded his advice and did 3 years of medicine and surgery but I still feel that even more training, particularly in general practice, paediatrics and geriatrics, would be extremely helpful for psychiatry. On both ward and community jobs, it is certainly requisite and at times on the wards, it can feel like one is the in-patient GP without GP training. Fortunately, the real GPs are extremely helpful over the phone. We are lucky that some of our colleagues in core training posts are GP trainees and perhaps we should be using this opportunity to draw upon their knowledge. Maybe we should be asking them to teach us alongside our MRCPsych classes? Conversely, should we as psychiatry trainees be doing GP placements beyond the FY2 level to improve our patient care both on wards and in the community? After all, the medication we prescribe contributes if not causes some of the chronic health problems the GPs will be following up. would defer cardiologist. I wonder how many consultants or SpRs are comfortable commencing statins or hypoglycaemics rather than suggesting it to the GP? The Royal College has recognised the need for education on physical health. There are good CPD modules on the RCPsych website. The college hosted a Physical Health Conference last November on recognising the 'deteriorating patient and avoiding catastrophe. ECGs are another interesting topic. We are required to perform and interpret them but how many trainees feel genuinely comfortable reading them? Moreover, how many consultants or SpRs would sign off an ECG that their CT was unsure about? Most, I imagine, to a Do we accept responsibility for managing the adverse effect profile of medications in the community or is it more appropriate to hand this over to the GP? Shared care is always ideal but obligations are firmer than recommendations. Psychiatry is potentially one of the most difficult specialities to choose because it straddles mental and physical health. Sophie Gascoigne Cohen CT1, UCLP responsibility it should be for such monitoring. Mental health staff to introduce physical ‘MOT’ to reduce deaths, https://www.england.nhs.uk/2014/ 05/15/physical-mot/ SHARED CARE, DIVIDED OPINION BRIDGING THE COMMUNITY GAP Where it is clear that primary care “should” be responsible for a lot of this physical health monitoring of our community patients, in reality this is not always the case, and it can cause confusion and conflict amongst both primary and secondary care colleagues. Stephanie Young ‘It can cause confusion and conflict’ We all readily acknowledge that many of our psychiatric patients have significant physical health comorbidities stemming from the nature of their illness, medication side effects and unhealthy lifestyles. We all know about the importance of physical health monitoring and there are numerous guidelines (eg: NICE, Maudsley Prescribing Guidelines, Lester Cardiometabolic Tool) which tell us how often investigations should be done and whose As a community rehabilitation psychiatrist, I have had mostly positive experiences with the GP practices I work with. They have not refused any requests for physical health monitoring and are better at sending back results of investigations without too much prompting. This has probably been due to regular meetings between my team and GP practices to jointly discuss our patients’ physical health, in conjunction with increasing publicity about the importance of parity of esteem for our psychiatric patients via the Public Health England agenda. Not all of us will have experienced positive feedback from primary care. I know from reading medical blogs and websites, that there are GPs out there who feel annoyed, or pressured, by what seem to be unreasonable requests to monitor “x” or to check “y”. To be fair, they are not just targeting psychiatry but also other hospital specialties. I think part of this reason stems from longstanding issues with commissioning boundaries rather than simple stigma against our patients (and psychiatrists!). These GPs are wondering why community psychiatrists cannot for instance, do our own ECGs in our outpatient clinics, or remember to order a blood glucose in 6 month’s time as we are “proper” doctors. From their point of view, this may actually be a valid question. They don’t always appreciate that if primary care is prescribing the psychotropic medication, then general consensus is that they ought to be responsible for the physical health monitoring. However, they often assume that psychiatry will just leave it up to them, which is not the case. It is also important to stress to primary care that even if the psychiatrist is prescribing the psychotropic medication, primary care would still be the first point of call for general physical health issues of our patients, in addition to helping us facilitate monitoring. ‘Until such a utopian time...’ Until such a utopian time, where all community psychiatric teams might have in-house physical health clinics (spurring healthy debate over who would best staff and fund these), there are important things that we can do to support our primary care colleagues with this monitoring. We can help them assess capacity for our most difficult patients who are non adherent to health checks. We can continue to educate them about when and why monitoring should occur (although a lot of GP surgeries already have special alerts on their computer systems, which remind them of this). We can try more innovative ways to better encourage our patients to attend for monitoring (eg; texting them, linking appointments to a social outing), but this is not always realistic or appropriate especially with everyone’s time pressures. So what is the solution? I think it’s about breaking down artificial barriers and boundaries and communicating more effectively. We need to ensure our reasons are clear for monitoring in primary care so that we are not interpreted as being merely work-shy. At times, we may need to step in and take more of a lead; for instance we might need to repeatedly give investigation forms to patients or carers on home visits or at CPAs, although this is still no guarantee that patients will agree. Ultimately, both primary and secondary care need to remember that the benefit of monitoring, no matter who takes the lead, is to allow our patients to achieve a better quality of physical care and treatment, which must also contribute to their better mental health. Stephanie Young, Consultant in Rehabilitation Psychiatry South London and Maudsley NHS Foundation Trust [email protected]. uk DO HEALTH CHECKS LEAD TO BETTER OUTCOMES? Afia Ali 1. Health checks in people with Learning disabilities Currently all patients with learning disabilities (LD) are eligible for an annual health check providing their GP surgery has signed up for the Directed Enhanced Scheme. This scheme provides renumeration for GPs carrying out annual health checks in this population group. The scheme was introduced in 2008 following concerns raised by Mencap, the Disability Rights Commission and an independent Government inquiry (1), about the inequitable access to healthcare experienced by people with LD, which was leading to premature deaths. This was due to unacceptable delays in investigating, diagnosis and treating physical health problems in people with LD. Diagnostic overshadowing (where physical health problems are missed as symptoms are attributed to the person’s LD), lack of knowledge & institutional discrimination, including discriminatory attitudes of clinicians towards people with LD, were some of the factors thought to be responsible. The Confidential Inquiry into the Premature Deaths of People with Intellectual Disability (2), found that 37% of deaths in people with LD could have been prevented by the provision of good quality health care, compared to 13% of deaths in the general population. The Equality Act requires that all public bodies such as the NHS make “reasonable adjustments” to accommodate the needs of people with disability. Health checks were introduced as a “reasonable adjustment” because of the difficulties experienced by people with LD in expressing or communicating their health needs. The aim of the scheme is to identify and treat health problems early, to improve health promotion and improve health outcomes. The health checks include an annual blood test, an assessment of feeding, bowel and bladder function, an assessment of hearing and vision and additional checks if the person has a specific genetic syndrome. The quality of health checks is variable and there is a clear need to standardise the assessments. In addition, the uptake of annual health checks by people with LD is only 53%. So, has the introduction of annual health checks led to better care and treatment outcomes for this group? Evidence suggests that health checks do lead to more diagnoses of conditions that were previously undetected. ‘The health improvement network database…’ A recent study using the “The Health Improvement Network” primary care database, compared 8692 patients from 222 practices carrying out health checks with 918 patients in 48 nonincentivised practices (3). They found that practices carrying out health checks were more likely to carry out blood tests, general health measurements, specific health assessments (e.g. hearing) and medication reviews, and were more likely to identify thyroid disorders, gastrointestinal disorders and obesity compared to practices not carrying out health checks. Health checks therefore appear to have some benefit, even if the only perceived benefit is a regular meeting between the patient and GP. However, we currently do not have any “hard outcomes” such as a direct link between health checks and mortality data to suggest that health checks lead to fewer premature deaths or evidence to suggest that health checks have long term gains. 2. Health checks in people with severe enduring mental illness Patients with severe and enduring mental illness (SMI) also experience inequalities in accessing health care, and have a higher prevalence of disorders such as diabetes and cardiovascular disease, compared to the general population. Life expectancy is 15-20 years less compared to the general population. Physical health monitoring of patients with SMI is a priority area, as highlighted by the NICE guidelines (4), which recommend that patients with psychosis or schizophrenia should have a comprehensive physical assessment at least once a year to include measurements of weight, waist, pulse, blood pressure and blood tests. However, agreements about who should carry out these tests needs to be made locally and the results shared between primary care and mental health care. NHS England has also developed CQUIN targets for physical health monitoring of inpatients in psychiatric hospitals. In addition, GPs are expected to maintain a register of patients with SMI and they receive payment under the Quality Outcomes Framework for carrying out health checks, which includes an assessment of metabolic indices. In spite initiatives, of all these the health monitoring of patients with SMI remains poor. What do we know about the effectiveness of physical monitoring in patients with SMI? Is there evidence that it improves health outcomes? A recent Cochrane Systematic Review did not identify any randomised controlled trials examining the efficacy of health monitoring in people with SMI (5). It concluded that current recommendations for monitoring of physical health were not supported by good evidence. In conclusion, although health checks in people with SMI and LD are in principal good practice, more evidence is required to establish whether they produce long term health benefits including reduced mortality rates, and whether they are cost effective. Afia Ali Senior Clinical Lecturer (UCL) & Honorary Consultant Psychiatrist, at the Waltham Forest Community Learning Disability Service, North East London NHS Foundation Trust. [email protected] 1. Michael, J (2008). Healthcare for all: report of the independent inquiry into access to healthcare for people with intellectual disabilities. Department of Health. 2. Heslop, P, Blair, PS, Fleming, PJ, Hoghton, MA, Marriott, AM & Russ, LS (2013). Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD): Final report. Norah Fry Research Centre. 3, Buszewick M, Welch C, Horsfall L et al (2014).Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study. Lancet Psychiatry, Vol 1: p522–530. 4. NICE (2014) Psychosis and schizophrenia in adults. NICE guidelines (CG178) 5. Tosh G, Clifton AV, Xia J, White MM (2014). Physical health care monitoring for people with mental illness.Cochrane database of Systematic Reviews. FACETIME LINDA GASK THE PHYSICAL HEALTH CARE OF PSYCHIATRIC PATIENTS AND ‘PATCHING THE SOUL’ I met with Professor Linda Gask ,who maintains the Royal College website for Physical Health Care to find out more about her ideas about improving the physical healthcare of our patients and how these had evolved Her career took flight as a General Adult Psychiatry Senior Registrar in Manchester with a PhD under the supervision of Professor David Goldberg while she continued clinical work in psychodynamic psychotherapy .She maintains her subsequent brief therapy skill set had been one of her most useful acquisitions. In 1990 she took up a shared post in primary care research and psychiatry at the University of Sheffield. Her research into training GPs in mental health skills continued, while her first consultant post was with a substance misuse team, where she gained skills in dealing with people who were ambivalent about treatment . She moved on to a Senior Lecturer post in Preston, where she was directly involved in the program of deinstitutionalisation. This was a stressful period due to problems with the Trust but she made a definitive move to academia in the primary care department in Manchester as a founder member of the National Primary Care Research and Development Centre. As well as her research field into primary care, particularly in the field of co-morbid long-term conditions and mental health, Linda’s work history has left an interesting legacy reflecting her clinical passions. She helped set up a novel IAPT service in Salford, where she provided supervision and psychiatric input to a service run using a ‘collaborative care’ model making it possible to manage more complex patients at step 2. This service survives now as a social enterprise (Six Degrees), receiving input from a liaison psychiatrist and GP. The STORM project, set up originally on the back of research into suicide prevention, successfully provided suicide training and has also now spun out as social enterprise from the University of Manchester. Her ideas about how to tackle the physical health problems our patients are generated from her unique insight as a psychiatrist and researcher at the primary care interface. She feels the MH Trust and Acute trust divide created a significant split in healthcare severely affecting relationships between psychiatrists and other medical colleagues, including GPs, wiping out forums for meeting informally, particularly grand rounds and postgraduate sessions. Another issue has been the direction in which General Practise has been evolving ,turning into an immediate speciality with systems colluding against direct communication and personal relationships, with GPs working at higher pressure with multiple problems and having to switch their mind rapidly from one thing to another and with a need to get an immediate outcome with less free time to chase specialists. A further challenge in acute services and primary care is the phenomenon of ‘psychiatric overshadowing’ ,which continues to be a problem for people with long term mental health problems when they seek help for physical health problems. The COINCIDE study of people with co-morbid diabetes and/or cardiovascular disease also revealed GPs tended to pay less attention to their mental health needs. During her own career, she identified her diminishing skills in physical health care and the potential conflicting impact of trying to be both physician and therapist to patients as barriers to flitting into generalist mode when needed . Furthermore, working closely with GPs and her own personal experience of physical health problems convinced her that it was impossible for a psychiatrist to ever be a first class generalist and replace a GP. She feels Psychiatrist needed to both attend to improving their own physical health skills and engaging people with their GPs and then finding a way to work more closely with them. The differing cultures of primary care and psychiatry do not help communication but it is now become even more essential to reach out to primary care through personal visits and telephone accessibility. She has also explored several novel ways of working at the interface The COINCIDE study trained IAPT workers working with people with long-term conditions, such as diabetes how to liaise with primary care, particularly practice nurses. They were subsequently much more effective in improving outcomes for these patients. In Salford, she found clinical specialist nurses in the diabetes and COPD services - working between acute trusts and primary care to be very useful resources and often very successful in engaging people with long term mental health problems who were no longer in touch with secondary care services . She witnessed the COPD team in Salford making systematic efforts to engage smokers with psychiatric co morbidity for preventative work, who had disengaged from psychiatric services . These observations have instilled in her the importance of systematic follow up if you have a medical condition ,often at odds with Psychiatry’s desire to practise as an art and also highlighted the need for a commitment and the skill set to work with people with ambivalence towards seeking or accepting help .She feels these skills should be a prerequisite of all psychiatric professionals. Her experience has sometimes been of clinicians failing to explore why a person is unable to commit to treatment and using their ambivalence as justification for discharge, particularly when professionals were feeling overwhelmed by service pressures. This work has clearly had an influence on her take on collaborative care, which she defines as a way of systematically following people up people using protocol /evidence based treatments with improved communication channels between primary and specialist care. Needing a systematic connection with the GP so information is shared adequately’ and ideally provided by case managers She is currently a grant holder for a new NIHR programme , PARTNERS 2 looking at the best way to step down service users with both long term Mental and Physical Health Care needs back to primary care using collaborative care principles. Linda also shared her own experience of depression. She is pro- drug but much more interested in how patients tackle the psychological background to their illness. She equates psychological work at the primary care front line of mental health to a ‘psychiatric first aid’ post. Sometimes in this setting all than can be offered is a ‘sticking plaster’ rather than ‘total repair’, but it may well be what that person wants at that time. Meanwhile therapy services expect people to wait long periods without adequate support and then expect them to make difficult and painful changes to their lives in only six sessions. In her personal and professional experience, change happens more gradually over the course of a lifetime after repeated contacts with services. This observation was the inspiration for her memoir, originally called ’patching the soul’, which weaves together her life experiences and problems with her own mental health and what she learnt in parallel from her patients. Linda currently holds an academic appointment as Emeritus Professor of Primary Care Psychiatry at the University of Manchester .Her memoir ‘The Other Side of Silence: A Psychiatrists Memoir of Depression’ is out in September 2015 and she blogs at www.lindagask.com. Zaubia Alyas Consultant Psychiatrist Supported Living Team South London & Maudsley NHS Foundation Trust [email protected] PETER HUGHES helps manage the stresses of NHS work. The VIPSIG was launched in June 2011. What have been the highlights for the group in the last 4 years? Consultant Psychiatrist at South West London and St George’s Mental Health Trust Chair of the Volunteering and International Psychiatry Special Interest Group (VIPSIG) Vice Chair London Divison Royal College of Psychiatrists What led you to be interested in international psychiatry? Several reasons, like family influence. For example, my sister has done international humanitarian work in Africa for many years. I’ve always been interested in travelling and different cultures. After I “ran out” of places to go for pleasure, this kind of international work was a great way of having new experiences. You reach another level, as it is completely removed from working in the NHS but also The enthusiasm of people, our annual conferences, getting people doing interesting assignments world-wide and making a real difference. We get a lot of positive feedback from host countries; it’s nice to get emails about the success of our training and to see peoples’ knowledge of mental health issues improve as a result. What do you think the main priorities should be for international psychiatry? For the group, it’s to put this interest area on the map. Everyone should have the opportunity, privilege and joy of volunteering- it helps make them better doctors in the UK whilst helping others worldwide. Globally as per WHO’s Mental Health Action Plan (20132020), priorities include universal health care, leadership and governance, data and information systems, health prevention and promotion, integrating mental health into primary care and human rights -based care. Briefly tell us about the WHO’s mhGAP (Mental Health Gap Action programme) and how you have been involved in the training abroad? I first heard about this tool when I was in Haiti in 2010 after their earthquake. It was in the process of being developed and I commented on some chapters. The principles are that primary care doctors should manage the vast majority of mental health problems. Complex cases need specialist advice and this is where secondary care comes in. The training tool includes a manual and the general training is over 5 days. However, the key element is the supervision which follows. MhGAP is now used in over 60 countries. I’ve done the training in 10 countries including conflict zones like Syria and Iraq. You must have many inspiring stories from your international work. Tell us one of them. It’s difficult to choose just one! In general, I’ve been inspired by the people we’ve trained, who are now dedicated to work in mental health. They have treated and managed people who were chained up by their families. They have unchained them. They have given these people a better quality of life. I see interesting and harrowing cases, and within despair, you can see recovery. How does your international experience influence your clinical work as an inpatient psychiatrist? I’ve learnt a lot about psychosocial management. Every day on my ward, I use relaxation techniques, problem-solving and psycho-education. It’s helped me work better in a team and being very aware of cultural issues. It’s helped me manage resources and always ensures that I prioritise carers and families in management. How could trainees get more involved in volunteering for overseas psychiatric projects? There are many ways. There are many interesting countries which offer volunteering experiences from two weeks to up to 3 months. Have a look at our VIPSIG website for information. Register to be part of the VIPSIG and you’ll get regular Facebook updates. #psychvolunteer http://www.rcpsych.ac.uk/ workinpsychiatry/specialint erestgroups/volunteeringan dinternational.aspx SEBASTIAN KRAEMER FRCP FRCPCH FRCPsych Stephanie Young Consultant in Rehabilitation Psychiatry South London & Maudsley NHS foundation trust [email protected]. uk In July, Dr Sebastian Kraemer will retire from the NHS, aged 72. He leaves behind him a remarkable legacy: generations of psychiatrists and paediatricians inspired by his passion and brilliance inthe Child and Adolescent field. Qualifying in 1970, Dr Kraemer trained first in paediatrics, then in psychiatry at the Maudsley and the Tavistock Clinic, where he was appointed consultant in 1980 along with paediatric liaison sessions at the Whittington Hospital. After retiring from the Tavistock in 2003 he continued his liaison work. He has written widely, on topics including systemic family therapy, attachment and parenting, multi- professional working and health policy. He is vice chair of the Royal College of Psychiatrists Paediatric Liaison Network. You have been an inspiration to countless doctors. Who inspired you? My father, William Kraemer (FRCPsych), who had to leave Germany aged 22, studied medicine in Siena and then practiced as a Jungian analyst in Britain. The paediatrician Ronald MacKeith; psychiatrist/psychoanalyst Christopher Dare; family therapist Salvador Minuchin; John Bowlby; child psychotherapist Margaret Rustin; psychiatrist/psychoanalyst Ron Britton; my wife, psychoanalyst Wilhelmina Kraemer-Zurné. What is the essence of Liaison work and why have you loved it? Improvisation within a clear model of relationships. We need to be attentive to the family's experience of our interaction with paediatricians. Then, whatever the problem, we can always make more sense of a child's predicament as a patient by exploring his or her perception of the family's story; a genogram helps. Often it feels like being a detective, seeking a pattern. What does it mean to be an adolescent in 2015? www.sebastiankraemer. com A lot more anxious than the already anxious adolescent of the past. "what will become of me, where can I afford to live, who can I love who will also love me?" Rory Conn Your website is a repository for your academic work. Of which are you most proud? The Fragile Male made me famous for 15 minutes. Even Michael Rutter praised and cited it. My proudest is rarely cited though I put most work into it, written in the pre-internet era using ex-library loans from the Tavistock; the Origins of Fatherhood. ST5 CAMHS Trainee & Darzi Fellow Great Ormond Hospital CONFERENCE WATCH What’s the future? THE FACULTY For child psychiatry, it depends on the next generation's capacity to give colleagues, patients and families what they need, which is an integration of medical science and therapeutic wisdom. For me, I expect to keep on supporting colleagues at the front line, to go on writing, and have more time for music, family and friends. OF CHILD AND If you could do it all over, what would you do differently? Get in earlier with more perinatal work Street ADOLESCENT PSYCHIATRY ANNUAL CONFERENCE (2014) Hemma Velani This conference was an amazing and invaluable experience. It was held between 17th – 19th September 2014 in Cardiff. A number of lecturers talked about Autism and ADHD, the genetics involved, the risk factors for developing the disorders and the deficits seen in these conditions. When I later returned to these topics in my revision notes, I found I had absorbed these areas much more than others. I can only suggest that this was because of the interesting manner in which they were expressed. Attending this conference helped my exam preparation which was a bonus. Throughout the many lectures, symposiums, presentations and workshops, patients I’ve seen in clinic with Autistic Spectrum Disorder (ASD) kept popping into my mind. One speaker told us that Aripiprazole (commonly used in adults because of the lower risk of weight gain), in fact causes weight gain when used in adolescents. Clinically this was significant and useful to me as I currently monitor my patients’ weights closely. Another lecturer enlightened us with new developments in research; for example, the increase in the overlap between ASD and other neurodevelopmental disorders. This made me aware of the importance of reassessing symptoms, reformulating the diagnosis and adjusting the care plan in patients with ASD. The talk I found most valuable was a symposium on Mentalisation-based treatment for young people who self-harm. It inspired me to think about and read further about this topic The presenter articulately explained that if an individual had a failure in mentalisation, other people no longer made sense to them leading to an unbearable internal state associated with thoughts and feelings such as “I hate myself” (described as development of the “alien self”) resulting in self harm. I found it fascinating to hear the clinical picture described in such a way. As a Core Trainee, I sometimes feel our primary goal is to “get our exams out of the way” before we can start concentrating on more relevant and interesting activities, such as reading journals, doing audits and attending conferences. With an exam date looming, some of us focus solely on exam preparation, but I chose to attend this conference in the hope that I would gain knowledge and guidance in an interesting way. I was glad I did. The conference confirmed to me the importance of achieving balance with my “need to do” and “want to do” activities throughout my training. This is the way forward. Dr Hemma Velani CT2 in CAMHS Hounslow, London [email protected]. PSYCHIATRY AND SOCIETY: WILL NEUROSCIENCE CHANGE UNDERSTANDINGS AND PRACTICES I was attracted to the title of this conference. The speakers were all recognisable leaders in their fields. It was held on the 12th May at the Royal Society of Medicine in London. It served well as an easy going and thought provoking neurosciences update and involved some good discussions It opened up with Psychiatric Ethics, with Professor of Psychiatric Ethics ,Jonathon Glover, focusing on the impact of biological determinism on moral responsibility and agency of individuals with discussant Professor of Neurosicence and Society, Ilina singh, author of cutting edge work on theory of mind in children. We then took a detour into the world of genetics.US Genetics Expert , Professor Pamela Sklar skipped us through the last two decades of genetic research into Schizophrenia .Describing the demise of individual research groups using linkage analysis to hunt down a single culpable gene.Their work scuppered as technological advances systematically identified more and more defective genes . A more collaborative way of working ensued, the success of which was highlighted in 2014 with the psychiatric genomic consortium announcing identification of 108 defective genes linked with increased risk of schizophrenia. The associated phenotypes being wide-ranging from components of Calcium channels, post synaptic components and neurodevelopmental systems. Researchers logically progressed to work on quantifying an individual’s polygenic risk. Giving each gene variant score according to whether they were common variants (conveying a small risk to the individual) or rare variants (conveying a large risk) . Adding up scores from each type of defect then gave the polygenic risk score Professor Robin Murray continued to talk about polygenic risk scores, telling the audience Polygenic risk scores were found to correlate highly with other important aetiological factors in schizophrenia higher in cannabis abusers and those with childhood adversity and adverse life events Many of the same variants predicting schizophrenia had also been shown to predict bipolar and one fascinating application of the polygenic risk factor score has been to predict the likely nature of illness after a first episode i.e, bipolar or schizophrenic trajectory His talk returned to the question of biological and more specific gene determinism and whether genetic changes seen were risk factors or purely epiphenomena He talked about the rising field of Epigenetics looking at the question of whether environmental failure was secondary to genotype or whether the at risk individual induced environmental exposure provoking the disorder. Prof Stephen Hyman (Harvard, Neuroscience) peddled the successes of neuroscience research going methodically through recent advances in aetiology including showing Psychotherapy causes plasticity of the brain and several findings related to Schizophrenic brains .Findings of lower density and disrupted connectivity of neurones in the adult brain and abnormal cortical thinning in adolescents. Going on to advances in treatments the use of viral vectors to deliver genes to treat Retinitis Pigmentosa, stem cell therapies for Parkinsonism, a new Mendelian gene therapy for Autism .Deep brain stimulation used for Parksinsonism and a Brain machine interface allowing control of a robotic arm with the power of thought in quadriplegics He discussed the ongoing limitations of studying the brain - its inaccessibility during life ,the opacity to introspection in animal models and reminded us serendipity remained an important mechanism for advancement .Discussant George Smuckler also warned about the risks of biology being assumed as a cause rather than consequence of long term illness . Professors Wessley and Murray were able to draw out fascinating parallels between past and present Professor Nikolas Rose (Social sciences) slated the neurobiological leanings of the new dsm4 classification system ,pushing a need for a more ontological system reflecting the experience of the ordinary person .Discussant, Prof Wessley gave an impassioned account of how circular arguments of this nature had raged through the years and this was a position we had been in before. Murray’s talk which followed referenced Prof Wessley’s historical challenge at the end .He reminded us that the current advances in genetics supported a social (dimensional) v medical (categorical) model of psychosis whereas ,when he had entered psychiatry the world of aetiology was polarised between RD Laing’s social model and Slater’s genetic model , that one gene caused Schizophrenia. He ended his talk ,neatly wrapping up the debate by pointing out that paradoxically geneticists of the future had proven the empiricists of the past correct! I left with the feeling that what we had all suspected all along had been proven ,that the field of genetics seemed much less esoteric and society like psychiatrists were still struggling to amalgalmate psychosocial and biological aetiologies including what this meant in real terms for our own morality. Zaubia Alyas ROUND UP LONDON DIVISION EXECUTIVE COMMITTEE MEETING JUNE 2015 This is a new feature ,which will be linked to the official minutes and serves to highlight in more detail some of the discussions at the Divisional meetings Dr Rachel Gibbons gave a passionate talk about the outcomes of her official review of suicides at London tube stations .She described the scale of the problem - everyday 30 people were led away from track side ,that it was the main way of suicide in young people The government were understandably sensitive about the figures and transport companies did not want to advertise hotspots for fear of inciting more suicides . There was direct evidence of the success of barriers and these must be considered an integral safety feature in all new builds . The discussion moved on to how suicides continue to happen at psychiatric hospitals and patients continue to defy systematic safety systems and find the most unlikely ligature points .Dr Gibbons discussed how experts believe that most suicides even those of the chronically ill were very likely to be impulsive acts, something taken seriously by the those at the Samaritans ,who liken the impulsivity in the lead up to suicide with anxiety in a panic attack .They aim to keep their suicidal callers on the phone for over 20 minutes, after which they feel the acute impulsivity subsides . There was discussion about the evolving US model based on the Detroit service model aiming to make suicide a zero event within services and the rising pressure this puts on Psychiatrists. Dr Gibbons shared her experience of running a support group for psychiatrists that had been through the process of a suicide inquiry and how their perspectives changed with time. The group this would be a useful source of support for new consultants. Dr Jan Falkowski described the colleges endeavours to support new consultants, especially through the hardest first 5 years ,with a series of support events Dr Shakeel Ahmad (Chair) continued to impress upon the group the need for the London MAC chairs to have some form of organizational link to the London Division, preferably via the MAC Lead sitting in the Executive. Alliances have been directed historically towards the trusts organizational structures and even these are highly variable between the trusts .His desire would be that trust issues reached the college in this way and the college could serve as more directly supportive. Weblink to minutes http://www.rcpsych.ac.uk/login. aspx?ReturnUrl=%2fworkinpsych iatry%2fdivisions%2fexecutiveco mmittee%2fexecutivecommittee minutes.aspx LONDON DIVISION VACANCIES If you would like to get involved with the College, and you are: up to date with regards to the standards required for postgraduate education and CPD; have a keen interest in maintaining standards of consultant and other career grade psychiatrists; have a keen interest in post graduate psychiatric education and CPD; understand the national and College standards for CPD; be a full, current Member or Fellow of the College; have held a substantive consultant post for at least three years; be in good standing with the College for CPD; be able to fulfil the requirements of the post; Why not apply for one of the following posts? Regional Representative: South East London Liaison South East London Intellectual Disability South East London – Academic South East London – Addictions South East London – Neuropsychiatry committees of Schools of Psychiatry South West London - Child & Adolescent South West London – Academic South West London – Intellectual Disability South West London – Liaison South West London – Neuropsychiatry The closing date for all the above posts is 14th August 2015 NW London – Forensic NW London – Liaision – Works at CNWL NW London – Neuropsychiatry Download a job description: http://www.rcpsych.ac.uk/ workinpsychiatry/divisions/l ondon/vacancies.aspx Contact Lydia Bocko, London Division Manager on 020 3701 259 [email protected] Newsletter Editor : C& NE London – Child & ADolescent Job Purpose: To work closely with other Specialty Regional Representatives, Regional Advisors and Deputy Regional Advisors in providing relevant specialist advice to employers in relation to the development, assessment and approval of job descriptions for Consultants, Specialty Doctors and Associate Specialist Grades; To offer specialist advice at an early stage with a view to enabling the job description to be assessed and approved in a timely manner; To hold other offices where appropriate i.e. membership of a Division. Faculty or Section, specialty tutors or members of sub We have a vacancy for a new editor on our team. No previous editorial experience is necessary but you must be enthusiastic and motivated with excellent writing ability. If you are interested, then please send a covering letter to together with an article about the challenges you have experienced working in psychiatry (maximum 450 words). Deadline Aug 30th 2015 Please submit to Lydia Bocko, London Division Manager on 020 3701 259 [email protected] Design Competition : UNLEASH YOUR CREATIVITY We are looking for a new logo for the London division newsletter. Design a logo and have the logo featured on all newsletters! Prize includes free entrance to any divisional event Deadline for Submission – August 31st 2015 [email protected] Elected Member LONDON DIVISION EXECUTIVE COMMITTEE Dr Sally Porter Learning Disabilities Dr Olivia Protti Perinatal Advisor Dr Shakeel Ahmad Chair Dr Konstantinos Agathokleous Financial Officer Dr Zaubia Alyas Newsletter Editor Dr Mark Ashraph Elected Member Ms Emily Collins Carer Dr Ian Collis Regional Adviser Dr Maja Dujic Forensic – MAC Link Dr Jan Falkowski Regional Adviser Dr Charlotte Feinmann Liaison Psychiatry Faculty Dr Peter Hughes Vice Chair Dr Rosemary Humphreys PTC Rep Dr Sujeet Jaydeokar Learning Disabilities Link Dr Eric Johnson-Sabine Eating Disorders Dr Martin Lee Service User Dr Ilyas Mirza Dr Sujaa Rajagopal Arokiadass Elected Member Dr Lorna Richards Eating Disorders Section Dr Samrat Sengupta Regional Adviser Dr Arvind Sharma Elected Member Dr Fiona Stormont Old Age Faculty Dr Shaji Sukumaran Affiliate Representative