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:
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
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
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.
teifion.davies@kcl.ac.uk
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
Stephanie.Young@slam.nhs.
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.
afia.ali@nelft.nhs.uk
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
zaubia.alyas@slam.nhs.uk
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
Stephanie.Young@slam.nhs.
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
hemmav@doctors.org.uk.
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
LBocko@rcpsych.ac.uk
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
LBocko@rcpsych.ac.uk
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
LBocko@rcpsych.ac.uk
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