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January 2006

25 January 06

Last week I made the move to Scotland and will start my new post as staff grade psychiatrist on Monday. Change undoubtedly brings with it a mixed bag of emotions and responses – exciting, stressful, frightening, longed for, uncomfortable….

I want to see change in the area of stigma and mental health. I want to see this couplet of words divorced from one another, but surprisingly I have seen that the very people who most need help in terms of their mental health can be those who are most resistant to this change.

Take Mary, for instance. She had taken an overdose of Ibuprofen, not serious of course but she did not know that. In her ignorance of the toxicity of various medications, she had taken this with the intention of doing herself serious harm. As I interviewed her, it was readily apparent that she was suffering with a moderately severe depressive illness. I realised that this young woman needed help and that her ongoing sucicidal thoughts meant that she was at risk of making another attempt on her life unless some intervention was made. Having discovered that Ibuprofen was not lethal, I could see that Mary, an intelligent woman may find rather more serious ways of harming herself.

I talked to Mary about depression, explained that it was an illness and that like any other illness it could be treated. I suggested that she talk to our community mental health team who were based in the A&E department. At this Mary erupted, the tears disappeared and the anger emerged. “What you think I’m mad, do you? I’m not seeing any one like that – they’re for people who are ‘mental’!”

This was not the first time that I had come across this sort of attitude and my response was to become equally offended. With a calculated look of shock on my face, I would explain how psychiatrists and mental health nurses treat patients who are ill. Mental health problems are experienced by a large proportion of the population. Most do not even see their own GP, let alone see psychiatrists but all of them deserve to be treated with respect.

Mary’s anger abated and her face softened. “I’m sorry”, she said “I just thought that maybe you were saying…….” Her voice tailed off. “No” I said, “you are not mad. You are just suffering with a common illness that needs some treatment. Soon you will be feeling much better.” She thought for a moment or two. “Yes, I’ll talk to someone if you think it will help” she said. Much relieved I referred her and encouraged her to start checking in with her GP. She accepted what I told her without a struggle, sadly it is not always quite so easy.

Cathy Wield

Research Digest

Fortney and colleagues report on the design and implementation of the ‘Telemedicine-Enhanced Antidepressant Management’ Study (TEAM study). This is a preliminary report of a randomised controlled trial to determine whether it is possible to implement collaborative care for depression in small rural primary care clinics (as opposed to large urban practices where collaborative care approaches have been successful). They adapted the collaborative care model especially for small rural practices in the United States utilising ‘telemedicine technologies’. This, in essence, is interactive video-equipment used to facilitate the collaboration between on-site primary care professionals (PCPs) and off-site depression care teams. The nature of the intervention follows the stepped care collaborative treatment model for depression. Five types of providers were involved in the depression treatment: PCPs, consultant ‘telepsychiatrists’, off-site depression nurse, off-site clinical pharmacist and a psychiatrist supervisor. Though the results of this study are pending, they have been able to enrol adequate patients to be able to evaluate telemedicine-based collaborative care and should be published soon.

Fortney JC et al. Design and implementation of Telemedicine-Enhanced Antidepressant Management Study. General Hopsital Psychiatry 2006. 28: 18-26

Bruce Rollman et al reported on a randomized trial to improve the quality of treatment for panic and generalised anxiety disorder in primary care. They too a evaluated telephone-based collaborative care treatment package. They randomised 191 adults with panic and/or generalised anxiety disorder. The intervention involved non-mental health professionals who provided psychoeducation, assessed patient preferences for guideline-based care, monitored treatment responses and liaised with their doctor about their care preferences and progress. They found that telephone-based collaborative care is more effective than care as usual in improving anxiety symptoms, quality of life and work-related outcomes.

Rollman BL et al. A randomized trial to improve the quality of treatment for panic and generalized anxiety disorders in primary care. Arch Gen Psych 2005.62: 1332-1341

Gavin Andrews, Richie Poulton and Ingmar Skoog have written a very timely and thought provoking editorial in the British Journal of Psychiatry. They ask the question ‘What proportion of the population will suffer from depression’? That reviewed the evidence from cohort studies and come to the conclusion that a staggering 50% of the population will suffer form depression at some point in their life, with peak incidence in the very old and very young.

Andrews G et al. Lifetime risk of depression: restricted to a minority or waiting for most? B J Psych 2005. 187: 495-496

Joo et al have further explored the ongoing controversy around the adequacy of depression management in primary care (in the US). They found the majority of depressed patients in primary care were treated adequately, with no age or race disparity. However, patients with mild to moderate depression were treated less adequately than those with more severe depression. This makes sense, as the evidence for best practice in mild to moderate depression is less well established than that for moderate to severe depression.

Joo JH et al . Predictors of adequacy of depression management in the primary care setting. Psychiatric Services 2005, 56:12, 1524-1528

Paul Walters

Mental health: Fun on their minds
A project in Stockport is helping young people with mental health problems to take part in regular youth activities. Andy Hillier finds out how it works

Fifteen-year-old Brian would never have dreamed of going to a youth club under normal circumstances. He suffers from a rare condition called body dysmorphia that means he is excessively worried about his appearance and doesn’t like going out in public.
"In his mind, he views himself as ugly and deformed," says Laurie Carefoot, development worker at the Sound Minds project in Stockport. "He thinks he’s overweight and that everyone’s looking at him."
Brian is one of eight young people currently attending Sound Minds, a youth group for 13- to 16-year-olds living in Stockport who are experiencing mental health difficulties.
Equal treatment
Set up last year, the project is run by Stockport Youth Service and is funded through contributions from the community child and adolescent mental health service (CAMHS) programme. The scheme provides young people with the chance to take part in a range of regular youth activities such as outings to theme parks, outdoor education trips, as well as arts and environmental work, music, drama and photography sessions. "They get to do the kind of things other young people do," says Carefoot.
The young people are referred to the project by a variety of professionals including teachers, social workers, mental health workers and GPs. They are then screened by a community CAMHS panel made up of a range of professionals, which decides whether the project is appropriate for the young person or not.
Some of the young people have been diagnosed with clinical conditions, while others have been identified as being at high risk of developing a mental health problem.
"Many of the young people have conditions such as eating disorders, depression, grief, communication problems, anxiety, behavioural problems and obsessive-compulsive disorders," says Carefoot. "Some have severe problems, but many of them just need a little help."
Before a young person is placed on the programme, a project worker will visit them in their home and explain the situation and what will be involved in the programme. At first, the young people can be quite defensive about taking part. "They know there is a stigma attached to mental health and they see the referral as negative and an indication that something is wrong with them," says Carefoot. "But we try to explain that they are just here to have some fun and this is not counselling or group therapy."
Over a period of two months, the young people attend one afternoon a week during school time. These sessions include group work activities such as problem solving, looking at personal and social development, as well as projects on assertiveness and anger management. These groups are deliberately kept small because many of these young people don’t work well in crowded situations.
"For many of the young people, just attending the group is an achievement in itself," says Carefoot. "Often they find it hard to leave their home because of their condition and don’t cope well in groups. But the barriers they face normally are broken down because they’re all in a similar situation."
Space to relax
Lisa Ward, CAMHS operational manager in Stockport, says the young people appreciate the project because the emphasis is on providing informal learning in a relaxed setting. "It’s a different sort of involvement to what they’re used to," she says. "It’s not in school or at the hospital and it’s not all sitting and talking. The balance of activities really helps their self-esteem and confidence."
So far feedback from the young people has been positive, but Carefoot acknowledges that the programme is not successful for everyone. Despite receiving lots of support, some of the young people find it hard to cope with the activities and drop out after a few weeks. He believes this is an inevitable part of working with young people with complex needs.
One of the biggest beneficiaries of the programme has been the parents, many of whom have seen a noticeable improvement in their child’s attitude and wellbeing.
"Lots of the parents comment on how their son or daughter has come out of their shell since they’ve been on the programme," says Carefoot. "The work we do to raise young people’s confidence has an impact on all aspects of their lives."
For Brian, the project is already starting to make a difference. Not only has he started to make friends, he is also optimistic about returning to mainstream school. "It’s differences like this that matter in these young people’s lives," says Carefoot.
Name of young person has been changed.
www.youthfulminds.org

Ezine News

Look, listen and test: mental health assessment: the WONCA Culturally Sensitive Depression Guideline

Ivbijaro, Gabriel O.; Kolkiewicz, Lucja A.; Palazidou, Eleni; Parmentier, Henk
Primary Care Mental Health (ISSN: 1476-4717); Volume 3, No. 2, pp. 145-147(3); June 2005

Abstract:

The World Organization of Family Doctors (WONCA) published the Culturally Sensitive Depression Guideline in 2004. This guideline recognises the difficulties faced by family physicians in the recognition and management of depression in patients from diverse cultural backgrounds. It explores the metaphor used by patients from different ethnic backgrounds when describing psychological distress. It recognises the importance of a longitudinal approach to history taking in general practice, recommends the use of interpreters to aid communication and proposes 'look, listen and test' as a schema for mental health assessment in primary care.

Issue 35 of NIMHE West Midland’s E Bulletin is now available from their website and can be accessed using the following link:
www.londondevelopmentcentre.org

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