George: Schizophrenia, Cognitive Decline & Antipsychotics

11.11.08	George admitted on a Section 117.  George is sixty-three with a long history of schizophrenia having being diagnosed in 1969 (24yr old).  Revolving door patient although mainly inpatient.  Usual stuff (in some cases) believing he was well (if discharged) and stopped meds resulting in re-admittance.  Intractable auditory hallucinations which seem to govern his thought process.  Well educated and apparently his life fell apart after university and his first employment being his last.  Physically well (statins and senna).   No known NOK.   Stayed in his room, appears distracted, unresponsive to communication.
12.11.08.	George has remained in his room again this AM.  Does not initiate conversation but appears to welcome it, smiling and holding out his hand for you to take it.  He is a very pleasant man with a seemingly gentle disposition.  Distracted this PM, quite haunted appearance.  Will not communicate or make eye contact. OK by teatime.
18.11.08	George appears well settled.  Stays in his room most of the time but will venture into the lounge occasionally. Other residents appear to have accepted him into the fold and include him in conversation to which he enters – although still does not initiate same.   Often distracted by auditory hallucinations to which he does respond, often angrily.  Other residents seem to tolerate this, some amused by it, others ignore it and the rest by nature of experience, understand it.
09.12.08	George very well settled.   He has been designated his own chair by his circle of friends!  Goes out each morning for his newspaper accompanied by staff.  Remains fully compliant with meds.   Does not initiate conversation but readily responds.  Auditory hallucinations continue.
18.03.09	Section 117 terminated – George now free to leave the building without supervision.
21.01.11	George returned to the home (by the police) for the third time in succession after apparently getting lost.  No evidence of cognitive decline when in the home – but perhaps too subtle?  Monitor.  George now to be accompanied by staff whenever he leaves the home.
26.08.11	Cognitive decline continues.  Defecates and urinates inappropriately.  Manually evacuates bowel smearing contents in room.  Very hostile during interventions, always verbally, often physically.   After re-referral to psychiatry, depot discontinued and ‘given’ as oral meds.  Donepezil initiated.
23.02.12	Further decline evident.  Needs assistance in all aspects of daily living.  No longer able to feed himself.  No longer mobilises.   No longer speaks bar that of responding to his voices, but this being of a bark.  His psychiatrist continues to decrease and reduce (the amount of) his antipsychotics.  We don’t understand why!  Donepezil stopped.
17.10.12	Apart from a rare moment when he smiles that smile and offers his hand for the taking, George appears to exist in a permanent state of torment (hell!), he appears distracted to the point of being haunted most of the time, haunted by his voices that he no longer understands.  Every intervention becomes a battle – how horrific his life must be for him.  We have requested his GP refer him (urgently) to psychiatry; he is on the lowest dose of one med only; how can this be right?
14.11.12	Accompanied George to see his new psychiatrist  - always seem to be temporarily filling a post before they move on elsewhere  - who despite explanations refused point blank to visit him in the home.  I suppose one benefit of him not doing so allowed him to see George at his most agitated.  But benefit it wasn’t.  He (the psychiatrist) was adamant that George’s problems/behaviours’ lay with his ‘dementia’.  He has ordered that George’s remaining antipsychotic be reduced across the next fortnight then stopped.  I am horrified and dare question his judgement.  His response: We both know of the dangers associated with antipsychotics and dementia, don’t we?  WHAT ABOUT HIS SCHIZOPHRENIA?
14.11.12 -present	George’s existence must be pure hell.  Psychiatry will not have a re-think – so this is George’s lot until the day he dies.  The rare smile continues, lost as it is amidst his continuous torment as he barks in response to his voices and lashes out at all those who go near him. He has ‘dementia’ but his voices haven’t. Perhaps his psychiatrist is following the ‘wisdom’ here, but perhaps he should visit here where it is concluded that most elderly patients remain symptomatic and impaired. Perhaps I don’t know what the hell I am talking about as I am not a psychiatrist – but what I do know, what is so horribly evident to me, is that George is tormented by his voices and psychiatric services will do naught to alleviate his obvious distress.   How can this be right?

Image: Courtesy of Wikimedia Commons

Author: Gert Germeraad

In Praise of Psychiatric Services? (2)

Dr Rant

I’ve just tried to change my password to ‘Community Mental Health Team’ but Facebook said: contains too many useless characters.  (Facebook 16/12/11)

Sorry Community Mental Health Teams  (CMHTs) – I find this to be true – well certainly in my neck of the woods.   God help the unfortunate soul who experiences an exacerbation of mental health ‘ishoos’ while residing in social care for they are truly lost!

I have written about this before and unfortunately nothing has changed.  The CMHT completely ignore us (staff) in that they do not seek our input, our knowledge and our concerns.  Liaison – what’s that?  Do they consult the referring GP (?) – I tend to think not (and indeed sometimes know) as GPs are equally frustrated re the lack of communication and cooperation between ‘colleagues’ and that (wrong) decisions are made (by the CMHT) after a thirty minute interview with the poor resident in question.

Ted entered our home some five years ago – he does not have any problems related to memory but that of depression and apathy which has dogged him since a traumatic incident in early adulthood.   He is isolated due to social anxiety which increases his depression and feelings of hopelessness and low self-worth. 

This has been his life for nigh on thirty years and increasing apathy, hopelessness led to Ted being at high risk of self-neglect and increasingly vulnerable to those in society who ‘befriend’ him and rob him of his benefits and thus him becoming a welcome resident of our home.  Our home is now his home.   (It is Ted's home - I/we have the privilege of working there!)

For some time Ted has become reflective re his personal situation and this in itself has led to a deeper depression (‘I am worthless’) and as he is comfortable in his home he is also able to express anger (‘I am useless!’) both verbally and physically (as in punching inanimate objects and destroying his own personal effects).

Ted has – for the first time – begun to self-harm.   He also exhibits behaviours that some might construe as sexual in nature – but to me (and I have discussed this with him) are an expression of his need to be loved and reverting to babyhood and the intervention required is to him, proof of caring.

Ted’s GP referred him to psychiatric services requesting the input of a psychiatrist.  In turn, said psychiatrist did not see Ted rather placing Ted’s future in the hands of the CMHT.   What is the purpose of the CMHT?   A CMHT meets the needs of people with mental health problems who don’t need a psychiatrist.

So it needs to be asked:  Does this little collusion of anonymity (psychiatrist and CMHT) have an agenda?    Why is the GP referral of secondary importance to that of the CMHT – who make their decisions based on a thirty minute interview without liaising with other interested professionals who know Ted?

The CMHT in their wisdom decided that Ted did not need to see a psychiatrist.  This decision – to Ted – was further evidence of his unimportance (‘Why is no-one interested in me?’).

Ted’s continued and deepening depression began to compromise his physical health in that he ceased to eat and had poor fluid intake causing an electrolyte imbalance which led to problems and the need for medication to counteract this.

Ted’s GP, who had long realised that Ted’s needs were beyond his expertise again contacted psychiatric services, pressing for the input of a psychiatrist and again this led to a swoop by the CMHT, who again decided that Ted did not need to be seen by a psychiatrist?

Six months ago, near death (malnutrition and dehydration), Ted was hospitalised.  He was at this time (finally) seen by a psychiatrist and when strong enough was transferred to a psychiatric hospital to treat his depression!

The psychiatrist contacted the home for a history of Ted and requested our thoughts – something the CMHT (and indeed the psychiatrist prior to this) did not!

It appears to me that the little collusion of anonymity ensured Ted paid a high cost both physically and mentally by denying him access to a psychiatrist – but that is what collusion of anonymity is all about – bouncing patients back and forth from one specialist/discipline to another with nobody taking responsibility for the patient as a person.

Ted is a person.

Before I close I would like to assure those who exist in CMHTs that this is a specific post to experiences in my neck of the woods and is not a gross generalisation of all.  I am sure that team members offer a vital hand to those in the community who do not need to see a psychiatrist.

Why do psychiatrists not take heed of GPs here?  Why in these instances are decisions left to CMHTs as to whether a patient requires the input of a psychiatrist – why does the psychiatrist not see the patient and make the decision him or herself?   Just wondering, that’s all…

What say you?

Anna :o]

In Praise of Psychiatric Services?

What does a Community Mental Health Team (CMHT) actually do?  Of course I do know what the remit of their existence is:  Meeting the needs of people with mental health problems who don't need a psychiatrist.

But what if your GP decides you do need the input of a psychiatrist, why isn't her/his decision acknowledged, respected and action taken, rather than the CMHT swoop down on you instead?

We have a sixty year old resident ('Winnie') with complex mental health problems including ongoing addiction.  You might think we are being remiss in not addressing her addiction but our hands are tied by Safeguarding Vulnerable Adults (SVA) and Deprivation Of Liberty Safeguards (DOLS) legislation, and of course, importantly, whether this legislation exists or not, Winnie has the right to choose her own path in life.

Winnie presents as quite a strong character with a seemingly happy disposition, but there are strong suggestions (of late) that all is not well.  I love my job and see my main purpose as that of promoting well-being and being 'there' for the residents.  I have regular daily chats with many residents and these chats, quite rightly represent the bulk of my work.

Winnie is one of these residents.  We chat about everything past, present and future.  As said, of late, there are obvious signs that all is not well and our chats have taken on a deeper nature.  She talks of a deep depression that she hides under her happy veneer and indeed, my last post is based loosely on that she has disclosed - the real Winnie.

Her depressions is something that she has coped with for the majority of her adult life.  She receives antidepressant medication and it has been enough - along with her own self-medication of alcohol - to control her symptoms until a recent event led to feelings of helplessness and hopelessness that dogged her in her early twenties.

We contacted her GP who is a good GP who visited Winnie in the home and spent time with her, listened to her, increased and augmented her antidepressants and referred her to psychiatric services.

Psychiatric services initiated a CMHT visit, although which professionals were represented in this team we do not know as we were not privy to this information.  Why might this be - perhaps the bad reputation of care homes and the assumption we would not be interested?  If this is the case - it is bad practice.

The team spent half an hour with Winnie and left - no staff being approached to give input into Winnie's situation.  A few days later, my manager was contacted by a psychologist (who had not been part of the team) to advise that the home was to be reported re SVA and DOLS issues in relation to Winnie.  Flabbergasted my manager asked why and the reason given was incredible.  He asked why he had not been contacted previously as to enable the team to be aware of the true facts and was met with an embarrassed silence.  We were not reported, nor did we receive a cc of the letter to the GP which is good practice and good manners as we are very much involved in Winnie's care.

Winnie continued to deteriorate both mentally and physically and my manager contacted the CMHT again requesting further input, only to be told that their work was done.

What is their purpose?

The good GP is bringing together a CMHT of her own making and being a good GP visits Winnie weekly as she shares our concerns.  In the meantime Winnie continues to suffer.  Hopefully, somewhere in the near future, Winnie will receive the input of a good psychiatrist, emphasis on good as we have four psychiatrists who serve the residents in our home.

One is a good psychiatrist - the old school variety of 'doctor knows best' who listens to and understands the real needs of his patients and follows up their care regularly.  His patients have the best outcomes.

The remainder are of the newer breed who offer choice-ism.  "Which tablets do you want to take?" and/or "I hear you attempted to strangle X - can we discuss this?" (if "No" to the latter it is not addressed!) and is all well and good until  you display florid psychosis and/or come very near to actually strangling X and are sectioned.  What kind of care is this?

You are never offered the choice of mental ill-health - but hey, even if you lack insight you can choose your medication based on the knowledge you acquired while being a medical student!  You were not a medical student?  You don't have a degree in psychiatry?   Never mind, your mental health issues may not be addressed - but hey, you do have choice!

You may think from the above that I believe those with mental health problems have no rights at all - but this is not the case as I am very BIG on the rights of residents, as is my home.  I believe they have a right to the best of treatment and not the superficial fluff of caring they receive now, although as said, even receiving superficial fluff takes an awful lot of time to get to as there is an awful lot of hoops to jump through first.  And you continue to deteriorate.

What say you?

Anna :o]