America’s Medicated Kids – Review

Louis Theroux is without doubt a very personable soul. He comes across as likeable and curious – the opposite of aggressive, but not in a passive way, more of a reconciler perhaps. So by tackling the issue of whether children in the United States are over-dependent on medication for psychiatric ‘disorders’, he took himself to a clinic in Pittsburgh and met with psychiatrists, counsellors, children and their families to get to the heart of the issues at hand.

There was, without doubt, a bias towards a criticism of the decisions to medicate children as young as six who were diagnosed with bipolar disorder, ADHD and Oppositional Defiant Disorder. We looked into the lives of three children in particular, whose homes Louis visited, and in one case, stayed as a guest, to get into what it was like to be a child with a label.

I had a feeling that Louis concluded with more sympathy for the families than he might have started with – but with a heavy heart – or maybe that’s how I felt after the programme. He asked some very intelligent questions to the families and the doctors.

What was the difference between personality and symptoms? How much of the child is the illness? When the medication starts and the labelling starts, how difficult would it then be to stop?

I was struck by the child whose mother was asked about the difference when she takes her medication and when she doesn’t and she said, of her 15 year old daughter – that when she takes her medication, she is ‘like my friend’ and when she doesn’t, she is obstinate and disagreeable. A part of me remembers myself at 15. I don’t think I would have been a parent’s ‘best friend’ at that stage.

Another angle that struck me was the child with ADHD and Aspergers’ who had begun his journey through the psychiatric system when he had been expressing ‘suicidal ideations’. I can’t imagine how difficult it must be to have a child with these difficulties. How frightening it is. But again, I felt sad that he seemed to have become defined by his diagnoses. It made him now feel special.

I think it was a well-made film and I’d recommend watching it. It is a thoughtful insight into some of the difficulties that exist but I wonder about an over-dependence on medication and not just for children. One family explained that all family members (except their daughter and including their dog) were on some kind of medication.

The film did not tie up with any conclusions. It filmed the interviews, talked to some of the parties involved and left us with an open question – but enough questions were left at the end to suspect that nothing is as straightforward as we would like it. The issue of drugs companies was never really raised, for example.

I am not against ‘medication’ for the record. I have seen how much positive difference a prescription can make to someone’s quality of life and have no doubt that it is entirely the right option for some people and some children as well. I suppose the concern comes in the increased propensity to medicate because it may be easier and cheaper than more costly psychological therapies. And the damage within families may be too high a price to pay for the time it might take to treat by other means.

America’s Medicated Kids is available to watch on the BBC iPlayer.

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Murdered for Medication

I saw this story on the Guardian website and was amazed that it was the first I heard of it.

Rachel Baker, the manager of Parkfields Nursing Home is on trial accused of murdering two women who were in her charge, and stealing their prescription medication that she was addicted to.

Baker, 44, who ran the Parkfields care home in Butleigh near Glastonbury, Somerset, became addicted to drugs, including heroin, after being prescribed painkillers for migraines. She allegedly fed her addiction by “diverting” drugs prescribed for residents at the care home. She either stole the drugs from residents who needed them or exaggerated or made up symptoms so that drugs the elderly people did not really need were prescribed.

Baker has admitted eight charges of possessing controlled drugs and one of intending to pervert the course of justice. She denies the murders.

Just imagine the coverage if the victims had been 5 and 7 years old rather than 85 and 97 years old and that, I think, tells us all we need to know about society’s ageism.

Feeding Tubes

I was appalled by this story in the Guardian this morning that residents entering some nursing homes are being required to have feeding tubes fitted as a condition of admission – this comes in a report from the Royal College of Physicians which recommends that artificial feeding should be used ‘as a last resort’ which seems perfectly obvious to me.

In all the years that I’ve been working in the field of care for the elderly and more specifically in the last few years in a specialist mental health team, I have to say I have never come across this in any nursing home that I have been involved with – so the report came as a complete shock to me.

The article goes on to state that

A recent national confidential inquiry into patient outcomes and death (NCEPOD) investigation found 19% of those undergoing the procedure had it fitted inappropriately. “They described it as futile,” said Burnham. Almost half of those who died (43%) did so within a week.

While a nasal tube is safer than a device fitted in the abdomen, a so-called PEG, the best option for patients is normal feeding wherever possible. “‘Nil by mouth’ should be a last resort,” says the report.

The speculation is that the time taken to feed a resident who has higher needs and requires more personal attention is lacking and that is why the procedure might be done.

Any adherence to the Mental Capacity Act would hopefully be able to regard all such procedures in a more patient-centric way and certainly it would flag immediately as a possible deprivation of liberty (although not necessarily as there are differing circumstances in all cases) which would at least require a lay and a medical opinion to authorise – through the assessments of a Best Interests Assessor and a Medical Assessor.

Even prior to an admission to a home, I wonder if a medical procedure of this kind would not need some kind of ‘best interests’ decision to be made and that being the best interests of the individual rather than the management needs of the care home in question.

Honestly though, I’m amazed this news isn’t on the front pages of all the newspapers this morning. For me, it is one of the most scandalous stories I’ve read in a long time.

Of CTOs

Community Treatment Orders – Supervised Community Treatment – however it is termed it is one of the aspects of the amended Mental Health Act that I thought I would likely not have significant contact with on a day to day basis. I was right. But my experience might be far from typical as the take-up of these Community Treatment Orders has been much higher than was estimated by the government.

As Community Care reported a couple of weeks back

The statistics revealed that 2,134 community treatment orders were issued in England from November 2008, when they came into force, to March 2009. The government expected there to be 450 CTOs in England and Wales in the first year.

That figure of about 2000 is only until March – currently the whispers (from various training courses) say that the figure is nearer 4000.

So what are they for?

And who do they affect?

This was one of the more controversial parts of the amended Mental Health legislation in England because it allowed for conditions relating to treatment to be placed on patients in their own homes. It allows for a process of ‘recall’ to hospital is the conditions relating to treatment are not met.

We, in our training and discussions, are often signposted to people who may have a very clear history of ‘revolving door’ admissions with similar sets of circumstances and the CTO provides a means of enforcing treatment with the threat of recall to hospital in the background and a legal framework being provided in order to do so.

The general discussions that I’ve been party to in my local trust area seems to revolve around a few consultants being very much in favour of using them and others not using them at all so the national figures are high. It is another way of managing risk through compulsion and in an increasingly risk averse culture, it can be seen as an additional safeguard.

I have been involved in a couple of CTO-related decisions in my role as an AMHP (Approved Mental Health Professional). Generally the RC (Responsible Clinician) will be the one to arrange the CTO however before it is valid, the forms have to be signed by an AMHP in order to serve as one-man check and balance system to ensure that the conditions set are fair and appropriate and that the least restrictive path is met.

The other role of the AMHP is in the revocation of a CTO. If, when a patient is recalled to hospital by their Responsible Clinician it is seen fit that they need to revert to the section that they were detained under prior to the CTO, a signature of an AMHP is required on the paperwork in order to validate it.

The only CTO-related issues that I have been involved in so far have been to revoke a CTO – in the situation, the patient was not someone I knew very well but I had been involved in the initial community assessment and bringing her into hospital as a result. I was asked to consider the revocation of the CTO and saw that she was extremely unwell – at least as unwell as the point of the initial assessment considered that it was far more appropriate at that time that she was in hospital for a while longer.

The other decision is more recent so will probably come back to it at a later date and is, as of now, unresolved which is more reason for me not to dwell on details but it has raised interesting dilemmas about how much influence can be placed to sign some of the pink forms (all Mental Health Act forms are pink – for the record) if it will ‘make life easier’. As I said, it’s probably something I will return to at some point.

I was involved in some in-house training about the new Mental Health Act legislation and to be honest, because of the time involved, we skimmed very briefly over CTOs – thinking that they wouldn’t necessarily be relevant within over 65s services however, we are considering a few refresher sessions because, as Pope wisely said ‘A little knowledge is a dangerous thing’..

The Drugs Don’t Work (or do they?)

Medication is not my forte’, but working as I do, in a multi-disciplinary team where there are doctors and nurses present, I have a great opportunity to check any information I’m need clarification about.

I make liberal use of the BNF (British National Formulary) website which lists comprehensively all the medications that are used, I also found particularly useful a book called ‘The Approved Social Worker’s Guide to Psychiatry and Medication’ which I’d recommend highly as a non-medic’s text to, well, psychiatry and medication which assumes some background knowledge of mental health (although it has a clarity which makes it useful across the board to non-experts).

Anyway, with that proviso, I came across a couple of articles at the weekend relating specifically to medication.

Firstly an article at Psychminded which challenges the assumption that schizophrenia needs to be necessarily treated with medication. Medication has it’s place but it not exclusively.

rselph at flickr

Then an article I have to say I found a little sobering from a magazine called ‘Woman’s Day’ which publishes ‘Six tips towards Choosing an Antidepressant’. As we know, information is empowering but I just found it a little incongruent that drugs should be compared like candy. The article itself is useful in that it points towards possible factors that should be discussed in order to best choose but honestly, I’d hope any prescribing doctors would (and do)  take these factors into account anyway.

I wonder how much there is a culture of leaning on medication as the ‘easiest’ option through a period of difficulty. I am by no means anti-medication. I have seen some almost miraculously positive results and pharmacology is a vital part in most treatment plans but something about the normalisation of antidepressant medication seems to sit uncomfortably.

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Vitamins, Dementia and Hope

A new trial is being carried out in the New Year to look at the effects of dosages of B3 vitamin to people who have been newly diagnosed with Alzheimer’s and this is reported in the Guardian.

It worked on the mice so there is going to be an open trial on humans.

All well and good. Research is a good thing and anything that might help should not be scoffed at.

It brought to mind a conversation I had last week with the daughter of a woman who has Alzheimer’s that I work with. Her mother has been diagnosed for about 5 years and has been stable for about three years now. No improvement but no noticeable deterioration either.

Things are manageable at home. More or less. She has moved in with her daughter and her daughter’s family but all is quiet. There are occasional upsets, like when she opened the door for the toddler to wander out of, but these serve as warnings.

Her daughter asked me about trials for medications and news she had seen about ‘cures’ for Alzheimer’s.

I explained that trials were still at early stages and that although we should be happy about the possible cures and treatments that will be available in the future, it is not likely that any will be available for her mother.

She told me she would pay anything to join the trials. She said she would travel up to Scotland if necessary – stay every day, do absolutely anything she could to trial a drug that may help her mother.

I wish there was a drug. That comment is a bit expedient. Everyone wishes there was a drug to help.

We talked about trials for a while. And hope. And how thin the strings are on which the balloon of hope can tie itself to ideas before I snipped the strings to let it fly away into the ether.

Sometimes I feel that I do a lot of snipping at the strings of hope. My nature is something of a realist. I bumble around, chopping down those fanciful ideas that allow some people to cling on to the idea that things might get better.. someday.. and bring them tumbling back down to earth.

Hope has a role though, but it is better based on at least a semblence of reality and honesty.

Image by vic15 via Flickr

At least another article in the Times at the weekend relates further research from University College, London by Cornelius Katona,  which indicates the importance of a full social life to people with dementia.

I found it to be an interesting piece of research, people with Alzheimer’s at different stages were asked various questions (in various forms) relating to how happy they were with their lives. They were then asked again 18 months later.

those with the highest sense of wellbeing were also those who scored highest on “social relationships” measures – how many people they regarded as close, how often they saw them, and what the relationships were like. People who had the best relationships were the most happy, and stayed happy longer. The results also showed that the happiest people were those who hadn’t any indication of mental health problems such as anxiety and depression at the onset of Alzheimer’s. This, says Katona, indicated that they were ageing “successfully” – despite their decline in cognitive function. It means we should be careful not to judge a decline by our own standards, rather than their own.

In some ways, it isn’t surprising. We are taught and there is something also instinctive about knowing that good social networks make for a better quality of life in all aspects and areas. Sometimes people think that once the memory goes, these interactions aren’t remembered. The words might not be but the quality of the interaction remains important nonetheless.

The study also notes that

When you compare how a carer rates the quality of life of someone with dementia with how the person with dementia themselves rates it, then you find the carer always rates it lower. This is all probably related to the carer’s own susceptibility to anxiety and depression, because their lives are so stressed.

I mention this as it rings very true to me. I spend a lot of time supporting spouses and children of people with dementia. Talking them through the possible progression and the various ideas and plans that can be made to improve quality of life for both the person with dementia and the family around them.

We often ‘put ourselves in their shoes’. Think how we would feel in those circumstances. It sometimes helps neither the carer nor the patient.

It’s good to see that there is hope though.  Katona states that

If we’re going to prepare for an ageing population, with a higher proportion of people with dementia, we need to tackle anxiety and depression better whatever age it strikes. And we need to facilitate social networks in middle and late life, before people start becoming more dependent.

So who knows if the vitamins will help in the longer term. Or the wonder drugs? At least when I cut at those balloon strings of hope, there is something more concrete and more immediate that can be offered.

The hope doesn’t have to live in the cure, but in the living well. Or as best as possible.

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Happy Birthday, NHS

Today is the 60th anniversary of the founding of the National Health Service.

There has been a lot of coverage over the last week in every kind of media source to commemorate this.

From finding people born on the same day to relive their lives through access to the health system to much polemic and debate about restructuring and restructuring again.

A look at the past – and a look at the future in the face of the recent reviews that have come out.

Image via Wikipedia

I don’t think I can add anything new to what has already been said – but in some ways, having been born into and grown up with the system as is, I find it hard to imagine things any other way.

I expect to go to the doctor without thinking of cost.

I expect to get a prescription for medication that I need (and still pay my fixed fee for it!).

I expect to be referred to secondary medical services if and when I require.

I am fortunate to be and to have been in good enough health that I can’t  ever remember  having been in a hospital overnight – a few visits to casualty here and there for minor stitching ups really is about as far as it goes.

I have family members who have been recipients of a great deal of care of an exceptional quality – and of course, now, I work within (although not for) the health service.

There are likely to be many changes in the future as the health needs of the population change. Introduction of ‘market forces’ has already started. Management layers are added and exist to increase the drive towards efficiency.

Always new restructuring, always new developments.

Expectations of what a health service can and should deliver are changing too – and this monolithic structure – oft-quoted as being the third largest employer in the world – does need to adapt.

But I think she’s not been doing at all badly, when all’s said and done.

And here’s to another 60 years and many many more beyond.

Happy Birthday – and at some point today, I’ll raise a glass to Nye..

Image via Wikipedia

And in other, marginally connected news, The Guardian in its Work and Careers section, spotlights a Social Worker (marginally connected because she is a hospital social worker!).

Inside Alzheimer’s

There is an interesting article published by Geriatrics entitled Does Alzheimer’s really exist?. It consists of an interview with two authors of a book called The Myth of Alzheimer’s.

I thought it raised some crucial points. Of course, biologically, Alzheimer’s exists and that isn’t the issue that is being made, but the book seems to try to approach the onset and development of Alzheimer’s from a different angle.

Rather than focusing on the scientific search for a cure, they emphasis the need to look at ways in which the development of Alzheimer’s can be managed within a sociological, cultural and community framework.

One of the authors,  Dr Whitehouse, states

‘Instead of asking ourselves, “What drug should I prescribe”? we should be asking, “How can I help my patient stay alive, enjoy a good quality of life and remain engaged in society”? We have medicalized aging to an extreme degree.’

Image via Wikipedia (donezipil)

It seems like they are carrying out a lot of studies related to how older people with Alzheimer’s interact and what kind of interactions benefit them and in what ways.

I have to say, it was a heartening and inspiring interview and I thought it was a key approach to take as often we work, within our service, in a psycho-social model but sometimes it feels that we are battling against a tide of medication (which, don’t get me wrong, has its place but not by any means exclusively).

I sometimes feel frustrated that age has so many negative connotations in our society. It is not seen necessarily as a part of the life as a whole or the aged, confused individual as a part of who they were, are and will be.

Daniel George, the other author, writes

‘We are all going to grow older. We are all going to die. That may sound somewhat negative, but it is reality, and it carries a message of hope. No matter what we do, we can’t fix all the problems of aging. But we can foster a sense of solidarity. We are all in this boat together. And we can’t throw anyone overboard just because they’re unfortunate enough to be labeled with a mental illness such as AD.’

In a society that sometimes seems to eager to throw those that don’t fit the ‘model’, overboard, it is good to see the work being done.

Dr Whitehouse and Mr George continue to update their blog in relation to their research and ongoing methods. I’ve found it useful to keep track of.

Reasons to be angry

Reuters reports that lower levels of Serotonin can lead to increased anger.

There is a scientific reason why people become more grizzly when hungry, namely that

‘the essential amino acid needed for the body to create Serotonin is only obtained through diet.’

It did make me think though, about how much emotion and feeling is governed by chemicals in the brain. Probably more than we’d like to admit.

Image via Wikipedia

It’s quite interesting to link this report to an article in the Independent which asks if drugs can be an answer to all manner of behavioural problems.

The article goes on to list a series of ‘behaviours’ that are being medicalised and says, for example, of temper that

‘Losing your temper could lead to a diagnosis of intermittent explosive disorder (IED), a condition that is acquiring its own family of drug and other therapies. Just what IED includes, and excludes, is not clear, but  Mayo Clinic  doctors say: “Road rage. Domestic abuse. Angry outbursts or temper tantrums that involve throwing or breaking objects. Sometimes such erratic eruptions can be caused by a condition known as intermittent explosive disorder.” Some 8 per cent of adults suffer from IED, and doctors at Chicago University are using divalproex sodium, a drug used for epilepsy and bipolar disorder, to treat it.’

I am no scientist (although I did get a GCSE in Chemistry..) but something about medicalising behaviour seems to move away from personal responsibility.

Maybe I just need to make sure I keep a cereal bar on me at all times for those days when I don’t have time for lunch..

Differences in Depression

Breaking completely unsurprising news.. Men and women express different symptoms of depression according to a study from Cardiff.

But there are some interesting points that I wasn’t aware of. The breakdown of the symptoms is quite interesting. According to the study

‘Female patients reported certain depressive symptoms more often than men, namely diminished libido (62% vs 35%) excessive sleep (19% vs 10%) self reproach (96% vs 87%), and diurnal variation (46% vs 32%).’

There don’t seem to be any symptoms listed though that men suffer more from than women.I’d be interested though to know if there are any symptoms that men express more than women.

Perhaps I’m not reading this correctly, and I’m certainly no academic, but does this mean that women just suffer from more of everything in relation to depression?

There is a higher propensity to depression in women. That is fact. There are more women who suffer from and seek help with depression during their lifetime and many arguments, discourses and studies including ones here and here.

I’m no medic either and certainly not one to fly in the face of scientific evidence, but instinctively, it seems that our society is more able to accept the model of female depression. It fits into a stereotype very easily. Would that mean that doctors are more likely to prescribe anti-depressants to women? Well, without actually conducting any research I can’t say, but a quick search on the subject (Google is a wonder resource!) seems to indicate that

More women are prescribed anti-depressants than men as noted by the WHO who say

‘Female gender is a significant predictor of being prescribed mood altering psychotropic drugs.’

and yet

male GPs are far more likely to do the prescribing

Of course, the first point would come as no great surprise if more women are actually suffering from depression (which is, I think, undeniable) – it makes sense that they are assisted pharmacologically, if that is what’s needed, of course – and more women are diagnosed with depression after all.

The second study though, if anything was more interesting in that female GPs were more likely to favour talking therapies.

Perhaps we have become more used to self-diagnosis and are asking GPs for particular medications, as The Times highlighted last year saying

‘Research on doctors’ habits also revealed that many felt they were prescribing the drugs too often, but did so because patients wanted medication. They said that funding was often not sufficient for alternative behavioural therapies and other counselling treatments, despite NICE guidance that they can be as effective as antidepressants for those with mild to moderate depression.’

So funnily enough it leads back to funding.

The likelihood of male GPs to prescribe more than female GPs remains a little baffling in the light of this discourse. Perhaps some female GPs have more sensitivity to the subject. Perhaps, became in general, women are more likely to want to talk about feelings, they can transfer some of this approach to their patients.

Or are women with depression more likely to want to talk to a female GP about their problems in the first instance so female GPs take some of the initial consultations when the depression is less severe?

I don’t know really, but I’d be interested in more information about that study. There must have been some more answers and reasons offered than just gender.