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.

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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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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.

image 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.

Looking for beds

The new president of the Royal College of Psychiatrists, Professor Dinesh Bhugra, will according to the Guardian use his inaugural speech to lament the problems caused by the shortage of acute psychiatric beds in the system.

This is something we hear a lot about, and indeed, something described on There and Back Again’s blog about waiting for a hospital bed as an inpatient on leave when the ward is running a 150% occupancy rate recently.

Hospital beds in the hospital empty chamber. Kharkov, Ukraine.

 

 

Image via Wikipedia

Bhugra suggests that

No ward should ever be more than 80 per cent full if patients are to be safe, properly treated and cared for.

and while the sense of this can be obvious, it is rarely, if ever, the case in practice – or certainly isn’t in my own, admittedly limited, experience.

So something has to be done and Bhugra has a suggestion

‘ (Bhugra)..  is calling on the government to introduce a compulsory kitemark system of accreditation for all acute, inpatient psychiatric wards: ‘Until there is a compulsory kitemarking scheme, my prediction is that, as overcrowding increases, funding becomes more stretched and morale of patients and staff fall, overall conditions are likely to continue to deteriorate.’

Interesting. I know I rant against target-based practice but in can work in some areas. Perhaps if Trusts are told that funding will be cut or increased on the basis of their ability to find these beds – or that the levels of occupancy will be monitored by the Mental Health Act Commission and there will be financial penalties for applying poor standards – there will be more incentives to hospital managers to actually work on a solution – which doesn’t seem to be being done at the moment.

This Kitemark would measure against other standards such as staffing ratios as well and, indeed, in another article in the Guardian which focuses on current inpatient care, a spokesman for MIND says

‘A compulsory kitemark is a fantastic idea; these wards slip under people’s radar and that’s dangerous,’ she added. ‘When patients are sectioned, they literally have no choice at all about where they go. This makes it vitally important for society to be 100 per cent aware if these vulnerable people are ending up in wards where conditions don’t meet the minimum acceptable standards.’

Beds have been reduced as the focus has been on community care but the fact remains that some people need inpatient care and there isn’t always a reasonable substitute.

And with the incoming President of the Royal College of Psychiatrists in stating that

‘Acute psychiatric wards are now so poor, he (Bhugra) has admitted in an exclusive interview on the eve of his appointment, that he would not use them himself – nor allow a member of his family to do so.’

That is, perhaps, the saddest indictment of all.

Its pleasing that at least the situation is getting some more attention and will get even more when Bhugra actually makes his speech on Wednesday but one of the criteria that I have consistently tried to work on when considering placements for residential care is ‘would I be prepared for a close family member of mine to go to that home?’ and if the answer is no, I at least look for alternatives as I won’t use a home that I wouldn’t be prepared for a family member of mine to go to – or at least without offering the families and prospective residents an alternative option (which isn’t always taken or perfect for other reasons, like location but that’s another discussion for another day)

However as far as psychiatric wards go, that’s another matter.

Running acute wards at a 100% + occupancy doesn’t do anyone any favours in the long run and can lead to possibly longer or more frequent inpatient stays.

Where I work, I am fortunate in that I have a lot of faith in the psychiatric wards I normally use when people I work with are admitted.

Certainly on the over 65s wards where I know the staff much better, I can confidently say, I would be happy to spend time on those wards and would, without doubt, be happy for my father (only close family member I have that is over 65!) to go there. Because I know the wards are well-managed by an excellent nursing and medical team.

The other wards in the hospital, that I’ve had a bit less interaction with, have given me at least some faith in my interaction and observations of the interactions between patients and nursing and medical staff. I do know that this hospital is perhaps ‘one of the better’ ones.

Until I was on my placement in a different borough in my ASW course, my current hospital was the only psychiatric hospital I’d been to – I know that people had said it was a pleasant enough hospital but I didn’t know what to compare it to.

On placement I assessed and organised  an admission for a patient to a hospital I had heard about but never been to. We arrived. I was genuinely shocked myself about the look and feel of the ward. She was taken to her room and I honestly didn’t realise that there were wards like that around still. I think and have thought about it a lot. It has to change.

And the more publicity and public attention that is focused on the quality and care that is provided on some (but by no means all) of the psychiatric wards, the more hope that there will be for some change.

As for the running at over-capacity – the only solution in my own, simplistic mind, is more beds which means more money. Not very popular, I fear.

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.

A Healthy Mind

A lot of discussion exists around mental illness and disorder but while I was reading the Oxford Handbook of Psychiatry yesterday, I came across an interesting passage about good mental health.

Good mental health is more than simply the absence of mental disorder, it requires:

  • A sense of self sufficiency, self esteem, and self worth
  • The ability to put one’s trust in others
  • The ability to give and receive friendship, affection and love.
  • The ability to form enduring emotional attachments.
  • The ability to experience deep emotions.
  • The ability to forgive others and oneself.
  • The ability to examine oneself and consider change.
  • The ability to learn from experience.
  • The ability to tolerate uncertainty and take risks.
  • The ability to engage in reverie and fantasy’

I don’t think I had ever seen ‘criteria’ for good mental health before as a lot of the literature seems to focus on the negative so it made for an interesting read.

The list makes it much clearer how tentative the line is between the health and the illness.  I’m not sure many people could tick all those boxes with a clear conscience on a daily basis.

The Secret Life of a Manic Depressive discusses very eloquently, the relation between mental illness and self and by looking at the list it seems that a lot of factors that are very much fundamental to who we are as individuals are included. Surely some people are more forgiving than others, more thoughtful and reflective than others, but does that make them less sound of mind.

I thought it was an interesting guide, in any case!

(and the book seems to be available free in electronic form on Google Books – the above text is taken from page 7 if anyone cares to investigate!).