People living in London and four other strategic health authorities are currently receiving information in the post about the rollout of the NHS Summary Care Record (SCR) system.  SCR is part of the NHS Care Records System, a large UK government IT project which aims for more effective sharing of patient records between NHS services.  When the system is in full swing, NHS staff in Newcastle (say) will be able to access the medical records of someone requiring care whose residence and GP is in Penzance.  The SCR will initially contain records of such things as medications and allergies, but may eventually become more detailed and also allow access to specialists’ letters and scans.

Controversy about this centralised system has been rumbling on for some time and before you read further I must declare my hand: I have opted out.

No record system is perfect.  Whenever you meet with any NHS healthcare professional a record will be made of your interaction and, in these days of team working and shift work, this could be seen by a fairly large number of people.  Equally if you are a patient on a ward, patient notes are most often not kept under lock and key and are therefore accessible to any nosey parker who happens to walk by.  Patient records are currently kept locally, for example within a particular NHS trust, and are shared within NHS organisations on a ‘need to know’ basis.  Most specialists who see a patient will write and inform their GP.

As with other large database projects – of which this country now has legion – the advantages of sharing information must be balanced with the possible pitfalls.  The SCR’s benefits are most obvious for forgetful people who have a serious medical condition or allergy and are visiting friends out of town.  This is a relatively small number of people and for the rest of us the benefits appear to be marginal.  The rollout of the SCR raises serious questions around the issues of privacy, legality, effectiveness, and cost.

Privacy

In order for medical care to function effectively it is clearly absolutely essential that patients feel that their records are kept confidential.  In line with this the leaflet Changes to your health records states that ‘anyone who has access to your records… must be directly involved in caring for you’.  However this Connecting for Health document concedes that access will also be possible, without a patient being informed, ‘in the public interest’, ‘by statute’ or by court order.

The wide access necessary for the SCR to be effective massively increases potential for snooping.  This is something of which Gordon Brown and Alex Salmond may already be aware.  In order to police access to the SCR all NHS staff will be issued with a chip and pin card and retrieval of any record will leave an audit trail.  But this does not address unauthorized access through logged in but unattended terminals, a common occurrence, or the accidental accessing of an incorrect patient’s record as a result of partial patient identifying details.  Audit trail or not, it is hard to imagine that such a vast database can be effectively policed.

Central to the concept of privacy is deciding to whom your personal details should be displayed.  Inclusion in the SCR is currently ‘opt-out’.  Unless you make your wishes known, as I did, your patient records will become part of the SCR by default.  This use of ‘presumed consent’ presupposes that individuals are aware of the SCR’s existence; yet in pilot areas many people were not (section 6.1.7).  The recent mailings do not include an opt-out form, and opting out appears to be being made deliberately difficult.  GPs are for instance unable to order opt-out forms in bulk.

The BMA has called on the department of health to suspend the SCR rollout as patients are not receiving the information they need to decide if they wish to be included on the SCR.  London GPs have also been unenthusiastic.

Legality

The SCR is vulnerable to legal challenge.  In a 2009 report by the Joseph Rowntree Reform Trust the SCR was awarded an ‘amber light’ indicating ‘the system demonstrates significant worrying failings and may fall foul of a legal challenge’.  European law requires that systems which store sensitive personal information such as medical records either have the free and informed consent of the data subject, or be based on specific legal provisions that are sufficiently narrow to make their effect foreseeable.  Such provisions must also be proportionate and necessary in a democratic society.  The SCR would appear to fall short of these stipulations.

There are doubts about whether it will be possible for people to have themselves removed from the SCR.  The DoH has been quoted as saying that it will be impossible, on the basis of medico-legal considerations and cost, to remove someone’s record once it has been entered.

Effectiveness

I am unaware of any evidence that the SCR will dramatically improve care.  For some people, making relevant medical information available to emergency medical staff may be very beneficial and for a few possibly life saving.  However for the vast majority of us it will be of little or no use.  For a discussion of whom it may help click here.

In 2005 Amanda Campbell, died from septicaemia despite having been assessed by eight doctors.  During a Today programme interview Dr Eccles, medical director for Connecting for Health, mentioned her case as an example of where centralized records would have been of benefit.  Whilst centralized records might have been useful this account suggests that her avoidable death was at least as much a result of the substandard medical care that she received, something outside the remit of a centralized records database.  The SCR does not work abroad or even work across the whole of the UK, as Scotland has a different system.  And relying on a single system means that errors can be propagated;  I would not recommend that anyone leave their medical alert bracelet.

Cost

Originally expected to cost £2.3 billion over three years, in June 2006 the total cost of the NHS National Programme for IT was estimated by the National Audit Office to be £12.4bn over 10 years.

Links

SCR opt out form

The Big Opt Out – NHS confidentiality campaign

Database State – a super report (if you happen to think this sort of thing is interesting) about the failings of UK Government IT projects

Henry Porter on the SCR writing in the Guardian’s Liberty Central

I have had an educational piece published in the BMJ today.  You can read it free of charge in the published form here.   It took me an exceptionally long time to write.

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Endgames case report: “A series of unfortunate events”

Stephen Ginn, psychiatry core training year 3
Ladywell Unit, Lewisham Hospital, London SE13 6LH

A 24 year old man presented to the accident and emergency department because he had been planning to take an overdose, but had decided instead to seek help from mental health services. He had intended to take the contents of several blister packs of paracetamol, together with alcohol. He had been having suicidal thoughts for a week but they had become particularly pronounced over the past two days.

His recent history was one of a “series of unfortunate events” that had left him feeling desperate. Four months ago his flatmate stole money from him, which meant that he was unable to repay several loans. His debtors had started to threaten him and he had been forced to move to a different city and leave his job. He had become socially isolated, and continuing financial difficulties had resulted in poor relations with his new landlord. Just before his presentation he had been awaiting a cheque for housing benefit. However, this had not arrived, and he described this as “the last straw.” He reported feelings of hopelessness and thoughts of “what’s the point?”

He had no history of suicide attempts, self harm, or suicidal thoughts. Five years previously, however, he was admitted twice to a psychiatric ward with psychotic symptoms associated with the use of cannabis. Currently there is no evidence of psychosis, and no relevant medical history. He came to hospital on his own, but a friend provided a collateral history on the telephone. The patient says that if he goes home he is worried that he will take the large amount of paracetamol tablets that await him there.

Questions

1 How would you assess his risk of suicide?

2 How would you manage this patient?

3 What are the general principles of suicide prevention?

Answers

1 How would you assess his risk of suicide?

Short answer:
The likelihood of future suicide should be estimated during an unhurried and sympathetic interview by establishing the motivation for, and circumstances of, the suicidal ideas or act in question, as well as the presence of known risk factors. It is useful to obtain a collateral history from a friend or relative if possible. The three most important risk factors for future suicide are current suicidal intent, history of suicide attempts, and presence of a psychiatric disorder. Once you have inquired after risk factors and have an understanding of the patient’s circumstances you should be able to form an opinion on the patient’s suicide risk.

Long answer:
A suicide risk assessment is normally performed in hospital by psychiatric trainees or psychiatric liaison nurses, although knowledge of risk assessment with suicidal ideation is useful for doctors working in all specialties. This answer is written from the perspective of a psychiatric trainee conducting an assessment in hospital, but assessments elsewhere and under other circumstances follow the same principles.

Before assessing a patient you should establish his or her state of physical health and, if appropriate, level of intoxication. The appropriateness of assessing a patient who is physically unwell, or compromised through drug or alcohol use, is often a cause of friction between psychiatric and non-psychiatric professionals. It may be wise not to see patients who are acutely physically unwell until they have improved, because their physical health may be a more pressing concern and may prevent a satisfactory assessment. However, if the patient is physically stable, then their physical problems need not be a barrier. Although it may not be safe to wait until someone is no longer intoxicated before they are seen, an assessment of mental state performed under these circumstances should ideally be repeated.

When assessing a patient for suicide risk your main task is to gather information that will help you decide whether a future suicide attempt is likely. The first major area to cover in the assessment is the context in which the patient’s suicidal act took place and the motivation behind it. This involves a detailed review of events leading up to the act, the act itself, and the circumstances under which the patient came to hospital. Life events typically precede suicidal acts, with disruption of a relationship with a partner being particularly common.¹ The features of the circumstances surrounding the act provide an indication of seriousness and hence chance of it being repeated. The table lists features of an attempt that suggest high and low risk of repetition.

Once the circumstances surrounding a suicidal act have been established, specific risk factors for future suicide must be explored.

The main risk factors indicating continued high risk are:

• A statement of continued intent. Although clinicians may be reluctant to ask such a blunt question, patients are often surprisingly open about their current state of mind.
• History of previous suicidal behaviour. Many people who complete suicide have made a previous attempt, and a history of self harm or suicide attempts is present in at least 40% of cases.³ You will need to ask details about previous attempts, such as whether hospital admission was necessary?
• Presence of a psychiatric disorder. About 90% of people who have completed suicide have a psychiatric disorder at the time of death.³ Affective disorder carries the highest risk of suicide, followed by substance misuse (especially alcohol), and schizophrenia; comorbidity greatly increases risk.³ A key factor linking depression to suicidal acts is hopelessness or pessimism about the future, and this should be included in the history taking.⁴

To establish the presence of a psychiatric disorder an assessor should inquire after the common symptoms of psychiatric disease, any contact with mental health services, and whether any psychiatric drugs are being prescribed. Clinical descriptions and diagnostic guidelines for mental and behavioural disorders are found in ICD-10 (International Classification of Diseases, 10th revision).⁵

Once these three main risk factors have been dealt with, further risk factors associated with suicide are:²

Age 25-54 years

• Male sex
• Unemployed or retired
• Poor physical health
• Separated, divorced, or widowed
• Living alone
• Lower socioeconomic class
• Criminal record
• History of violence.

Scales are available to help assess the risk factors for suicide, such as the Beck suicidal intent scale⁶ and the SAD PERSONS scale,⁷ which has a mnemonic that is easily remembered.

Other areas that must be covered during an assessment include the patient’s medical history, medications, and family history of medical or psychiatric disease. A suicide attempt can be a response to stress learnt by example, and a family history of suicide increases the risk at least twofold, independently of family psychiatric history.⁸ Personal history should also be sought and include schooling, accommodation, personal relationships, and employment.

It can be useful to talk to a friend or relative to gain a collateral history. When taking such a history, the assessor must remember to respect the patient’s confidentiality. Collateral history is especially valuable if the patient is deliberately trying to mask his or her mental state and seems to be telling you what he or she thinks you want to hear rather than how they actually feel. It is also necessary to evaluate the degree of support available to the patient should they return home. If the patient’s suicide attempt seems to be as a result of a situation at home to which they are proposing to return, this would obviously be of concern.

If in doubt about a patient’s level of risk it is wise to consult a more experienced colleague.

2 How would you manage this patient?

Short answer:
It may be possible to discharge patients who are thought to be at low risk to the care of their general practitioner for follow-up, whereas those with moderate risk will probably need an urgent appointment with a community mental health team or involvement of a home treatment team. Patients thought to be at high risk may need hospital admission and possible assessment under appropriate mental health legislation. Follow-up services will consider whether further interventions—for example, psychotherapy and pharmacotherapy—are appropriate. This patient was thought to be at moderate risk because of continuing suicidal intent and access to lethal drugs. He was admitted informally to a psychiatric inpatient unit.

Long answer:
It is important to make thorough notes on your consultation. Although this is true for any patient encounter, it is even more important here because your record serves as potentially valuable material for future risk assessments should the patient attempt suicide again. The steps taken to protect the patient should also be documented.

Suicidal acts occur for a variety of reasons, and often the primary aim is not death but some other outcome, such as demonstrating distress to other people or seeking change in their behaviour.⁹ Therefore, the needs of individual patients will vary widely. If you have asked about the risk factors above and have an understanding of the context of the suicidal act then you will have formed an opinion as to a patient’s suicide risk. Any patient with a concerning level of perceived suicide risk will, for a time, need supervision and restriction of access to lethal means. Your assessment will establish to what level and for how long these restrictions should be enacted.

If you think that a patient’s suicide risk is low and you are assured that they have good support in the community, they can be discharged from hospital and followed up by their general practitioner or community mental health team, to whom a copy of your assessment should be sent. A patient discharged home should be advised to attend appropriate services, such as the accident and emergency department, if they or their family are concerned in the future.

You may feel that the suicide risk is moderate. This might be the case for patients who say that they have no continuing suicidal ideation, but in whom you have identified several risk factors for a further attempt. In this situation, although it may be appropriate to discharge the patient from hospital, the local community mental health team should be urgently informed so that they can provide follow-up. Some psychiatric home treatment teams will be willing to see patients at this level of risk.

For any patient you discharge who has had recent suicidal thoughts or has performed suicidal acts you must be convinced that the environment to which they are discharged will be safe and supervised by friends or relatives whom you judge to be reliable, who wish to care for the patient, and who understand their responsibilities.

An example of a patient who is at high suicide risk would be someone who continues to have suicidal intent, has made several previous attempts, and has a psychiatric disorder. Hospital admission is appropriate for such patients. If they refuse the offer of an informal (non-compulsory) hospital admission, you may wish to recommend that they are detained under the relevant mental health legislation.

After their assessment it is the responsibility of the assessing doctor to be confident that, before the end of their shift, the appropriate follow-up services will be provided with all the information that is needed.

3 What are the general principles of suicide prevention?

Short answer:
Two broad approaches to reducing the total number of suicides exist. The first is to take steps at a population level; an example of this is to sell paracetamol in smaller size packs. The second involves targeted strategies, such as evidence based treatments, aimed at high risk groups about whom healthcare professionals should be aware.

Long answer:
The two main approaches for reducing the number of suicides in the population are: preventive strategies that can be applied to the population as a whole and those that are targeted towards high risk groups.

Population strategies^{10 11}:

Improving the ability of primary care doctors to recognise and treat depression and other psychiatric disorders has been shown to be valuable because studies have reported that 16-40% of people who die by suicide have visited a family doctor in the week before their death.¹²

School based programmes aimed at improving psychological wellbeing could contribute to suicide prevention in young people by increasing knowledge of psychological symptoms and help seeking behaviour.

Gatekeepers are community members, such as clergy, whose contact with potentially vulnerable populations provides an opportunity for them to help identify at risk individuals and then direct them towards appropriate assessment and treatment.

Suicide screening aims to identify people at risk and direct them towards treatment.

Public education campaigns have been aimed at improving understanding of the causes and risk factors for suicidal behaviour and reducing the stigmatisation of mental illness and suicide, with the aim of improving the recognition of suicidal risk and increasing help seeking.

Restricting the availability of the means by which people commit suicide, such as installing safety barriers on bridges, saves lives. Substitution of one method for another can happen, but studies indicate that many people have a preference for a given method.¹³

The media can help educate the public about suicide, but it can exacerbate matters by glamorising suicide. Restrictions on reporting and codes of conduct can help lower suicide rates.

Strategies applicable to high suicide risk groups^{10 11}:

Some people are at particular risk of suicide, and healthcare professionals should provide these people with treatments that reduce the risk of suicide attempts. Patient groups at particular risk of suicide include people with psychiatric disorders—those who have just been admitted or just been discharged from psychiatric hospital in particular; elderly people; high risk occupational groups, such as medical practitioners, pharmacists, farmers, and vets; and prisoners. Major risk factors for suicide in prisoners are previous attempts, recent suicidal ideation, being in a single cell, presence of a psychiatric disorder, and a history of alcohol problems.

Psychiatric disorders should be treated in high risk patients, and pharmacotherapy and psychotherapy are key treatments. Because of the chronic and recurrent nature of mental illness, and the difficulties in engaging patients with treatment, the best possible acute and long term psychiatric care needs to be available.

Even with near perfect care and risk assessment, and despite the best efforts of friends and professionals, suicide is not something that can be entirely predicted or prevented.

Patient outcome

Our patient was judged to be of moderate-high risk of future suicide. He had been having suicidal thoughts for some time and had a method in mind. If he had been discharged he would have returned to an unresolved stressful social situation with continued access to lethal methods. Particular risk factors for repeat suicide were a possible diagnosis of depression and statement of continued intent. Other risk factors were male sex, social isolation, and unemployment. His friend confirmed his story and said that he had seemed to be low in mood recently.

We thought that there was sufficient cause to warrant an informal inpatient hospital admission. The admission lasted three days, during which time antidepressants were started, his relationship with his landlord improved after the intervention of a social worker, and he denied further suicidal ideation. At the end of his stay he was discharged into the care of a community mental health team.

Further reading

The reader is referred to the relevant NICE guidelines on assessment and management of self harm.¹⁴

References

1. Cavanagh JTO, Owens DGC, Johnstone EC. Life events in suicide and undetermined death in south-east Scotland: a case-control study using the method of psychological autopsy. Soc Psychiatry Psychiatr Epidemiol 1999;34:645-50.[CrossRef][Web of Science][Medline]
   
2. Hawton K, Taylor T. Treatment of suicide attempters and prevention of suicide and attempted suicide. In: Gelder M, Andreasen N, Lopez-Ibor J, Geddes J. New Oxford textbook of psychiatry. 2nd ed. Oxford University Press, 2009:969-78.
   
3. Cavanagh JT, Carson AJ, Sharpe M, Lawrie SM. Psychological autopsy studies of suicide: a systematic review. Psychol Med 2003;33:395-405.[CrossRef][Web of Science][Medline]
   
4. Beck AT, Steer RA, Kovacs M, Garrison B. Hopelessness and eventual suicide: a 10 year prospective study of patients hospitalised with suicidal ideation. Am J Psychiatry 1985;145:559-63.
   
5. WHO. The ICD-10 classification of mental and behavioural disorders: clinical descriptions and diagnostic guidelines. 1992.
6. Beck A, Schuyler D, Herman J. Development of suicidal intent scales. In: Beck A, Resnik H, Letteri DJ. Prediction of suicide. Charles Press, 1974:45-56.
   
7. Patterson W, Dohn H, Bird J, Patterson G. Evaluation of suicidal patients: the SAD PERSONS scale. Psychosomatics 1983;24:343-9.[Web of Science][Medline]
   
8. Qin P, Agerbo E, Mortensen PB. Suicide risk in relation to socioeconomic, demographic, psychiatric, and familial factors: a national register-based study of all suicides in Denmark, 1981-1997. Am J Psychiatry 2003;160:765-72.[Abstract/Free Full Text]
   
9. Hjelmeland H, Hawton K, Nordvik H, Bille-Brahe U, De Leo D, Fekete S, et al. Why people engage in parasuicide: a cross-cultural study of intentions. Suicide Life Threat Behav 2002;32:380-93.[CrossRef][Web of Science][Medline]
   
10. Hawton K, van Heeringen K. Suicide. Lancet 2009;373:1372-81.[CrossRef][Web of Science][Medline]
    
11. Mann JJ, Apter A, Bertolote J, Beautrais A, Currier D, Haas A, et al. Suicide prevention strategies. A systematic review. JAMA 2005;294:2064-74.[Abstract/Free Full Text]
    
12. Pirkis J, Burgess P. Suicide and recency of health care contacts: a systematic review. Br J Psychiatry 1998;173:462-74.[Abstract/Free Full Text]
    
13. Daigle MS. Suicide prevention through means restriction: assessing the risk of substitution: a critical review and synthesis. Accid Anal Prev 2005;37:625-32.[CrossRef][Web of Science][Medline]
    
14. National Institute for Health and Clinical Excellence. Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. 2004. www.nice.org.uk/CG016NICEguideline.

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20% off Saints Scrubs with code “saints”

Charles Bonnet syndrome is a cause of complex visual hallucinations.  The core features are the occurrence of well formed, vivid, and elaborate visual hallucinations in a partially sighted person who has insight into the unreality of what he or she is seeing.  Its prevalence in patients with visual impairment varies from 10% to 15%.  To diagnose the condition there should not be features which might lead to an alternative explanation such as psychosis, dementia and intoxication.

The syndrome occurs most commonly in elderly people, probably because of the prevalence of visual impairment in this group. The common conditions leading to the syndrome are age related macular degeneration, glaucoma and cataract. The hallucinations may last from a few seconds to most of the day and may persist for a few days to many years, changing in frequency and complexity. Many patients can voluntarily modify them or make the image disappear if they close their eyes.. The imagery has no personal meaning and is varied and may include groups of people or children, animals, and panoramic countryside scenes.

The condition is named after the Swiss naturalist and philosopher Charles Bonnet. He reported the hallucinations of Charles Lullin, his 89 year old otherwise healthy and cognitively sound grandfather, who was blind owing to cataract and yet vividly saw men, women, birds, and buildings.

There is no definitive treatment for the condition but it is reported that reassurance and explanation that the visions are benign and do not signify mental illness has a powerful therapeutic effect. Hallucinatory activity may terminate spontaneously, on improving visual function or on addressing social isolation. There is no universally effective drug treatment but anticonvulsants may play a limited role.

Read more:

Charles Bonnett syndrome – elderly people and visual hallucinations – excellent BMJ paper (paywall)
Complex visual hallucinations in the visually impaired: the Charles Bonnet Syndrome.
Charles Bonnett Syndrome – Wikipedia

It’s interview week here at Frontier Psychiatrist and I’m very excited that Dr Iain McGilchrist has agreed to be featured on this website.  Dr McGilchrist is a psychiatrist with an unusual background as, before he turned his attentions to psychiatry, his first career was in the academic study of literature.  He has recently published ‘The Master and his Emissary’ a book which posits that the division of the brain into two hemispheres is essential to human existence, making possible incompatible versions of the world, with quite different priorities and values.

If readers would like to find out more about Dr McGilchrist’s ideas then the introduction of the book is available for download from his website.  He has also published an essay in the Wall Street Journal: The Battle of the Brain: The mind’s great conflict spills over onto the world stage

You’ve had a very varied career, most notably starting off as a scholar of English literature before training as a doctor and then as a psychiatrist. What was the motivation behind your change of tack?

Much as I loved working with literature, I began to see that the explicit approach to a work of art, which the critical process demanded, was inherently unsatisfactory. It substituted something abstract, cerebral and generalised for an entity the whole purpose of which was to lead us in the opposite direction.  The encounter between the work of art – the poem or whatever – and ourselves was not like dealing with an object, more like the encounter of two people, each unique, each embodied, each an indissoluble whole that could be only mis-represented by examining its parts.  The value of the work of art depended on things that were radically altered by their context, which were implicit, and had to remain implicit, if they were not to lose their power.  The relationship between mental experience and the physical fact of our own embodied selves seemed to be central to this conundrum, and I studied what the philosophers had to say about the so-called ‘mind-body problem’.  Eventually it became clear to me that they were themselves too prone to deal with this fundamental fact of existence in an abstract, decontextualised, disembodied fashion, and I thought I ought to train in medicine and find out for myself, in a more embodied way, what it was like when things went wrong with people’s brains and bodies, and how that affected their minds.  So I wrote a book about my concerns, called Against Criticism, and went off to study medicine.  Then after a brief spell of  neurology, I went to the Maudsley to train as a psychiatrist.

How has a training in literary scholarship informed your practice as a psychiatrist?

You might expect me to say that perhaps the reading of great novels and so forth has influenced the way I think about disease and death.  Maybe it has, but if so it is at a level beneath my awareness – implicitly, one might say, rather than explicitly.  What I would say, though, is that having a training in the humanities in general makes a vast difference to how we see what it is we are looking at when we approach the human being, the human body.  Many medics, whether they are aware of it or not, accept unquestioningly the scientific model of the body as a machine.  I say ‘scientific’, but of course the paradox is that in physics a far more sophisticated understanding of what matter is has been forced on its practitioners, with the result that their universe is far less mechanical than that of biological scientists, who remain becalmed in the untroubled waters of Victorian scientific materialism. 

Medicine could be seen as a branch of psychiatry, and psychiatry as a branch of philosophy.  Philosophically speaking, many medics are quite unreflective.  I think that the Americans have got it right in making medicine a second degree.  Of course at the simplest level, it allows people time to mature, and to make sure they have made the right decision – some doctors I have encountered clearly didn’t.  But, even more important, it permits a period of intellectual exploration and questioning, before getting stuck into a medical degree, with its overwhelming demands for rote learning and the acquisition of information, largely without time to question.  As a result the fundamental questions don’t get asked by those who actually have the experience – the questions are left to philosophical outsiders.  It is no kind of piety to say that, hard as we work for it, the experience we have as physicians of the mind and body is vastly precious, a real privilege that the others, the professional philosophers, can only imagine, and we must never lose the ability to stand back and look at what it all tells us in the broadest possible context.

Can you explain what you mean by ‘medicine could be seen as a branch of psychiatry’

When I was a House Physician, I remember there were all these patients who came in on take with chest pain.  Of course we did ECGs and cardiac enzymes – but no luck.  Sometimes we sent off all manner of rarified tests.  All negative.  I remember working for the Professor of Medicine: the tests we were supposed to send for extended all down one page of A4 and half way down the next.  But no-one thought of – possibly, it occurs to me now, no-one even knew how to – sit down with them and ask about their lives: their families, their wives or husbands, their children, their jobs.  And when I was the House Surgeon it was the same, except the problem now was abdominal pain, rather than chest pain.  But the same picture – loads of tests, drips and invasive procedures: zero insight into the most common cause of abdominal pain.  The psyche.

It still seems to me a scandal, in view of the fact that over 60% of GP consultations are ultimately psychiatric in nature, that you can’t become a GP unless you have done attachments in obs & gynae, and paediatrics, but you don’t have to know the first thing about psychiatry.

That is in a way trivial answer, but I hope a vivid one. 

A more serious one is that we need to see every complaint, physical or mental, in the context of the whole person.  Typically physical medicine looks only at this ‘machine’, the body.   I want us to look at the person as whole, by far the most important and complex part of which is the psyche.   Every physical illness affects the mind; every mental illness affects the mind.  Every symptom reported comes via the patient’s mind.  That is why medicine is a branch of psychiatry.  It is just the report of the person of physical as well as mental symptoms.  To understand mental symptoms you need to understand psychiatry.  To understand physical symptoms you need to understand – psychiatry.

Also it’s not clear to me why you write that physicists are less mechanical in their thought than biological scientists.  Surely if mechanistic thought has a place it is within the realm of physics?

You may not have kept up with contemporary physics!  If you look at Bohr, Bohm, Dirac, Planck, Heisenberg, Davies, Polkinghorne,  you will see that all the mechanistic assumptions of Newtonian physics have had to be abandoned, in the face of evidence that reality is not determinate, precise, atomistic, explicit, but indeterminate, probabilistic, interconnected and implicit. A vast topic, and one that has been very widely explored, but one that is of ultimate philosophical importance, and sets the ‘hard’ sciences against the current intellectually lazy mindset of biology.

Having started off working for the NHS you now work exclusively in private practice. What motivated your switch?

I never foresaw that I would end up working privately – I was completely committed to the ideal of the NHS; and to this day I do not have health insurance myself.  But I could not ignore what was happening.  I felt I was deskilled working as a psychiatrist in the NHS.  A largely politically motivated, and in my view deeply mistaken, drive to marginalise the role of the psychiatrist, and with it the skills of diagnosis and appropriate treatment, has been disastrous.  And the range of conditions with which, in practice, one gets to deal in the NHS is too limited, the therapeutic resources at one’s disposal are too meagre, and too much time is taken up with paperwork, ticking boxes, and keeping various bureaucrats happy – far too little in patient contact. 

On top of that, I wanted freedom to be in control of my time and the way in which I worked.  I knew I wanted to write the book that became The Master and his Emissary, and I knew that there was no way I could do that unless I could choose to work as I do now, fitting a normal week’s work into three very long days (during which, incidentally, I get as much clinical contact as I would have done in weeks in the NHS). This gives me a fighting chance of spending the intercalated days in the library and on research.  I also felt, rightly or wrongly, that the sausage machine that academic psychiatry has become was no place for someone like myself, who wanted to do something unconventional – despite the fact that many people probably see me as a natural academic.  The constant pressure to publish papers would not have given me time to develop a long piece of work, and would have prematurely foreclosed the direction of my thinking.  And you can no longer get funding unless the work you do is fairly similar to what other people have already demonstrated to be ‘fruitful’, produces ‘positive’ findings in a limited period, and brings in money and prestige for the research group to which you belong. I fear that this is likely to have a stifling effect on originality, and can only encourage us to go ever more down the path we are already treading.

What are the main differences between NHS and private psychiatry?

First of all, I think the difference between private medicine in general and private psychiatry is enormous.  In private medicine (or surgery) all you get by going privately is a chance to jump the queue and, when you get into hospital, to have a glass of wine in your hand.  The range of conditions covered, and the standard of treatments, is largely the same.  But private psychiatry is different.  There are whole swathes of suffering humanity who get little or no help under the NHS.  Unless you are psychotic, and about to kill yourself or someone else, you don’t stand much of a chance.  However there are enormous numbers of people, who, to my eternal shame, when I was in the NHS I learnt to think of as ‘the worried well’, who suffer at least as much as the psychotic, and in some cases more, from a range of anxiety and depressive disorders, often quite subtly interlaced with personality factors, and sometimes addictive behaviours, that are simply given short shrift in the NHS – because they are too complex and time-consuming to treat – but are treated, along with the psychotic, by private psychiatrists almost alone.   I am glad to say that I see many psychotic patients, in whose treatment medication plays a central part, but I am also able to help people who need much more than a drug can give.  And having control of one’s time is not only personally liberating, but makes it easier to be kind to people and to listen to them carefully.

Moving onto your book: the relationship between the right and left sides of the brain is not something that concerns most psychiatrists.  How did you come to be interested in it?

I think it again relates to my philosophical background.  That the two hemispheres interpret and create the world differently, with different modes of attention, different priorities and different values, emerged from Bogen and Sperry’s work in the 1960s and ’70s.  That should have been of the highest interest, since the world we inhabit is brought into being for us by our brains.  And at the time it did give rise to a lot of speculation.  But we were looking for different ‘functions’ for the two halves of the brain to do, as if it were a machine with a lot of little specialised modules –language here, maths there, or reason here, emotion there – again in a ridiculously naïve way.  Over time, we discovered that each so-called ‘function’ was carried out in both hemispheres, not one, and people gave up looking for a real difference.  This is despite the fact that there are obvious, undisputed objective differences in the shape, size, neuronal architecture, neurochemistry and neuropsychology of the two hemispheres.  It seems obvious to ask: what does all that signify?  What I began to see – and it was John Cutting’s work on the right hemisphere that set me thinking – was that the difference lay not in what they do, but how they do it.  In particular, the right hemisphere was capable of appreciating ambiguity, the implicit and the metaphorical, where the left hemisphere tended to require certainty, the explicit and the literal; the right hemisphere saw the broad context and the world as a seamless whole, interconnected within itself, where the left hemisphere focussed on detail and produced a lot of separate fragments; the right hemisphere was far more capable of understanding new information, while the left hemisphere dealt with the already known; the right hemisphere saw individuals where the left hemisphere saw categories; the right hemisphere realised the importance of what is intuitive and embodied, where the left hemisphere prioritised abstraction and rationality (here I distinguish mere ‘rationality’ from the all-important, and far more complex, ‘reason’, to which both hemispheres need to contribute).  This illuminated problems in the nature of human thought and experience that I had struggled with all my life, and which had been brought into focus by my study of literature.

Can you briefly tell us about the thesis of The Master and his Emissary?

Well, some of it I have already referred to.  I posit that evolution has kept two types of attention apart, because they tend to interfere with one another; it has separated them by the hemispheric divide.  There is now an enormous and expanding body of literature that suggests that in birds and animals the left hemisphere provides focussed attention on something that we have already decided is of significance, while the right hemisphere keeps an open attention for whatever may be, without preconception.  This enables them to feed (focussed grasp of what needs to be manipulated) while staying alive (the broadest possible open attention for conspecifics or predators).  For example, chicks use their left hemisphere (right eye) to pick out the seed from the gravel on which it lies, while their right hemisphere (left eye) remains vigilant for predators.  Equally mates and kin are best identified with the right hemisphere (left eye) in most species. 

Humans have large frontal lobes, which enable them to stand back from experience: this puts the hemisphere division to new use.  For purposes of manipulation, the brain needs a relatively simple map of the world which enables it to be efficient in getting hold of things: denotative language and the ability to grasp with the hand are its tools in this representation and manipulation of the world, and they are controlled, as one might expect, from the left hemisphere.  All the rest, the ability to pick up the complexity of experience and take the broadest view, goes on in the right – which also means that it sees us, not as atomistic, distinct entities in competition with one another, as the left hemisphere must, but as interconnected, interdependent entities. Empathy, social understanding, humour, metaphor, more subtle emotional understanding, the appreciation of individuals, the reading of faces, and much else goes on in the right hemisphere.  Fascinatingly there is clear evidence that the left hemisphere alone codes for machines and tools – even in left-handers, who would be using their right hemisphere to use tools and build machines in daily life. 

So the first part of the book looks at the evidence in considerable detail, and then explores the significance of this for the nature of the world which each hemisphere ‘sees’ – the take, if  you like, that it has on the world.  Overall it seems that the right hemisphere sees and knows far more than the left hemisphere, but does not have the left hemisphere’s  tools for asserting its point of view: denotative language and serial analysis.  Applying them achieves something very important, certainly, but it is also incompatible with seeing the whole.  Hence the need for separation of the two realms of thought and experience (the principle function of the corpus callosum is to inhibit).  But the relationship between them is asymmetrical, as is the brain itself.   The first appreciation of anything comes to us via the right hemisphere, and the ultimate understanding of it in context does so also. Some very subtle research by David McNeill, amongst others, confirms that thought originates in the right hemisphere, is processed for expression in speech by the left hemisphere, and the meaning integrated again by the right (which alone understands the overall meaning of a complex utterance, taking everything into account).  More generally I would see the left hemisphere as having an intermediate role: it ‘unpacks’ what the right hemisphere knows, but then must hand it back to the right hemisphere for integration into the body of our knowledge and experience.

The trouble is that the left hemisphere’s far simpler world is self-consistent, because all the complexity has been sheared off – and this makes the left hemisphere prone to believe it knows everything, when it absolutely does not: it remains ignorant of all that is most important.  The second part of the book explores the history of the Western World, looking at our changing way of thinking about ourselves in terms of what we know about hemisphere differences.  My overall conclusion is that what starts off well balanced in Ancient Greece, and again at the Renaissance, with both hemispheres working in tandem – the optimal, indeed necessary, state of affairs –  turns into unstable swings of the pendulum, with a relentless movement ever further into the world of the left hemisphere alone.

In your book you take us through, in light of your thesis, the movements which have shaped Western Civilization over the past 2,500 years.  However anthropologists hold that behavioural modernity emerged 50,000 years ago, so presumably the conflict of which you write started long before then.  Can you reflect on this? 

Yes, it’s an interesting question.  I do deal with that in Chapter 3 of the book, where I ask what kind of a thing language is, and why we have it.  The answers are, I believe, not at all what we might think. 

In any case, the Middle/Upper Palaeolithic transition 50,000 years ago which you refer to, also known as the Upper Palaeolithic revolution, reveals a massive and sudden expansion in artefacts, symbolic tokens and images which is thought to indicate the origins of language.  However language only became written much later, about 3,300 BC in Sumer.  In brief, the evolution of writing resulted in a complex tool which enables us to deal with what is no longer in front of us, to stand back from things in time and space and consider them at leisure and in detail.  Whether it was something to do with this or not, there was certainly what looks like an expansion in frontal lobe function evident in Greek civilisation: an ability to stand back from the world and from one another.  This enables us to be better at manipulating one another, to be sure, as we tirelessly hear, but also – and this seems to have been completely overlooked – to empathise more with one another, seeing others as individuals just like ourselves for the first time.  Hence Greek civilisation is marked by a need for an expansion in both what the right hemisphere does, and what the left hemisphere does.  One of these, the right, led to pre-Socratic philosophy, the sense of individual justice, of moral virtue, mythology, mathematics, empirical science, the evolution of drama, music, and poetry rich in narrative, metaphor and humour; the other to the development of Plato’s analytical philosophy, the codification of laws, military efficiency, the expansion of commerce, science in which theory came to predominate over empirical exploration, and in general the systematisation of knowledge.  There is an accentuation at this time in what each hemisphere can achieve – each becomes more individuated, in a way ‘more itself’, more distinguished from its counterpart.  Which means that they become more separate.  This is where the trouble starts.  At first they hold together like a pair of horses pulling a chariot at speed –later they pull apart and the wheels come off the chariot.  This may sound rather fanciful, since I haven’t got the space here to elaborate a very complex argument and to adduce the necessary evidence.  But I would just say to readers – please take a look for yourselves at what I have to say.

Your conclusions refer to Western Civilization.  Why do you not think that left/right conflict is more universal?

I suppose that I would have to say that I do not know enough about other civilisations to talk about them with any authority.  It may be that something similar can be found elsewhere.  But at the end of the book I do adduce evidence that has been gradually amassing over the last decade or two that Far Eastern peoples, the Chinese, Japanese and Koreans, use strategies of either hemisphere equally, in a very balanced way, in approaching the world and solving problems, whereas Westerners are very heavily skewed towards using only the strategies of the left hemisphere.  The Scientific Revolution which has, as Stephen Gaukroger, the great historian of science, puts it, led in the West to the ‘gradual assimilation of all cognitive values to scientific ones’, is ‘exceptional and anomalous’: in oriental cultures, where there were very sophisticated advances in empirical science long before we began to make them, science is seen as ‘just one of a number of activities in the culture, and attention devoted to it changes in the same way attention devoted to the other features may change, with the result that there is competition for intellectual resources within an overall balance of interests in the culture.’

My reading of your writings is that pervasive societal norms form a feedback loop with the relevant part of the brain reinforcing particular characteristics and it is this that has led to what you postulate as the current dominance of the left brain.  Do you think that that brain has evolved in the past 2,000 or so years?

Well, I believe that the world of experience obviously modifies the brain, and the brain in turn, modifies our experience.  There is a reciprocal influence.  What we experience, how we think, and what we do with our brains modifies the brain, by affecting synaptic growth and threshold, amongst other things: that modifies the likelihood of our brains responding to what they experience in a certain way.  Equally we tend to mould our environment according to how we think of the world: the cities and the great projects that we conceive and build express our values and our beliefs.  That means that we are constantly exposed to numerous positive feedback loops.  First, the more we think x now, the more we are likely to think x in the future.  Second, the more we think x, the more we will build a world that expresses x, and the more we will experience x, and so the more we will think x, etc.  

That looks like an argument for change being impossible.  But we know that it is not.  That is largely because we have in the past been open to new ideas, without preconception, in a flexible way, thanks to our right hemispheres, which are better adapted than the left to see, understand and take up new ‘information’, new habits of mind, and have a far greater repertoire of ways of thinking than the left hemisphere.  But the left hemisphere displays an unreasonable certainty that its own mechanistic construction of the world is the only one that has any validity.  The more entrenched its way of thinking becomes, the more it undermines the basis on which we might have been able to transcend its narrow way of thinking.  Remember that it deals with what it already (thinks it) knows.  Thus it ‘deconstructs’ everything that doesn’t fit its model – the power of nature, the importance of the implicit, of inherited cultural wisdom, of the meaning and value of religion and the arts – all of which the right hemisphere alone can really hope to understand.  So now we have a further positive feedback loop – the one that stops us evading the first two.

Amongst your conclusions is that Western society has become more decontextualised with prominent loneliness and materialism as a result of left brain dominance.  Are there not other ways of explaining this same outcome without invoking brain structure?  Increasingly complex societies with market triumphalism at their core for instance?

Of course you are right.  There are a very large number of levels at which one can account for any human phenomenon.  If I ask you why you robbed an old lady, you could give a number of different answers: economic – ‘I needed the cash’; psychosocial – ‘I was under irresistible peer pressure’; culturohistorical – ‘in Mrs Thatcher’s Britain it was considered normal to rob old ladies’; neurochemical – ‘I was on speed’; genetic – ‘my father was a psychopath’, etc.  Which is the right answer?  My book is about how the brain constrains the possible views of the world we can take.  As I have said above, I do not say that the brain is not in dialogue with its world.  But to speak of market triumphalism, or societal complexity, is to beg the question why we have market triumphalism and a society that is in this sense ‘complex’, or as I would say more bluntly, deracinated and fragmented.  I would say that these are direct consequences of capitalism, and the mechanistic way of thinking that characterises the Enlightenment, out of which it arose: a new way of thinking about ourselves and our relationship – or rather lack of it –  with the world.  This way of thinking happens to reflect remarkably closely the sort of world that the left hemisphere creates.  The point of my book was to draw attention to that fact, amongst others.  But I agree one could prioritise economic history, as Marx does, and try to account for everything in terms of that.  I’m just not convinced that that gets to the bottom of it at all, and I think it often leads to worse misconceptions.

Is your right/left brain conflict best viewed as a metaphor or something more ‘real’?

Well, first of all, I don’t think that metaphors are an alternative to reality: I believe they are intrinsic to all forms of understanding whatever, including scientific understanding.  They are just so deeply buried in scientific discourse that we hardly see them, and are not encouraged to question them.  But there is little doubt in my mind, having spent so long gathering evidence about the difference between the hemispheres, that they do yield different experiential worlds in the most literal sense available to us – ie, if you have damage to one or other hemisphere, predictable things happen to your world.  And the differences are not a rag bag of odd findings, either, but lead to two (in their own terms) completely coherent, but philosophically distinct, worlds.  The differences I record are all backed up by scientific evidence, whether from lesion studies, imaging or EEG studies, Wada tests, commissurotomy, ECT or TMS studies, or tachistoscope or dichotic-listening experiments, and in most cases I have drawn evidence from more than one source, and always from repeated findings. 

However knowledge is never certain, always provisional. At the end of the book I say that it would surprise me if there turned out to be no correlation between the two ways, not just of thinking, but of ‘being in the world’ that I describe, and the two cerebral hemispheres, but I would not be unhappy.   I say that, not as one reviewer seemed to assume, because I don’t believe my own thesis, but because having drawn attention to these two coherent ‘takes’ on the world is itself an important step forward.  Many people will not care whether these ‘takes’ are actually to do with differences in their hemispheres or some other part of the brain or even the spinal cord – so for them it would still have meaning, I hope.  But while, like all models, it is provisional and just a basis for further thought by others, I would be amazed if it were ever shown to have no validity at all.  There is just far too much evidence.

In his review Grayling said that neuroscientific knowledge isn’t advanced enough to allow you to reach the conclusions you’ve drawn.  Would you care to comment on this?

Of course I disagree profoundly.  But he said a lot of very generous things, as well, so I don’t want to make too much of it. 

If, as is clearly the case, an emphasis on right or left hemisphere function in an individual results in certain things happening to the way that individual conceives the world, it cannot help being the case that such an emphasis in a group of individuals who share values, concepts, habits of thought – in other words a culture – will result in the same sort of things happening to the way that culture conceives the world. 

Grayling sees himself as ‘quite considerably a left-hemispheric creature’.  That may be part of the problem.  So are the majority of scientists these days – though not in the past, and with some very great exceptions among the most distinguished scientists of all.  For the left-hemisphere crowd, there will never be enough neuroscientific knowledge to relate the brain to culture.  For them not only is everything valid only within its own compartment of knowledge, but each little fragment of knowledge within that compartment, each little research paper, is just that – another tiny piece of information.  The bigger picture is lost, and even professionally frowned on.  At what point, according to Grayling, would one have enough information to be able to make sense of it at the phenomenological level – in the world where we live?  And one might ask gently, how would he know?  The information grows at an absolutely staggering rate every day.  Indeed my worry is that soon there will be so much of it that, unless someone like myself is foolish enough to try to make sense of it now, we will never be able to see what is going on at all.  More information does not necessarily lead to philosophical insight.  And it’s that, not information, that we lack.  And it’s that, not information (though there is a lot of it in my book), that I hope I have offered.

How would you like your book to influence the thinking of psychiatrists like me, and the way we conceptualize mental illness?

I would like it to humanise psychiatry, and help us to see that we need to relate what we know about the body and the brain to the history of humanity.

***

There are reviews of Dr McGilchrist’s book available on the internet:

Bryan Appleyard – Sunday Times November 29 2009 – Divide and rule: man is the new machine
The Economist November 26 2009 – The human brain: right and left
Mary Midgley – The Guardian 2 January 2010 – The Master and His Emissary: The Divided Brain and the Making of the Western World by Iain McGilchrist
A C Grayling – Literary review – In two minds

And here an appearance of Dr McGilchrist on the Today Programme 14 November 2009

The Master and his Emissary Wikipedia page has some further links

Today Frontier Psychiatrist is honoured to feature an interview with fellow blogger Prozacville.  For those of your unfamiliar with this site Prozacville is – in its own words – a cartoon about ‘existential discomfort and other things that go bump in the night, starring a cast of walking-talking Prozac pills’.  And I think that it’s entirely brilliant, which is not something I write without due consideration.

***

Can you tell me about why you started the Prozacville site?
The pedestrian answer to ‘Why Prozacville?’ is that I’d been doing a lot of drawing, painting and illustration, but was finding it all a little untethered, abstract, free-floating, and was trying to think of a way of tying it together more with words. The David Shrigley route was one way of doing this, but Shrigley was already having a good crack at doing Shrigley, so although I dabbled for a while in Shrigleyness, I think I was waiting for something to come along and unlock my creative-quandary. This came in the form of Hugliekur Daggson of all people, who reminded me that cartoons can be profoundly visceral and ’shocking’ (in the best sense of that word – ECT for/by the unconscious, if you like), a million miles away from the classic set-up + joke nature of traditional cartoon strips. Daggson ‘allowed me’ to begin drawing and thinking in a certain way and the early cartoons were thus a kind of homage or paying-of-dues to him.

[Early Prozacville cartoon - 2007]

But then I quickly realised that I couldn’t be Hugeilekur Daggson, and didn’t want to be Daggson, who is (in the best and most interesting sense) a sort of One-Man Viz Comic, the Id-Unleashed (in pen and ink). In order to do what he does, a kind of simple substitutional defence mechanism needs to be at work: acupuncture-humour, pushing needles into anything and everything that feels like a taboo. But where’s Daggson himself in all of this? I’ve always enjoyed those writers and artists who leave enough cracks and spaces for the viewer or reader to see (or at least think they’re seeing) Joe Schmo standing behind the neatly-produced ‘answer’ pulling the cranks and levers to maintain the illusion of that (provisional) answer. Perhaps I’m talking here about Projection and Sublimation (which I think/hope Prozacville invites), but also the difference between Sublimation-as-Displacement (AKA: Taking The Piss) and Sublimation-as-Intellectualization (AKA: Ooh, Clever Me). I obviously have a greater need for the latter. I mean, it’s great if you laugh (or even, god forbid, LOL) at Prozacville,  but even better if you’re taken onto the cusp of a set of conflicting emotions. That’s where the interesting ’stuff’ is happening (all the time, in our heads) and that’s what I think I’m trying to do with the drawings. Adam Phillips says in Terrors and Experts with his usual delicious cultivation of paradox that “the unconscious is a logic that dispels the illusion of minimal alternatives”. Prozacville gives me (and hopefully you) the feeling of having greater access to that.

[2007]

Where do you get your inspiration for your cartoons?
It’s very much a mish-mash: things I’m reading about, things happening to me or those close to me, newspaper articles, tweets, bleats, Negative Automatic Thoughts, advertising hoardings, the general whirr and whirl of the world flooding into into eyes and ears and sparking off something that feels like a Prozacville idea.

[2009]

[2009]

If you’ve had anything to do with psychiatrists, what do you think of them?
I’ve not experienced psychiatrists as a patient. I envy though you having that medical background on which to stitch a psychology/psychotherapy training as it seems to me just plain common-sense that mental illness is a biopsychosocial phenomenon, and let’s face it, you’ve got the bio bases better covered than I have. I do wonder though, if coming from a medical background means you are also more prone to ‘diagnose’ and pathologise, as I believe the the power of the work can sometimes be found in not putting someone into a DSM-IV category, maybe even that very category in which they themselves have become quite comfortable in. But saying that, I also think we all diagnose or label to a certain extent. If you think  someone’s weltschmerz stems largely from loneliness, this existential category/causality is as much a ‘diagnosis’ one might argue as formulating the notion of them as having something like an avoidant personality disorder. Isn’t it just a problem of nomenclature? You say potato, I say paranoid personality disorder, so let’s call the whole thing off? Linked to this is the problem that the mental health world seems to be so deeply fractured and splintered. Most of the time psychiatrists, (good) GPs, clinical psychologists, counsellors, psychotherapists (of all schools), psychoanalysts, psychiatric nurses, and dare I say I even say it, homeopaths, priests, imams and rabbis (of a certain self-reflective hue) are all involved in quite similar processes, but you’d never glean that from reading what they think about each other, or the ways in which they try to distinguish themselves from each other. I think we’re back here in the realm of ‘illusory miminal alternatives’.

[2008]

Can you give us an idea of how you occupy your time when you’re not drawing cartoons?
Apart from the psychotherapy/counselling, I also lecture at a London Uni, though in an unrelated subject area. In order to keep my own mind, body and spirit together, at the moment I’m pretty evangelical about Bikram yoga and will probably try and get you into a Bikram oven were you to express even a passing interest in the subject.

What you you think of medication as a way of treating psychiatric disorders?
There is no easy/pat answer to this, is there? I’m sure we both know people who wouldn’t be here today if it were not for psychoactive medication, but then it’s also sometimes a way for us as a society to ‘fob off’ or sedate those who are in mental pain with a relatively low-cost, low-person-intervening chemical cosh. It would be great if everyone could have access to both good psychiatric assessment and drugs (if they needed them) and/or long-term talking therapy. But that’s very much the Utopian ideal, isn’t it? If you think that it costs the NHS a few grand to give someone a year of once-a-week talking therapy at somewhere like the Tavistock, but probably less than a tenner to supply generic SSRIs for the same period, well, you can see why most people ends up with pills and/or (if they play their cards right) six to twelve sessions of CBT.

Which other cartoonists do you recommend?
On the website I list some of my vertical influences/authorities (the ‘parents’ of Prozacville, if you like) and horizontal ones (siblings). On and offline though, I probably spend more time reading mental health blogs and books (fiction/non-fiction) than cartoons or webcomics, because even if I’m looking for entertainment I still want to be moved in some way, and  on the whole cartooning/comics is a medium that doesn’t seem to take that part of the equation hugely into consideration. It’s really great that after about three years of doing Prozacville, the mental health/blogging world has ‘discovered’ The ‘Ville. This has always been my ‘target audience’ and so it’s really gratifying that you/they seem to like  what I  do.

Here is a letter I wrote to forth.ie

Sir,

On 7 December I wrote an opinion for this site about the launch of identity cards in Manchester. I received one comment, from Joan Burton, who wrote: “It’s a cliche but a true one – if you’ve done nothing wrong you have nothing to fear.”

One of the problems about the current UK government’s overarching surveillance project has been a lack of debate, both publically and in parliament, so I welcome any engagement with these issues.  I have heard the above sentiment voiced before and I address it here to provide clarification and, I hope on Ms Burton’s part, reevaluation.

Public protection from criminal activities is a key responsibility of the state but this should not allow the state whatever means it wishes in the pursuit of this goal.  Governments need to keep in mind that their populations predominantly comprise law abiding citizens whose rights and wishes should be balanced against any reasonable requirements the state may have to pursue its duties.  The ‘done nothing wrong/nothing to fear’ paradigm ignores any need for balancing public and private needs to the extent there is nothing that cannot be justified by its invocation.  It would, for instance, endorse the enforcement of the fitting of positioning devices to everyone living in or entering the UK, something that might drastically reduce crime but at the expense of massive state intrusion.

Thinking this way ignores the need to evaluate state surveillance projects and dismisses those who object as oversensitive to individuals’ rights, or failing to see the threat that we face.  The point I wished to make about ID cards is that not only are they intrusive, but they fail to meet any of their objectives, even though these objectives have changed over the years.  Now, more than ever, the UK Government must be careful with its taxpayers money and, civil liberties issues aside, that project of the expense of that of the ID cards is now being promoted as first and foremost a convenient way to prove identity at the post office is of concern in itself.

Finally within ‘done nothing wrong/nothing to fear’ thinking there is a tacit assumption that governments are inherently benign and have the interests of their populations at heart.  Whilst this may be broadly so for the UK it is foolish to think that this is a universal attribute of governments or that adverse change is not possible.  It is a sad fact that the majority of acts of violence committed in the modern world have been visited by those in governmental power against those who are out of power.  Indeed the word ‘terrorism’ actually dates from the French revolution and refers to the use of terror by governments against their own populations (1).  One estimate holds that during the 20th century governments killed 7.3% of their populations.  ID cards have  been documented as having been assets in mass killings both recent and historical and continue to be used to target vulnerable populations.

Yours etc.,
Dr. Stephen Ginn MD,
London.

References:

Fluoxetine hydrochloride (3-(p-trifluoromethylphenoxy)-N-methyl-3-phenylpropylamine HCl) was first described in a scientific journal in 1974 as a selective serotonin -uptake inhibitor.  It was licenced for use in the treatment of depression in Belgium in 1986 and the USA in 1987.  Before its launch, to introduce it to the public, its manufacturer Eli Lilly funded eight million brochures (“Depression: what you need to know”) and 200 000 posters.  It would become one of the best selling pharmaceuticals of its age; by 1992 annual sales had reached US$1bn and by 1995 they had doubled to US$2bn.  In 1999 ‘Prozac’ – the trade name of fluoxetine – was named on of the ‘Products of the century’ by Fortune magazine.

The impact of the drug is hard to overstate, both in terms of the culture of the treatment of mental health disorders and in Western society at large.  Prior to the introduction of fluoxetine antidepressants had a reputation of having side effects and were cautiously prescribed as they were toxic in overdose.  Fluoxetine, on the other hand, was relatively benign and its introduction practically created a market in drugs for mood problems that could be safely prescribed to anyone who wanted them.

Other SSRIs followed in fluoxetine’s wake and the result has been an explosion in the diagnosing of depression and the prescribing of antidepressants.  This is all the more incredible when one considers that the revenue from antidepressants sales in 1975 was US$200million and the market was considered to be saturated.  ‘Prozac’ has since entered the popular lexicon and spawned its own sub-genre of literature.  Of these perhaps the best known is Prozac Nation, a bestselling – but in my view rather tedious – memoir of mental illness written by Elizabeth Wurtzel.

There have been some hiccups along the way.  Fluoxetine doesn’t have as few side effects as originally thought and, amongst those who are prescribed it, anorgasmia is quite common.  Nausea is often experienced initially and it can sometimes increase rather than reduce anxiety.  There have been concerns about other SSRI drugs, notably paroxetine, increasing suicide risk in young adults and in 1989, Joseph Wesbecker shot and killed eight people and injured 12 others in Kentucky before killing himself.  More recently a meta-analysis of 35 clinical trials of four antidepressants including fluoxetine concluded that the action of the medications was not clinical significance for any patient who was not severely depressed.

In 2007 Eli Lilly began to market fluoxetine for dogs under the name Reconcile.  In this incarnation it’s chewable, tastes like beef and is intended to treat something called ‘canine separation anxiety’.  This disorder amounts to a set of behaviours displayed by a dog when being left alone for too long.  A dog so affected may urinate in inappropriate places or chew furniture.  At the time of launch Lilly said that their research showed the up to 17% of dogs suffered from this behavioural disturbance.  Reconcile comes in a once a day chewable beef flavoured capsule.

I don’t know much about dogs, but other people seem to really like them.  I’ve been trying to think about what antidepressants for dogs tells us about ourselves.  Many people see dogs as part of their families and as such project onto them human attributes.  In their advertising Lilly avoid suggesting that Reconcile is a treatment for ‘canine depression’ but other articles written at the time of Reconcile’s launch are not so careful, here in the Times:

In Britain, research among pet-owners carried out for Sainsbury’s Bank in 2003 indicated that 632,000 dogs and cats had suffered from depression in the previous year.

Nearly three times as many pets had suffered from behavioural problems that which could be linked to depression, often resulting in the animal damaging its home or becoming moody or aggressive, according to the research.

The experience of a human disease such as depression involves complex human attributes such as thoughts, emotions and language.  To suggest that we can extend the concept of a specific human mental illnesses such as depression to dogs is to stretch the paradigm almost to breaking point and shows at once how loosely lay people apply the concept and how engrained widespread mental illness it is in everyday thinking.

Not that this association will worry the pharmaceutical companies.  Marketing antidepressants to dogs tacitly encourages dog owners to consider that their dogs have mental health conditions previously described in humans and this can only be good for sales.  Many pharmaceuticals develop mission creep whereby manufacturers endeavor to win them licences to allow their use to treat disorders distinct from those for which they were initially licenced.  Initially cleared for depression only, Fluoxetine is now used for anorexia and bulimia nervosa, obsessive compulsive disorder, panic disorder, premenstrual dysphoria and generalized anxiety disorder.  Viewed in this light, the launch of Reconcile, and fluoxetine’s crossing of the species barrier, is just part of the drugs product lifecycle.

This is not to say of course that fluoxetine doesn’t have its uses for animals.  In similarity to human subjects it may have impressive effects in some, moderate for others and no effect for a substantial number.  The emphasis is on the problem being in the dog and nowhere else,  just like in humans.

Links:

Animals can model psychiatric symptoms – Psychiatric news 2003
Pooches Pop Prozac to Treat Behavioral Problems
Prozac for your dog – Technology Review 2007
Eternal Sunshine – Observer May 2007

Emotions in animals – Wikipedia

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15% off scrub pants with code “frontierpants”

Here’s a short piece I wrote for BMJ.com blogs:

According to a recent article in the Guardian newspaper I’ve worked in the two most polluting buildings in the UK. Over the course of one year the Royal London Hospital in Whitechapel was responsible for the emission of 46,218 tonnes of CO2, (rated G). Cambridge’s Addenbrooke’s hospital – in whose A&E department I worked – was the second worst, receiving an F rating. Overall eight of the ten worst polluting buildings in the UK were hospitals which on average emitted 4089 tonnes of CO2 per institution yearly. At the other end of the scale, tourist information centres emit on average 140 tonnes per year.

Hospitals are always going to struggle to be energy efficient. Despite modernisation many are still sprawling behemoths with “legacy” buildings whose origins sometimes stretch over the course of more than a century. In those days ‘energy efficiency’ was having a rest before beating the maid. Unlike offices, the nature of health care means that hospitals never close and heating costs will be high due to the needs of ill patients.

But still, walk into any hospital department and you’ll find every room is lit at all hours and every computer terminal is on whether or not it is being used. Heating systems are unresponsive and temperature regulation tends to involve opening the windows. This profligacy is hardly surprising as there’s little incentive to conserve* and things like computers aren’t designed to be powered down anyway. Some lights have most likely not been turned off for several years and I’ve only every worked in one place with motion activated lights.

All this will change I hope, although compared with, say, hand disinfecting energy efficiency has a very low profile in the NHS.

* NB: Lest it be thought I am preaching, I am no better than anyone else in this regard.

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Links

BMJ and the Hippocratic Oath: how the BMJ fails on both

NHS sustainable development unit – they’re not completely ignoring the problem it seems

Maisy and George and the future of their planet – a rather mawkish film by the BMJ, but some interesting interviews

NHS needs to tackle energy consumption – Telegraph 22 June 2007

Also known as ’sympathetic pregnancy’, Couvade syndrome affects biological fathers, particularly during the first and third trimesters of pregnancy, who suffer the somatic features of pregnancy.  Cessation of symptoms occurs upon birth or shortly within the postpartum period.  Rarely other relatives including children may be affected.

The syndrome is relatively common and epidemological studies report couvade symptoms in 11-36% of pregnancies predominantly affecting the gastrointestinal tract.  The commonly reported symptoms include indigestion, increased or decreased appetite, weight gain, diarrhea or constipation, headache, and toothache

The name derives from an ancient custom whereby a new father took to his bed to be cared for by his recently delivered wife for a defined period of time and comes from the French word ‘couver’ – to brood

There have been a large number of theories put forward to account for the origins of the syndrome.   It has most popularly been considered likely to be a somatic expression of anxiety.  Psychoanalytical theories contend that it is a consequence of the man’s envy of the woman’s procreative ability or foetal rivalry whilst psychosocial theories hold that it occurs due to the marginalisation of fatherhood and as part of a transitional crisis to parenthood. Paternal theories suggest a connection between the man’s involvement in pregnancy, role preparation and the syndrome.  Some of these theories have not been thoroughly investigated and findings are generally inconsistent.

Wikipedia – there’s some extra stuff here, but also a woeful lack of citations
Couvade syndrome equivalent? Case report Psychosomatics 46:71-72, February 2005
A critical review of the Couvade syndrome: the pregnant male Journal of Reproductive and Infant Psychology, Volume 25, Issue 3 August 2007 , pages 173 – 189

Also check out Uncommon psychiatric syndromes – Enoch, Enoch and Ball

Here is a piece I wrote for the RCPsych London division December Newsletter.  It’s about Triage ward on the Ladywell unit in Lewisham.

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Triage ward is one of five general adult wards serving the inpatient psychiatric needs of the Lewisham area.  It is based in Lewisham hospital and is part of the Ladywell Unit which in turn is part of the South London and Maudsley NHS Trust (SLAM).  Judging by the number of visitors we have had to the ward whilst I have been working here, there is a great deal of interest in the way we do things. 

Triage ward is part of an unusual model for managing psychiatric admissions, and one that is soon to be implemented across SLAM.  As a ward it acts as a single point of admission for all patients who enter the Ladywell unit.  It is aimed that patients will stay for a maximum of two weeks, whilst their needs are considered.  If, after this time, they need to continue as an inpatient for a further spell, they are then transferred to a longer stay ward.   This model contrasts to the established paradigm whereby ward allocation is sectorized, where patients are on admission immediately assigned to wards depending on their postcode or the location of their general practitioner and there is no envisaged limit on admission duration.  The impetus for establishing Triage was a desire to address common problems found within psychiatric in-patient units where wards are busy and overcrowded, leading to patient overspill into the private sector and a high staff turnover.  It was established in 2003 by Dr Martin Baggaley, who is now medical director of SLAM.

Triage is a mixed ward and its maximum capacity is 16 patients.  Asides having an airlock and being more secure, it looks much like any other inpatient psychiatric ward, although newer than some.  The provision of staff is generous compared to other sites and asides a contingent of skilled nursing staff, there are two CT1-3s doctors, a ST4 doctor, two part time consultants (full time equivalent), and a social worker. 

Triage’s aim is that, after admission, patients should have their needs met and be discharged to the community or another ward as quickly as possible and much of what we do has this goal in mind.  The turnover of patients is extremely high and amounts to 920 patients per year.  There can be as many as four new patients in a day across a wide ethnic mix.  Some patients seem to go before one has even met them and after a returning from a week’s annual leave the ward’s inpatients will have almost completely changed.  This constant flux means it’s difficult to form a rapport with any of the patients.   The life of a junior doctor is very busy and a recent new duty is a completion of an OPCRIT computer based diagnostic assessment for each patient.  Unlike other SHO jobs, time constraints mean that we don’t complete the patient discharge summaries and this responsibility is passed onto the ST4 trainees.  Fellow CT trainees on other wards are jealous of this concession!

A lot of my work is administrative, which can be dull but in compensation there is plenty of opportunity to learn at the consultant lead ward round, which is held daily to ensure swift patient movement through the system.  Here my role is to make interview and management plan notes and this is done on a computer terminal which is projected for all to read.  With two different consultants it is possible to observe different interviewing styles.  I have found interviewing more difficult than I expected and my ability to undertake a mental state examination has much improved.  The presentations of our patients are very varied and sometimes the ward rounds can be quite dramatic.  About half of our patients are under section at any one time and, much is as one might expect, depressive, psychotic and personality disordered presentations predominate.  We work closely with the local crisis resolution service and a member of their team is often present.  The downside of such regular ward rounds is that with senior doctors so regularly available, there’s little latitude for independent thought. 

Triage might perhaps appear foreboding to the uninitiated.  The ward and staff base can feel as busy and noisy as general medical wards post take, but there are plenty of calm periods too.  The staff base is shared between doctors and nurses.  This makes for good multi-disciplinary communication and although we’re short of computer terminals this is never a cause of friction.  I have however become resigned to our second printer being permanently broken.  There can be an air of unpredictability and the ward panic alarm is activated a lot.  I’ve never felt personally threatened, although it’s not unheard of for a member of the nursing staff to be assaulted.    

Patient treatment is predominantly medication based and I think it’s a shame that there are no psychologists on the ward, but there is a social worker available to address social needs, which oftentimes is the most important thing.    The air conditioning we have is a mixed blessing as patients often complain of being cold in bed at night.  The ward environment is rather boring for the patients, although there is a daily newspaper and a table tennis table; the nature of the disorders with which we deal means that some patients, who might wish for peace and quiet, are disturbed by other more vociferous residents. 

Overall my experience of working on Triage ward has been very positive.  On other wards on which I have been employed patients can sometimes be admitted for several days before they are seen by a consultant, an experience that can be very frustrating.  However on Triage ward, with its daily ward round, things move much more quickly and it is also hard not be impressed by the financial savings Triage has bought to the SLAM trust, as it is now almost unheard of for a Ladywell patient to be accommodated in the private sector.