The wilderness years

Dr Dermot J Ward

Two recent British Journal of Psychiatry publications addressed the lamentable state psychiatry – and psychiatrists – are in. Sadly, we psychiatrists have not exactly covered ourselves in glory.

However, as Ernest Hemingway reminded us , the sun also rises. For me the first shaft of sunlight was the September 2007 BJP editorial, What is the heartland of psychiatry? .(Goodwin and Geddes). This drew attention to the idea that some 20 years ago a publication, that I had never read, had asserted that schizophrenia was the heartland of our specialty. Dr Guy Goodwin and Professor John Geddes (both of the department of Psychiatry Warneford Hospital Oxford) not only question the appropriateness of schizophrenia being so selected for this imprecise attribution but also posit such label as having been detrimental to not only the public image of psychiatry itself, but most important of all, damaging to patient care.

That I might have a quibble on a point or two is quite insignificant. My great difficulty is that what they have written is so elegant, concise and pithy that plagiarism dangerously beckons! They so obviously echo views, reasonably informed I hope, of a number of senior psychiatrists on both sides of the Irish Sea and most certainly held by the Society of Clinical Psychiatrists for whom I can speak. As an Irishman and one who has worked at different times over a number of years on each side of the Irish Sea, I have been heartened that psychiatry, even during the darkest days of ‘the troubles’ has, through its Royal College, been an unfailingingly unifying body through its membership. Sad to say that link has recently shown signs of attenuation as psychiatrists in Southern Ireland, unimpressed, even alarmed, with politically-driven trends in England NHS psychiatry policy, have embarked on the creation of an Irish College of Psychiatrists which is expected to be up and running in 2009. Concerns have revolved around preservation of best patient care and possible undermining of professional integrity by insufficient robustness in defending care standards.

Goodwin and Geddes suggest that some psychiatrists choice of schizophrenia as its heartland was influenced by a number of factors which they dissect. They consider that if there is any useful validity in psychiatry in having a ‘heartland’ that bipolar disorder would have been a more appropriate choice in the medical setting than schizophrenia. They do not neglect reference to aspects of hospital  bed numbers which are widely seen to be, and have been so for many years, a huge unmet need.

The hindering activities of NICE are touched upon in the context of NHS-approved medication and they could also have mentioned the unsatisfactory hindrance of NICE ECT guidelines, an area of its activity conspicuous by its quite inadequate psychiatrist input and its claim that evidence that it led to improved quality of life was lacking. This society’s efforts to encourage NICE, by reference to relevant literature to recognise and accept that there was such evidence was eventually successful. It was unlikely that any experienced psychiatrist would have claimed lack of evidence for ECT’S beneficial effect on quality of life.

The Awakening

If for many of us Goodwin and Geddes heartland piece was itself a wake-up call for British psychiatry this cri de Coeur was answered definitively in the July 2008 truly multi-authored article appropriately titled, Wake-up call for British psychiatry. It is telling that in the declaration of interest of its thirty-seven authors that ‘all are members or fellows of the Royal College of Psychiatrists and currently work within,  or have recently worked within the UK National Health Service and hope that both of these organisations will be influenced by this paper.

It is chilling that they have to point out during that what I would term the twenty or so wilderness years in psychiatry during which psychiatrists, specialist physicians in psychological medicine, have been substantially side-lined, (although they are the sapiential leaders in psychiatric patient treatment), ‘that this downgrading could not have occurred without the collusion or acquiescence of psychiatrists.’; that some psychiatrists have adopted the renaming of patients as ‘clients’ and allowed ‘mental health’ and ‘mental health problems’ to virtually extirpate mental illness from the psychiatry lexicon.

The paper deplores the referral of patients to anonymous teams and pleads for a return to the practice whereby general practitioners  refer patients to a named consultant psychiatrist.

They also make the interesting observation that despite the recent attempt to caricature a medical psychiatric approach as being narrow, biological and reductionist they are impressed by how keen other members of staff are for themselves or their relatives to be seen by an experienced psychiatrist when mental illness assails them. I have but skimmed over the many disquieting aspects of psychiatry’s and psychiatrists’ disempowerment and its natural consequence of poorer clinical services for patients.

It is a pellucid analysis of where psychiatry finds itself now, sidelined to the extent that ‘social care’ rather than psychiatric diagnosis and treatment – the mental illness discipline most capable, because of its particular medical model base, of achieving the goal of holistic patient assessment – has become the DoH ‘big idea’ for the future of psychiatry. It is especially critical of the initiatives jointly developed by the UK government’ National Institute for Mental Health and Royal College of Psychiatrists . The report, New Ways of Working for Psychiatrists: Enhancing  Effective, Person-centred Services Through New Ways of Working in Multidisciplinary and Multi-agency contexts, which blurs leadership and could mean that many patients would not benefit from a thorough psychiatric diagnostic assessment before starting treatment.

(The academic texture of the eminently pragmatically correct Wake-up paper is enriched by reference to Reil, in this his 200^th anniversary year, regarded as the father of psychiatry.)

The implications of these recent difficulties for recruitment, training and retention of future doctors is addressed and the importance of patient stigma. In the context of the latter this society has long contended that the strongest combatant of such stigma is the speedy and effective treatment of acutely ill patients. And the corollary of that is that if such patient receives only ‘social care’ in the community then stigma is magnified for not only that inadequately treated patient but also for the mentally ill generally. The Society of Clinical Psychiatrists is grateful for , and strongly supports, the content, and all associated with the production of, these two important papers.