Who’s at risk?

Next week I’m hoping to return to work after a few months off. It’s been a year since I became ill this time – I returned early last year, but it was too soon, and I found myself off again. I have a diagnosis – bipolar disorder – and I’m on quite a lot of treatment, both mood stabiliser, antipsychotic, antidepressant, and, more unusually, weekly maintenance ECT. I feel better, but, being honest with myself, I think I probably need this treatment now – I hope that I will be able to reduce some of it reasonably soon, but know I need to avoid doing this too precipitously.

I asked to be referred to occupational health for support with my return to work, as it can be very easy to rush a phased return, and that definitely happened last time. This experience has sadly been disappointing, with a focus on what my colleagues would or should do if I were to appear ill or put patients at risk. This has never happened in more than twenty years of illness. I am mostly well, and either stop work myself or take advice to do so if unwell. I don’t think I have ever felt this way before, that I am perceived as a potential risk to my patients. The stigma associated with mental illness is alive and kicking, sadly.

Today I met with a friend, who, like me, has experienced both sides of mental health services. We talked about our experiences of meeting some brilliant people; but you also meet others who you can’t help wondering why they chose this as a career; and there are many floating somewhere in between. But we also talked about the structure and the organisation, and how these contribute to services, and it made us feel very uncomfortable.

There are many different diagnoses in psychiatry, but some are more likely than others to lead to hospital admission, at least in general adult services. I don’t want to pretend to cover them all, but schizophrenia, or mood disorders, with perhaps especially mania, may be more likely to result in admission, with psychotic symptoms an obvious risk. Low mood and suicidality, and, let’s face it, a diagnosis of personality disorder may also be a risk, and there are other, rarer, diagnoses. I think that this is what you might expect – it gives the opportunity for treatment, as well as keeping patients safe. No-one wants to admit someone who doesn’t need to be there, but what we reflected was that, as clinicians, there can often be considerable pressure not to admit people. It can even be seen as a positive achievement to avoid admission. Bearing in mind that it is sometimes the least experienced clinicians who are admitting out of hours, this does seem quite worrying. Ultimately, I suppose it reflects the problems throughout the health service in this country, that care can be driven by what is available and affordable rather than what would always be recommended.

This may pose risk to patients – we have all been in situations where we were unable to get the treatment for our patients that we felt was required and safe. But it also gives a message to patients, that we don’t see their diagnosis and distress as valid. You may learn about management of suicidal depression in a textbook or from experts, but if you tell the patient that they are not sufficiently ill to merit admission, then what are you telling them? As patients it is bewildering; as younger clinicians, what does it teach? I don’t think it teaches kindness. I think it teaches that keeping patients away and at arm’s length is to be lauded.

But – there are still very many very kind people working in mental health services, and my point is more that the structures make it hard to act according to this, and to work within a therapeutic culture. I have personally experienced quite a lot of kindness, probably more so in recent years. I think it is possible that both my diagnosis and my role as a consultant have made this possible. But we all know people who have not experienced kindness – things have gone wrong for them early on, and once things go wrong, it can be very hard to turn this around. It’s also very easy to criticise, and I experienced this myself from both family and services when I was first unwell. I consider myself to have been extraordinarily lucky to have received the right treatment, and to have managed to return to work after I first became ill. How I became a psychiatrist is still beyond me – however I believe that it certainly offers me some protection now when I am ill.

Sometimes I still think that it might all be a mistake, that my diagnosis and my treatment were only given to me because I’m a doctor, and now a psychiatrist. If I’d been, for example, a history teacher (my preferred option!), would things have been better or worse? What makes people believe people? I often don’t know.

I do believe in mental illness, though. I think it’s taken me many years to start to understand, and I’m still learning. Of course illness can occur in the mind or brain – why on earth not? And of course distress and unhappiness occur, and of course these can occur as well as biological illness. So I believe in the many biopsychosocial treatments available – they don’t always work, but they are worth trying. And I really wish that we could always offer admission to therapeutic, hospitable units when we feel necessary. I think it would help.

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