Is it common for patients to try to escape?
Do you have patients who don’t want to be treated? How is this handled?
Do you have patients who you suspect of faking or exaggerating their symptoms?
No worries, irishgirl. I just wanted to let you know that I wasn’t trying to build any criticisms.
I have to admit my own opinions of ECT changed radically the first time I met a patient who was eagerly looking forward to her next session, because that was all that helped her deal with problems.
Around here, PICU is a pediatric intensive care unit. What is it on your side of the world?
The Weird One patients try to abscond (not escape, the powers that be think abscond sounds nicer) all the time.
If they’re a voluntary patient I get very annoyed because really all they had to do was sign themselves out.
If they are detained (i.e. a risk to themselves or others) and leave the ward without permission we search the grounds, if they can’t be found we alert the police. Most patient will either return of their own accord or will be brought back by family members. Very few will need to be brought back by the police.
Like I said, we’re not a prison, so it’s not exactly difficult to absond if you aren’t on special obs or in a locked ward. Absconding whilst detained is PICU behaviour.
Yes, we have patients who don’t want to be treated. There is a truism in psych though- the sickest patient are the least trouble. Usually the really sick people want help and will co-operate pretty well.
Unless someone is a risk to themselves or others we can’t treat them against their will, but usually a little cajoling and people take their meds. Sometimes we negotiate about dose or formulation or timing, sometimes we don’t- it depends on the person, their illness, insight and personality. Very, very rarely we will sedate people in order to administer medications, but it’s not a daily or even weekly occurrence.
Re: fakers and exaggerators. Short answer…yes.
Long answer…There are psychiatric diagnoses known as personality disorders. Specifically people with borderline personality disorder will fake and exaggerate symptoms.
These patients are often extrememly difficult.
They will take overdoses and self-harm, not because they want to die, but because they crave attention or have poor impulse control. They often quite like hospital and don’t like to go home, so will, for example, fake a seizure or threaten to hang themselves the day they are due to be discharged.
There isn’t really an effective pharmacological treatment for PD because it is not a biochemical imbalance as such, but a disorder of the person’s personality, i.e. there is something deeply wrong with their worldview and the way they relate to others. Various psychological therapies can help modify behaviour, but there is no real cure. Sadly, it is common and affects a fairly large proportion of psychiatric in-patients.
They are extrememly difficult to manage and very, very frustrating to deal with on a daily basis, hence my jaded, cynical view of personality disorder and why I often feel like Supernanny.
PICU in the context of mental health is the psychiatric intensive care unit. PICU in the kiddies’ hospital is the Paediatric ICU.
That’s medicine for you- confusing acronyms abound.
OK - I’ll bite…
Is the place haunted (or more pc - is it rumored to be haunted)?
What does ECT stand for?
ECT is electro-convolsive therapy, a sort of last-line treatment for depression and some other psychiatric conditions. The largest concern is short-term memory loss centered around the treatments.
Er… no. The largest concern in modern medicine is the short-term memory loss.
Historically it could be used as a punitive measure to keep mental patients in line, and there are some real horror stories out there WRT to ECT. I won’t say that I believe that One Flew Over the Cuckoo’s Nest is an accurate description of mental health care at the time it was filmed. I will say that it showed some of the worst conditions and treatment that the mentally ill had been subjected to, prior to that time.
A lot of people involved in patient’s rights for the mentally ill have a huge disconnect between how the treatment is used now, and how it had been used in the past. There are a lot of people who equate ECT with lobotomies as treatments that exist solely to convert a patient into an easier-to-care-for vegetable. And while I disagree with that equation, for modern psychiatry, it’s worth noting that within living memory it had been used that way.
I’m not indicting anyone now practicing psychiatric medicine in the First World by saying that, and especially not irishgirl. But as a treatment, ECT has a prior history of being associated with abuses, just as involuntary sterilization, or even involuntary commitments have. IMNSHO the rational response is to monitor closely the instances where such treatments are deemed necessary. There are a number of people, however, who either through educated opinion, or simple prejudice, do not agree.
My sister is severely bipolar plus has Parkinson’s disease, and is currently in a hospital getting her meds readjusted (as you can imagine, it’s a serious juggling act between those two). The other day one of the women on her unit attempted suicide, and apparently did a good job of it; she’s not expected to survive.
This is obviously not had a good effect on the rest of the patients.
Have you seen this happen, where one of your patients succeeds in suiciding? Does it seem to have any long-term ramifications for the patients (as opposed to the staff, who obviously are under a microscope trying to figure out how they let it happen)? I’m not talking on an open ward; I’m talking about a closed unit. Do you think the patients in your closed units are closely enough monitored to prevent something like this from happening?
In what ways does your hospital work with patients’ families?
I’ve got lots of random Qs actually, most of its sorta shaped though on what I’ve experienced growing up in the States though. So I’m kinda curious about Psych Hospitals over the Oceans.
Do you deal with Forensic Psychiatry any- ie: the criminal elements who have pleaded insanity or are court ordered to attend your hospital?
How does that compare to treating the other patients? As you mentioned you don’t have any restraints of any sorts, which makes me think your hospital doesn’t deal with this issue as much.
Do you have a Geriatrics wing? Or I suppose more generally- what is the make-up of your patients in terms of Age, Gender, Background?
Do you feel comfortable with all your patients, or were you ever afraid of any of them due to their disorder/illness?
-What does your hospital [or Hospitals in Europe maybe even, I’m not sure] try to emphasize: Treatment of the patients, rehabilitation, or simply trying to take care of those who cannot be cared for by others, or a blend? (ie: Is there another location where you send those more troublesome or difficult patients, or are you the last line)?
How do you unwind when you go home from the hospital?
How did you end up choosing this as a career choice in Medicine?
Any advice to those who wish to pursue this career?
~R
Son of a Forensic Psychiatrist in the US
When I was younger, I was placed in a locked psych ward for a few days because I told a psychiatrist that I had the desire (and means) to kill myself (Psychiatrists can do this, apparently, at least in California). I was a little bewildered, but in retrospect the experience was good for me, and it may have even saved my life.
Anyway, the staff was great, but one of the little quirks I found annoying was that none of them would make eye contact with me or the other patients. Instead, they would stare off to the side slightly when they were talking to me, as if they were focusing on one of my ears. Is this standard procedure at a psych hospital? I assume the purpose is to avoid setting off the more aggressive and excitable patients. It made me feel like an unperson though.
I was surprised during my stay that most of the other patients did not seem stereotypically “crazy”. I saw one or two people babbling or wandering aimlessly, but the rest seemed very normal and friendly. A little bored, maybe, but certainly not ranting and raving, and not particularly out of touch with reality. Are all psych hospitals like this, or did I just get lucky? Do most of your patients act “ill” to you, or would they fool you if you met them on the street and had a conversation with them?
Ok, silly question, do places such as this really have padded cells?
Also, is this your calling within the NHS? Or just some experience everyone has to pick up in the medical service?
This interests me too. As the wife of a son of a bipolar mother, I can see the huge (detrimental) impact her illness has had on his life and I think he would have greatly benefited from counselling as a child.
As a BPD patient, I believe I speak for my fellow PDers when I say…
Ha Ha, Got your pen!
I remember, from a previous stay at a MHF, jacking with the techs, particularly this one girl who I almost had convinced that I slept 40 minutes out of every hour and only got up for five minutes at a time every fifteen minutes to sit in the day room when she did her updates so it looked like I was awake all day.
Of course, I was awake all day, but I almost had her going there.
I never messed around with the Doctor though. I knew he could help me or, if needed, give me something that would really fry my noodle (not necessesarily ECT, there are some pretty powerful meds out there) and I wanted help so I was nice to the medical staff.
The techs were fair game though. Not too fair, annoy them too much and they could take away privileges and make you eat in the ward instead of in the cafeteria. Either that or jam a hypo of Haldol in your back side. They didn’t use physical restraints but I did see them use chemical restraints a couple of times.
I guess my question is: Given the recent (since the 60’s and 70’s) shift from inpatient and analysis based therapy to a more outpatient pharmaceutical based therapy, where do you see the future of the field? Is this shift global (it is here in the US but is that the perception over seas)? Has this shift varied across various health systems, for example the private insurance system here in the states vs. NHS or Canada’s system? I ask this because it was kind of my impression that the shift was due to a costing issue rather than a treatment issue.
Oh, and here’s your pen back, sorry about that.
Pixilated- yes.
The main building is an old building set in parkland, so there literally are bats in the belfry, birds in the chimneys, mice in the walls and squirrels in the trees. Lying in bed in the doctor’s on call bedrooms you can sometimes hear scratching and squeaking in the walls (our rooms are up in the attic). One of my colleagues refuses to sleep in the big bedroom because it’s louder there and can get a bit creepy. We know it is bats or mice, but it’s still not very nice. Of course there are rumours about hauntings, but you really couldn’t expect anything less.
Mama Tiger- none of my patients have killed themselves on the ward, but yes it has happened in the past. The staff learn something from every event, and often things are changed to try and prevent it happening again, but bottom line is that if someone is determined enough to harm themselves, they will find a way to do it. There are patients in the past who have managed to electrocute themselves with light fixtures, cut their wrists with broken ceramics, chewed through their own wrists, and hung themselves from door handles with their clothing- we now have different door handles, light fixtures and no ceramics in the canteens…but you can only do so much.
When it happens there is much fallout- it makes the depressed patients sad, the paranoid patients more scared, the manic patients more elated and the BPD patinets tend to try to copycat (but in less serious ways, without actually intending to die).
We risk assess everyone on admission and once a week thereafter, but some people are able to hide their intentions very well.
fessie- it depends on the family, the illness of the patients and what exactly needs to be done. We offer everyone contact details of support groups, next of kin are approached for collateral histories and everyone is free to make an appointment to speak to their relative’s consultant to discuss any aspect of the situation they wish.
Once a week we have a ward round where relatives can come and speak to the team in general. If someone is themselves suffering from poor mental health because of their social situation, we can get them treatment and support should they require it.
Our teams include social workers, nurses, occupational therapists, physios and psychologists and they can provide the family with help and support if they need it.
RoOsh- we aren’t the main forensic unit, so we don’t really deal with that aspect, as I said we deal with people who have forensic histories, but not really those who are sentenced to detention in a psychiatric unit rather than prison.
We’re split pretty much 60:40 between general adult pscyhiatry and old age psychiatry (over 65s) and about 50:50 between the genders. Most of our patients are from lower socio-economic backgrounds and many are on some sort of disability allowance because their severe mental illness prevents them from working.
I don’t work with the older patients day to day, but many of them are people with dementia and challenging behaviours that make them unsuitable for ordinary nursing home care and are awaiting a place in an EMI (elderly mental illness) nursing home. The remainder are older people with new onset depression (such as after the death of a spouse) or who have had a chronic illness such as schizophrenia or alcoholism for many, many years.
I’m a very small person physically and some of the male patients are quite intimidating. I carry a rape alarm at all times, and if particularly uneasy about a patient I can also carry an attack alarm that alerts the whole hospital when the button is pressed.
Without getting into details, I have genuinely only been scared when dealing with a patient who has since been diagnosed as having dissocial personailty disorder (i.e. a psychopath).
The aim of the hospital is always to get people as well as they can so that they can go back home, or to supported accommodation, while recognising that that isn’t always going to happen. It’s a combination of treatment (drugs and talking) and rehab (occupational therapy, socialising, parenting and life skills classes, drug and alcohol treatment).
We have a secure ward, so unless someone requires physical restraint on a day to day basis, we’re the last stop for most people, except those who are taken over by the forensic team, who then get transferred to their unit.
Having said that, our eating disorder patients are often waiting for beds in specialised clinics in England or Scotland, and some of our personality disorder patients go to a therapeutic community in England.
I unwind with a glass of wine, a nice dinner, cuddles from my husband, a DVD or posting here. I manage to stay fairly detached and while some things can make me need to take a few minutes to breath deeply or wash my face, I find it easy enough to switch off outside work.
Pushkin I didn’t chose psychiatry as a rotation- it was just one of the places I had to go this year as part of my generic training. Next year I start the specialised training to be a GP. Like I said, it’s not for me as a career, but short-term, it’s do-able.
I prefer my days to be rather more action-packed. The pace is really slow compared to medicine, and a 30 minute chat with a patient is considered a good morning’s work. I’m quite a goal-oriented person and if I’m at work I like to be working. In medicine there is always busywork, in psych you spend a lot of time thinking, watching tv, reading medical journals and waiting for a patient to decide if they’d like to talk to you.
If you want to do this, you really have to like people.
Not just nice people, or people who are rewarding to talk to, but people who drain your energy and who can make you unhappy simply by being in the same room as them. You still have to like them enough to keep doing your job by talking to them and listening to them…even the ones you secretly want to slap very hard.
Yes, we have a padded cell (2 actually, one male, one female, on each of the locked wards). It’s not where we keep people long-term, more where people go to calm down until they can control their agression or we can trust them not to harm themselves in an ordinary room. It’s usually empty.
Arithosa- part of the mental state examination is gauging how well someone maintains eye contact. Not a staring competion, just whether they’re avoiding your eyes or staring at the floor, or trying to stare you down. I’m generally trying to have a conversation with my patients, so I try to talk to them just as I would anyone else- I don’t consciously try to avoid eye contact.
Some people are quite florid and you’d know they weren’t well a soon as you saw them, others only reveal the extent of their illness after detailed and very specific questioning. It’s a big spectrum.
However, you don’t usually ask people whether they believe other people can hear their thoughts or remove thoughts from their heads when you meet them casually on the street- if you did you might be surprised how many “normal” people are psychotic.
nd_n8- thank you for appreciating that treating BPD can be a challenge for doctors as well as patients!
I think our aim has moved away from analysis and in-patient treatment towards outpatient treatment, not just because the drugs are better than they used to be, but because the evidence suggests that people do better in their own homes than in hospital. CBT is replacing psychotherapy for anxiety and depression and has evidence to back up its effectiveness.
I don’t think it’s as much about cost as about recognising that it is difficult to be a productive member of society if you’re stuck in a hospital getting more institutionalised every day. With the right support most people can stay in their own homes and continue to parent their children, have relationships with their spouses and look after themselves.
I very rarely just prescribe a tablet and leave it there, most often I’ll do one or more of the following too:
Get the person in touch with voluntary services (CRUSE, Women’s Aid, AA, Rape Crisis Centre, Victim Support etc)
Organise them some self-esteem or anger management classes
Put them in touch with the Citizen’s Advice Bureau or a social worker
Arrange for a mental health nurse to visit them at home
Refer them to the clinical psychology service for CBT or psychotherapy
Bearing in mind that most mild to moderate depression and anxiety is managed by GPs, and I tend to see only the worst cases and the psychotic and bipolar illnesses.
How much of mental illness do you think is nature, and how much nurture? Is it mostly a matter of triggering tendencies, with some people more vulnerable and others exposed to more triggers?
I’m just always curious about the extent to which bad parenting makes people crazy.
thank you for your responses. And good luck to you in your GP!
Any increased agitation among the patients during a full moon?