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Physical health of patients in rehabilitation and recovery: a case for surveying all records?
Lack of consensus over standards for physical investigations for psychiatric in-patients
This is why I read medical journals...
Organic Causes of mental disorder in detained patients
Physical Health monitoring in a Medium Secure Seting
Physical Health in Rehabilitation Psychiatry
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Andrew R Bickle, Senior House Officer in Forensic Psychiatry Rampton Hospital, Retford ,Nottinghamshire
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andy.bickle{at}gmail.com Andrew R Bickle
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The pitifully poor physical health of those with chronic mental health problems is huge concern rightly addressed in this survey. Very few of us, I suspect, will have been surprised to read that physical health parameters are recorded badly in psychiatric notes and Dr Greening is right to draw our attention to the guidance given by NICE. I do, however, feel that in failing to discuss the role of other healthcare professionals, especially GPs, the paper offers a limited view and does not put the findings in their proper context. The survey studied patients under a rehabilitation team. All psychiatric patients should be encouraged to register and utilize primary care services and this is especially so for rehabilitation patients where it is part of returning to a “normal” way of living life. When working in rehabilitation psychiatry I found it was common for patients to leave the residential unit to attend ordinary GP appointments. We felt it appropriate and non-discriminatory for our patients to have their physical health attended to by generalists who see a lot of it. Sometimes (probably not often enough) we would be informed of these consultations by letter, but even then I doubt whether very many of us would copy this information into the handwritten notes. I am concerned that by only looking at secondary care case notes this survey would not have adequately detected input from primary care. I accept that it was valid to compare the performance of psychiatrists against the pronouncements from NICE, but feel that the real question here should be “How is the physical health of our patients recorded in its entirety?”. The proper procedure for “shared care” between primary and secondary care may not yet be understood, but the new general medical services contract is explicit that primary care is responsible for the provision of physical healthcare for people with serious mental illness (Lester, 2005). I am worried that in omitting mention of primary care’s contribution in any part of the discussion this paper invites us to conclude that these findings represent the full extent to which the physical health of mental patients is recorded by those who are responsible for doing so. This is potentially misleading. Reference: Lester H (2005) Shared care for people with mental illness: a GP’s perspective. Advances in Psychiatric Treatment, (11) p133-141. |
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Alexandra L Pitman, SHO in Psychiatry Charing Cross Psychiatry Training Scheme, Michael Phelan, Consultant Psychiatrist
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alexandra.pitman{at}imperial.ac.uk Alexandra L Pitman, et al.
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Dr Greening’s survey of the attention paid to physical health parameters of patients in rehabilitation and recovery (Psychiatric Bulletin, June 2005, 29, 210-215) highlighted inadequacies in routine monitoring and a lack of clear guidelines from policy-makers over what a full assessment might constitute (NICE, 2002). Standards of competence in physical examination amongst psychiatric trainees have been widely denigrated and suggestions have been made regarding expected practice (Garden, 2005). In January 2005 we audited standards of physical healthcare on an acute psychiatric unit and found wide variations in the use of routine blood tests, urinalysis, and BMI monitoring. With increasing attention paid to the metabolic effects of schizophrenia and of atypical anti- psychotics (Jin, Meyer & Jeste, 2004) it was felt that clinicians needed to agree a minimum standard for routine testing of all in-patients. Following discussion of this audit at the unit’s academic meeting, views were assembled over which tests should be regarded as routine. An investigations summary sheet was designed, similar to those used on medical units and including BMI and prolactin. This allows changes over time to be tracked at a glance and has been added to the admission notes to prompt requests for appropriate tests. The aim is to re-audit these standards in one year in anticipation that they will have translated into a more rigorous approach to the physical health of psychiatric in- patients. Alexandra Pitman, SHO in Psychiatry Michael Phelan, Consultant Psychiatrist Hammersmith and Fulham Mental Health Unit, Charing Cross Hospital London W6 8NF References: Garden G. (2005) “Physical examination in psychiatric practice” Advances in Psychiatric Treatment, 11, 142-149 Jin, Meyer & Jeste (2004) “Atypical anti-psychotics and glucose dysregulation: a systematic review” Schizophrenia Research 1;71, 2-3, 195- 212 National Institute for Clinical Excellence (2003) “Schizophrenia; Core interventions in the Treatment and Management of Schizophrenia in Primary and Secondary Care” Clinical Guideline 1. London: NICE. |
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Gertrude Jones, Musician
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gertrude_jones20{at}hotmail.com Gertrude Jones
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The study says it all really.When I was recovering and in the uncapable hands of primary care, the only blood tests I received were at my request. The only advice I was given was to stop smoking. I was never asked how much alcohol I was drinking, my medication was never reviewed, and all I ever seemed to leave the GP's surgery with was more depression. So, now I take care of my own health with the help of online medical journals and I've never been healthier. And an understanding and capable psychiatrist has helped too. |
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David M Hambidge, Freelance Consultant Psychiatrist Self Employed
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Cotlow9{at}aol.com David M Hambidge
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I have recently had a brief article published (Progress in Neurology and Psychiatry, Vol 9, Issue 4, May 2005, pages 8-12) which looked for very similar physical examination and investigations in detained patients. The results were equally discouraging, particularly for syphilis, elevated white cell counts, elevated blood sugars and use of EEG. I am also concerned by the under-use of ECG recording before administration of known cardiotoxic anti-psychotic drugs. As the roles of medical psychiatrists become ever more intruded on, rightly or wrongly, by other professions, is it not our responsibility to make sure that our patients are medically well looked after? |
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Vinesh Narayan, Senior House Officer in Psychiatry The Edenfield Centre, Prestwich, Manchester, Anand Sharma, Consultant Psychiatrist
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vineshnarayan{at}yahoo.com Vinesh Narayan, et al.
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Your survey regarding the monitoring of physical health of patients in rehabilitation and recovery (psychiatric bulletin, June 2005, 29, 210- 215) brings to light the apparent inadequacies of recording the physical health care of our patients. There is now good evidence emerging with regards to the risks major mental illness may pose towards physical ill health (Marder et al, 2004). However, there are no widely accepted standards of practice for the physical health care of psychiatric inpatients. We are currently conducting a similar audit in a forensic setting with 97 inpatients. Many see secure psychiatric hospitals as modern day asylums with long lengths of stay and where patients have reduced access to primary care. Under the principle of reciprocity, psychiatrists have an increased duty of care towards this population. The audit looks at the utilisation of a standard protocol we had introduced for recording of physical health parameters. This may be seen as a proxy measure of the overall quality of health care delivery. The initial results analysing the monitoring of height, weight, BMI, ECG, lipid levels and blood sugars indicate that there is little room for complacency. Through this audit, we hope to elucidate the level of morbidity in this population and assess the effect of setting physical health care standards for inpatients. References: Marder et al (2004) Physical Health Monitoring of Patients with Schizophrenia. American Journal of Psychiatry 161:1334- 1349. NICE (2002), Clinical Guideline for Schizophrenia. |
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Satnam Singh Kunar, Staff Grade in Psychiatry South Warwickshire PCT
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amanda.green{at}swarkpct.nhs.uk Satnam Singh Kunar
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Re: response to Physical health of patients in rehabilitation and recovery: a survey of case note records by Dr.J.Greening. Psychiatric Bulletin (2005) 29: 210- 212. Dear Sir, In response to the article by Greening (2005), I have recently undertaken an audit of the physical healthcare of patients in our Rehabilitation & Recovery Unit in Warwick. Unfortunately, my preliminary results show a similar picture to that reported by Dr. Greening. However, we do have a local GP who has two sessions allocated per week reviewing any physical health problems; the type of “shared care approach” suggested by Lester (2005) and Bickle (2005). It must be stressed though that it is not the responsibility of our GP colleagues to trawl through reams of notes (which most Rehabilitation patients have) but rather up to the psychiatric team to ensure that patients are having appropriate investigations that can then be discussed with primary care. For my audit, I initially drew up a “checklist” (standards) of the investigations that patients should have depending on what type of medication they are prescribed and how often, if at all, this ought to be repeated. I used the Maudsley Handbook, BNF and consulted pharmaceutical companies in drawing up the standards for each psychotropic – one must not forget mood stabilisers and antidepressants that also require monitoring. Although rather time consuming, it is a more rigorous method than collating the views of colleagues as was done by Pitman's team (2005) prior to their audit and is better than a battery of “routine tests” which may be incomplete. In addition to this, we have put together a Health Screen Protocol for each patient that not only looks at issues such as diet, smoking, BMI and exercise but also, among other things, posture/mobility, eyes, ears, teeth/oral hygiene, hair/scalp, immunisation history (although this can be difficult!), menstrual cycle, UTIs and constipation. Each female will also be given appointments for mammograms and cervical smear tests as and when necessary as well as leaflets on breast examination. All male patients will be given leaflets on testicular examination, provided by the primary care service. We will review the protocols annually but some areas will need to be addressed more often. If patients refuse any of these investigations then it will be recorded in the notes both to guard against possible medico-legal action and so that it can be flagged up at the next CPA review. I hope that by implementing these protocols using the shared care approach we are promoting a better quality of life that our patients deserve. References Greening, J. Physical health of patients in rehabilitation and recovery: a survey of case note records. Psychiatric Bulletin (2005) 29:210-212. Lester, H. Shared care for people with mental illness: a GP’s perspective. Advances in Psychiatric Treatment (2005) 11:133-139. Bickle, A.R. Physical health of patients in rehabilitation and recovery: a case for surveying all records? Psychiatric Bulletin e-letter. 16.06.2005. Pitman, A.L. Lack of consensus over standards for physical investigations for psychiatric in-patients. Psychiatric Bulletin e-letter. 23.06.2005. The Maudsley Prescribing Guidelines 2003. 7th edition. Publisher: M.Dunitz. British National Formulary. March 2005. |
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