Psychiatry is a constantly evolving medical specialty, whose responsibility it is to treatment, study and prevent mental disorders. This is a term similar to that on German physician Johann Christian Reil in 1808, who is often considered the founder of German psychiatry[1].
Psychiatry is different from many other medical professions but much more so in the sense of its reliance on good communication skills, as where a surgeon may never really need to have an in-depth talk with the patients. This skill which psychiatrists develop allows them to talk to their patients about highly sensitive issues in a way that makes the patient open up and freely give out information that may be helpful.
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History
The history of psychiatry dates back to 5th century BC where the Greeks and Romans saw the traits of mental illness to be supernatural [2]. some work went into understanding mental illness which resulted in Hippocrates to theories that the visible traits of mental illness where due to physiological abnormalities, a view that was quickly forgotten when religious leads got to power and started exercising early forms of exorcism to try and cleanse the soul (a practice that still goes on in parts of the world) [2-3].
The real breakthrough into mental illness came from the medieval Islamic world in the 8th century AD, where the first psychiatric hospital was built in Baghdad in 705 AD [4-5]. The study of psychiatry was known as Ilm-al Nafsiat (roughly translated to “study of the self”) and was revolutionary in its time, as most Christian clerics relied on spiritual help, which saw the patient as a demonic soul of some sort and treatment normally caused the patient a great deal of pain. The study into Ilm-al Nafsiat resulted in a eventual descriptions of different mental illness such as psychosis (Kutrib), and mania (Dual-Kulb) by the Arab physician Najab ud-din Muhammad [6]. The types of treatments that was offered by the Islamic physician ranged from baths to drug medication and showed a much more moral and humane stance on treatment of mental illness.
Medieval Europe started to build hospitals in the 13th century such as Bethlem Royal Hospital in London which has remained active until 1947 until the site was eventually moved [7]. These hospitals where however rarely places for treatment and were utilized much more as prisons for mentally ill. Around the 17th century forensic psychiatry had started up and “insane” offenders were being sent to Bethlem [8]. However as time wore on places like Bethlem started to become more focused on treatment of patients and around the mid to late 18th century mental illness was seen as a disease that could be cured or managed.
In the 20th century psychiatry due to the work of Sigmund Freud and the development of drugs such as chlorpromazine’s (used in the treatment of schizophrenia ) [9] and lithium carbonate (commonly used to stabiles mood)[10] psychiatry became much more focused on treating patients in a humane way rather than just locking them up as happened in the past. Over the past 30-40 years in Britain there has been a movement away from hospital and asylum based treatment to a more home based treatment. Forensic psychiatry is one of the few places in the UK where mental illness patients a detained for periods up to and over 2 years. To enter a forensic unit the patient must be convicted of a criminal offence and been section (37) under the mental health act. Other than that mental illness patients no longer spend much time in hospitals.
Hospital and Home Treatment (Recent History)
In modern day psychiatry patients no longer spend more then 2-3 weeks in hospital and the enfaces has moved much more into home treatment, this is due society starting to accept and somewhat understand mental health and especially the appalling news stories that came out of hospitals. This all goes very well with the government movement to produce more patient centred care.
The problems that faced the old system of putting mental illness patients into hospitals was that overcrowding became rife, which is not surprising given that about 1% of any population suffers from mental illness. As a result of that some patients were paid less attention and commonly suffered from malnutrition, these patients were known as back ward patients and they suffered a great disadvantage as there mood seemed stable and as a result less attention was paid to them. Another major problem of these large institutes was that the patients often got bored due to lack of activity. Mix in that they are often cut off from any social network they had e.g. family (due to the distance of these institutes) will lead patients to other forms of entertainment that is sometimes disruptive. These could cause one patients negatively influencing another. This all and societies changing attitude has led to their closures and reintroduced of these patients into society.
Since the pressure of living in society has become so difficult for most of these patients special accommodations have been set up which consists of levels ranging from high to low which allow the reintroduction for suffers of mental health back into society. In the high level of support there will be a member of staff sleeping in the accommodation, while in low there is no contact with health professional unless they chose so.
The new preferred method of home treatment comes with a lot of merits when compared with the old system, as it is much more sensitive to the needs and requirements of patients. The new system offers a multidisciplinary team approach in which not only is the doctor and nurse there to help a patient but a whole team of health professionals ranging from social workers to fitness instructors. At home the mental health suffers will be in an environment where they are relaxed and feel safe. They will be encouraged to take part in a job if possible through agencies like mosaic or fountain house, allowing suffers to build social networks and generally a sense of purpose. On the other hand with community psychiatry patients are not constantly being monitored and thus may not take medication.
However mental hospitals have not completely gone and are still used for extreme exacerbation of symptoms or when a patient gets sections under the mental health act. Hospital wards for mental health patients are still around as they have benefits in cases where a patient may pose a risk either to themselves or a member of the general public and gives them a period to cool off. In this period they can be properly supervised to make sure they are taking the correct dose of their medication. Another helpful benefit is that some of the cases by just simply removing the patient from a stressful environment such as home or streets and to an environment they feel safe in will cause a decrease in exaggerated symptoms.
Reflective account
Placements – River House
This institute is medium security rehabilitation clinic housing suffers of mental illness that have been convicted of a violent natured crime. The medium security status means that fences have to go up around the perimeter, wards are locked using a vacuum lock system and keys worn on the belt. In total there are six wards in this hospital, five of which cater for males only and one for the females
Me and my partner visited river house on three occasions and the first of which we were show around by Dr Schwarz. On this first visit we were unsure of what was expected of us and we became slightly nervous as we started to fill in forms to allow us to gain entry into the building. After there was a bit of confusion as Dr Pierzchniack wasn’t in, so instead Dr Schwarz showed us around the admin block and we sat down for a chat. He explained to us in which circumstances patients are admitted to river house and why this institute exists such as violent offered who have section 47. We also went into discussion about the home office and its role on releasing offenders. After talk moved onto the demographic of the patients here, and why such a disproportional amount of them seem to be 2nd generation black males from the Caribbean or Africa. He explained that the demographic is partly due to the catchment area and also the environment plus social class of these patients, as poorer people normally have less access to good medical care. He also explained the vast majority of the patients in river house are known drug users which could probably increased their risk of mental illness but the drug use alone doesn’t result in mental illness and the genetic dispositions are also a key factor.
On our next two visits Dr Pierzchniack was there to show us around. In these visits we got to see Norbury (very acute) and Thames (acute) wards and also facilities available, which I was very impressed with as it gave an impression of an open and relaxed environment. We also received a small lecture about psychiatry where he explained that terms such as schizophrenia are just syndromes and not diseases. On one of ward visits a patient showed us his room, he was very polite and kept an immaculately clean room, this came as quite a shock to me as his demeanour seemed very stable and not what I had expected especially after I later found out he was convicted of manslaughter. Another important aspect we picked up during out tours is the multidisciplinary teams that are located in the hospital from the nurses to the consultants to the gym instructors etc.
We also got to sit in on a review of patients on Thames ward, this proved very useful in showing us the importance of good communication between different members team and how good communication allows for faster and better work. In this meeting it turned out that some patients had gotten of possession of drugs through a fishing system (where the patient will let down a bag into a lower ward to collect the drugs) and used them. Now this can be very problematic as it affects their rehabilitation process.
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Room for improvement
All in all I think river house is run very well and suits its purpose. The only main problem I see with the facility is the problem with drug flow. I feel if slightly better precautions where put in places such as full body searches of anyone suspecting to carry drugs could make a vast difference, however I understand that this causes a rights issue and is a system that can be misused as a form of punishment and therefore cause more harm than good. Another aspect I feel would help the rehabilitation and stop reoffending is a change of location, rather then exposing the patients to the same environmental factors that contributed to their convictions. This should only be done voluntarily though as some patients may prefer to live in areas they are more familiar with.
Kennington Lane – Community Mental Healthcare Team
This is an assessment and treatment centre consisting of consisting of doctors, nurses, psychiatrists and social workers. There are different teams in this facility such as anxiety assessment (rapid response) team who are responsible for short term care of patients or the recovery support team which is involved in the long term recovery of suffers with Schizophrenics or Bipolar disorder. There are also two home treatment teams, one of which is Assertive Out-reach which deals with patients of a more difficult nature and the other is Leo which is this team focuses on early treatment of people who have just started suffering from mental illness.
On my first visit to Kennington lane I shadowed Dr Rajagopal. When I first came in he showed me around the place and introduced me to all the member of the multi disciplinary team, which surprisingly large. We then went into a consultation room and discussed the different fields and teams involved in psychiatry. We also talked about the computer based communication system that was installed and how it was useful only when used properly, as if it is not filled in regularly this will lead in gaps in information that later might be useful. I was then allowed to sit in a rather interesting consultation of a patient he previously knew and suffered from schizophrenia. This patient was required to take regularly blood test’s to see medication levels in her blood something I thought was a very intrusive, but later I found out that she was on a lithium based medication that could be dangerous if levels fluctuate. During the course of this consultation it became apparent that she has started to hear voices again and the previous increase in medication had little effect. However Dr Rajagopal told me this patient has vastly improved in a short period of time and this is only a very small relapse. He also explained that she is an irregular patients in that she admits to a mental illness and that is the reason for her improvement. Other patients don’t have this same view and once they’ve recovered they stop taking medication which causes relapse (revolving door patients). During this session I also had the opportunity to witness a weekly staff meeting. In this meeting they were reviewing some patients that were referred and through the discussion it became very clear in all the cases that not enough relevant and up-to-date information was available on these patients so they had to reject them and ask for better information. During this staff meeting it also showed that the staff stretched in terms of patients they had under their supervision as when only one member of staff (nurse) needed to leave for a holiday break it stretched everyone else to the maximum load they could carry.
On another visit to Kennington lane I shadowed Dr Ramsey, resulting in a home visit of a patient. As soon as we arrived at the gentle man’s house we were able to see in what kind of conditions he lived and how well able to look after himself he was, something you might not be able to pick up if the patient came to you. This patient had suffered a stroke and his movement was impaired which resulted in a home visit. The reason for his referral from his GP is that he was thought to be suicidal but it became apart that he wasn’t, however during the consultation another problem surfaced in that he wanted to go back to work. It was clear that he won’t be able to, due to his lack of movement. This resulted in Dr Ramsey asking about what he does and whether he felt he could be able to work. This technique paid dividends as the patient came somewhat to accepting his impairment.
Room for improvement
I feel Kennington lane is a well run CMHT but it could certainly do with more members of staff, an issue which is hard to deal with due to the lack of interest in this field of medicine. However the major drawback in this and most CMHT is a problem with communication. Now it has become clear to me after talking to various members of staff and my SSM tutor that the current computer based system is slow and very time consuming and that most communication problem between different departments stem from here. So an improvement that can be implemented across the UK is a providing a better computer system. The reason this hasn’t already been done is the issue of funding as a project this large will just be too expensive in current circumstance however as technology gets cheaper this option may be available in the near future.
Lambeth hospital
This is an outpatients clinic were patients that have already been discharged from hospital come for a review session or becomes they want to see the doctor. This recovery and support unit is for long term suffers that need contact with psychiatrist to make sure they are doing well. Some patients may need more sessions then others and contact with the psychiatrist is variable between patients.
In these session me and my partner were able to shadow Dr Bindman. In these session it was very hands on and we got to see a vast number of patients and what was extremely helpful was that Dr Bindman would go through things after the consultation with us. In one such consultation a patient came in with an offensive odour. He taught us how to go about dealing with this situation without causing offense which could be very counterproductive, he taught us to seek information such as why do they smell is it a physical problem that requires treatment or a mental issue, then we should find out whether this patient is able to clean himself or does he require a carer and finally see if they realise they have a problem. Problems like this he also explains a negative symptoms of schizophrenia (apathy, lack of emotion, poor or nonexistent social functioning) and that there are positive symptoms (hallucinations, delusions, racing thoughts). We also interesting sat in a consultation where the patient required a letter stating that he had a mental illness so he can received a disability allowance but in such a way that he did not admit he had a condition. This just goes to show the sort of role a psychiatrist may need to play to help there patient.
Another patient that stood out also suffered from schizophrenia but the reason as to why it was so interesting talking to him was that we were able to do it on our own. We found it very difficult to make him tell us what is wrong with him as he didn’t feel there was any problem and seemed to want to cover up any problems he had. However after several attempts he explain that he was sectioned as he had an argument with his landlord due to him feeling people where coming into his house and moving stuff. We were able to find out the this was a delusion as he held a sound belief in something that wasn’t true, as what he said was incoherent and evidence such as moving four times for the same reason seemed to go against it, also this was not something of a social norm. This patient was also interesting for another reason and he seemed no different to normal people and in fact gave us sound advice on our medical careers. Later after the consultation it seemed what he had told us was very much different to what he tells Dr Bindman as the issue of people coming in and moving stuff never came up in previous consultations, the reasons for this are unknown and the patient may have just lied to us to let us hear what we wanted to?
Room for improvement
I feel thing are run extremely well here and the only criticism I can have on Dr Bindman is that I feel he may be able to develop a much better understanding of patients if he does more home visits. This is an issue he is aware of but with the limited amount of time and funding available and amount of patients he had this was a near impossibility and only in cases where the patient was in urgent need of help would a home visit be warranted
Personal Reflection
The experiences I have received while on placements helped me develop a much more realistic view of mental illness, rather than what’s portrayed in the media. This is a problem I suffers from and I believe society in general needs to learn more about mental health to overcome the stigma of mental illness. I have also taken away the fact that mental illness suffers are much more a risk to themselves rather than others and even when they do hurt others they should still be treated as patients rather than criminal as in there frame of mind they may have done nothing wrong. Also in situation when I was able to talk to these patients it was not always obvious that they suffered from anything and only later when talking to them did it become apparent that they had a form of mental illness. This has all caused me to have a much more open mind to things I don’t understand in general as preconceptions are not always right.
Conclusion
To conclude I feel there have been major innovations in the field of psychiatry over the past decades and I feel there is a lot more to come as after all this is one of the least understood sciences. I also think that it is vitally important to get in place a better communication system in place rather than the one already in place as all major review into community psychiatry or social services show that problems arise from miscommunication. I have also come to the realisation the importance of community psychiatry in helping patients from just there day to day life problems such as noisy neighbours to prescribing medication and giving out advice. This mixture of cognitive behavioural therapy, pharmacological treatment and social/legal support allows suffers to live in the community in peace.
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