Mental health merry-go-round
Posted Thursday 10 June 2010
Guest post from Zarathustra of Mental Nurse
A friend of mine recently phoned me up in a panic, “My GP's sending me to a psychiatrist! I'm so scared. I think they're going to section me.”
After she calmed down, it turned out to be a routine referral to the Community Mental Health Team (CMHT), as the GP felt that the antidepressants he'd prescribed her weren't helping. I reassured her that this didn't mean she was about to be sectioned, that these referrals happen all the time, and it wasn't anything to be scared of.
I ended by giving her a note of caution, “You don't need to worry about being whisked away. You'll probably wind up more pissed off about how little they'll do than how much they'll do.”
A few weeks later, I spoke to her again. Her previous fear had turned to annoyance and anger. “I had an assessment with a CPN and a social worker.They suggested I might get CBT and an appointment with the psychiatrist to look at my medication options. Then a few days later I got a letter saying they weren't going to offer me a service, and I should just go back to the GP.” She felt dismissed, humiliated and let down.
I've seen this pattern quite a few times. Somebody is referred to a CMHT with little explanation of what it's for and why. When they arrive at the CMHT, they still aren't given any explanation, and at times are given false expectations. The result is that people are left oscillating between fear about what might happen to them, and disappointment from hoping for a service that doesn't materialise.
At worst, this can resemble a squalid exercise in buck-passing. The GP has tried a couple of antidepressants. They didn't work, so he's washing his hands of the patient and packing them off to the CMHT. The CMHT fill out their assessment, then write back to the GP and tell him they're not taking the patient, and he should try another medication. Like a bureaucratic exercise in mental health pass-the-parcel.
In all fairness, there are often good reasons why so many CMHT assessments end with a referral back to the GP. Mental health services are notoriously under-resourced, and when somebody gets offered a service by the CMHT they often remain with them for a long time. For that reason the CMHTs insist they need to have a high benchmark for offering someone a service, so that they can concentrate on complex conditions such as bipolar disorder and schizophrenia. They also point out that they often have little to offer people with depression and anxiety that can't be offered by a GP. For that reason, they take the view that people with mild-to-moderate mental health problems should remain at the GP level, leaving the CMHT to focus on people with severe and enduring mental illnesses.
In addition, they also argue that some referrals are genuinely inappropriate. Sometimes a GP hasn't done as much as he or she could have done before referring the patient on. At other times the person being referred can be signposted on to other, more suitable services for their needs – for example a bereaved relative who might be better off seeing Cruse rather than a mental health service.
These arguments are valid and I don't dispute them. But what I would suggest is that there needs to be clear communication so that people have realistic expectations of what is and is not likely to happen to them. If a GP is referring somebody to the CMHT, then that GP needs to explain what a CMHT is, why they are referring them, and what will happen as a result. GPs need to remember that, although the stigma of mental illness is much reduced these days, being asked to see a psychiatric service is still a deeply frightening prospect for many people. Above all, GPs need to avoid giving people the impression that they're getting rid of them, and need to advise patients that the follow-up from the assessment could be either from the CMHT or back with the GP.
Just as GPs need to communicate clearly, so too do CMHTs. It's all too easy to promise somebody this or that when they're sitting in front of you in in an assessment, then discuss it in the team meeting the next day, decide you're not going to do anything, and then write the patient a letter that can be summarised as “bugger off”. People shouldn't leave the assessment having been given a set of false promises, and then be left devastated when the letter arrives. Just as GPs need to tell people that a CMHT assessment can often wind up as no more than an assessment, so too do the CMHTs need to give the same message, and give it clearly.
Ultimately, the brutal truth is that NHS resources are limited, and not everyone can be offered a service. But if that's the case then clinicians need to be open and honest about that, to avoid further distress to an already-troubled person.
Zarathustra blogs at Mental Nurse.
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