Psychosomatic Medicine in the U.K. A Personal View. Structure of presentation. Ms F. Ms F. The National Health Service-(NHS) Mr A.

Transcription

1 Psychosomatic Medicine in the U.K. A Personal View Julian Stern St. Mark s Hospital, London (Presentation to Lausanne, May 2008) Structure of presentation 2 cases The structure of the UK National Health Servicefragmentation between Body and Mind and answers about Psychosomatic Medicine in the UK The St Mark s Psychological Medicine Unit The future threats and opportunities 26 y.o. ex-it consultant, living in Kent with her husband and 2 dogs Ms F Ms F The surgery-how do we understand what she arranged, in terms of : Herself and her own psychological needs? The surgeon and his motivations? (The recruitment of a health professional into one s own DSH) How has it affected her? Mr A 45 year old man, with 5 year history of Irritable bowel Syndrome Seen by Gastroenterologists-major psychological morbidity Referred to Psychological Medicine Unit The National Health Service-(NHS) Founded in 1948-universal provision of free Health Care to the entire population Many threats, changes over the years

2 The National Health Service-(NHS) Central role of General Practitioner (G.P.), as controller of referrals, and family doctor Separation over past 10 years of Specialist services into 2 discrete authorities i.e. Acute Medical Trusts and Mental Health Trusts Gastro Gynae Neuro Acute Medical Trust General Practitioner Generic Mental Health Worker Mental Health Trust The N.H.S.-Fragmentation Patient with Irritable Bowel Syndrome, Depression and Anxiety, seen by GPreferred to whom? 1) Gastroenterologist 2) Primary care counsellor 3) Mental Health Services Quite likely, no communication between them The N.H.S.-Fragmentation Often a total division between the treatment of the body and the treatment of the mind-a split in services paralleling the split between psyche and soma Extremely unhelpful to the patient (but may correlate with the patient s overt wishes) Local Psychiatry Services So who do Adult Psychiatrists see? Mainly SMI (Severe Metal Illness)- schizophrenia, bipolar disorder, and services for addictions, personality disorders, eating disorders etc But less and less do they treat complex patients with psychosomatic/ neurotic conditions Local Psychiatry Services Patient will be seen by by a generic worker (triage)-could be a psychiatric nurse, occupational therapist, psychologist, psychiatrist. If the patient does not reach the threshold for Severe Mental Illness -may not be seen by a psychiatrist, may be offered brief Cognitive Behavioural Therapy; self-help literature; computerised package; sometimes psychological therapy

3 Medical Services- who do the Physicians see? GP can refer any patient to the Outpatients Department. 50% of all gastroenterology outpatients = functional Management: Usually will try medication- rarely have psychological services working with the team-discharge patient back to GP (Government target of new : follow-up ratio 1 : 1.8). So who treats the Psychosomatic patient? Generally the GP Sometimes specialist nurses attached to various clinics Sometimes psychologists attached to various clinics e.g. pain teams, some gynaecology units, our unit at St Mark s hospital Some Exceptions to the fragmentation First 200 patients seen at St Mark s Psychological Medicine Unit St Mark s Hospital Psychological Medicine Unit Royal Free Hospital Pain team 50%-Functional bowel disorders-irritable Bowel Syndrome, chronic constipation. Female preponderance Often Obsessive-Compulsive Symptoms Often anxious, depressed Sometimes abuse in childhood First 200 patients seen 30% - Crohn s Disease / Ulcerative Colitis (Inflammatory Bowel Disease); M=F Young adults with relationship difficulties. Psychosexual problems, body image disturbance Narcotic use Depression Compliance issues First 200 patients seen 6%: women with eating disorders Bulimia and/or anorexia Undiagnosed Denial ++ Secrecy ++ Poor prognosis

4 Recent increase in referrals from Intestinal Failure Unit Mr A DSH to central line following wife s affair Mrs B fistulation following weight reduction surgery Mr C non-compliance and refusal of surgery in a young previously with SMA infarction First 200 patients seen Psychotic depression with somatic delusions Body Dysmorphic disorder-pertaining to the anus Acute sudden depression following surgery (PTSD-like state, mutism) Munchausen syndrome Reactions to illness-stoma s, pouches, fistulae, solitary rectal ulcers. 1. Does the term Psychosomatic Medicine exist in the UK? 2. Who takes care of PS issues? 3. Who does the patient see if suffering from PS complaint? Answers 1. Does the term Psychosomatic Medicine exist in the UK? 2. Who takes care of PS issues? 3. Who does the patient see if suffering from PS complaint? Psychosomatic patients are predominantly held by the General Practitioner, also any specialist who receives a referral on the patientdermatology, gynaecology, gastroenterology etc; Alternative medicine (homeopathy); Some psych-iatrists/-ologists/-otherapists Answers But the organizational separation of Mental Health from Acute Medicine promotes fragmentation and multiple referrals rather than co-ordinated care 4. Are there outpatient polyclinics? 5. Are there inpatient clinics? Again, not usually designated as Psychosomatic. However on the NHS, there are some inpatient units for Personality Disordered patients, certainly for Eating Disorders. The Cassel hospital in South London was initially founded to treat shell shock after World War 1-interest in PS matters

5 4. Are there outpatient polyclinics? 5. Are there inpatient clinics? Some Medical Units-in and outpatient-will have a psychologist or counsellor attached to them e.g. pain teams; chronic fatigue teams; oncology and palliative care. The approach is usually problem oriented, often adopting brief models of therapy especially CBT 6. Is PS medicine refunded by Medical Insurance? 7. Is it a luxury? For private patients, in order for medical insurance to pay, generally you have to designate an ICD or DSM diagnosis-depression, anxiety etc. Sometimes the insurance excludes mental conditions. I would not propose the diagnosis psychosomatic to an insurer! 6. Is PS medicine refunded by Medical Insurance? 7. Is it a luxury? Many insurance companies do not understand any link between, for example, Irritable Bowel Syndrome and the need for psychological input. My opinion: not a luxury at all! 8. Define PS therapy (!) An approach which respects the interconnectedness between the production and maintenance of bodily symptoms, and mental processes; this approach recognises the importance of the patient s conscious and unconscious thoughts, emotions and fantasies, both with regard to influencing bodily function, and also with regard to the relationship between patient, and medical professionals How is Psychosomatics taught in UK? Medical schools-varied in their approaches Excellent scheme at University College Hospital London (Heinz Wolff, Peter Shoenberg) Selected Medical Students take on patients with medical symptoms for up to a year of weekly supervised psychotherapy Others take part in 12 week Balint groups with skilled facilitators. How is Psychosomatics taught in UK? Experience at University College Hospital, London Follow-up study those having taken on the patient have significantly higher rate of becoming psychiatrists than controls; and regard the experience as very helpful in learning to relate to patients Yakeley, Shoenberg, Heady (2004) Psychiatric Bulletin Emulated by some other universities, less so in most

6 How is Psychosomatics taught to postgraduates? Psychiatry training-may have Balint groups; little Psychosomatics in the syllabus; may do some Consultation/Liaison psychiatry Physicians training-little/none; no obligation to do any time in psychiatry GP-varied-have a Balint group; little in the formal syllabus though How is Psychosomatics organised? Within Psychiatry there is the Faculty of Consultation /Liaison Psychiatry- Liaison psychiatry is the sub-specialty which provides psychiatric treatment to patients attending general hospitals, whether they attend out-patient clinics or accident & emergency departments or are admitted to in-patient wards. (Royal College of Psychiatrists website 2008) Some members C/L Psychiatry members have been active in the recent establishment of the European Association for Consultation-Liaison Psychiatry and Psychosomatics. (Royal College of Psychiatrists website 2008) How is Psychosomatics organised? Balint society Journal of Psychosomatic Research No Faculty of Psychosomatics; no Professor of Psychosomatics Is there any national organization that is high profile, totally associated with a Psychosomatic approach to research, teaching, training and treating? The future of PS approach-threats and opportunities Hegemony of Evidence Based Medicine Predominance of CBT model in Psychology; reluctance of Psychoanalysis to join in research Predominance of pharmacological model in psychiatry Mindlessness of algorithms, brief treatments The future of PS approach-threats and opportunities Disillusionment of the public with mindless medicine-be it the reliance on drugs; brief treatments; fragmentation Some research-guthrie on IBS; Crimlisk on longevity of hysteria The future of PS approach Within the UK, we require professionals to champion PS Medicine, separate from C/L psychiatry or health Psychology Internationally- co-operation Must ensure representation at various levels of decision making e.g. DSM/ICD; NICE; medical education; text-books

7 The future of PS approach How can we work together to ensure that Psychosomatics remains healthy and grows, both as a method of treatment and as a body of knowledge? Thank you! References Creed F (2003) Cost-effectiveness of PT and paroxetine in IBS. Gastroenterology 124: Shoenberg P (2007) Psychosomatics;the uses of psychotherapy Palgrave Stern JM (2003) Review Article: psychiatry, psychotherapy and gastroenterology-bringing it all together. Alimentary Pharm Therapeutics. 17;