World Mental Health Day 2014

Tomorrow is World Mental Health Day - a unified day of action to support people with mental health problems.

This year the focus is on schizophrenia, an illness which thousands of people live and work with on a daily basis.

At South London and Maudsley NHS Foundation Trust (SLaM) we have a National Psychosis Unit which specialises in treating a wide range of psychotic illnesses, including schizophrenia.

Dr Fiona Gaughran, lead consultant at the National Psychosis Unit, said schizophrenia is still widely 'misinterpreted'.

In a blog, written exclusively for World Mental Health Day, Fiona describes a typical day on the unit and her experiences with schizophrenia and psychiatry.

Lead consultant in National Psychosis Unit, Dr Fiona Gaughran, on schizophrenia

I have been asked to write a little bit about my role as lead psychiatrist in the National Psychosis Unit, where I work helping to treat people with psychosis who have not got better with the usual treatments.

First of all, it might be good to explain what psychosis is and, more importantly perhaps, explain what it isn't. According to NHS Choices, ‘Psychosis is a mental health problem that causes people to perceive or interpret things differently from those around them. This might involve hallucinations or delusions’. The most common psychotic illnesses are schizophrenia and some forms of bipolar disorder.

The word schizophrenia certainly is still misinterpreted in many settings, including in the popular press. Schizophrenia does not mean that you have a split mind or a split personality. It definitely does not mean that one is necessarily violent and or that one can't make one's mind up about things.

The diagnosis, schizophrenia is how we describe a particular a collection of symptoms and observations when they come together. We don't have a blood test or a brain imaging scan that will tell us whether somebody has schizophrenia or not, so it's a very clinical diagnosis. The core experiences that we call psychotic are either various different forms of delusions - fixed false beliefs out of keeping with your cultural background despite evidence to the contrary - or hallucinations. Hallucinations are perceptions one experiences without a real stimulus. They can occur in any of our senses, hearing, seeing, smelling, tasting or feeling and they are seen in many different types of psychotic disorder.

But on top of these psychotic symptoms, there are other symptoms that are associated with schizophrenia. These include negative symptoms where your motivation is impaired, you have reduced content of your thinking and your personal self-care may be impaired. People may also have some cognitive symptoms where the ability to think or plan might be affected.

In addition, people with schizophrenia can also have various different mood aspects to their presentation. As with many physical health conditions, it is possible to have more than one problem at the same time. About 40 per cent of people with schizophrenia can have depression and about 25 per cent can have various different forms of anxiety disorders. It is really important to pick up when this is the case, as identifying and treating depression or anxiety disorders may help.

What do I do as part of my job?

Well, I have a very varied job because I don't just have a clinical role; I also have a role in service development, in particular in planning physical health strategy for all patients with psychosis attached to SLaM, which is also where my research interests lie.

The week starts with clinic day. We see people from all over the country for a second opinion. People are referred when they haven't responded as hoped to conventional treatments for their psychosis. The idea is that we will work with their clinicians and make suggestions to improve things overall.

People come to the clinic to see us or, if they are not well enough to travel to us, sometimes a member of our team will go out and see them. The team all meet at lunchtime to discuss the patients that we have seen over the last week and been asked to consult on. This is important because when it comes to a national level service it is not that people haven't received good treatment locally - it's that their teams have identified that their treatment needs a bit more thinking time and possibly a different approach. We have found that by getting together as a group of experts we are able to make sure that we don't miss potentially useful approaches.

It also ensures that our approaches don't become stale as we are able to suggest ideas to one another. This makes sure that it is as helpful a process as it can be for everybody referred. Later on, I meet with some of the junior doctors for supervision of their training; contributing to the training of the next generation of doctors is a really important role of consultants in any medical specialty.

The next day, we’re off to the Bethlem for the main ward round and even though we have moved it to start earlier in the morning, it still seems to run on well past lunchtime!

I have eight patients on the ward at any one time so it is a long morning with lots of coffee and biscuits to keep us going. We meet patients and sometimes their families and see how things have gone over the last week. We are working with people for the best outcomes, fine-tuning their care to find a management plan that they are happy to stick with over time. The end of the afternoon can be taken up by business meetings, meeting with the ward manager and the psychologist and sometimes meeting with the larger Trust and management team in order to make sure that our ward quality systems remain high.

Wednesday is primarily a research day. My own research focuses on improving physical health in people with psychosis. When somebody gets a diagnosis of psychosis, it doesn't just affect their mental health. The statistics show that physical health is hampered as well. Some of this is because people make unhealthy lifestyle choices - people are more likely to smoke even before their diagnosis with psychosis and then even more so when the illness persists. Also, once someone becomes unwell, maybe losing motivation, they don't feel like sitting down and making a healthy meal for themselves or getting to the gym three times a week without a lot of encouragement. It is difficult enough when you are feeling absolutely healthy, but it is even more difficult when you are not feeling your best. So lifestyle choices need work, but also there are other factors. The medication may lead one to eat more and put on weight so very commonly we find that our patients are overweight and haven't made the lifestyle choices needed to get the weight down. There are ways of helping people manage to lose weight – or avoid putting it on - so it’s really important to work with people on this – otherwise sometimes people can think that the answer is to stop medications – but that leads to problems with both mental health and physical health.

The other really important factor is that if you are actively unwell in terms of your mental health, it can be difficult to access physical healthcare well. If your thinking is less clear at that time, it may be difficult to explain what the problem is in the first place or difficult to follow a treatment plan for your physical health, so access to care can be complicated. We are just finishing a large research programme, funded by the Department of Health, looking at how common cardiovascular risk is in our patients with psychosis and doing a big trial of a psychological intervention (IMPaCT) to try and improve lifestyle choices in people with psychosis. We are hoping to have the outcomes of that over the coming months, which is quite exciting. 

I am also involved in other work with colleagues on the ward, such as with our consultant psychologist, Juliana, and our head pharmacist, Siobhan, working with carers to evaluate their understanding of medication. We are also running a trial to see whether vitamin supplementation in people with early psychosis helps improve outcomes.

On Thursday I am back on the ward again. We have a management round, following up on decisions and may have scheduled appointments. We also have what we call a ‘referrals meeting’ where we discuss patients that have been referred to the service and ensure that everything is going smoothly regarding their access to the service. I also do a lot of my clinical paperwork, which is substantial, on a Thursday and have various other meetings.

Not everybody we work with will agree with the medical perspective on their mental health. Often people believe that they do not have any mental health problems and then it is really important to be able to reach a consensus with a shared goal of making things easier in life, especially if one's been stuck in hospital for a while. It’s important to agree how one goes about that in a way that one does not feel compromised, and one feels in control. The ideal with treatment is always is to hand back control to the person themselves, because otherwise, in the long term, it is much more challenging.

On a Friday, we are back to research and physical health service development once more, as well as linking with the Department of Health funded BRC Bioresource Team. They are particularly interested in recruiting patients for research into mental illness, in particular psychosis, to see how we can move towards having better and more individualised treatments in the future. They are operating across the Trust and would be delighted if anybody wants to contact them to work with their research either as a service user or a healthy “control”.

So, it becomes a very busy week with lots of meetings, although the clinical work always comes first. Very often, my work runs into the evening time and indeed sometimes into weekends, trying to keep up with everything. I have just given you the bare bones, but often there are conferences to speak at, a lot of teaching outside of the Trust and writing papers and grant applications to try and get new innovations in place. 

I have to say I would recommend psychiatry as a career for any doctor. I think you are first and foremost a doctor but you are looking after the whole person, their physical health as well as their mental health - taking into account their social situation and their own personal individual preferences, as well as their own personal biology. We are very lucky that we have the time to be able to do that in our service and I am privileged to be able to call myself a psychiatrist.