Working in Psychiatry

Introduction

Psychiatry is a varied and interesting specialty, though not without challenges. It is a very useful placement to experience in the foundation years, as much of the learning and experience can be applied in other areas of medicine.

During your placement in psychiatry, I recommend you remain open-minded, curious and reflective to get the most out of this time.

This guide is an introduction to working in psychiatry for newly qualified doctors (F1s) and doctors new to working in psychiatry. 

Basic principles

What is your role?

Your role will depend on your placement, so speak with your supervisor about this at the start of the placement. You should not be expected to work outside of the scope of your level of training, work without appropriate supervision or hold inappropriate levels of risk and responsibility.

Your placement should offer an adequate learning experience and accommodate your other teaching and training requirements. If you are concerned about the nature of your job, it is vital to raise this with your supervisor as soon as possible.

There are many areas of psychiatry, and it is worth speaking to your supervisor about extra experiences available outside of your core job. As in all areas of medicine, documentation of your work is vital, and you should be shown how to complete this in your placement.

What sort of mental disorders will patients have?

There are a lot of different mental health disorders, and the nature of those you see will depend on your specific placement but may include:

• Mood: depression, mania, bipolar affective disorder, catatonia
• Neurosis: anxiety, phobias, PTSD, OCD, dissociative, stress adjustment
• Developmental: ASD, ADHD, tics/tourettes
• Psychotic: schizophrenia, schizoaffective disorder, first episode psychosis, drug-induced psychosis, delusional disorders
• Personality: emotionally unstable, antisocial
• Functional/somatic
• Organic: encephalitis, delirium, substance misuse
• Eating disorders
• Sleep disorders
• Perinatal disorders
• Gender identity disorders
• Learning difficulties/disabilities
• Conduct
• Old age: dementias, mental health symptoms related to other degenerative disorders

Keeping yourself safe

Most people suffering from mental disorders are not violent towards others, and by following common sense and simple advice, it would be very unusual for you to be at risk during your placement in psychiatry.

Some trusts will offer specialist training in personal safety and features such as personal alarms for inpatient units. It is important to engage with these. There are also simple things you can do to keep yourself safe:

• Never take unnecessary risks. Follow your gut instincts; if you are concerned, then leave the situation.
• Utilise emergency services if appropriate.
• Gather information about the person you are going to see.
• If appropriate, take another member of staff with you.
• Ensure your team knows where you are and when you are expected to be seen again. If it is the end of the day and you are heading straight home after a visit, this may involve calling your base to let them know you are home.
• Never put yourself in a position where you cannot leave. This includes entering a locked area without a swipe card or allowing the patient to position themselves between you and the door.

The nature of the work can be emotionally challenging. It is important to utilise supervision and reflection to consider the impact of your work on your well-being and seek further support if needed. Some areas may offer a Balint group to reflect on your experiences at work.

Assessing a patient with a mental disorder

Talking to a patient with a mental disorder

Many people worry about “saying the wrong thing” to someone who has mental illness. The best approach is to remain curious and honest. You are there to try and understand the patient’s experience, not to challenge or collude with their experience.

Open questions and active listening are important. It can often help to talk about a topic of specific interest to the patient to gain rapport before attempting to gather more sensitive information. It can also help to allow the patient to express their main concerns first rather than focus on your agenda.

We often rely on a lot of collateral information, so involving the network around the patient is essential.

History taking

There is a specific article discussing history taking in psychiatry. Your history may include:

• Presenting complaint and history of presenting complaint
• Past psychiatric history
• Past medical history – including medication
• Family history
• Social history: includes education, work, housing, finances, family, friends, relationships
• Developmental history
• Drugs and alcohol history
• Forensic history

Mental state examination

There is a specific article discussing the mental state examination; components include:

• Appearance and behaviour
• Speech: rate, rhythm and volume
• Mood and affect: subjective and objective
• Thought: form and content
• Perception
• Orientation
• Insight

A mental state examination can be completed even if a patient does not engage or talk.

Capacity

Capacity is specific to a specific decision at a particular time and is governed by the Mental Capacity Act (2005). This applies to people over 16 (under this age, we would refer to Gillick competence and Fraser guidelines).

There are five statutory principles of the Mental Capacity Act (2005):

1. A person must be assumed to have capacity unless it is established that he/she lacks capacity
2. A person is not to be treated as unable to make a decision unless all practicable steps to help him/her to do so have been taken without success
3. A person is not to be treated as unable to make a decision merely because he/she makes an unwise
4. An act done, or decision made, under this Act or on behalf of a person who lacks capacity must be done, or made, in his/her best interests
5. Before the act is done, or the decision is made, regard must be had to whether the purpose or which it is needed can be as effectively achieved in a way that is least restrictive of the person’s rights and freedom of action

Assessing capacity

Capacity to make a decision requires four criteria to be met:

1. The person can understand the information required to make that decision
2. The person can retain the information required to make that decision
3. The person can weigh up the information required to make that decision
4. The person can communicate their decision

For more information, see the Geeky Medics guide to capacity assessment.

The person assessing capacity should understand the decision to the extent that they can give adequate information to the patient in a way that the patient understands. This is usually also the person who will act on the decision, so it does not always have to be a doctor or psychiatrist.

Some decisions may require the involvement of a multidisciplinary team, particularly if a patient lacks capacity. In some cases, lacking capacity to make certain decisions may lead to the use of Deprivation Of Liberty Safeguards (DOLS) or Lasting Power of Attorney.

Risk

There is a specific article discussing risk assessment; please refer to this for more information. It would be appropriate for a foundation doctor to assess risk and discuss this with seniors or the team.

Different risks you may need to assess include:

• Self/self-harm/suicide
• Others – verbal, emotional, physical
• Vulnerability
• Self-neglect
• Mental health deterioration
• Compliance with treatment
• Absconding
• Drugs and alcohol
• Physical health
• Finances
• Driving
• Sexual

When considering risk, you may choose to use the “Four P’s” to consider biological, psychological and social factors:

1. Predisposing factors: characteristics of the patient that cannot be changed but affect risk. These might include age, gender, development, social circumstances
2. Precipitating factors: changes in circumstances that may have directly led to the change in risk
3. Perpetuating factors: circumstances that cause the risk to continue
4. Protective factors: things that might reduce the risk

You should not be expected to manage risk independently. It is important to discuss any concerns with your supervisor or the team and offer safety netting advice in the form of contacts for local crisis services. Your trust may have a team dedicated to safeguarding or risk management team that can be very helpful in risk management advice.

If there is immediate risk to the patient or others, it may be appropriate to break confidentiality. If possible, this should be discussed with your patient and supervisor first.

Diagnosis

It is unlikely that you will be expected to offer definite diagnoses for patients, but it would be appropriate to consider your impression and discuss this with your supervisor for your learning.

You will likely hear references to the International Classification of Diseases 11^th revision (ICD-11) and Diagnostic and Statistical Manual 5^th edition (DSM-5). The ICD-11 is a global tool, and the DSM-5 is an American tool. These are often used when making and coding psychiatric diagnoses.

Some clinicians favour “formulation” over diagnosis. This offers a more detailed consideration of the patient’s strengths and difficulties.

Managing a patient with mental illness

You will unlikely be expected to make management plans without supervision. Still, it may be helpful for your learning to consider how you may manage the patient and discuss this with your supervisor or team.

Management is likely to be varied and may include psychological therapies, medication, further assessment, and signposting to other services, amongst a variety of holistic considerations.

Different settings

Mental health services exist in a wide variety of settings, including inpatients and outpatients, and management should reflect the environment the patient is in.

Specific considerations for inpatient management might include the level of observation (may vary in description and management between units, but these may include; general observation, intermittent observation, continuous observation, arms reach observation with different staffing levels), regular ward reviews (often weekly in psychiatric units), leave off the ward, and assessments by other therapists (such as occupational therapy, speech and language therapy, physiotherapy, psychology).

Patients may be detained under section (see below) or admitted informally (voluntarily).

Psychological therapies

There are a large number of “talking therapies”, but some of the more common therapies you may encounter include:

• Cognitive Behavioural Therapy (CBT): commonly used for depression, anxiety, phobias, OCD
• Dialectical Behavioural Therapy (DBT): useful in emotional dysregulation and personality disorder
• Mindfulness: useful for anxiety and emotional dysregulation
• Psychodynamic psychotherapy: tends to be a more lengthy therapy referring to experiences in the early years
• Acceptance and Commitment Therapy (ACT): used in depression and anxiety
• Family therapy: helpful for complex family dynamics and eating disorders
• Eye Movement Desensitisation and Reprocessing (EMDR): helpful for PTSD and trauma
• Interpersonal Therapy (IPT): addresses difficulties in current relationships
• Creative (art/drama/music/play therapy): helpful where verbalising difficulties is challenging

Medication

You are unlikely to make significant medication decisions independently, but it is helpful to become familiar with common psychiatric medications, including antidepressants, antipsychotics, mood stabilisers and sedatives.

These are most commonly administered orally, intramuscularly or in depot form. Referring to the British National Formulary and The Maudsley Guidelines for prescribing is helpful.

Pharmacists can often help answer queries about medication. Your hospital may have a rapid tranquilisation policy for managing acute agitation.

The two main medications which require blood test monitoring are lithium and clozapine. Please refer to NICE and local guidance for this. Some medications require bloods to be taken at a specific time of day, and some medication doses will be titrated according to blood level. Medications must be reviewed regularly.

Electroconvulsive therapy (ECT)

Electroconvulsive therapy (ECT) may be required for patients with severe depression, catatonia or mania, which poses such risk to the patient that they cannot wait for alternative treatment, or alternative treatment such as medication is not effective. You may have the opportunity to observe ECT during your placement.

The Mental Health Act (1983)

The Mental Health Act (1983) is an extensive code of practice covering many areas. The most common areas you may encounter include:

• Section 2: following assessment by two doctors and an AMHP (Approved Mental Health Practitioner). Detention for up to 28 days for assessment and treatment. If 28 days are completed, the section may be revoked or application may be made for Section 3.
• Section 3: following assessment by two doctors and an AMHP (Approved Mental Health Practitioner). Detention for up to 6 months for treatment.
• Section 135/136: allow police to remove a patient at risk from their home (135) or a public place (136) to a place of safety for assessment.
• Section 5(4): nurses’ holding power lasting for up to 6 hours. Can only be used if the patient is admitted on a ward (not ED). Cannot be used for treatment. Leads to review by their consultant to either end the Section 5(2) or lead to a Mental Health Act assessment.
• Section 5(2): doctors holding power (FY2 onwards) lasting up to 72 hours. Can only be used if the patient is admitted on a ward (not ED). Cannot be used for treatment. Leads to review by their consultant to either end the Section 5(2) or lead to a Mental Health Act assessment.
• Section 17: leave off the ward for patients detained on section. Will have requirements such as duration, frequency, escort, location. This may include overnight leave.
• Section 117: aftercare provision for patients having been on certain sections (including section 3)
• Community Treatment Order (CTO): order for supervised treatment in the community. Specified conditions may include engagement with services or treatment. Can be recalled to hospital if these conditions are not met.

Most trusts have a Mental Health Act office that can advise on any queries about the Mental Health Act.

Physical health

Patients with serious mental illness (a diagnosed mental illness that interferes with the patient’s life) should have a physical health review annually as a minimum.

This is likely to include weight/BMI/waist circumference, lifestyle information (smoking, alcohol, diet, exercise), physical observations, blood tests (including lipids, HbA1c) and consideration for an ECG. Depending on their medication and other medical needs, more frequent monitoring and additional tests may be required.

Different placements have different guidance on the management of physical health for inpatients in psychiatric units but it is important to remember that some patients with mental illness may have limited contact with healthcare services, so admission can be a good opportunity to promote general health and wellbeing.

On admission, patients may require a physical examination, blood tests, ECG, urine dip, drug screens, and CT/MRI head scan.

They will likely have regular physical observations daily, weekly or more frequently, but this should be checked with your local unit. Many staff on mental health units are not extensively trained in physical health as they may have trained specifically in mental health. Therefore, your medical input is particularly important.

Considering how mental and physical health can be closely related is helpful. For example, considering underlying organic pathology such as thyroid disease when a patient presents with psychiatric symptoms. Also, consider the impact of mental health medication on physical health, such as raising prolactin levels and prolonging the QTc.

Psychiatric ‘on-calls’

You may be required to complete psychiatric on-calls. The nature of these will depend on your placement, but common calls include:

• Clerking new patients: there is likely to be a local process that needs to be completed to clerk new patients; check with your placement
• Informal patients wanting to leave the ward: it is worth asking ward staff to speak to the patient first to establish why they want to leave, as this may be easily resolved over the phone. However, do not underestimate the impact of offering a conversation with a doctor to the patient to listen to their concerns. Often, patients agree to address these with the day team during working hours. If the patient still wishes to leave, a risk assessment must be completed, and you may need to consider section 5(2). Discussing these cases with your senior on-call is often appropriate, and this should occur if you feel that section 5(2) is inappropriate.
• Agitated patients: staff often appreciate the support and leadership of the on-call doctor in these challenging situations. De-escalation techniques should be used first before considering rapid tranquillisation as per your local policy. Discuss with your senior on call if necessary.
• Physical health concerns: remember that many staff in psychiatric units are mental health trained, but physical health training may vary. If you are covering an old-age psychiatry unit, fall reviews are often common.
• Medication advice: as above
• Self-harm assessment: for example, review following cutting and review following ligature attempts.

There should always be appropriate supervision available, though this is often available by phone rather than in person in the first instance. Ask your placement who you should contact for support and how they can be contacted. The SBAR tool may be helpful when handing over to seniors and colleagues.

Psychiatric emergencies

Several specific psychiatric emergencies are important to consider. These include:

Serotonin syndrome

Serotonin syndrome is caused by medication that increases serotonin (serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and monoamine oxidase inhibitors, amongst others). It may present with neuromuscular excitability (hypertonia, myoclonus, hyperreflexia, tremor, seizures), autonomic instability (hyperthermia, cardiovascular instability), gastrointestinal upset and altered mental state (delirium, agitation).

If suspected, stop responsible medication immediately and seek senior medical advice.

Neuroleptic malignant syndrome (NMS)

Neuroleptic malignant syndrome is a rare, life-threatening side effect of medication, particularly antipsychotics. May present with altered mental state (confusion, reduced consciousness), autonomic instability, muscle rigidity and hyperthermia. Stop antipsychotics and transfer immediately to an acute medical setting.

Lithium toxicity

Lithium toxicity can be seen after overdose, renal impairment, dehydration, diuretic use, or concomitant medication use (e.g. NSAIDs, ACEI). It may present with gastrointestinal symptoms (nausea and vomiting, diarrhoea), neurological symptoms (ataxia, slurred speech, nystagmus, fasciculations, hyperreflexia, coarse tremors, seizures) and altered mental state.

Lithium levels are checked every five days whilst it is initiated and should be checked after dose adjustments. Bloods must be taken 12 hours after their dose. Lithium should be discontinued, and seek medical advice.

Neutrophilia/agranulocytosis secondary to clozapine use

Clozapine requires weekly full blood count checks for the first 18 weeks, then fortnightly for the rest of the year and then monthly due to the risk of neutrophilia. Presents with low WCC. Follow local guidance around ongoing clozapine use and seek senior advice.

Alcohol withdrawal

Requires medical admission for controlled detox with benzodiazepines and high-dose thiamine to prevent delirium tremens and Wernicke’s encephalopathy.

Catatonia

Catatonia may present with immobility, agitation, mutism, withdrawal, refusal to eat, staring, negativism, rigidity, posturing, waxy flexibility and stereotypy. Usually secondary to another underlying illness such as mood disorders or psychotic disorders. Discuss with a senior if you suspect undiagnosed catatonia.

Management involves the removal of medication that could be contributing and giving a “lorazepam challenge” followed by high-dose lorazepam. ECT may be required.

Acute dystonia

Acute dystonia may present after antipsychotic use as painful muscle spasms, torticollis, or oculogyric crises. Seek medical advice, usually managed with benztropine.