Thread by @HZiauddeen

Making treatment decisions in the psychiatric clinic 🧵

So this is a thread about how we think about someone's treatment in the clinic and it is partly about addressing some misconceptions about what we do.

(It contains a fictional case story)
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This was occasioned by a recent tutorial I did with some medical students that reminded me of how we are failing on some aspects of clinical education.

To be v. clear, this thread is not criticising medical students, it's criticising us who are teaching them (incl me)
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Also because this is a psychiatry thread, I ought to make clear that this will be about psychiatric illnesses and will include some discussion about medication and so may not be for people who are not keen on either of those areas.
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This is the fictional patient we were discussing:
A 37-year-old teacher (married, mother of 3 kids aged 7, 5 and 2) has become progressively depressed over the last 18 months, following her mother's death. Her depression is mod-severe, with increased sleep and appetite.
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She's gained 15kg in the last year and we don't know what impact it's had on her Type 2 diabetes. She's given up work because she can no longer manage it. She can't get out of bed till midday and can't concentrate for more than 10 minutes at a stretch.
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She is struggling to manage all aspects of her life and feels like she is failing everyone in her life. No suicidality.
This is the first time she's sought help but she says she got depressed after her second and third child were born but never spoke to anyone about this.
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The last piece of information is esp. important because it raises the possibility that this lady may have been depressed for much longer than the 18 months, possibly from after the birth of her youngest child (now 2) & maybe even since the birth of her second child.
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The longer people have been depressed the more likely that substantial adaptations have happened over the period of illness. Many of these adaptations are often losses, aspects of life that have been given up because there simply isn't the reserve to manage them.
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This can be very insidious and people may not realise this because as the depression continues and the cost of functioning increases, one starts to live increasingly in the short-term to survive (see thread below for details).
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https://twitter.com/HZiauddeen/status/1303836408289861633?s=20

One's image of oneself can change significantly over such timescales but a major part of this new self image may be the depression. And if neither you nor your clinician recognises the above, you will both think about prior to 18 months as your baseline.
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There a massive difference between:
'You were ok till 18 months back and then you started to become depressed.'
vs
'You'd been depressed for about 3 years before this but 18 months ago, things got a lot worse.'
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In the latter situation you have someone who has lost a lot (being depressed for 5 years is a lot of time out of the life you could have had) and in terms of getting them better, you want to try and get them back closer to the version of themselves from 5 years ago.
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Getting back to the version of someone from 5 years ago is helping them recover the emotional range and strength, the mental and physical stamina and the cognitive abilities they used to have because 5 years (± illness) will change you as a person.
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So this is what I put to the students and then asked them how they would treat this lady. Amongst the responses were 'treat her holistically', 'don't rush in with drugs', 'think about psychological treatments first'.
All very sensible and reasonable options.
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All options I have heard from psychiatric trainees, options I have heard in some lectures as a trainee myself.
But all of these are generic and non-specific and have no consideration of the specifics of the patient we are trying to treat.
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They also all relate to some very pervasive beliefs about mental illnesses and how they should be treated. In most of the rest of medicine, I don't think we would be thinking of our treatment approaches in terms of treatment modality as the first step.
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My suggestion was that they think about how they would go about thinking about her treatment if it was rheumatoid arthritis she was suffering with, and if so, what would we consider first in planning her treatment.
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We would think about what the person is suffering with and try and figure out which of our various treatment options (pain relief, physio, DMRDs) would be most appropriate and helpful.

We should do the same with her depression (or indeed any other mental illness).
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So here's the approach:
1. What is the suffering, severity and disability?
2. What is the urgency? (this is very condition dependent)
3. What are the main elements to treat?
4. What are the treatment options (and how optimal are they)?

(1,2,3 include patients' views)
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Once you have thought about the above, then you discuss them with the person:
5. Which options are acceptable/preferred?
6. Is the option decided on tolerable enough to try?
7. If tolerable enough to try, is it effective?
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8. If effective, is it effective enough AND tolerable enough to continue for the required duration?

So let's apply these to our lady.
1. Suffering is intense, illness is fairly severe, disability is significant (this is wrt to her baseline, a within person comparison)
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2. Urgency: This lady has been ill and suffering for a long while and we need to get things better as quickly as possible. I also need her to get better so that I can try and treat other aspects of her condition.
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3. Main elements to treat:
-depression (mood, energy, sleep, concentration)
-Type 2 diabetes
-Functional impairment and loss
-Possible grief*
-Possible issues with bonding with third (and possibly) second child.*

*won't get a clear sense till the depression gets better.
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4. Treatment options:
-antidepressants, CBT for depression
-improve dietary control, weight loss, increase physical activity.
-Specific psychological and psychosocial interventions for grief, bonding, parenting.
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All these will address one or more of the key elements we want to treat. Here's what we need to consider:
1. How much will it help?
2. How quickly will it help?
3. How much effort will it require the person to put in?
4. When in the treatment will be best to use it?
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Given that she is struggling with energy, motivation and concentration, she is going to find psychological work and increasing physical activity difficult at this point. Even she is able to manage the sessions, it will take some weeks for this to be effective.
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You can try and support her with both of these with nurse and a support worker but you need to be mindful that it will be difficult and may take a fair bit of time till she is well enough to be able to use these well.
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Similarly for dietary control and weight loss.
For the explorations of grief and looking at bonding and attachment, she needs to be much better and much stronger. I forgot to mention possible self-esteem work earlier but the same goes for that.
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Medication: good evidence base, you’d expect to see benefits in 1-2 weeks once she is able to tolerate a treatment dose. If you’re thinking it takes 4-6 weeks, that’s not the case. Reduction in amygdala hyperactivation to negative faces occurs with single doses of SSRIs.
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People experience at least a lightening of the intensity of their pain, a distancing from their emotional pain, and reductions in anxiety and emotional hypersensitivity in the first 1-2 weeks. You have to gather enough info on these up front to monitor these changes.
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The more data you collect about the person's illness and experience, the more precise your treatment goals and monitoring can be. It may take longer for people to subjectively notice these changes themselves.
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The 4-6weeks ‘to see an effect’ is the time for an adequate trial i.e. how long to wait for before you make a call to stop/switch. Related to this, the idea of ‘get worse before you get better’ is about specific side-effects such as initial increases in anxiety.
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My plan for this lady would be start an antidepressant, check her glycaemic control and start addressing it right away, support with increasing physical and social activity, get her to best position possible for her to start CBT and/or other psychological work.
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Now I need to see what she wants and what she is comfortable with and work with that. I'd explain my thinking to her so she knows what I’m recommending and why. We then go with what she feels comfortable with and take it from there.
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Whichever options we try, we keep revisiting questions 6-8, checking tolerability and effectiveness. We definitely need to do this for medication but we should also do the same for psychological and other interventions.
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We need to keep monitoring the various elements we are trying to treat. We need to have a plan in mind for when to terminate trials of treatment and at least what the next 2 possible options might be i.e. have a treatment algorithm in mind right from the start.
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We keep going to see how much better we can get her and how of her life we can help her recover. This is the first time she's sought treatment so we should aim to get her fully recovered (as described above, this is a within person measure).
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When we're dealing with people who have had longer illnesses, treatment goals may be different (see thread below for a lot more on this).
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https://twitter.com/HZiauddeen/status/1211423334703026177?s=20

Along the way the picture may evolve, her needs and goals may change. We need to be mindful of these and adapt.
We need to recognise mistakes, acknowledge, apologise and correct them.
We also need to be aware of our own biases, here are mine:

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https://twitter.com/HZiauddeen/status/1312661142419001345

Hopefully that gives you some sense of what we do in when thinking about treating people in the psychiatric clinic. Please bear in mind that the fictional case story here is a fairly straightforward one, as such stories often are. Real life is often very different.
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Addendum to original 🧵
Thanks for all the comments and feedback. As I've said in the replies, this was just about thinking about treatment and I did not go into the many areas to explore in the history. I think it is hard to do that and stay under 100 tweets.
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I am however going to bring up one particular area (with thanks to @Foreman1David) which is about the importance of thinking about how having and looking after children shapes people's lives and especially their mental illnesses and their presentations.
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We often tend to think about having children as being a normal and natural part of life (which it often is) and this means that we can fail to take into account that even for people with the best internal and external circumstances, it can be very hard.
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(The factors that put you at risk of mental illness are usually not the best int. and ext. circumstances)
There are very powerful societal beliefs and expectations managing/succeeding as a parent and it is very hard if your experiences don't fit with these.
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These are very asymmetric in that women have it much worse (women are judged, mothers are judged on another level all together, as are women who choose not to be mothers or are unable to).
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There are also multiple practical ways in which life is hugely changed, which while also 'normal', are still bloody hard.
Without going into exhausting detail, this needs to be factored into thinking about people's lives and their illnesses.
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To give two extreme examples:
(1) some parents may push themselves beyond the limit to hold things (incl themselves) together for the sake of their children. This means they may not seem as ill as they are.
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(2) some parents may decompensate far quicker, revise your thresholds accordingly.

Finally, bear in mind the reciprocal interactions. With regard to children, we are reasonably good at thinking about risk and safeguarding and to some extent, attachment.
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But we need to think about the impacts in reciprocal & dynamic terms e.g. impact of parent's depression on child, impact of this on their relationship, impact of this on parent's depression...
This example is very simplistic but hopefully gives some sense of the issue.
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Finally, looking after parent's mental illness is looking after their children's wellbeing as well as ameliorating the kids' future risk of mental illness.
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Addendum to addendum:
With thanks to @mamamtoto for pointing out that I missed out the massive impact of the gendered division of labour on mothers in cis-het couples and possibly on one parent more than the other in non-cis-het couples.