Interview

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The College of Psychiatrists of Ireland Winter Conference 2018 will be held in the Brehon Hotel/INEC in Killarney, Co Kerry, later this month on Thursday and Friday 15-16 November.

This year’s event is titled ‘From the Biome to Bipolar’ and has a wide range of speakers over the packed two-day schedule, on issues as varied as professionalism to prison work, from the future of personality disorder services in Ireland, to the writings of Kafka.

President of the College of Psychiatrists of Ireland Dr John Hillery told the Medical Independent (MI) that he is looking forward to the conference and believes that the eclectic range of talks and speakers will provide something of interest for all attendees.

The opening session on the Thursday of the conference is on ‘Professionalism and the Trainee’. During this session, three speakers will address the theme, including Prof Trudie Roberts from the University of Leeds, UK, who will talk on ‘Professionalism and Integrity: Challenges and Consequences of Modern Medical Training’.

As ever, professionalism remains an important topic, Dr Hillery said.

“Well, we are continuing the theme of professionalism and as you see [in the meeting programme], there is a long opening session on it;  I think that is always important,” said Dr Hillery.

“Probably, people might say it is more important now because of all the recent issues that there have been in the public discourse about the way doctors interact with patients. It is something that we are all reflecting on; the College has always taken a position on making it a core aspect of discussion for trainees.

“But in the last few conferences, we have also been [raising]…ideas of professionalism in psychiatry. It means that it is an important theme for us, and it is one that we will continue to do at all our conferences.”

Prisons and the homeless

Later on Thursday, there is a session on ‘Prisons and the Homeless’ delivered by Dr Damian Smith and Dr Kevin Kilbride, and on Friday, Dr Conor O’Neill from the Central Mental Hospital, Dublin, will talk on ‘Men with Psychotic Illness in Remand Prisons’.

Homelessness is very much in the news at the moment, and Dr Hillery said it has a particular mental health impact.

“The services for the homeless are rather geographically confined,” he said.

“But we know historically that people with mental illness are probably more at risk of homelessness.

“When you look at dealing with mental illness and the treatment of it, we have to look at society’s approach to vulnerable people, so it is something we want all our trainees and ourselves to be conscious of, of those needs, and to keep it out there.

“Why do people end up homeless? Can we have earlier interventions? As you probably know, it is a theme we have been putting out there to the public about resources, and lack of resources, and that interventions are not as early as they should be, which is leading to people getting more serious illnesses, leading to greater morbidity and possibly mortality.”

On Friday before lunch, there is a session on bipolar disorder, with some of the presentations including Dr John Cooney from St James’s Hospital, Dublin, talking on ‘Mood Disorders in Liaison Psychiatry’ and Dr Aditya Sharma from the Institute of Neuroscience, Newcastle University, UK, speaking on ‘Pharmacological Management of Bipolar Disorder in Under-18s’.

The day before, on Thursday, there is a series of NCHD research oral presentations spanning a wide range of topics.

 “The key to advances in psychiatry is research and the key to insuring that good research happens is by encouraging trainees to do it; it’s important that we support it. Of course, it is also important that their [NCHDs] contract supports it and their employers support it. So this is a manifestation of that, which is very good. It’s a key issue, and it’s great to see such interesting and quite varied papers coming through,” said Dr Hillery.

Sláintecare

Dr Hillery said that the College of Psychiatrists of Ireland remained concerned about the lack of representation of psychiatrists on the recently-established Sláintecare Implementation Advisory Council. “It’s quite disheartening,” he said. Dr Hillery added that he remains disappointed “and my colleagues support me on this, that we have a council dealing with the implementation of a 10-year plan for health, which doesn’t have any input from people who deal with people with serious mental illness.”

“By doing that, it is giving the message out that mental illness is not really part of what our health services are about. I think that’s unfair to the people who put together Sláintecare because the document does give a lot of thought to people who have mental illness,” according to Dr Hillery.

The College President was also not satisfied with aspects of the recent Budget 2019. “The Budget…was announced to great fanfare, about how much money was given [to mental health]. But if you do the math, it doesn’t actually increase the percentage of the health budget for mental health by much at all.”

“We are still of course expressing our disquiet with the lack of investment in the mental health services for people with mental illness.”

Recently, the College released a statement saying it was disappointed with recent findings from the Inspector of Mental Health Services. The College said the findings showed an  “increased use of seclusion and restraint in our hospitals”.

 “The College is very disappointed to see the data… on levels of restrictive practices in hospitals. This is another manifestation of the under-resourcing of services for people with serious psychiatric illness,” the College said in its statement.

“Seclusion and restraint should only be necessary in extreme circumstances, as early intervention and support should prevent any individual becoming so unwell that their safety or the safety of others requires such intervention.

“Unfortunately, the experience of frontline psychiatrists in Ireland currently is that they lack the resources in trained personnel to ensure all people in need get the variety of evidenced-based, individualised interventions they require.”

Literature

The upcoming Winter Conference in Killarney, ends on an interesting and unique topic. Prof Femi Oyebode from the University of Birmingham, UK, will talk on ‘Abnormalities of the Self and Embodiment in the Writings of Franz Kafka — Lessons for Psychiatry.’

“This is something we want to bring in more,” said Dr Hillery.

“Dr Femi Oyebode has been writing for many years on the area of literature and mental illness…we are delighted she is coming to speak on this. It looks far too intellectual for me,” he laughs.

“But I’m looking forward to hearing it. Once again, there has been a long history going back to the 1800s of people in psychiatry, or whatever it was called at that stage, being involved in the arts.

“Also, when I was training, several of my trainers pointed me towards people, writers such as Dylan Thomas and Frank O’Connor, to look at the development of people’s inner thinking. So it is something we have to be very careful about in psychiatry, that we promote the scientific aspects of things, but we don’t lose that other side of it either.

“Because if we are trying to work out how humans behave and how individuals behave, the writings of the great writers are really important from that point of view.”

In terms of its own publications, last month the College announced the Irish Journal of Psychological Medicine (IJPM) was successful in its application for indexing on Medline, the “largest and most prestigious” internet search engine for medical research.

As the official research journal of the College, much of the research published in IJPM is relevant to an Irish audience, “although the journal has a large international readership and maintains the high publication standards worthy of an international journal.”

According to a College spokesperson, this indexing will “result in Irish-based mental health research being more visible and widely-read by clinicians and researchers, both in Ireland and around the world. It will also increase the likelihood that this research will be used by people to inform clinical practice through internet searches.”

Dr John Lyne, Editor-in-Chief for the IJPM, explained what this indexing could mean for the delivery of services. “The journal aims to advocate for better mental health services for all by highlighting key topics of current relevance to mental health. By reaching a wider audience, IJPM can act as a forum for positive change in how mental health services are delivered, both in Ireland and internationally.”

The Gathering Around Cancer 2018 conference will take place in Croke Park Convention Centre, Dublin, on Thursday 8 and Friday 9 November. The conference is one of the major oncology events of the year and will feature presentations from a wide panel of experts, who will give their perspective on the major developments within their specialty. 

The inaugural meeting took place in 2013 to coincide with the Gathering events being held that year to mobilise the Irish diaspora. Since then, the event has gone from strength-to-strength.

“We had a very large meeting, a three-day meeting, at that time,” according to organiser and Consultant Medical Oncologist in the Mater Misericordiae University Hospital, Dublin, Prof John McCaffrey, who co-founded the event with Consultant Medical Oncologist in St James’s Hospital, Dublin, Prof David Gallagher.

“And it was so successful that we decided to carry on. It became a meeting that wasn’t disease-specific, but covered everything. It is mainly medical oncology but we take in radiation and surgery and paramedical also, so I think it satisfies all the things we needed and has become the meeting that people want to have.”

Speaking to the Medical Independent (MI) ahead of the 2018 meeting, Prof McCaffrey said he is delighted by the positive response the meeting has generated among the oncology community.

“Myself and David Gallagher continually get very positive feedback that people like the way we do it. We want stay fresh, so we try to change things a little bit each year,” according to Prof McCaffrey.

“But I think the formula we have now suits people.”

After the welcome address on Thursday, the first session of the conference will be devoted to presentations from ‘Young Investigators’. The topics in this session will range from immunotherapy in breast cancer to overcoming EGFR TKI’s resistance in lung cancer. Prof McCaffrey said that this is always one of the most popular sessions.

“A lot of these people will be known to the community in Ireland, and then to see the step up that people take when they go abroad is quite impressive,” Prof McCaffrey stated.

“And these are the people who will be our future leaders, so it is great to see it happening.”

Burnout

The following session will be on the subject of ‘Global Oncology’. CEO of the Irish Cancer Society (ICS) Ms Averil Power will begin the session with a talk on patient advocacy. The next speaker, Dr Patricia Scanlon, Muhimbili University, Dar Es Salaam, Tanzania, will deliver a talk on the challenges of running an oncology programme in the developing world. Other talks concern ‘The Future of AYA Oncology’ and ‘Burnout in Oncology: A Global View’, which will be delivered by Dr Scheryll Alken, St James’s Hospital and Our Lady’s Children’s Hospital Crumlin and Dr Blanaid Hayes, Dean of the Faculty of Occupational Medicine, RCPI, respectively.

Prof McCaffrey told MI that meeting organisers felt that it was essential to cover the theme of burnout, given the enormous workload pressures those working in the field of oncology face.

“The inability of male and female doctors to disconnect from work isn’t something we pay a great deal of attention to,” according to Prof McCaffrey.

“Our only fear is that we are not giving it enough time on the programme. It is a huge issue and a topic that needs to get more air-time than is currently the case.”

Dr Sean Ennis from Genomics Medicine Ireland will give the last talk of the session on population genetics, industry and academic collaboration.

Screening

The final session of the day will be on the timely and controversial subject of cancer screening.

Head of Services and Advocacy at the ICS Mr Donal Buggy will talk about screening from the patient’s perspective. There will also be a presentation specifically on cervical cancer screening, which will be delivered by Prof Grainne Flannelly, St Vincent’s University Hospital, Dublin. Given the recent controversy concerning CervicalCheck and the publication of the Scally Report, these talks are sure to be of extreme interest to delegates.

Two of the presentations will be on the subject of breast cancer screening. Prof Fidelma Flanagan, Mater Hospital, will deliver the first talk, while Prof John Crown, St Vincent’s University Hospital, Dublin, will talk about the “benefits and pitfalls” of breast cancer screening.  Colon screening will also be covered by Prof Diarmuid O’Donoghue, St Vincent’s University Hospital.

“I think it is to reaffirm the importance of screening in the various areas; to take a look at what has been achieved, to hopefully show that we are saving lives,” according to Prof McCaffrey.

“If we are doing something not right, that will come up at the meeting, and what are the steps that can be taken to reassure us as the practitioners and the wider public that there are clear benefits to doing it [screening].”

The first session on Friday will concern ‘Updates in Medical Oncology’. Prof Donal Brennan, University College Dublin, will start the session with a talk on gynaecology cancer surgery. This will be followed by a talk on ovarian cancer by Dr Dearbhaile O’Donnell, St James’s Hospital. Other subjects to be covered in the session include: Cervical/endometrium cancer; radiation therapy gynaecology; renal cell carcinoma; the central nervous system; and lung cancer.

GI, breast and prostate cancer

The next session will discuss aspects of GI cancer specifically. Presentations will cover upper GI cancer and lower GI cancer. Dr Steven Hochwald, Roswell Park Cancer Centre, New York, US, will speak about ‘Advances in Surgery for Gastro-oesophageal Malignancy’ in an eagerly-anticipated talk.

Dr Hochwald’s research focuses on technical advances in minimally-invasive oesophageal and GI surgeries and developing new targets and agents for treatment of pancreatic and other GI cancers. He has lectured both nationally and internationally on Western approaches to minimally-invasive oesophageal and gastric resection for malignancy and has published broadly on these topics. He has taught several courses and organised symposiums on minimally-invasive oesophagectomy. He serves as Editor of the book titled Minimally Invasive Foregut Surgery for Malignancy, which was published by Springer in 2015.

Prof John Reynolds, St James’s Hospital, will also give a presentation on the interesting topic of the relationship between obesity and cancer, while Prof Frank Sullivan, NUI Galway, will talk about diet and weight loss in cancer.

The final session of the conference is on both prostate and breast cancer. Subjects under discussion will include prostate surgery, radiation therapy, and systemic therapy. Prof David Gallagher will deliver a presentation on the role of the BRCA gene in prostate and breast cancer. Genetics will also be the subject  of talks by Dr Janice Walshe, St Vincent’s University Hospital, who will discuss ER + HER2- stage IV breast cancer and Dr Cathy Kelly, Mater Hospital, who will talk about HER 2+. Dr Con Murphy, Bon Secours Hospital, Cork, will also deliver a presentation on triple-negative breast cancer.

Cancer strategy

The event comes just over a year since the National Cancer Strategy 2017-2026 was published. Prof McCaffrey believes that implementation of the strategy over the past 12 months has been “steady”.

“I think we are all encouraged by the need to improve manpower, especially in medical oncology centres, but also supportive staff, including dietetics and psycho-oncology and the nurse specialty. I think they are all important things. A 10-year plan always needs to be given time to work. Now in its third iteration, I think we have made huge progress in the time since we have had the strategies. Of course, you don’t get to where you need to be every time, but that’s the nature of the evolving landscape. Things like genetics and genomics need to be incorporated into the management of cancer also. Overall, I think on-the-ground resourcing is the most important thing to achieve in terms of implementation.”

In 5-6 October in the Convention Centre Dublin a dedicated two-day meeting hosted by BMS/Pfizer on stroke prevention in non-valvular atrial fibrillation (NVAF) and the prevention and treatment of venous thromboembolism (VTE) will take place. The event will feature presentations from leading multidisciplinary international experts from Europe and Canada, as well as local expert Dr Rónán Collins, about the latest clinical advances in anticoagulation and practical guidance on how to apply this knowledge in patient practice.

In an interview with the Medical Independent (MI), Dr Collins stressed the need to increase awareness of atrial fibrillation, and its connection to stroke among both clinicians and the general public and the best ways to clinically manage it.

Dr Ronan Collins

“Atrial fibrillation is the commonest cardiac arrhythmia and affects about 5 per cent of people over the age of 60, and about 10 per cent of people over the age of 75, so therefore it is a very common condition and it is a growing problem because of our demography in Western Europe and also particularly in Ireland. Because of the huge risk factor for stroke, particularly in Ireland where about 35 per cent, a bit over one-in-three, strokes are caused by atrial fibrillation, it is crucially important in any stroke strategy that we pay attention to prevention.”

Dr Collins was involved in the development of the newly revised European Heart Rhythm Association (a branch of the European Society of Cardiology (ESC)) Practical Guide on the use of non-vitamin K antagonist oral anticoagulants in patients with atrial fibrillation (2018).

This Practical Guide, like its predecessors from 2013 and 2015, supplements ESC guidelines on how to use non-vitamin K antagonist (VKA) oral anticoagulants (NOACs) in specific clinical situations for stroke prevention in patients with atrial fibrillation (available at www.NOACforAF.eu).

“We extended it this year beyond the traditional remit of just atrial fibrillation in general to consider special populations with atrial fibrillation, for example, those who are frail and quite old who may be quite prone to falling, they may have co-existent dementia, have age-related kidney issues, have lower body weight, etc. So for those reasons it was important that the document focused on special populations this year. It is within that context, as one of the authors of the guidelines that I will be speaking at this week’s meeting about optimising treatment management, with particular reference to older people, frail people, people who have just had a stroke and the importance of multidisciplinary working as well,” he explained.

Dr Collins stressed that a multidisciplinary approach to atrial fibrillation “is a critical point” that has been “an ESC recommendation for the last two years”.

“We are probably one of the few places in Europe that have an interdisciplinary atrial fibrillation clinic. In Tallaght Hospital our atrial fibrillation clinic is a joint effort between cardiology, geriatric and stroke medicine, clinical nurse specialists and pharmacy. We think that is the right way forward to deal with atrial fibrillation.”

Awareness

Awareness of atrial fibrillation among the general population is poor in Ireland. Dr Collins noted the Irish Heart Foundation has run campaigns to try to address this but awareness still remains quite low; according to the most recent data less than 30 per cent of surveyed people in Ireland had heard of the condition. “Which is amazing as it is so common. The awareness is slightly higher in older people, which is good as older people are more likely to have it and it is slightly higher in higher socio-economic groups,” he said.

In addition, in people who have heard of atrial fibrillation most do not realise the connection with stroke, which is quite worrying, Dr Collins commented.

“Public awareness is low and we know it is even low in people who have atrial fibrillation; we know from a paper from Birmingham on people attending an atrial fibrillation clinic that less than half of them knew what it is. So if that was in a specialist clinic you can imagine what it [awareness] is like among the general public. Basically we know that only 25 per cent of people know anything about atrial fibrillation and only half of those are aware it is associated with a risk of stroke. So there is a lot to be done. I don’t think Ireland is very different from other European countries. There is a taskforce to get European Parliament engagement on this as a public health issue but we have a lot to do.”

Anticoagulation

In relation to anticoagulation of those who are at risk of stroke, Dr Collins said that while more people are being treated, there is still much unmet need. He noted that the use of NOACs has increased dramatically in the last five years in Ireland and that it is now well-established that warfarin is no longer the gold standard of care with the newer NOACs being the first choice for anticoagulation as per the ESC guidelines.

“To be fair I think we are doing much better in this regard. If you look at the pharmacoeconomic data there has been a huge increase in the use of NOACs. Therefore, there are a lot more prescriptions being written… Clearly these drugs cost and I’m not saying pharmacoeconomics aren’t important, but stroke is our third leading cause of death and our leading cause of acquired neurological disability. That’s a fact and atrial fibrillation is one of the major causes of stroke in Ireland and in Western Europe and that is also a fact. So therefore the pharmacoeconomics have to be set in the context of what the drugs are actually doing. The country has a lot of expenditure on drugs and it is important that we police it, but these are effective drugs. Sometimes I do wonder when it comes down to discussing drugs, for example, cancer, because cancer can be such an emotive issue, the pharmacoeconomics might get looked at, but it doesn’t get the same drilling as a preventative drug, so paring atrial fibrillation back to its core message: It is very common, the consequences of atrial fibrillation can be very severe. Atrial fibrillation can be detected before it causes any major health problems and the health problems can be prevented by effective intervention. The effective intervention is relatively cheap and relatively well-tolerated and there is a huge economic gain in preventing stroke to the health service and a huge personal gain in preventing stroke for people who have suffered one.”

Screening

Dr Collins pointed out that the World Health Organisation (WHO) criteria for screening programmes is based on the 1968 Wilson and Jungner criteria that if “a condition is common, that it is easily detectable by an acceptable means, that if you do not detect it, it causes a major health problem, that if you do detect it you can intervene to prevent that major health problem and that it is cost-effective, and atrial fibrillation ticks all these boxes”.

“This is something that causes one-in-three strokes in Ireland. And stroke is our third leading cause of death and leading cause of adult acquired disability so I think atrial fibrillation is a massive public problem.”

He commented that diseases like breast cancer “do not affect 5 per cent of people over the age of 60 or 10 per cent of people over the age of 70, but we have screening programmes. And I’m not saying we shouldn’t have screening programmes for that; that’s not the point I’m making. The point I’m making is that atrial fibrillation is a very serious problem but because it is not directly associated with something with the same emotive or terrifying understanding of cancer [it is overlooked]”.

“So there are other important things we should be screening for and atrial fibrillation is one of them. But in order to have an effective screening programme you must have public knowledge of the issue as well, so that is the starting point. And then we must get engagement with the HSE to look at this for screening. I have to say in Ireland we did a health technology assessment (HTA) of pulse screening [in a general practice setting] under Dr Breda Smyth [Consultant in Public Health, Department of Public Health Galway, HSE Health and Wellbeing Division] in the West of Ireland and the Dáil has approved the pulse check. It is not a comprehensive screening programme, but it has been approved by the HTA, by the Department of Health to be included in the health programme and it is probably part of the ongoing GP contract negotiations.”

However, Dr Collins reiterated that the medical community must further collaborate to raise awareness of the importance of atrial fibrillation. “We have to do our job better, we have to work out a way as to how we get this message across, how do we get people to understand. Once you get public engagement the rest of it tends to fall into place. If you don’t have public engagement you don’t have anything.”

Coming back to this week’s meeting, Dr Collins expressed his excitement at the “world class speakers” who will be giving presentations, including Prof Stefan H Hohnloser, Professor of Medicine and Cardiology at the Johann Wolfgang Goethe University in Frankfurt, Germany, where he is the Head of the Department of Electrophysiology; and Prof Giancarlo Agnelli, Professor of Internal Medicine and Director of the Department of Internal, CV Medicine and Stroke at the Perugia University Hospital, Italy. “They are at the top of their game. It would be hard to get a group of people with such expertise in one room as is being brought to Ireland for this meeting.”

A full exclusive meeting report from the event will appear in a future edition of MI.