The issue of suicide will be accorded particular focus at the upcoming Spring Conference of the College of Psychiatrists of Ireland, which takes place in Athlone on 12-13 April.
A presentation on ‘Suicide in Doctors — What we Should Know’ by Dr Justin Brophy, Clinical Advisor to the National Office for Suicide Prevention (NOSP), opens the morning session on 12 April, followed by an examination of contemporary suicide prevention strategies by Professor of Mental Health Sciences at Ulster University, Prof Siobhan O’Neill.
Also speaking will be Consultant Liaison Psychiatrist Dr Siobhán MacHale on the role of psychiatrists in respect of suicidal behaviour; and Prof Ella Arensman, Director of Research at the National Suicide Research Foundation and an expert on the epidemiology of suicide.
Later in the day, two presentations will further examine this important public health issue: ‘Not Waving but Drowning: Suicide Crisis Intervention in an Ocean of Risk’ by Clinical Director of Donegal Mental Health Services Dr Cliff Haley; and ‘Assessment of Risk of Suicide’ by former Inspector of Mental Health Services Dr Patrick Devitt and Consultant Psychiatrist Dr Declan Murray.
Speaking to the Medical Independent (MI), College President Dr John Hillery said suicide is a “constant” concern for psychiatrists. Nevertheless, in wider society, psychiatrists’ management of patients with suicidal thoughts is not always well-understood, he suggested.
“People may feel suicidal but they don’t always want to share that, because they would think people would get alarmed, they’d send them to hospital and they’d be admitted, when really they would rather carry on trying to deal with this in the community with the support of people. And yet, if there is a suicide, the professionals who have been dealing with that person often come in for very close scrutiny and even criticism,” outlined Dr Hillery.
Dr John Hillery, President, College of Psychiatrists of Ireland
“So the role of the psychiatrist is to enable people, not to disable people. In enabling people, we have to take risks and the trouble is, if the risk goes wrong, what is the outcome for the psychiatrist as well as for the patient, obviously? But if we don’t take risks and allow people to plan their own recovery and to try to deal with their own issues with our support, rather than the old days when everyone ended up incarcerated, we are not being good doctors either.”
Suicide is of concern within the body of psychiatrists in respect of their patients, but there is growing recognition of the risk to doctors themselves. Sadly, a number of suicides of doctors have occurred in Ireland over recent years. Dr Hillery feels this will be an important focus at the meeting. “What is it about our health service, and the wonderful privilege it is of being a doctor, that it can result in such a negative outcome?” he commented.
“I remember when I was President of the Medical Council, we ran a full day [conference] on doctors’ health and [the late, renowned psychiatrist] Anthony Clare was there. At the end of it, we had a large group discussion; Anthony Clare said we really needed to realise that being a doctor was a huge privilege — very exciting, interesting work, but also very stressful… between the hours and the commitment, and we need to be teaching doctors about resilience from an early stage in their career.”
On a different tact, health economics from a mental health service perspective will be the focus of a presentation by Dr Caragh Behan, Consultant Psychiatrist and PhD in Health Economics.
Dr Behan’s workshop will outline how utility values are generated and why equity issues are so important in mental illness. In the UK, the National Institute for Health and Care Excellence (NICE) requires that interventions provided by the health service prove their ‘utility’. In order to receive funding, the cost of the intervention has to be under a certain amount per quality-adjusted life year (QALY). In Ireland, to date, this has only applied to medication reimbursement and some screening, but as Dr Behan will outline, it is expected to become increasingly prevalent in time.
This workshop will also be an opportunity for delegates to further discuss under-funding of mental health services, a matter that has perturbed the College for many years. “The mental health budget remains way behind equivalent countries, as well as behind A Vision for Change, which is over 10 years old. The College say it should be between 12-to-13 per cent [of the overall health budget], but it’s about 6.5 per cent,” commented Dr Hillery.
Other afternoon sessions on 12 April include a presentation on body image and eating disorders in men. This will be delivered by Consultant Child and Adolescent Psychiatrist Prof Fiona McNicholas and Consultant Psychiatrist Dr Caroline Maher, who chaired the College’s Clinical Advisory Group on the development of the model of care, and Dr Niamh McNamara, psychologist, UK.
Consultant Psychiatrist Dr Lorcan Martin will chair a debate titled ‘Our Daily Lives are Incompatible with Maintaining Professional Competence’, which Dr Hillery predicted will elicit “robust discussion”, particularly as many psychiatrists are working above a whole-time equivalent post.
“A lot of people are covering much more than they should be and are working without [the required numbers of] junior doctors or allied health professionals, and getting criticised as they are not giving people access to the other things which they’d love to do; when do you find the time for personal reflection on your practice, which is very important, and keeping up your competence?”
According to Dr Hillery, recruitment and retention in psychiatry remain of deep concern.
He emphasised that there has been positive feedback to the Medical Council from medical graduates who enter specialist training in psychiatry.
However, there are also perceptions that mitigate against medical students and junior doctors opting for a career as a psychiatrist in the first instance, outlined Dr Hillery.
“There is a perception, first of all, about psychiatry, that you are dealing with people with chronic illness and they never get better and it is very depressing. We obviously work to overcome that, because there is a well-known phenomenon called the ‘hidden curriculum’ where in medical schools, general practice and psychiatry are portrayed to medical students as places for people who aren’t able to do other things in medicine, or places where you are really not dealing with scientific stuff — it is just not true, but it is a battle.”
Many doctors who enter psychiatry training often fear that they will not have the time and resources to practise appropriately as a consultant, added Dr Hillery. Moreover, trainees want to be working in teams with fully-trained specialists, “not locums who are just passing through. We have a problem in this country with having locums who aren’t on the Specialist Register — that’s a difficult one too. Once again, that discourages people from staying to train here.”
The College has at times experienced difficulties filling all training posts in recent years. However, this year it requested a 10 per cent rise in numbers into basic specialist training (to 66), but was only accorded a 5 per cent increase (63). “We are a bit concerned because we know we can fill the training posts,” said Dr Hillery.
“This year, we actually have enough people for more training posts applying for our scheme and of a quality that we’d be happy to accept, if we could. This is a ‘good news story’ but unfortunately, they [HSE] are giving us less than we wanted, but more than we had before.”
Dr Hillery pointed out that non-training posts involve doctors in the General Division of the Medical Register who don’t have the same level of supervision. He also alluded to the barrier to entering training experienced by some non-EU doctors, whose internships are not deemed equivalent by the Medical Council. He said the College has advocated for an amendment to the Medical Practitioners Act 2007 in this regard.
Meanwhile, among the highlights of the Spring Conference’s final day will be a presentation on early parent-infant interaction and attachment, and why infant mental health matters. Child and Adolescent Psychiatrist Dr Aoife Twohig will discuss a range of findings, including those from a study on the effects on maternal sensitivity and infant social-emotional development of an early attachment-focused intervention using video interaction guidance for parents of very preterm infants born at less than 32 weeks’ gestational age, in the neonatal ICU.
The presentations on 13 April will conclude with an examination of mental capacity in legislation and practice implications for professionalism, ethics and care (Prof Brendan Kelly); mandatory reporting/legal requirements in relation to children (Dr Brendan Doody); and professionalism in medicine (Dr Anthony Breslin).
One-in-five people will develop heart failure (HF) in their lifetime. There are up to 90,000 people in Ireland living with HF and the estimated cost of the condition is €660 million per annum.
The Irish Heart Foundation has launched a new campaign, ‘Pay Attention to the Signs’, to raise awareness of HF symptoms. The campaign, supported by Novartis, aims to encourage those aged 50 and over to be aware of the signs of HF, as early detection of the symptoms can significantly improve a patient’s prognosis.
Swollen ankles, fatigue and shortness of breath are warning signs that should never be ignored in patients, according to the campaign.
Due to Ireland’s ageing population, the condition is set to increase dramatically, leading to a rise in HF hospitalisations of more than 50 per cent over the next 25 years.
Dr Angie Brown, Consultant Cardiologist and Medical Director, Irish Heart Foundation, said that HF can often go unnoticed because its symptoms come on gradually. “It’s easy to attribute tiredness to a busy lifestyle, and breathlessness to being out of shape. These are signs we need to watch out for.”
One-in-five people over 65 years presenting to their GP with breathlessness will have unrecognised HF, Dr Brown told the Medical Independent (MI). Furthermore, the incidence is expected to increase substantially over the next 30 years, but despite this, Ireland’s public awareness of the signs, symptoms and causes of HF is very low, she noted.
“This is why our campaign is aimed at the general public. In addition to the discussions on the radio, our campaign materials include posters, leaflets and a brochure; there is also information on our website or via the nurses helpline, 1800 25 25 50. Any GP can get in touch and receive the materials or download from our website [www.knowyourheart.ie].”
Dr Brown said it is important that GPs remain aware of how common HF is. She said that while GPs are well aware of HF symptoms, it can often be difficult to diagnose.
“Some of the main symptoms are breathlessness and fatigue, which are quite non-specific and can be due to other things, such as a chest infection or underlying lung disease, or even in some people due to deconditioning. It is therefore important to have a high index of suspicion, particularly in patients with risk factors such as ischaemic heart disease, hypertension, valve disease or diabetes. If heart failure needs to be excluded, a blood test to measure the natriuretic peptides (BNP) is very useful, as it is elevated in heart failure. Patients can then be referred for an ECG, ECHO and specialist review.”
Dr Angie Brown
Once a diagnosis of HF has been made, the patient will be started on several types of medication (ACE inhibitors, beta-blockers, angiotensin receptor blockers (ARBs), hydralazine with nitrate, diuretics, aldosterone antagonists, sacubitril/valsartan, ivabradine and digoxin, etc) to improve the heart function, control blood pressure and heart rate, and remove any fluid from the lungs. These medications can improve symptoms as well as heart function and lower mortality. “Other treatment may be necessary, depending on the cause of heart failure — for instance, if it is due to a narrowed heart valve, this may need replacing, or if it is due to blocked heart arteries (ischaemic heart disease) then the patient may need a stent or a heart bypass. Some people may need a special sort of pacemaker. All of the treatment available now means that people’s symptoms and prognosis if they have heart failure has improved compared to years ago, when these weren’t available,” Dr Brown said.
Women often have different cardiac symptoms to men and can underplay their symptoms, Dr Brown noted. “Women are protected in part by their hormones but after the menopause, the risk of developing heart disease increases and catches up with men, so it is equally important for women to be investigated for heart failure if they present with fatigue, dyspnoea, swelling of the ankle [and] some may complain of ‘gasping’ or inability to lie flat in bed or wake up at night breathless. Some may have palpitations or dizzy spells.”
In summary, Dr Brown said it is important for everyone to be aware of their HF risk factors, “so to get blood pressure, cholesterol and blood sugar checked, try and keep to a healthy weight, eat a healthy diet, cut down on alcohol, stop smoking and if a person has breathlessness, fatigue or swollen ankles, that they get a check-up with their GP”.
Patient information meetings
The Irish Heart Foundation will hold two public information meetings on HF in the coming weeks. The meetings are suitable for people with HF and their families, healthcare staff and anyone with an interest in HF.
The evening will feature talks by leading medical experts from University Hospital Waterford, including Consultant Cardiologist Dr Pat O’Callaghan, to increase awareness and understanding of the condition. The Foundation will launch a HF support group at this meeting.
Date: Thursday, 19 April.
Location: Woodlands Hotel, Dunmore Road, Waterford.
The evening will feature talks by leading medical experts from the Mater Hospital, Dublin, including Consultant Cardiologist Prof Niall Mahon, to increase awareness and understanding of the condition.
Date: Thursday, 12 April
Location: Ashling Hotel, Parkgate Street
The Irish Heart Foundation also runs a National Heart and Stroke Helpline staffed by specialist nurses. Freephone 1800 25 25 50, Monday to Friday, 9am-5pm. A range of patient support and information booklets are available at https://irishheart.ie/publications/.
Dr Neil Martin is a medical advisor to the world-class performance programme for British swimming and many other UK national teams and elite sports, and manages asthma for a number of international athletes and sports teams.
He attended medical school in Edinburgh before training as a chest physician through the UK’s Royal Navy in Edinburgh and served as a Medical Officer with the Royal Navy, where he developed specialist interests in diving medicine, submarine medicine and undertook a tour of Afghanistan.
Dr Martin started as a Consultant Physician in 2011 at the Glenfield Hospital, Leicester, where he continues to carry out clinical duties one day per week, while he also works for GSK’s Global Medical Expert Team of the Respiratory Franchise. He was in Ireland recently on behalf of the company to talk to respiratory physicians in a number of hospitals about treating refractory asthma and how to use the new anti-interleukin-5 (IL-5) biologics to do so.
In an interview with the Medical Independent (MI), he emphasised that having asthma should not prevent athletes from reaching their full potential, once properly managed, and that all patients should aim for optimum asthma management, whatever their circumstances.
“I think asthma in general is something we need to get better at managing. I think if we look at the last 10-to-15 years in the general asthma population, we have had good guidelines and good medications for asthma… but we have had no impact on the prevention of asthma deaths in the same time point, so we are at a bit of an impasse. We are making the same mistakes again and again and we are trying to push and develop better treatments for asthma patients but actually, fundamentally, we need to be making sure we are using the treatments we’ve actually got to the best of our abilities,” he said.
Dr Martin noted that medication compliance is a key issue in optimum asthma management and that therapies must be as straightforward to use as possible.
“Patients’ adherence to medication is a big factor in terms of asthma control. How we structure asthma services and communicate to patients is another big factor. But I think in asthma in general, doing the basics well is what we need to do. So we have good guidelines and good medicines but what we need to do is translate those good guidelines into good clinical practice.
“The things we need to do are educate our clinicians better, so that is [in] primary care in terms of GPs and nursing staff, educate our patients better in terms of what the disease is and how we treat it, and really look at control as a key thing we concentrate on, so we want a control-centred approach.
“The last thing is to tackle non-adherence to asthma medication, because non-adherence to medication is by far one of the biggest risk factors for asthma deaths or serious exacerbations of asthma,” he told MI.
Dr Neil Martin
Dr Martin pointed out that while some children can ‘grow out’ of asthma in adolescence, “as an adult, growing out of your asthma is a rare thing. So asthma is a life-long condition. The challenge for asthma patients is that once they feel better, they stop taking their treatment and invariably, there will be a period of time where they are building up inflammation of their lungs, they have an exacerbation and they go back onto their treatment. People will continue to do that.
“The idea for patients is, feeling like you don’t have asthma is entirely what we are trying to achieve with your medicine, so the whole point is that we are trying to remove barriers to your daily life.
“When you talk to most asthma patients and you ask them ‘how’s your asthma?’ [They answer] ‘it’s fine’. But actually, when you ask them a structured question about control of their asthma, many of these patients will have poor control and the reason their control is poor is because they have adapted their lifestyle to their asthma.
“They’ve stopped doing things that will set-off their asthma symptoms. They no longer exercise, they no longer go into dusty environments, they don’t play with their grandkids, they don’t run around with their kids.
“So they adapt their life around poor asthma control and they think they are fine, that ‘well, I should be like this, I’ve got asthma’. But realistically, our goal of asthma treatment and the international guidelines is that you feel you don’t have asthma, and you feel you don’t have any side-effects from your medicines. And in many patients, that guideline-defined total control is possible. But we just need to get patients and doctors to understand that that is where we need to be… ”
In relation to asthma in sports, Dr Martin acknowledged that while there had been some concern over asthma medication and performance enhancement, the World Anti Doping Association (WADA) in 2012 decided that none of the asthma inhalers created performance advantage, that they “were standard asthma medications” and did not need therapeutic use exemptions, just a threshold for their use.
“Pretty much now most standard asthma medications you can use in competition without any significant paperwork and I think that is the right thing to do. Still, among children, talking about pre-school and infant school children, a diagnosis of asthma links into a life-long level of inactivity. So little kids running around getting wheezy and instead of effectively treating them, again they adapt their lifestyle.
“Parents, teachers — everyone is well-meaning but they limit what they do in case it might set-off their asthma. That generates into life-long physical inactivity. We have an obesity epidemic in adults anyway, and therefore those kids will go on to be less active adolescents and adults…
“What we need to be doing is maximising their treatments and allowing them to do what they like, and that is exactly what we do with athletes — we maximise the therapy that they require to allow them to continue to compete at the highest level, and that is what [all] asthma patients should be trying to achieve for themselves.”
Dr Martin also noted that the British Thoracic Society (BTS) guidelines on asthma had recently seen a major revision across a number of areas, including a significant update to the section on pharmacological management of asthma, and updates to the sections on supported self-management.
“The BTS guidelines last year moved to treatment with inhaled corticosteroids for six weeks, with a structured clinical assessment before and afterwards to try and assess asthma control… open-ended questions such as ‘how do you feel?’ are very ineffective in all areas of medicine… we need objective measurements, such as an asthma control score, evidence of lung function change, reduction in exacerbation frequency, so we need to move to that structured assessment for all patients,” which allows for a step-wise approach to management.
Some long-diagnosed asthmatics never gain proper control of their asthma, he pointed out, and this needs to be addressed, with a reassessment of their diagnosis vital.
“Einstein’s definition of insanity is doing the same thing over and over again, expecting a different result. So by the time you are on your fourth or fifth asthma medication and they haven’t got better, maybe we’re not treating asthma.”
Exacerbations for refractory patients are a significant issue and are costly, both economically and physically on the patient. So while working to reduce exacerbations has a cost, “it is cost-effective” as there are long-term savings.
About 5 per cent of asthma patients are refractory, which can be due to incorrect diagnosis, non-adherence to therapy or unsuitable therapy, or they may have a comorbid disease, Dr Martin explained.
Once a patient is determined to be truly refractory, however, there is now the option of biologic treatment, he outlined, describing it as “the dawn of a new era for respiratory medicine”.
“It has been a very complex pathway [to biologic use] … with unmet need for patients with recurrent exacerbations and hospital admissions, some of them life-threatening admissions, driven by eosinophilic inflammation, and we have no effective therapy for that.”
He said the development of the anti-IL-5 agent mepolizumab, a humanised monoclonal antibody used for the treatment of severe eosinophilic asthma, for example, sought to address that.
“We are at the stage now where we have more and more biologics for asthma coming onto the market. We are probably a decade behind our rheumatology colleagues [regarding biologics]. I think we are, as a group of clinicians, cautious. We tend to look for things that are cost-effective. We don’t want to spend the taxpayer’s money unnecessarily, but I think there is a groundswell of opinion now that these biologic agents really are the answer for a lot of the complex things we’ve seen at the severe end of the asthma spectrum.”
It is hoped that anti-IL-5 therapy will finally be reimbursed for severe asthma in Ireland this year by the HSE. It has been available in many other European countries for a number of years, Dr Martin noted.
“I think there is certainly a need for anti-IL-5 therapy for patients in Ireland. The academic centres we have been to [in Ireland] have all expressed a desire to get going. They have patients who are waiting for treatment… ”
However, he acknowledged that healthcare budgets are under increasing pressure, “so there is a challenge there for us physicians to use the medicines correctly, there is a challenge for us to do the simple things well so the patients don’t necessarily need the complex medicines and there is a challenge back to the pharma industry to make things more cost-effective, to reduce the costs of medicines, so we have to work together to do that… the balance has to be right”.
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