Very sad to hear of the passing of Dr David Sturgeon, retired consultant liaison psychiatrist.

https://www.theguardian.com/society/article/2024/jul/09/david-sturgeon-obituary

I remember SO clearly my placement as a 4th year medical student, on Dr Sturgeon’s Liaison Psychiatry team at UCLH.

Until that point I had in mind I might be an Orthopaedic Surgeon. I had no concept of psychiatry as a career. In truth, I’d not really encountered severe mental illness, certainly not with my eyes open. I had no idea what to expect.

We began the day by going, not directly to the ward, but to a coffee shop on Tottenham Court Road. He bought all 3 or 4 of us students a hot drink. This was unheard of generosity! We sat down to have a conversation….

He said something about what to expect, and steeled us a little for the day ahead. I don’t remember his words entirely, I was still so shocked that a consultant had bought me a coffee and wanted to interact in this human way, with us.

Feeling entirely at ease, I followed him to an acute medical ward, where we met a patient who had made a serious attempt on her life. Again, I was naive, and this was pretty shocking stuff. How could anyone be this desperate? How would you begin to explore the story?

Immediately, in the quiet side room, I observed a process I had never before encountered. An intoxicating mix of compassion, thoughtfulness, inquisitivity, patience, & deep, deep understanding. He seemed to KNOW her immediately, reading her effortlessly. They had never met before.

Psychodynamic interpretations flowed. The emphasis was not on illness, and cure, but shared sense-making. He showed me the biopsychosocial formulation, live.

On we went to another complex patient, whom the surgical team believed was “interfering” with their own recovery by opening up their wounds. My jaw must have been on the floor when I watched him at work. Effortlessly kind and curious in equal measure.

This was the first day I wasn’t bolting for the door to go to a social event, sports, or the pub…. I was mesmerised and wanted to see more.

I think the placement was 4 weeks, but I was won over to psychiatry in that very first morning. This was revolutionary stuff for me. A privilege to watch someone so masterful in their communication, with such purpose and a determination to explore emotional difficulty, head-on.

It was THE turning point in my medical education, without a doubt, and perhaps the most profound of introductions I’ve ever had.

As with all the most inspirational teachers, Dr Sturgeon had made me feel like I was being handed a baton; that the encounters had been for ME, as well as the patients. That I was part of a core tradition of inter-generational learning.

He seemed to have all the time in the world, for the patients, and for us as students.

This obituary shows I was far from the only doctor in training to have such a formative experience. Dr Sturgeon must have given 100s if not 1000s of such impressions over decades of teaching.

And the truth is, I’ll be happy if only ONE student feels as inspired by me as I was by him, back in 2005.

Rest In Peace.

Attending the Paediatric Mental Health Association (PMHA) Winter Conference today, I have enjoyed a talk from Dr. Barry Coughlan, British Academy Research Fellow, University of Cambridge. My notes from this follow:

IMPORTANT STARTING POINT:

• Conceptualising maltreatment is difficult
• Conceptualising mental illness is difficult
• Lots of child maltreatment is never recognised, and no intervention is made

BEST EVIDENCE REVIEW SHOWS :

• Between 12-35% of people report maltreatment in childhood
• Maltreatment is a robust predictor of mental health problems
• The magnitude of associations vary, according to different meta-analysis

Question arises: which forms of maltreatment predict which mental illnesses?

MULTIFINALITY – A given maltreatment experience can have a range of different outcomes

EQUIFINALITY – A range of maltreatment experiences can have the same outcome

RESEARCH FINDINGS:

Contrary to conventional wisdom, the results do not support that some maltreatments are more likely to contribute than others – Associations are similar across the board (internalising vs externalising)

Those on CP plans / Looked after children are (approx. 3x) more likely to be in contact with MH services than those not.

More likely to be referred with DSH/Conduct/Attachment/PTSD

Less likely to be referred with Psychosis/Eating Problems/OCD/Phobias

50% of looked after children experience MH symptoms. But many have no contact with appropriate services – only approx. 20% are in contact – and fewer still of these will be receiving an actual intervention.

Negative Affectivity – view of oneself and the world are generated by the maltreatment, this then predisposes to patterns of negative thinking.  NA is a broad personality trait that refers to the stable tendency to experience negative emotions (Watson & Clark, 1984) – a heightened likelihood to experience negative emotions such as worry, apprehension and sadness.

??Double Jeopardy?? – A question to be explored is whether neurodiversity serves as an additional risk factor – ie if there is ASC/ADHD etc, will any maltreatment be magnified in impact?

We discussed the fact that there have been far more presentations (anecdotally) of disordered eating since the pandemic – as a form of self harm, or “care seeking” – as opposed to a clear mental health disorder, such as anorexia nervosa.

Some areas of the country will have dedicated mental health teams who attend to children in care – but this is not universal

TAKE HOME MESSAGE:

• It is clear that maltreatment is a major risk factor for mental illness in childhood – and therefore in later life, too.
• EARLY Investment in mental health provisions for this group, will clearly be time and money well spent.

Here is a fantastic and FREE range of resources – video testimony of patients, concerning their physical and mental health conditions. Understanding that the lived experience is every bit as important as an understanding of the science behind them. There is a whole subsection on Young People’s experiences (eg Type 1 Diabetes, Acne, Eating Disorders. I have embedded below just one example – the lived experience of psychosis.

Psychosis (young people)

The following has been written for my local colleagues working in Child and Adolescent Mental Health Services (CAMHS), and our patients. The hope is to explain to young people and parents/carers that diagnoses and medications are not the only ways to receive help. We live in an increasingly medicalised world, and we need to keep a broader perspective on childhood distress.

The primary approach in managing emotional difficulties in young people, as well as adults (be it stress, anxiety, low mood, behavioural challenges) is through ‘Talking Therapies’. There are a range of these, (from individual, to family, to group based) and we need to take time to determine which type of these therapies might be suitable for each young person, and also where these should be delivered. There are many providers outside of CAMHS that can deliver such therapeutic approaches and it is not uncommon for us to recommend that help is received elsewhere.

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Child and Adolescent Mental Health Services use a “bio-psycho-social” model of assessment and treatment. In short, this means that every assessment should consider the aspects which relate to brain development, emotional factors, and aspects to do with the child’s environment.
Commonly, what is needed is a change around the child, rather than a change within them. Parents/carers may need additional support in how to manage their own responses to the child’s distress.
It is especially important that we avoid “pathologizing” distress which might be situational (caused by modifiable factors in the child’s environment) and/or natural, for example a response to bullying, or bereavement. The child may need additional support at school, for example, to benefit their learning.

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Families and young people may come to CAMHS expecting a “diagnosis”. They may leave from an appointment with a sense of disappointment if this has not been given. In all fields of medicine it is recognised that symptoms do not necessarily fit into diagnostic criteria. Many symptoms (abdominal pains, for example) will come and go. Particularly in children, who have developing brains, we may choose to watch and wait before giving a particular descriptive term, if at all. Labels can be damaging if they are seen to define a child. So, in CAMHS we make “needs based” plans, in the hope of being clear about how we might improve the quality of life for young people we care for.

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Families may also hope that there might be a “medication” fix. This understandable. Medications can be life changing. However, it is important to note that in some difficulties, they will not play a role. For example, there is limited evidence base for the use of “psychotropic” medication in neurodevelopmental disorders such as Autism, unless there is an additional mental illness.
Regardless, it is most likely that before any medications are considered, the young person and their family will be advised to follow non-medication approaches (for example good sleep hygiene techniques).
All medications come with potential side effects, and some of those used in mental health, can cause a worsening of mood state. It is very unusual that medication is an appropriate first step. The National Institute of Clinical Excellence (‘NICE’) guidelines are followed closely in our team.

This is a superb video about how Mental Illness in a parent or carer (considered to be an “Adverse Childhood Experience”) can impact on the emotional wellbeing of a child or adolescent. Also how early intervention and support for the whole family is crucial. Made in Collaboration with Devon Partnership Trust, and in particular Dr Jo Black, consultant perinatal psychiatrist.

Produced by ForMed Films CIC

Incredibly grateful for two of our expert patients, Astro and Malcolm, who have generously shared their stories here about being helped by CAMHS. They are both instrumental in supporting our services now – sitting on interview panels, and helping shape our services. They also give sessions for our medical students to educate the next generation of junior doctors. Please take a look at their videos:

The Royal College of Psychiatrists have run a successful campaign overseen by Dr Kate Lovett, to promote psychiatry as a career to medical students and junior doctors. It’s had a major impact, improving application rates significantly. Here is the latest recruitment video:

https://www.rcpsych.ac.uk/become-a-psychiatrist/choose-psychiatry

On Good Morning Britain in August of this year, there were some extraordinary claims made. The mental health charity STEM4 had published results of an online “survey” which appeared to suggest that as many as 37% of 12-18 year olds were taking / had been prescribed antidepressants.

This story was run by GMB in rather sensational fashion:

An exclusive GMB survey with charity Stem4 has found that 4 in 10 young people between 12 & 21 have been prescribed antidepressants for their mental health difficulties.@drniharakrause tells @kategarraway & @richardm56 that the 'prevalence of mental ill health has been rising.' pic.twitter.com/jTmOPfV2Oa

— Good Morning Britain (@GMB) August 3, 2022

I, and other child psychiatrists raised immediate concerns about this data. I approached STEM4 to understand how this survey had been conducted, and found the explanations wanting. This was not credible research. NHS data shows that rates of prescribing of antidepressants in young people sits somewhere in the low single figures – perhaps 10x less common than was being suggested.

The problem here was that a single study (with no robust scientific planning that I could be shown) was being used as an eye catching news story, hugely distorting the realities of the clinical situation. It’s findings went against the evidence from a number of large and credible data sets.

I was pleased to liaise with BBC “More or Less” show, who looked into this in greater depth. Their findings are available in today’s excellent show, “debunking” the claims – please have a listen:

https://www.bbc.co.uk/sounds/play/m001cq31

Why does this matter so much? Many young people are particularly vulnerable at present. We know the prevalence of all mental disorders in young people is on the rise. There is no doubt, for example, that rates of anxiety are increasing. However, it is essential that normal human experience is not pathologised. The pandemic has caused huge disruption and uncertainty. Many young people are feeling unsettled. This is compounded perhaps by the war in Ukraine, financial instability, and the climate crisis, to name just a few subjects which are at the fore of many young people’s minds.

A distressed teenager might read such a headline and think: “Am I ill, too?” or “Why is it that I can’t have medication, when others are?”. Parents may press GPs and CAMHS services to prescribe, even when the evidence for doing so is not there. The rates of private prescriptions of drugs like Fluoxetine might (ironically) rise as a result of this sensationalisation.

The key lessons here: 1) We need more research in the area of child and adolescent mental health 2) We need those advocating for young people to do so on the basis of sound evidence 3) We need journalists to exercise caution, and question the reliability of such claims.

Increasing numbers of children and young people are requiring admission to paediatric wards with restrictive eating, and physical compromise.

This is a FICTIONAL account of a multiprofessional discussion regarding Nasogastric feeding, and the potential for restrictive practices and restraint, with consideration of legal frameworks.

Those involved in this teaching are clinicians involved in this work regularly. The video itself forms part of a teaching day run by the Royal College of Paediatrics.

https://charliewaller.org/mental-health-resources/managing-difficult-feelings/help-for-young-people-worried-about-self-harm

The Charlie Waller Trust, Young Minds & Royal College of Psychiatrists produced a range of mental health resources around Self Harm in 2016, including some fantastic videos to raise awareness and bring hope to those suffering. These resources were under the banner of “No Harm Done: Things Can Change”. We are now looking to update the information alongside these videos. Please take a moment to view the pages and send any feedback here, particularly if you are a young person or carer for whom this is directly relevant.

Thank you.