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The Royal College of Psychiatrists Improving the lives of people with mental illness

Quiz!

 

Try being a Psychiatrist

You are called to A+E to assess a 70 year old man who has taken 50 paracetamol and his supply of antidepressants. He has had depression for many years. He had been saving the tablets for some time and left a suicide note. He tells you he does not want to go on since the death of his wife from cancer. He is medically stable following his overdose.

 

What is his risk of a further suicide attempt?

a)       low risk

b)       high risk

c)       no risk

 

 

Which of these factors contribute to an increased risk of suicide?

a)       depression

b)       male gender

c)       older age

d)       all of the above

 

 

What would you do?

a)       give him another supply of antidepressants

b)       send him home and write to his GP

c)       admit him to the psychiatric ward

 

Answers

 

1. The risk is high

2. His risk is increased by:

  • being male
  • being an older adult
  • having a diagnosis of depression
  • having suffered a recent bereavement
  • having planned his suicide attempt (saving the paaracetamol)
  • having thought he would succeed in killing himself (leaving a suicide note)

 

3. The best course of action would be to admit this gentleman to the psychiatric ward for assessment and further management. You should not give him another supply of antidepressants to take home as he could overdose with them again. He should not be sent home as he could harm himself before you can contact his GP.

 


 

You are asked to visit a 76 year old lady at home who is having problems with her memory. Her memory has been deteriorating for several months and she is forgetting important dates and names. Sometimes she gets lost when she is walking back from the shops.

 

What is the likely diagnosis?

a)       old age

b)       anxiety

c)       dementia

 

 

What information would you like to confirm the diagnosis?

a)       history from a relative or friend

b)       memory testing

c)       physical examination and blood tests

d)       all of the above

 

 

What other professionals may be involved in assessment and management?

a)       social worker

b)       community psychiatric nurse

c)       psychologist

d)       all of the above

 

Most people with dementia live:

a)       at home

b)       in a residential home

c)       in a nursing home

 

 

Answers

 

1.  The most likely diagnosis is c. dementia. People can become more forgetful in old age but this is much less severe than in dementia. Anxiety can make it difficult to concentrate and therefore make people feel that their memory is terrible but it would be unlikely for them to lose their way home.

 

2.  d. It is important to do all three. Information from a relative or friend of the patient is important as they may have noticed additional symptoms or may remember things that the patient has forgotten. A formal memory test should be carried out to determine the nature and degree of the memory loss. A physical examination and blood tests are important as physical conditions can cause or have an influence on dementia, for example a stroke can affect people’s memory.

 

3.  d. Assessment and management of a patient with dementia involves the whole multidisciplinary team. A psychologist may perform special memory tests. A social worker may be involved in assessing whether the patient needs to move to more suitable accommodation. A community psychiatric nurse may monitor the patient in the community and help educate their family about dementia.

 

4.  a. The majority of patients with dementia live at home. However, when some patients deteriorate it is necessary for them to have more support and help and this can be provided in a nursing or residential home.

 

 


You are a recently qualified doctor, and are currently in your Psychiatry rotation. You are asked by the staff in Accident and Emergency to see a 20-year-old woman, who has taken an overdose of paracetamol, though has no significant physical complications as a result.

 

When you arrive in A and E you are told she has recently split up with her boyfriend and drank a bottle of vodka before taking the overdose.

 

How do you approach the situation?

 

1.     Tell her everything’s going to be alright and arrange for her to go Home: this is just a “cry for help”

2.     Immediately arrange for her to be admitted to hospital after spending 10 minutes talking to her

3.     Tell her that she has wasted the doctors’ time, and that she should behave better in future

4.     Take a full history of events prior to the overdose

5.     Take a medical history and personal history, trying to understand how she copes with life stressors

6.     Ask about symptoms of psychiatric illness, eg depression and further thoughts of suicide

 

Answers

 

1. A number of healthcare staff have this attitude regarding self harm, and though this may be a cry for help, and a direct result of her getting drunk in he context of a life stressor, it is important to rule out any evidence of psychiatric illness (eg underlying depressed mood) that pre-dated the overdose. She may have done this before, and is at a considerably higher risk of committing suicide than other members of the population (up to 50 times)

 

2. Arranging for her to come into hospital may well be necessary, but bear in mind that it may be equally detrimental. You need to take a good history from her to see if this would be useful, and if you are going to admit her to hospital what are you going to offer her?

 

3. Believe it or not, this is still a response of some staff. Do you really think this is going to help her, or help in the doctor-patient relationship?

 

4. This is useful: did she take the overdose in secret, did she write a will, did she regret taking the overdose afterwards, was she intoxicated, was she hearing voices telling her to kill herself?

 

5. Again, this would aid you in finding out precisely why she took the overdose, does she react to all life stressors in this way, has she had a difficult upbringing, has there been a recent bereavement, does she have a medical condition that would predispose her to depression, eg epilepsy?

 

6. Yes, this is necessary: is she suffering from a depressive illness that has resulted in her feeling low in mood, made her energy levels lower and meant that she couldn’t enjoy things she used to? Did this cause her relationship to end? Does she have plans to commit suicide at the moment, and does she have the necessary means?

 

She tells you she has felt low since the death of her grandmother a year ago, who brought her up following her parent’s messy divorce, her father being an alcoholic. She recently lost her job as a hairdresser, feels “low” most of the time and does not enjoy things she used to, like playing tennis. Her energy levels are low, she does not eat and has dropped down 2 dress sizes to an 8. She feels “silly” about the overdose, which she took after her boyfriend left her. Her boyfriend turns up, and explains how she has become more irritable, but now wants her to come back home. She relates well to him, and says she does not want to come into hospital but would happily go to an outpatient appointment.

 

There are no other symptoms of psychiatric illness.

 

 

What do you do?

 

1.     Give her an antidepressant prescription and arrange an out patient follow-up

2.     Detain her under the Mental Health Act and bring her into hospital against her will?

3.     Arrange counselling for her at her GP practice

4.     Ask her to go see her GP when she leaves hospital

5.     Explain to her that you think she is depressed, and explain the factors that cause depression, using this as a model for treatments that can include antidepressants, talking therapies and involving family members and close friends

 

 

Answers

 

1.You could consider this, but do you not think option 5. looks better? Also, all antidepressants take at least 2 weeks to work, and have side effects: they should not be started without careful thought and without involving the patient in their own treatment

 

2. Given the description above, you would be on shaky ground here: depending on where you live in the UK there are different rules governing detention. However, if the patient does not pose a serious risk to themselves or others and you think they could be looked after in the community detention would not be warranted (or appreciated by the patient)

 

3. This may be useful for her though given her symptoms and story, it would be better for her to receive a more focused treatment for depression, which might include other forms of talking therapy and/or medication

 

4. Again, this may be all that is required:  should speak to her GP about her case, or send a prompt letter telling them about her case, and then make a joint decision about how best to arrange follow-up care. The GP may well have seen her with these symptoms before, or equally may not have a lot of experience with mental illness and value a further specialist opinion

 

5. This seems like a sensible approach doesn’t it? Depression has a number of different causes, that usually interact with one another to produce a depressive episode: biological (eg certain genes types, certain illnesses affecting hormones in the body), psychological (people’s ways of looking at situations are shaped by their life experience and certain ways of thinking can predispose one o depression) and social (bereavements and different types of abuse make depression more likely to occur). Targeting treatment at these factors can not only treat depression but also prevent it recurring.

 

 

How much do you know about Psychiatry?

1. Do you believe that people who are depressed?

 

a.        Should pull themselves together

b.        Are weak

c.        Need help and support

d.        Have only themselves to blame

 

 

2. To become a psychiatrist, which of the following must you study after A levels?

 

a.        Psychology

b.        Anthropology

c.        Medicine

d.        Psychotherapy

e.        Sociology

 

 

3. How many people on average will experience a problem with their mental health at some point in their life?

 

a.        1 in 2

b.        1 in 4

c.        1 in 100

d.        1 in 1000

 

 

4. Which of these would a psychiatrist not deal with?

 

a.        Depression

b.        A heart bypass

c.        Learning disabilities

d.        Anorexia

e.        Autism

 

 

5. Where can psychiatrists work?

 

a.        Hospitals

b.        Residential Homes

c.        Prisons

d.        Schools

e.        Courts of Law

f.         All of the above

 

 

6. How long does it take to train to become a psychiatrist after medical school?

 

a.        About 3 years

b.        About 5 years

c.        About 8 years

d.        About 10 years

 

7. What qualities does a good psychiatrist need?

 

a.        Good communication skills

b.        Scientific background

c.        Genuine interest in how people think and feel

d.        Good investigative skills

e.        All of the above

 

 

8. Which of these would a psychiatrist not treat?

 

a.        Adolescents

b.        Adults

c.        Children

d.        Animals

e.        Older people

 

 

9. In terms of public health, which psychiatric disorder is most common?

 

a.        Schizophrenia

b.        Depression

c.        Eating disorders

d.        Drug addiction

 

 

10.  Which of the following categories of person are vulnerable to developing mental illness?

 

a.       People of low intelligence

b.       People with weak personalities

c.       Older people

d.       Everyone

 

 

Answers

 

1.c        2.c        3.b        4.b        5.f         6.c        7.e        8.d        9.b        10d

 

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