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
Which of these factors contribute to an
increased risk of suicide?
d) all of
What would you do?
him another supply of antidepressants
him home and write to his GP
him to the psychiatric ward
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
- having thought he would succeed in killing himself (leaving a
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?
What information would you like to confirm the
from a relative or friend
physical examination and blood tests
d) all of
What other professionals may be involved in
assessment and management?
community psychiatric nurse
d) all of
Most people with dementia live:
b) in a
c) in a
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
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
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
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
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
There are no other symptoms of psychiatric
What do you do?
1. Give her an
antidepressant prescription and arrange an out patient
2. Detain her under
the Mental Health Act and bring her into hospital against her
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
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
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
a. Should pull
b. Are weak
c. Need help and
d. Have only
themselves to blame
2. To become a psychiatrist,
which of the following must you study after A
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?
b. A heart
5. Where can psychiatrists work?
e. Courts of Law
f. All of the
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
7. What qualities does a good psychiatrist
c. Genuine interest
in how people think and feel
e. All of the
8. Which of these would a psychiatrist not
e. Older people
9. In terms of public health, which
psychiatric disorder is most common?
10. Which of the following categories of
person are vulnerable to developing mental illness?
of low intelligence
with weak personalities