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

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11/09/2014 17:01:05

Assisted Dying for the terminally ill: the debate continues


  • Annabel Price,  Consultant Liaison Psychiatrist, Cambridge
  • Simon Wessely, President RCPsych

On 18 July, after a ten hour debate involving 130 members, the House of Lords allowed Lord Falconer’s Assisted Dying Bill to pass through Second Reading to Committee stage. This means that the Bill will now be scrutinised line by line and amendments proposed before moving to Report stage. This process is likely to happen over the Autumn.


The Assisted Dying Bill 2014 is a Bill to enable terminally ill, mentally competent adults to end their own lives by self-administration of a lethal medication with physician assistance. 


This is the fifth attempt to pass a Bill in England and Wales allowing physician assisted suicide for the terminally ill, and the second attempt to pass this particular Bill (which was first tabled last year but time did not permit debate). Previous Bills have not passed through second reading so this is the furthest an assisted dying Bill has progressed in England and Wales.


The Assisted Suicide (Scotland) Bill is also currently in process though Scottish Parliament having been tabled in November 2013 by the late Margo MacDonald MSP.


The Assisted Dying Bill (England and Wales) proposes that a patient requesting assisted suicide would be assessed by two doctors to determine that they a) are terminally ill (have a progressive incurable condition who would not reasonably be expected to live beyond six months) b) have the capacity to make the decision to end their own life and c) have a ‘clear and settled intention to end their own life which has been reached voluntarily, on an informed basis and without coercion or duress’.


As with previous Bills in England and Wales, and in line with jurisdictions where assisted suicide is permitted, there is a clause whereby doctors would be able to conscientiously object to involvement in the practice were it not compatible with their own values or beliefs.


We are aware that psychiatrists will hold a range of views on the legalisation of assisted suicide for the terminally ill. Indeed, in the August RCPsych eNewsletter members were invited to take part in a vote, albeit a fairly crude one, on this matter - but we can anticipate a polarisation of views, just as was visible in the impressive House of Lords debate on the Bill.


Whilst our individual views and consciences will guide our own participation if assisted suicide were legalised, the role of the College is to consider only those issues that are specific to the profession of psychiatry.  So it is reasonable that the College should assist in the on-going debate on matters that are directly fall within our specific expertise.  Individual members are of course free to express their own views in which ever way they chose – be it lobbying their MP, writing to members of the House of Lords, or even for the privileged few, speaking in the Lords itself.  What we set out to do in this blog is make some observations relevant to the debate, from the perspective of psychiatry.


We start with some cautions. It seems likely the role of the psychiatrist will if anything be fairly limited. If the experience of jurisdictions where assisted suicide is legal is echoed in England and Wales, psychiatrists will be infrequently consulted for second opinions where mental capacity is in doubt and or there is concern that mental disorder is impacting negatively on the patient or their decision making. This Bill does not make psychiatric assessment mandatory or even recommended in cases where capacity is in doubt, in other words we are not following the Oregon example. But nevertheless, it is likely that there will be occasions when psychiatric assessment will be indicated.


The key issues of relevance as we see it relate to the determination of mental capacity, the psychological impact of advanced progressive disease and the phenomenon of response shift, the factors that impact upon on the desire for hastened death in the terminally ill and lastly the stability of desire for hastened death in patients with terminal illness.


  • Mental Capacity

In clinical practice psychiatrists are frequently asked to support to colleagues in determination of capacity in physical health settings. The Bill construes mental capacity according to the Mental Capacity Act 2005 and specifies that capacity is assessed at two points during the process, firstly at the time the person is making the request, and secondly at the time they intend to ingest the lethal medication. There is no guidance within the Bill beyond reference to the Mental Capacity Act as to how capacity should be determined, what standard of competence should be reached, or any specific considerations in assessment of capacity for this decision. Variation in concepts of capacity for assisted suicide have previously been identified in experts presenting to the 2010 Commission on Assisted Dying and no further clarity has been given within the wording of the Bill. It only states that the Secretary of State may issue guidance in this area. The recent report of the post-legislative scrutiny of the Mental Capacity Act 2005 showed that the intended principles and provisions of the Act are not always followed in practice and a survey of psychiatrists in Oregon showed that individual values influence individuals’ ideas of how stringent standards of competence should be. In our opinion this suggests that without clear standards of competence and assessment and reporting processes there is a risk that this safeguard will not work as intended. 


  • The psychological impact of advanced disease

Diagnosis of potentially life limiting disease and the progression to non-cure focussed care in more advanced disease are often times of great distress which for some will be accompanied by the desire for death and suicidal thoughts.  Few maintain these high levels of distress and those familiar with patients with progressive disease will have witnessed the adaptive processes that can take place even in the face of great physical limitation. Situations that could not prospectively be countenanced can be still result in successful adaption when they do occur, a process known as “response shift”.  An acceptable or even good quality of life can still return even in these situations of severe adversity. Desire for hastened death in terminally ill patients is uncommon and, for the majority transient, and strongly associated with depression and the experience of distressing physical symptoms, and there is evidence to show that antidepressants are effective in the treatment of depression for patients with life limiting disease


Experience with patients in other contexts also shows us that suicidal thoughts and intent are often fluctuating and rarely fixed. The determination of a ‘clear and settled intent’ is not straightforward and much may change with time, good symptom management and treatment of remediable depression, even if prognosis is short.  Thus a “one off” assessment over a relatively short period of time may not give a true picture.  


  • Conclusion

We believe that the above observations are relevant to the current debate, and hope that these concerns will be heard and reflected on. We will continue the debate at the October meeting of Council, and will continue to keep the membership informed, as well as welcoming comments and feedback.


But whether our professional views are listened to or not, the debate will continue. As individuals and citizens we also cannot fail to acknowledge that notwithstanding our appropriate cautions and caveats,  there will still be those who continue to believe that their current circumstances are unendurable and unacceptable.  Each of us will have our views on how we should respond to these situations.  We do not think that the College should take a specific position on this.  Finally, the decision on whether to legalise physician assisted suicide is a matter for Parliament and the Courts. The only position the College takes on this matter at present is that we will always act within the law.

September 2014

08/07/2014 09:40:14

Happiness: The greatest gift that I possess?

Today sees the launch of the Centre Forum’s Mental Health Commission report ‘The Pursuit of Happiness: A New Ambition for our Mental Health’.  I won’t be there, as by the time you read this I will be struggling on my bike up French hills, but having given evidence and seen the final version, the report is to be welcomed. This comes as no surprise as our previous President, Sue Bailey, was a commission member.

The report enthusiastically embraces the concept of public mental health. This is unequivocally ‘A Good Thing’, as Sellars and Yeatman would have said in 1066 and All That.  And indeed, there are passages that might just as well have been lifted from the College’s own report No health without public mental health.  

Mental health is an important public health issue (RCPsych, 2010) since mental disorder is responsible for an astonishing 23.6% of the years lost to disability in the UK – the second largest cause behind musculoskeletal disorders (Murray, 2013). Such a large burden of mental disorder is due to a combination of high prevalence, early onset in the life course, and broad range of impacts including in public health related areas. These impacts result in an annual cost to the English economy alone of £105 billion (Centre for Mental Health, 2010) and, looking further afield,  annual global costs of US$2.5 trillion (Bloom et al, 2011) and €532.2 billion in the European Union (Olesen et al, 2011). Vastly more importantly, this represents a wealth of human suffering.


We know that many of the problems we face can best be tackled taking the population as a whole. Hence the College has and will continue to support not just the development of alcohol treatment services (currently in some disarray), but also the policy of Minimum Unit Pricing - currently out in the long grass, but we hope to see it back in play.


Likewise, we know good public health depends on good information, which includes the local size, impact and cost of the intervention gap for treatment of mental disorder, prevention of mental disorder and associated physical illness, and promotion of wellbeing. The impact of this intervention gap is particularly large since only a minority of people with mental disorders (except psychosis) receive any intervention (McManus et al, 2009). Inclusion of such information in Joint Strategic Needs Assessments is vital to inform the decisions of CCGs and Health and Wellbeing Boards, although sadly it’s often missing. Nevertheless, the Department of Health deserves credit for authorising a repeat of the Adult Psychiatric Morbidity Survey, and we hope after some gentle pressure, its counterpart covering children and young people.


And we know that a public mental health approach shows the virtues of early intervention as well as the appropriate coverage of such interventions. So many of the disorders that wreak havoc in adults have their origins in early life - one review of research showed that half of all lifetime cases of diagnosable mental illness, other than dementia, have begun by the age of 14 (Kessler et al, 2007).  Thus the current major disparities in the provision of perinatal services, the subject of another major report published this week, is of concern not just because we need to provide good, timely, local management for mothers with mental disorders but because of the long term effects it has on the subsequent mental health of their children, as Lynne Murray’s work and that of others has shown beyond all reasonable doubt.  


There were many positive areas of focus, such as closing the treatment gap, making workplaces more ‘mental health friendly’, promoting early intervention and the mental health of children, and seeking parity of funding. However, one of the report’s recommendations stood out to me as a pillar of public mental health – encouraging a cross-governmental focus on the wider determinents of mental illness such as employment, housing, welfare and education.


Again, this is an issue firmly in our sphere – as Michael Marmot has powerfully shown, inequality is a key determinant of both mental and physical illness. One of the reasons why many of us are uneasy (and if you think this is an example of British understatement, you might very well think so, but I couldn’t possibly comment) with the Health and Social Care Act is because so many of its provisions seemed designed to increase, not reduce, inequality.  Thus for example the proposal to remove GP practice boundaries in order to allow patients to choose their own GPs will actually widen inequalities under the mantra of ‘choice’ instead of reducing them - as I pointed out in the Guardian at the time.   Likewise, as we debate the ‘’ mess, one of the reasons that I am personally strongly opposed to moving to ‘opt in’ is again because it will disadvantage the poor, ethnic minorities, the marginalised, and those with mental health problems. 


A commitment to public mental health also means a commitment to evidence.  It is one thing to create a mass of correlations, vulnerability factors, predictors of outcome and so on, but it is much harder to know what to do about it.  Back in the Dark Ages when I was studying at the London School of Hygiene and Tropical Medicine, it was drummed into us that collecting evidence was at the heart of all public health, and a commitment to high standards was essential.  It is thankfully policy that no NHS screening programme can be introduced without evidence from high quality RCTs -  an excellent decision.


And we should insist on the same standards for public mental health interventions as well. If we look at the history of broad social interventions, and look for the best evidence, their impact on mental disorders is erratic. Take for example, the extraordinary decade long study by Kessler in which 4604 families were randomised and basically moved from a poverty stricken neighbourhood to one that was distinctly more salubrious.  Indeed, looking at the girls in the study, the results were good - less conduct disorder and less major depression.  Unfortunately the opposite was true for the boys – more PTSD, more depression and more conduct disorder.


At the same time public mental health is also being included in a wider social issue- the current debate loosely around what we might call the ‘wellbeing agenda’.  Few people, and probably no members of this College, can, or will, deny the importance of strong communities, families and relationships, to name but three, to our general sense of well being.   But in my opinion we need to be a little more cautious about mixing public mental health with this ‘dash for happiness’ – and its various facets such as positive psychology, well being and optimism.

There are several reasons for a more careful approach.  All of us want to be happy.  Whether or not this is the fundamental purpose of government is perhaps more contentious -  should government be more concerned with improving schools, creating jobs and reducing crime as an end in itself, rather than a step on the road to happiness?  I am not sure, although I am sure that there is a wide range of views on this - political, social, medical and probably even theological.


But as an academic psychiatrist with a major interest in population approaches, I am not yet convinced that this will do something significant about reducing the burden of morbidity that we deal with – for example disorders ranging from major depression, phobic disorders, OCD, autism, schizophrenia and so on and so forth.  The evidence for this is slender, and largely theoretical, extrapolating from Geoffrey Rose’s lectures when I was doing my epidemiology Masters at the London School of Hygiene rather a long time ago.  He would show how if you reduce the population mean of a particular parameter (for example blood pressure) you would shift the entire curve to the left – in other words reducing the mean also reduces those at the extreme.


So a general improvement in population happiness would hence reduce the numbers of those with severe disorders.  The problem is that there is precious little evidence for this. 

Ideally we could do both.  Support what we traditionally do, and what our patients expect from us, whilst at the same time also lending our support to the broader agendas that are now being looked at by all three political parties.  Unfortunately as we all know “there is no more money”.   And my worry is that the money for the experimental interventions, which is what they are, will come from our own budgets.  I have noticed that is often the case – something that is new, buzzy, smart and promises much tends to be more attractive precisely because it is innovative, and will take resources from what is seen as “conventional”.


We need to put our weight behind the new Health and Wellbeing Boards, speak up for mental health (and I genuinely believe we will find a very receptive audience), but also make sure that there is no raiding of our already over stretched mental health budgets for this. That said, it’s fair to say (as the CentreForum report does) that you can come at this from the other direction i.e. that by treating their mental illness patients will inevitably become happier as their suffering is alleviated. And I certainly can’t argue with that.


So if we have to make choices, we should remain on the side of patients, carers and the evidence.  It’s a difficult balancing act, one that confronts all the three main political parties as they prepare their health manifestos. In the meantime, let’s pursue happiness, but equally let’s not expect that happiness alone will deal with the problem of mental disorder.




29/05/2014 15:27:26

My first blog

Depending on when you read this, I am either about to become, or have just become, the next President of the Royal College of Psychiatrists.  And so I have to produce my first blog, and have been dabbling with various opening sentences.


Sometimes, when I am in a good mood, the words “honour”, “privilege” and “exciting” crowd the page.  At other times, when as now I have just read another article on cuts in services, these are replaced with “challenging”, “tough” and “difficult”.   And finally, when I allow myself a brief moment of honesty, I find myself typing “scary”, “nervous” and even “terrifying”.  But I have just realised that the moment of taking office occurs during our Annual Congress next week, which is taking place at the Barbican in London.  So to reduce my anxiety I have decided to use distraction, and take a wander through the programme on offer.


And what immediately catches my eye is the session for our new “Pathfinder” fellows, presenting at their first Annual Congress. These are a group of medical students/foundation year doctors, who will eventually be 30 in number, selected after a highly competitive process,  to receive high level mentoring and funding to carry out research on any topic relevant to psychiatry.  So my first request as President is for a good turn out for their presentations, starting on Tuesday afternoon and ending Friday morning, and be sure to cheer on our “student of the year” on Friday morning.


But seeing that made me muse about what the rest of the programme might tell them about the current state of psychiatry.


They will be left in no doubt about the prevalence and public health impact of the illnesses that lie at the heart of psychiatry – there are presentations every day about schizophrenia, autism, dementia, depression, eating disorders and so on.  And despite rumours to the contrary, they will discover that diagnosis does matter.  Any lingering doubts that psychiatry is not scientific will hopefully be dispelled, since the science of psychiatry is on constant display from the start to the finish of the conference.  This year one of the threads running through the conference is psychopharmacology.  If the students diligently attend every session, they will find out how to use psychotropic medication wisely, what we know and don’t know about the mechanisms involved, and what might lie ahead in the future.


And if inspired by all the research on offer – ranging from psychopharmacology, epidemiology, social psychiatry, genetics, imaging, neurochemistry, randomised controlled trials, inflammation and much more, they are attracted to an academic career, the single largest workshop is there to assist them and all those on the academic pathway (Thursday afternoon). 


Our Pathfinders will learn that we have close links with, but are different to, neurologists.  I hope they will attend at least part of our annual update on neurology, run as ever by neurologists who secretly wish they were psychiatrists and psychiatrists who wish they were neurologists.  They will need to be there early, because it is invariably over subscribed –starting with Jon Stone’s tour de force on the five minute neurological examination (Tuesday), and moving on to popular updates on neuroimaging, and that wonderful, enigmatic and endlessly fascinating problem that is conversion disorder.


They will see that we are the most democratic of colleges.   We welcome the views of patients and carers – it is not a coincidence that the conference will kick off with a session on “What do patients and carers want from psychiatrists?”  (Tuesday), and will also give patients a platform to debate trust and coercion (Thursday).  Furthermore, not only are we one of the few that elect our officials by universal suffrage, we then expose them to regular grillings.  So come and challenge your College Officers during the Question Time on Wednesday lunchtime –please be as brutal, rude or condescending as you want – I really don’t mind because I will still have 24 hours left to be able to reply “Yes I know, isn’t it awful, and it’s not my fault”.  I think we will probably drop this session next year.


Of course psychiatry, like all branches of medicine, has its trends.  So this year we will be discussing mindfulness, Avatar therapy, compassionate therapy (is there another kind?), and Big Data.


We do not shy away from controversy, even if we sometimes seem to try and hide behind euphemism - so we have sessions on factitious disorder (ie Munchausen’s), confabulation (ie lying), placebos (eg homeopathy) and transgender (ie transgender).   We embrace the social and political (What should we do about stigma? Do veterans deserve special treatment?).   We welcome historical scholarship – not the pointless efforts to prove what ailed Darwin or killed Mozart – but a serious look at the past and its contemporary relevance (Wednesday afternoon).


We recognise that a career in psychiatry is no soft option – you have to work at it, and keep working at it.  Alan Currie will tell us next Tuesday afternoon that it is “a marathon, not a sprint”.  Support for new consultants is vital, and will be on offer, although I need to apologise to Mark Taylor who asked me for my thoughts before his Tuesday talk on “how to stay up to date and sell yourself as an expert”.  My response (“If you find out, please tell me”) wasn’t that much help.  And we give the stage to our retired Great and Good to tell us how it all went right for them in the end (Thursday morning).  


But before you become a consultant, you have to be a trainee. And I hope that all the students looking around the conference in between presenting their papers or standing by their posters, will be reassured from another thread running through the meeting that our College recognizes that its primary function remains training – recruiting, setting standards and supporting trainees.  And it is fitting that our outgoing President, Sue Bailey (about whom more anon) has chosen that her last session wearing the Imperial purple is called “Trainees: The Heartland of Psychiatry” (Friday afternoon).


Most of all, I hope that our guests will take away the endless fascination of psychiatry. In what other discipline could you have four talks on gangs (next Tuesday afternoon)?  Ironically all come from the same institution – our own “Gang of Four”.   Where else could you encounter the twitter phenomenon known as @mentalhealthcop, or Inspector Michael Brown to his friends (next Wednesday afternoon). If he is as good in the flesh as his blog this will be worth the trip alone.


And psychiatry is entertaining.  Hunt and Salter will continue the tradition of the Shakespearean case conference with a debate on whether Ophelia died by suicide.  There will be post match discussions with Raj Persaud after the screening of “Silver Linings Playbook” next Wednesday evening, and a chance to learn what flying upside down really means in psychoanalytic terms after watching “Flight” on the Thursday.   And mention of post match discussion brings me to the post mortem that might follow England’s last match in the group stages late Tuesday afternoon.  If you can’t bear to watch that, we have a wonderful alternative for you - head off to Alex Langford and MEDFEST.  By the way, it took some courage to schedule “Is sport addictive?”  after the results of the group stage will be known  - “aversive” might be nearer the mark, especially given that the last talk in that session is “When athletes retire”.


And when our Pathfinders leave next Friday afternoon, I hope that they concluded that the state of psychiatry is good.  They will have detected the sense of optimism that others have finally started to recognise the importance of psychiatry in the modern health service. Suddenly everyone is talking about long term conditions, GPs are demanding an obligatory training period in psychiatry, and the public clearly want an NHS in which doctors are expected not just to be technical wizards but also decent human beings. “Parity of esteem” seems to be the new mantra.   And best of all, we are about to witness a massive expansion of Foundation Year posts in psychiatry, about which I will have much more to say, including to the organisers of next year’s conference.


No, it’s not plain sailing. Parity of esteem may now be policy, but still we take more than our fair share of cuts.  Recruitment has not recovered from the double whammy of Modernising Medical Careers and New Ways of Working, and will be my main focus for the next three years.  But looking at the breadth, depth, interest and enthusiasm of what we have on offer next week at the Barbican, I hope that we are making the Pathfinders an offer that they can’t and won’t refuse.











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Professor Sir Simon Wessely


Professor Sir Simon Wessely


Simon Wessely is Professor and Head of the Department of Psychological Medicine and Vice Dean for Academic Psychiatry at the Institute of Psychiatry (IoP), King’s College London. He is a clinical liaison psychiatrist, with a particular interest in unexplained symptoms and syndromes.

As Vice Dean he has overall responsibility for undergraduate and postgraduate psychiatry training, and is particularly committed to sharing his enthusiasm for clinical psychiatry with medical students. He also remains research active, continuing to publish on many areas of psychiatry, psychological treatments, epidemiology and military health.