A story to renew our focus for 2025

Details have been changed and anonymised for confidentiality purposes. Alex is not the patient’s real name.

It’s natural that this time of year gives us a moment to reflect on all that has been achieved over the past 12 months – and there is a lot – but it also gives us time to consider what lies ahead for the coming year.

The focus for 2025 must be on treatment and care, as well as increasing understanding of mental illness. In all the discussion about social risk factors for mental illness, sometimes there is a fallacy that this means that clinical treatment is far less important. In fact, just the opposite is true, good clinical treatment is needed now more than ever.

As psychiatrists we are experts in the biological, psychological and social determinants of mental illness. We provide people with timely holistic care to get them back on their feet and remain productive. This not only helps the individual and their families, but frankly, it also helps the nation’s prosperity.

Like many of you, I am becoming increasingly frustrated that individuals are receiving imprecise and unhelpful diagnoses from well-meaning, but inadequately trained, or untrained practitioners...or even apps. Often these diagnoses do not include proper consideration of the antecedent risk factors, protective factors and a formulation etc that will help a person understand why they are unwell; what caused them difficulties in the first place; how their life leading up to the precipitating negative events has impacted on how they are presenting and crucially, how they might best recover...and stay recovered. Being nice and meaning well is just not enough.

I’d like to share with you an example from my clinical work that sets out why patients need skilled and comprehensive assessment with formulation that supports more precise understanding of their individual needs plus early treatment and intervention - before their condition progresses to a stage where addressing the missed diagnoses or inadequate intervention takes longer than treating the original issue.

In my clinical role I regularly undertake assessments. I was asked to provide a second opinion on a patient, Alex, a very senior leader in a multinational company, who had fallen on hard times.

Alex’s difficulties began following a negative work interaction with another senior leader, who informed them that they didn’t like them and didn’t want to work with them, and that most of the other people in the department didn’t like them either (some people will do anything to win an argument).

Alex became increasingly anxious about their engagement with others at work. Their sleep was affected; they began having nightmares; their heart would race and they would become breathless when they had to go to work and eventually, even when they thought of work. This gradually led to them avoiding interactions with their colleagues – something that was inadvertently facilitated by hybrid working.

Eventually, Alex could think of nothing other than their interactions with their colleagues and what they should have, and could have, said. Their concentration was affected, as was their work performance. After nearly crashing their car, because they were so distracted, Alex was forced to see their GP by their spouse. The GP correctly identified that Alex was suffering with severe anxiety and was showing signs of depression and recommended a combination of talking therapy and antidepressants. The GP also signed them off work for four weeks.

Alex spoke to a friend who warned them against taking the medication as it would cause them to have suicidal feelings. Alex took the friend’s advice above that of the medical advice given by their GP.

Following an assessment with a talking therapist, they started eight weeks of CBT. It was after the fourth session that Alex realised that for two or three days following the appointments they would feel worse than ever. They were more anxious, more forgetful, kept finding themselves in places that they hadn’t meant to be. They felt they were looking at the world through frosted glass and felt cut off from everything and eventually Alex stopped leaving the house altogether.

At the final session, the therapist asked how CBT had been for them. Alex confessed to the therapist that they felt the CBT had made them worse and that they were no longer going out of the house. They had begun to worry that they might be a danger to those around them – after all, isn’t that what happens when people have “mental problems”.

The therapist told them that from the symptoms they were now describing it was clear that they must have PTSD as a result of what had happened at work. The therapist said that it was no surprise that the eight sessions of CBT had not worked because really the treatment that Alex needed was EMDR. Alex’s internet search confirmed their fear that PTSD could be associated with violent behaviour.

By this time Alex had not been at work for over a year. They signed up for EMDR therapy, which was not readily available on the NHS and they could not pay for private sessions.

Another friend suggested that the bullying at work had caused the PTSD, and recommended that Alex should sue, which again Alex listened to. A lawyer convinced Alex that there was a strong case and as a former high performing top executive who was now housebound because of work-related PTSD, they could get a six figure pay out.

It was at this point I was asked to see Alex. It was clear to me that they didn’t have PTSD - it cannot be caused by a negative interaction with someone at work (unless that interaction involves life-threatening physical violence or something similar).

What Alex required was a good assessment and clinical treatment. Alex did have severe anxiety and biological symptoms of depression and would have benefited from an antidepressant and along with this, someone to explain and monitor the full side effects, inform them how to use the medication and, when the time was right, how to ensure they came off it safely.

Alex also needed psychological therapy that focussed not simply on CBT to treat their anxiety symptoms but also understanding and treatment of their dissociative episodes. The therapy needed to provide some psychodynamic understanding of what it meant for Alex, who had always been so successful in their life academically and socially to be told that someone didn’t like them and didn’t want to work with them. It was such a blow to their self-esteem that they had become unable to function. And Alex needed someone who could help their family understand what had happened to them and how they could best function in their environment.

Alex would have been better off being seen quickly by a psychiatrist who could have provided a comprehensive assessment of their issues and needs with formulation and then a sensible treatment plan that could be reviewed.

The psychiatrist did not have to provide all the treatment, but they could oversee it, checking in periodically that the therapy and medication were working appropriately. Then, maybe, by the time I saw this person, some four years after their work colleague shattered their confidence, they wouldn’t have been someone who was no longer able to work and who was housebound.

With appropriate treatment, I estimated that it would take about a year for them to improve. Add to that the four years of inadequate/no treatment, that is 10 times the four to six months it would have taken for them to get back to good health and back to work if they’d received the right clinical treatment in the first place.

So why did it end up in this way? A number of factors come to mind:-

• A lack of knowledge and understanding from some lay people and even some professionals about mental illness.
• The therapist’s somewhat “tickbox”, symptom-driven approach with limited understanding of mental disorders and a failure to understand the biopsychosocial, holistic and somewhat complex nature of human beings.
• The fear of psychotropic drugs – driven in part by historically poor prescribing, but also by an all too prevalent antipsychiatry, anti-medication bias.

In this scenario everyone else felt they knew better – the therapist, the friends – so much so that psychiatrists weren’t involved until the person’s functioning was significantly impaired.

Imagine how different things might have been if not only mental illness, but the role of psychiatrists was better understood and therefore more valued. Imagine the benefits to individuals, their families and frankly, the health and productivity of the country.

Better understanding and better treatment – our specialty

With a new government in place, several important bills making their way through Parliament and with key health policy in development, the time to act is now.

Next year, the College will continue to campaign for people who have a mental illness, driving positive change to ensure they receive the best care and support possible. By working together, we will improve understanding of the excellent work we, as psychiatrists, do and raise the profile of the profession.

I know some of you will be working and treating patients over the festive season while others will be taking a much-deserved break. However you are spending the holiday period, I hope you enjoy yourselves and find time to be with your nearest and dearest. More than anything, I want to express my appreciation for all you do.

Look after yourselves and your loved ones.

Your President, Lade