Does the emphasis on risk in psychiatry serve the interests of patients or the public? No

Large, M.

doi:10.1136/bmj.f857

Cited by 11 publications

(8 citation statements)

References 7 publications

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“…Psychiatrists and other physicians should be able to embrace the dut the ha e ega di g the safet of thei patie t a d the patie t s fa il a d to a ds the public as a whole. 198,199 Psychiatrists should be able to provide optimal care according to the treatment needs of each patient.…”

Section: The Problem With Existing Mental Health Lawmentioning

confidence: 99%

The WPA- Lancet Psychiatry Commission on the Future of Psychiatry

Bhugra

Tasman

Pathare

et al. 2017

The Lancet Psychiatry

345

187

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Executive Summary BackgroundThis Commission addresses several priority areas for psychiatry over the next decade, and into the 21st century. These represent challenges and opportunities for the profession to sustain and develop itself to secure the best possible future for the millions of people worldwide who will face life with mental illness. Part 1: The patient and treatmentWho will psychiatrists help? The patient population of the future will reflect general demographic shifts towards older, more urban, and migrant populations. While technical advances such as the development of biomarkers will potentially alter diagnosis and treatment, and digital tech-nology will facilitate assessment of remote populations, the human elements of practice such as cultural sensitivity and the ability to form a strong therapeutic alliance with the patient will remain central. Part 2: Psychiatry and health-care systemsDelivering mental health services to those who need them will require reform of the traditional structure of services. Few existing models have evidence of clinical effectiveness and acceptability to service users. Services of the future should consider stepped care, increased use of multidisciplinary teamwork, more of a public health approach, and the integration of mental and physical health care. These services will need to fit into the cultural and economic framework of a diverse range of settings in high-income, low-income, and middle-income countries. Part 3: Psychiatry and societyIncreased emphasis on social interventions and engagement with societal expectations might be an important a ea fo ps hiat s de elop e t. This ould e o pass ad o a fo the ights of individuals living with mental illnesses, political involvement concerning the social risk factors for mental illness, and, on a smaller scale, work with families and local social networks and communities. Psychiatrists should therefore possess communication skills and knowledge of the social sciences as well as the basic biological sciences. Part 4: The future of mental health lawMental health law worldwide tends to be based on concerns about risk rather than the protection of the rights of individuals experiencing mental illness. The United Nations Convention on the Rights of Persons with Disabilities, which states that compulsion based in whole or in part on mental disability is discriminatory, is a landmark document that should inform the future formulation and reform of mental health laws. An evidence-based approach needs to be taken: mental health legislation should mandate mental health training for all health professionals; ensure access to good-quality care; and cover wider societal issues, particularly access to housing, resources, and employment. All governments should include a mental health impact assessment when drafting relevant legislation. Part 5: Digital psychiatry-enhancing the future of mental healthDigital technology might offer psychiatry the potential for radical change in terms of service delivery and the development of new treatm...

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Section: The Problem With Existing Mental Health Lawmentioning

confidence: 99%

The WPA- Lancet Psychiatry Commission on the Future of Psychiatry

Bhugra

Tasman

Pathare

et al. 2017

The Lancet Psychiatry

345

187

View full text Add to dashboard Cite

show abstract

“…It is clearly an inefficient use of staff time if they spend twice as long recording information about a patient as they do in face-to-face therapeutic contact with that person. Mental health systems now usually involve completion of complex risk assessments, even though, such assessments have little or no predictive validity, and there is no evidence that they reduce harms associated with mental illness [21–25].…”

Section: Discussionmentioning

confidence: 99%

Integrated liaison psychiatry services in England: a qualitative study of the views of liaison practitioners and acute hospital staffs from four distinctly different kinds of liaison service

Jasmin

Walker

Guthrie

et al. 2019

BMC Health Serv Res

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Background Liaison psychiatry services provide mental health care for patients in physical healthcare (usually acute hospital) settings including emergency departments. Liaison work involves close collaboration with acute hospital staff so that high quality care can be provided. Services however are patchy, relatively underfunded, heterogeneous and poorly integrated into acute hospital care pathways. Methods We carried out in-depth semi-structured interviews with 73 liaison psychiatry and acute hospital staff from 11 different acute hospitals in England. The 11 hospitals were purposively sample to represent hospitals in which four different types of liaison services operated. Staff were identified to ensure diversity according to professional background, sub-specialism within the team, and whether they had a clinical or managerial focus. All interviews were audio-recorded and transcribed. The data were analysed using a best-fit framework analysis. Results Several key themes emerged in relation to facilitators and barriers to the effective delivery of integrated services. There were problems with continuity of care across the secondary-primary interface; a lack of mental health resources in primary care to support discharge; a lack of shared information systems; a disproportionate length of time spent recording information as opposed to face to face patient contact; and a lack of a shared vision of care. Relatively few facilitators were identified although interviewees reported a focus on patient care. Similar problems were identified across different liaison service types. Conclusions The problems that we have identified need to be addressed by both liaison and acute hospital teams, managers and funders, if high quality integrated physical and mental health care is to be provided in the acute hospital setting. Electronic supplementary material The online version of this article (10.1186/s12913-019-4356-y) contains supplementary material, which is available to authorized users.

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“…The tick-the-box diagnostic questionnaires were used to assess and measure patients' individually experienced moods, thoughts, feelings and behaviour. These tools served to stabilise the uncertainty in the clinical encounter but diagnostic tools can transform psychiatric practice into a technical performance undermining the importance of the clinicians' experience and knowledge (Godin, 2004;Large, 2013;Mulder et al, 2016). These medical technologies have emerged as solutions to the problem of diagnostic uncertainty in psychiatry but, as Nikolas Rose (1998;) has noted, the tools can be used as 'risk' technologies in screening the risky individuals from the population in the name of early intervention (see Castel, 1991;Holmes & Warelow, 1999).…”

Section: Discussionmentioning

confidence: 99%

“…The clinical usefulness of these risk management tools has been found to be inadequate for many reasons, mainly because of the gulf between the population and individual levels of prediction (e.g. Godin, 2004;Holmes & Warelow, 1999;Large, 2013;Mulder et al, ., 2016).…”

Section: Different Understandings Of Riskmentioning

confidence: 99%

Uncertainty work and temporality in psychiatry: how clinicians and patients experience and manage risk in practice?

Hautamäki

2018

Health, Risk & Society

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In psychiatric clinical practice, professionals pursue risk management alongside various uncertainties concerning diagnoses and treatment decisions. In this article, I draw on an ethnographic study of understandings of bipolar disorder in Finland to argue that risk management in psychiatry is better characterised as practical uncertainty work. I show how both the clinicians and the patients coordinate the uncertainties of bipolar disorder symptoms, risks and treatment decisions, into something that can be managed. I examine the ways in which temporality structures this uncertainty work and I explore two different modes of framing time. Clinical time stems from the current psychiatric thinking committed to the standardised diagnosis and the ideals of evidence-based medicine. Through this, professionals frame a task-oriented and linear treatment path from diagnosis and treatment to a managed life with bipolar disorder. Experienced time, in contrast, relates to the logics of care and self-care amid the embodied experiences of different actors. This framing of time involves a cyclical process where the patient, the clinician and the treatment interventions each need to adjust to changing situations.

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Does the emphasis on risk in psychiatry serve the interests of patients or the public? No

Abstract: Identifying patients who are likely to harm themselves or others has become central to psychiatry. John Morgan (doi:) argues that though the methods are flawed, identifying risk is essential, but Matthew Large thinks we should focus on the wider harms that patients may experience

Cited by 11 publications

References 7 publications

The WPA- Lancet Psychiatry Commission on the Future of Psychiatry

The WPA- Lancet Psychiatry Commission on the Future of Psychiatry

Integrated liaison psychiatry services in England: a qualitative study of the views of liaison practitioners and acute hospital staffs from four distinctly different kinds of liaison service

Uncertainty work and temporality in psychiatry: how clinicians and patients experience and manage risk in practice?

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