Reflections on the management of medically unexplained symptoms

Abstract

CorrespondenceHow can a young person wait over 90 hours in an emergency department for a bed?We have recently been involved in a difficult case of a young person who remained in a local emergency department bed for over 90 hours while several specialty registrar (StR) doctors spent the majority of their on-call time attempting, and failing, to find an appropriate available bed. Over the course of this time, at least 40 units were contacted, numerous referral letters faxed and the case was handed over 6 times, all while the young person waited in an unsuitable setting that offered little to meet his mental health needs.Although this is an extreme case, it reflects the trend we have observed of difficulty in finding beds, especially out of hours, and the fact that bed finding is becoming a major aspect of our on-call time. As Hillen & Szaniecki demonstrated, 1 the majority of referrals are made between the hours of 5 pm and 9 am when daytime services are closed.We have read with interest the findings of NHS England's Child and Adolescent Mental Health Services (CAMHS) tier 4 report 2 published in July 2014, which reported that the number of NHS-funded CAHMS tier 4 beds has increased by just 136 in the past 8 years, compared with a 284 rise between 1999 and 2006. This means that there were 1264 beds available nationally in January 2014. The BBC have declared this a problem of 'patchy provision' and, based on their findings, NHS England have identified a need and promised 'up to 50 new beds around the country with further beds moved according to need'.2 While this goes some way to providing more beds, this is only part of the problem.There is currently no system to find out which beds are available at any given time and no external support to make the bed-finding process efficient. In our experience, weekly published lists are not representative of genuine availability and are quickly obsolete. There is no universal referral form so each referral necessitates new paperwork and often indiscriminate, convoluted processes of speaking to each individual bed manager, night nurses and support staff who do not have the responsibility to admit patients out of hours. A young person with complex problems and behaviours that need careful management is considered too risky for an open ward and so they are refused. Beds alone will not solve this; we need places that can be accessed out of hours with appropriate staffing levels and staff adequately trained to confidently manage the potential risk.Because of these difficulties in admission, we are concerned that a prolonged wait in an emergency department will become more commonplace and that measures such as the Mental Health Act 1983 will be used to compel young people into admissions as their mental health deteriorates while waiting for a bed, and low-secure units become the default due to their ability to tolerate risk.We are surprised that there is no centrally produced daily bulletin of national bed states and no provision to make NHS England accessible out of hours to assis...

Developing Services for Patients with Depression or Anxiety in the Context of Long-term Physical Health Conditions and Medically Unexplained Symptoms: Evaluation of an IAPT Pathfinder Site

“…Therefore, GPs may have referred less MUS patients due to issues in alliance formation preventing discussion of a potential referral to the IAPT service. Unigwe, Rowett and Udo (2014) noted that MUS patients experience a mismatch between their physical problems and being offered a psychological intervention. As “body-based problems” are paired with “body-based solutions”, this may contribute to reluctance (or distrust of) consideration of psychological therapies.…”

Assessing the Effectiveness of Brief and Low Intensity Psychological Interventions for Medically Unexplained Symptoms and Health Anxiety: A Systematic Review of the Literature

“…This may be partly explained by previous reports that GPs feel inadequate and discouraged when dealing with MUS cases [26]. Furthermore, as previously highlighted, research has indicated that MUS patients believe there is disparity between their physical symptoms and a psychological intervention [27]. The difference in referral rates between LTC and MUS patients suggest a need for separate dedicated services for each of these patient groups [28].…”