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A new perspective on Deep End practices

Henk de Vries is a GP at Marisco Medical Practice and previously worked for CIty Health Care Partnership in Hull for 10 years. He has a special interest in drug and substance misuse, teaching how to deal with aggressive patients, psychiatric comorbidities, and of mental health assessments in primary care.

The treatment of complex patients in inner city practices with high levels of deprivation, also called Deep End practices1 is complex because of its increased morbidities. The S-curve of their mortality and associated comorbidities is shifted towards the left2 and they pose an increased burden on police services, social services, and local accident and emergency (A&E) departments.

The goals of treatment for drug and substance misuse disorders and desired outcomes have not been consistent over time, and different definitions have existed as ‘cure’, ‘rehabilitation’, and ‘hierarchy of objectives’, with different levels of funding from the Home Office, depending on which political leaders have influence.3 In this article I will propose that the definition of addiction and treatment outcomes should be broadened to manage the most vulnerable patients more comprehensively.

The presentation of mental health problems in general practice are significantly different from what gets presented to psychiatry departments. We see a lot of drug-seeking behaviour in the context of addiction to prescription drugs,4 which poses additional distinct problems, as with these kinds of addictions it is difficult to engage patients in recognising prescribed drugs as harmful and patients often remain in ‘treatment’ as long as the practice continues to prescribe.

While treatment for addiction problems often starts after motivational preparation and planning, that remains an obstacle if the GP continues to prescribe.

While treatment for addiction problems often starts after motivational preparation and planning, that remains an obstacle if the GP continues to prescribe. Diversion of these tablets can also be a significant problem that one may only recognise by the absence of withdrawal symptoms on acute cessation of these drugs. Despite popularity of gamma-aminobutyric acid inhibitors in these populations, they remain off-licence indications for pain management. They are also associated with increased mortality.5

Few patients in general practice present with acute psychotic disorders. The majority have personality disorders, which are often associated with psychiatric comorbidities like addictions, depression, and general anxiety disorders. The core management of these personality disorders is psychotherapy, while the evidence of pharmaco-therapy is contested. The National Institute for Health and Care Excellence does not support this in principle, while The American Psychiatric Association guidelines are more supportive.6

In the past, personality disorders were regarded as static, not changing over time; recent evidence suggests this is not the case. Personality disorders do change over time: negative affectivity, antagonism, and disinhibition increases, while positive affectivity and detachment increases.7 While severe depression and schizophrenia treatment outcomes in trials and clinical practice are well defined, this is for the treatment of personality disorder, the brunt of the problems we see much less defined.

Personality disorders are characterised by help-seeking behaviours, compliance with treatment, coping styles, risk-taking, lifestyle, social support networks, therapeutic alliance, eating and drinking habits, smoking habits, and sexual habits, and treatment goals can be narrowed down by focusing on thoughts, feelings and emotions, behaviour, social (interpersonal) functioning, insight, and occupational, family, and social aspects. This works best by setting realistic and prioritised goals over a long-term time frame.8 It should be noted that personality disorders are 50% heritable, hence these disorders are often seen in families and should be considered as a diagnosis before the age of 18, set by the Diagnostic and Statistical Manual of Mental Disorders, versions 4 and 5.7

In the past, personality disorders were regarded as static … recent evidence suggests this is not the case.

Another increasing emergence of disorders being recognised are autistic spectrum disorders, although ‘ADHD suffers from the familiar mindset that major depression and post-traumatic stress disorder have endured, where symptoms on a continuum of normal experience lead to accusations of medicalization: “everyone loses concentration”, “we all get distracted and forget things”’.9 Their symptoms are often associated with generalised anxiety disorders, simply because these patients are unable to process complex information.

Again, this impacts on the patient’s ability to form relationships and may jeopardise employment, contribute to a vulnerability to addiction, depression, and anxiety, make driving safely difficult, and cause premature deaths from accidents.9 The Karolinska Institute report an expected life expectancy of 50 years,10 and treatment has been demonstrated to be effective by Ginsberg et al in a prison setting, which has a high prevalence of this disorder.11 Pharmacological treatments have impressive effect sizes and the therapeutic relationship should be defined on ‘humour […] flexible, engaging and direct’.9

The high prevalence of all these disorders, including personality disorder and autistic spectrum disorders, will make it impossible to deal with by specialist psychiatrists only; the latter has been described as a rainbow metaphor with various light spectrums in the definition of these disorders,12 an analogue one could extend to personality disorders as well.

Although models have been used like the Care Program Approach,8 this does not include general practice, where many of these patients will present in the first instance. My view is that it is possible in Deep End practices to shift the assessment and treatment into primary care where psychiatry services would be less overwhelmed with patients.

A ‘shared’ care model in the UK from a small, non-ringfenced budget from the Home Office seems wholly inadequate in my view.

A ‘shared’ care model in the UK from a small, non-ringfenced budget from the Home Office seems wholly inadequate in my view. GPs simply sign prescriptions for stable opiate dependency but with little other involvement than key workers. Chaotic patients still present to primary care but often without access to specialist services, and they take a huge amount of time and resources in the practice and beyond.

Most practices are not able to deal with this and hence patients get allocated to specialised surgeries. It assumes that these patients are prescribed this for addiction only when often this also gets prescribed, rightly, or wrongly, for pain control or mood stabilisation. The population, in presenting to Deep End practices, is different from the referred group as this group are those who do not engage well or adhere well to treatment. They nevertheless continue to put a burden on local services, like A&E, the police, and social services.

This burden, I believe, can improve by shifting and centralising these services to Deep End practices where a lot of the therapeutic approaches mentioned can be delivered by GPs with specialist interests into a primary care consultation. This carries the prospect of reducing secondary care attendances as well as improving communication between police, prison, and social services. Drug budgets can be better contained and delivered to those who will benefit from this most, rather than being counter-productive. This will ultimately result in improved outcomes for this difficult group of patients.

 

References

1. Sturgiss E, Tait PW, Douglas K, et al. GPs at the Deep End: identifying and addressing social disadvantage wherever it lies. Aust J Gen Pract 2019; 48(11): 811–813.
2. Barnett K, Mercer SW, Norbury M, et al. Epidemiology of multimorbidity and implications for health care, research, and medical education: a cross-sectional study. Lancet 2012; 380(9836): 37–43.
3. Berridge V. The rise, fall, and revival of recovery in drug policy. Lancet 2012; 379(9810): 22–23.
4. Smith BH, Higgins C, Baldacchino A, et al. Substance misuse of gabapentin. Br J Gen Pract 2012; DOI: https://doi.org/10.3399/bjgp12X653516.
5. Mathieson S, Lin C-WC, Underwood M, Eldabe S. Pregabalin and gabapentin for pain. BMJ 2020; 369: m1315.
6. Bateman AW, Gunderson JM, Mulder R. Treatment of personality disorder. Lancet 2015; 385(9969): 735–743.
7. Newton-Howes G, Clark LA, Chanen A. Personality disorder across the life course. Lancet 2015; 385(9969): 727–734.
8. Davison SE. Principles of managing patients with personality disorder. Adv Psychiatr Treat 2002; 8(1): 1–9.
9. Geffen J, Forster K. Treatment of adult ADHD: a clinical perspective. Ther Adv Psychopharmacol 2017; 8(1): 25–32.
10. Hirvikoski T, Mittendorfer-Rutz E, Boman M, et al. Premature mortality in autism spectrum disorder. Br J Psychiatry 2016; 208(3): 232–238.
11. Ginsberg Y, Hirvikoski T, Lindefors N. Attention deficit hyperactivity disorder (ADHD) among longer-term prison inmates is a prevalent, persistent and disabling disorder. BMC Psychiatry 2010; 10: 112.
12. Brugha TS. The psychiatry of adult autism and asperger syndrome, a practical guide. Oxford: Oxford University Press, 2018.

 

Featured photo by Brandon Hoogenboom on Unsplash.

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