Last month (September 2017) the National Health Service in England issued official guidance for general practitioners (GPs) on older people and mental health (Mental Health in Older People: A Practice Primer).
The guidance is written by four psychiatrists and a GP: Alistair Burns, professor of old age psychiatry at the University of Manchester and national clinical director for mental health in older people and dementia, NHS England; Amanda Thompsell, Christoph Mueller and Daniel Harwood, all old age psychiatrists at South London and Maudsley NHS Foundation Trust; and Peter Bagshaw, GP.
There is a brief paragraph about ECT, which is described in the following terms:
“Electroconvulsive Therapy (ECT) is a treatment used in a small number of people with depression, which involves passing a small electrical current through the brain under a general anaesthetic, to induce an epileptic seizure.”
The current used in ECT is in fact a powerful one, usually 800 milliamps, enough to cause immediate unconsciousness if the anaesthetic hadn’t already done so, and about one hundred times the current that would produce a painful electric shock. There is no mention of risks or adverse effects of ECT, or of maintenance ECT.
Reading the rest of guidance I felt at times that I had stepped into an episode of Dr Finlay’s casebook (a TV series from the 1960s that was set in the 1920s). GPs are told, in a section that reminds them not to overlook physical conditions, that a “patient’s breath smelling of wet leaves may indicate tuberculosis”. There are about a thousand new cases of tuberculosis a year in older people in England, meaning that on average each GP may see one such case during their career, although in practice, since tuberculosis is not evenly distributed over the country, some will see none and some more than one. When I googled the sentence “A patient’s breath smelling of wet leaves…” the only example that came up was in a detective novel by Patricia Cornwell. Perhaps one of the authors of the official NHS guidance is a Patricia Cornwell fan or perhaps the wet leaves are just a piece of medical folklore, like “red sky at night…”
In general the guidance is confusing when it comes to distinguishing between physical and mental conditions. For example, it tells GPs that older people with depression may report physical symptoms, for example, constipation, instead of emotional symptoms, while it goes on to say that “simple constipation may present as either confusion or low mood”.
When it comes to diagnostic tests for depression, GPs are spoilt for choice, with the guidance listing five different tests, from the 15-item Geriatric Depression Scale, via the 4-item version, the two questions recommended by the National Institute for Health and Care Excellence, the one question recommended by the authors (whether someone enjoys visits from their grandchildren), to gut instinct (“A person who consistently annoys you could well be depressed or have a personality disorder, and a person who perplexes you might be psychotic.”) One of the questions on the 15-item Geriatric Depression Scale asks “Do you think that most people are better off than you are?” Surely, for a proportion of the population, it is a simple truth, not a symptom of mental illness, that most people are better off?
The guidance contains some case histories, for example a nun who is getting forgetful and is prescribed mirtazapine and a bereaved man who drinks “cheap wine”. Does it matter how much the wine costs? The nun’s case is used to illustrate the difficulty in distinguishing between dementia and depression. The guidance given to GP’s is that “a pragmatic approach would be carrying out a dementia blood screen and a 6-week trial of antidepressants”, in spite of the fact that one of the authors, Christoph Mueller, recently co-authored a paper that concluded that the “prescription of antidepressants around the time of dementia diagnosis may be a risk factor for mortality”.
Old age apparently starts at 65. That, the guidance explains, is because it was the qualifying age for an old-age pension when German chancellor Otto von Bismarck introduced social security in the 1880s. Actually, it isn’t; Bismarck set the age for pensions at 70 (it was reduced to 65 in 1916). But anyway, why does psychiatry have to follow what a German chancellor did a hundred years ago?