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Hello and good evening. Welcome to our six education evening update for April. Um As always, I'm going to shamelessly start these by plugging the Scottish Intensive Care Society, the Scottish intensive, many of you will be familiar and maybe members but for anyone that's joining our evening education updates for the first time, just a little bit about um SI S so the Scottish Intensive Care Society is an organization which aims to improve the care delivered to critically ill patients throughout Scotland. And really, that's achieved in one of three ways through education, through research and through audit and quality. Um There are a number of different membership categories for intensive care society. Um And there's a number of benefits that come with being a member, including reduced rates at meetings, comprehensive transfer insurance, and access to a number of different travel and kind of project bursaries. And we've got a number of really exciting um events coming up. So um there are some bursaries available for HP specifically, which will close soon. So we'll have a look on the website if you're interested in that. Um And then we are with, in collaboration with the, the faculty of intensive care medicine. We are running the UK consultant, intensivist and transition course in Edinburgh in the May on May the 21st and 22nd of this year. So, um, please have a look on the website if you want to um, to read more about that. And so on to this evening speaker. I'm delighted, we are delighted to be joined by Doctor Roger Smith, who is going to talk to us about psychiatry in ICU. And it's really interesting. I heard Roger speak a few weeks ago and it's a topic that we don't get a lot of necessarily formal teaching on. So I thought it was really interesting and that he could come along and give us some teaching on this topic. Just tell you a little bit more about him. He is a consultant psychiatrist in the Department of Psychological Medicine at the Royal Infirmary of Edinburgh and an honorary clinical senior lecturer at the University of Edinburgh. His main year of clinical interest is the psychiatric care of organ transplant patients. He is the lead author and editor of the book of Psychiatry and chairs, the Legislative Oversight Forum at the Royal College of Psychiatrists in Scotland. So Roger, I'm going to hand over to you. Thank you so much for joining us. Ok. Thank you very much Julie for the introduction and for the invitation. The indirect reason why I'm here speaking to you tonight is because of delayed discharges within the infirmary and I suspect that delayed discharges from one part of the hospital to the other are probably a common experience across Scotland bed pressures have probably never been or great in days gone by people who took overdoses, particularly large overdoses requiring ATU management would often move on to er downstream wars, particularly clinical toxicology. And my team er, would review them there. But over recent years, we've been seeing more people who are held up in the ITU. And so uh two specialties, which probably haven't got much overlap because one can only really deal with patients when they're awake and one has patients who are mostly asleep and we're sort of bumping into each other a little bit more. And some of my colleagues at the infirmary said, you know, we're seeing more of you guys, you're coming in to see people, you're going in behind the blue curtain, you're giving advice and it's not clear to us what the basis for your assessment is and what the basis for your decision making is. And perhaps some of you have seen people will come in with overdoses and some of them we will detain and take against their will to psychiatric care and some of them we will discharge and perhaps it's not entirely clear what the basis for those decisions is. And so this really isn't a talk about how you can do a particular area of your practice better. It certainly isn't uh highly scientific talk about some particular discovery or innovation. What it is is just sharing, er, from one specialty to another, er, associated specialty. Um, some thoughts and information about our practice for interest's sake. But also the more we know about each other's work, the more we can effectively communicate with each other and the more we can effectively communicate with patients. So at least of interest sake, I hope but potentially of some clinical benefit got, I'm gonna speak with the balance of uh 35 40 minutes and then allow some time for interaction and questions. II, if if you so choose the biggest part of my talk is going to be about what factors are on our minds. When we assess patients after self harm, what's going on behind the curtain? When the patient after the big overdose of the self harm episode wakes up and speaks to us, I couldn't help but put a little sliver of law in which is my, my sort of happy place. And then I want to talk about something that is pretty niche and really only applies to the royal infirmary. But some of you will transfer patients into the infirmary in full lymph hepatic failure and perhaps will wonder what the basis for the psychiatric decision making is alongside the decision making about other aspects of the transplant decision. So those are the the three things I want to talk about. One reasonably large and and 2222 fairly small. So, as I said, the biggest part of the talk is about self harm and that's because that is far and away. The biggest single number of patients that we see on the infirmary site. My, my service is based within the Royal Infirmary. We're not based on the psychiatric hospital to work exclusively with patients with comorbid physical disorders or with emergency department patients. And if I take a look at my, er, referral er, types at the end of the year, I er, get something like this mood and anxiety problems are, are the biggest suicidal ideas, confusion, legal issues, psychotic all the way down to, to comparatively rare, er, presentations. But I always take out er, um, suicidal acts. And the reason I do is because if you do it, the rest, if you put those numbers in the whole chart becomes a bit hard to read the numbers of patients with self harm about 2.5 1000 episodes per year with, on within the infirmary. It dwarfs all of the other work we do. Although um, some of the other work might well take up more time because the cases are relatively, er, relatively, more, more complex. And that's, we assess all patients after self harm. Particular guidance from our college and the College of Emergency Medicine suggest that all patients after a self harm episode should have a psychosocial assessment rather than attempting to take out a particular subset for assessment. But what types of self harm do we say? Well, that will vary across the country. But within the infirmary over the last 10 years, here has roughly been our percentages and so in green and yellow we have poisoning and that's about 90% of the self harm cases that we, we have seen. And the vast majority of that is, is drugs over the counter drugs and uh uh prescription drugs, but a small sliver is some sort other sorts of, of toxins, often household or, or agricultural chemicals. And of the remainder, the, the, the physical methods, 8% is is cutting of some part of the body and only a small sliver. 2% is other physical methods such as attempted hanging, jumping in front of, of, of moving vehicles, er, jumping into water and a very, very small sliver in Scotland at least, or loathing, at least of um firearms, which are extremely, extremely rare. So after the patient has been brought in with the self harm, obviously, the particular specialty dealing with it will depend on the form of self harm. Clinical toxicologists, er intensivist trauma or vascular surgeons, er, in the main, hopefully the patient will medically or surgically recover and or their itu admission will come to an end with them being woken up and recovering and then we'll move in to try and assess them. And what are we going, what are we going to do? Well, in many ways? It depends on the case and it is extremely tailored both to the type of case to the mental state of the patient at the time they wake up and their previous psychiatric history. But whenever I'm bringing trainees up to, er, er, the point of making self harm assessments and, er, given the numbers, of course, the, the trainees have got to be extensively involved, albeit with, uh, with, with clinical supervision, I say to them, look what I want you to do is come back with the answers to three questions. I want you to try and assess in the balance of 40 45 minutes that you spend with them in the initial assessment, come to a conclusion as to whether you think the patient is at risk of death by suicide. In other words, the self harm is a marker for future death by suicide. I want you to consider, is there evidence of mental disorder? And if so which one? And then finally, if the answer to questions, one and two are no, um then are there other problems we could help with? Because it's important to remember that it's very easy to think of suicide and self harm as being one sort of almost one overlapping with the other one being AAA super set of the other. In actual fact, self harm may have a different meaning than a suicide which, but for chance has failed to result in the person's death. And while there's a good deal of overlap, particularly in the types of mental disorder which predisposed to each one. They, they are not absolutely synonymous and it's entirely possible that self harm does not reflect overt acute suicide risk. So, how do they get the answer to those three questions? Well, II usually ask them to follow the, er, er, er, um, particular pieces of information on the right and usually go from bottom to top rather than top to bottom, to explore the personal and social history, the background of the person, their stresses, but also conversely, their supports. I want them to go and explore the history and symptoms of mental disorder uh and to explore the symptoms in the normal way. But to particularly ask directly about mood symptoms, drug and alcohol and symptoms related to personality disorder. But any other symptoms that come up such as food restriction, hallucinations, memory impairment, one would follow those along in the normal way and then looking at the risk of completed suicide in the relatively near future. We'd be looking at the history of the act itself and its preceding and succeeding events to try and explore what the meaning of the event was, what the intent of the event was and what the associated risk is in the patient going forward. That cannot be an exact science. There are all kinds of um rating scales and clinical instruments have been devoted to this and the vast amount of clinical time has, and we are poor at predicting suicide. The reason is that the incidence of suicide in the self harm cohort is significantly higher, two orders of magnitude higher than in the general population. But it still remains extremely low. That's of course, a good thing. But it also should give rise to therapeutic optimism in people such as yourselves who are bringing people out of that suicidal, er, er, period or that high risk period after self harm, sometimes one can get demoralized even at the best of times and think, well, what's the point of what we're doing if we're doing all this effort? And I, I'm not suggesting that this is in any, any way, a restriction or judgment. I'm just saying that it's a human reaction, er, if the person is gonna go back out and do it again. But the fact of the matter is that if you follow these patients up long term, only a very small proportion of self harm cases go on to completed suicide depends on the particular population that you, that you, that you look at, but it's certainly never higher than about 2% in the subsequent five years. So the vast majority of patients after self harm will go on, er, er, er, er, er, to survive and not, er, er, to complete in suicide and that should give rise hopefully to some therapeutic optimism. So, the three questions then in order and again, this is really just to reflect to you what we do rather than to suggest to you that you would be carrying this out. So there is the person at risk of death by completed suicide in the near future. And you'll always be familiar if you look at textbooks is that people have very confident sociodemographic, er, risk factors. Er, er, um, for this, um, what are predictors of completed suicide suicide is much more common in men than women. Nearly three times more common in men than women in Scotland. It's more common in the elderly rather than the young. The completed suicide cord is much older than the self harmed cohort. It's much more common if you are not married. Uh, and that effect is even more pronounced for men than for women. Men get more out of marriage than, than women in all kinds of ways. Um, it's um, in those who are living alone with poor social support or those who are unemployed and are low socioeconomic status and then you can go on to personal and mental health risk factors. And again, these are things which demographically seem to predict suicide. A history of previous self-harm law, I said the association is strong but not marked any mental disorder, some more than others. A dependence on alcohol or drugs and a particularly marked factor. Recent inpatient psychiatric treatment, a very strong risk factor. Although lot not an independent risk factor, it obviously correlates with other things concurrent physical disorder, particularly if disfiguring, painful or socially stigmatizing or alienating and recent bereavement. And again, that's not an independent risk factor if you've recently been bereaved, just like you now are not married if you, if you are or have lost some, some measure of, of, of social support. But of course, all of those things are already fixed for the person before you go and see them. They, they don't give you much of much of a, much of a guide. And it's entirely possible uh to imagine that a, a AAA young woman who's in, in a marriage has none of these risk factors could be high risk. And an elderly man living alone might be comparatively low risk. The fact features of the act itself and the cognitions and uh and particular meaning of the person around the act are probably more important than these things. And they're certainly the thing that are going to make, you are going to guide you much more in looking at risk factors. So it's features of the act itself, you look at the period before. Was there planning or was it impulsive just in response to some kind of immediate stressor or their final acts with their suicide notes, putting affairs in order, putting pets into, into care or there precautions to avoid discovery? Was it a repeat act? Uh something that was done before and the person survived, were there some kind of triggers triggers to it? Thinking about the act itself. What was the lethality? Was it a small amounts of, of medication? Was it an attempted hanging? But also more important? Not, not more important, but perhaps as important. What were the beliefs about the lethality? We know how toxic drugs are? But what were the person's beliefs? Sometimes people believe antibiotics are extraordinarily toxic. Sometimes people believe that, that iron, er, is exceptionally safe. What were the person's beliefs? What was the setting? Where did they go to do it right in front of other people or did they go to some dissent face? Were there unusual or ritualistic or bizarre features that are worth comment that are, that require some kind of explanation? And then what were the person's actions afterwards? Did they seek help or were they brought to help? Did they make any kind of communications via phone or all the range of social media that, that the older people in the audience probably haven't even heard of? Did they announce themselves on tiktok or whatever the latest thing is now, how did they get to hospital and what's their attitude to treatment? Did they accept it? Did they refuse? It, was it only under the provisions of, of, of, of some sort of legal order and what's their attitude now to survival? Because of course, the trouble with this is this is going to be a moving target as the person changes. Perhaps it might get better as family support gathers in, perhaps it might get worse as, um, you know, the reality of particular losses is brought home to them. Again, I'm not going to suggest any easy way. You can look at all these factors and all the information you'll get if you get even all of this and you'll probably get more. But I guess if you think about at the lower end of the scale, a young woman who has taken a very small impulsive overdose. And as a result of abandonment, less tablets than, uh, than, than less fewer tablets than were taken at a, at a, at a, you know, a survived attempt a number of weeks ago, taken in impulsively in front of somebody with, you know, no real risk of, of, of, of harm. And on the other hand, you think of perhaps an elder man after a business failure, going away to the woods and, you know, attempting to hang himself and only found unconscious onto the branch by a jogger the next day, I think we can probably agree those kind of represent very widely spaced risk of further completed suicide. Um, but of course, the number of factors at play mean that it's quite difficult to make that decision. And as I said, we know that clinical interview, clinical experience and a properly supervised team, er, is the best guide to prediction of suicide and even that is not particularly good. So the best we have currently clinically is not good and all of the assessment and so on and attempting to do it by computer. Um I'm sure there is work undergoing to try and do this by A I. But past past attempts would suggest that that is, is, is, is, is, is, is doomed to failure, but you never know beyond the actual act itself. It's important in the interview and I say this to trainees to explore the meaning of the act. It's very easy for people to imagine that the act was either an unequivocal attempt to die or some type of, of, of, of, of cry for help that had no intent to die. Um And that the the fully intend to die ones were just saved by chance. In actual fact, there, there, there's a quite a wide range of, of, of, of, of reasons in people's minds and they find it very hard to articulate this and also this will change depending on when you will make the assessment. Some people, undoubtedly the issue was unequivocally to die. Some people may be e ambivalent about their survival, may let the chips fall as they may. Sometimes the act is impulsive in response to a stressor. Sometimes it's designed more to communicate the stress. Look how bad you're making me feel. Sometimes it's about eliciting change behavior in others. The most of this is people who don't fancy spending the night in the cells and take an overdose to spend the night with us and I often wonder, er, whether they're making a good choice there. So it is to escape from intolerable symptoms. It's not to get to death, it's to get away from where they are, whether pain or anxiety or psychotic symptoms or whatever. And probably the largest group, those is intent is, it is unclear or moves around between these, depending on the mental state which may be fluctuating due to the underlying mental disorder. As I've said to you there, there's been quite a lot of attempts to really get a solid scientific basis to suicide prevention and to prediction of completed suicide in individuals, er, with self harm or some other form of screening for mental disorder. And we're lucky in Scotland to have one of the world's leading researchers, Rory o'connor who works in the um, University of Glasgow and this is, this is his model, this, this is the motivational volitional model, er, er, er, that enables you to explore a patient's psychological state and to attempt to predict their suicidal behavior. This is a very good model. It's a very robust model. It's well tested, but it's far too complicated for me. And so this is the Smith like model to understand um suicidal acts. And basically my observation is that a suicidal act, you know, why did it occur on Thursday night, the 25th rather than any other day? This year is because it rests on a sort of three legged stool three things coalesce at once to make a thing more likely. First of all, there is chronic stress and a variety of stresses that might be homelessness, worthlessness, abusive relationship, uncertain refugee status, chronic physical health issues, there's then an altered mental state that most likely due to mental disorder but can be drug or alcohol intoxication or just the intense emotion. And then in acute stress, pretty young people are good at, you know, dealing with acute stresses. But if they happen in the kind of chronic stress that can overwhelm a person's resources. A last bill, a last abandonment, a particular debt, a particular new piece of negative diagnostic information and assault. You get a combination of chronic stress long enough severe enough, even at quite a low level, if it's chronic enough and acute stress and the chronic sub ultra mental state self harm episode can occur and you know, hopefully the patient will get help and a certain percentage and will come to us in the hospital and a subset will come to yourselves in itu either because the, the um the consequences of the self harm episode are severe enough to land them in it or perhaps the behavioral disturbance or mental disorder in in the ed is such that, that um aesthetic support is, is required to stabilize the situation. So that's really a little bit just a little sliver on, on thinking about how you might answer the question. Is this person at risk of death by completed suicide. There is no single tool that is gonna enable you to make that assessment. What you need to do is focus on the person, their strengths, their weaknesses, their stresses, er, both acute and chronic, what mental disorder they may be suffering and look in great detail at the act itself. And it's, it's, it's, it's, it's, you know, the events that occurred before, during and after and what, um, and what the meaning of the act was to them, then we're gonna go on and think about evidence of mental disorder. And clearly this is, this is our business more than yours. But just, just think a little bit about uh, um, if I'm giving guidance or giving some steer to you, I'll frame it as I did before. In the same way I do to trainees coming new to psychiatry. Um II asked them to think about uh self harm in, in, in, in, in two groups, major and minor. How do I get to those groups? Well, often you see in texts, they'll say poisoning is one group that's sort of comparatively low level. And as I said before, that's 90% of our group and then physical methods, er, um, which are sort of more major self harm. That's not really been my experience. It's more, er, fine grained than that. What I would do is I would divide poisoning into poisoning with drugs and poisoning with non drug toxins. And I would drive, er, I would divide physical methods into cutting and then other physical methods, all of the jumping and hanging and shooting. And I'd go further, I would divide, um, cutting into cutting of the arms, particularly the ervol surface of the forearms and the legs and other cutting, er, um, into a thorax, abdomen, er, and particularly head and genitals, er, where there's a significantly, er, er, greater concern and I would divide those into minor and major, but I need to make a switch in order for my, er, model to work, I need to put cutting of arms and legs down into minor and you need to put poisoning with toxins. Er, this is taking bleach and, and, and industrial chemicals and so on and put this into major. What I say to my trainees is patients with minor self harm, have to convince you they're mentally ill, they don't try very hard, but you have to convince yourself they're mentally ill patients with major self harm have to convince you that they are not mentally ill. There's a, a much stronger suspicion in that second cohort for me, at least uh than, than the first. What types of mental disorder do we see? Well, we see all types of mental disorder essentially with the possible exception of very severe intellectual disability and very severe dementia where the intent cannot be formed. All forms of neurocognitive mental and behavioral disorders have an increased incidence of, of self harm and an increased incidence of a completed suicide. And what you will see is very large numbers of the common mental disorders because while self harmed suicides is not extremely common in those, the disorders themselves are very common. And then you find well good representation of the less common disorders where um you know, the disorders are not particularly common, but self harm is much more represented in those groups. things like anorexia, nervosa and bipolar disorder. But thinking of the disorders, depressive illness, alcohol misuse and personality disorders would really be the big three in terms of presentation with self harm. But you will see schizophrenia and the other primary psychotic illnesses, drug misuse, of course, anxiety, acute psychotic episodes, bipolar disorders, LD adjustment disorders, and even dementias as well as anorexia, which is a rare disorder, but significantly overrepresented in self harm as well as of course, occasionally presenting to it for, you know, the fundamental um reasons related to weight loss. I just want to, I mean, again, we're not going to, we can possibly do a self harm. Uh I'm sorry, a psychiatry type course, but just a few little pointers about these depressive illness is going to be very well represented in self harm and is significantly overrepresented in completed suicide. Depressive illness is common lifetime instance, in woman is just shot 10% in men is, is, is just shy of 5%. So extremely common disorder, usually mild to moderate. But at the severe end and particularly in the sphere with some recovery associated with self-harm and completed suicide and of course, can be comorbid with alcohol and drug misuse or personal disorder or a wide range of other mental disorders. Depression is associated with completed suicide and successful treatment of depression is associated with lowered risk of completed suicide. And so whenever you have a patient with self harm and survival who has a new diagnosis or has a a revealed as more severe than we thought diagnosis of depressive illness. Instigation of appropriate treatment is beneficial for the person. And that we would like to make them feel better regardless of of, of other risks, but also is associated with improvement of the suicide risk. The correlation of depression with suicide is strong and the correlation of poorly or undertreated depression is significantly greater than with well treated depression. An observation that we make is that the severity of depressive symptoms correlates pretty strongly with completed suicide. But the strongest predictor within the depressive cognitions is a sense of hopelessness towards the future. That is the factor that we're most concerned about absolute mood correlates. But the sense of hopelessness correlates most strongly. What I say depression improves the treatment and there's a very strong correlation of poor or undertreated depression and completed suicide. All psychiatrists are wary though of improvement followed by completed suicide. One of the real danger zones is in a patient with severe vegetative depression who is, begins to be effectively treated and then just gets themselves to the point where they've got enough volition to complete suicide while they've got the cognitions which drive suicidal impulses. And so we, we always almost always have more of a watch on people in those early weeks of effective treatment. But even if things are going well, er, than, than, than people in that very, very early stages under outcome issues common over the entire hospital, there's no one in the hospital that does not see alcohol issues well represented, uh pleaded suicide in alcohol is, is chronic through the whole, the whole disorder. It's easy to become despondent with, with patients with alk issue disorders. They sometimes appear to be coming in repeatedly, they appear to be doing it to themselves, they appear to be taking no ownership of the problem and uh they appear to be putting the responsibility onto you at times. Um But all of us have had the experience I'm sure and certainly working in the transplant unit, I've seen this is that you've got to have a never give up attitude. It is very possible for patients even with apparent, hopeless, hopeless alcoholism, a declining trajectory, even for cirrhosis to recover. Uh sometimes you have to go around the cycle of recovery multiple times, but sometimes you get there and you, you see somebody a year into treatment, they're, they're sober, they're recompensed, they're alcoholic liver disease, you almost can't believe it's the same person. So some, some of you've just gotta, you've just gotta keep going, you've just gotta keep them in the game. And of course, in anesthetics, particularly ICU anesthetics, you're very good at, at keeping people in the game. So a chronic refusal to be beaten, recovery focused model, one thing I've got to be, you've got to be very worried about in alcohol misuse disorders is that late suicide often, particularly in some of the illnesses. Um The illnesses, particularly chronic illnesses, bipolar disorder, recurrent depressive disorder suicide is, is, is common common early on is the reality and the losses begin to become apparent. But in alcohol, it can often come later, particularly after a final loss. You know, there's been a, a job loss, there's been a loss of the person's uh um you know, social status and there's been a loss of a marriage but the the ex-wife has remained involved, but then one final bridge is burned and, and she walks away. And after that final loss, you can get a significant increase in in suicide risk. And you've got to watch out for that. The personality disorder is extraordinarily common and can be mystifying and baffling to clinicians, but they're equally mystifying and baffling with the person concerned here. We're talking about as we're not talking about discrete disorders like depressive iness bipolar. We're talking about a disturbance of the formation of the personality which has been present from at least mid to late adolescence and persistent through the life. We used to talk about a variety of subsets of personality disorder, narcissistic and borderline. And it's like schizo, the, the, the new diagnostic manual of the SD 11 just deals with mild, moderate and severe and you'll all be familiar, I think with patients who present with repeated self harm episodes, sometimes without seemingly much association with the risk of completed suicide, sometimes with rejection of treatment and real difficulty in management within the hospital. It's easy to be baffled, it's easy to be frustrated. Um But with personality disorder, you have to take the long view very often with these patients. You, you, you, you, you are not going to see much difference between age 23 and age 24. But the difference between age 23 and age 28 is like night and day and very often it's not so much the individual interventions, but the longitudinal intervention with decider skills with DVT that behavioral therapy and with sort of structured psychological therapies that enable the person to be built to be in the relationships and the normal function which lead them into a different and better sort of life. So you've got to have a horizon that goes to five years plus with these, with these, these patients and again, don't let your shoulders go down if you, you know, we say we've been with this young woman five times in, in ICU or Ed in the last year, you've got to have a longer time scale and that and not be demoralized. Those recoveries that I can report to you with confidence I've seen in the late twenties and early thirties wouldn't have been possible without the, the, the, the bailout help and the recovery provided by Ed toxicologists and, and ITU, and then, uh finally, um, just, I'm only going to eliminate a couple of these, these ones. Uh the primary psychosis, probably the functional psychosis, the schizophrenia, the delusional disorders and, and, and, and so on. These are um the, the um um self harm, particularly severe self harm that might land run an itu associated with, with a psychotic drive is often of great concern to us because um psychotic beliefs, particularly delusions, they may seem very bizarre to, to outsiders. They might seem bizarre to the person themselves want to recover. But a delusion by its definition is absolutely real and the actions are predicated, your actions are predicated on your, on your beliefs. If you believe your house is on fire, you will try to run out if you believe that you are about to suffer torment by the devil, you know, in the next 10 minutes, then maybe the only way to save yourself is to, to jump off Arthur's seat. So we are most concerned about these, one of the things that you see in it with psychosis and it's a trap that I always advise our trainees against is apparent early clearing of the psychotic ideas. When psychiatry used to have great believers in insulin coma therapy for psychotic illness, we would put people into an insulin induced coma, they wake up, the psychosis would seem to clear, looking back on it. That was a lot of nonsense. But I can see why people believed it worked because very often we have people that have seen this multiple times. Er, I am, of course, getting to the stage of my career, my anecdotes are, are, are almost like that and I love that phase but I, I'll tell you this definitely happens. Um, a patient who undoubtedly has psychotic illness, they've been observed to be psychotic by their family or by their CPN, they have a major episode of self harm where they jump, they have extensive fractures or they have extensive poisoning. They end up an itu they're there, they're a ventilated for a couple of days. They wake up on waking, they appear to be free of psychotic symptoms. But then over the next 12 or maybe 24 hours, these things begin to creep up. You've, you've rebooted the computer but you haven't, you haven't solved the software problem and they appeared settled 12 hours after waking up. But then they begin to say, who's that nurse? What's going in there? You can, I trust this person. What's that? And, and the delusional system begins to reboot itself and come on. So beware of early clearing of apparent psychosis, these patients will sometimes not always have bizarre self harm. These are the sort of subgroup you will see carving of, of, of crosses into the thorax or bizarre mutilations or bizarre actions. And they're probably, they're certainly the most likely that we will deal with these patients by movement to, to, to inpatient psychiatric care, perhaps involving use of the, of the mental health Act. These are the most likely that you will see us take the patient on into that sort of setting. And with that in mind, I II sorry, I before I get to that, um if you, if if you look at this, do they have a su risk of suicide, do the mental disorder? It might well be even in an itu case, this is a little probably a small extra proportion in that, that you will say no, they're not particularly high risk of computer suicide. The the the reasons that we've explored the risk is low, there's not a treatable or diagnosable mental disorder, but there may well be other problems that you've explored, particularly in the range of chronic stresses. And one of the nice things with a big city and this will be, be, be, be less um well developed is the further you move away from the Central Belt is that for relationship problems, financial alcohol, domestic abuse, homelessness and all kinds of other other um uh particular issues there are peer groups, there are support, there are charities that are available that can provide a very good deal of input. And you need to be, if you're going to work in, in, in, in psychosocial care after self harm, you need to be very involved in building relationships with organizations like the Sartan, like the city city cafe, like the access practice, like the sirenian in order to help people with areas that are beyond the remit of, of, of, of, of, of mental health care. And you also need to be aware that these things often have temporary funding and often are quite small and their quality may well vary as staff change and turnover. So you need to keep those relationships and keep your eye on the services that are available. And I mentioned that the patients with um particularly um psychosis, but other types of self harm might well require use of the mental health care and treatment Act could spend a whole lecture. I could spend a whole course on this. But since I'm here, I just wanted to briefly point this out to you. You'll all be very familiar with treatment of people under the 2000 Act, The Capacity Act and I ICU is where the, the section 47 forms, the Act five forms are best filled out in the hospital. But you may be less familiar with use of the mental health Current Treatment Act A W I Act, the Incapacity Act can allow for treatment, er er you know, to a process to replace the consent that would be taken from a capable patient. But the A W I precludes the U its use for use of detention, er er beyond what is immediately and urgently necessary. And so deprivation of liberty within Scotland must be sanctioned by use of the 2003 Act. And so, and what would be available to nonpsychiatric doctors? The 72 hour detention of the emergency detention certificate, you need to consider whether a person is detain. In other words, they must have a mental disorder, mental illness, personality disorder, intellectual disability and mental illness certainly does include the consequences of brain injury, uh acute confusional state, secondary to infection and so on. They must have significantly impaired decision making ability, a very closely aligned concept to incapacity. They must be written to the person or others. They must require hospital treatment and the making of the order must be necessary. No, no psychiatrist must be immediately available. It must be required that you do it yourself and there are, there are seven exclusions, but I like my slides to look symmetrical. So I've got them like this but you you're not mentally disordered in Scotland and therefore cannot be detained for that reason alone, only by reason of your sexual orientation, sexual deviancy in the words of the Act, transvestism or transsexualism rather outdated terminology. Now you cannot be detained in Scotland solely for a reason of dependence on the use of alcohol or drugs. Although you might well be detained for associated reasons such as delirium tremens or depressive illness or psychosis. You can't be detained for behavior which causes harassment, alarm to another person only again, that's a police matter and you're not mentally distorted in Scotland because you act as no prudent person would choose to act to fill out an A DC. You must review your patient detained a patient. You haven't personally seen. Uh you must make a decision on detain using the criteria I've given you and you II should not noted this here, but you'll all know this. You must be a fully registered doctor with the, with the General Medical Council. You must seek the review by a special trained social worker called a mental health Officer. If time allows only you can do it without them. If time does not allow, like if the person is running out the door, you must complete the form and you must submit the form to your hospital managers. It, you, you submit that you detain a person by the authority of the hospital managers and the health board, not in your own authority and you must seek review by an approved medical practitioner, someone like myself or one of my colleagues, er er the next working day in order to consider on detention time is not going great, but it's going ok because I only have a few more minutes, er, to, to, er, er, er, seek your time. Er, and this is really, um, to talk about a very narrow sliver of my work, probably the most niche thing that I do, which is to provide psychiatric opinions for the Scottish liver transplant units. Er, we're doing liver transplants in Edinburgh since 1992. This was our 25th, er, reunion picture, er, in 2017, er, we would have had um our 30th in 2022 but, er, that was canceled for reasons that you'll all remember. And this nice picture, er, which includes the unit but also includes the many 100s of people who would not have been alive for this nice picture without a transplant, er, transplant is AAA wonderful thing that is available and it is available because of the generosity of donors and donor families. And so all of us in the transplant community have to consider the best use of the available donor organ. And I like this picture to remind myself of that and also because it's probably the last such picture because I don't imagine, er, we're going to have a world in the future where we'll be able to gather together 100s and 100s of profoundly immunosuppressed people in one room ever again. Tho those days have probably gone bias. But one of the things I'm asked to do from time to time is um during the week I spend my time going to see a subset of the patients who come to Edinburgh for transplant assessment. Um All that's not for all indications that for alcohol related liver disease patients with mental disorder patients with drug or alcohol problems or patients where there are compliance issues. There's no such thing as psychiatric suitability for transplant. In more general, the issue is whether or not the addictions issue or they are a mental disorder unrelated to um transplant is, is, is the need for transplant is going to affect the decision to transplant and to convey that opinion to the transplant team in the routine assessment meeting, which is held every Friday. But of course, you'll know that people don't have chronic liver disease, they have acute severe liver injury and some of them will go on to full of hepatic failure and far and away the most common cause of that in Scotland this past season overdose. And so I'm often asked to give a view on those er patients. Um And uh I left this slide in, unfortunately, when I was giving this talk to the psyche registrars and none of you need to know this. This is just the background of my involvement in in liver transplantation. And I have to do this from scratch with the transplant reg charge, but none of you will need to know any of this about paracetamol overdose. Um But you'll all know that there's a subset of patients on the green line who, with successful fluid resuscitation N AC and other treatments they go, um, their coagulopathy gets worse but then gets better. And then there's a proportion of people who despite intervention don't, and I'll be asked to see people usually between hour, 48 and hour 60. The reason we don't wait until it's absolutely clear from hepatic failure is of course, that by that point when we're at 72 hours and the the line is, is way up at the top, the person will not be interviewable. And most of the value I can add is to interview the patient. And we'll be looking at a the patient in the context of from hepatic failure. Thinking about are they are psychosocial contraindications of transplant in line with our pre criteria uh that we have decided ahead of time. And so we'll be looking at for absolute contraindications for transplantation. These are the ones that we, we consider is there repeated episodes of deliberate self harm and we somewhat arbitrarily, but you've got to draw the line somewhere, consider five or more lifetime episodes. Uh Usually it doesn't come down to five or six. You'll know that people take no lifetime overdoses or maybe one or multiple. And there are many patients who five episodes would occur even in the last week alone. So we cannot take on patients with a history of recurrent overdose. Um Because of the risk to the graft liver, we cannot accept patients on the transplant list with uh current severe substance dependence, whether alcohol or drugs or chaotic substance misuse. Again, this is partly because of the risk to the graft liver, but also because in fairness to people on the routine waiting, this we can't have any paradoxical uh route to to someone who might be for ongoing dependence, take an overdose and have a different criteria. And so we will not accept people with ongoing substance dependence or use. I would always like to advocate for um good treatment of patients with mental disorder and for equal treatment of mental disorder. But it can't be denied that some chronic severe poor prognosis, mental disorders uh either because they're refractory appropriate treatment or because they are recurrent despite that or where people have no capacity to express wishes or under understand circumstances mean that the person cannot be reasonably expected to consistently comply with the requirements of post transplant life in particular uh anti rejection medication. And then the fourth one is simply a statement of legal reality. Um patients with capacity refuses transplant can refuse transplant just as any patient can reject any treatment, even if refusal would result in their death. But obviously, you'll think in the context of perhaps evolving iny and recent overdose that is the most difficult call to make, but it is probably the rarest and then associated with number one to number three, a history of poor compliance with medical or psychiatric care. And that would probably be less on the psychiatrist and for a wider discussion within the emergency transplant team and then the relative contraindications are simply the, the uh softer versions of, of, of, of all of those I really mentioned the, the the the the the the transplant thing just to give a little bit of this is a very special niche subset of the self harm cohort where the issue isn't prediction of completed suicide. The issue isn't diagnosed with mental disorder. The issue is, should we list the person for super urgent liver transplantation or are the psychosocial, you know, negative factors so extreme that we should go for the best available supportive care. And um that will be an, will be an opinion for the psych, the transplant psychiatrist, but fed into the wider team made up of the anesthetic anesthetist, the physician and the surgeon for overnight, I was aware of my time was not as well managed as I thought it would be. I was aware that my speed was increasing as I went along. I was also aware that the sequence of meaning was, was gathered but was not exceptionally focused. Er, but anyway, I hope that was at least of some interest and er, of some value to your time, er, on a sunny late spring evening. So I'm gonna unshared my slides and I think we're gonna go to, er Q and A if available. If any questions are available, pleasure to speak to you. Thanks very much for your attention. Thank you so much, Roger. It's a really um a really useful runover of uh of kind of basic concepts of psychiatric assessment and it's something we see you, do you say you go behind the blue curtain, but we also see you go behind the blue curtain and it's really interesting to hear um about um about what actually happens. Um uh If you have a question for Dr Smith, please pop it in the chat box just now and we can, we can have a few questions. Um, I've got a couple, one that is, uh, I guess, straightforward and one that is maybe slightly more controversial. So my straightforward question is how on earth as a healthcare professional, do you manage all of the risk that comes with decision making in psychiatry? Yeah. Um, I mean, first of all, you, it's not, there's not unique to psychiatry. Sometimes people go to psychiatry because they get very stressed out by medicine or Ed or whatever. And then they realize that it's, it's not as acute and hot, it's not like a gi bleed in front of you. But it's, it's, it's sort of more low level and smeared across time and more chronic and then they realize they've made a bad call. But if you're gonna do medicine, you're gonna have to make decisions and you're gonna have to accept some level of risk because unless you're going into it with the idea that you're always going to be at every particular intervention, be 100% correct. You know, in which case you are deluded and then you're going to have to take out some risk. And all you can do is make the best assessment. You can be prepared to change your mind when new information comes along, particularly in acute situations. I mean, I in liaison, we're often going into the ed pulling back the curtain, the police tell us a little bit and I come up with an idea, but I'm, I, you've gotta be prepared to change your mind and go back on it. And I mean, occasionally things will go wrong. I mean, you know, if, if, if you're going to do psychiatry, then some patients are going to complete suicide that you, that you dealt with and you're gonna have to go through suicide reviews and see their family. Some will be extremely angry and some will be very grateful for the care they provide and some of them will make you feel guilty because you didn't feel you'd done the best you could and some will make you feel a bit annoyed because you probably do what they can and you don't deserve this, this anger. But you know, it, it, it, it comes with the territory, there's no point asking for any kind of um any kind of uh you know, compensation for that. If, if you don't want to do it, you write a letter and 12 weeks later you're free, you know. Um but in general, people don't do as badly in mental health care as people think they do because sometimes people that only briefly dip into it and then come out of it into other specialties, like four months and they think, thank the Lord. That's over. Right. Radiology. Here I come. They don't really get a chance to be in it long enough to see that quite a lot of patients do well and patients doing well is what we like and that buoys us up with the inevitable downsides because II don't think I have anything like the amount of stress and real low lows of, of, of ICU because, you know, many people do do well, but a heck of a lot don't. And you've got to do with that every day and it's right there in front of you. And so II think we've got a very much milder version of what you experienced, although perhaps perhaps more, more, more, more, more, more chronic and sort of more smeared through, through our overall workload. So, um yeah, it's, it's part of what you do and uh you hope that overall the good outweighs the bad, both in the good that you do versus the, the harm you do. Hopefully not much. Um but also the, the, the good outcomes you get to, to, to bore you up versus the bad outcomes of which there will be plenty. Yeah, there's a question here from. So she, um, uh, psychiatric services always seem to be planned for the patient once he, he or she is discharged from it and back to the ward, should patients be assessed earlier? And do you think it would help in any way? And as I said, the reason why a hurry asked me to do my talk was I think, because he noticed I was seeing me more and more and more and that isn't really the way it's supposed to work. When I first started the infirmary, I went into itu sometimes, you know, for, you know, mental health patients who were being woken up and, and of course for the transplant work, but most of the self harm would get moved on to or, you know, trauma orthopedics or to toxicology. Um I II think patients should be seen as soon as they're fit for assessment. Sometimes there will be a little bit of disagreement on that. Not so much for the anesthetist, but sometimes physicians have got a slightly over optimistic view of what assess assessable means. Um you know, sort of barely awake versus, you know, actually accessible. But once people are accessible II II think they, they, they, they should be assessed my own personal view. And I think probably nieces would agree with me that once people are not needing ICU care, they should be moved to, to a ward environment. I think it's nicer for the patients. Um, and II think it's less stressful. It's pretty stressful if you're in a highly ened emotional state and then people are ventilated and having cardiac arrests up and down there and people can come out quite wide eyed. Um, and you can overstate the adverse effect this will have on people. They might just be freaked out by it. So, I mean, II think people, I think the system should, should be set up to allow people to be assessed in a downstream ward. But I wouldn't have any truck with, with psychiatric teams saying we don't, we don't assess them until they leave itu if itu delays are becoming 12 hours, 24 hours or, or whatever, you just have to go where the patient is. So if I had my way, people would move downstream faster and we'd see them there. But if we see them whenever they're awake, that's fine by me. Um I have a question and you can, you feel free to, to not answer to this? Should you, should you not wish to? I guess I was just listening to your chat there. There was a lot of discussion around, um, I guess psychiatric disorders and the, and the, and the chronic distress that they can cause people throughout their lives. I'm aware that the kind of the, the kind of right to die bill is being debated in, in Scottish parliament at the minute and I'm aware that in other places they had, you know, that in which, um, I guess euthanasia has a legal framework supporting it. There are some patients that have chose, with psychiatric disorders who have chosen, um, to, to get in their lives. I just wondered about your opinion as a psychiatrist who spends quite a lot of time trying to make these patients better about whether or not that should be considered amongst the discussion that's happening in parliament. Yeah, let me just, first of all say, I certainly will answer the question because I'll, I'll answer any question that's put to me. But um I'm chairing our legislative oversight forum on that. So we'll be making a response. We have a live consultation with college members in Scotland about that. And so in a sense, it doesn't matter what I personally think it's what my role as, as, as, as the college. So II don't want to, you know, it says commit myself in, in this form because I've, I've got the feedback from my own college members to get and I've got to work it through our process and we will respond to the consultation. And if the previous two bills are anything go by, we will be uh will go in front of the Scottish parliamentary committees. Uh um Li mccarthur Bill, it's a draft bill. It's not just um AAA consultation at present. So there is a draft bill that you can read on the Scottish government website and it suggests that the illness, beer untreatable and progressive, but it also specifically preclude CLS that the decision be as a result of mental disorder and ask that the person has capacity. There's a rather strangely worded thing in that, in that you as they will presumably be oncologists and neurologists and old age physicians really well, also GPS and also maybe yourselves. It's got this strange thing where it asks you to sort of think that it's not mental disorder and then that's it. You do that by yourself. But if you think the person is incapable, there's a kind of call out where you can ask a psychiatrist and it seems to be like most physicians in I people will probably go solo on the capacity before they would go solo on the diagnosis of mental disorders. So I think that probably will be reworded. But the proposal in front of the Scottish Parliament and I think this is about broadening support for it is to go the Canada route, at least Canada has currently exists route of precluding mental disorders rather than the Belgian route of allowing, you know, intractable mental distress, untreatable anorexia or, or, you know, putatively untreated anorexia or personality disorders. Um There's, there's, there's a number of arguments which I'm sure I'm going to hear from colleagues. There's the argument that we, that psychiatrists should never agree to something that has differential treatment between physical and mental disorders. There's an argument that they are different and that we have disorders where people as a part of the disorder seek seek seek death uh fundamentally driven by the disorder rather than somebody who says, you know, if I could cure the motor neurone disease tomorrow, I would. But I'm, you know, it, it, it there's an intrinsic part of the, the the death seeking that that is, is not there for other disorders. Um And there's considerable concern, I think about how it would affect practice if that were available. What would you be doing in self harm? Work? How would it sit if you were seeing people and every effort including using the law to stop them from completing the suicide and then going to another part of the hospital there, there's, there's a whole lot of issues and our college hasn't come. I say we're at, we're at the, at the internal consultation stage within the college hasn't come to a view and, and I'll be asked to help organize that view and present it to, to the government, the, the currently drafted bill pre precludes mental disorder and the incapable for its consideration. And I think that was deliberate because I think that is about broadening um support for the bill. It's entirely possible that the bills drawn up one way and changes as is proposed in Canada. It's entirely possible that it is kept more narrowly focused as it has been in, in Switzerland. Er, but you know, it is, if, if you looked at the issue of mental disorder and said you were absolutely unconcerned. II would say that you, you haven't thought about it deeply enough. That's really interesting to hear your, your, your thoughts on that. Um, are there any other questions for Doctor Smith? I can't see any. So that is perfectly timed a minute to go. Uh, so thank you so much for joining us. We've really um really enjoyed having you. Um uh This will be available um for on, on kind of catch up um for your uh anyone who hasn't been able to make it to catch up on. So please tell your colleagues. Uh we will be back next month with another uh uh evening education update. So please get your eyes peeled for the information and the sign up link for that and I hope you all enjoy the rest of your evening. I'm about to post a little feedback link in the chat box. If you click on that and complete the feedback, you'll be, you'll be off, your CPD certificate will automatically be generated. So thank you so much for joining this evening. Um And we'll see everybody soon. Mhm.