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Psychiatrist’s $64,000 discharge error

A court has found a psychiatrist breached their duty of care to a patient for the injuries she sustained in a car accident while driving home following discharge from the hospital.

The patient alleged that at the time of her discharge, she was excessively tired and/or sedated and should not have been permitted to drive home. She claimed the psychiatrist and admitting hospital’s negligent conduct had caused her to lose control of the car and sustain personal injuries.

In reaching its decision, the court considered a range of evidence from the psychiatrist, hospital, witnesses, experts, as well as medical notes and letters.

Ultimately, the court found the psychiatrist and the hospital each liable for negligence, and apportioned responsibility between them. The hospital and the psychiatrist were ordered to pay the patient $32,167 and $64,333, respectively, plus costs.

The case highlights the risks when discharging patients potentially under the influence of sedating and psychoactive agents, and the importance of conducting and documenting a careful assessment before allowing any unattended patient to drive home.

Car accident following discharge

The patient was a woman with a background as a registered nurse, who had been terminated from her job due to absences because of back pain following a work accident. She visited her GP complaining of depression and feeling suicidal, and was admitted to an acute hospital’s mental health unit for about a month. She was then admitted as a voluntary inpatient, to a private hospital under the psychiatrist.

During her admission, which lasted another month, she suffered both insomnia and daytime tiredness. She was taking multiple psychoactive drugs including antidepressants, opiates and other strong analgesics as well as Stilnox at night.

During a consultation the day prior to the patient’s discharge, the psychiatrist assessed her readiness for discharge in relation to her mental state. The patient was able to assure the psychiatrist she was no longer suicidal and the psychiatrist authorised discharge for the next day.

On the morning of discharge, the patient took her regularly prescribed OxyContin. Prior to discharging her in the afternoon, a nurse completed a driving risk assessment and then returned the patient’s car keys so she could drive the 50 kilometre journey home. Unfortunately, the patient drove off the road and into a wall, quite close to home.

She was taken by ambulance and treated at an acute hospital for her injuries, including pain in her neck, head, shoulder, lower back and leg. She was then re-admitted to the private hospital under the original psychiatrist, where she remained for another month.

Court’s findings

The court heard in the days prior to discharge, the patient was often excessively drowsy and would fall asleep even while sitting eating meals. On the day of discharge, the patient had again fallen asleep over breakfast. Nursing staff had tried to wake her on several occasions, but she kept falling back asleep.

The court noted medical records from the hospital in which staff had reported the patient appeared over-sedated and drowsy. The nurse’s risk assessment completed at the time of discharge, also stated, “reports tiredness lately – Psych aware”.

Given the “overwhelming evidence”, the court found the patient was tired, drowsy and sedated upon discharge.

“I find she was not in a fit state to make a decision about her capacity to drive and find that she relied upon her carers to advise as to whether or not it was safe for her to drive herself home and warn her of the risks of drowsiness,” the court said.

The court concluded the car accident occurred as a result of the patient falling asleep due to tiredness, fatigue or excessive sedation.

Psychiatrist’s grounds for negligence

While the psychiatrist conceded the scope of their duty of care extended to reasonable care of treatment, they sought to deflect liability on the basis of s50 of the Civil Liability Act (CLA), claiming they had acted in a manner which at the time was widely accepted in Australia by peer professional opinion as competent professional practise.

In determining the psychiatrist had breached their duty of care to the patient, the court noted they had granted the patient permission to drive her car and was the sole person with control over whether the patient drove. Based on hospital protocol, staff could only give the keys to the patient with the psychiatrist’s permission.

The court accepted the patient’s evidence she had expressed concern to the psychiatrist about driving due to drowsiness, to which the psychiatrist had responded, “you should be fine to drive.”

The court found that at no stage during the consultation before her discharge, did the psychiatrist discuss how she would travel home. Furthermore, the psychiatrist admitted they left the decision up to the patient as to whether she was fit to drive.

“To leave it up to a psychiatric patient who suffered from pain, fatigue and sedation, which would vary from day to day, to decide whether to she was fit to drive at the time of discharge, is a complete abrogation of the psychiatrist’s duty of care and responsibility,” the court said.

The psychiatrist was also found negligent by failing to review the patient or enquire about her condition on the actual day of discharge, despite her observations of the patient the day before discharge and personal knowledge of the patient’s sedation, as evident in the records and other correspondence.

In a letter to the patient’s insurer, the psychiatrist had reported increased sedation over the last week which the introduction of OxyContin may have caused. Another letter to a neurologist said in the three days prior to discharge, the patient was “excessively sedated” and had some semi-falls.

The court accepted expert opinion that in allowing the patient in such a state to drive unattended, the psychiatrist and hospital breached accepted professional standards, and had not acted in a manner which would be widely accepted by peer professional opinion.

Hospital breaches duty of care

The hospital argued they had relied upon the fact the psychiatrist had authorised the patient to drive, as well as the patient’s own assessment of her capacity to drive and knowledge of the effects of the medication, given she was a registered nurse. The court rejected these defences.

The hospital was found to have breached its duty of care to the patient for permitting her to drive following discharge in circumstances where she was unfit to drive.

No basis for patient’s contributory negligence

The court rejected claims made by the hospital and psychiatrist against the patient that her actions constituted “contributory negligence”, by failing to take reasonable precautions against her risk of harm. The court found the sedating effects of the medications impeded her ability to make a responsible decision in the circumstances.

Key lessons

  • Doctors and hospitals have a responsibility to carefully assess the safety of their patients being discharged from their care. This includes identifying suitable arrangements for transport home and may require prolonging admission if no arrangements can be organised.
  • Doctors should remain aware of the risk of excessive sedation of patients taking psychoactive agents, especially in combination, and carefully assess their risk for harms. In preparing patients for discharge it is good practice to carefully review their use of sedating medications and other risky agents warranting special advice. This of course extends to showing caution when prescribing sedating medication in the community including sleeping tablets, strong analgesics and psychoactive agents, and adequately warning of the risks.
  • Doctors should always carefully document their assessments of patients, especially in higher-risk contexts such as transitioning from care. It is important to record the relevant positive and negative findings which would justify discharge and to outline the discussed options and agreed plan.

This article was originally published by Avant Mutual. You can access the original here.

Is psychiatry ready for medical MDMA?


Within five years, science will likely have answered a controversial question: can methylenedioxymethamphetamine (MDMA) treat psychiatric disorders?

After some studies showing a positive effect, MDMA-assisted psychotherapy is entering final clinical trials as a treatment for post-traumatic stress disorder (PTSD). If these trials show positive results, MDMA will go from an illegal drug to a prescription medicine in the United States by 2021, potentially prompting movement in this space in Australia and Europe.

MDMA would move from the fringes to mainstream psychiatry, becoming recognised as a mainstream treatment option. What remains less clear is how psychiatry will deal with questions arising from this new treatment approach.

MDMA in medicine: a brief history

German pharmaceutical company Merck patented MDMA in 1912. However, it appears not to have been used in humans until later that century.

Better known as a street drug in the rave scene of the 1980s and ’90s, MDMA was used in the 1970s by a small band of US psychiatrists and therapists. This group believed it enhanced the therapeutic bond and improved treatment for ailments ranging from marital distress to, potentially, schizophrenia.

Following rebranding as “ecstasy”, large-scale recreational use of MDMA led to its 1985 listing as an illegal drug in the USA (Australia followed in 1986). The MDMA-therapy community unsuccessfully protested against this designation.

Advocates for MDMA-assisted psychotherapy have been playing the long game ever since, undertaking a painstaking process of research and advocacy, which has culminated in the upcoming trials.

MDMA versus ecstasy

Advocates for MDMA-assisted psychotherapy have been at pains to distinguish the street drug ecstasy from MDMA the medicine. Ecstasy can contain a range of substances as well as varying doses of MDMA.

This is unsurprising given early evidence that high repeated MDMA doses – more relevant for recreational than therapeutic use – damage serotonergic neurons in animals.

Catastrophic predictions of a lost generation of ecstasy users, however, failed to materialise. Indeed, numerous people have received MDMA doses similar to those proposed for therapy in laboratory studies. This shows that MDMA can be safely administered under controlled conditions to well-screened healthy adults.

It remains unknown whether the same is true of groups excluded from most studies. This includes children and older people, and those with psychiatric or physical illnesses. Studies to date do, however, suggest acceptable safety in adults with PTSD.

Pharmacologically enhanced treatment

One aspect of MDMA therapy attracting less attention is that it involves a fundamental shift in psychiatric medication. All currently approved psychiatric medications treat symptoms rather than the disease itself. Relapse is common after stopping treatment.

MDMA-assisted psychotherapy, by comparison, involves limited MDMA doses over two or three sessions of eight to ten hours. The aim is to “fast-track” psychotherapy to produce long-lasting changes.

Possible mechanisms of such an effect are unclear. One suggestion is that the effects of MDMA, such as feelings of empathy, openness and reduced fear, might allow people to reprocess traumatic memories during psychotherapy.

Other medications are also being considered as adjuncts for psychotherapy. These include potent psychoactives like LSD and psilocybin, or drugs thought to enhance psychotherapy via mechanisms other than psychoactive effects (e.g. d-cycloserine).

It is possible, however, that a broader range of pharmaceuticals could be used in this way. Thus, a potential benefit of MDMA’s approval could be to spur further research in this area.

The challenges of regulation

The potential approval of MDMA for prescription gives rise to pressing questions about regulation. For instance, should prescribing be limited to physicians with specific qualifications? What training should be required for those conducting the psychotherapy? How should the drug be handled and stored by pharmacists?

The combination of a drug-affected patient with non-drug-affected therapists could make patients vulnerable during psychotherapy. This suggests a need for stringent training and oversight of MDMA-assisted therapy.

Approval of MDMA will also lead to off-label prescribing, with doctors prescribing the drug for conditions other than PTSD. This could include a range of conditions, such as depression and substance use disorders, and various patient groups.

A particular issue is prescribing to children/adolescents. To date no controlled studies have assessed the safety of MDMA in young people. Planned studies in adolescents with PTSD will thus be important.

Is anything ‘penicillin for the soul’?

The slow progression of MDMA-assisted psychotherapy from the subcultural margins towards approval has been driven by the belief of those advocating for it.

Without this motivated community, MDMA would likely not have been developed as a medication, as it is off patent. The downside of this robust advocacy base is that it can lead to rather extreme claims (e.g. “penicillin for the soul”) and experimenter bias.

In addition to well-designed studies that control for experimenter bias, there is a need for researchers and clinicians outside the MDMA-advocacy community to be involved in the ongoing development of this research direction.

The ConversationIf MDMA is to become a part of mainstream psychiatry’s armamentarium, many questions will need to be answered. The next few years will be critical to see if MDMA joins the ranks of failed psychiatric treatments, or offers new hope to people suffering from PTSD.

Gillinder Bedi, Assistant Professor of Clinical Psychology (in Psychiatry) University of Melbourne and Orygen National Centre of Excellent in Youth Mental Health, University of Melbourne

This article was originally published on The Conversation. Read the original article.

Tokophobia: what it’s like to have a phobia of childbirth


Catriona Jones, University of Hull; Franziska Wadephul, University of Hull, and Julie Jomeen, University of Hull

It’s very common for women to feel anxious about labour and birth. Worries about the pain of contractions, interventions and the uncertainty of the process are not unusual. But for some women, the fear of labour and birth can be so overwhelming that it overshadows their pregnancy and affects daily functioning.

This severe fear of birth is called tokophobia – which literally means a phobia of childbirth. And for some women, this also includes a dislike or disgust with pregnancy.

Tokophobia can be split into two types – primary and secondary. Primary tokophobia occurs in women who have not given birth before. For these women, a fear of birth tends to come from traumatic experiences in their past – including sexual abuse. It can also be linked to witnessing a difficult birth or listening to stories or watching programmes which portray birth as embarrassing or dangerous. Whereas women who suffer from secondary tokophobia, tend to have had a previous traumatic birth experience which has left them with a fear of giving birth again.

It is difficult to say how common tokophobia is. Research suggests that between 2.5% and 14% of women are affected by tokophobia. But some researchers believe this figure could be as high as 22%.

These figures vary so much because women with different levels of tokophobia were included in the research. So while some women may have relatively mild tokophobia, for others, the condition is much more severe. The figures may also include women who have anxiety and depression rather than tokophobia.

Not a happy occasion

Women with tokophobia come from a wide variety of backgrounds. It is difficult to predict who might be affected, although it is clear that women with tokophobia are also more likely to experience difficulties with anxiety and depression and other mental health problems.

Research suggests some women with the condition choose to avoid pregnancy altogether – or may consider a termination if they find themselves in that position. When pregnant, women with tokophobia may request a caesarean section to avoid the process of actually having to give birth.

Some women find pregnancy itself very difficult, particularly dealing with the growing bump and feeling the baby’s movements. Anxiety, insomnia, sleeplessness, eating disorders and antenatal depression or increased risk of postnatal depression, have all been identified as consequences of tokophobia.

Mothers with tokophobia can struggle to bond with their babies.

Some of the consequences for women with tokophobia – which emerge during labour – are longer labours. These are usually with an epidural and increased need for forceps or ventouse – this a cup-shaped suction device which is applied to the baby’s head to assist the birth. All of which can have implications for both the woman and her baby.

Afterwards some women with tokophobia may have a less satisfying bond with their babies. And a difficult experience of birth can make women more afraid of birth if they become pregnant again.

Tokophobia treatment

Anecdotal evidence indicates that clinical care for women with tokophobia is patchy. But the good news is that there is help out there for women with this condition. Some women find it helpful to talk through a previous experience of a traumatic birth, others might be reassured by information about labour and birth. Other women, however, may need more targeted treatment – a number of counselling approaches can be helpful.

Giving birth to a child is one of the most intense experiences the body can go through.

Many women also find it helpful to visit the maternity ward and talk to midwives and obstetricians during pregnancy. Some women find the condition can be very isolating, feeling that nobody else shares this intense fear. For these women, simply knowing that they are not alone, can be very comforting and helpful.

Overcoming a phobia

In Hull and East Riding of Yorkshire, where there is an established perinatal mental health service for women and their families, there has been a recognised need for a consistent approach to caring for and supporting women with tokophobia.

This has led to a group of practitioners, academics and patients to work together to explore the care and support available to these women – and to help address the gaps in service provision.

This pioneering work, which is at the forefront of tokophobia service provision and research in the UK, aims to ensure that women get the right support, and that their psychological and pregnancy needs are met.

The ConversationTokophobia can have debilitating effects on women and their families. Some women will avoid pregnancy, even though they might want to have children. For those who do become pregnant, the condition can overshadow pregnancy and affect the choices they make for labour and birth. This is why we need to work towards preventing tokophobia if possible – as well as providing effective treatment for women who suffer from this difficult condition.

Catriona Jones, Senior Research Fellow in Maternal and Reproductive Health, University of Hull; Franziska Wadephul, Research assistant, University of Hull, and Julie Jomeen, Professor of Midwifery and Dean in the Faculty of Health Sciences, University of Hull

This article was originally published on The Conversation. Read the original article.

Postnatal depression: men get it too


Over the past few years, there has been an increase in media reports about postnatal depression and other maternal mental illnesses, and campaigns have led to greater understanding about the need for more specialist services. Although this is encouraging, very little is said about fathers. But men can get postnatal depression, too.

Currently, only mothers can be diagnosed with postnatal depression. The psychiatrists’ “bible”, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), includes a diagnosis of “peripartum depression”. Peripartum depression is a form of clinical depression that is present at any time during pregnancy, or within the four weeks after giving birth, although experts working in perinatal mental health tend to be more flexible, extending that period to the first year after giving birth.

In many ways, postnatal depression varies little from traditional depression. It, too, includes a period of at least two weeks where the person experiences low mood or a lack of motivation, or both. Other symptoms include poor sleep, agitation, weight changes, guilt, feelings of worthlessness, and thoughts of death and dying. But the biggest difference is that a depression at this time involves a significant additional person: the child.

Evidence suggests that the long-term consequences of postnatal depression on the child can be damaging, including developmental problems, poor social interaction, partner-relationship problems and greater use of health services (including mental health services).

Around 7-20% of new mothers experience postnatal depression. A common view is that it is caused by hormonal changes. Although this is partly true, it is far more likely that life factors are responsible, such as poverty, being younger, lack of support and birth trauma. Another potential cause is the sudden overwhelming responsibility of having a baby to care for, and the life changes that it entails.

Depressed mothers also feel intensely guilty about the way they feel about their baby, and fear shame and stigma from society. As a result, at least 50% of mothers will not report a mental health problem. Other mothers will not tell their health provider out of fear of having their child taken away by social services.

Prevalence of postnatal depression in men could be as high as 10%.
Pushish Images/Shutterstock.com

Mounting evidence

All of the above factors can equally apply to fathers. But there is no formal diagnosis of postnatal depression for fathers. Yet evidence from several countries, including Brazil, the US and the UK, suggests that around 4-5% of fathers experience significant depressive symptoms after their child is born. Some other studies claim that prevalence may be as high as 10%.

The cause of these feelings in fathers is similar to what we see with mothers, but there are extra complications. Men are much less likely to seek help for mental health problems, generally.

Societal norms in many nations suggest men should suppress emotion. This is probably even more a factor for fathers, who may perceive their role as being practical and providing for the family. Fathers – especially first-time fathers – might experience many sudden changes, including significant reduction in family income and altered relationships with their wife or partner. These are major risk factors for depression in fathers.

The importance for supporting fathers at this time is as vital as it is for mother. Evidence suggests that a father’s depression can have a damaging effect on their child’s development. Despite this, it has been shown that fathers are also less likely than mothers to seek help, and that health professionals are less likely to consider that fathers need support, compared with mothers. More evidence is needed to build a case that fathers need support as much as mothers.

Poorly equipped

The ConversationIt has been argued that, until recently, health professionals have been poorly equipped to recognise and treat mental illnesses associated with the birth of a child. Recent campaigns in the UK have led to changes in policy, funding and health guidelines. However, the recent revision of the National Institute for Health and Care Excellence (NICE) guideline on perinatal mental health does not address fathers’ needs. Despite a campaign to address this having support from several professionals and academics, a NICE spokesperson told the BBC that guidelines are unlikely to be changed as there is no evidence that men experience postnatal depression. However, if we discount hormonal factors in new mothers, the remaining risk factors for postnatal depression also apply to fathers. And we need support that recognises that.

Andrew Mayers, Principal Academic in Psychology, Bournemouth University

This article was originally published on The Conversation. Read the original article.