The best kept secret in psychiatry by Maria Grazia Turri

In one of Georges Simenon’s short novels, Maigret’s Doubts, Inspector Maigret receives the visit of a man who suspects his wife of wanting to poison him. The man tells of having been off colour recently and accuses his wife on the basis of having found some rat poison in the broom cupboard. Inspector Maigret is left questioning (hence the doubts of the novel’s title) whether his visitor is mentally insane. He consults a number of psychiatric books and he is left with the impression that “by investigating the anomalies of human behaviour, classifying and subdividing them, in the end it was impossible to tell what a man of sound mind might be”. As the investigation leads Maigret to get acquainted with the man’s private life and his close relations, he begins to understand: “he felt, finally, that he was dealing with people of flesh and blood, men and women with passions and interests”.

In 2003, in my first job as a junior doctor in psychiatry, I was asked to interview a middle age woman, I will call her Mrs A. She was an inpatient receiving Electro-Convulsive Therapy (ECT). She had been diagnosed with treatment-resistant psychotic depression for the past two years. She believed that she was being controlled by a little man inside her who made her behave oddly, commanding her to crawl instead of walk and to babble like a new born rather than talk. She was prescribed two antidepressants and an antipsychotic, as well as sleeping tablets and a course of ECT. While I was diligently conducting my semi-structured psychiatric interview, checking how many hours she was sleeping per night, was she waking up early, had she lost her appetite, could she concentrate on watching TV or reading a book – and I will spare you the rest – I noticed a very brief exchange between Mrs A. and her visiting daughter, which made me question whether some family trouble may be contributing to her depression. Questioning family relationships was not part of the semi-structured interview, but it led to a referral for a family therapy meeting, at which I was present. An hour interview with an experienced family therapist unravelled the secret history of this patient, secret because it had never been told outside the domestic walls. That one interview was enough to make us begin to understand.

Mrs A. had run the family business and brought up three children all single- handed for many years. Her husband had had several mistresses during their marriage and had spent lots of the family money on expensive holidays with them. Nevertheless, they stayed together and played the happy couple at family gatherings or for the local community. During all that time Mrs A. had managed without developing a mental illness. But then three years before, her husband had fallen ill with cancer and Mrs A. had become his full time carer. He had no more mistresses now, and even after his recovery, he remained faithful to her and a permanent asset to the domestic environment. He had however taken over control of the family finances and patronised her into following him in expensive holidays that she did not enjoy. That is when she had developed depression. Now I understood why she believed that she had a little man inside her controlling her and making her crawl rather than walk and babble rather than talk. Or at least I thought I understood. There were tears shed in the family meeting. It seemed like the elephant in the room had materialised and was brushing its tail against our eyes, and those of the lady, and her children. Her husband was the only one to remain unmoved and said little.

The family meeting had been an eye-opening experience for a junior psychiatrist.

A few years afterwards when I was working as a Specialty Registrar, I teamed up with a general adult psychiatrist to set up what we called ‘the systemic assessment clinic’ (SAC). Both of us had had extensive experience of systemic family therapy and had come across repeated instances of epiphanies in ‘heartsink’ cases similar to those of Mrs A. The SAC was a weekly clinic where we assessed patients who were referred to his general adult psychiatry team with a different model from the one used as a standard in general psychiatry. We asked referred patients to bring along anyone they felt was significant to their lives. Patients brought their partner, their parents, their adult children, siblings or, sometimes, a close friend. In the spirit of family therapy we shifted the focus from assessing the symptoms in the individual to investigating the ‘problem’ in the system. We felt that at the end of these assessments we could almost always say: “we begin to understand”. We asked patients and carers to rate their satisfaction with the process and scores were high.

Nevertheless, our many attempts to get support or endorsement of the SAC from our local NHS Trust failed. We were told it was not ‘evidence-based’ and were encouraged to apply for a NIHR grant – 56 pages long, it took a year to write, it pulled together a team of 8 experts and was rejected.

Trying to provide some evidence for the SAC’s benefits, I carried out a service evaluation. I compared outcomes for 22 patients seen in the SAC from 2013 onwards and 22 comparable patients who were assessed in standard psychiatric assessment during the same period of time. All patients were new to psychiatric services. Outcomes were measured as: time spent in psychiatric services after assessment, type of services used, and number of times patients were referred back to psychiatric care after discharge. Follow up was between 2 and 3 years after assessment. The results were very interesting and some of them impressive. In both groups, the immediate post- assessment use of psychiatric services was comparable: a small fraction was discharged back to their GP immediately, the majority were referred for an intervention lasting between 6 and 12 months, and a small minority were referred to tertiary services. Rates of referral to psychology and psychotherapy were comparable across the two groups, although – perhaps surprisingly – somewhat higher in the standard assessment group. In both groups the mean time from assessment to discharge from psychiatric services was comparable, although the number of patients discharged within 6 months was 11 for the SAC and only 6 for the standard assessment group. The great surprise came when we counted the number of times patients were re- referred to psychiatric services once discharged. For the standard assessment group 9 of the 22 patients were re-referred within the 3 years period, and of these, 5 were re-referred twice (for a total of 14 re-referrals). But for the SAC group, only 1 patient out of 22 was re-referred once within the next 3 years. You may conclude that the SAC scared people off from coming back to psychiatric services… Our impression was that, by engaging people in meaningful conversations from the start, it allowed for the development of a purposeful care-plan which was recovery-oriented, while standard assessment tended to make them chronically ill.

The interesting part of the story comes now.

Conscious of the fact that such a small study could not gain attention in the main clinical press, in February 2016 I sent a paper  summarising its results to the Bulletin, a journal published by the Royal College of Psychiatrists and which specialises in the publication of audits and opinions. It has an insignificant impact factor but it has the advantage of being circulated to all psychiatrists in the UK as an addendum to the prestigious British Journal of Psychiatry, with the potential to reach a sizeable audience. After submitting, I was surprised to hear from the Editor that he was not going to send my paper out for peer-review. I wrote back, politely but passionately asking him to reconsider. The Editor sent the paper to a member of the editorial board for a
second opinion, and they enthusiastically replied that the paper should be sent for peer-review. The Editor obliged. I therefore resubmitted to the Bulletin in April 2016 and received a positive opinion from the reviewers, who suggested some revisions, which I dutifully carried out. In June 2016 the revised copy was resubmitted to the Bulletin. In September 2016 I received confirmation that the resubmission satisfied the requested changes and could therefore, according to the reviewers, be published. However the Editor stepped in and declared that he was still “unable to accept this paper for publication” and nothing could be done to alter his opinion. He justified himself by saying that he did not believe the validity of the data. I was gutted but in November 2016 I had the moral strength to bring the matter to the attention of the then President of the Royal College of Psychiatrists. I expressed my concern that following a lengthy review process the Editor had decided single- handed to go against the recommendations of the peer-reviewers and to stop the publication of the paper. In January 2017 the President replied that the Editor’s opinion should be upheld and I was advised not to “ waste any more time and energy on this submission”.

This experience has made me think, and I am still thinking about it. Psychiatric interventions (particularly biological ones) are tested on a large scale on the basis of a diagnostic system which is founded on the standard psychiatric interview. Or shall we say, that the standard psychiatric interview is founded on the official diagnostic system? It’s a chicken-and-egg situation. On this chicken-and-egg is grounded all the evidence that determines whether therapeutic interventions are efficacious or not. And yet there is absolutely no evidence-base for the diagnostic system (and many have written about this), and there is no evidence-base either – and this is the best kept secret in psychiatry – for the standard psychiatric interview. Most evidence-base in psychiatric research has been built on quicksand.

The antipathy for my paper is much more telling and significant than if the paper had been accepted. My paper was the tail of an elephant, brushing against the eyes of the psychiatric establishment: like Mrs A’s husband, they would rather be left blind.

Maria is now a lecturer at Queen Mary University of London

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