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  • Writer's pictureJerry Marzinsky

Psychiatry overwhelmed by referrals for 'normal emotions'

By Helen McArdle@HMcardleHT Health Correspondant

December 30, 2023



Dr Joanna Bredski says we have come to perceive normal negative human emotions 'as problems that need a service' (Image: PA)


Acute mental health services are becoming overwhelmed by referrals for people with "normal negative human emotions" who may actually be harmed by treatment, a leading psychiatrist has said.


In an interview with the Herald Dr Joanna Bredski, a consultant psychiatrist and deputy chair of the BMA's Scottish consultants committee who has produced prize-winning research, said it was "dystopian, potentially harmful, and wasteful" that people presenting with "normal human emotions" were being given drugs and psychological therapies.


She said: "It's normal for humans to feel negative emotion about 50% of the time. It's totally healthy to have negative feelings like sadness, anger or anxiety in at least half of their day to day life.


"If you don't have that, you're either very fortunate or you're very good at processing your feelings or maybe you're numbing them in some way by over-eating, over-drinking, or other things.


"The point is that it's healthy to have negative feelings a lot and yet I think we come to believe that it's not okay to feel sad, it's not okay to feel anxious, it's not okay to feel angry.


"We have come to perceive normal negative human emotions as problems that need a service, and that's fundamentally unhelpful."


She said she would like to see more done with social prescribing, such as exercise or initiatives to ease loneliness, as well as a bigger role for psychiatry in tackling the social determinants of mental health such as "income, education, schools, parenting, and nutrition". 


It comes as the latest Scottish Health Survey, published on December 5, found that mental wellbeing in Scotland was at its lowest level since 2008.


Dr Bredski studied medicine at Aberdeen before going on to qualify as a psychiatrist over a decade ago, when she was just 30.


As a specialist in rehabilitation psychiatry, she works at the "deep end" - with patients who have severe mental health disorders such as schizophrenia and other forms of psychosis - but said the surge in the number of people in Scotland being prescribed antipsychotic drugs is "problematic".


She said they were increasingly being used without evidence as treatments for insomnia, distress, and anxiety.


Official data shows that between 2010/11 and 2019/20 - the last year for which annual figures are available - the number of people on antipsychotic medication increased by 42%, from 75,763 to 107,206.



Dr Bredski said antipsychotic prescriptions have risen much faster than diagnoses of psychosis in the community (Image: Newsquest)


"The rate of antipsychotic prescribing has mushroomed over the last 10 years - much much more compared to the very slight increase in rates of psychosis in the community," said Dr Bredski.


"Antipsychotics are being prescribed for distress, insomnia and anxiety, and they don't have an evidence base for those things at this point in time.


"Some antipsychotics have been quite well marketed and some clinicians have been encouraged not to prescribe benzodiazepines like diazepam, and so choose these other things like antipsychotics which can be harmful."


The strain facing mental health services is illustrated by vacancy rates.


As of September, general psychiatry had a shortfall of more than 50 consultants - the largest number of vacancies for any medical specialty - while more than a quarter (25%) of consultant posts in Child and Adolescent Mental Health Services (CAMHS) were empty.

The situation has led to warnings that the profession is in a "death spiral".


Dr Pavan Srireddy, vice chair of the Royal College of Psychiatrists in Scotland, told Holyrood's Public Audit Committee in November that high turnover and staff leaving due to burnout meant that locums were now filling 20% of consultant posts resulting in a "critical loss" of capacity for consultant-led functions such as training, supervision, and critical incident reviews to learn from mistakes.


He said: "The numbers have become so low that it has become virtually impossible to provide a safe service, let alone a good quality service, in large parts of the country. And that is an emergency that we really need to sit up and look at."


Dr Bredski said that the system was also being "pulled apart" by waiting times targets that prioritise activity over need, and a lack of clarity over what belongs in secondary care.

Under Scottish Government guidelines, at least 90% of patients referred for psychological therapies are supposed to be seen within 18 weeks.


In the three months to June this year, that was being achieved in 82% of cases - largely unchanged from a decade ago - yet the number of people starting treatment has more than doubled over that period, from around 7,900 in April-June 2013 to 18,450 in April-June 2023.


"The waiting time target is managed in such a way that there's no flexibility about who you pick up next," said Dr Bredski.


"There's no triage happening, so you'll just pick up the next person on the list.


"The problem with that is that the next person on the waiting list might be reasonably stable with relatively low level anxiety and depression who is still able to work; the next person after that might have a severe, life-threatening anorexia nervosa.


"As clinicians, I think it should be possible to focus our resource on the most severe and the most ill where usually there's the most benefit to be added."


She added that specialists such as herself were now having to manage both an influx of lower level mental health cases as the bar for access into secondary care had been lowered over time, as well as an increase in referrals for patients who would previously have been managed by forensic psychiatry where the entry criteria has been tightened.

Dr Bredski said: "There's more complex stuff in the adult psychiatry caseload that's come down from above, but there's also much more from below.


"Historically, 90% of mental healthcare was done by GPs and it was just the 10% of people with severe and difficult to treat mental disorders that would be referred into secondary care.


"What we're seeing over time is a change in where the entry point sits in secondary care.

"It's not my 'deep end' patients who are out there asking for treatment - it's people at the other end of the spectrum seeking therapy, and I think what has happened over time is that we've just accepted that is the demand, and we've attempted to meet that demand, without thinking carefully enough about whether it's helpful: is it adding value, or is it wasteful and potentially harmful?"


Mental Wellbeing Minister Maree Todd said: “We want people in Scotland, regardless of their background or circumstances, to have access to the right help, in the right place, at the right time, when they struggle with their mental or physical health.


“That’s why we published the National Specification for Psychological Therapies and Interventions and the Core Standards for Mental Health, to improve the delivery of psychological therapies, the quality of mental health services and to ensure that individuals, their families and carers know what they can expect from services.


“Despite workforce expansion, and higher numbers of people receiving psychological therapies year on year, performance still varies across health boards, and we continue to direct tailored support to those boards not on track to meet the standard.”

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