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  • 20th March 2017 | By David Jolley

    A colleague pointed me to an interesting article in the Psychiatric Bulletin from Professor Julian Leff, now retired but still busy and reflecting on ‘The most important things I have learnt in my career as a psychiatrist’. http://pb.rcpsych.org/content/41/1/51

    This is the week the Law Commission has released its report on a possible alternative to DoLS. Like many others, I am reading it, but it will take a while to digest and to do justice to in response. In the meantime Professor Leff’s ruminations encouraging and revealing. We shared them at a seminar for consultants and trainees in psychiatry, looking for a spark to counter the shadow which says that few doctors wish to work in our field.

    Julian Leff’s interest in psychiatry was stimulated by his experience as a medical student at University College in London. Students were expected to take on a patient for psychotherapy, under supervision. This was an arrangement I had heard about first from Professor Neil Kessel, who was professor in psychiatry in Manchester when I came here as a young trainee in 1970. Neil Kessel had also trained at University College after a period at Cambridge. It was here that he met Heinz Wolff, a talented consultant physician who himself had undergone an Analysis and was later to become a psychiatrist. It was the enthusiasm of Heinz Wolff as a physician which brought psychotherapy to the medical students and ‘converted’ both Neil Kessel and Julian Leff to the cause.

    A generation of doctors who came to this country expecting to become physicians, but who found their prospects to be so much better in psychiatry, gave us so much. Aubrey Lewis himself was one such. Felix Post, in our own field, was another http://journals.sagepub.com/doi/abs/10.1258/j.jmb.2007.05-63?journalCode=jmba

    Heinz Wolff was an odd one out, in that he became a physician but then opted for psychiatry. His interest in the subject and its processes was infectious.

    Leff’s humility in pursuing more training, is impressive. Time devoted to learning medicine, but at the same time taking in the culture of the East End. Never to stop working with clinical responsibility, to listen to the patient and their family and to respect their vision and interpretation of their condition.

    He was an important member of Professor John Wing’s Social Psychiatry research team but took himself away to the long corridors and long stay wards of Friern Hospital to establish his credentials as an independent mind. Fascinating to read his account of the corridors. Fascinating to remember his use of the natural experiment of the time, to close hospitals and find alternative services for severely damaged individuals. Wonderful to find that our younger members have not heard of Neil Kessel, John Wing, Felix Post, Aubrey Lewis, The TAPS project.

    Julian Leff’s greatest insights have come from his listening to atients and families. His work on Expressed Emotion was known to us all. It is most clearly understood in relation to schizophrenia but is at least as relevant with mood disorders and probably a range of other conditions, physical as well as psychiatric. The use of atavars in countering psychotic phenomena which are resistant to other treatments was news to me. www.ucl.ac.uk/news/news-articles/0513/29052013-Avatar-therapy-helps-silence-voices-in-schizophrenia-Leff

    It came from his willingness to listen, to be open minded, to take in ideas from other disciplines and to think in terms of complex systems, rather than along straight lines.

    There are many other wisdoms in this article but it is these very personal reflections which carry the greatest power for me. They demonstrate the importance of learning from other great men, both intellectually and emotionally and always remaining curious.

    Maybe we can bring more students and trainees to catch something of the fascination and rewards of work with older people and the mental health problems, including dementia, which come to them, if they are brought close to patients in psychotherapy from the start, and closer to the giants of the disciplines by sharing their stories rather than bury them as ‘history’.

    For me an important and moving article of similar ilk came from Felix Post as he looked back on the extraordinary changes achieved in the treatment of involutional melancholia in the 1940s.

    Some things we learn. Let us not forget

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    13th March 2017 | By David Jolley

    Headlines in the Manchester Evening News at the beginning of this week told us that an 89 year old man had been arrested for killing two middle aged ladies. He was driving his car in the vicinity of Withington Community Hospital. Both he and the women had been attending the hospital for reasons not immediately known.

    My granddad was in his nineties when he drove gently into the back of a bus at the traffic lights in Chapel Ash, Wolverhampton. No damage done to persons, nor to vehicles but he never took the car out again. It was moved to live with Uncle George for safe keeping.

    Friday at our regular seminar we were drawn to consider the case of a gentleman who is quite changed by dementia. Frailty means that he does not go out alone but he does enjoy shooting squirrels in his back garden. His airgun does not require a licence but clearly has potential hazards. There is the wider issue of licences for guns when individuals are known to have a mental disorder, be that a progressive dementia or a recurring or persistent disorder of mood or psychosis. Inevitably this brought Donald Trump into our discussion for he has recently overturned a law which required careful checks on the abilities of gun owners who have a history of mental disorder www.theguardian.com/us-news/2017/feb/02/gun-control-congress-social-security-mental-disorders

    He will no doubt argue that this move is to destigmatise the mentally ill and to remove government chains from citizens. The loss of life by shooting in the USA is enormous compared with the UK and most deaths are not caused by people who are mentally ill, but in both countries there are incidents etched on the public memory where mental illness has contributed to tragedies of this nature.

    And then by Saturday we discovered that an older neighbour has spent a night trapped in her bath despite clear instructions and her agreement not to attempt a bath unless there was someone in the house with her. Her home, her life, but this is reckless. She survives but rather the worse for the experience.

    The statistics tell us that older drivers are mostly extremely safe and certainly less of a hazard to themselves and others than young men. It would be very reasonable to prohibit driving until individuals are 21 years or older. Certainly more reasonable than banning drivers who are aged over 80 or even over 90. But those deaths at Withington hospital are a tragedy for the driver, his family and for the women he killed and their families. It must be possible that his lase was due to pathology which might have been identified and all this might have been avoided.

    Should I plan to stop driving at 80, or 85, or 90?

    Surely the presence of dementia of moderate degree should be sufficient reason for individuals to lose their gun licence, here or anywhere else in the world.

    Now baths are something else.​

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    6th March 2017 | By David Jolley

    ​It was good to learn that the Dementia Roadmap is alive and healthy and that it has been modified to be in cinque with NHS England’s Dementia Well Pathway www.england.nhs.uk/mentalhealth/wp-content/uploads/sites/29/2016/03/dementia-well-pathway.pdf

    My embarrassment is that I had not noticed the change earlier. The puzzle and frustration is why this useful device has not been more widely adopted in England. There is encouragement from the launch of the Dementia Roadmap for Wales http://wales.dementiaroadmap.info/

    The point of Dementia Roadmaps is to bring together national and international knowledge and wisdom about dementia and best practice in all aspects of life affected by it, with information about the strengths and weaknesses of local initiatives. It does need commitment from local CCGs or similar organisations carrying responsibility for communities. Having said that, even if a CCG supports a Dementia Roadmap, it will only live and its potential benefits be realised if there is activity amongst families, voluntary groups and health and social care professionals demanding use of it and modifications to make life better.

    The Dementia Well Pathway is a matrix with columns which address preventing, diagnosing, supporting, living and dying well with dementia. For the most part this is fine, though it does not have space for ‘treatment’ and the whole thing risks blinkers which exclude important aspects of life, with or without pathology or disability, such as mood and spiritual adjustment.

    Mark Wiberforce picked up on last week’s blog to draw attention to the editorial in International Psychogeriatrics from Ruth Barlett, Lore Windemuth Wolfson, Keith Oliver and Tom Denning. They point out that, though no one feels it right to refer to people living with dementia as ‘dementia sufferers’, dementia is sometimes associated with its own unique dimensions of suffering. Keith Oliver admits it is tiring and dispiriting to feel you have always to be positive and only talk of the ‘wellness’ that can be achieved living with dementia.

    Most of us will agree that there are times when things feel grim and hopeless. The more so when undermined by uncertainty of what has gone before and wonder about the present and the future.

    None of this is diminish what is being achieved by these initiatives, but we have sobering reminders not to be carried away by words. These reminders say that all people are people. Each is unique, but no one is alone in the sense of being unreachable or uninfluenced by is happening in the world around them, or the world from which they have grown.

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    27th February 2017 | By David Jolley

    Maybe every week is just as busy, but it has felt that personal stories of people with dementia and their families have been somewhere in the news throughout this past week.

    First came the revelation that David Cassidy, pop star and former member of the Partridge Family, believes he has dementia. Now in his 60s, his condition may not be straightforward. When are they ever! He reports that his mother had dementia and so he has often worried that it would come to him. But commentaries mention other stresses which may be having an impact on his health and cognition. We will all hope for him that there will be a good resolution to his difficulties.

    The Baddiel family bravely shared details of the perplexing symptoms of father Colin’s Pick’s Disease www.theguardian.com/tv-and-radio/2017/feb/21/the-trouble-with-dad-review-david-baddiel symptoms of mood and personality change which are more marked than the cognitive impairment which dominates in Alzheimer’s disease. This is an important reminder of the complexity of dementia. It is not a ‘one trick’ challenge.

    But the story which grips me most strongly, and may yet yield additional details and learning, is that of Sir Nicholas Wall. At one level we have simple accounts in the death notices of serious newspapers. But these give more information than is usual.

    He ‘died by his own hand’.

    ‘After years of suffering he was recently diagnosed with a rare dementia of the frontotemporal lobe.’

    The Independent has it that he was initially diagnosed with depression and later the diagnosis of frontotemporal dementia was made, soon after which he killed himself, though receiving care in a nursing home. www.independent.co.uk/news/uk/home-news/nicholas-wall-family-court-judge-kills-himself-demential-diagnosis-suicide-a7598236.html

    There are aspects of this which are painfully familiar. Several of the families in Lucy Whitman’s Telling Tales on Dementia complain that their relative was misdiagnosed with depression and received fruitless attempts to treat this before the penny dropped and dementia was recognised.

    But depression is common and it is treatable. When it becomes severe and persistent, it can very easily be mistakenly diagnosed as dementia. Felix Post wrote movingly of the plight and deaths of wards full of people suffering Involution Melancholia in mental hospitals of the 1940s. Suffering which was relieved by treatment when it was made available. http://bjp.rcpsych.org/content/133/1/83

    So errors can occur in diagnosis and these errors may be in either direction. Looking for the treatable is always to be commended, but optimism must be tempered by the evidence. It is certainly not unknown for people who are depressed to develop dementia. That is not to say that they were not depressed, nor that it would be unreasonable to treat that depression. It is not uncommon for symptoms of depression and dementia to coexist.

    Suicide is not a common mode of death amongst people with dementia. When David Baxter and I reviewed deaths to patients known to the Salford Psychiatric Case Register we found that patients with a diagnosis dementia were the only ones with a lower suicide rate than the control population.

    Nitin Purandare and colleagues reviewed all deaths by suicide, or given an open verdict, in England and Wales April 1996 to December 2004. Of 45,012 cases so recorded only 118 carried a diagnosis of dementia and more than half received an open verdict rather than suicide. They represented 1% of the 11,512 cases who were known to mental health services at the time of their death. The publication does not reveal how many were resident in a care home, but 63 had been admitted to a psychiatric ward previously, seven were inpatients at the time of death. Fifty had a history of self-harm, 43 were known to have depressive symptoms at the time of death and 37 were prescribed an antidepressant.

    These figures might not give us all the answers we would wish for but are sufficient to suggest that suicide is relatively rare in dementia and dementia as a primary psychiatric diagnosis is rare amongst people dying by their own hands or receiving an open verdict. The interrelationship between dementia and depression is there to be seen, though the dynamics of individual cases requires a more detailed analysis than was possible in the retrospective study from summary records.

    Sadness surrounding the death of Sir Nicholas Wall is matched with respect for him and for his outstanding contributions throughout his life, and thanks to his family for sharing something of their thoughts during the struggles and revelations of these last months.

    For us, sensitivity to the importance of depression and other psychiatric symptoms for the quality of life of people with dementia and their families, should need no reminders. Dementia does not occur in isolation but in real multidimensional individuals living within a complicated current world, with depths into a long past and projected thoughts on the future.

    Returning to the theme of last week. Treating dementia as an isolate may not be the wisest plan, a wider view has much to comment it.


    Jolley D. and Baxter D. (1997) Mortality in elderly patients with organic brain disorder enrolled on the Salford Psychiatric Case Register. International Journal of Geriatric Psychiatry 12(12) 1174-1178.

    Purandare N et al 2009 Suicide in dementia. British Journal of Psychiatry 194. 175 to 180.​

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