The choking woman

Key messages

• Fragmented, reactive service provision leads to less compassionate, less safe, more costly care, especially in people with multiple co-morbidities.

• The health and social care needs of the 21st century western population require generalist practitioners in hospitals, as well as in the community.

• Case management and mental health expertise are useful approaches for managing people with multiple morbidities.

Why this matters to me

As a higher trainee in liaison psychiatry, I was keen to discharge as many of my long-term outpatients as possible. I remember feeling frustrated that my consultant wanted to keep people on for so long when it did not really feel as though we were doing anything for them. This case has helped me to reflect on why it might be beneficial to keep patients in our clinics for longer term work.

In this case, my patient and I have an explicit plan in which we are moving towards eventual discharge, but at a pace that feels right for her. She has, through this process, been able to develop an ability to self-care and take responsibility for her medication regime and therapy, which she would not have been able to do four years ago. I have also learnt a lot about the importance of the therapeutic relationship and its role in maintaining well-being.

As a liaison psychiatry team, every day, my colleagues and I see people on the medical and surgical wards who have multiple co-morbidities. All specialists deal with their own bit of the body with not enough attention being paid to the whole. This is not their fault; the system has become increasingly fragmented with not only training, but also the way we measure departmental success being geared towards silo working. The liaison psychiatry clinician, along with the elderly and palliative medicine clinician, seems to be the only generalist left in the hospital. Generalism is a highly skilled specialty, which we are in need of in today's health environment as our population becomes increasingly multi-morbid, and perhaps it is time to give it the kudos it deserves.

Abstract

Background

There is a small, but significant cohort of patients that receives inappropriate care, in the wrong setting, and that utilises a disproportionate amount of healthcare resources. People with multiple co-morbidities and often-undetected mental illness fare better with integrated care and case management approaches.

Setting

In North West London, we have been working in the ‘Integrated Care Programme’ for four years to try to improve the care this cohort receives.

Question

Can psychiatric intervention with case management improve outcomes for this cohort?

Methods

We describe the case of a 64-year-old woman who presented at an Emergency Department (ED) with functional dysphagia 25 times in the space of eight weeks. During that time, she was referred to numerous specialists, and had multiple invasive investigations even though her symptoms were not suggestive of organic pathology, and were in fact suggestive of anxiety.

Results

Her pre- and peri-psychiatric intervention healthcare costs were, on average, £3330/month. These reduced to an average of £276/month after three months of psychiatric intervention.

Conclusions/discussion

We reflect on the possible reasons why the story unfolded in the way it did and suggest generalised implications for clinicians caring for this cohort and for service delivery in future.

The story of a choking woman

Background

There is a small, but significant cohort of patients that receives inappropriate care, in the wrong setting and utilises a disproportionate amount of healthcare resources.

A high percentage of these patients have complex presentations and multi-morbidity, including: physical and psychiatric illness, cognitive impairment, psychosocial difficulties and substance misuse issues.¹ Of the 15 million people in England who have at least one long-term condition, a quarter also have at least one mental health co-morbidity.²

Case management and an integrated multidisciplinary approach have been shown to improve outcomes for patients and to reduce costs.³

In North West London, we have been working in the ‘Integrated Care Programme’ for four years to examine these types of issues. We are now embarking on a new stage – whole systems integrated care (WSIC) – in which we can take these and other lessons about how our fragmented NHS can become more integrated.

Here, we describe the case of one patient, comparing her outcomes and costs prior to and after case management and psychiatric intervention.

Summary of the clinical problem

The patient is a 64-year-old woman with:

• multiple presentations to ED, complaining of choking;

• weight loss because of her fear of choking;

• multiple investigations by multiple specialties;

• increasing doses of benzodiazepines being prescribed for anxiety.

The story

A 64-year-old woman presented with a three-week history of a sensation of choking. This started with food and then moved on to include liquids. It was not long before she stopped eating completely because she was afraid of swallowing anything and as a result lost over 28 pounds in weight within three weeks.

She presented terrified, on numerous occasions, to the ED. She was usually seen by a junior ED doctor, who invariably found no physical cause for her symp- toms. The usual impression was one of an anxiety disorder.

She would usually be sent home after each presentation with small doses of diazepam and a referral to a variety of specialists for further exploration of her symptoms. Initially, she was referred to ENT, then to gastroenterology and eventually to neurology, to ensure that there was nothing else going on. On two of her visits to the ED, she was admitted medically for further investigations.

Each speciality investigated the symptoms according to their specialty protocols and so she underwent an array of inpatient and outpatient tests. These included CT of her head and neck and MRI brain and neck, barium swallow and endoscopies under ENT and gastroenterology, as well as an electromyogram (EMG). She was even booked in for a muscle biopsy shortly before she met the psychiatrist.

The total outcome from all of these investigations revealed nothing but gastric reflux and a small, but clinically insignificant pharyngeal pouch with which she became preoccupied.

During one of the admissions, 12 weeks after seeking medical advice, the liaison psychiatry service was contacted for an opinion, which confirmed anxiety as part of a long-standing generalised anxiety disorder with current exacerbation secondary to a family illness.

Actions implemented by the psychiatrist

• Diagnosed anxiety disorder, somatoform disorder and benzodiazepine dependence and shared these results with the patient (see Box 1).

• Explored the option of cognitive behaviour therapy (CBT), as per National Institute for Health and Clinical Excellence (NICE) guidelines, but the patient was not able or willing to engage with this.

• Arranged instead, to see the patient on a regular basis, initially fortnightly, and began relaxation and education techniques with the patient.

• Took over sole responsibility for benzodiazepine prescription and instituted a controlled and gradual dose-reduction regime.

• Treated with antidepressant medication, initially a selective serotonin reuptake inhibitor (citalopram), which was not tolerated in terms of gastrointestinal symptoms, and then a tetracyclic antidepressant (trazadone).

• Discussed at multidisciplinary meetings so that all specialities were aware of the psychiatric diagnoses when considering further investigations and follow-up appointments.

Box 1. Somatoform disorder in International Classification of Disease (ICD) 10.

• A category of psychiatric disorders characterised by the presence of physical symptoms that suggest a medical condition but are not fully explained by any known medical reasons.

• Disorders characterised by bodily symptoms caused by psychological factors.

• Disorders having the presence of physical symptoms that suggest a general medical condition but that are not fully explained by a general medical condition, caused by the direct effects of a substance or by another mental disorder. The symptoms must cause clinically significant distress or impairment in social, occupational, or other areas of functioning. In contrast to factitious disorders and malingering, the physical symptoms are not under voluntary control.

Progress

Three months later the patient had:

• started eating small amounts of food and gained 14 pounds in weight;

• completely ceased attendance at the ED;

• stopped being sent for physical investigations.

Six months later the patient had:

• started to eat a normal diet and returned to her premorbid weight;

• gained an understanding of her anxiety and how to self-manage it, but was still not willing to engage with formal CBT;

• reduced her frequency of attendance with the psychiatrist to two or three times monthly;

• been discharged from all non-psychiatric specialties.

Four years later

The patient experienced new onset of involuntary choreiform movements in her arm. She contacted her psychiatrist before anyone else.

The psychiatrist established that there was no other physical abnormality and that the movements were correlated with increased stress beginning in the context of a family problem. The movements were observed to diminish when the patient was distracted.

The most likely diagnosis was therefore a somatoform disorder. Nevertheless, the psychiatrist liaised with a movement disorders neurologist and showed him a video of the movements – they decided together that a CT head would be helpful to rule out a new infarct (she was too anxious to tolerate an MRI) and this showed nothing new compared with her scans from four years previously.

The psychiatrist recommenced weekly reviews with relaxation techniques and helped the patient to solve family problems. She was referred for CBT and received 16 sessions.

Within six months, the patient was managing the anxiety and the involuntary movements with relaxation and distraction, and it was no longer a concern to her.

She believes that this episode would have led to further multiple investigations (which would have increased her anxiety), and other healthcare utilisation, if she had gone to her general practitioner (GP) about these symptoms.

Figure 1 shows the number of attendances to ED, the GP, medical and surgical clinics, medical inpatient admissions and physical investigations. The red line demonstrates the number of times she was seen by psychiatry. The increase in psychiatry input and investigations during summer 2013 is due to the involuntary movements.

Figure 1.

Financial cost of care

We accessed the care records from hospital and primary care.

Using Department of Health Reference Costs and British National Formulary, we calculated the cumulative costs of all investigations and interventions (including medications) in order to compare the cost prior to and including three months of psychiatric intervention with the cost of case management and psychiatric intervention three months after it had begun. During pre-case management/psychiatric intervention and the first three months of case management/psychiatric intervention, the average cost was £3330/month (psychiatric costs = £50/month; medical inpatient costs = £1440). From three months after the start of psychiatric intervention this reduced to an average of £276/month; a 92% reduction. There were no social care costs for this patient as she lived with her family who were able to provide care when needed.

Lessons from the case

1. The physical examination and initial investigations pointed to no underlying physical pathology but did indicate the presence of anxiety, yet clinicians continued to investigate in search of a physical cause.

Evidence suggests that more investigations do not reassure patients.¹ Little et al found that almost half of the investigations ordered by clinicians are not thought, by the clinician, to be necessary. The investigations were ordered because of perceived (rather than actual) pressure from their patient.⁴

There is also reasonable evidence, through follow-up studies (eight months to six years later) of somatoform disorders, to suggest that the majority of patients do not go on to develop an organic disorder.^5–6

Guidelines for generalised anxiety disorders (GAD) suggest that GAD should be considered in anyone who frequently attends primary care with physical health complaints. This is especially so with older people or people from black and minority ethnic communities, as the GAD may be manifested only through somatic symptoms.⁷ In our case study, anxiety had actually been considered from the outset as the preferred diagnosis, but the psychiatrist was the last specialist to be contacted.

Implications

Rather than do more and more tests, clinicians can keep an eye on such patients through follow-up appointments, work on symptom management and self-management and seek specialist advice if required.

2. Despite anxiety being the main diagnosis, it was 12 weeks before a referral was made to psychiatry.

Reid et al found at a three-year follow-up of 61 patients with medically unexplained symptoms that psychiatric morbidity was high and in turn that functional impairment was also high.⁸

There is strong evidence to suggest that treating the underlying psychiatric disorder improves all outcomes, mental, social and physical. Equally, there is strong evidence to suggest that delaying diagnosis of an underlying or co-morbid mental health issue significantly worsens the long-term prognosis for that patient conditions that are very amenable to treatment are left untreated.²

Implications

We should commence patients on the recommended treatment for underlying mental health issues sooner rather than later for the best outcomes.

3. Benzodiazepines lead to dependence, falls and other problems. They are contraindicated in anxiety. Inappropriate prescription of benzodiazepines remains a common problem.⁷

Despite significant expansion of IAPT (Improving Access to Psychological Therapies) services nationally, there is concern about access to CBT. A report by the We Need to Talk Coalition, highlighted that 50% of patients were waiting over three months for treatment, with 10% waiting over a year.⁹

This access challenge may be impacting the decision the front line clinician makes about referral. The above report also states that 40% of patients who were referred to IAPT had to ask rather than be offered it.

Implications

IAPT and CBT should be offered to people with anxiety because they have excellent outcomes in a wide range of patient groups, while selective serotonin reuptake inhibitors can be used to alleviate symptoms in the short term. Benzodiazepines should not be the treatment of choice.

4. Numerous specialities were involved in this complex case, but there was limited communication between them about a generalised approach.

The King's Fund calls for health and social care systems to consider how services can be better funded in bundles of care, or through delegated or capitated budgets. This in turn may help integrate the necessary elements of care and reward collaboration.¹⁰

There has been increasing recognition that the population we look after would be better served with a rebalancing between the number of generalists and specialists, and that a blurring of boundaries between primary and secondary care would also be beneficial.¹¹ Shape of Training, published this year, calls for postgraduate training to respond to the changing demographic and patient needs and asks that patients and carers are used in the training.¹¹

Conclusion

This case demonstrated a dramatic change to the patient's healthcare utilisation and clinical outcomes as a result of: (1) diagnosing and treating the underlying mental illness and (2) one clinician taking over responsibility for her care using a case management approach.

We were able to compare, in one person, the impact of fragmented care with integrated care on cost and clinical outcomes – but this is not an unusual case.

The reactive and episodic model of care not only does not work for this cohort of people, but also can be detrimental because it cannot incorporate the longitudinal, holistic view to the degree that is required.

Providing mental health expertise, case management and the space for multidisciplinary reflection on the short-, medium- and long-term goals of management is increasingly being seen as a useful way to approach the new health and social care challenges we face. Our information, governance and finance systems, as well as workforce development need to be able to support this challenge.

CONFLICTS OF INTEREST

None.

ETHICS/CONSENT

Written informed consent was obtained.