Psychiatric outpatient services are a bit different from the norms of medical care. There are no white coats, stethoscopes or shiny equipment. They usually take place outside hospitals in unadorned offices and sometimes in the street or car park. Among my psychiatric outpatients in the East End, around half hail from an immigrant background.
The routine outpatient slot is 20-30 minutes, with up to an hour allowed for new patients. Depending on their illness, patients will be reviewed every one to three months, and discharged in under a year – though chronic schizophrenia or depression will mean at least two to three years of follow-up. Those with relapsing illnesses such as bipolar disorder become old friends.
Thus David, who is Irish, has had agoraphobia and has been drinking too much for years. He tries to go out to the library but feels that all eyes are on him. He is aware that the five pints of Stella Artois he drinks each day is well beyond the “safe” limit, for men, of 21 units a week – and says he will try to cut down. He would like more diazepam, a standard tranquilliser (although he uses it quite sensibly, just for going out). Does he have insight into his condition, a key factor in patients?
Mrs P, from Ghana, is very quiet. She had been homeless for three or four years (but not certain how long) and was brought in by police after throwing tins of food at the GP surgery. Following three or four months of inpatient care, where she was detained under the Mental Health Act and given depot injections (antipsychotics), her delusions gradually cleared. She now lives in a room alone, without funds because she is an asylum seeker, and with little contact with her family. She does not know what she wants to do, goes to church and worries about her sick mother in Ghana.
Idris, from Cyprus, and Hyacinth, from Jamaica, also have longstanding versions of schizophrenia, but both are doing all right. They take their medication, visit family, complain of difficulty thinking, and show occasional mouth tremors (orofacial dyskinesia), the side effect so typical of people receiving antipsychotics. We talk of normal things, check mental states and medications, and drop a note to the GP.
There is a small English contingent, Eastenders of generations past, who like to come and chat. All attempts at discharging them back to their GP are met with frowns and guerrilla tactics (they ask for another referral, because they are “suicidal”). They want to talk to the same doctor they have talked to for the past 10 years, not some fly-by-night GP doing a locum. Their illnesses centre around the notion of “depression”, with a strong mixture of anxiety, loneliness, recreational drugs, and doomed attempts to persuade their children not to behave like them.
This was a great morning, because most people are doing OK, and no one required hospitalisation. The new patient did not turn up. This was no surprise, since the GP letter mentioned he was fearful of going out – so sending him an outpatient appointment was not exactly the smartest approach. Psychiatric outpatient services tend to accumulate those with chronic illness and deracinated lives, only partially relieved by treatment. A good morning will see one or two discharged, but the majority struggle along, grateful for any support and interest.
Trevor Turner is a consultant psychiatrist working in east London. Some details have been changed to protect identity. Sophie Harrison is on maternity leave