Panel consisted of Dr Danish Malik, Dr Hasan Mehmood Rajput, Dr Arshad Javaid
Sh and Dr Saleem Akhtar Rana.Choice of questions was with the panel. Any error
in reporting is the responsibility of editorial board.
Interview lasted for more than two hours. Wide-ranging issues were discussed.
Replies were very candid and practicable. Local Circumstances were reflected in
the wealth of experience and huge education of our expert. Panel was obliged to
be benefited by the lifetime experience of a very intelligent, competent, sharp,
up-to-date professional who is at the peak of his carrier. We were overwhelmed
by the simplified approach, based upon sharply defined ideas, for the benefit of
family physicians. WHO and WPA must be very lucky to have such a person. It was
a nice experience.
Following text has been prepared from the answers given to questions of the
panel.
Doctor Patient relationship.
This is the most important aspect of psychiatric management. Following key
elements must be inculcated in the behavior of doctors.
Gain the confidence of Patient.
Family physicians are usually busy and sitting among many patients.
Psychiatric patients may not like to talk in huge crowd. Talk to them
sympathetically. Listen to them as much as patient desires. If these two
elements are fulfilled 50 % of therapy is done there and then. Assure the
patient about the secrecy of contents of his history and reassure him that his
history or secrets will be kept top confidential and no one will get to know
these, (just to elaborate). Don’t rush the patient. He will not fully confide in
first session. You need second or third visit before he feels comfortable and
confident that he can discuss the compulsions, obsessions or the things worrying
him. Family physicians can call them back daily, even, for few minutes. If
situation demands tell the patient and family to come back in your relative free
time. Reassure them that you want to listen and examine in detail. You are
planning special attention for you! This will go a long way to win the
confidence of the patient and family.
Never say No cure for any disease since Allah Almighty is all-powerful.
Do not say to patient or family that patient has no disease. You may clarify
that patient has no physical illness. When they come to you they have a problem,
which is very serious disease. Never tell them that you could not understand the
disease. It will dampen their spirits. No matter how poor or hopeless prognosis
is (e.g. mental retardation), never ever disappoint and staightway tell the
family/patient that there is no treatment for this condition. They have come to
you with great expectations. You can always do something. At least you can
listen and reassure. Whatever good can be done do it. Assure the patient that
things will become better with treatment and time. This is almost always so.
Patient and family have problem. They have to seek help. If you will disappoint
then they will not sit down back in their homes and accept your advice but they
are bound to knock at other doors. Why not yours?
Answer all questions.
Patient and family have many many questions about the disease, treatment,
prognosis and many other aspects. Answer all questions to the satisfaction of
them. Again do not tell them that we do not know this or that. Give some
plausible explanation to the best of your ability. Unknown aetiology should not
be translated to patients that sorry we don’t know. It creates uncertainity in
the minds of patient and family. Satisfy them. Explain according to locally
acceptabe cultural context and ensure follow up and compliance.
Laugh with the patient.
Just to relax the patient and family are pleasant. Try to make the atmosphere
light by reassuring words, sharing some jokes or titbits with patient or family.
It will help to gain the confidence and evaluate emotional response.
Do not forget to offer Confidentiality.
Many patients will not tell the doctor about their real worries, tensions,
compulsions, obsessions untill they are dead sure that their secrets will be
well kept. Do not forget to offer confidentially at some stage of your
management. Many a times just you’re listening to patients real thoughts
completes the therapy and takes half of the illness away.
On Referal to Specialists.
- If family physicians complain that they do not get their patient’s feed back
or they do not receive the advice, they are right. System of referal is at
fault.
- Which specialist to refer and reason for referal. Please be precise in your
reason for referal. Is it diagnosis or management or simple opinion?
- Refer to that specialst that you know well and who understands your language?
With whom you are on good wavelength. Meet him. Invite him. Consult him about
the patient you are refering to him and share the contents of the problem.
Adopt a proper system of referal.
- Print forms as family physicians. Please provide specialist all information
about disease, family backgrounds, economic situation (you can always seek
concession) etc. Please always commit a provisional diagnosis. Specialist may
not be always right. Your opinion about the diagnosis is a very special help.
Never be afraid of making a mistake. Who does not?
- On the same form leave the space for comments of specialist? Ask specific
questions from specialist, about which, you are seeking advice. Instruct your
patient to get this part of the form filled by the specialist and report back to
you. This will ensure compliance on both ends. Patient, in his own interest,
comes back to you. To know your opinion about the treatment of specialist.
- If this sytem is followed then you can always give a phone call before
refering or after recieveing him back, to clarify any point. Never hesitate. It
is your right and privillige.
On New Drugs.
Unfortunately most of the education, we receive, after graduation is from
Medical representatives. They highlight only those points, which favour their
product. We should always educate ourselves. We should always ask what advantage
new and expensive drugs have over old ones. Very rare side effects like tardive
dsykinesia (which you may never see in your life) should not lead us from old
time tested and cheap drugs. Newer drugs usually in promotional material compare
antidepressents with tricyclics and antipsychotics with largectil. These are
still the gold standards. Usual claim is that new products are as effective as
these gold standards. Advantage is claimed on side effects. Ask yourself how
many times you have seen the side effects. Go for cheaper drugs and prescribe
according to patient’s affordability and therapeutic efficacy.
Management of Hysteria.
- Never declare to patient or family that there is no disease. This is definite
disease and there is a definite protocol to treat it.
- First and foremost thing is to listen very sympathetically. Examine in detail.
If there is any investigation to be ordered, do it. Then assure the patient and
family that no body has ever died with this disease. It is always cured. It may
take sometime but it is going to be totally cured. Own the patient. Reassure
him.
- Treat with Largectil and Diazepam in proper dosage, to manage the crisis.
Continue it for few days. About hospital admission, do calculate that going back
to same environment, which you want to avoid, may not cause recurrence of
symptoms.
- There are always some internal conflicts at the background. These may be
related to Job, environment or personal life of patient. Patient may confide in
you, usually, later on, not on first visit. Advise parents not to treat hysteria
with marriage. If circumstances permit, energies of patient should be diverted
to some beneficial activity such as household duties, education, cooking classes
embroidery etc.
- Do not forget to advise the family that this type of problems may happen
again. Nothing to worry about. Bring patient back to me.
Malingering
Usually a motive of benfit to be gained is quite obvious. This
differentiates it from hysteria.
Panic Disorders.
Tofranil and diazepam or Tryptanol and diazepam in combination used in
judicious doses can control the symptoms. Later on patient can be labeled
appropriately and treated.
Anxiety/Depression.
Typical symptoms are a common knowledge. How to differentiate anxiety from
Depression? He defined a very simple yardstick. Any mood disorder going beyond
two weeks should be labelled as depression. It should be treated as depression.
Benzodiazepines.
Duration of action should be main criteria to choose one. Longer acting is
usually what is required in most circumstances. For example Diazepam or Librium
or lorazepam. Short acting ones like alprazolam have to be repeated.
Use of benzodiapines for arrythmias or tachycardia is not recommended. Specific
cardiac drugs are now easily available and quite effective. To promote these
specifically for cardiac problems or tachycardia is not justified.
Main use of benzodiazepines is nowadays only for the time period; you give
antidepressents to eastablish their effect.
Hypnotics. If drug is needed to induce sleep then use long acting ones.
There is a special group of drugs known as hypnotics. These include mogadan and
Dormicum and add 25 mgs of largectil, which will acts as good hypnotic.
Antidepressents.
All antidepressents are safe, effective and these should be cheap also to suit
the pocket of patient.
Dosage of Flouxetine should be flexible. He uses upto 80 mgs daily.40 mgs daily
is quite common in his practice.
SSRI can be combined with low doses of tricyclics. For example 3 tab of Tofranil
can be combined with 40 mgs of Flouxitine.
To avoid or expedite the delay of relief with tricyclics and related drugs, he
advises to start with 50-100 mgs daily build to 150-175 mgs daily. People, who
need these drugs, do not show intolerable side effects. Alternatively Tofranil
25 mgs tid for 3 days and on 4th day onwards it can be increased to 50 mgs tid
very easily. It will establish the response at earliest, on 4th or 5th day.
Tofranil and Amitryptaline 175 mgs daily can be used for 7 days straight away
without any untoward effects. Normal effects will be there in one-week time.
If there is psychomotor retardation and activation is needed then Tofranil and
flouxitene are prefered. If sedation is required then tryptanol or Lantanon is
the best.
Mood and mood stabilizers.
- Mood can be defined as what you can see on the face and say about the mental
state of the patient after observing his facial expression, condition of
clothing, characteristics of gait, volume and tone of voice, listening to him
and the total imression you get about the feelings of the patient. Sad, Happy,
Worried isolated disinterested agitated etc.
- Lithium alone or in combination with carbamazepine is a true mood stabilizer.
Valporate is still under study. Lithium can be safely prescribed.1-2 tabs daily
usually do not cause problem. Lithium levels done once only, give idea about the
metabolism by the liver and the level is maintained at 0.5 –0.9 mgs/litre.
Psychosomatic disorders.
Professor Ijaz Haider has advised a very simple approach. Once patient is
labeled as having this disorder after examination and investigation, symptoms
should be taken as physical form of depression.
Management should be exactly as of depression. Doses should be similar.
Prognosis is as good as that of depression.
Psychosexual disorders.
- Prof Ijaz Haider feels very strongly about the oppurtunities, which we as
doctor have to render our services on this issue. Lot of misery and even many
suicides can be avoided.
- This is the sector of health, which we are not dealing optimally. This is the
domain mainly of family physicians.
- First thing is education about sexual matters. Doctors should make sure that
at proper age parents and even doctors educate youngsters. Many young males
commit suicide next day after marriage because they could not “perform well”.
There must be somebody to tell them before this catastrophy that majority of
couples can not and do not do it on first day.
- About tackling such patients we fail on following points.
- We fail to gain their confidence. Provide good atmosphere. Isolation where
they can talk freely.
- When we take history we are not thorough. We must use crude language and
phrases to enquire about different components of intercourse and points of
weaknesses. Nothing should be left unexplored as we have been taught in
Physiology.Nothhing should be supposed. Each and every detail must be brought
under discussion.
- Confedentiality must be maintained and assured.
- Gain the confidence of the patient and assure him of total confidentiality.
- Never take complaints of patients lightly. Give them as much weight as patient
is giving.
- Quack sex clinics are successful only and only because above mentioned they
are practicing approaches in much rigorous ways then we are doing. Their
advertisements are highlighting same ideas and they are trapping the patients
only by using the language and concerns of the patients. Doctors need lot of
improvement on this front to enjoy good practice.
- Once a problem is scietifically defined then treatment for a doctor is no
problem.
Old age and dementia.
- After 35 years of age and not 55 years, all mental and physical faculties
start slow downhill course. Speed is different in different individuals and thus
aging starts at 35 years can be felt at 45 years and visible at 55.
- Before we blame senile dementia for loss of memory or other symptoms, we must
judge about all faculties. Day to day performance in all sectors. If there is
total deteriation then memory loss can be a part of this. If there is single
faculty affected alone then there may be some other cause or patient may be
malingering or functional.
- Mild behaviourral problems such as abusive language, related with senile
dementia can be treated with 1-2 mgs of flaunxol, 10 mgs of Melleril or
Largectil.
Aetiology of Pschiatry Disorders.
Many symptoms are common in all these conditions. Many a times it is difficult
to label anyone of these immediately. For diagnosis of these illnesses following
diagrams may be helpful. Each triangle represents one disorder. Three sides of
triangle represent 3 major aspects to be noted in particular in each patient.
On Councilling.
To a question that whom to refer and how to refer to psychotherapist, Prof Ijaz
Haider answered that a psychotherapist has to be
Older person
Married Person
Trained in his trade
Knowledgeabe about the patient, his family and his disease.
In his opinion all these qualities are present in family physicians. They should
do the councilling. Family members can contibute a lot.
If patient can afford and proper person is available then two sessions are
enough.