Correspondence Paracetamol and risk factors in Newcastle Restrictions on easy access to paracetamol have reduced death from paracetamol overdose in the UK. However, ﬁgures from Newcastle show that hanging and jumping deaths have become more common.1 Since paracetamol overdoses are usually not instantly fatal, second thoughts are possible. This is not the case with hanging and jumping. Is this an unintended consequence of paracetamol restrictions? Treating paracetamol overdose is expensive for the National Health Service but surely it is a worthwhile expenditure. Does this make a case for easing restrictions on access to paracetamol? Alasdair J. Macdonald, retired consultant psychiatrist, UK; email: [email protected]
Linsley KR, Schapira MA, Schapira K, Lister C. Changes in risk factors for young male suicide in Newcastle upon Tyne, 1961-2009. BJPsych Bull 2016; 40: 136-141.
Terrorism: it’s not mental illness - it’s politics Hurlow et al 1 appear to argue that psychiatrists have a major role in preventing terrorism. This might lead one to think that there has been a massive wave of attacks by people who are mentally ill. In fact, Britain is fortunate to have had only one terrorism-related murder since 2005! By contrast, Northern Ireland saw almost 1 000 terrorist killings by unionists/loyalists and 2000 by nationalists/ republicans - Dr Hurlow’s home city of Birmingham had 21 people killed in the 1974 IRA bombings. The contribution of mental illness to the 3000 killings was, in essence, totally negligible. Indeed Lyons et al 2 noted that terrorists were mentally healthier than ‘ordinary’ killers. This has face validity: it is doubtful that a person or persons with psychosis could plan and execute the sort of sophisticated attacks we have witnessed in Birmingham, Brighton, Enniskillen, Madrid and London. Did police contact psychiatric services in the wake of the Paris attacks in November 2015? Of course not! Terrorism is, by deﬁnition, politically motivated. Politicians, the media and others all too often respond to terrorism by lazily and superﬁcially claiming it to be ‘psychotic’, ‘crazy’, ‘insane’, ‘psychopathic’ or (most mindlessly of all) ‘mindless’. Islamic State are disgustingly murderous, but Abu Bakr al-Baghdadi and his activists are not driven by mental illness. It is very worrisome if psychiatrists contribute to this unscientiﬁc discourse. There will always be a tiny number of mentally disturbed people who respond to the current zeitgeist and act out violent fantasies. Psychiatrists must always take account of the risk to other people from such individuals and act appropriately. However, to extrapolate from this a new obligation to routinely monitor our patients and work in close contact with antiterrorism policing is both stigmatising to people with a mental illness, and damaging to our independence and professional reputation. Crucially, it is also useless in preventing serious terrorism. If colleagues are in any doubt about this, I would
suggest that they speak to the real experts in terrorism: senior police ofﬁcers in Northern Ireland. Philip J. McGarry, consultant psychiatrist, Belfast Health and Social Care Trust, Belfast, UK; email: [email protected]
Hurlow J, Wilson S, James DV. Protesting loudly about Prevent is popular but is it informed and sensible? BJPsych Bull 2016; 40: 162-3.
2 Lyons H, Harbinson H. A comparison of political and non-political murderers in Northern Ireland, 1974-1984. Med Sci Law 1986; 26: 193-7. doi: 10.1192/pb.40.5.285a
Guidance on advance care planning Waterman et al 1 perform a useful service in drawing attention to the need for psychiatric in-patient units to develop expertise in terminal care. It is a shame that they have not acknowledged the guidance on advance care planning developed by the Royal College of Physicians2 in conjunction with the Alzheimer’s Society, the Royal College of Psychiatrists, and other lay and professional groups. The authors have also misunderstood the status of advanced decisions to refuse treatment made under the Mental Capacity Act 2005. To be valid, an advanced decision must specify a particular treatment which is not to be carried out or continued (section 4 of the Act). It is not possible to make an advance decision to die at home and not go into residential care (although it would not be possible to use the Deprivation of Liberty Safeguards to require a person to stay in hospital to receive treatment that had been refused in advance). It is not possible to require health care professionals to provide a speciﬁed treatment.3 It is best to regard advance care plans as statements of wishes and feelings about what is in the patient’s best interests. The Mental Capacity Act places particular emphasis on relevant written statements made by the patient when he/ she had capacity (section 6a; see also the Mental Capacity Act Code of Practice, paragraphs 5.40-5.45). There are likely to be times when most psychiatric patients will lose capacity to make some decisions. Ascertaining how patients would like to be treated when they are unable to make decisions for themselves should be part of routine practice with all psychiatric patients.
Declaration of interest J.W. has been appointed as a Court of Protection Special Visitor under section 61 of the Mental Capacity Act. Jonathan Waite, consultant psychiatrist, Nottinghamshire Healthcare Foundation Trust, Nottingham, UK; email: [email protected]
Waterman LZ, Denton D, Minton O. End-of-life care in a psychiatric hospital. BJPsych Bull 2016; 40: 149-152.
2 Advance Care Planning: National Guidelines. Royal College of Physicians, 2009. Available at: https://www.rcplondon.ac.uk/guidelines-policy/ advance-care-planning. 3
R (Burke) v GMC  EWCA Civ 1003.
Author’s reply: We thank Dr Waite for alerting readers to further useful guidance on advanced care planning. While we agree that there is much to be done from the 2009 Royal College of Physicians report, we have chosen to address the aspects of Mrs S’s end-of-life care. In particular, we have focused on the synergies between the psychiatric staff and the local hospice. On one particular point we stated that people can express their wishes about preferred place of treatment in an advance decision. However, we never stated that an advance decision is always binding - on the contrary, we said that Mrs S’s was invalid.
The debate raised around Burke v GMC is around providing treatment not in a patient’s best interests and is not directly relevant to our paper. However, Dr Waite’s ﬁnal broader point that ‘ascertaining how patients would like to be treated when they are unable to make decisions for themselves should be part of routine practice with all psychiatric patients’ is welcomed. Ollie Minton, consultant in Palliative Medicine, St George’s University NHS Foundation Trust, London, UK; email: [email protected]
Correction The expansion of the Foundation Programme in psychiatry. BJPsych Bulletin 2016; 40: 223-225. The title was incorrect in the print version of this article. The online version has been corrected post-publication. doi: 10.1192/pb.40.5.286a
Obituaries Ian Reid MB, ChB, PhD, FRCPsych Formerly Professor of Mental Health and Head of Department, School of Medicine and Dentistry, University of Aberdeen
Ian Reid, who died tragically early at the age of 53 on 15 June 2014, played a leading role in British, especially Scottish academic psychiatry for over two decades. His particular interest was in electroconvulsive therapy (ECT), which he regarded as a neglected, undervalued but highly effective form of treatment for depression and bipolar illnesses. He was passionate in his attempts to destigmatise
ECT and to puncture the myths surrounding this controversial treatment, while highlighting that it was safe, effective and evidence based. He made successful bids to extend the work of his research team into the psychometrics of mood and at the time of his death, he and his team - through collaboration with the neuroimaging team in Aberdeen - were discovering exciting new biomarkers for mood disorder and the mode of action of ECT. Ian was a founding member of the Scottish ECT Accreditation Network and became Chair of the Royal College of Psychiatrists Special Committee on ECT and Related Treatments in 2011. He was also an effective advocate for the appropriate use of antidepressant medication. His collaborative research with primary care colleagues in Aberdeen into prescribing of antidepressant medication led directly to the withdrawal of a Scottish Government Health Efﬁciency Access Treatment target to reduce antidepressant prescribing. This research, quoted by the Public Audit Committee of the Scottish Government, had widespread media coverage and led to a robust debate in the BMJ. Internationally, he collaborated, for example, with colleagues in India, via the Trusted Mobile Platform for the Self-Management of Chronic Illness in Rural Areas. He was a proliﬁc contributor to the literature, editing and contributing chapters to the standard textbook on the subject, Fundamentals of Clinical Psychopharmacology, as well as being associate editor of Therapeutic Advances in
Psychopharmacology. He regularly reviewed papers for numerous other journals. Ian was a long-standing member and staunch supporter of the British Association for Psychopharmacology (BAP) and an elected member of BAP Council for 4 years. He contributed much to the BAP over the years, including teaching at educational events and supporting young colleagues presenting research ﬁndings at the annual meetings. Highly active on the Scottish psychiatry scene, Ian was an expert panel member of the Scottish Medicines Consortium and of the Scottish Intercollegiate Guidelines Network review group. He was also a member of the Healthcare Improvement Scotland Integrated Care Pathways for Mental Health steering group, which set national standards for healthcare in Scotland, and chaired their bipolar disorder subgroup. Despite his national and international responsibilities, he kept his feet very much on the ground in Scotland, remaining active in Aberdeen. He never tired of telling his colleagues that he was one of the few academics north of the border who still led an adult community mental health team. He was also keen to remind them that this team worked within the most deprived catchment area in the city of Aberdeen. As an indication of the great respect with which he was held, his multidisciplinary team readily accepted tertiary referrals of patients with treatment-resistant affective disorder, despite the heavy workload. Ian Reid was born and brought up in Dunfermline in Fife. His father John was a school head teacher and mother Rae a special education teacher. He was educated at Dollar Academy where he was a brilliant student, gaining entry at the age of 16 to the School of Medicine and Dentistry, University of Aberdeen. After qualifying in medicine, he began his postgraduate training in psychiatry and early academic career in Grampian, with Professor George Ashcroft, before pursuing his higher clinical and academic training, including his PhD in cognitive neuroscience, in Edinburgh, with Professor Richard Morris. After returning to Aberdeen as a clinical senior lecturer, he moved to the University of Dundee as a new Chair of Psychiatry in 1995 at the very young age of 34. In Dundee, Ian became a major force for clinical service change and was involved in establishing community mental health teams and developing a state-of-the-art ECT service. Along with Professor Keith Matthews he established an innovative affective disorders service that provided a specialist clinical service as well as multidisciplinary training and research opportunities for junior psychiatrists, psychologists and nurses. In 2003 he succumbed to the lure of a return to Aberdeen to take up the Chair of Mental Health, a much-cherished post that he held until the time of his death. Despite his sometimes crusty demeanour, Ian was an incredibly caring, supportive and knowledgeable colleague whose passion for patient care was almost unequalled. His commitment to teaching, training and mentorship was reﬂected in his ability to persuade non-psychiatric trainees to change their career path to psychiatry. Although at times he could be challenging to trainees and others, he was always driven by a core desire to do all he could to improve patient care and management of those with major mental illness. One of Ian’s greatest personal strengths was an ability to connect with anyone at their level. A memory shared by almost all who
met Ian would be of his black baggy jumper, well-worn leather jacket and omnipresent can of Coke Zero. At a recent dedication ceremony at Royal Cornhill Hospital, during which the ECT suite was renamed the ‘Professor Ian C. Reid Centre’ in Ian’s honour, one of his former patients described Ian as being ‘the best man I ever knew’, a sentiment shared by many who knew him. Ian is survived by his daughter Alis, of whom he was incredibly proud, his second wife Linda Treliving, a highly respected psychotherapist, his two stepsons, Lawrence and Matthew and his sister Susan, a consultant radiologist. Ross Hamilton and Alastair Palin doi: 10.1192/pb.bp.116.053777
B 2016 The Royal College of Psychiatrists. This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/ licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Dr Sabina Strich BCh, DM, MRCPath, MRCP, FRCPsych Formerly Honorary Consultant Neuropathologist, The Bethlem Royal and The Maudsley hospitals, Reader in Neuropathology, Institute of Psychiatry and Consultant Child and Adolescent Psychiatrist, Croydon Child Guidance Clinic
Dr Sabina Strich, who died aged 90 on 23 May 2015, made pioneering discoveries in the 1950s on the effects of head trauma on the brain. While carrying out histopathological studies with Peter Daniel in Oxford, she identiﬁed characteristic changes to brain cells following severe head injuries. She showed that shearing injuries, arising as a result of rapid acceleration or deceleration at the time of trauma, produced diffuse degeneration of the cerebral white matter1. The histopathological changes she described later became known as diffuse axonal injury (DAI) or Sabina Strich syndrome. She claimed that cellular changes of this type were the cause of later dementia. In 1957, shortly after the
publication of this highly original work, she followed Peter Daniel to the Institute of Psychiatry, London where she continued her work on the histopathology of the brain, being appointed senior lecturer and subsequently Reader in Neuropathology. However, in 1973, she decided to change specialties and retrain as a child psychiatrist and psychotherapist. In many ways a private person, she volunteered little on what led to that change. Even to close friends, she only revealed that she was more interested in the mind than the brain. One conjectures an epiphany associated with having undergone a Freudian and then a Jungian analysis, linked perhaps to her family’s cultural heritage and lifelong interest in ideas. Two years after becoming an honorary clinical assistant at the Belgrave Hospital for Children, she moved on to senior registrar posts, ﬁrst at King’s College Hospital and then at The Royal London Hospital. In 1977 she was appointed consultant psychiatrist to the Croydon Child Guidance Clinic. Here she particularly enjoyed working with families and joined The Association of Family Therapists. She was noted for her friendly but idiosyncratic clinical style, often forthright, but touched with a warm humour. In addition to the beneﬁts deriving from her own psychoanalysis, she obtained experience of group work during the early years of the Institute of Group Analysis. Later, as a member, she was actively involved in training group analysts on courses as far apart as Manchester and Heidelberg. By the time of her retirement in 1984, she recalled with some pleasure that she had attained membership of the two Royal Colleges devoted to medicine and pathology, and fellowship of the Royal College of Psychiatrists. Sabina Strich was born in Munich into an intellectual Jewish family of private means. An older sister died when 9 years old. Her younger sister moved and brought up a family in the United States, where Sabina was a frequent visitor. With the rise of the Nazi party the family ﬂed Germany, settling in Cambridge, where she attended The Perse School. In 1943 she won a scholarship to study medicine at Lady Margaret Hall, University of Oxford, gaining a degree in physiology before embarking on clinical studies as one of the earliest clinical students of the Oxford Medical School at the Radcliffe Inﬁrmary. She qualiﬁed BM BCh in 1949. Following house posts in medicine and surgery in Oxford and Swansea, in 1951 she was awarded a Medical Research Council (MRC) scholarship for training in research methods, initially at Manchester and then in Professor Sir Hugh Cairns’ surgical department at Oxford. Here she obtained a personal MRC grant to study the neuropathology of severe head injuries with Peter Daniel. After her retirement she returned to Oxford, in many ways her spiritual home. She bought a riverside apartment and set about creating a new and active life. She loved companioned walking and travelling far aﬁeld. Not ready to give up psychotherapy, she approached the Isis Centre, an open access NHS counselling service whose small number of core staff was augmented by associate counsellors. Sabina generously
volunteered in a number of roles - such as a consultant in weekly case discussion groups - and in a range of educational events. She ran a client group and an experiential group for nurses studying psychodynamic practice, saw couples and did some family work. She was especially valued as a supervisor in all these modalities as well as in individual work. She developed a small private practice and took active roles within the Oxford Psychotherapy Society, of which she was a founding member. She spoke on a number of occasions, as well as submitting articles and commentaries. To all her professional activities she brought a distinctive ‘Sabinoid style’. As a supervisor, her comments tended to be few and authoritative, but never critical, thus facilitating an ambience which encouraged others to develop their own ideas. After 11 years she left the Isis Centre, but remained linked with her many friends in the psychotherapy world. Towards the end of this period, she developed a new interest. Having been led to believe as a child that she had no artistic abilities, she experimented with clay and was surprised and delighted to discover that distinctive, often quirky ﬁgures, with vitality and movement, emerged from her ﬁngertips. Encouraged, she took lessons in sculpture and soon became an accomplished sculptress, exhibiting her work in local private exhibitions. Maybe it was in this creative work that her belief in the unconscious, her self-assurance and above all her empathic interest in people came to the fore. Recognising mild cognitive impairment, in her 80th year she moved to a pleasant apartment in a retirement complex. Art exhibitions, theatre and music played an important part in her life; she regularly attended concerts and read widely. Always fond of poetry, she published a small book of her own verse, with poems which were short, powerful and laced with dry humour. She found increasing deafness and lapses in memory deeply frustrating but - typically - Sabina responded by forming a group for the elderly with early dementia. She was active in maintaining her interests in medicine, religion, philosophy and psychoanalysis, attending a seminar in the last week of her life. Ever a realist, and having contentedly reached 90 years, she was reconciled to her own death and died after a short illness. Dr Peter Agulnik 1
Strich S. Diffuse degeneration of the cerebral white matter in severe dementia following head injury. J Neurol Neurosurg Psychiatry 1956; 19: 163-85.
B 2016 The Author. This is an open-access article published by the Royal College of Psychiatrists and distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.