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Mental fitness: Brain Stimulation Therapy

 

Author: Dr Kavita Das, Consultant Older Adult Psychiatrist

 

I, along with my colleague, Dr Meetu Singh took the opportunity to attend a conference, with a view to further enhancing our knowledge of the latest research on rTMS (Repetitive Transcranial Magnetic Stimulation). It was a fruitful day! I am therefore taking this opportunity to write about this innovative treatment.

 

rTMS is one of the new and innovative brain stimulation treatments in addition to Vagus nerve stimulation (VNS), Magnetic Seizure therapy (MST) and Deep brain stimulation(DBS). Electro-convulsive treatment (ECT) is the best studied and utilised physical treatment for depression.

Brain as widely known, is an electrical organ that functions through electrical signals being passed between nerve cells. rTMS uses magnetic stimulation to activate or inhibit this electrical activity depending on the disorder. rTMS is based on Faraday’s law of electromagnetic induction i.e.- electrical activity in the brain tissue is modulated by a strong magnetic field. The rTMS machine produces brief pulses of electrical current inside a coil and this in turn generates this strong magnetic field that passes through the scalp and skull painlessly, activating the neurons in the brain. High frequency rTMS facilitate brain tissue excitability while low-frequency rTMS can suppress activity in the hyper-aroused brain, for example in anxiety disorders. Low or high frequency rTMS can be used solo or in combination, depending on the mental disorder being treated.

Unlike ECT, in which electrical stimulation is more generalized, rTMS is targeted onto a specific site of interest in the brain. Another major difference is that while ECT effects are through causing fits, rTMS causes changes by painless magnetic waves directly stimulating the tissue. It therefore does not require anaesthesia or admission into hospital. Also, this understandably improves the side-effects profile and is better received by the patients. Unwanted effects may include scalp pain, headache or burning sensation locally, none of these tend to last long. Rarely, when given in very high doses (not the currently available and approved doses) it has caused seizures. There is also no loss of memory, unlike that reported with ECT. Patients may complain of scalp pain, headache or burning sensation, which can appear during the treatment and do not last long.

First developed in 1985, it has been studied extensively for use in depression and chronic pain. In 2008, the FDA approved rTMS for use in patients who did not respond to at least one antidepressant medication in the current episode or did not want to take medication due to side effects. National Institute of Clinical Excellence (NICE), UK, approved rTMS for treatment of depression in 2015, after careful consideration of published research. It is now offered in USA, Canada, Germany, Japan, Australia and UK. rTMS has produced encouraging results in treatment of many other disorders both mental (e.g. anxiety disorders, eating disorders, PTSD) and physical (e.g. Post- stroke rehabilitation, tinnitus, migraine, chronic intractable pain) apart from depression.

Future of rTMS appears to be bright; as it gradually becomes more known amongst medical professionals as well as patients. Encouraged by the efficacy and tolerance to rTMS, Oaktree Clinic has initiated this service in September 2016. The results here since then with this form of treatment have been nothing short of phenomenal.

 

Dr Kavita Das, MBBS, MRCPSYCH, MSc (Gerontology), Cert (Mental Health Law)

Dr Das is a Consultant Psychiatrist with experience in assessing and treating the whole range of mental health & psychological issues in older adults. She works within the NHS and Private sector. Dr Das has special interest in treating memory problems (Adults of all ages), Alcohol & Substance Misuse in Older People and Physical & Mental Health issues in Older People with forensic history.

For more information please see my website: drkavitadas.co.uk

Employers need more awareness of MH issues
GBCC | Mental health costs £1.72b/year, Birmingham Uni report revealed. https://t.co/HCiL3bodlZ

— The Oaktree Clinic (@OaktreeClinicUK) June 13, 2017

 

A Case Vignette

I recently saw a “72yr old man in my clinic whose family have noticed gradual worsening of memory. He is observed to be missing things in day today life which he previously would have happily paid attention to or remembered.  He lives on his own having lost his wife quite suddenly two years ago. He did not cope very well, became depressed, had significant problem with sleep and started to withdraw socially. He was started on antidepressant and hypnotic to help sleep. He had started to take more than prescribed hypnotics, cut down following a consultation with GP. He has started to drink 3-4 pints of beer most nights. He is also on co-codamol for widespread osteo-arthiritis. There is past history of anxiety & depression for which he sought help. He said that he, all his life drank heavily but never had any problem so did not seek help. He has history of hypertension and a lifelong heavy smoker, has cut down to 10 a day recently.”

I recently attended a college conference on addiction and in the same week saw a patient (mentioned above) that highlights the complexities an older adult with substance (alcohol/drugs) misuse may face or present to a practitioner. I thought I’d pen few lines down.

The first UK based report of the older Person’s substance misuse came out in June 2011, followed by a comprehensive cross-faculty report on substance misuse in older people in 2015. I am aware that a further review is due this year.

 

How common is the substance misuse problem in older adults?

The proportion of older adult in the population is increasing and projected to double by 2031. The number of older adults with substance misuse problems is also reported to be increasing. Substance misuse is top ten risk factors for premature death and health problems and rate of death due to substance misuse is more in older adults than younger people.

Substance misuse problems in older adults are most often associated with the misuse of alcohol and over-the-counter (OTC) and prescription drugs. Older adults frequently show complex patterns of substance misuse; alcohol use with prescription medications, tobacco, over-the-counter drugs or illegal drugs. Multiple drug dependence aka polypharmacy is a particular problem in older adults with physical and mental health problems.

In recent data released from Office of National Statistics (ONS) for England shows that Baby Boomers (people aged 45 and over) are drinking frequently and at more hazardous level. Alcohol related hospital admissions have increased by 64% in a decade and highest ever level. A few older adults use illicit substance, mostly marijuana, however this is projected to increase as the over 45yrs old who use illicit drugs, get older.

Majority of older adults with substance misuse problems are simply continuing a pattern of behaviour or addiction that began earlier in their lives and invariably have a family history of alcohol and drug addiction. About a third of older adults develop substance misuse problem in the later years, usually in response to bereavement, social isolation or lack of social support.

 

Physical and psychological factors associated with substance misuse in older adults

As people age, body loses muscles, gain more fat as a result metabolize substance slowly, develop increased sensitivity and reduced tolerance. The kidneys and liver may not be functioning as well. Alcohol consumption in the presence of other medical conditions or medications may create danger by causing or complicating medical conditions, compound medication interactions and increase falls or confusion. It is not uncommon to find lack of communication between the physician and the older person to allow correct dosing, titration, interactions and side-effects leading to multiple medications being prescribed for medical problems.

Misuse of alcohol and drugs can affect physical health; hypothermia, stroke, heart disease, cancer and poor liver functioning. Psychological problems like self-neglect, anxiety, depression and insomnia are common. Long-term use leads to dementia and cognitive impairment.

We cannot ignore the fact that drinking and drug use can have detrimental effects on the near and dear ones, causing anxiety, stress and sometimes relationship breakdowns.

 

Difficult to identify the problem

Research show that physical, social, psychological  and legal problems associated with substance misuse in older adults mean they are likely to have regular contact with health and social care services. However, early identification of substance misuse is more difficult than in younger people.

The nature and pattern of older adults’ substance misuse make the problem less obvious; they consume substance at home, in local pubs or in social settings, less likely to be involved in trouble with the police, get into arguments or miss work due to substance use.  Research has identified that family, care-giver and clinician may be complicit in the addiction process in the older adults. Substance misuse is a hidden problem and Royal college of Psychiatrists have quite rightly referred older adults with substance misuse problem as “our invisible addicts”. Health and social care professional may not always spot heavy drinking or drug misuse in older adults. Older adults may not talk about their misuse due to perception of stigma, shame or embarrassment, the effects of alcohol or drug misuse may mimic physical or mental health problem, and most importantly they are often not asked the question regarding alcohol or drug use as they are assumed not to have the problem.

 

Pooling help

Health professional generally find easier to treat alcohol and drug problems in older adults than in younger people as they are motivated and want more contact with their family members especially grandchildren.

Older adults who misuse substances may have complex or multiple needs that are often difficult to assess and may warrant further investigations. A comprehensive assessment, including physical and mental health examination is needed. Additional corroborative history, laboratory tests would assist identification.

Screening is a brief process that aims to determine whether an individual has a drug and/or alcohol problem, health-related problems or is showing signs of risk behaviours. Several screening tools are usually accurate in identifying alcohol misuse in older adults; Cut-down,Annoyed,Guilty,Eye-Opener (CAGE); the Short Michigan Alcoholism Screening Test-Geriatric version (SMAST-G); and the Alcohol Use Disorder Identification Test (AUDIT). While screening is important, it may not always lead to effective treatment. Brief interventions e.g. counselling and education at the primary care setting help. Psychosocial interventions, such as CBT, motivational interviewing, as well as supportive, non-confrontational approaches and group therapy for older people are likely to be effective.

 

Self-help groups e.g. AA exclusively for older adults are better, so do specialized treatments; outpatient, detoxification, inpatient, residential and recovery services tailored to the needs of older people. It is critical to understand, no one-size-fits-all approach.

Limited research to understand medication misuse in older adults show that computer-based and group health education may be useful. Medication leaflets/passports to accompany medications have been helpful. Medication review by professionals at primary and secondary care settings, in nursing homes are recommended. Brief information and intervention sessions represent viable options. Electronic medical records and databases that connect the information systems of physician and pharmacists are effective in addressing the problem.

 

Support organisations; Addaction, AgeUK and Alcoholics Anonymous all aim to improve later life through information, advise, campaigns, products, training and research.

 

“The first step towards getting somewhere is to decide that

You are not going to stay where you are” – unknown

 

 

Dr Kavita Das, MBBS, MRCPSYCH, MSc (Gerontology), Cert (Mental Health Law)

Dr Das is a Consultant Psychiatrist with experience in assessing and treating the whole range of mental health & psychological issues in older adults. She works within the NHS and Private sector. Dr Das has special interest in treating memory problems (Adults of all ages), Alcohol & Substance Misuse in Older People and Physical & Mental Health issues in Older People with forensic history.

 

The Oaktree Clinic are proud to announce that we are planning an Open Day.

So on Thursday 25th May at 4:30pm The Oaktree Clinic is opening our doors to the public so we can help de-stigmatise the image of mental health in the community.

There will be drinks, refreshments and a whole load of knowledge that our mental health professionals will impart to those that attend.

The open day will feature the following sessions:

• Quick Clinic
  • Overseen by Dr Singh, these sessions will give a chance to ask psychiatrists questions about cases, for advice, about psychiatry, about medicine or the brain. Basically it’s a psychiatry drop-in session! For those that feel they might need help, or those with a burning question about the mind.

• Basic Intro to CBT
  • One of the most common forms of psychological treatment at the moment is Cognitive Behavioural Therapy or CBT. Here there will be explanations of what it is, how it works, what an initial session would consist of (the condensed version) and a patient example. As well as a Q&A.

• rTMS
  • A revolutionary method for treating depression, anxiety and most other neuro-psychiatric issues, rTMS is currently not widely known in the UK. Here our trained professionals will explain about the treatment, how it works, the practicalities of the treatment, even how it feels! Then there’s also the science part – scans, the brain, and the relationship between psychiatry and neurology. Get completely clued up on this wonderful new treatment.

• Tours
  • You may have seen The Oaktree Clinic from the outside, but now you can be guided around and see the causal warmth and unique decor of the interworking of Oaktree yourself.

• Relaxation
  • The world is an increasingly stressful place… sometimes you need to take some time to relax and unwind. Experience some relaxation techniques such as muscle relaxation, visualisation and breathing relaxation.

• Emotional Regulation
  • Life, as a great man once sang, is a rollercoaster. In our Emotional Regulation session we will give you the opportunity to learn some techniques for managing emotions in daily life.

The open day is from 4:30pm-7pm on Thursday 25th May at The Oaktree Clinic in Edgbaston. Hopefully we will see you then.

Does Mr Ben Brooks-Dutton have a point?

You may have heard in the news recently of a man whose wife was killed by an older driver who mistook accelerator for the brake. On the back of this traumatic incident, Mr Ben Brooks-Dutton has started a popular online petition for over 70s to be retested every year for fitness to drive. Many have agreed and yet some have posted some vile messages.

Generally speaking, older drivers are safe drivers for many reasons; they drive few miles, drive locally, and avoid rush hours and night driving. It is unfortunate that accidents involving older drivers often call attention to their driving.

Statistically speaking, the rates of fatalities increase slightly after age 70 and significantly more after 85. We all age differently, some more than others. Some have better physical and mental agility than others. The common denominator however is ‘increasing age’. With age, come physical and mental changes that can affect driving abilities. The physical changes that are seen include: decrease in vision, hearing impairment, decrease in muscle strength, reduced flexibility in the joints and impaired co-ordination. Reduced motor reflexes can affect the threshold of reacting to a hazard on the road. Various medical conditions and medications also add to the physical health burden. Mental capabilities to deal with the melee of sensory stimulus and stressors on the road may also reduce.

It is of utmost importance that an older driver takes charge of their health and steps to stay safe on the road. Practical steps consist of regular health MOT (eyes, hearing, sugar and cholesterol level check-ups), making changes to the car for effortless driving (automatic car, adaptation for smooth steering and brakes) and being mindful of driving practices that may help limit accidents (keeping safe distance from the driver at the front, parking with an adequate space to get in and out, aware of crossroads and intersections etc). Being aware that if vehicles do not flow with the traffic and speed, road-rage is not uncommon. Digital technology in newer model of cars is generally considered to be distractions by the older folks. However if used appropriately they can be immensely useful. I am not surprised to hear three-point turning is going to be replaced by the test of ‘appropriate use of SATNAV’ in the driving test, in keeping with current trend and preparedness for the future.

The tricky stage is when concerns set in. Driving a car represents a sense of achievement (I know the very feeling when I passed my test!), a sense of control and independence. Understandably the thought of relinquishing driving is emotionally charged and not easy to absorb. Generally older people continue to drive confidently and safely.  When, how and who are important aspects when considering conversation about driving limitations with an older person. Near misses, accidents, health changes and self-regulations may provide an opportunity to discuss concerns. Being sensitive and respectful of feelings of the older person towards driving is the first step towards sharing your concern. Having open, periodic and graded discussions about safe driving helps towards preparedness. Men may require repeated conversations compared to women. As per surveys, older persons generally like to hear of any concerns about driving from somebody they trust; spouse, elder children, or a close friend. Studies have shown that when the ultimate decision of cessation of driving has to occur, older persons prefer to hear hard facts from a doctor (GPs as the first port of call and secondary specialist like us, when there are health problems).

In my experience, conversation regarding driving cessation is akin to ‘breaking bad news’; requiring sensitivity, a minimum of two consultations, presentation of evidence of concerns (usually gathered from family or friend) and laying down the facts of how health issues impact driving abilities. A family dialogue with the older person ahead of seeing a doctor helps in the decision process. A doctor may refer a patient to a specialist-driving centre for a comprehensive evaluation.

Although the transition from driver to passenger is not easy, older people generally achieve a balance between safety and independence. Older people and families can avail informal advice from local charitable organisations e.g. AgeUK, AgeConcern and Alzheimer’s society. Written and formal advice are also available on DVLA website.

“STAY SAFE AND ENJOY YOUR DRIVING”

Dr Kavita Das, MBBS, MRCPSYCH, MSc (Gerontology), Cert (Mental Health Law)

 

Repetitive Transcranial Magnetic Stimulation (rTMS) is a treatment for adult patients with Clinical Depression and many other psychiatric disorders. It is effective, pain free and with few or no side effects. NICE has recently approved magnetic treatment for depression and is gaining in popularity in USA, Australia and the rest of Europe but not so much in the UK. This is a grand step towards neuromodulation and physical interventions in clinical mainstream psychiatry.

We have organised a workshop where professionals could not only refresh their knowledge about the latest research about efficacy of rTMS but also about the practicalities of working with the TMS equipment. The workshop is relevant for GPs, Psychiatrists, nurses and other mental health professionals who would like to know more about this groundbreaking and effective treatment. It is in collaboration with the Royal College of Psychiatrists.

The programme is as follows:

 09.15 – 10.15 – Overview of GMC complaints data and investigation process

“1 in 4 people, like me have a mental health problem. Many more people have a problem with that”. – Stephen Fry.

I was recently asked by the Oaktree Clinic to write a blog for their page. In the midst of myriad of thoughts, the Podcast (Bryony Gordon’s: Mad World) in which Prince Harry talks about his counselling that he sought after 20 years, could not have come at a better time! Yes let’s talk about stigma in mental illness…..

In the interview the Prince, who is now 32, talks of seeking help after 20 years and especially enduring “total chaos” for two years that affected both his personal and professional life. He could not be persuaded to talk of his emotions earlier by his older brother, Prince William.

He talks of his emotional state very normally and openly. The big question is: why it took him so long to seek help? Bryony Gordon equally makes a very powerful statement- “It is perfectly normal to be weird….actually, may be weirder to feel perfectly normal”.

One in four of us suffer from some sort of emotional problem at some point in life. This tells us that emotional problems are common. So why don’t we talk about it?

Mental health illnesses are a leading cause of disability. If not caught early and treated, leads to problematic interpersonal and family functioning. The life expectancy is also lowered. Aforementioned problems are preventable. However help-seeking, is either delayed or void. To nip-in-the-bud, remains a public challenge till this date.

In a recent study that reviewed most of the stigma related studies in depth. Help-seeking behaviour is found to be influenced by four types of common stigmas; perceived public stigma (perception about a person who has a mental illness endorsed collectively by members of the general population), personal stigma (personal attitude towards a stigmatised group), self-stigma (endorses stereotypes, believes to be devalued member of the society and anticipates social rejection) and attitudes towards help-seeking (self perception about need for help). You can well see how multifaceted stigma is.

The significant finding in the recent review is that the “attitude towards a behaviour are associated with engaging in the behaviour itself in other situation”. In other words, people with ‘personal stigma’ tend to avoid contact with stigmatised group and therefore abstain from seeking help. Other stigma that influenced negatively is ‘attitude towards help seeking’. This group believes that the battle could be won on his/her own and also has low perceived need for help. It is indeed not uncommon to find that people would recommend seeking professional help for emotional problems or may report an intention to ask help when affected by mental health problems themselves. Unfortunately when it comes to ‘walk the walk’, a considerable low proportion of people would actually ask help.

Last but not the least, we ought to encourage people to talk about emotional problems, encourage help-seeking, educate on treatment options and long-term adversaries of untreated mental health problems.
Prince Harry has made a start, kudos to the young man!

I look forward to 9 more Podcasts in which Bryony Gordon would talk to high profile people, who would talk about their mental health issues.

 

Dr Kavita Das, MBBS, MRCPSYCH, MSc (Gerontology), Cert (Mental Health Law)

According to the Health & Safety Executive 2013/14, in the UK 40% of workforce reported work-related stress. 1 in 5 visits to GPs are related to stress.

What causes this stress, I hear you ask? From research, heavy demand, lack of control over work, low level of support from colleagues and management, bullying and harassment, constant change, are the culprits. You know you are stressed when you start worrying about work at home, dread going to work, lose sleep, and become increasingly short tempered.

Here are some recognised Stress Busters to help you combat the strains of work-related stress:

• Recognise signs early
• Don’t bring work home
• Learn to say no.
• Always take breaks.
• A few minutes of exercise every day goes a long way.
• Speak to your supervisor; employers have a duty of care.
• Create a network of support: family, friends & colleagues
• Get involved in activities you enjoy outside work, ex: hobbies, voluntary work, learning new skills, something positive to cherish.
• Avoid smoking/drinking excessively to cope. Alcohol worsens low mood.
• Use time management strategies to work efficiently.
• Accept things you cannot change, like a full ‘in tray’, irrespective of how hard you work.
• Learn Relaxation Techniques. Meditation & Yoga can help.
• Contact your occupational health department, they may be able to access professional counseling for you.
• Attack the root cause. Ask questions like: Do I like my job? Could I be better somewhere else?

If all above fails then seek professional mental health advice. Depression and anxiety disorders can come in the guise of stress. These are treatable disorders, requiring assessment, treatment and support.

 

 

Here at The Oaktree Clinic we are never ones to rest on our past achievements. We always strive to be the best and up-to-date mental healthcare team we can be. This attitude to be the best has lead our clinicians to continue their training through the process of CPD.

CPD stands for Continuing Professional Development. Simply put, it is “the holistic commitment of professionals towards the enhancement of personal skills and proficiency throughout their careers”.

Five times a year our various mental health professionals meet up for a sharing of knowledge. Previous presentations have covered various far-reaching disciplines of mental health, from Neuropsychiatry, Child and Adolescent psychiatry to CBT, Mindfulness and much more. Each presentation, devised by our team, expands and updates our clinicians already vast knowledge base.

While it would be easy to assume that with seven plus years training to become a qualified mental health expert would be enough education to last anyone a lifetime, our CPD sessions at Oaktree reinforce our skills, knowledge and make sure that you the client get a better experience.