CORRESPONDENCE.

Sir: As a psychiatrist and general practitioner (GP) who moved to the UK to train in the National Health Service (NHS), we are concerned that controversial proposals for wide-sweeping reform may damage mental healthcare provision. According to a Department of Health spokesman (as widely reported in the news media, 11 March 2011), the UK government proposes to ‘cut bureaucracy and give doctors the power and freedom to make the service more responsive to patient needs’. general practitioners are to be handed budgets to commission specialist services, including mental health services, with an emphasis on competition, not collaboration. We are concerned that these reforms are another step towards the privatisation of the NHS. Experience in countries with private, competitive healthcare systems is that mental health service users may be at a disadvantage and the quality of care variable. Recent US healthcare reforms towards a more inclusive model, based on social care and supporting the more vulnerable in society, reinforce this view.

The evidence for the need for transformation has been on the basis of poorer health outcomes in the UK compared with countries with similar levels of spending on health. This evidence has been contested robustly (Appleby, 2011; Goldacre, 2011). Moreover, the British Medical Association has stated that the reforms are ‘potentially damaging’ (as reported on 1 October 2010), particularly where competition as opposed to collaboration risks fragmentation of services.

The implications for mental health services are unclear. However, a number of UK mental health groups have expressed disquiet at the potential effects of these proposals. A survey by the charity Rethink (2010) found that most GPs did not feel equipped to commission mental health services. The mental health charity Mind (2011) has called on the UK government to ensure that any changes to NHS commissioning do not jeopardise the continuity and quality of care currently received by people with mental health problems. It emphasised the difficulties people already face in a relatively well provisioned NHS mental health service. Mind (2011) also raised the spectre of GP ‘doorstep lobbying’, which may mean that mental health loses out in the battle for resources. A study by the Institute for Public Policy Resource Research (2011) suggested that the quality of dementia care would suffer under the reforms. The Institute reported that just 31% of GPs in London feel that they have received sufficient training to diagnose dementia. Furthermore, productivity improvements could be put at risk by the reforms, as could joint working, according to a report by the King’s Fund and the Centre for Mental Health, with input from the Royal College of Psychiatrists and other stakeholders (see King’s Fund, 2010). Substantial long-term financial savings can be made by integrating mental health and social care services according the King’s Fund study.

It is difficult to see how the proposals in their current form might promote integration and collaboration when their focus is on competition and fragmentation. Collaborative working across and between services, and optimal care pathways, are a cornerstone of successful mental health service provision. Countries undergoing healthcare reform might wish to follow both developments and mental health outcomes in the UK over the next few years.

Sir: I chose a psychiatry elective because of my interest in Uganda. There is a high rate of post-traumatic stress disorder (PTSD) among the Acholi people in the north, following the 1986–2006 guerrilla war between the Ugandan government and the rebel Lord’s Resistance Army (LRA).

The LRA is infamous for using child soldiers (during the conflict, 30 000–60 000 children were abducted, making up over 90% of LRA troops) and committing atrocities against civilians. Villages were attacked, their inhabitants killed, beaten and raped; crops and stores were stolen and roads made impassable. In an attempt to gain control, the Ugandan government moved over 90% of the population of the north into camps for internally displaced persons; by 2005 these contained 2 million people. Unable to farm, the Acholi became dependent on the World Food Programme.

PTSD is found both in former child soldiers and civilian victims. Gulu town, once at the centre of the conflict, is now at the heart of regeneration. I worked with three organisations there:

Gulu Regional Referral Hospital Mental Health Unit, the main psychiatric centre in the north, which runs outreach and daily out-patient clinics

The Peter C. Alderman Foundation, an American non-governmental organisation (NGO) which specialises in rehabilitating victims of trauma, and which works closely with Gulu Hospital

the African Centre for Treatment and Rehabilitation of Trauma Victims (ACTV), staff from which spend up to 4 days at a time in the field addressing all aspects of victims’ lives.

Psychiatry is very paternalistic in Uganda, but PTSD management seems an exception, focusing on talking therapies, involving the patient in treatment. Medication is used in most cases, primarily antidepressants (usually amitriptyline), often with an antipsychotic (haloperidol). Almost universally, patients I spoke to had seen a benefit from therapy, especially meeting others who shared their experiences. But the further people are from Gulu town, the harder it is for them to access help.

The ACTV works effectively using a multidisciplinary approach. It has discussions led by social workers and drama projects which recall and deal with the trauma of the past. A clinical officer manages medication and a staff physiotherapist deals with stress-related musculoskeletal pain. Lawyers and social workers offer advice on everything from domestic violence to the land wrangles which resulted when families returned from camps to find strangers occupying their land. All aspects of patients’ problems are covered.

Although there were fewer hands-on opportunities for me than there might have been in a medical elective, all the teams involved me fully. I found my psychiatry elective an excellent way to develop the brief grounding I had as a student – and by visiting a low-income country I learned a way of practising using limited resources. The ‘Western’ way of treating patients simply is not possible (for instance following guidelines produced by the National Institute for Health and Clinical Excellence).

A place as traumatised as northern Uganda will not heal overnight; but hope remains as long as victims of trauma have someone to talk to – even though, as one ACTV social worker told me – ‘sometimes the best you can do is listen to their stories and say “I’m sorry”’.

Sir: There are an increasing number of substances appearing on the recreational drug scenes in Europe, North America, Oceania and Japan (International Narcotics Control Board, 2011). In 2009 for example, 24 new psychoactive substances were notified in Europe, compared with 13 in 2008, including synthetic cannabinoids, tryptamines, phenethylamines and synthetic cathinones, according to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA & Europol, 2009).

Many are synthesised by chemists who modify the structure of existing psychoactive substances controlled by United Nations conventions so that they remain legal. These new generations of ‘designer drugs’ are marketed as ‘legal highs’, and sold in ‘head shops’ and increasingly over the internet as ‘research chemicals’. Purity levels are very high; they are laboratory manufactured and sold, for example, as ‘synthetic cocaine’. Thus, the products appear to potential consumers as both legal and safe.

Such assumptions are dangerous. If sold under a ‘brand name’, the contents and active ingredients are not listed; consumers do not know what they are taking. Even if a substance is advertised using its chemical name, is extremely pure and is chemically related to drugs with known desired psychoactive properties, there is no guarantee that it does not have potential adverse or even toxic effects. Adverse effects reported by users in recent years include psychiatric conditions such as psychoses, depression, anxiety, paranoia and suicidal ideation. Physiological effects similar to those experienced by overdosing on amphetamines, cocaine and ecstasy have been reported by attendees at emergency departments. Sometimes, these complications have resulted in fatalities (Ghodse et al, 2010).

Such occurrences led to risk assessments being conducted at national level in many countries, resulting in substances being controlled. For example, the Council of Europe on 2 December 2010, following a formal risk assessment (EMCDDA, 2010), adopted a Decision submitting mephedrone to control measures (Council of Europe, 2010). Following new controls, some chemists further manipulated the molecules of these chemicals so that they complied with the law.

New psychoactive substances are appearing at an increasingly faster rate than hitherto. Users are exposed to all types of unknown risks, as research and analyses have not been undertaken. Branded products may contain different active ingredients than when first marketed. For instance, initially, ‘Ivory Wave’ contained mephedrone, methylenedioxypyrovalerone (MDPV) and other cathinones but, following their control, desoxypipradrol was substituted. Imports of this latter chemical were restricted, but retailers released older stocks containing MDPV.

One beneficial effect of the control of mephedrone in the UK and media coverage of the adverse mental and physical properties of the substance was a fall in the number of suspected and confirmed fatalities involving its use.

Health professionals should be aware of the ever-changing nature of recreational drug use and the potential mental and physical health problems that may be caused by the consumption of new psychoactive molecules. Patients should be asked about their use of ‘legal highs’, as well as other substances misused.