11.7d Psychiatry and psychiatric services

i) Diagnosis

Another important environmental factor is to do with psychiatry and psychiatry services in their own right.

The majority of psychiatrists and psychiatric services tend to use the DSM IV to make diagnoses and they use the DSM IV to allocate treatment options and to make available services.

The majority of public mental health services focus on the major functional psychiatric illnesses such a schizophrenia, major depression or bipolar disorder, and these conditions are defined by DSM IV.

When a person has a brain injury their diagnosis goes within the realm of organic mental conditions and sometimes psychiatric services will not see themselves as being placed to manage patients with organic mental conditions.

The other issue is the diagnostic scales that we use, for example, DSM IV or ICD 10 are usually designed around psychiatric patients who do not have neurological illnesses. These people are often excluded when these diagnostic systems are designed and a number of authors have suggested that we need to devise in our own right diagnostic systems related to the organic mental illnesses, Ahmed  and Fuji (Ref The spectrum of psychotic disorders: neurobiology, etiology, and pathogenesis.  Cambridge University Press 2007)suggest we need to have a diagnostic system for psychotic disorders following traumatic brain injury. We can also argue that this should be the case for the anxiety mood disorders and changes in cognition that occur following brain injury.


ii) Skill and expertise

One of the greatest challenges that we have in psychiatry services is the lack of necessary skill or expertise.

Psychiatry trainees or mental health workers get very limited exposure to people with traumatic brain injury. They often do not understand the differences between the effects of brain injury and the effects of psychiatric illness.

There is a very reduced supply of suitably qualified people with expertise in both areas who are able to recognise when a person with a traumatic brain injury is more than just a person with a traumatic brain injury, when that person has a mental illness as well.

This lack of expertise, particularly in rural and regional Australia, is a substantial issue particularly regarding the quality of care that can be offered to patients.



iii) Resources to make a diagnosis

One of the challenges from the perspective of the psychiatrist is having the resources to make a diagnosis - this may seem a strange concept. But, in many cases, the reason a person with a mental illness and a traumatic brain injury does not receive the appropriate diagnosis and therefore not receive the appropriate management, is that the person making the assessment does not have enough information.

There were challenges in the assessment of Sam in not having any information about the severity of his brain injury. There was family data to tell about how his behaviour had changed but if you can imagine, there are patients who come to the specialist with a one line referral letter, they cannot tell the clinician how bad their injury was, they cannot say what parts of the brain were damaged, they often do not even remember why they are being referred. There may be no information about their cognitive skills or ability, their family background or what has been happening in recent weeks and months. The patient cannot give the information. There will then be not enough resources to make a diagnosis because a psychiatric diagnosis is based not only on what is happening at the time the person is sitting in front of the psychiatrist but what has been happening over the past weeks or months.

This lack of resources to make a diagnosis is a very important issue, from the perspective of brain injury staff, if you are wishing to make an assessment of a psychiatric illness the more information you present, be that the case manager goes to the assessment or you make sure a family member goes along, the easier it is going to be for that psychiatric diagnosis to occur.

As I have mentioned before, Sam was an easy diagnosis. He was so severely disturbed that the lack of information was not an impediment as far as his initial assessment was concerned but that is often a rarity rather than a reality.



iv) The rehabilitation team

The rehabilitation team also can present a number of challenges for the appropriate diagnosis and assessment.

Each individual team member in rehabilitation will have a different threshold of what they consider normal. All of us have a threshold of what constitutes normality or what constitutes abnormality. A team member's threshold is going to influence whether or not they say "I think there is a problem here, you better get a psychiatrist in" and how much disturbance of behaviour they will tolerate.

Sometimes rehabilitation teams are overworked or they do not see the person having a particular need for psychological treatment and therefore they may not have enough information as to what is going on to be aware that there is a problem and make the necessary referral.

But the greatest problem is for the traumatic brain injured patient who does not have a rehabilitation team either because no one has diagnosed that they have a traumatic brain injury or that it has been a number of years since the time of the brain injury. The majority of services usually focus on the acutely injured rather than the long term impaired and so they do not have anyone who is around there picking up that problems are emerging.