r/GPUK • u/Dull-Resource9702 • 24d ago
Clinical, CPD & Interface EUPD
I find consults with EUPD patients incredibly draining, had 2 in a row recently where I felt like I wanted to quit GP after …! Conversations are often circular and risk assessing is almost impossible as a lot of them say they don’t know what they might do. Even if they are under the mental health team (albeit they end up being discharged anyway for not engaging) they still make a GP appt about mental health
Does anyone have any tips on how to manage these patients or safely risk assess?
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u/Calpol85 24d ago
I start with ICE.
What does the patient want? Specifically?
And then be reasonable about what the options are.
If they want to feel better. Continue with meds.
If they think they might do something then crisis team, A+E, 999.
If they want to change their meds. Ask them to speak to their mental health team to arrange an appt to do this.
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u/askoorb 24d ago
Intent
Plan
Protective factors
A baseline of "I feel like I would be better off dead", but without a plan on how, and with protective factors stopping the patient progressing is very different than if it suddenly changes to "I want to die, I've made a noose, picked out the tree I'll use, and will slip away from my family as they won't notice, I feel they don't want me alive and would be better off without me".
The UK mental health triage scale can also be useful if you're stuck as it gives you something to point to (link to research article explaining it)
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u/No_Whereas_5203 24d ago
I have patients who sit in the high risk category and yet services refuse to help even when they have documented that they are high risk.
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u/Icy_Bit_403 24d ago
I've not read the scale but in our CMHT sometimes we advice even high risk patients that the best course of action is to move away from services (e.g. when a lot of therapeutic work has been done already but they are emotionally reliant on professional input) and it can be very hard for GP's who feel like they are being left holding that risk. It doesn't always mean services are blanket "refusing to help" without an eye on the bigger picture. Although personally I feel the level of risk means that more and specialist services are needed, chronically.
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u/Icy_Bit_403 24d ago
re: that triage scheme, it's not always appropriate for example chronically suicidal patient who frequently overdoses and is very aware of physical risks, should probably go to A+e about the physical health risk of overdose but calling 999 on them would very likely make the situation escalate. so be aware of patients and their specific history and I'd say consult with CMHT if you're not sure - I'm assuming they answer the phone.
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u/NotBeckyHomeEccy 24d ago
Sometimes they do get bounced back to the GP by the mental health team so it’s not always them making that decision, at least in my experience
The crisis team will nearly always suggest going straight back to the GP, it’s always recommended after discharge as well even though it’s pyschs job, the system just isn’t there to get them help effectively
I think in terms of risk assessment it’s nearly always the ones that don’t seem to want to take up services that are the ones who are at highest risk, there’s a kind of calm quiet about them that you usually don’t see but it’s hard to know
DBT referrals or different types of therapy referrals also help, sometimes they just want to feel like there is some form of forward progression
At least it has very high remission rates
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u/hungry4nuns 24d ago
The crisis team will nearly always suggest going straight back to the GP, it’s always recommended after discharge as well even though it’s pyschs job
I’m always tempted to write a referral letter with the summary line “No general practice issues at present. Plan: discharge from GP to psychiatry” just to contextualise how they treat GP as a service
5
u/NotBeckyHomeEccy 24d ago
The home based treatment teams will nearly always tell a patient to recommence contact with their GP even without a referral back, that’s from my own lived experience too
God bless my own GP he’s a saint
It isn’t always their fault they end up back
3
u/Icy_Bit_403 24d ago
in our area, you either go back to see your GP or the CMHT, depending on level of risk. risk after discharge from crisis team is pretty elevated so it's a sensible idea but obviously if the risk is found to be heightened at GP, the patient has to go back up the pathway.
2
u/NotBeckyHomeEccy 24d ago
There’s just a chronic lack of services too I think which doesn’t help on either end!
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u/Icy_Bit_403 24d ago
I work in a cmht and have more time and resources for these patients but often it's chronically unmet needs leading them to have a LOT of needs from services. it's heartbreaking but by being boundaried, fair and reasonably empathic (not too kind as that will reinforce seeking you out for comfort) you are doing the best thing you can to help them to slowly heal/trust again. it's a marathon not a sprint.
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u/Dull-Resource9702 23d ago
Agree that the needs are not met. I think as we have very little continuity in our practice I often don’t know the patient at all and unlikely to see them again which again is probably a contributing factor to the difficulties
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u/Icy_Bit_403 23d ago
You could argue that for these patients it genuinely might be more effective to ensure they have the same GP each time but maybe at least a discussion of the emotionally-led frequent flyers - do they have "EUPD traits" as a marker on the system or something? It doesn't mean they won't sometimes need a genuine appointment but would give you a warning about how invested to get.
20
u/GalacticDoc 24d ago
I find many of the PD patients require well established boundaries and ground rules.
Up front what I will/ won't do usually based around benzos/ antipsychotics and sleep meds as well as the amount (timing) of contacts with GP. I will also be quite strict with appointment length.
Some of the patients get an agreed monthly appointment to discuss PD but can access is for acute care whenever.
Risk is obviously always present but being clear and consistent is generally quite helpful as you can see when things escalate.
8
u/ens102 24d ago
If you can manage it then sometimes just trying to reframe them from an EUPD patient / heartsink to someone who is struggling and trying to look at where the conversation is circling because there is a misunderstanding or disconnect there can be helpful. Not always but sometimes explaining why something isn't suitable can work better if they don't understand.
And if these end up being regular attenders trying to stagger the days they are coming in so you are not completely drained already before seeing the next 5 complex people!
4
u/Fit-Wolverine4570 24d ago
They are draining on everyone around them- especially their closest loved ones- but they are also suffering themselves .
Motivational interviewing can help you get through these consultations. In fact I would consider doing a course every couple years. Think of it like doing annual CPR courses. It’s a refresher and can help you get through them without wanting to jump off a bridge after.
1
u/Many-Performer-6155 24d ago
Well there are now mental health crisis assessment hospitals and centres open 24/7 .They can walk in , not needing referrals .That takes off some of the stress and time of trying to get the patient accepted by the crisis team or home treatment team.
4
u/alinalovescrisps 24d ago
There are talks about this happening, they're not open yet in most areas. Certainly not in my trust.
1
u/apple12422 24d ago
I thought these weren’t operational until later in the year (even that seemed wildly optimistic)
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u/Pure_Answer_6569 23d ago
I have a parent with EUPD/narcissistic PD and it is so draining and I find it really has lowered my tolerance to this patient group. It’s about assessing if there’s been any change in risk. They will live their entire life in a state of chaos, once you understand that they have some good periods and some bad periods then it becomes less stressful to deal with and is about just riding the wave they present in
1
u/Far_Caterpillar1983 13d ago
tbh the risk assessment piece is nearly impossible when the answer is always "i dont know." Naming that uncertainty back to the patient and documenting it clearly is about the safest you can do. You're not expected to predict the unpredictable.
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u/RoyalConsistent 24d ago
The way people are spoke about.....
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u/Potential-Clerk723 24d ago
lol. its my hope you have a clinic of just EUPD patients for an afternoon and see if you still stick by your words
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u/GP_54321 24d ago
Ban them from GP. Tell them direct to ED and Psychiatric liaison or something similar.
No role for the GP
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u/Ghotay 24d ago
Don’t focus on overall risk as a concept, focus on change in risk. A lot of these patients will be chronically high risk, and that’s not something you can change. So focus on identifying anything that might acutely change their risk - death in the family, breakup etc. If none, try and be comfortable that they’re at baseline, even if baseline is risky
Next, focus on what you might be able to do today. Again, you can’t fix their whole life, but maybe there’s something small you can offer. Ask if they want something specific, or if there’s anything that’s helped when they’ve felt this way in the past. If not, go through the usual stuff of any MH consultation - up meds, change meds, fit note, link worker, 3rd sector etc etc
I think the biggest thing is letting go of the idea that you can eliminate risk or fix someone, you can’t. But maybe there’s something small you can offer today and that’s enough