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Meeting the needs of the most complex patients

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As a specialist provider of mental health support, caring for some of the most clinically complex patients in the UK’s mental health system, St Andrew’s has a team of experts to provide the bespoke support to enable vulnerable patients to recover. Here, NR Times meets consultant neuropsychiatrist, Dr Vishelle Kamath

 

Can you summarise your role and career to date?

I work as a consultant neuropsychiatrist on the brain injury admissions ward. I have worked both in the NHS and at St Andrew’s within the independent sector. I have been fortunate to have the opportunity to have worked both as a clinician and as a manager of clinical services in a clinical director role. 

Aside from my day-to-day job at St Andrew’s, I am an honorary neuropsychiatrist at UCL Queen Square, the National Hospital for Neurology and Neurosurgery. It helps me to keep my skills updated and understand services across the country, which then allows me to use that knowledge to support the team at St Andrew’s and the patients I care for.

Tell us more about the Neuropsychiatry brain injury service at St Andrew’s? 

We support people who have had a recent or long-standing brain injury. These can be acquired either by trauma, like a road traffic accident (RTA) where there is structural damaged to the brain, or through different illnesses, such as encephalitis or meningitis, where the illness itself causes a change in the way the brain functions and leaves people with both physical sequelae as well as psychological and behavioural elements. 

Physical symptoms from brain injury are something you can see – such as difficulties with speech, swallowing, walking, and mobility – but there can be significant psychological and behavioural sequelae of brain injury, not necessarily visible to the eye, which may include the way someone thinks, how they process information, use judgement, plan, and make choices for themselves. 

The impact of trauma can be far-reaching, for example, a brain injury may affect parts of the brain that control appetite – a person can eat excessively as they do not know when they are full – or alternatively, they don’t have any feelings of hunger or thirst so do not eat or drink. 

A brain injury may also affect the way a person perceives other individuals. They may not see them as helpful, and instead see people as persecuting them or harming them, which results in agitation, aggression and resistance or non-compliance with care. 

People admitted into our service may have experienced significant brain trauma and the loss associated with the attendant physical, cognitive and psychological deficits are life changing.  This is aside from the impact that this has on loved ones and families. 

How do you support patients living with these types of brain injury and symptoms? 

Much of the work we do relates to understanding an individual’s specific needs and what has happened to them. Many people come from acute trauma centre or step down neurology wards and have been sedated for long periods or intubated. 

Patients usually come to us at the point when they are beginning to realise what has happened to them and are coming to terms with not being able to care for themselves in the way they had been able to, prior to their brain injury. 

Some individuals come to us with significant memory loss and their ability to learn new things is impaired. Some people have evident mental disorder as a sequelae of their brain damage. They may have developed psychosis, anxiety or depression as a sequelae of their brain injury. We help them to process the environment, situation and the trauma they may have had so they can develop coping strategies. 

During the assessment process we employ many tools and clinical observation assessments to understand what difficulties a person may be experiencing; their ability to function, what they can do for themselves, including simple things such as daily living activities, feeding, changing, recognising the need to go to the bathroom, which can all be affected by a brain injury.

Once we understand this, we can think about interventions that may support a patient to achieve a level of functioning similar to that which they had prior to their injury, and we subsequently develop holistic neurobehavioral and neurocognitive programmes tailored to the individual needs of each person.

A huge part of the service is also about supporting loved ones of the patient, who themselves are often struggling to understand what has happened, and helping them to understand the process. Establishing the pace of recovery, and setting realistic expectations as to what an individual’s journey may be, is part of what we do.

What is the difference between the St Andrew’s brain injury services and those elsewhere?

At St Andrew’s we are able to meet the needs of patients who present with significant behaviours that challenge. With our experience and expertise, we’re able to support people when they have layered complexities; complex physical health needs that are overlaid with significant and complex mental disorders and mental health needs. 

We have the procedural capability and wide breath of knowledge to support patients whose risk profiles cannot be met in other brain injury environments. 

On our assessment ward, we are able to get patients to a point where they are able to access neurorehabilitation at the earliest opportunity. Until a patient’s behaviour is managed in a way that allows them to engage with and access rehab services, it is unlikely they will achieve the outcomes they want for themselves and return to their premorbid functioning. 

How has your work been affected by COVID-19? 

The pandemic has been a huge learning curve for us. We have continually needed to ensure that patients are risk accessed appropriately in terms of their potential of contracting COVID and the likelihood of them developing a more serious illness. 

Early on in the pandemic, I devised a COVID risk assessment tool and care plan which helped clinicians to systematically think about and understand the risks to other patients with strategies to support all patients and staff safely. This risk assessment is co-produced with the patients and their families, understanding what their views are around escalation of care and any elements of advanced care planning, to reach a shared decision. 

One of the key things in our brain injury service is that we are true advocates of the value of the patient voice and within the context of COVID understanding what the patient wants for themselves, whether we agree or disagree, is a key to the development of these care plans. 

In line with PPE requirements, we all wear masks, we are bare below the elbow, and we maintain a two-metre distance where possible. Staff use appropriate techniques when delivering care during the pandemic. We have hand hygiene audits and are regularly reminding staff of good Infection Protection Control (IPC) measures. We implement periods of isolation and wear scrubs that are discarded/washed appropriately centrally. 

All of our patients are high risk and we undertake four hourly physical health assessments, using a NEWS2 tool to detect any change in physical health, this is especially important for patients who are unable to articulate in the way they feel or report physical health symptoms. We have had to think more creatively, but allow our patients safe ways to access the community, leave and contact with families. Importantly, we have been helping patients and families to understand why restrictions have been put in place.

What are the challenges you face in your role?

I love working in brain injury. As a neuropsychiatrist, I love the interface between organic illness, mental disorder, the layered complexity it has with physical health and various individual elements based on how that person acquired their brain injury and the subsequent physical and psychological sequelae of their condition. 

There is a tendency for brain injury to be seen as a physical disorder and many healthcare settings place all the emphasis on physical rehabilitation, there is limited understanding of neurocognitive and neurobehavioral rehabilitation and this is a challenge across the wider sector. 

Everybody has a different story and some of the obstacles we need to overcome are around how we support patients with high needs, including how we help them to step down into community settings because provision across the country is very limited. 

What do you most enjoy about your role? 

The complexities of individuals and the interface between physical and mental health. Understanding patients in the context of who they are (mother, father, their education and interests, and so on) is integral to any neurobehavioral programme and these are the elements I really love.

Working in a diverse, multi-disciplinary team is also extremely rewarding. I’m very fortunate to work as part of a very skilled team using a comprehensive multi-disciplinary approach and the different perspectives it brings is something I love. 

What do you enjoy doing away from work? 

I love the time I spend with my family and love to cook. 

I also love to travel, exploring different places, enjoying the food and culture. There are so many stories of travel that have enriched my life. I was brought up in South Africa, but explored lots in South East Asia, India, Thailand, America, Europe, Australia and New Zealand. My parents used to love travelling, so I was very fortunate to have travelled when young and when at University. I lived in India for a while, which again was a very enriching experience.

Exploring, cooking and sitting down to a board game or movie with my children and husband are things I really enjoy. The banter I share with them on a day to day basis is the best part of my day.

News

World-first AI Alzheimer’s drug trial to launch

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The world’s first Alzheimer’s disease drug candidate designed by artificial intelligence (AI) is to enter Phase I clinical trial in the US.

The study will assess whether DSP-0038 has improved antipsychotic effects in patients with Alzheimer’s psychosis and evaluate if it can improve the behavioural and psychological symptoms of dementia, including agitation, aggression, anxiety and depression.

DSP-0038 is the third molecule created using Exscientia Ltd’s AI technologies and the second molecule to enter trials from the company’s partnership with Sumitomo Dainippon Pharma.

The two other compounds are DSP-1181, developed in collaboration with Sumitomo and entered trials to treat obsessive-compulsive disorder in 2020, and EXS-21546, an immuno-oncology agent which began trials earlier this year.

Joint research between Exscientia and Sumitomo Dainippon Pharma designed DSP-0038 to be a single small molecule that exhibits high potency as an antagonist for the 5-HT2A receptor and agonist for the 5-HT1A receptor, whilst selectively avoiding similar receptors and unwanted targets, such as the dopamine D2 receptor.

According to Exscientia, designing selective molecules with dual targets continues to be a major challenge for conventional drug discovery, particularly for psychiatric indications which require exceptional selectivity to avoid off-target effects. It stated that the successful design of DSP-0038 demonstrates how AI can be used to design selective molecules with dual activity.

In the trial, to be run by initiated by Sumitomo Dainippon Pharma, DSP-0038 will be assessed for improved antipsychotic effects associated with AD psychosis, as well as improvements in behavioural and psychological symptoms of dementia which include agitation, aggression, anxiety and depression.

“This is further validation that our AI platform can turn complex biological challenges into high-quality clinical candidates quickly,” says Andrew Hopkins, chief executive of Exscientia.

“To have what we believe to be the world’s first three clinical molecules created using AI arising from our own platform – two with Sumitomo Dainippon Pharma – is a wonderful achievement. We hope that through the creation of DSP-0038 improved treatments for Alzheimer’s disease psychosis will be realised.”

Toru Kimura, representative director, executive vice president and chief scientific officer of Sumitomo Dainippon Pharma, adds: “We have been impressed by the outstanding productivity of Exscientia’s AI technologies.

“The combination of Exscientia’s AI with our company’s deep experience in monoamine G-protein coupled receptor (GPCR) drug discovery has now led to two molecules reaching our clinical pipeline from this collaboration.”

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Community rehab

‘Recovery from ARBD is the norm, not the exception’

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Reflecting on the recent ‘Recovery and Rehabilitation in The Community: Alcohol Related Brain Injury in Ireland’ event, senior clinical psychologist Dr Nichola Robson shares her analysis for NR Times 

 

It was a pleasure to listen to some of the leading professionals talk about alcohol related brain injury (ARBI), a condition arguably encountered in most areas of clinical practice. 

The theme of ‘hope’ ran throughout the event, which was hosted remotely by Leonard Cheshire, with the central message that recovery from alcohol related brain damage (ARBD) is the norm, not the exception. 

With the right kind of specialist intervention (including the provision of long-term residential placements), an estimated 75 per cent of individuals with ARBD experience a degree of recovery, with complete recovery possible for the remaining 25 per cent.

The day consisted of presentations from experts, interspersed with video anecdotes from service users’ family members and staff from Leonard Cheshire ARBI unit, ending with an interactive discussion between the audience and expert panel members.

 

Dr Jenny Svanberg (consultant clinical psychologist), clinical expert and author in the field, kicked off the day with an excellent summary of the available evidence regarding alcohol and the brain. She provided stark prevalence data and discussed the impact ARBD has on utilisation of non-specialist treatment services. 

She also explained mechanisms through which alcohol damages the brain (both transient and more longstanding effects), the neurological structures affected, and how this maps onto the neuropsychological symptoms and clinical presentation. 

Dr Svanberg outlined inherent diagnostic complexities due to subtle initial impairments often being masked by intoxication and chaotic lifestyle. She also highlighted issues of stigma faced by those with ARBD, and how their difficulties are often at least in part, often attributed to free choice. 

However, she explained that due to the neurological impact of alcohol, specifically on the frontal areas of the brain, and associated cognitive impairment later in progression, reasoning and subsequently choice, is significantly impaired, as is the ability to engage with treatment.  

Next, Professor Ken Wilson (Professor of Old age Psychiatry, Liverpool University), delivered a captivating talk on the clinical characteristics and experience of individuals with a diagnosis of ARBD. He used illustrative excerpts from clinical sessions to demonstrate the how these individuals present in clinical practice. 

He discussed how intact working memory can mean that individuals present plausibly in conversation, however due to short term and longer term (episodic) memory impairment, they experience significant retention and functional difficulties. Due to their cognitive profile these individuals present with reduced insight, a high degree of confabulation and suggestibility, and are therefore exceptionally vulnerable. He discussed the implications of this for assessment of risk and mental capacity. 

Prof. Wilson too emphasised the need to better understand the complexities surrounding this condition, including typical neuropsychological impairments, in order to challenge stigma and support engagement with treatment services (where available). In the absence of any specialist service pathway, individuals with ARBI tend to experience repeated relapse and readmission, with significant human and economic cost.

Following on from Prof. Wilson, Grant Brad (team leader, Glasgow Addiction Services’ ARBD Team) discussed the process of setting up and securing funding for specialist ARBD services. He talked through the service pathway in Glasgow, which covers acute and community settings (including assertive outreach), and offers holistic treatment provided by a specialist multidisciplinary team. 

Grant emphasised the need for a lead care group to support diagnosis and navigation of treatment pathways. He also presented evidence of significant cost savings (primarily due to reduced service utilisations) and reduced mortality associated with the service. He addressed the complexities of assessment and suggested that in absence of formal cognitive testing (contraindicated due to ongoing alcohol use), assessment should involve establishing a timeline of issues, consulting medical records, assessing functional ability through observational methods, assessing and managing risk. 

Grant’s team in the process of developing an audit tool to be piloted in the near future, to evaluate the effectiveness of the treatment provided. He is also keen to see the development of a professional network to facilitate the sharing of good practice. 

Next, Diane Watson (ARBI clinical lead, Leonard Cheshire) provided an overview of the recently opened specialist fourteen bed alcohol related brain injury unit, which offers rehabilitation and residential placements (of up to three years). Diane discussed the service pathway, referral criteria, team configuration, and treatment approaches. She also provided some reflections on the journey so far, detailing substantial successes and some challenges, the latter mainly related to COVID restrictions.  

Dr Anne Campbell (senior lecturer) and Dr Sharon Millen (research Fellow) from Queens University Belfast outlined their mixed method evaluation of the Leonard Cheshire intervention. They aim to measure outcomes relating to psychological wellbeing, functional abilities, relationships, and community participation as well as capturing the lived experience of service users, family members and staff. Preliminary findings suggested an improvement on measures of anxiety, depression, cognition, and function.

The final session was co-chaired by Dr Shield Gilheany (CEO, Alcohol Action Ireland) and Dr Helen McMonagle (Rehabilitation Coordinator, Alcohol Forum), and involved an interactive discussion regarding “the way forward”. Expert panel members included Dr Marie Goss (Consultant Clinical Neuropsychologist), Prof John Ryan (Consultant Hepatologist, Beaumont Hospital), Dr Kieran O’Driscoll (Consultant Psychiatrist, Bloomfield Mental Health Services) and Grant Brand. Discussions centred on the development of specialist treatment pathways (spanning acute and community settings) as well as the use of legislation to protect vulnerable individuals with ARBD.   

To summarise key messages from the day: the impact of ARBD often goes under-recognised and there is a lack of specialist treatment pathways across the UK. Increased education (both public and professional) is needed to improve awareness and understanding of underlying pathology, pattern of impairment, presentation, and treatment needs. 

Dr Nichola Robson

Undoubtedly there is a way to go, but this conference provided a valuable opportunity to showcase innovative service provision models supported by high quality data demonstrating effective outcomes, and in doing so sees us one step closer to meeting complex needs of this population. 

One can only hope that these service provision models (or similar) can eventually be commissioned and rolled out across the UK.

* Written for NR Times by Dr Nichola Robson, senior clinical psychologist (neuropsychology) at Sunderland & Gateshead Community Acquired Brain Injury Service (CABIS), Cumbria, Northumberland, Tyne & Wear NHS Foundation Trust

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MND

£1m dedicated to MND research through 7 in 7 Challenge

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A £1million fund has been created to lead new research into potential treatments for Motor Neurone Disease (MND) through the efforts of an iconic challenge by Kevin Sinfeld. 

Kevin, director of rugby at Leeds Rhinos, raised over £2million through his 7 in 7 Challenge, inspired by his former team-mate and close friend Rob Burrow. 

Rhinos legend Rob was diagnosed with MND in December 2019, and Kevin completed seven marathons in as many days to help boost badly-needed research into the condition. 

Now, with £500,000 of the money raised through the 7 in 7 Challenge ring fenced for research, that sum has been matched by medical research charity LifeArc. 

The move has created a £1million joint fund established by the MND Association and LifeArc, which will support research projects focused on developing new therapies or repurposing drugs already approved for use for other conditions.

“This is fantastic news and an amazing contribution from LifeArc,” says Kevin. 

“When we set out to complete the 7 in 7 Challenge we hoped to raise awareness and funds to support the MND community but it is so wonderful to see the inspiration it has given people and organisations, like LifeArc, so they too can support the need for more research.

“Our hope, like that of everyone affected by this brutal disease including Rob, is that this money will make a real difference and help find the breakthrough we all desperately want.”

Researchers are now able to apply for a share of the funding, with the criteria that they will be expected to conclude their project within three years and be target driving with set milestones and a credible delivery plan – including a clear route to reach MND patients.

Dr Brian Dickie, director of research development at the MND Association says: “We are so grateful to LifeArc for this generous contribution and are looking forward to working with them to identify projects which have a real chance of making a difference to our community in the coming years.”

Melanie Lee, LifeArc’s chief executive, emphasised that the focus of the new funding is on boosting research around potential treatment options based on the latest understanding of the disease.

“The ambition around stimulating the search for new treatments fits with LifeArc’s approach over the last 25 years to translate early science into health care treatments or diagnostics that can transform patients’ lives,” she says. 

“Our partnership with the MND Association is the latest in a series of strategic partnerships that maximise LifeArc’s expertise in translating strong discoveries from the lab into benefitting patients with conditions with few or no effective treatment options.”

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