[Posted on 25 September, 2018 by David Eberhard]
A few years ago, when I was appointed as chief of the Prima adult psychiatric clinic at Liljeholmen, there was a special unit for neuropsychiatric examination and treatment at the clinic itself. The problem was that it was not enough. I thought about how to solve the issue, but ultimately I had to restructure everything. This meant that the neuropsychiatric unit, such as it existed at the time, was shut down. I imagined a different solution than the one previously implemented. This was met with many objections from the people who worked there, especially the psychologists running the examinations. They ended up resigning, and even went so far as to spread misinformation about me in a psychology forum on Facebook.
It seems reasonable that these particular people would be offended by my decision. After all, they were meant to ensure that the clinic would perform good examinations. And of course, there was nothing seriously wrong with the examinations they had carried out. Why I did what I did had nothing to do with them, something I futilely tried to explain to them on several occasions. It had everything to do with prevalence.
Those of us working in adult psychiatric services have been completely taken aback by all the different disorders originally described by child and adolescent psychiatrists. These are childhood-onset problems that explain much of what we have seen in our adult patients, and yet they were previously framed only in terms of other psychiatric syndromes. The proportion of people with several different concurrent psychiatric syndromes is, at any given time and no matter the kind of psychiatric problems, exceptionally large. This is nothing new.
As we all know, the distinction between sick and healthy can sometimes be quite blurry. As such, prevalence rates naturally vary depending on the strictness of the diagnostic criteria. This is true of all psychiatric conditions. Even taking this into account, there are now an inordinate number of people turning to adult psychiatric services, whether on their own or through referrals, for examination of previously unexamined childhood-onset problems. For example, a very large proportion of the population has ADHD, but many of them have had to get by without being offered any help from psychiatric services.
Over the last few years I have been working with the GNC on a research project where we have diagnosed and examined around 150 young adults who have turned to adult psychiatric services for the first time. As expected, they obviously have many different sets of problems. However, one thing that we did manage to predict beforehand was that a very large number of them would get in touch with the clinic on account of possible ADHD or autism spectrum conditions. In fact, well over half of all the participants had problems in one or both of those areas.
This is not unique to Liljeholmen – this is obviously how it is all over the country. And nor is it unique to young adults. Given the previous structure of psychiatric services, it is more likely the other way around. Neuropsychiatric issues might be even more overrepresented among the elderly. It is only in recent years that different kinds of ESSENCE problems have started to gain widespread attention, which means that a lot of people with potential ESSENCE issues will now want the examinations they never got as children or young adults. Sometimes they seek treatment, but in many cases they just want to know what it is that has plagued them or made them feel different their entire lives. This is perfectly natural, but also something that pushed me to shut down the neuropsychiatric clinic when I was appointed as chief. More specifically, ESSENCE problems are so comprehensive that they must be familiar territory to anyone working in psychiatric services. There is of course a need for specialised units, but typical outpatient clinics do not have enough specialised personnel to perform all the required examinations. Moreover, any such examinations would typically end up being overly comprehensive relative to other psychiatric diagnosing processes, resulting in very long queue times.
These disorders are among the most common problems we face across all psychiatric services. ADHD was significantly more common than depression among the young adult patients who participated in my study. In light of this, not letting all formally qualified personnel assist in examinations is bound to create bottlenecks across our health care services, as well as queue times long enough to jeopardise patients’ health. Unfortunately, that is exactly the situation that many places across the country are in today. So, how well did our clinic manage to integrate ESSENCE after re-structuring our services? When I started at Liljeholmen in 2015, queue times were over two years long. Today, almost four years later, with every psychologist and doctor actively involved in the process, queue times are down to about one to two months.