Magical thinking and moral injury: exclusion culture in psychiatry.

SUMMARY: This is an article about exclusion. We might not like to admit it - even fail to realise it - but National Health Service (NHS) mental health service structures have become increasingly focused on how to deny people care instead of help them to access it. Clinicians learn the art of self-delusion, convincing ourselves we are not letting patients down but, instead, doing the clinically appropriate thing. Well-meant initiatives become misappropriated to justify neglect. Are we trying to protect ourselves against the knowledge that we're failing our patients, or is collusion simply the easiest option? Problematic language endemic in psychiatry reveals a deeper issue: a culture of fear and falsehood, leading to iatrogenic harm. An excessively risk-averse and under-resourced system may drain its clinicians of compassion, losing sight of the human being behind each 'protected' bed and rejected referral.

Intramuscular levothyroxine: a solution to a mental health related thyroid crisis.

A 53-year-old woman was admitted with thyroid storm and severe behavioural problems. She had longstanding bipolar affective disorder. She was psychotic and obstructed in-patient medical management for thyroid storm. She required one-to-one psychiatric nursing and was placed under section 3 of the Mental Health Act meaning she could be detained in hospital for psychiatric treatment for up to 6 months. She underwent a total thyroidectomy. Due to her paranoid mental state, she refused treatment and the administration of thyroid hormone replacement was difficult. Postoperatively, intramuscular levothyroxine was used effectively to stabilise her thyroid function. There are no consensus guidelines on the use of parenteral levothyroxine and intramuscular levothyroxine is rarely used. This case uniquely illustrates its utility with bi-weekly blood tests showing a fast and stable response to intramuscular hormone replacement.

'The patient is medically cleared'.

It is standard practice for psychiatric nurses and junior doctors working in emergency departments to ask that patients be 'medically cleared' before psychiatric admission or even assessment. However, there is a lack of agreement over what this process should entail.