Safeguarding patient’s mental health

Safeguarding mental health has been more and more under the spotlight recently and with calls from the NHS for Superdrug to deliver tougher psychological wellbeing checks for patients, we explore the wider issues involved.

Last month Superdrug hit the news again after vowing to introduce additional mental health safeguards for patients undergoing cosmetic injectable treatments at its Skin Renew Service.

The move came after the health and beauty retailer received a letter from NHS England medical director Stephen Powis, who voiced concerns over the safety and ethics of the high street chain providing Botox and fillers. 

Powis first wrote to Superdrug chief executive Peter Macnab in September 2018, outlining his concerns and asking for reassurance that staff providing the injectable treatments would be appropriately trained to identify and screen out people with body dysmorphic disorder. 

It was then announced on January 19 that Superdrug had agreed to introduce the checks in the form of additional questions during each patient’s initial one-hour consultation. A spokesperson for Superdrug commented: “We remain fully committed to including recommended protections for mental health. We met with the NHS to ensure we have the highest safety standards and quality of patient care.

“We’ve always assessed a patient’s mental health as part of our Skin Renew consultation process. This assessment is woven through the consultation by our trained and qualified aesthetic nurse practitioners, whose experience and qualifications far exceed current standards.” 

But many practitioners are still concerned that offering such procedures in a high street store that also sells cosmetics and personal care items undermines their medical nature. Cosmetic doctor and hair restoration surgeon Dr Max Malik, who also holds a MRCPsych qualification, commented, “There are many potential problems with high street stores offering Botox and fillers. The obvious point is that it devalues medical treatments and puts them almost in the same bracket as buying lipstick or make-up. These are medical treatments and should only be performed by medically qualified and suitably trained professionals. This needs to be clearly enshrined in law. We have all seen what can go wrong if safety is not paramount. Those affected are often scarred for life.” 

Nofie Johnston who is an aesthetic nurse but also a qualified mental health nurse commented, “Our specialty needs now, more than ever, to rise to the challenge in ensuring we practice ethically. I would ask Superdrug which mental health conditions are they screening for? More than half of people aged 16 to 64 years who meet the diagnostic criteria for at least one common mental health disorder experience co-morbid anxiety and depressive disorders.There are ethical concerns regarding treatment of a person with a mental health condition that is not stable and the risk of psychological decompensation for certain diagnostic groups.

“I would also want to know, does the screening or assessment of body image dysphoria and other mental health conditions include more than a questionnaire and has sufficient time been given to the appointment for other aspects of a mental health assessment to be followed to accurately check the information provided in the questionnaire? And do the nurse practitioners have access to post-registration training in mental health or at the least have access to mental health colleagues who can provide supervision?” 

Aesthetic nurse Lou Sommereux, who also has a background in mental health, commented, “I don’t think Superdrug is the most appropriate place to have a clinic targeted at millennials however I applaud the proposed mental health questionnaire. Psychological and underlying mental health indications in the main are not addressed in most clinics. I think this must begin to be addressed as integral in initial consultations.”

THE WIDER DEBATE

The news has stirred a wider debate about the importance of safeguarding patients’ mental health and wellbeing within aesthetic practice. 

DRG Plastic Surgery, based in London’s Harley Street recently announced that it has taken on a specialist cosmetic surgery psychotherapist to help identify and safeguard patients who are approaching a major surgical procedure for the wrong reasons. 

Consultant plastic surgeon and co-founder of DRG Plastic Surgery David Gateley explained, “Those carrying out both surgical and non-surgical cosmetic procedures have a duty of care to their patients, not just in terms of how a procedure is delivered and the aftercare, but in terms of turning away patients for whom a cosmetic procedure is not appropriate. No one wins if surgery is undertaken for the wrong reasons, both the patient and surgeon will get their fingers burned. If the patient is unhappy the surgeon will be required to complete multiple follow up surgeries – and for those seeking a physical solution to a psychological problem these could be endless.

“Many surgeons and cosmetic practitioners believe their experience alone is enough to pick out patients that aren’t good candidates for surgery and some practices do use psychometric questions. But often it is a tick box exercise and surgeons do not have the psychological understanding to correctly diagnose inappropriate drivers which lie under the surface of patients’ answers. Sadly, some surgeons are also not willing to walk away from cases for commercial reasons. A much more integrated approach is needed with psychotherapists working in-clinic alongside surgeons to help identify and safeguard those at risk.” 

Plastic surgeon Mr Paul Banwell was one of the first to introduce psychological support on site at his clinic, The Banwell Clinic, back in 2015 when consulting psychologist and psychotherapist Gaylin Tudhope joined the team. This continues to be a key part of consultation and assessment before and after any procedure. He said, “We took the pro-active decision to introduce the service following the Keogh review, which identified the need for better regulation, training and professional support in the cosmetic surgery industry.” 

Malik added, “I believe the psychological aspect is one of the most important factors when offering any cosmetic procedure to a patient, whether it is a surgical face-lift, hair restoration surgery or an anti-wrinkle treatment. The most common complication in aesthetic medicine is not vascular occlusion or even lumps and bumps, it is, in fact ‘the dissatisfied patient’ by a huge percentage.

“I psychologically screen all my patients. I am fortunate in that I am also a psychiatrist, however, I do believe aesthetics requires higher levels of communication skills and understanding of the patient than many medical consultations.” 

Johnston added, “There has been a role for psychiatric or psychological assessment and evaluation prior to surgical treatments because there is an evidence base that indicates a significant proportion of patients seeking surgery have a mental health condition (see K Hayashi 2007, BAAPS 2006 etc). However in non-surgical cosmetic medicine, perhaps the temporary nature of the treatments and/or reversibility has potentially led clinicians to not apply the same rigour as surgical colleagues. Although GMC (2016) guidance clearly states to consider the psychological needs of the patient.

“Screening via a questionnaire is an efficient and discrete method of collecting information which assists with a mental health assessment. However, validated questionnaires and screening tools in cosmetic medicine inevitably focus on patients with dysmorphic views of their body. They are only as reliable as the information entered into them and also only form part of the assessment.”

RECOGNISING BDD

Aesthetic practitioners may be more likely to come into contact with patients with Body Dysmorphia Disorder due to its its association with fixation on appearance. 

Dr Steve Harris commented, “BDD is fairly common – up to 15% of aesthetic patients. It has been shown that aesthetic procedures lead to an exacerbation of BDD symptoms in the long run. Patients with BDD have significant comorbidity with severe depression and have an unusually high suicide rate so this is very worrying. They tend to be very dissatisfied with the outcome of aesthetic procedures and seek multiple revisions often involving multiple practitioners. When dissatisfied they can become aggressive and violent and are the most likely to sue their practitioner. As a general rule patients with BDD should never be treated with aesthetic procedures. They should always be referred for specialist care which will typically involve a combination of Cognitive Behaviour Therapy (CBT) and antidepressant (SSRI) medication. The prognosis in such cases is fair.”

Sommereux believes more training should be available for aesthetic practitioners in this area. She said, “Mental health and body dysmorphia are fortunately spoken about issues these days, however, I feel much more education and workshops are needed in the aesthetic arena. Not just in a foundation training but as part of our continual professional development. Patients with varying degrees of body dysmorphia are usually the red flag patients we all meet. My simple advice is don’t treat. There is a lack of standards in assessing mental health practitioners need to have the ability to recognise these issues. Aesthetic professionals with a mental health background have different skill sets to identify underlying issues and may have signposts for patients with recognised mental health issues. In my practice I am adjacent to a CBT center staffed by psychotherapists whom I can refer my patients to if I feel the intervention is needed. I would encourage others to source a similar pathway.”

Malik agrees and has developed a psychological complications course entitled ‘Your Psychological Aesthetic Consultation and The Patient Journey’, which he will soon be delivering for aesthetic practitioners. He said, “The course is designed to help us improve our psychological skills in aesthetic medicine so that we can pick up problems such as BDD, which are not always quite so obvious and in fact are often missed even in psychiatric clinics.

“I believe it is essential that we improve the quality of our practice of this in aesthetic medicine. When we understand the psychological importance of our consultation for our patients’ wellbeing, that is what will give us better outcomes, not only aesthetically but in the patients’ understanding and satisfaction levels. It is clear that the majority of complaints and legal actions revolve around communication, or a lack of clear communication. As practitioners we can minimise the risk of sleepless nights to us and increase patients’ satisfaction, if we adopt a more of a high-quality medical approach. Within this there is no scope or justification for high street medical treatments, these are simply bad or even dangerous for the public and bad for aesthetic medicine.” 

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