First Psychiatry Job as Junior Doctor

This guide aims to signpost junior doctors towards useful resources when starting their first post in Psychiatry. This document is largely a reflection of my own experience and one can appreciate there are huge variations in working patterns in mental health teams across the country. Therefore, I must point out that this does not replace your local protocols and guidelines in any way.

Before starting your first post in Psychiatry you can do a number of things to improve your understanding of Psychiatry as a specialty. It is of great importance to develop good psychiatric history taking skills as well as sound knowledge of common psychiatric conditions. Understanding of management principles in relation to psychiatric emergencies and of the Mental Health Act. Access to a basic guide such as the Oxford Handbook of Psychiatry is a good start for beginners.

Attending your trust induction is important, unfortunately, some of the non-training jobs are only available at staggered times across the year resulting in doctors missing the main induction.

Gather information about your local trainee representative and senior core trainees and meet them before your start date. Find out if there is a Trainee peer network as this can be excellent support for new doctors.

Psychiatry History Taking and Mental State Examination:

History taking and mental state examination are basic skills for psychiatry junior doctor. Your trust may be using a standard format or forms (paper or computer) for psychiatry history taking and you should familiarise yourself with the local protocols.

As a general guide, you can use this resource below to understand the basic principle of psychiatry history taking.

Mental state examination (MSE):

Before starting your job in psychiatry, you should also familiarise yourself with the basic principles and format of MSE. It is an assessment of the individual’s current state of mind. It assesses the range, quality, and depth of perception, thought processes, feelings, and psychomotor actions. Direct observation of the individual is required for the completion of the MSE.

Click to access mentalstatusexam11.pdf

NICE Guidelines:

The National Institute for Health and Care Excellence (NICE) UK provides national guidance and advice to improve health and social care. These guidelines are free to access and readily available online.

A variety of guidance relating to mental health conditions can be found on the NICE website. These are also very helpful in understanding the principles behind the treatment of common mental health conditions.

Please study the guidelines on common psychiatry conditions like depression, anxiety, self-harm, bipolar affective disorder, schizophrenia, personality disorders, and dementia.

Maudsley Prescribing Guidelines:

These guidelines are updated on regular basis using research evidence base. They are very useful not just for clinical practice but also for MRCPsych examination preparation.

Currently, the 13th version of Maudsley Prescribing Guidelines is available and can be bought from leading medical bookstores or online. Most hospital libraries will stock this if you are unable to purchase a copy. It is worth having your own copy as you will use it regularly.

Medications and treatments to be aware of before starting:

  • Anti-depressants (different groups)
  • Anti-psychotics
  • Treatment regime for psychosis, schizophrenia and bipolar affective disorders 
  • Lithium carbonate (Indication, titration, side effects, toxicity, and monitoring protocol)
  • Clozapine: (Indications, titration, side effects, and monitoring)
  • CBT and other forms of psychotherapies
  • ECT

Maudsley Prescribing Guidelines will give you a good overview but please also explore NICE guidelines and your local guidelines and protocols.

Diagnostic criteria for Psychiatric illnesses:

There are two main diagnostic criteria used for psychiatric illness.

DSM-5 (published by American Psychiatric Association)

This is available in book format which you need to again purchase or borrow from the  library.

ICD-10 (chapter 5) – Published by WHO and available free online

Please find out which diagnostic criteria your team is using more routinely and familiarise yourself with the diagnostic guidelines for the common psychiatric conditions.  

ICD-11 version is work under progress and will most likely replace ICD-10 in the future.

Basic understanding of Mental Health Act (MHA):

It is essential that you have a basic understanding of mental health act, your powers as a junior doctor and rights of patients.

I suggest reading section 5(2), Section 5(4), section 2, section 3, section 136, section 135 and CTOs (Community Treatment Orders).

This website of Lancashire care NHS trust gives good information and video clips explaining the basics of mental health act in England and Wales.

Your trust may have local section 5(4)  and 5(2) guidelines. Please read them.

General Adult Wards:

Psychiatry wards work in different ways and you need to familiarise yourself with local protocols. General duties of junior doctor may include

  • Clerking new patients, arranging routine bloods, ECG and physical examination.
  • Conducting ward reviews and ward round with seniors
  • Participation in the ward meetings
  • Reviewing patients requiring urgent medical or psychiatric attention.
  • Liaising with community teams and families.
  • Liaising with medical colleagues or other specialist if required.
  • Preparing discharge summaries and arranging follow ups.

A fair understanding of commonly used psychotropic medication used for common psychiatry conditions and on PRN basis is required.

Psychiatry ward rounds are conducted in various different formats and they differ from medical or surgical ward rounds. I highly recommend junior doctors to review patients expected to be discussed in the ward rounds a day before the actual ward round if possible, record the current mental state and the general progress of the patients and present the case to seniors, by doing this you will start actively participating in the ward rounds from the very start.

It is essential to be able to recognize signs of sepsis and rapidly deteriorating patient on a psychiatric ward and understand the protocols to escalate your concerns.

Old Age psychiatry wards:

Generally speaking, there are two kinds of old age psychiatry ward,

  • Wards for functional illness (like depression, anxiety, psychosis).
  • Dementia assessment and treatment wards.

Functional wards work more or less in the same manner as adult psychiatry ward but older adults may have a complex physical health history and may require closer monitoring of their physical health.

Dementia assessment and treatment wards may work differently. You are still required to carry out normal ward duties as mentioned above but you need a better understanding of

  • Mental capacity act, DOLS (Deprivation of Liberty Safeguards)  
  • Cognitive assessments and cognitive assessment tools.
  • Various type of dementia
  • Treatment principles for behavioral symptoms of dementia
  • How to identify and differentiate between delirium vs dementia
  • Common causes of delirium in elderly
  • Principles of end of life care (EoL)
  • Falls on inpatients wards and protocols to follow especially if the patient is on anticoagulants

It is common for elderly patients on psychiatric wards to become medically unwell and may lead to health complications. You should familiarise yourself to protocol and referrals in relation to physical health concerns in psychiatry patients. It will be handy to familiarise yourself with local guidelines and protocols for common presentations such as inpatient falls, urinary tract infections (UTI), hospital-acquired lower respiratory tract infection (LRTI) and cellulitis.

It is essential to be able to recognize signs of sepsis and rapidly deteriorating patient on a psychiatric ward and understand the protocols to escalate your concerns.

Community Teams:

There are huge variations across the country and within subspecialties of psychiatry on how community teams function and their titles. They may be called

  • Crisis resolution home treatment team (CRHTT)
  • Home treatment team (HTT)
  • Community mental health team (CMHT)
  • Assertive outreach team (AOT)
  • Early intervention team
  • Memory team (relating to dementia assessment, dialogises and support)

Familiarise yourself with your local community team structure and functioning as even when you are working on a psychiatry ward based job you will liaise with community teams on a regular basis.

Work out of Hours:

Psychiatry on-call patterns and structure varies across the country. You need to understand your local working shift patterns and protocols. If this is your first NHS job, if possible, arrange some shadowing of on-call with a senior trainee.

During psychiatry on-calls, you will deal with psychiatry emergencies which may include

  • Self-harm attempt or risk assessment
  • Suicidal  attempt or risk assessment
  • Emotionally unstable personality presentations
  • Severe depression or mood disorder related presentation  
  • Acute psychotic symptoms or manic episode
  • Severe behavioral disturbance
  • Severe anxiety, anxiety spectrum disorders
  • illicit drugs or alcohol-related issues
  • Behavioral symptoms of dementia 

Find out about local policies and protocols on alcohol detoxification, rapid tranquilization, section 5(2) and escalating concerns to seniors.

Don’t ever hesitate to ask for help when you are not sure.

Psychiatric urgent situations to be aware of:

Neuroleptic malignant syndrome (NMS)

Serotonin syndrome

Delirium Tremens: Alcohol-use disorders: diagnosis and management of physical complications.

The following link is a guideline example is from a trust in Wales.

Please find your local guidelines on the same topic. 

Click to access alcohol%20detox%20guideline%20-%20whole%20UHB.pdf

Other protocols to be familiar with are recognition and management of Lithium toxicity, patients absconding from the ward, self-harm or suicidal attempts on the ward.

Balint Groups and local post grad teaching activities:  

Psychiatry core trainees attend regular Balint groups and as a psychiatry junior doctor, you may be asked to attend them as well.

This blog post explain the basics of Balint Group.

Attend and participate in the local educational activities as much as you can. Most places psychiatry training attend MRCPsych related courses and explore if as a non-training doctor you can attend the same teaching.

Learning needs and continuous professional development:

Identify your learning needs very early in the process, document them and discuss them with your clinical and educational supervisor. Explore various ways to meet your learning needs and work on to improve your skills on regular basis. Make a habit of writing reflections and learn from all interesting interactions.

This blog post is an example of a CT-1 level Personal Development Plan (PDP). Make your own PDP and find ways to achieve your goals.

Further Helpful Readings:

Suicidal risk assessment examples:

Rapid Tranquilisation Policy example:

Please find your local one, this is just an example

Click to access Rapid-Tranquilisation-Policy.pdf

RCPsych leaflets on mental health conditions.

National Centre for Mental Health (NCMH) information about mental health conditions and medications:

Assessment of Cognition:

The practical toolkit is very useful and is supported by Alzheimer’s Society and Department of Health.

Click to access alzheimers_society_cognitive_assessment_toolkit.pdf