Literature Flashcards
Relapse rates of MDD within 12 months of ECT cessation in TR MDD
50%
Lithium in TR MDD
Adjuvant agent best supported by clinical trials for use
Rasmussen KG 2015
Lithium for post ECT depressive relapse prevention
?optimal target blood level,
duration of use and concomitant antidepressant use
Decriminalisation of mentally ill in terms of EEO. The problem with EEA
Paul Brown AP 2015 The current decriminalisation is the term which I apply to the relatively novel practice of police officers (and ambulance officers) who, under various state mental health acts, deposit the dangerously mentally ill at emergency departments. The point about the EEO is that it is a first-order solution to a problem that requires a second-order solution. The latter is usually couched in economic terms. Meantime, the police are currently the arbiters of diagnosis of much mental illness. Perhaps we should be providing them with more training?!
Kerry Dawes re medical students in private practicw
Interestingly, we found that those students placed in the private facility reported a much more positive view of psychiatry as a profession and a more optimistic outlook for those with mental health problems than those placed in the public sector. This is an area that needs further evaluation. Reference 1. Galletly CA, Turnbull C and Goldney R. Medical student teaching in the private sector – An overlooked opportunity? Australas Psychiatry 2016; 24: 198-200.
AP polypharmacy
Antipsychotic polypharmacy (APP), the concurrent use of two or more antipsychotics, is generally debated, discouraged and still likely implausible. It implies total higher-than-required D2 blocking doses (>60% for antipsychotic efficacy) with: •• Lack of evidence base •• Greater side-effects burden •• Possible drug interactions •• Jeopardizing treatment adherence •• Added costs.
Patrick et al.1 reviewed the literature and found three out of four double blind studies, and nine out of 13 open-label trials showing combination therapy was effective in reducing symptomatology ostensibly in clozapine partial responders.
As Goff and Dixon4 put it, polypharmacy
does not produce side effects;
it is the specific drugs and doses that
matter.
A meta-analysis of 19 studies by Correll and Gallego3 found a significant advantage for antipsychotic polypharmacy relative to monotherapy as regards efficacy and all-cause discontinuation, notably when clozapine was included and when used simultaneously rather than sequentially
It then behooves clinicians to neither refrain from APP nor to have an allopathic compulsion to go for heroic combos from the outset. Sound clinical judgment/acumen would dictate when APP might be well reasoned, and as Stahl famously put it: ‘never say never but never say always!’
Development of community care unit
The process of deinstitutionalisation across the
developed world began in the 1950s leading to
downsizing and closing of asylums.1
In Victoria,
non-governmental organisations (NGOs) managed halfway
houses or hostels built to allow patients discharged
from such asylums to adapt to living in the community.
A 10-bed residential rehabilitation unit separate to the
halfway houses or hostels with 24 hour on-site clinical
staffing was established in 1988. This became the
state’s first community care unit (CCU). Over time several
CCUs were established as part of Australian mental
health strategy (1992).
They were developed as purpose
built cluster housing developments, modelled on the
concept developed in the United Kingdom of locating
the ‘ward in the community’.
There has been limited research into CRCs, and of CCUs, since the deinstitutionalization period. Comprehensive evaluation of the processes and outcomes of these services is needed to guide best practice.
Recovery approach
“gaining and retaining
hope; understanding of one’s abilities and limitations;
engagement in an active life; personal autonomy; social
identity; meaning and purpose in life; and a positive
sense of self.” NSW consumer advisory group 2009
Recovery focus is about strengths based and wellness oriented approach. Enable people to live meaningful lives in the community
The key principle underlying the model of care is to
place the consumer at the centre, and recognise the
unique physical, emotional, social, cultural and spiritual
dimensions of each individual and empower and support
them to make decisions about their treatment and
recovery. The concept of increased patient autonomy as
part of recovery-oriented care has required a whole new
staff culture to be created.
Application for research
Research projects require review of both ethical and
scientific acceptability, and compliance with local
research governance prerequisites. For the former,
either the Application Form for Ethical and Scientific
Review of Low and Negligible Risk Research (LNR) or
the National Ethics Application Form is used.
Contacting the Executive Officer of the Human
Research Ethics Committee (HREC) for advice regarding
appropriate selection of forms and HREC was
informative and easy.4 The LNR is used where the risk
to participants does not exceed inconvenience or discomfort
as formally defined.5 Low and negligible risk
research is eligible for expedited HREC review.
Research governance pertains to an institution’s consideration
of pragmatic issues such as experience of researchers
and accountability. A relevant Site Specific Assessment
form must be submitted to the research governance officer
of the participating institution. Approval from the
Scholarly Project Branch Training Committee (BTC) can
then be sought.
Pharmakokinetic and pharmacodynamic failures in TR schizophrenia
All of these aspects need to be factored in the differential diagnosis. Failure to do so might result in the hasty changes of medications to the detriment of patients.
Pharmakokinetic-> absorption, distribution, metabolism
Pharmacodynamic-> at receptor, supersentivity. Drug-drug interactions
Dopamine
supersensitivity has been tied to
substance use, social isolation, organicity and genetic polymorphisms. Pharmacodynamic
relapse might also be related to
antipsychotic tachyphylaxis with
continuous treatment
Aripirazole- high affinity, can displace other antipsychotics. Then acts like a partial agonist, reducing overall activity. May see a relapse.
Job satisfaction for psychiatrists Rostein et al 2017 AP
> 80% of respondents experienced overall job satisfaction
would like to see changed, participants raised issues
related to patient variety, administration, work hours,
workplace safety, training and job satisfaction. Some
respondents indicated a desire for increased variety in
patient diagnoses, more psychotherapy, research and
academic work. Excessive paperwork, including form
filling and meeting KPI (key performance indicator) targets,
was viewed negatively by many respondents who
saw these activities as detracting from clinical work. A
number of respondents indicated they would prefer
reduced working hours and less overtime, and a significant
number had concerns relating to safety in the workplace.
Safety was a particular concern in the acute public
sector. Training issues included limited choice of rotations
and diversity of experiences, length of training and
difficulties balancing service needs and training commitments.
“Too much work, too little time” number one stressor
stress of training examinations Rostein et al
For trainee psychiatrists
74.5% found examinations moderately/
extremely stressful and 88.1% of trainees found training
hurdles moderately/extremely stressful
It is imperative
for the College to continue its work towards optimising
the health and well-being of its members.
bullying in the workplace
In 2015 the Australian Medical
Association (AMA) revised their position statement on
workplace bullying and harassment and noted a ‘culture
of bullying and harassment that has, over time,
become pervasive and institutionalised in some areas
of medicine’.
Karasek’s model of job strain
Karasek’s model of job strain which considers the
balance between demands on the employee and their
degree of autonomy
work life balance for psychiatrsists Evans et al
Previous research has suggested that doctors have higher
rates of mental illness, marital dissatisfaction, substance
misuse, and suicide.8,10 It has been argued that medicine
is a “challenging career where a stoic work ethic is the
dominant culture, and personal needs are secondary to
the needs of both patients and employers.”11 However,
this ignores the fact that “a critical element contributing
to the stress that many conscientious doctors experience
is internal.”12 Our research demonstrated that both
internal and external factors impact on WLB.
Furthermore, past research shows that doctors find it
hard to seek help when ill.10 Thus, we can infer that
addressing stress and burnout in doctors is likely to be a
complex undertaking.
Kahneman D.
Blaming the external environment may be
more comfortable than reflecting on internal motivation
and thinking: “It is much easier, as well as far more
enjoyable, to identify and label the mistakes of others than to recognise our own.”
Reconciliation
Action Plan 2016–2018
The launch highlighted the importance of reconciliation and engagement with Aboriginal and Torres Strait Islander peoples, as well as the RANZCP’s continuing vision to contribute to the reduction of inequality in mental health outcomes for Aboriginal and Torres Strait Islander people.
neuromodulation techniques S Hussain 2017 AP
In summary, evidence is mounting regarding the validity
of the potential novel neuromodulation techniques.
Therefore, it is crucial to adopt a balanced strategy to support
research in neuromodulation and maintaining
healthy optimism. Furthermore, it is prudent to assert the
learnt morals from history to refrain from adopting a
defensive or reductionist attitude towards or against any
of these approaches in a way that restricts innovation and
further development of treatment modalities and deprives
patients from what can be life-saving treatments.
self-illusion psychotherapy Steve Stankevicius
Our usual experience of the self is an illusion. Rather than a discrete entity, it is a network of processes
that maintains apparent irreducible unity via alterations of perceptions, beliefs, intentions and memories
William James conceptualised the self as consisting
of two components: the minimal self (moment-tomoment)
and the narrative self (extended in time).
Indeed, illusion
is defined as “the perception of something
objectively
existing in such a way as to cause misinterpretation
of its actual nature”.
Selfgenerating
elements, including memories, beliefs, intentions
and invariant representation, can be conceptualised
as the partial circles of the Kanizsa square illusion.
Memories support the self, but are also constrained and shaped by the self. Memory-self system
Invariant representation involves
cortical processes that shape our perceptions by constantly
creating predictions about what is coming next.
Since these predictions are formed by factors such as our
memories and emotional state, they are dependent on
the self, and in turn reinforce the self
Indeed, we should remember that
the forces of evolution by natural selection have not
necessarily favoured continually happy organisms, but
coherent beings able of constructing and executing an
aligned set of plans in order to survive and reproduce in
a hostile environment.
Cognitive dissonance can be utilised in psychotherapy
to achieve therapeutic gains. For example, behavioural
therapy encourages a patient to repeatedly act in a way
that contradicts self-orientated beliefs; discordance that
motivates revision of incongruent beliefs
Early findings from diffusion tensor
imaging and functional magnetic resonance imaging
studies have shown that some forms of psychotherapy
and mindfulness result in significant changes in white
matter and functional network efficiency of the brain
The self is an illusion from neuroscientific, philosophical
and experiential perspectives. Rather than a unitary
and pervading inner subject of thought and experience,
it is a complex network of perceptions, beliefs, intentions
and memories. Though it is an illusion, the self
provides a “center of gravity” around which these facets
are moulded to maintain individual coherence.23 This
unity allows one to experience, predict and interact with
the world efficiently.
conversational model psychotherapy Korner et al
Conversational Model Therapy remains an important evidence-based option in fostering recovery
and growth for many patients with traumatic disruptions and restrictions of self. It is one of an emerging group of
relational psychotherapies, broadly reflecting a change from a one person to a two person (intersubjective) psychological
paradigm in psychotherapy.
Russel Meares
It has demonstrated
maintenance of progress with long-term followup;
6,7 replication of findings with a different cohort;8
and cost-effectiveness
sustained improvement has been demonstrated
five years after completion of therapy
The essential forms
of intervention are seen to be analogues of a healthy
developmental relationship and involve the communicative
responses of ‘coupling’ (staying close to what is given
by the patient); ‘amplifying’ (building on what is most
alive); and ‘empathic representation’ (sharing what has
been understood in a tentative, collaborative way that
gives priority to the patient’s view). Where a patient is
engaged with the therapist in a medium- to long-term
therapy, the therapist will contribute to disjunctions and
will need to work on repair, which, if done adequately, is
often an opportunity for therapeutic growth
Suckling infant Henry moore
From 1920 onwards, Moore deconstructed the Palaeolithic
Venus figurines, before moving to the mother–infant
motif – a fundamental obsession throughout
his life.5 His
confronting sculpture Suckling Child (1927) intuitively
captures the essence of Klein’s theories, visually evoking
the ‘paranoid schizoid’ position. Suckling Child is a baby’s
perception of the mother as breast only (part object) existing
for the baby’s immediate gratification. The mother
(whole object) is almost obliterated (Figure 2).
Psychotherapy registrar position
This psychotherapy registrar position is a novel role that provides an opportunity to work in an intensive
and sustained way with patients and within multidisciplinary teams whilst being supported by supervision and
a rich teaching milieu. It offers experience of psychotherapeutic work not usually available in public mental health
services. It thus assists the development of psychotherapeutic skills that are likely to enhance the future practice of
those undertaking the role.
concept of mental wealth
The term was coined by
Beddington and colleagues,1 who showed that economic
and social capital builds to a peak in early adult
life. Seventy-five per cent of mental illness emerges
prior to or during this period and poses the greatest
threat to economic and social development of nations.
So prevention, early intervention and effective treatment
for children and emerging adults are the keys to
safeguarding ‘mental wealth’.
We continue to suffer
from serious underinvestment in direct and proactive
mental health care, and this is costing the Australian
economy tens of billions annually through huge downstream
productivity and welfare costs.
Implementation science is concerned with the translation
of the best currently available evidence into clinical
practice. The evidence-based
paradigm has been misused by vested interests through
the tactic of raising the bar and demanding ever-perfect
evidence to block an overdue reform.
This is otherwise
known as ‘clutching at flaws’. Reform can never depend
on perfect evidence. The perfect is the enemy of the
good and so we must make decisions now on the best
available evidence, and just as importantly know how to
implement these decisions in the face of inertia, discrimination
against mental health in funding allocations,
and predictable undermining by vested interests. What
is clear is that the ‘right’ reasons, such as relieving suffering,
reducing disability and the logic of making the latest
scientific advances available to patients in a reliable
and equitable manner, are necessary, but nowhere near
sufficient.
impact of headspace Pat McGorry
So
headspace represents a new entrance hall and front
room of our health system, not a total solution. For full
effect and to transform outcomes, prevention and early
detection programs, novel, technology-assisted ‘onramps’,
and the addition of other spaces in the building,
where more specialized expertise can be accessed, need
to be built. The advent of headspace has further exposed
the latter gap. This is preventing the waiting list for specialized
care being hidden or denied, and will force state
and federal governments to fund this gap.
In 10 years,
more than 270,000 young Australians have received help
and treatment through headspace services. The report
was overwhelmingly positive and highlighted significant
successes achieved by headspace, and top of the list was
the improved access, engagement and satisfaction.
The ‘soft entry’ approach of headspace favours
simple solutions with minimal professional input for
those who do not need this. It also means that those with
emerging complex disorders can be fast tracked into
stepped care and preemptive care
