Management of Mental Illness Flashcards
Factors in the biopsychosocial model
-Genetic predisposition
-Biological vulnerability
-Biological alterations in brain functioning
=Symptoms and signs
-Early adverse experiences
-Personality/ temperament
-Traumatic/ adverse life events
-Social circumstances
-Alcohol/ substance misuse
-Physical illness
What levels can interventions be made at?
-Biological:
=Aetiology – contributory biological factors can include physical conditions, prescription medications, substance misuse etc…
=Management – usually refers to pharmacological treatments
-Psychological:
=Aetiology – contributory psychological factors can include psychiatric conditions, trauma, learned behaviours, personality etc…
=Management – spectrum from relaxation, mindfulness, counselling, range of psycho / exposure / behavioural therapies
-Social:
=Aetiology – contributory social factors can include poor social support, role models, finance, occupation, housing, relationships, substance misuse etc…
=Management – many social issues can be managed through 3rd sector agencies
Examples of 3rd sector agencies
-Citizens advice for debt and many other things
-Drugs and alcohol: turning point, recovery hub, AA/CA/NA, Al Anon
-Gambling: GA
-Self-harm: Penumbra
-Relationship counselling: Relationships-Scotland
-Accommodation: Access Point
-Studies: personal tutor, university counselling
-https://edspace.org.uk/
What is formulation and what does it include?
-Term used by psychiatrists to describe the integrated summary that helps explain a particular patient’s problems in context
=Description of patient
=Differential diagnosis
=Aetiology
=Management
=Prognosis
Describe description of patient
-Usually in the form of a case summary:
=Identifying information
=Main features of PC
=Relevant background (psychiatric Hx, PMH and FH)
=Positive findings in examinations(MSE and physical)
Describe differential diagnosis
- Schizophrenia
-For: symptoms present for more than 1 month, ICD-10 and first-rank symptoms of delusions of control or passivity (thought insertion): delusional perception; and third person running commentary, hallucination, clear and marked deterioration in social and work functioning - Schizoaffective disorder
-For: typical symptoms of schizophrenia
-Against: no prominent mood symptoms - Mood disorder (manic or depressive episode) with psychotic features
-Against: on MSE, mood mainly suspicious secondary to delusional beliefs, no other prominent features of mania or depression, mood-incongruent delusions and hallucinations - Substance-induced psychotic
-Against: long duration of symptoms, no evidence of illicit substance or alcohol use - Psychotic disorder secondary to medical condition
-Against: no signs of medical illness or abnormalities on physical examination
Describe aetiology
-Predisposing factors
=What made the patient prone to this problem?
=Biological: FHx schizophrenia
-Precipitating
=What made this problem start now?
=Biological: peak of onset for schizophrenia men 18-25
=Social: break up of relationship, recently started college
-Perpetuating
=What is maintaining this problem?
=Biological: poor concordance with medication due to lack of insight
=Psychological: high expressed emotion family
=Social: lack of social support
Describe management
-Immediate to short-term
=Biological: antipsychotic medication, with benzodiazepines if necessary
=Psychological: establish therapeutic relationship, support for family (carers)
=Social: admission to hospital, allocation of care coordinator (care programme approach), help with financial, accommodation and social problems
-Medium to long term
=Biological: review progress in out-patient clinic, consider another antipsychotic then clozapine for non-response, consider depot medication for concordance problems
=Psychological: relapse prevention work, consider CBT and family therapy
=Social: regular review under care programme approach, consider day hospital, vocational training
Describe prognosis
Depends on:
-Natural course of condition (predicted based on patient studies)
-Individual patient factors (social support, compliance, comorbid disease or substance misuse)
Describe Step 1 in stepped care model
Prevention and promotion
-Support that can be utilised before approaching health or social services:
=friends and family;
=self-help, spiritual advice;
=self-help groups;
=occupational advice;
=national and local mental health organisations;
=telephone helplines;
=advice agencies;
=welfare rights;
=housing;
=employment;
=leisure services;
=carer support.
Describe step 2 of the stepped care model
-Recognition in Primary care
‘Watchful waiting’…with further assessment; self-help; guided self-help; expert advice; short-term (distress) brief interventions; signposting to /mobilising resources outlined in Step 1
Describe step 3 of stepped care model
-Assessment/ Primary care intervention
Mental Health Assessment; short term psychological interventions; physical health checks; medicine review; computerised CBT; social prescribing; signposting to / mobilising resources outlined in Step 1
Describe step 4 of stepped care model
-Secondary/ Specialist services
=Comprehensive specialist assessment (General Adult, Addictions, Liaison, ID,CAMHS, Older Adult, Forensic, Psychotherapy); specialist services based in the community or outpatient clinics – e.g. crisis/home treatment, early intervention, assertive outreach, eating disorder services, ADHD, perinatal, rehabilitation; formal measures under the Mental Health (Scotland) Act (e.g. patients on community-based orders); more complex care coordination (possibly using the Care Program Approach); supervision of risk/relapse management plans; crisis accommodation.
Describe step 5 of the stepped care model
-Specialist services
=Range of assessment and treatment in-patient services working with high risk, complex patients requiring specialist interventions; use of powers under the Mental Health (Scotland) Act & Adults with Incapacity Act; high level of care coordination/risk relapse management (may be possible in some crisis / home treatment teams)
Describe the role of the primary care service in mental health
-95% of mental illness is managed by Primary Care alone.
-The most common disorders are mild-moderate mood and anxiety disorders, and alcohol misuse.
-Note, around 50% of all mental illnesses can go undetected in primary care due to patients only describing the physical symptoms (reluctant to discuss emotional issues – stigma, embarrassment)
-Primary Care Liaison Teams are available in some areas to act as a single point of contact for a GP to refer to if they feel secondary services may be required – referrals are assessed and referred on to psychiatric, psychological, Community Mental Health Team (CMHT), Occupational Therapy (OT), or Social Work services as appropriate
Reasons for referral to secondary mental health services
-Moderate to severe psychiatric illness (e.g. severe depression or anxiety disorder, bipolar, schizophrenia)
-Patient poses a serious risk of harm to themselves or others
-Uncertainty regarding diagnosis
-Poor response to standard treatments (despite adequate dose and compliance)
-Specialist treatment required (e.g. psychological therapy, specialistmedication regimes)
Types of secondary care services
-Community mental health teams
=Multidisciplinary team
-Care programme approach
=Assess, care plan, care coordinator
-Outpatient clinics
=GP practice, CMHT centres, hospitals
-Liaison psychiatry
=Hospital, self-harm, suicide
-Day hospitals
=Alternative to inpatient
-Assertive outreach teams
=Similar but more intensive CMHT
-Crisis teams
-Early intervention in psychosis teams
-Inpatient units
=High risk of harm to self or others
-Rehabilitation units
-Accommodation
