Organisation and Delivery of Psychiatric Services

Question 1

Goldberg & Huxley (1992) - Levels and filters model of the pathway to psychiatric care

Answer 1

Level 1. The community. 260-315 per 1000
Level 2 Primary care total) 230 per 1000
Levels 3 Primary care (conspicuous). 101 per 1000
Level 4 Psychiatric opt care. 23 per 1000
Level 5 Psych inpatient care 6 per 1000

Question 2

Service-based recovery definitions

Answer 2

symptom remission
being out of hospital
living independently
being involved in work or school

Question 3

User-based recovery definitions

Answer 3

overcoming the effects of being a patient in mental healthcare
establishing a fulfilling, meaningful life with positive sense of identity
process of personal discovery of how to live with enduring symptoms

Question 4

Model of prevention (1st attempt)
Person
Year

Answer 4

Caplan

1960

Question 5

Caplan’s model - primary prevention

Answer 5

intervening before a problem exists
aims to reduce incidence of an illness, directed at those at risk
subdivided into universal, selective and indicated prevention
e.g. prophylactic use of antipsychotics for sub-syndromal schizophrenia

Question 6

Caplan’s model - secondary prevention

Answer 6

aims to detect and treat disease that has not yet become symptomatics and therefore to lower the rate of established cases of the disorder
aims to lower prevalence of disease, through early detection and treatment
E.g. screening procedures

Question 7

Caplan’s model - tertiary prevention

Answer 7

Care of established disease with attempts to restore highest finction, prevent complications, minimise negative effects
aime to reduce disability
E.g. use of lithium to prevent episodes of mania in pts with bipolar disorder

Question 8

Prevention - Institute of Medicine

Answer 8

1992

Prevention redefined - only those interventions used before the initial onset of disorder

Question 9

Universal prevention

Answer 9

General public or whole population - not identified as being individual risk
Advantage when cost is low, risk is low, its effective and acceptable to population
e.g. healthy eating and exercise

Question 10

Selective prevention

Answer 10

targets individuals whose risk of developing mental disorder is higher than average
may be imminent or lifetime risk
Most appropriate when cost is moderate and risk of negative effect is minimal or non-existent
e.g. support for socially isolated elderly people, programs offered to children exposed to risk factors

Question 11

Indicated prevention

Answer 11

Targeted to high risk individuals who are at a prodromal stage of illness
Reasonable if costs are high and even if the intervention entails some risk
e.g. low-dose atypical antipsychotic and CBT for pts with prodromal sx of schizophrenia

Question 12

ECT

Answer 12

Italy 1938
Ugo Cerletti first used

First line in: sev depression with

• attempted suicide
• strong suicidal ideas/plans
• life threatening illness
• stupor
• marked psychomotor retardation
• depressive delusions or hallucinations

2nd or 3rd line in other depressive illness unresponsive to antidepressants

Question 13

ECT (NICE)

Answer 13

Used when other treatments have been ineffective and/or when the condition is potentially life-threatening in individuals with:

• severe depression
• mod depression (only if depression has not responded to multiple drug treatments and psychological treatment)
• catatonia
• a prolonged or severe manic episode
• NOT in schizophrenia
• NOT recommended as maintenance for depression

Question 14

ECT - drugs that reduce seizure duration

Answer 14

benzos - avoid

anticonvulsants - may need higher stimulus

Question 15

ECT - drugs that increase seizure duration

Answer 15

TCAs (possibly) - avoid in those with cardiac disease and elderly (risk of arrthymia)
Lithium (possibly)
Clozapine and phenothiazines (limited data)

Question 16

Neurostimulation

Answer 16

Involves use of electromagnetic energy targeted at the brain

• TMS
• Deep brain stimulation
• ECT

Question 17

TMS - what is it and how is it given

Answer 17

Neuromodulation
non-invasive, non-convulsive technique used to stinulate neural tissue
Stimulation can be single pulse or repetitive (rTMS)
A small insulated electromagnetic coil is placed on the patient’s scalp - left DLPFC (Brodmann 9+46)

Question 18

TMS - indications

Answer 18

unipolar treatment resistant depression without psychosis
Daily sessions for 4-5 days a week for 4-5 weeks
Approved by NICE in 2015

Question 19

TMS - contraindications

Answer 19

• history of epilepsy or organic brain pathology
• sleep deprivation
• acute alcohol-dependence syndrome
• use of drugs that significantly reduce the seizure threshold
• severe or recent heart disease
• presence of cochlear implant or cardiac pacemaker (or other magnetic material)

Question 20

TMS - side-effects

Answer 20

• seizure induction
• transient acute hypomania
• syncope
• transient headache
• neck pain and local discomfort
• transient hearing changes
• transient cognitive changes

Question 21

rTMS - outcomes

Answer 21

produces 3 times higher short-term response rates

5 times higher short-term remission rates compared to sham

Question 22

DBS

Answer 22

neurosurgical
place an electrode within the brain to deliver a high-frequency current in a specific subcortical or deep cortical structure
Used to treat Parkinson's in 1987
OCD and Tourettes in 1999
In OCD - main target is striatal region

Question 23

CPA

Answer 23

1991
4 main parts:
1. Assessment
2. A care plan
3. A key worker (CC)
4. Regular review

2 levels: standard and enhanced

Question 24

Measures of deprivation

Answer 24

• Jarman score (initially for GP workload measure)
• Townsend Index (material measure)
• Carstairs index (material measure)
• Index of multiple deprivation
• Index of local conditions

Question 25

Human Rights Act

Answer 25

1998 - incorporated rights contained in the European Convention on Human Rights into UK law

Question 26

Human Rights (1)

Answer 26

The right to life
• Freedom from torture and degrading treatment
• Freedom from slavery and forced labour
• The right to liberty
• The right to a fair trial
• The right not to be punished for something that wasn’t a crime when you did it
• The right to respect for private and family life
• Freedom of thought, conscience and religion, and freedom to express your beliefs

Question 27

Human Rights (2)

Answer 27

Freedom of expression
• Freedom of assembly and association
• The right to marry and to start a family
• The right not to be discriminated against in respect of these rights and freedoms
• The right to peaceful enjoyment of your property
• The right to an education
• The right to participate in free elections
• The right not to be subjected to the death penalty

Question 28

Gillick competency and fraser guidelines

Answer 28

used to assess whether a child has the maturity to make their own decisions and understand implications

Question 29

Fraser guidelines

Answer 29

It is lawful for doctors to provide contraceptive treatment without parental consent provided that:
the young person will understand the professional’s advice
• the young person cannot be persuaded to inform their parents
• the young person is likely to begin, or to continue having, sexual intercourse with or
without contraceptive treatment
• unless the young person receives contraceptive treatment, their physical or mental
health, or both, are likely to suffer
• the young person’s best interests require them to receive contraceptive advice or
treatment with or without parental consent

Question 30

Count me in Census

Ethnic variation

Answer 30

introduced in 2005

• 23% of all inpatient and those on CTOs were from black and ethnic minority groups
• Black minority groups had higher rates of admission
• Higher rates of detention for black minority groups
• Higher than average rates of seclusion for black minority groups

Question 31

Count me in Census (explanation)

Answer 31

Patient factors - higher rates of mental illness in certain groups. perceptions of certain ethnic groups being at greater risk

System factors - inherent racism