Organisation and Delivery of Psychiatric Services Flashcards
Goldberg & Huxley (1992) - Levels and filters model of the pathway to psychiatric care
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
Service-based recovery definitions
symptom remission
being out of hospital
living independently
being involved in work or school
User-based recovery definitions
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
Model of prevention (1st attempt)
Person
Year
Caplan
1960
Caplan’s model - primary prevention
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
Caplan’s model - secondary prevention
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
Caplan’s model - tertiary prevention
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
Prevention - Institute of Medicine
1992
Prevention redefined - only those interventions used before the initial onset of disorder
Universal prevention
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
Selective prevention
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
Indicated prevention
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
ECT
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
ECT (NICE)
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
ECT - drugs that reduce seizure duration
benzos - avoid
anticonvulsants - may need higher stimulus
ECT - drugs that increase seizure duration
TCAs (possibly) - avoid in those with cardiac disease and elderly (risk of arrthymia)
Lithium (possibly)
Clozapine and phenothiazines (limited data)
Neurostimulation
Involves use of electromagnetic energy targeted at the brain
- TMS
- Deep brain stimulation
- ECT
TMS - what is it and how is it given
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)
TMS - indications
unipolar treatment resistant depression without psychosis
Daily sessions for 4-5 days a week for 4-5 weeks
Approved by NICE in 2015
TMS - contraindications
- 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)
TMS - side-effects
- seizure induction
- transient acute hypomania
- syncope
- transient headache
- neck pain and local discomfort
- transient hearing changes
- transient cognitive changes
rTMS - outcomes
produces 3 times higher short-term response rates
5 times higher short-term remission rates compared to sham
DBS
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
CPA
1991 4 main parts: 1. Assessment 2. A care plan 3. A key worker (CC) 4. Regular review
2 levels: standard and enhanced
Measures of deprivation
- Jarman score (initially for GP workload measure)
- Townsend Index (material measure)
- Carstairs index (material measure)
- Index of multiple deprivation
- Index of local conditions
Human Rights Act
1998 - incorporated rights contained in the European Convention on Human Rights into UK law
Human Rights (1)
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
Human Rights (2)
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
Gillick competency and fraser guidelines
used to assess whether a child has the maturity to make their own decisions and understand implications
Fraser guidelines
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
Count me in Census
Ethnic variation
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
Count me in Census (explanation)
Patient factors - higher rates of mental illness in certain groups. perceptions of certain ethnic groups being at greater risk
System factors - inherent racism