Organisation of services Flashcards
What is Primary Prevention?
Aim is to intervene before a disease or problem begins. It aims to reduce the incidence of an illness in the community, and is directed at individuals who are at risk for developing a particular disorder i.e. PREVENTS new cases
What are the subdivisions of Primary Prevention?
Universal, selective, and indicated prevention
What is an example of Primary Prevention?
Prophylactic use of antipsychotics for sub-syndromal schizophrenia
What is Secondary Prevention?
Aim is to detect and treat disease that has not yet become symptomatic and therefore to lower the rate of established cases of the disorder (REDUCES number of cases). This is achieved through early detection and treatment i.e. screening
What is Tertiary Prevention?
The care of established disease, with attempts made to restore to highest function, minimise the negative effects of disease, and prevent disease-related complications
What is an example of Tertiary Prevention?
The use of lithium to prevent episodes of mania in people with bipolar disorder
What is Universal Prevention?
Targeted to the general public or a whole population that has not been identified on the basis of individual risk. The intervention is desirable for everyone in that group.
When do Universal Prevention interventions have advantage?
- when their costs per individual are low
- when the the intervention is effective and acceptable to the population
- when there is a low risk from the intervention
What is an example of Universal Prevention?
School-based programs offered to all children to teach social and emotional skills or to avoid substance abuse
What is Selective Prevention?
Targeted to individuals or a population subgroup whose risk of developing mental disorders is significantly higher than average
When do Selective Prevention interventions have advantage?
- when the cost is moderate
- if the risk of negative effects is minimal or non-existent
What is Indicated Prevention?
Targeted to high-risk individuals who are identified as having minimal but detectable signs or symptoms foreshadowing mental, emotional, or behavioural disorder, or biological markers indicating predisposition for such a disorder, but who do not meet diagnostic levels at the current time
When might Indicated Prevention still be indicated?
- if costs are high
- if the intervention entails some risk
Who first came up with ECT?
Cerelleti and Bini
NICE recommend ECT first line for what in depression?
- emergency treatment depression when rapid definitive response required
- treatment resistant depression that has responded to ECT before
When may ECT be considered in depression?
- refusal of fluids and food
- high suicide risk
- stupor
- marked psychomotor retardation
- psychotic depression
- pregnancy if there are concerns about tetragenicity
When may ECT be considered in mania
- life threatening physical exhaustion
2. prolonged severe mania not responding to other drugs
When is ECT 2nd/3rd line in depresion?
When not responding to other antidepressants
When may ECT be considered in Schizophrenia?
4th line after failure of 2 antispsychotics and Clozapine
Apart from depression/mania/schizophrenia when else may ECT be considered?
catatonia - when benzos have proved ineffective
Parkinson’s - as an adjunctive treatment for motor, affective and psychotic symptoms
Neuroleptic malignant syndrome
Intractible seizures
Are there any ABSOLUTE contraindications for ECT?
No
What are the RELATIVE contraindications for ECT?
- Acute respiratory failure
- within 3 months of MI
- Uncontrolled heart failure
- cardiac arrhythmias
- within 1 month of CVA
- raised intracranial pressure
- untreated cerebral anuerysm
- intracerebral haemorrhage
- untreated phaeochromocytoma
- unstable major fracture
- DVT (until anticoagulated)
- acute/imprnding retinal detachment
- high anaesthetic risk
- pregnancy
Which type of ECT causes more cognitive impairment?
Bilateral ECT is more effective than unilateral ECT but may cause more cognitive impairment.
is there any significance of the number of ECT sessions a week?
No
but optimal treatment is 2x weekly for 6-12 sessions as a course
(if no improvement after first 6 sessions then unlikely to work)
What proportions of patients who undergo ECT have significant memory loss?
1/3
What are the early side effects of ECT?
- Headache (MOST COMMON) - 30% patients
- temporary confusion
- nausea/vomiting
- muscular aches
Does ECT cause structural brain damage?
No
Which type of amnesia can ECT cause?
Both anterograde and retrograde
- anterograde amnesia resolves rapidly when ECT is stopped
- patients more likely to be left with retrograde amnesia
What’s the relapse rate of ECT?
37.7% by 6 months, 51.1% by 12 months
so use of antidepressants after is important
Which category of antidepressants have most evidence for use after ECT?
TCAs
What work up is required for ECT?
- medical history including medications
- physical examination
- FBC
- CXR/ECG in some cases
Where is the electrode placement in bilateral ECT?
Center should be 4cm above and perpendicular to the midpoint of a line between the lateral angle of the eye and the external auditory meatus
Where is the electrode placement in unilateral ECT?
One in same place as bilateral, other over parietal scalp on non-dominant hemisphere
What has been shown to improve confusion and therefore recovery time following ECT?
Donepezil
What are the ECTAS guidelines for administration of ECT?
made by the Royal College of Psychiatrists
- A psychiatrist must be present during a treatment session
- ID bands are preferred but may not be worn if there is a significant issue with self-harm.
- The college recognises that there are clinics which can provide nurse administered ECT
- It is recommended that each patient is offered something to eat and drink before they leave the ECT suite
- A patient’s memory must be monitored carefully throughout the course of treatment
Which medication should be stopped before ECT?
- Avoid benzos
- Stop clozapine 24 hours before
- Stop moclobemide 24 hours before
- Lithium is associated with an increased risk of prolonged seizures so may need to be reduced before
Which decade was ECT invented?
1930s
What is necessary for effective ECT treatment?
- generalised seizure activity - motor seizure lasting 20 seconds
- EEG monitoring
When is it appropriate to administer bilateral ECT?
Where unilateral ECT has failed
Where deciphering cerebral dominance is difficult
Where speed and completeness of recovery have a priority
When is it appropriate to administer unilateral ECT?
Where minimising memory impairment is particularly important
Who invented Transcranial magnetic stimulation and when?
Anthony Barker in 1985
What has single TMS been useful for treating?
Migriane
What is rTMS approved for?
Depressed patients who have not responded to antidepressants or psychotherapy
Which area of the brain does TMS target?
The left or right DLPFC (dorsolateral prefrontal cortex) - usually the left
What’s the procedure for rTMS?
Placement of an electromagnetic coil to deliver a short, powerful magnetic field pulse (1.52.0 T) through the scalp and induce electric current in the brain
What is a course of rTMS?
30-40 mins a day for 4 weeks
What are the contraindications of rTMS?
- a history of epilepsy or organic brain pathology
- sleep deprivation
- acute alcohol-dependence syndrome
- use of drugs that cause a significant reduction in seizure threshold
- severe or recent heart disease
- presence of surgically placed ferromagnetic material such as a cochlear implant or cardiac pacemaker
What are the potential side effects of rTMS?
- seizure induction
- transient acute hypomania
- syncope
- transient headache
- neck pain and local discomfort
- transient hearing changes
- transient cognitive changes
What is Deep Brain Stimulation?
neurosurgical technique which involves placing an electrode within the brain to deliver a high-frequency current in a specific subcortical or deep cortical structure - this temporarily arrest activity in that area
What are the indications for DBS?
Movement Disorders -Parkinson's -Tourette's -essential tremor -Dystonia Evaluated for use in: depression, OCD and chronic pain
Which area of the brain would DBS target for Parkinson’s?
Subthalamic nucleus
Which area of the brain would DBS target for OCD?
Internal capsule
What are the side effects of DBS?
Surgical complications -infection -intracranial haemorrhage -Stroke -lead migration, fracture, erosion -death Neuropsychiatric -impulse control -mania -depression -anxiety
What is vagal nerve stimulation and what is it used for?
Stimulation of the left cervical vagus nerve
Used in the treatment of resistant partial-onset seizures
Who carried out the first pre-frontal leucotomy and when?
Moniz and Lima in 1995
What are the criteria for psychosurgery?
- Severe mood disorder or OCD that has been resistant to all other treatments
- patient must have capacity and provide consent
How do Mental health services (service-based recovery definitions) define recovery?
- Symptom remission
- Being out of hospital
- Living independently
- Being involved in work or school
How do PEOPLE with mental health problems define recovery? (user-based deifinition)
- Overcoming the effects of being a patient in mental healthcare
- Establishment of a fulfilling, meaningful life and a positive sense of identity
- Process of personal discovery of how to live (and how to live well) with enduring symptoms
Which type of amnesia is ECT most likely to cause?
Retrograde
What are human rights?
- 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
- 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
Is the right to work a human right?
No
Phototherapy has the most extensive evidence base for which conditions?
Depression
SAD
ADHD
What is Phototherapy?
The treatment consists of sitting next to a bright light for 1-2 hours
Is phototherapy for SAD recommended by NICE?
No
The Fraser Guidelines related to what?
Doctors being able to provide contraceptive advice and treatment without parental consent
What are the Fraser Guidelines?
- 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
Based on the 2001 UK Census, ethnic minorities form what proportion of the UK?
9%
Which ethnic group has been consistently been found to have the highest rate of detention (compulsory admission) in the UK?
Black (men)
What % of BAME population were inpatients or on CTOs in the ‘Count me in Census’?
23% of all inpatients and those on CTOs
Who described the pathways to care?
Goldberg and Huxley
What does the pathways to care describe
Only a small proportion of people with a mental disorder receive specialist psychiatric care
What is ‘Rose’s Paradox’?
Majority of cases of a disease come from a population at low or moderate risk of that disease, and only a minority of cases come from the high risk population. This is because the number of people at high risk is small. The common example is Down’s syndrome.
What is ‘Simpson’s paradox’?
A trend that appears in different groups of data disappears when these groups are combined
According to the 2010 ‘Count me in Census’, which ethnic groups were found to have lower than average rates of admission?
- Indian
- Chinese
- White British
Which case led to the development of the Fraser Guidelines?
Gillick 1982
Higher rates of mental illness has been found which ethnic minority group?
Black
4-6x that of white British population
Where was the National comorbidity survey conducted?
In the USA
Which fully structured diagnostic interview did the National comorbidity survey use?
It used the Composite International Diagnostic Interview (CIDI)
Does presence of a pacemaker contradindicate ECT?
No
Proportion of Europeans with mental health problems in past one year that attended GP?
33%
According to ESEMeS
Proportion of Europeans with mental health problems in past one year who have seen a psychiatrist?
21%
Proportion of people in primary care who have major depressive disorder?
5-10%
Who has the highest incidence of BPAD according to AESOP study?
African Caribbean
Average lag time between onset and testament of depression?
3 years
According to NESARC
Mean age of onset of depression
30 years
Mean number of episodes of depression in lifetime of MDD
5
Prevalence of hallucinatory experience in healthy British repsondents from community samples
4%
Why is prevalence of mental health problems greater in community than clinical samples?
Existence of diagnostic filter along the pathway of care
Godlberg and Huxley
Low concordance with medications is predicted?
Young age of patient
Strongest predictor of long duration of untreated psychosis
Insidious mode of onset
Most crucial illness related factor associated with long duration of untreated psychosis
Negative symptoms
MacArthur Competence Assessment Tool evaluates what?
Fitness to plead
Decreasing the likelihood of suicide attempt in a high risk patient is what type of prevention?
Secondary prevention
What % of patients will relapse despite treatment with maintenance ECT for severe depression after initial positive response?
1/3
How long does a patient with BPAD needs to remain stable with full insight to be able to drive according to DVLA?
Group 1 - 3 months
Group 2 - 12 months
Who is associsted with transorbital leucotomy?
Freeman (1946)
According to DVLA how long do severely anxious/depressed patients new to be stable to be able to drive?
Group 1 varies
Group 2 6 months
Essential component of recovery oriented servcies
Being respect driven
When was the Care programme approach initiated?
Following the killing of a social worker by a patient in 1988
Levels of care in CPA
Standard and enhanced
Reducing contact instead of withdrawing care from unwilling/hostile patients is called?
Backing off
According to UK 700 study the most important predictor of efficiency of assertive community outreach team is
Case load
Which interventions have been evaluated for Early Intervention of schizophrenia?
Use of CBT and supportive therapy
Use of Olanzapine
Use of risperidone and CBT
Use of specialised team input
How does psycho surgery work?
Gamma radiation is used to target limbic structures
What is a potential side effect of psycho surgery?
Change in personality
Which condition can deep brain stimulation be used for?
Tourettes
No of adults who experience at least one mental health problem in their lifetime?
1/4
No of patients with depressive episode that develop chronic course of the illness?
1 in 10
No of persons aged >65 with depression at any one given time?
1 in 7
No of people living with a mental problem at any one given time?
1 in 6
