Psychiatric Services Flashcards
Aim of Primary Prevention?
Reduce incidence of disease by preventing development of new cases
Methods of primary prevention?
Elimination of aetiological factors
Increasing host resistance
Reduction of risk factors
Blocking modes of disease transmission
Example of primary prevention in Psychiatry
Reducing adverse social factors for psychiatric disorders (public health initiatives)
Aim of secondary prevention
Reduce total number of existing cases by more rapid effective interventions that shortens duration of illness
Methods of secondary prevention
Early identification
Prompt treatment of illness
Aim of tertiary intervention
For individuals to reach their highest level of functioning
Examples of tertiary prevention
Relapse prevention
Rehabilitation
What does the Institute of Medicine (IOM) classification focus on?
Prevention on interventions occurring before onset of formal disorder
Definition of prevention under IOM
Interventions which occur before onset of disorder
Types of prevention under IOM
Universal Preventive Intervention
Selective Preventive Intervention
Indicated Preventive Intervention
Who does a universal preventive intervention target?
Entire population
Who does a selective preventive intervention target?
Members of population with higher than average risk factors.
Who does indicated preventive intervention target?
Members of population with subsyndromal symptoms of a disorder, or diagnosed with another associated disorder.
What is the prevention paradox?
At population level, high-risk individuals who will get maximum individual benefit from prevention approaches contribute only for a small portion of disease burden.
Who described the prevention paradox?
Geoffrey Rose, 1981
Who conducted the first ECT and when?
Lucio Cereletti
Ugo Bini
1938
Indications for ECT
Depressive illness
Mania
Schizophrenia
Catatonia
Parkinsons
Neuroleptic Malignant Syndrome
Intractable seizure disorders (raises seizure threshold)
When is ECT first line treatment for depressive illness?
Emergency treatment where rapid response is needed
Treatment resistant depression where a person has responded to ECT previously
When is ECT a treatment of choice in depressive illness?
Life threatening situation because of refusal of foods and fluids
High suicide risk
Stupor
Marked psychomotor retardation
Psychotic depression
Pregnant and concern about teratogenic effects of medications
When is ECT considered second or third line treatment for depressive illness?
If not responding to antidepressant drugs
When is ECT considered as treatment for mania?
Life threatening physical exhaustion
Prolonged and severe mania with lack of response to all other appropriate drug treatments
When is ECT considered as treatment for schizophrenia?
4th line treatment for treatment-resistant schizophrenia if ineffective treatment with 2 antipsychotic medications and clozapine
When is ECT considered for Catatonia?
If ineffective treatment with benzodiazepine
When is ECT considered for Parkinsons?
As an adjunctive treatment for motor, psychotic and affective symptoms if severe disability despite medical treatment
Absolute CI of ECT?
None
Relative CI of ECT?
Acute respiratory infection
MI in past 3 months
Uncontrolled cardiac failure
Cardiac arrhythmias
CVE in past month
Raised ICP
Untreated cerebral aneurysm
Untreated Pheochromocytoma
Unstable major fracture
DVT - until anticoagulation (to reduce risk of PE)
Acute/impending retinal detachment
High anaesthetic risk
Which ECT is more effective; bilateral or unilateral?
Bilateral
Which type of ECT has greater cognitive impairment?
Bilateral
Does frequency per week affect efficacy of ECT?
No
Does electrical dose correlate with ECT efficacy?
Yes in bilateral ECT but not significantly
Side effects of high electrical dose of ECT?
In unilateral ECT, higher doses lead to greater time to regain orientation.
Does brief pulse vs sinewave ECT lead to differences in efficacy?
No
Early side effects of ECT
Headache
Temporary confusion
Nausea/vomiting
Muscular aches
Side effects of ECT
Memory deficits
Retrograde amnesia
Anterograde amnesia
Mortality: no greater than for GA in minor surgery
Who is mortality risk greatest for in ECT?
Patients with cardiovascular disease
Common causes of mortality with ECT?
VF
MI
When are memory deficits worse with ECT?
During treatment period
Bilateral ECT
Link between ECT and retrograde amnesia?
A time increases, reduction in extent of retrograde amnesia
Which retrograde amnesia is most likely to be recovered after ECT?
Personal memories
Link between ECT and anterograde amnesia?
Resolves rapidly after ECT is stopped.
Limitations of eCT
Time-limited
Poor durability
Relapse rate of ECT
51% in 12 months
37% in 6 months
Best antidepressants post-ECT?
TCAs
Optimal frequency for ECT
Twice weekly
6-12 treatments in total for one course
When is ECT unlikely to bring recovery once started?
If no clinical improvement seen over first six bilateral treatments
What should significant cognitive impairment during ECT lead to?
Reappraisal of electrical dose and placement
Where are electrodes placed in bilateral ECT?
Both temples
Centre of electrode should be 4cms above and perpendicular to midpoint of a line between lateral angle of eye and external auditory meatus
Where are electrodes placed in unilateral ECT?
Centre of one electrode is in same position as bilateral ECT.
Other electrode is over parietal surface over non-dominant hemisphere close to vertex of skull.
What is a necessary component for clinical efficacy of ECT?
Generalised cerebral seizure activity
Gold standard monitoring for ECT?
EEG
EEG monitoring during ECT
Four phases:
Build up of energies
Spike and wave activity
Trains of lower voltage slow waves
Abrupt end of activity followed by electrical silence
(35-130 seconds)
What is effective treatment with ECT defined?
Motor seizure lasting at least 20 seconds (from end of EC?T dose to end of observable motor activity)
When should maintenance ECT be considered
Index episode of illness responded well to ECT
Early relapse despite adequate continuation of drug treatment
Inability to tolerate continuation drug treatment
Patients attitude and circumstances are conducive to safe administration
When to use bilateral ECT?
Speed and completeness of response have priority
Where unilateral ECT has failed
Where previous ECT has produced good response without undue memory impairment
Where determining cerebral dominance is difficult
When to use unilateral ECT?
Where speed of response is less important
Where there has been a previous good response to ECT
Where minimising memory impairment is particularly important
Which drugs raise seizure threshold?
Benzodiazepines
Barbituates
Anticonvulsants
Which drugs lower seizure thresholds?
Antipsychotics
Antidepressants
Lithium
Which drugs need to be stopped 24 hours pre-ECT?
Clozapine
Moclobemide
Difficulties with Lithium and ECT?
Best avoided as may increase cognitive side effects and increase likelihood of neurotoxic effects of Lithium.
Who developed TMS for brain stimulation?
Anthony Barker, 1985
What is TMS used to treat?
Depression
How does TMS work?
Application of magnetic pulses on scalp surface which creates an electrical activity that stimulates neurons in cortical surface in line with Faraday’s principle of electromagnetic induction.
What is single pulse TMS useful for?
Migraine
What type of TMS is used for depression?
Repetitive pulses of TMS (rTMS)
How is TMS used for depression?
rTMAS is applied to left or right DLPFC for 30-40 minutes a day for at least 4 consecutive weeks.
Effect of TMS on cognition?
None
Aim of TMS?
Stimulate focal brain region without inducing generalised stimulation that results in seizure.
rTMS possibly harnesses inherent plasticity of brain circuits to strengthen connectivity between brain regions which are malfunctioning in depression.
Results for rTMS in depression
40% response rate that is sustained for 6 months
ECT vs rTMS short-term?
ECT is significantly superior
Side effects of TMS?
Discomfort over site of application
Transient headaches (not beyond treatment period)
Facial muscular twitching during stimulation
What other conditions has TMS been found to be effective in?
Resistant auditory hallucinations when applied to left temporoparietal cortex (close to Wernickes area)
Who carried out the first pre-frontal leucotomy and when?
Moniz and Lima
1995
Critera for psychosurgery
Severe mood disorder or OCD that has been resistant to all other appropriately reasonable evidence-based treatments tried in adequate dose for adequate duration.
Patient is competent and provides informed consent for the surgery.
How is psychosurgery carried out?
Employ stereotactic methods using pre-op MRI to establish target co-ordinates and a fixed stereotactic frame.
Lesions are localised to the orbito-frontal and anterior cingulate loop (limbic loop) which is implicated in the regulation of mood and emotions.
How are lesions produced inpsychosurgery?
Radio-frequency thermoregulation or gamma radiation (the gamma knife).
What are the stereotactic procedures used in psychosurgery?
Subcaudate tractotomy
Anterior cingulotomy
Limbic leucotomy
Anterior capsulotomy
What happens in subcaudate tractotomy?
Lesion made beneath head of caudate nucleus in rostral part of orbital cortex
What happens in anterior cingulotomy?
Bilateral lesions within cingulate bundles
What happens in limbic leucotomy?
Combining subcaudate tractomy and anterior cingulotomy
What happens in anterior capsulotomy?
Bilateral lesions in anterior limb of internal capsule
Side effects of psychosurgery
Headache & nausea
Confusion
Personality change
Change in social functioning
Post-op seizure
Weight gain
What happens to cognitive function after psychosurgery?
Tends to improve
Most response psychiatric disorders to psychosurgery?
Chronic intractable major depressive disorder
OCD
Which type of psychosurgery is used for OCD?
Stereotactic limbic leucotomy and anterior capsulotomy
What type of psychosurgery is used for mood disorders?
Stereotactic subcaudate tractomy
How does DBS work?
Use of fine wire implants in certain brain regions that can be triggered using a subdermal pacemaker device placed in the chest wall. High frequency electrical stimulation can temporarily arrest activity of brain region.
Indications for DBS
Parkinsons
Essential Tremor
Tourrette’s
Dystonia
Where can DBS be used for Parkinsons?
Subthalamic Nucleus
Internal globus pallidus
Where can DBS be used for OCD?
Internal capsule
Surgical side effects of DBS
Infection
IC haemorrhage
Lead erosions, fracture, migration
Post-op seizures.
Neuropsychiatric side effects of DBS
Depression, anxiety, mania
Impulsivity
Speech and language disorders
Decrease in cognitive performance
Postural instability - increased risk of falls
What is vagus nerve stimulation?
Stimulation of left cervical vagus nerve