recent advances & current challenges in psychiatry
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Recent Advances & Current Challenges in Psychiatry. Dr. Naresh K. Buttan M.B.B.S., D.P.H., D.P.M., D.N.B. (Psy), C.C.S.T., Sec 12 (2) Approved Consultant Psychiatrist (Gen. Adult)- PCH CIC TPD (CPT)- HE SW Peninsula PGME Hon’ Fellow, AT & Locality Psych Lead- PCMD [email protected]. - PowerPoint PPT PresentationTRANSCRIPT
Recent Advances & Current Challenges in Psychiatry
Dr. Naresh K. ButtanM.B.B.S., D.P.H., D.P.M., D.N.B. (Psy), C.C.S.T., Sec 12 (2) Approved
Consultant Psychiatrist (Gen. Adult)- PCH CICTPD (CPT)- HE SW Peninsula PGME
Hon’ Fellow, AT & Locality Psych Lead- [email protected]
Psychiatry
• Medical Specialty- subspecialties• Holistic view- Biopsychosocial model• Healthcare Services (NHS/ Pvt) – priorities• 3rd Sector – Insurance/ pharmaceuticals• Patients/ carers/ family- expectations• Society- understanding/ stigma• Stakeholders- plenty…
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances
Illness:1) Epidemiology2) Nosology/ diagnosis3) Investigations: Aetiopathogenesis Treatments: 1) Pharmacological2) Psychological3) Others
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances
Service models:1) NHS2) Social3) Private Legislations:1) MHAct/ MCA/ DoLS2) CQC/ IMCA/ IMHAs
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances-Epidemiology
• Move from Descriptive to Analytical.• Community Epidemiological Surveys: 1) US – UK Mental Health Hospital Project 1965-702) WHO- IPSS (International Pilot Study of
Schizophrenia), 1968-74, 9 countries.3) ECA (USA)- DIS (Diagnostic Interview Schedule-
Structured tool); 1980-85.4) National Comorbidity Surveys- (NCS, 1990-92), NCS- 2
(2001- 02), NCS – R (‘02), NCS – A.5) WHO (ICD- DCR)- CIDI (Composite International
Diagnostic Interview)- ICPE (International Consortium of Psychiatric Epidemiology, 1997).
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances- Epidemiology
• WMH 2000 - World Mental Health 2000 initiative- CIDI
surveys in 20 countries, findings: 1) Mental disorders- most prevalent chronic (Life Time to
date- 50%, 12 months- 15-25 %)
2) Earlier onset (anxiety disorders- teenage)
3) Mental disorders- most impairing.
4) Most severe in surveys- diagnosable.
5) Of these only minority received treatments & only small minority received long treatments.
6) Underreporting- common, lower bound estimates
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances- Epidemiology• Modifiable determinants of illness onset:a) Emerging evidence: Obstetric complications (Scz),
Exposure to famine during childhood (ASPD), Early exposure to Pb (Alz.)
b) Non- specific risk factors: SLEs, Stress Buffering, Coping mechanisms
• Modifiable determinants of illness course:a) Primary prevention – impossible/ unrealistic.b) Secondary Prevention (Health promotion) –school
based interventions at young age, stress buffering skills.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances- Epidemiology• Genetic epidemiology:1) Family, twin & adoption studies: higher rates in
offsprings & 1st deg relatives (Scz, BPAD)2) Chromosomal: deletions, mutations (Trisomy 21,
Klinefelter XXY synd., Turner XO synd.)3) Genetic: a) Polymorphism→ molecular fn → behavioursb) DNA sequence variation→ differencesc) STG (Serotonin Transporter Gene)- modulates
influence of SLE on risk of Depression (3X Gen population)
d) Linkage or association studies.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances- Aetiopathogenesis
• Older theories: structural or functional brain derangements, psychological/ behavioural, social.
• Newer theories: recent advances in imaging→ subtle brain morphological changes (white matter, functional MRI, PET, SPECT- different rates of glucose uptake- specific brain areas), Neurohormones (HPA- stress response, HVA levels), genetics (STG, SNVs), biochemical changes in body, others (psychosocial).
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Aetiology- Stress Diathesis Model
CMDs
Recent Advances- Treatments• Biological: 1) Antipsychotics: SDAs (atypical), LAIs (depots),
receptors- DA, MA, HT, GABA, NMDA. 2) Antidepressants: SSRIs, SNRI, NARI, NASSA, RIMA,
5HTagonist, ketamine, DBS.3) Others- AEDs, GABAnergic, Z drugs, CEIs
• Psychological: DBT, mindfulness, newer indications for known therapies.
• Social: Nidotherapy, IPSERT
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances- Service Models• Socio- politico- economic drives:A. NHS: ‘Liberating the NHS’ - April’13, DoH, 10
SHAs/ 152 PCTs- disappearing replaced by NHS CB (4 Regional Offices & 13 Area Teams), 152 Las, 211 Clinical Commissioning Groups (CCGs), HEE – 13 LETBs, PHE (4 regional & 1 local centres).
B. Social: SEs/ CICs, Social housing, others.C. Private: healthcare - contractual issues,
competition, Monitors in Foundation Trusts
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances- Laws• MHAct 1983- amendments 2007:1) Changes in definitions, roles2) Changes in sections & procedures3) Addition of SCT (CTO), safeguards for patients
• MCAct 2007/ DoLS 2009: safeguarding vulnerable
• Bodies: 1) CQC & AIMS (RCPsych)- accreditations, checks, responsible
for coordinating MHRTs, SOADs. 2) LAs/ NHS to arrange IMHAs/ IMCAs. 3) Court of Protection: Financial receivership/ appointee,
Public Guardian or displacing /appointing Nearest Relative.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Current Challenges
• Needs.• Climate.• Resources.• Professional• Illness & treatments.• Social.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Current Challenges- Needs• Demography: a) Aging population: demands on services, shrinking
workforce, complex needs, early diagnosis & treatment.b) Nuclear families- single parents, urbanization,
industrialization, early adversities.• Move to community:a) Reduction of hospital beds- single rooms, separate sex wards, delayed
admissions, early discharges, revolving door admissionsb) Community Based Interventions: CRHTs, Crises House, TCs
• Expectations:a) Patients: autonomy, respect, choices, rightsb) Society: humane, responsive, responsiblec) Professional: satisfaction, respect, autonomy, growth.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Current Challenges- Climate
• Social:a) Availability, accessibility & approachability.b) Diversity, globalization, information technology.
• Political:a) Governmental policies & priorities (‘No health without
Mental Health’- DoH 2011)b) Neighbourhood, migration, media, EWTD.
• Economic:a) Recession- cuts in fundingb) Currency of services- Payment by Results (PbR)c) Cost- effectiveness: closures of specialist centres.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Current Challenges: Resources• Manpower:a) Shortage across spectrum: Centre for Workforce
Intelligence (CfWI) report, Aug’11b) Poor recruitment, retention & early retirement.
• Money: total cost to economy £32 bn (~ Defense budget) by mental health problems (The Sainsbury Centre for Mental Health, 2001)
a) Spending cuts- public sector/ servicesb) Efficiency drive- current mantra.
• Material:a) Efficiency, efficacy, reliability.b) Use of advanced technology, IT.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Current Challenges- Professional• Changing roles: a) New Ways of Working’05- consultant- now a part of
MDT, distributed responsibility/ leadership in team.b) Changes in laws- MHAct- Approved/ Responsible
Clinicians, Approved Mental Health Professionals.c) New roles: Clinical nurse prescribers (CNP/CNC),
associate practitioner, STR workers.
• Changing expectations:a) Collaborative & flexible approachb) Multitasking- doctor, team player, leader etc.c) External agencies: Local authorities, courts, police, CQC,
Commissioners, media etc.Dr. N. Buttan, HESW Peninsula
PGME, MRCPsych Course, Sept'1418
Current Challenges- Illness & Treatment
• Illness:a) Multifactorial - no single specific cause.b) Diagnosis – syndromal not etiological, investigations – non
specific.c) Variations – symptoms, phenomenology, psychopathology
(Inter & Intra).d) Predictability – difficult as no concrete markers
• Treatment:a) Symptomatic – not always specific to illness.b) Long lag period – effects delayed, side effects-early.c) Relief – not permanent, need on long term, relapses delayed
after stopping these.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Current Challenges- Social
• Individual:a) Stigma – shame, isolation, delays help seeking.b) Impact – on all areas: work, relation, self esteem.
• Family/ carers:a) Service models – confidentiality, autonomyb) Laws – better defined role, rights & responsibility
• Society:a) Discrimination – understanding, less toleranceb) Burden of illness – complex needs, severe disability,
limited resources.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Role of Consultant Psychiatrist - RCPsych, OP 74, June 2010
• Good Doctor- Good Medical Practice, GMC June 2010
• Good Psychiatric Practice RCPsych, 2009
• CanMEDS Model of Royal College of Physicians & Surgeons in Canada, 2007.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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Recent Advances & Current Challenges in Psychiatry- Summary
• Psychiatry – medical specialty.• Advances – illness & treatments.• Challenges – service delivery in current & future
times.• Patient centred & holistic approach.• Evidence based, ethical, professional & reflective
practice.• Psychiatrists – Leaders, vehicles of change.
Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14
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