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Psychological Medicine Case Based Learning Year 4Student Guide

2019-20

CONTACTS

Dr Liz Forty Senior Lecturer FortyL@cf.ac.uk Dr Mat Hoskins Clinical Lecturer HoskinsMD1@cardiff.ac.ukDr Alan Slater Clinical Lecturer SlaterA4@cardiff.ac.uk

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Table of ContentsTable of Contents..................................................................................................................................2

Introduction.......................................................................................................................................... 3

Case Based Learning Framework.......................................................................................................... 4

“Cardiff Framework” grid:.....................................................................................................................5

Case 1 Learning Outcomes....................................................................................................................6

Case 1.................................................................................................................................................... 7

Case 2 Learning Outcomes....................................................................................................................8

Case 2.................................................................................................................................................... 9

Case 3 Learning Outcomes..................................................................................................................11

Case 3..................................................................................................................................................12

Psychopharmacology: Supporting information for students to apply to cases..................................14

Psychological Inventions: Supporting information for students to apply to cases..............................26

Self-Harm Risk Assessment: Supporting information for students to apply to cases..........................28

Mental Capacity Act and Mental Health Act: Supporting information for students to apply to cases31

Psychological Medicine Overall Module Learning Outcomes..............................................................34

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IntroductionIn phase 2 of C21 (years 3 and 4), clinical case studies will continue to be used to structure your learning. You will have the opportunity to work through a number of clinical cases whilst on placement. These cases are designed to complement the other placement learning opportunities that you will experience. The aim of the case based sessions is to promote active learning. There will be three cased based sessions timetabled during your four-week psychiatry placement plus an ISCE preparation session. The case sessions will usually be assigned in the same order as they appear in this handbook. However, as the timetabling of activities will vary according to locality, it may sometimes be more appropriate to reorder the case sessions.

The cases have been designed to integrate key elements of the psychiatry curriculum (with a particular focus on psychopharmacology/psychological therapy, suicide risk assessment and the Mental Health Act/ Mental Capacity Act). Facilitators and students are encouraged to take a flexible approach to case based learning whilst on placement. The aim of these sessions, and this handbook, is to provide a basic structure and degree of consistency across placements in Wales whilst allowing you to benefit from the particular learning opportunities that are available within your placement locality.

The three cased based sessions will focus on are…

A young woman with a history of anorexia nervosa who is later diagnosed with bipolar disorder

A young woman with a diagnosis of depressive disorder with psychotic symptoms A young man with a first episode of psychosis who is later diagnosed with schizophrenia

You may choose to follow the CBL templates included in this CBL handbook or to focus the CBL sessions on specific cases you have come across on placement (where these cases focus on the appropriate topics and will help you to achieve your learning outcomes).

If you choose to use the cases within this handbook, your tutor will also be able to provide you with case note information for each of the patients in the scenarios. You tutor may also support you in working through some role play scenarios based on these three cases.

How you should approach learning from a case in the clinical environment

The following steps provide a framework that you can use to approach learning both from the virtual cases discussed in the case based sessions and also the real patients you see whilst on placement. You should try to see as many patients as possible whilst on placement to enable you to broaden your learning experiences.

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Case Based Learning Framework

1. Students read/listen to the clinical cases/scenarios2. Students brainstorm using the Cardiff framework (see grid below)3. Students develop their learning outcomes (LOs) 4. Students think about how they are going to achieve their LOs5. Students consider which skills they need to learn/practice6. Student think about the relevant basic science.7. Students plan how they are going to organize their week – to help them achieve LOs 8. Group discuss case using the Cardiff Framework9. Students think about any further learning needs

Tutors will encourage all group members to take an active part in discussions. Tutors will also facilitate the group in developing your learning outcomes. You should continue to use th Cardiff Framework model throughout year 4. Using this framework will assist you in your learning about the aetiology, pathogenesis, presentation and management of a range of common conditions (those specified in the overall module learning outcomes in the main PMCNO handbook). Again, the use of this framework should assist you to develop your learning around the real patients you see on clinical placement but may also be useful in the case based sessions.

“Cardiff Framework” grid:

1. What Could it be?

Conditions Pathophysiology Causes

2. How am I going to find out

History Examination Investigations

3. What am I going to do?

Explanation Treatment Management

4. What could have been done?

Prevention Individual Prevention Population

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5. Why has this person presented?

Impact of Symptoms

Behaviour and Expectations

Risks Environment

Case 1 Learning Outcomes

These learning outcomes may be used to guide the CBL session. It will not be possible to cover all of these learning outcomes in full during the CBL session. Students/tutors may prefer to choose some of the outcomes below to focus on specifically during the CBL session, and to cover the remaining

learning outcomes in other clinical/teaching sessions.

Learning Outcomes

Recognise the clinical features of Anorexia Nervosa and Bulimia Nervosa as they may present in various settings.

Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis of anorexia nervosa or Bulimia nervosa.

Recognise the clinical presentation and diagnosis of bipolar disorder, based on the ICD-10 diagnostic criteria, as it may present in primary and secondary care.

Assess the likely course and prognosis for a patient with a diagnosis of bipolar disorder. Evaluate the biological, psychological and social factors that may influence vulnerability to

bipolar disorder, including predisposing, precipitating and perpetuating factors. Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis of

bipolar disorder. Appraise current pharmacological treatments for bipolar disorder (antidepressants, mood

stabilisers including lithium and antipsychotics) including their mode of action and side effects.

Appraise current non-pharmacological treatments and management options for bipolar disorder (including CBT and psychoeducation).

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Case 1

Olivia is a 32 year old lady with a history of mental illness. She was raised by her parents and has three younger sisters. There is some history of mental illness in the family, with Olivia’s mother having had depressive episodes and her maternal aunt having bipolar affective disorder. Around the age of 14, Olivia developed some problems related to food. She started to restrict her diet and lost a significant amount of weight. She was seen by her GP who referred her to a CAMHS (Child and Adolescent Mental Health Services) psychiatrist who diagnosed her with Anorexia Nervosa. Olivia received support and treatment for several years until she was discharged at the age of 17, having made a full recovery.

What are the clinical features of Anorexia Nervosa (AN) and how do they differentiate from Bulimia Nervosa (BN)? What clinical changes might the GP have asked about or measured? What are the causes of AN and how is it treated? What is the prognosis and risk of mortality?

At age 18, Olivia went to university to study Art. Olivia was the first person in her family to go to university. She found her first year hard but settled in and passed exams in first year. During the second year she began to isolate herself from her friends, had difficulty sleeping, and wasn’t really eating. She lost a considerable amount of weight in a short space of time, and deteriorated further until she saw the local GP who diagnosed her with severe depression shortly before her 20th birthday. Olivia was started on an antidepressant, Fluoxetine, and put on the waiting list for psychological therapy. At this time Olivia was taking aspirin for occasional headaches and regular oral (PO) ibuprofen for an old knee injury.

What are the other classes of antidepressants and why was an SSRI chosen here? How would you explain Fluoxetine to Olivia? What is it? How is it taken? How long before it works? What are the common, notable and serious side effects? What happens if it doesn’t work? What is the evidence base and number needed to treat (NNT) for treatment of depression and prevention of relapse?

Olivia remained well until the age of 24 when she experienced a further depressive episode. At 25 she experienced another depressive episode and later that year was admitted with a manic psychotic episode. She continued to be treated with antipsychotic medication in the community and is now in remission. You would like to explore adding a medication to help manage her future risk of relapse.

What antipsychotic may she have been commenced on? What medication may be introduced to manage her future risk of relapse? Consider the key points below in relation to these medications.

Which medications? Why? How does the medication work? What is the evidence base? Common, notable and serious SEs. Lithium- Baseline investigations and how it is started. The need for monitoring and important causes of toxicity including drug interactions. What else can help if it doesn’t work. How would you explain Lithium therapy to a patient/relative?

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Case 2 Learning Outcomes

These learning outcomes may be used to guide the CBL session. It will not be possible to cover all of these learning outcomes in full during the CBL session. Students/tutors may prefer to choose some of the outcomes below to focus on specifically during the CBL session, and to cover the remaining

learning outcomes in other clinical/teaching sessions.

Recognise the clinical presentation and diagnosis of depressive disorder with psychotic symptoms, based on the ICD-10 diagnostic criteria, as it may present in primary and secondary care.

Assess the likely course and prognosis for a patient with a diagnosis of depressive disorder with psychotic symptoms.

Evaluate the biological, psychological and social factors that may influence vulnerability to depressive disorder with psychosis, including predisposing, precipitating and perpetuating factors.

Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis depressive disorder with psychotic symptoms.

Appraise current pharmacological treatments for depressive disorder with psychotic symptoms (antidepressants, mood stabilisers including lithium and antipsychotics) including their mode of action and side effects.

Explain indications for ECT, its administration, evidence base and potential side effects. Appraise current non-pharmacological treatments and management options for depressive

disorder with psychotic symptoms.

Recognise the static and dynamic factors associated with risk; for harm to self or others and also risk of vulnerability and neglect.

Conduct an assessment of risk to self and to others. Create and communicate an appropriate risk management plan. Evaluate issues of risk in a balanced and informed way, which counteracts inaccurate and

stigmatising attitudes.

State the doctor’s duties and the patient’s rights under the appropriate mental health and mental capacity legislation.

Appraise the general principles of detention under the Mental Health Act as applicable under sections 2, 3, and 5(ii).

Assess a patient’s capacity to make a particular decision in accordance with legal requirements and the GMC’s guidance.

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Case 2

A young woman is found unconscious in the street by paramedics. There is a bottle of vodka next to her and several empty packets of paracetamol and risperidone. She is taken to A&E and regains consciousness. She is slurring her speech, agitated and refusing to tell you her name or what happened. She has no identification on her.

What are the next most appropriate steps?

She is physically restrained for blood tests and given rapid tranquilisation (lorazepam and haloperidol) and transferred to the Poisons Unit. We are contacted by local police and discover that she is 32-year-old Rachel, a missing person from Birmingham. She has a history of psychotic depression, absconding from locked wards and serious overdose and hanging attempts. After completing parvolex treatment she tells the psychiatric liaison nurse “I’m fine. It was an accident. I don’t want to die. I’m not fucking talking to you anymore so let me go”. She attempts to leave the ward and only nursing staff are available. What are the next most appropriate steps?

Consider nurses holding power s5(4). How long does it last for? What happens next?

She is detained under a section 5(4) and the medical SHO on call visits the ward and applies section 5(2). The emergency duty team are called to arrange a Mental Health Act assessment. In the meantime, Rachel manages to kick open a fire door and escapes from the hospital grounds in a nightgown and no shoes. What are the next most appropriate steps?

Helicopters locate her near a motorway overpass and the police detain her under section 136. She is brought to the local psychiatric hospital. Who should be present during this MHA assessment?

You discover that she took the overdose in response to voices telling her to kill herself. She is severely depressed, not eating or drinking much over the past week and lacks insight. She has no thoughts to harm others. She planned it for a week, thought it would be more than enough to kill her, travelled to Cardiff so family wouldn’t find her, drank alcohol to make it more lethal, did it in a secluded spot and told no-one her intentions. She was diagnosed with psychotic depression in Birmingham several weeks ago but disengaged from community treatment. She has never been admitted to a psychiatric ward. Under what criteria can she be detained? Which section may be applied?

On the ward she refuses all investigations and oral medications. She is distressed, floridly psychotic and self-neglecting. She hasn’t eaten or drank in three days continuously and has fainted on several occasions. What are the next most appropriate steps?

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Rachel is successfully treated to remission with ECT and stabilised on lithium and venlafaxine. She is allowed section 17 leave from the ward in a graded fashion and this goes well. She is discharged to the community in Birmingham and goes on the waiting list for psychotherapy. What kind of psycholoigical approaches are used in the treatment and relapse prevention of depression?

Rachel agrees to start a course of CBT but wants to know more about what it is and how it works. How would you explain this to her?

Rachel benefitted from 12 sessions of CBT but then, unfortunately, six months later, her CPN learns that she has stopped her medication, started using cannabis, and is again severely depressed and contemplating suicide. She is refusing her team entry to her flat and they are concerned that she is hoarding medication to use in another overdose. What are the next most appropriate steps?

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Case 3 Learning Outcomes

These learning outcomes may be used to guide the CBL session. It will not be possible to cover all of these learning outcomes in full during the CBL session. Students/tutors may prefer to choose some of the outcomes below to focus on specifically during the CBL session, and to cover the remaining

learning outcomes in other clinical/teaching sessions.

Recognise the clinical presentation and diagnosis of schizophrenia based on the ICD-10 diagnostic criteria.

Assess the likely course and prognosis for a patient with a diagnosis of schizophrenia. Consider the advantages and disadvantages of the use of the terms “first episode psychosis”

or “schizophrenia” in patients experiencing their first episode of psychosis. Evaluate the biological, psychological and social factors that may influence vulnerability to

schizophrenia, including predisposing, precipitating and perpetuating factors. Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis of

schizophrenia. Appraise current pharmacological treatments (antipsychotics, including clozapine) including

their mode of action and side effects. Appraise current non-pharmacological treatments and management options.

Recognise the static and dynamic factors associated with risk; for harm to self or others and also risk of vulnerability and neglect.

Conduct an assessment of risk to self and to others. Create and communicate an appropriate risk management plan. Evaluate issues of risk in a balanced and informed way, which counteracts inaccurate and

stigmatising attitudes.

State the doctor’s duties and the patient’s rights under the appropriate mental health and mental capacity legislation.

Appraise the general principles of detention under the Mental Health Act as applicable under sections 2, 3, and 5(ii).

Assess a patient’s capacity to make a particular decision in accordance with legal requirements and the GMC’s guidance.

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Case 3

George was raised by his parents and has two younger twin brothers. He suffered from violent homophobic bullying in secondary school, but had a group of close friends and supportive teachers. George had a few jobs when he left school but has not been in work since the age of 21.

At the age of 22, George experiences his first episode of psychosis. He is treated for 8 weeks with a therapeutic dose of haloperidol with a minimal effect on his symptoms. He then presents with very slow movements, a mask-like facial expression and noticeable tremor that is upsetting for him. He doesn’t want to take this medication anymore.

Consider explaining how side effects (SEs) caused by haloperidol can be treated. Which neurochemical pathways are involved. Next appropriate step would be second-generation antipsychotic (SGA). How would you explain the common, notable and serious SEs of olanzapine.

At the age of 24 George is diagnosed with schizophrenia.

How would you explain a diagnosis of schizophrenia to a patient/relative? What would be the key information/key issues here?

George was admitted four weeks ago with a psychotic episode. This was his third admission this year. He had been treated with risperidone at an adequate dose for eight weeks, but despite this, his psychotic symptoms have persisted. What are the options for further management now?

Consider diagnosis of treatment resistant schizophrenia (two antipsychotics failed after adequate dose and duration, one must be SGA) and use of clozapine. How would you explain clozapine to a patient? What is it, what is it used for, how is it given, how long before it works. Common, notable and serious SEs, monitoring and important interactions.

George suffers from an acute exacerbation of his asthma and is admitted to a respiratory ward in UHW. Whilst there he is treated with high dose steroids and then develops psychotic symptoms. He has paranoid persecutory delusions that the nurses are trying to poison and kill him and can hear the voices of the doctors plotting to take out his organs. He is agitated and refusing any treatment for his serious asthma. How would you proceed in this situation?

George has received medical treatment and his asthma is now improving, but he remains psychotic and is demanding to leave the ward. The medical SHO is concerned that George’s health and his personal safety will be at risk if he leaves. What can be done to prevent him from leaving?

George recovers from his physical illness and some time after becomes severely depressed. His mother visits him at home one day and finds him with a noose in his hand. The mother calls the out of hours GP who arranges a Mental Health Act assessment at George’s home. Who would attend a MHA assessment?

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What kind of questions would they ask of George to establish what’s happened, the seriousness and intent of the event, the mental state and his future risk?

What should you be screening for based on this presentation? What do you now want to know about the actual suicide attempt? Imagine you are going to have to recreate the event like a Crime Stoppers reconstruction. Imagine the set, the actors, the sequence of events. Ask questions to fill in the story.

You should have now covered the event. What can you say about the depth and length of preparation? The perception of lethality? Did this man believe he would be rescued? What was the margin for error? Was it performed isolation (time, place, person)? Were there any final acts carried out (note, affairs, comment on the degree of seriousness)? Were there precautions to remain hidden?

What are the most important aspects of the mental state right now (hopelessness, active suicidal ideation, unconvincingly statements to leave and complete suicide perhaps)?

How would you formulate his risk of completing suicide immediately or in the future? What would delay or reduce this risk? Any protective factors? What are the options if he's asking to leave A&E right now (think about immediate risk, using Common Law of necessity to stop him with security, asking Police to hold him, arranging MHA Ax).

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Psychopharmacology: Supporting information for students to apply to cases

Please note this guide covers most basic adult psychopharmacology but omits stimulants (for ADHD, narcolepsy), cognitive enhancers (dementia, performance enhancers) and recreational drugs. Please refer to Stahl’s Essential Psychopharmacology Prescriber’s Guide for more.

Basic Science that you should consider The discovery of chlorpromazine, imipramine, diazepam and lithium in the 1950’s revolutionised psychiatry. No longer were people institutionalised indefinitely but released from asylums and managed in the community.

Neurotransmitters (NTs)

Monoamines Histamine (H1-4) – involved in inflammatory

response, sleep, appetite, mood, learning, memory. Antihistaminergic drugs usually cause sedation and weight gain.

Catecholamines – Dopamine (DA), adrenaline, noradrenaline (NA)DA has two broad subtypes, D1-like (D1, D5) and D2-like (D2, D3, D4). Involved in reward, movement, attention, psychosisNA involved in arousal, alertness and mood. β blockers reduce BP, HR, anxiety and α blockers (clonidine, prazosin) also reduce panic, insomnia and nightmares. Blockade may explain dizziness, sedation and hypotension.

Tryptamines – serotonin (5HT), melatonin (M)5HT has many subtypes (1A-F, 2A-C, 3, 4, 5A-B, 6, 7). Related to aggression, anxiety, appetite, cognition, learning, memory, mood, nausea, sleep and thermoregulation. Most classical psychedelics exert their profound action through 5HT2a agonism (LSD, psilocybin, DMT)

Amino acids Glutamic acid – main excitatory NT, NMDA receptor is activated when glutamate and glycine

bind to it, involved in learning, anxiety, perception. Blocking it with Ketamine leads to dissociative anaesthetic and antidepressant effect. Regulates Brain Derived Neurotrophic Factor (BDNF). Low levels of BDNF are linked to depression and suicide.

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GABA – main inhibitory NT involved in regulating arousal, judgement and impulsiveness. Stimulating GABA leads to relaxation and anticonvulsant effect (benzos, NaValp, Gabapentin, pregabalin etc).

Acetlycholine ACh enables muscle action in PNS, learning, memory, attention, mood in CNS, muscarinic

and nicotinic receptors, ACh Inhibitors used to treat Alzheimer’s. Anticholinergic effects lead to sedation, dry mouth, constipation, urinary retention, blurred vision.

Pharmacological Treatments

AntidepressantsTricyclic antidepressants (TCA’s)An older class (secondary and tertiary amines), more side effects (SEs) and more lethal in overdose. E.g. amitriptyline, desipramine, clomipramine, nortriptyline.

Mechanism of actionSerotonin (5HT) and noradrenaline (NA) reuptake, as well as anticholinergic, antihistaminergic, and antiadrenergic effects – this is where most of the SE’s come from.

Notable side effects antihistaminergic SE’s - weight gain (also 5HT3c antagonism), sedation antiadrenergic SE’s – hypotension, dizziness, sedation, anticholinergic SE’s – sedation, dry mouth, urinary retention, constipation, blurred vision

(note, cholinergic rebound can occur on withdrawal) Hyponatraemia – any antidepressant or antipsychotic could cause this

Serious side effects Overdose can cause anticholinergic delirium

Someone would present as:Mad as a hatter – confusion, visual hallucinationHot as a hare – increased tempBlind as a bat – loss of visual accommodationRed as a beet – peripheral vasodilationDry as a bone – dried mucous membranesTreat overdose in hospital setting with Physostigmine (reversible acetylcholine-esterase inhibitor)

Cardiac – prolonged QTc, sudden death arrhythmias GI – hepatic failure, paralytic ileus CNS – EPSEs, lowered seizure threshold and rare seizures, hyperthermia Rare activation of suicidal thoughts (especially adolescents/young adults)• Rare induction of mania

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Selective Serotonin Reuptake InhibitorsMechanism of action – down regulation of 5HT1a autoreceptors secondary to increased 5HT availability, leading to increased 5HT tone.

Examples – fluoxetine (Prozac), paroxetine, citalopram, sertraline.

Notable side effects GI upset – low appetite, N&V Sexual dysfunction - anorgasmia, impotence, failed ejaculation, decreased libido CNS – insomnia, agitation, anxiety, headache, sweating Hyponatraemia – any antidepressant or antipsychotic could cause this SSRI discontinuation syndrome – antidepressants are not addictive, but abrupt withdrawal

can lead to dizziness, ‘flu like Sx, fatigue, gait disturbance, headache, insomnia, nausea. More likely with shorter half-life e.g. paroxetine (also more anticholinergic effects)

Rare bruising and bleeding – 5HT necessary for platelet aggregation, SSRIs inhibit 5HT transporter into platelets and increase risk of bleeding.Aspirin + SSRI = 2X risk of bleedingNSAID + SSRI = 4X risk of bleeding

Serious side effects Rare seizures Rare activation of suicidal thoughts (especially adolescents/young adults)• Rare induction of mania

Serotonin Noradrenaline Reuptake Inhibitors (SNRIs)May be more effective than SSRIs in refractory depression due to dual mode of action

Examples:Venlafaxine – short half-life, given BD, common SEs of increased sweating and hypertensionDuloxetine – given once daily, evidence of helping with chronic pain Sx

Serotonin Antagonists and Reuptake Inhibitors (SARI)These also have alpha-1-antagonismExamples:Trazodone – sedating, good anti-anxietyCan lead to priapism (painful sustained erection) → medical emergency, Rx with intercavernosal alpha-1-agonist

Noradrenaline and Serotonin Specific Antagonists (NaSSAs)Example:Mirtazepine – sedation, weight gain (through 5HT3 blockade), can improve nausea and vomiting (n&v) in chemo pts. Low risk of sexual SEs (so good alternative to SSRIs). Possible risk of bone marrow suppression.

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OthersBuprobion – Noradrenaline and dopamine reuptake inhibitor (Zyban, Wellbutrin) used for smoking cessation and as antidepressant. No sexual side effects but can exacerbate ADHD, tics, seizures and psychosis.

Buspirone – 5HT1a partial agonist, good anxiolytic effect.

Reboxetine – Noradrenaline reuptake inhibitor, poor evidence of efficacy

Mono-Amine Oxidase InhibitorsIrreversible – phelyzineReversible – moclobemide (safer to use, less diet restriction)

Cheese reaction – life threatening tyramine build-up (tyramine found in aged, fermented, cured, smoked, and pickled foods and drinks) : N&V, sweating, restlessness, headache, palpitations → sympathetic overdrive → hypertensive crisis

Rx with alpha antagonists (phentolamine, chlorpromazine)

Serotonin Syndrome Predictable and caused by excessive 5HT transmission usually due to 5HT2a overstimulation

There is a large number of serotonergic substances that can alone or in combination lead to SS :Antidepressants (e.g.MAOI plus SSRI, St John’s wort), opioids, CNS stimulants (MDMA, amphetamine), antipsychotics (olanzapine).

Sx emerge in minutes to hours

Common SxDiarrhoeaSweatingAtaxiaTremorDisorientationHypomania

Distinguishing SxMyoclonusHyperreflexia

Rx:Withdraw the causative agentSymptomatic support (in ICU if necessary)Benzos5HT2a antagonists (mirtazapine, chlorpromazine)

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Do antidepressants work? In 2008 a team led by Kirsch et al conducted a meta-analysis of antidepressants effect on depressive symptoms comparing fluoxetine, paroxetine, venlafaxine, and nefazodone. They found that antidepressants don’t work except in severe cases. This was loudly proclaimed in their press release and there followed a media storm of controversy and the author of the paper, a psychotherapist with a conflict of interest in the private psychotherapy business, released a book called the Emperor’s New Clothes. Others followed.

(see Mood Disorders lecture slides on learning central for more detail)

However, the study turned out to have serious methodological and statistical flaws. The included studies that looked at only a handful of antidepressants including nefazadone, something which is no longer used and probably less effective.

A subsequent meta-analysis by Melander et al found that the percentage of responders was greater for those given antidepressants compared to placebo at all levels of severity.

In fact, a systematic review by Geddes et al in the Lancet in 2003 found that the acute effects of antidepressants are powerful (NNT ~ 6) but prevention of depression relapse is one of the strongest effects seen in all of medicine

Geddes, J.R., Carney, S.M., Davies, C. et al. (2003) Relapse prevention with antidepressant drug treatment in depressive disorders: A systematic review. Lancet, 361(9358), 653–661

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This slide from the Geddes review shows the rates of relapse/recurrence after 12 months of antidepressant versus placebo. For each of these studies, the line down the middle represents no difference between antidepressant or placebo. The black box for each study is the relative risk and the line either side is the confidence interval. So a very large study with lots of people will have a large box and short confidence intervals, but a small study with few people will have a small box and huge long confidence intervals. When the CIs touch the line, it means there is no statistically significant effect. When you add them all up together you get a meta-analysis, which here shows us a statistically significant difference favouring antidepressants.

Antipsychotics also known as neuroleptics and previously called major tranquilisers.

Schizophrenia Associated with impaired dopaminergic neurotransmission in the brain:

Mesocortical pathway – hypoactive, associated with negative symptoms and impaired memory and learning

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Mesolimbic pathway – hyperactive, associated with positive symptoms (delusions, hallucinations)

Nigrostriatial pathway - normal activity, associated with movement regulation Tuberoinfundibular pathway – normal activity, involved in prolactin regulation

How they workAntipsychotics work by blocking dopamine. The higher the affinity for DA blockade, the more clinically potent the agent is. Blockade of DA in the striatal pathway leads to movement SEs and in the tuberoinfundibular pathway leads to hyperprolactinaemia.

Images taken from Prof Nutt’s lecture, 50 years of Psychopharmacology, Swansea June 2013

ClassesThere are two broad classes of antipsychotics, plus aripiprazole.

The older First Generation Antipsychotics (FGAs) also known as typical antipsychotics, and the newer Second Generation Antipsychotics (SGA) also known as atypicals.

Typicals generally have more SEs than atypicals, such as sedation, weight gain, postural hypotension, anticholinergic effects, metabolic syndrome and extra-pyramidal side effects

Extrapyramidal Side Effects (EPSEs)

Caused by striatal DA antagonismAcute dystonia – e.g. oculogyric crisisAkathisia – subjective feeling of restlessness and psychomotor restlessnessParkinsonism – think of what happens in Parkinson’s DiseaseCan Rx all of the above with antimuscarinc drug such as procyclidine

Tardive dyskinesia – oro-bucco-facial dyskinesiaCan occur late, due to chronic use of high potency agents, more common in elderly, can be irreversible. Rx by reducing and withdrawing agent, switch to clozapine or another atypical, add clonazepam

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Neuroleptic Malignant Syndrome (NMS) Unpredictable and life-threatening neurological disorder which can occur at any time with neuroleptics.

Onset is days to weeksHigh risk group are young males, post-partum females, anyone with Lewy Body dementia, using high potency agents, rapid increase in dose, or long-acting forms of drug

Presents with: Extreme pyrexia++ Stiffness, rigidity Confusion Autonomic instability (BP and pulse up and down) Raised WBC++ Raised Creatinine Phosphokinase (CPK)++++

(differentiating biochemical test between the clinically similar serotonin syndrome)

Leads to rhamdomyolsis → renal failure → 20-30% mortalityRx:Withdraw agent, transfer to ICU, dantrolene, bromocriptine.

Typicals (FGA)Mechanism of action – mostly blocking D2 receptorsChlorpromazine, haloperidol, zuclopenthixol, etc

Notable side effects Akathisia EPSEs, TD Sexual dysfunction Galactorrhea, amenorrhea Dizziness, constipation, urinary retention, blurred vision Weight gain Hypotension, tachycardia

Serious side effects Rare NMS Rare seizures and lowered threshold Rare jaundice, agranulocytosis Rare increased risk of sudden cardiac death and CVA

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Atypicals (SGA)As above, but have a better SE profile than typicals, mostly due to less EPSEs

Risperidone is the most “typical” of the atypicals and can give some EPSEs. Likely to cause hyperprolactinaemia, weight gain and sedation.

Olanzapine and quetiapine – have a “hit and run” profile of DA <5HT blockade, increased risk of DM and dyslipidaemia.

Aripiprazole is a partial D2 agonist , 5HT2a antagonistIt stabilises D2 in mesocortical and mesolimbic pathways. It is alerting and can reverse the effects of metabolic syndrome. Maybe not as effective as others in acute psychosis.

ClozapineUsed for treatment resistant schizophrenia – the most effective antipsychotic we can use.More D4, 5HT2, alpha-1, muscarinic and histaminic blockade.

Notable side effects Hypersalivation Sweating Nausea, constipation, hypotension Weight gain, DM and dyslipidaemia Sedation, dizziness, headache

Serious side effects PE Myocarditis Seizures (dose dependent) Paralytic ileus NMS Increased risk of sudden cardiac death and CVA

Agranulocytosis, weekly bloods, registered, traffic lights. Can cause agranulocytosis in 1/1000, highest risk in the first 18 weeks of treatment.

For this reason, pts are registered with a clozapine monitoring service, have weekly FBCs for 18 weeks, then fortnightly up to one year, then monthly after one year.

Patients will need to be registered with a Clozapine Monitoring organisation, usually the manufacturer (ZTAS), who will issue a traffic light warning on receipt of blood samples (green – ok, amber – repeat and monitor, red – stop immediately)

Coffee and cigarettes? A majority of our patients smoke and drink caffeinated drinks, and both nicotine and caffeine can affect the metabolism of clozapine (in opposite directions).

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Smoking induces the enzyme that breaks down clozapine (CYP1A2) → reducing plasma clozapine Caffeine inhibits the enzyme that breaks down clozapine (CYP1A2) → increasing plasma clozapineTherefore it’s important to enquire about changes in smoking and drinking caffeine.

…………………………………………………………………………………………………………………………………………………….

The Metabolic Syndrome

Obesity, hypertension, dyslipidaemia, insulin resistance and glucose intolerance→ carries a risk for developing DMT2 and CVD

There is a body of evidence supporting a link between DMT2 and schizophrenia (DMT2 is twice as common compared to general populations).

There is a higher incidence of metabolic syndrome in schizophrenic patients – even before the use of antipsychotic medication.

Risk of metabolic syndrome is increased 2-4 X when treated with most typical/atypical antipsychotics

→ but not aripiprazole, which seems to reverse the effects of metabolic syndrome.

…………………………………………………………………………………………………………………………………………………………..

Mood stabilisers

The only true mood stabiliser is lithium , which has antimanic/antidepressant, prophylactic manic/prophylactic depressant properties.

Mechanism of action – Not fully understood, alters Na transport across cells, alters catecholamine metabolism, likely inhibits inositol via the 2nd messenger system to increase tryptophan uptake and increase 5HT release

Examples – Priadel, Eskalith

Notable side effects Ataxia, dysarthria, delirium, tremor, memory problems Polyuria, polydipsia (nephrogenic diabetes insipidus) Diarrhea, nausea Weight gain Euthyroid goiter or hypothyroid goiter, possibly with increased TSH and reduced thyroxine

levels Acne, rash, alopecia Leukocytosis Side effects are typically dose-related

Life-Threatening or Dangerous Side Effects Lithium toxicity Renal impairment (interstitial nephritis)

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Nephrogenic diabetes insipidus Arrhythmia, cardiovascular changes, sick sinus syndrome, bradycardia, hypotension • T wave flattening and inversion Rare pseudotumor cerebri Rare seizures

Lithium is 100% excreted by the kidneys, unchanged. As such, ACE inhibitors, loop diuretics, NSAIDs and thiazides can increase lithium levels, leading to toxicity – please see lecture on Mood Disorders on learning central for more detail on toxicity.

Valproate (sodium valproate, valproic acid)Increases GABA release and reduces GABA breakdownSEs

Weight gain Thrombocytopaenia Hepatic impairment Polycystic ovaries Pancreatitis

Known human teratogen – neural tube defects, don’t give to women of childbearing age

CarbamazepineProlongs Na Channel inactivation and decreases glutamateAn enzyme inducer, causing it to interact with a variety of other medications

Other mood stabilisers are lamotrigine (good for bipolar depression), and some antipsychotics such as olanzapine and quetiapine.

…………………………………………………………………………………………………………………………………………………….

BenzodiazepinesWork as agonists at the omega site of GABA-A – facilitating GABA action and inhibiting neurotransmission.Long acting – diazepam (valium), chlordiazepoxideMedium/shorter acting – lorazepam (used in rapid tranquilisation because it can be given IM), temazepam, oxazepamAround 15% of people will develop dependence after taking them for longer than 2/52, 40% will develop dependence after a month.

HypnoticsZopiclone, zolpidem, zaleplonWork similarly to benzos but selective to the alpha-1-subunit of the omega site of GABA-AGood as anxiolytics and hypnotics but they are habit forming and do have abuse potential.

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Psychological Inventions: Supporting information for students to apply to cases

Psychological interventions can range from basic psychoeducation to long-term, complex psychotherapy. Psychotherapy, or the “talking cure”, was first discovered and explored by Freud and Jung, and many of their original descriptions are still used today, although modern psychotherapies are much more advanced and supported by high quality evidence (as opposed to Freudian and Jungian wild assertations about penis envy and mystical archetypes). Do you recognise any of the terms below? Research their meaning and fill in their description.

TransferenceCountertransferenceArchetypesEgo, id, superegoUnconscious drivesDefence mechanismsSplitting ProjectionRepressionConversionActing out

PsychoeducationThis is an important part of every patient’s recovery; understanding what their illness is, what their triggers are, how to reduce the risk of relapse and how to identify early warning signs of a relapse. Psychoeducation and vigilant symptom monitoring are especially important in BPAD. http://www.ncmh.info/resources/bepc/

Self-helpThere are a multitude of self-help gurus and self-help books, many of which will be charlatans or snake oil salesmen, so only recommend self-help books (bibliotherapy) where the underlying model has an evidence base, such as Mind Over Mood (CBT), The Mindful Way Through Depression (Mindfulness Meditation-based CBT), Overcoming Anxiety (CBT). Don’t forget that great works of literature are therapeutic in themselves!

There are now Apps that support self-help (some are free, many have a fee, HeadSpace etc) and increasingly there are Guided Self Help (GSH) interventions, which is a hybrid of brief face to face therapist contact and an App that follows a CBT approach.

CounsellingThere is no minimum legal requirement of qualification in the UK to call yourself a counsellor or therapist, so only refer patients to people who you can verify have had adequate training and supervision or groups who have a known track record (RELATE, CRUSE Bereavement, SARC, MIND etc). Counselling is a type of talking therapy where the patient can discuss their thoughts and

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feelings with a counsellor, who is trained to listen and help them come to their own solutions, as well as come to better understanding of their underlying though processes.

PsychotherapyPsychoterapy is the treatment of a mental disorder using predominantly psychological and to a lesser extent behavioural techniques. It can be given in a group but is more often 1:1 with a therapist. There are many different models for different disorders, but overall, thr strongest predictor of a good therapeutic outcome for the patient is the strength of the Therapeutic Alliance (the quality of the relationship between therapist and patient). An individual psychological formulation is key to understanding how best to help and individual.

Cognitive behavioural therapy (CBT)Cognitive behavioural therapy is probably the most commonly used form of therapy and it has a strong evience base for treating mental disorders, including depression, anxiety, phobias, OCD, trauma and it can also be helpful in schizophrenia. The model of CBT is based on an understanding that thoughts, emotions and behaviours are linked, and that by restructuring one component, the others will follow. For example, maldaptive behaviours are explored and challenged using behavioural experiments and behavioural activation (using the psychologiocal process of habituation or flooding) and negative automatic thoughts and destructive core beliefs are identified and challenged with Socratic questioning and re-appraisal. CBT is time-limited, focussed on the here and now and characterised by homework in between sessions. CBT can be given in a group, but is more often 1:1 with a therapist, who will usually meet for around 60 minutes a week over a course of roughly 6-12 weeks.

Dialectical behavioural therapy (DBT)Dialectical behavioural therapy is an amalgamation of approaches that were developed to help people who have problems controlling the urge to harm themselves, such as in Borderline Personality Disorder (Emotionally unstable Personality Disorder). During DBT people learn distress tolerance skills, interpersonal effectiveness skills, core mindfulness skills and emotional regulation.

Trauma-focussed psychological therapy (TFPT)Trauma-focussed psychological therapy is the umbrella term for evidence based approaches used to treat post-traumaic stress disorder. These include trauma-focussed cognitive behaviour therpay (TF-CBT), eye movement desensitisation reprocessing (EMDR), cognitive therapy for PTSD (CT_PTSD), prolonged exposure (PE) and many others.

Cognitive analytical therapy (CAT)Cognitive analytical therapy focusses initially on early life experiences, how they were survived, and how they relate to present difficulties. Therapist and patient work closely in collaboration to understand the chain of mental processes and actions that can lead to difficlutues, including snags, traps and dilemas.

Family therapyThis helps family members find constructive ways of helping each other. This is done by exploring each individual’s perspectives and beliefs. Family therapy is often used with young people, especially in Anorexia Nervosa, where entrenched and overbearing family dynamics can precipitate and perpetuate the disorder.

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Self-Harm Risk Assessment: Supporting information for students to apply to cases

You should review your notes from the introductory week self-harm small group teaching session. As well as reviewing what you have learnt from the introductory week session, the CBL session on placement should allow you to develop the communication skills necessary to conduct a thorough clinical risk assessment (for example, as a group you could discuss what you need to ask patients and how you would go about asking such questions effectively, and any issues you may encounter). You should consider the following: having empathy, actively listening, using appropriate silence and acknowledging the patient’s emotions.

You should think about how you will cover the following topics:

1. Obtaining more information about the attempt2. Evaluating the degree of suicidal intent and the seriousness of the attempt3. Assessing current mental state including suicidal thoughts4. Screening for Sx of depression/psychosis/other serious mental illness5. Obtaining information about past history and background6. Assessing coping methods and ability to seek help

Obtaining more information about the attemptThrough your questioning you should be able to visualise exactly what happened before, during and after the event.

For an overdose, you may want to know what tablets, how many, the dose, how were they obtained (what was in the cupboard, from visiting 5 pharmacies or hoarding own prescription). What did they think would happen to them after swallowing the tablets (fall asleep, die instantly, be saved by paramedics)? How long were they thinking about taking them before they did? Planning can be measure in duration and depth (thinking about it for a few weeks, researching on the internet etc)Did they take any drugs/alcohol as well (to potentiate or to disinhibit)Where were they, was the door locked, who else was at home?How and why were they discovered?What did they do afterwards?How did they end up in hospital?Why did they carry out the attempt?What things led to this, what made them think about wanting to die, what’s been on their mind?

Things to think about if the patient is guarded about what led to the attempt Arguments/abuse/betrayal in relationship Family problems Work stresses Finances/housing Health worries

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Legal problems (think about secondary gain from attempt e.g. avoiding custody/court)

You should think about non-suicidal reasons for self-harm (for instance by cutting or burning). Patients may harm themselves as a way of dealing with overwhelming emotions or to communicate their distress to others. This is a maladaptive coping mechanism and doesn’t necessarily imply that the patient wanted to die. However, it is important that you enquire about the method of self-harm, history (when did they start), usual precipitants and pattern. It’s important to check whether someone is self-harming with increased frequency and severity (e.g cutting very deep risks accidental death)

Evaluate the degree of suicidal intent and the seriousness of the attemptRemember the 4 P’sPlanning or impulsive – did they save many tablets for a long-time, taking more than what they thought would be lethal? This includes an inquiry into their perception of lethality and likelihood of being saved. Performance in isolation or in front of others – taken alone or in secluded areaPreparations made prior to the act - suicide note, last will and testament, putting affairs in order, arranging for childcare after deathPrecautions to remain hidden - locked door, no-one expected to be at home, did they convey suicidal intent to others before?

Assess current mental state including suicidal thoughtsHopelessness and active suicidal thoughts are important dynamic risk factors for completing suicide.

How does the patient feel now about being alive?How do they see the future?Do they think things will ever be better than today? Do they think anything could help?Are they still having thoughts of hurting themselves, what would they do if they left the interview?When would they do it?What stops them from doing it?How convinced are you that what they are telling you is true? Remember that if someone really wants to kill themselves then they may lie to you so they can carry out their plans.

Screen for Sx of depression/psychosis/other serious mental illnessYou should screen for and explore any Sx of depression or other mental illness.

Past history and backgroundPast psychiatric historyAny previous history of MH problems? Any SH in the past? What kind of professional support/admission/follow-up have they had? Any psychiatric medications or ongoing therapies?

Past Medical HistoryAny PMH? Medications or allergies? Any drug or alcohol use (including herbal/alternative/over-the-counter remedies).

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Family HistoryWho is in the family? Any dependents? Any hx of mental illness/substance abuse/SH or suicide in the family?

Personal/Social HxWho do they live with? Any significant relationships/friends/support? What do they do? How are they financially? Any trouble with neighbours/court/police?

Assess coping methods and ability to seek helpWhat would happen if the patient left the assessment? Any future plans? What would happen if they felt suicidal again? What would they do to get help? Who would they contact? Do they think they are unwell or need help? Would they accept hospital admission if deemed necessary?

Risk factors for completed suicideStaticHistory of SHSeriousness of previous attemptPrevious<Recent MH hospitalisationHx of mental disorder, substance abuse, personality disorder or traitsChildhood adversityFH of suicideAge, sex, marital status

DynamicActive suicidal ideation, communication, intentHopelessnessPoor treatment adherenceSubstance abusePsychiatric admission/dischargePsychosocial stressProblem solving deficits

FutureAccess to preferred/lethal methodDisengaging from servicesNon-adherenceNot responding to treatmentFuture stress

Extra resources:Columbia Suicide Severity Risk Scale (C-SSRS), a validated research tool for suicide risk.

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Beck Suicide Inventory (BSI), a useful clinical tool used in psychosocial assessments.

Mental Capacity Act and Mental Health Act: Supporting information for students to apply to cases

Mental Capacity Act: a recapThe Mental Capacity Act (MCA) is designed to protect and empower individuals who may lack the mental capacity to make their own decisions about their care and treatment. It is a law that applies to individuals aged 16 and over. It’s important to remember that we judge whether someone fails part of the two-stage test of capacity (having a disorder of brain or mind, being unable to weigh up information as part of decision making process) on the balance of probabilities. Often in psychiatry we are asked to give an opinion on someone’s mental state and whether this is affecting their ability to make a decision.

Useful resources: http://www.scie.org.uk/mca/practice

Why do we need the Mental Health Act?The vast majority of people with mental health problems want help and accept it voluntarily. If they need to come in to hospital it is under a voluntary or “informal” basis.

However, around ¼ of people in hospital are there without their agreement. But why? The most common symptom shared by people experiencing psychosis is loss of insight, so, many people do not believe that they are unwell, a risk to themselves, a risk to others, or in need of treatment.

The MHA 1983 (amended in 2007) provides statutory framework for mentally disordered patients to be detained in hospital, assessed and have their mental disorder treated against their will as a formal patient– colloquially known as being “sectioned”.

Who can be detained?For someone to be detained under the Act, the following criteria must be met:

The patient is suffering from a mental disorder* of a nature or degree which warrants the detention in a hospital for assessment, and

He/she ought to be detained in the interests of his/her own health or safety, or with a view to the protection of others

What is a mental disorder?Loosely defined under the Act as “any disorder or disability of mind”This includes mental illnesses (schizophrenia, BPAD, depression etc.), personality disorders, dementia, mental disorders due to drug use, mental disorders due to brain injury.

However, dependence on alcohol or drugs is excluded and you can only detain someone with a learning disability if it is associated with abnormally aggressive or irresponsible behaviour

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Who is involved in a MHA assessment?The most important person in the MHA Ax is the AMHP

AMHP – approved mental health practitioner. This is usually a social worker who has had higher training in mental health law. Other professionals such as nurses, pharmacists and occupational therapists are now permitted to perform this role, but rarely do in practice. They are the principle organiser of the MHA Ax and they make the application to detain someone. However, they need two medical recommendations to do so.

Section 12 approved doctors - is a medically qualified doctor who has been recognised under section 12(2) of the Act. They have specific expertise in mental disorder and have additionally received training in the application of the Act. They are usually psychiatrists, although some are general practitioners (GPs) who have a special interest in psychiatry.

Approved Clinicians (AC) and Responsible Clinicians (RC)An AC is a professional who is competent to become responsible for the treatment of a detained patient. They need special training and a portfolio of evidence. They are almost always a consultant psychiatrist but in some cases a clinical psychologist or nurse specialist could take on the role. An AC becomes the RC when they take over a patient.

Mental Health Act ManagersNon-executive members of the NHS trust board and lay associate members who represent the hospital. They hear appeals from patients detained under the act and review renewals of lengthy detentions. There are only two outcomes from a hearing; continue detention or discharge from section.

Mental Health Review TribunalsMental Health Review Tribunals also hear appeals against detention under the Act. Their members are appointed by the Lord Chancellor and include a doctor, a lawyer and a lay person. Detained patients have the right to be represented at MHRTs by a solicitor with legal aid. There are only two outcomes from a hearing; continue detention or discharge from section.

What are the sections?Most importantly, section 2&3Section 2 - 28 days detention in hospital for assessment. Treatment can also be given against their will if they do not consent. Leave must be granted by the consultant (called section 17 leave, which can stipulate where they go, who with, how long for etc. Leave is usually given in a graded fashion → accompanied in grounds → accompanied in community → overnight → weekend → weekly → discharge).

Section 3 – 6 months detention in hospital for treatment. Treatment can be given against their will for the first 3 months. If consent is not given after 3 months then a Second Opinion Approved Doctor (SOAD, an independent doctor, usually from another trust) will interview the patient, review notes, interview other professionals and say whether or not the treatment can continue to be given without consent, in the patient’s best interests.

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There is a safeguard in place for ECT. You cannot be given ECT if you refuse and have the capacity to do so, likewise if you have a valid advanced directive. However, the RC can authorise 2 ECTs in an emergency situation for people under section 3.

Leave needs to be given by the consultant (section 17, as above).

Other sectionsEmergency sectionSection 4 – this is when an AMHP and one section 12 doctor gives a recommendation. It is rarely used because in practice there is usually enough time to get a second medical recommendation.

Police sections Section 135 – a warrant is received from a magistrate for the police to enter someone’s home, place them under a s135 and take them to a place of safety to have a MHA Ax carried out. Section 136 – allows a police officer to take a person whom they consider to be mentally disordered to a “place of safety” (A&E, police cells, psychiatric assessment suite) where they can have a MHA Ax.

Holding powers to stop someone from leaving:When someone is admitted to a ward (any ward, medical, surgical, psychiatric) and wants to leave, but could pose a risk to themselves or others…..Section 5(4) – a nurse’s 6-hour holding power. You can physically prevent someone from leaving the ward by locking the door, call security or have the police bring them back. This buys you time until a doctor can see them. Section 5(2) – a doctor’s 72-hour holding power. Technically this should be the consultant in charge of the patient’s care, but is usually their nominated deputy (the oncall doctor for that specialty). A psychiatric on-call doctor cannot 5(2) a patient on a renal ward → it would be the renal consultant or their nominated deputy. At the end of the 72 hours the patient must either have a MHA Ax or be discharged by their consultant.

Community treatment order (CTO) and guardianship ordersThis is sometimes used to ensure a patient can be managed in the community e.g. if they fail to take medication and relapse, they can be brought straight back to hospital (CTO) of if they fail to reside at a specified address with curfew they can be brought straight back to hospital (guardianship).

What happens afterwards?People detained under section 3 are subject to section 117 aftercare and looked after using the Care Program Approach (CPA). Section 117 places a duty on the health and social services to make sure all the person’s needs (housing, benefits, medical, social) are looked after for as long as they have those needs.

People are managed according to CPA requires that health and social services assess need, provide a written care plan, allocate a care coordinator, and then regularly review the plan with key members of the MDT.

Psychological Medicine Overall Module Learning Outcomes

Learning Outcomes

At the end of the psychological medicine block you should be able to...

Covered/Achieved during Scholarship/Science;Practice;Professionalism.

LecturesSmall group teaching

Placement Tutorials

SDL

e-learning

Affective disorders: Depressive disorder & bipolar affective disorder

1.Evaluate epidemiological data in relation to affective disorders (e.g. prevalence, incidence, socio-demographics) and consider this in relation to patient management and care.

√ √ √ S

2.Recognise the clinical presentation and diagnosis of depressive disorder and bipolar disorder, based on the ICD-10 diagnostic criteria, as they may present in primary and secondary care.

√ √ √ S/P

3. Consider the spectrum of mood variation from normality to pathological. √ √ √ S

4.Assess the likely course and prognosis for a patient with a diagnosis of i) depressive disorder and ii) bipolar disorder.

√ √ √ S

5.Evaluate the biological, psychological and social factors that may influence vulnerability to affective disorders, including predisposing, precipitating and perpetuating factors.

√ √ √ S

6.Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis of i) depressive disorder and ii) bipolar disorder.

√ √ √ S/P

7.Appraise current pharmacological treatments (antidepressants, mood stabilisers including lithium and antipsychotics) including their mode of action and side effects.

√ √ √ S

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

8. Explain indications for ECT, its administration, evidence base and potential side effects. √ √ √ S

9.Appraise current non-pharmacological treatments and management options for affective disorders (including CBT and psychoeducation).

√ √ √ S

Schizophrenia & psychosis

1.Evaluate epidemiological data in relation to schizophrenia (e.g. prevalence, incidence, socio-demographics) and consider this in relation to patient management and care.

√ √ S

2. Recognise the clinical presentation and diagnosis of schizophrenia based on the ICD-10 diagnostic criteria. √ √ √ S/P

3. Assess the likely course and prognosis for a patient with a diagnosis of schizophrenia. √ √ √ S

4.Consider the advantages and disadvantages of the use of the terms “first episode psychosis” or “schizophrenia” in patients experiencing their first episode of psychosis.

√ √ √ S

5.Evaluate the biological, psychological and social factors that may influence vulnerability to schizophrenia, including predisposing, precipitating and perpetuating factors.

√ √ √ S

6. Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis of schizophrenia. √ √ √ S/P

7.Appraise current pharmacological treatments (antipsychotics, including clozapine) including their mode of action and side effects.

√ √ √ S

8 Appraise current non-pharmacological treatments and management options. √ √ √ S

Anxiety disorders: Generalized anxiety disorder, phobias, panic disorder, obsessive compulsive disorder, post-traumatic stress disorder

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

1.Evaluate epidemiological data in relation to anxiety disorders (e.g. prevalence, incidence, socio-demographics) and consider this in relation to patient management and care.

√ √ √ S

2. Recognise the clinical presentation and diagnosis of the anxiety disorders listed above based on the ICD-10 diagnostic criteria. √ √ √ S/P

3. Assess the likely course and prognosis for a patient diagnosed with an anxiety disorder. √ √ √ S

4.Evaluate the biological, psychological and social factors that may influence vulnerability to these anxiety disorders, including predisposing, precipitating and perpetuating factors.

√ √ √ S

5. Develop a basic biopsychosocial management plan for a patient with an anxiety disorder diagnosis (listed above). √ √ √ S/P

6.Appraise current psychological and pharmacological treatments for these anxiety disorders (including specific treatments such as exposure response prevention-CBT, trauma focused psychological therapy, graded exposure).

√ √ √

S

Eating disorders: Anorexia nervosa & bulimia nervosa

1. Recognise the clinical features of eating disorders. √ √ √ S

2. Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis of i) anorexia nervosa and ii) bulimia nervosa.

√ √ √ S/P

Risk assessment & management

1. Recognise the static and dynamic factors associated with risk; for harm to self or others and also risk of vulnerability and neglect. √ √ √ √ √ S

2. Conduct an assessment of risk to self and to others. √ √ P

3. Create and communicate an appropriate risk management plan. √ √ √ P

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

4. Evaluate issues of risk in a balanced and informed way, which counteracts inaccurate and stigmatising attitudes. √ √ √ √ √ S

Addiction psychiatry

1. Demonstrate the ability to take a detailed addictions history. √ √ P

2. Recognise the main signs of intoxication of commonly abused substances. √ √ √ √ S

3.Identify the physical signs, symptoms and management of i) alcohol dependence and withdrawal and ii) opiate dependence, including tolerance and withdrawal symptoms.

√ √ √ √ S

4. Recognise the signs and symptoms of opioid overdose. √ √ √ √ S

5. Examine the relationship between substance misuse and mental illness. √ √ √ √ S

Liaison psychiatry

1.Identify common psychiatric disorders (e.g. depression, anxiety, delirium) and medically unexplained symptoms in patients in general medical settings.

√ √ √ S

2. Examine the bi-directional relationship between physical health and mental health. √ √ √ S

3.Review potential psychological mechanisms underlying medically unexplained physical symptoms, somatoform and dissociative/conversion disorders.

√ √ √ S

Peri-natal psychiatry

1. Evaluate epidemiological data in relation to peri- and post-natal mental illness (e.g. prevalence, incidence, socio-demographics) and consider this in relation to patient management and care.

√ √ √

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

2. Evaluate the benefits and risks of psychotropic medication use in pregnancy and breastfeeding. √ √ √

Older adult mental health

1. Recognise common psychiatric disorders (dementia, depression, anxiety, psychosis, mania) seen within the older adult population. √ √ √ √ S

2.Differentiate between the cognitive, emotional and behavioural manifestations of common cognitive disorders including delirium and dementia syndromes.

√ √ √ √ S

3.Differentiate between potential causes of cognitive impairment (e.g. dementia, depression) and identify the basic diagnostic tools that may help with this process.

√ √ √ S

4.Recognise the symptoms and consider the aetiology of the main types of dementia, including Alzheimer’s disease, vascular dementia, Lewy body dementia and frontotemporal dementia.

√ √ √ S

5. Develop a basic biopsychosocial management plan for a patient with an ICD-10 diagnosis of dementia. √ √ √ S/P

6. Identify common psychopharmacological treatments that may be used to treat a patient with a diagnosis of dementia. √ √ √ S

7.Consider the presentation, risk assessment/management and treatment of older adult mental health patients and how this contrasts with that of younger adults.

√ √ √ S

Personality disorders: Emotionally unstable personality disorder & dissocial personality disorder1. Assess the relevance of personality factors to healthcare √ √ √ √ S

2. Review the classification of personality disorders √ √ √ √ S

3. Recognise the clinical features of borderline and antisocial personality disorders √ √ √ √ S

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

4. Review the general clinical approach to the patient with a personality disorder diagnosis √ √ √ √ S

Child & adolescent mental health

1. Recognise core psychiatric disorders (depression, anxiety, attention deficit hyperactivity disorder [ADHD] and autism) as they present in childhood and adolescence and review the basic principles of assessment and treatment.

√ √ √ √ S

2. Recognise the clinical presentation of ADHD based on the ICD-10 diagnostic criteria (hyperkinetic disorders). √ √ √ √ S/P

3. Develop a basic biopsychosocial management plan for a child/adolescent with an ICD-10 diagnosis of ADHD, including both pharmacological and non-pharmacological interventions.

√ √ √ √ S/P

4. Consider the assessment, presentation, risk management and treatment of child & adolescent mental health patients and how this contrasts with that of adult patients.

√ √ √ √ S

5. Recognise the importance of including families, carers and schools in the assessment and management of children and adolescents with mental health problems.

√ √ √ √ S

Learning disability psychiatry

1. Recognise the nature and presentation of learning disability. √ √ √ S

2. Evaluate common causes of learning disability focusing on pre-, peri- and post-natal factors (including genetic causes, e.g. Fragile X syndrome & Down’s syndrome)

√ √ √ S

3. Examine the range of common physical and mental health problems experienced by people with learning disability. √ √ √ S

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

4. Evaluate the ways in which learning disability can impact on patient assessment and management in psychiatry and how this can apply to medicine more broadly.

√ √ √ S

5. Communicate effectively with people with learning disability √ P

Mental Health Act & Mental Capacity Act

1. State the doctor’s duties and the patient’s rights under the appropriate mental health and mental capacity legislation. √ √ √ S

2. Appraise the general principles of detention under the Mental Health Act as applicable under sections 2, 3, and 5(ii). √ √ √ S

3. Assess a patient’s capacity to make a particular decision in accordance with legal requirements and the GMC’s guidance. √ √ √ P

Communication skills (please also refer to communications skills handbook)

1. Demonstrate the skills required for efficiently gathering information from the patient initially listening to their story and using open questions before moving to more closed and focused questions.

√ √ P

2. Demonstrate effective listening and clarification of information through the use of summaries. √ √ P

3. Demonstrate the use of appropriate language and terminology when interacting with, or referring to, patients with a mental illness.

√ √ P

4. Communicate effectively with patients, their family members and multi-disciplinary colleagues about the nature, diagnosis, management and prognosis of common psychiatric disorders.

√ √ P

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

5. Communicate with patients and colleagues about the range of services and professionals involved in the care of people with mental disorders, including the role of self-help, service user and carer groups.

√ √ P

Specific clinical skills

1. Take a full psychiatric history √ √ √ √ P

2. Complete a comprehensive informant interview to gather information from family members or friends of patients √ P

3. Carry out a mental state examination including a cognitive assessment. √ √ √ √ P

4. Produce a formulation of a case with a differential diagnosis. √ √ √ P

5.Produce a comprehensive biopsycosocial management plan taking into account the following contextual factors: accommodation, education, finance, treatment, relationships, personal care/physical wellbeing, social/cultural, work.

√ √ √ P

6.Prescribe psychotropic medication safely, effectively and economically, bearing in mind important drug interactions and common, notable and serious drug interactions.

√ √ √ √ S

7.Provide immediate care in psychiatric emergencies (such as de-escalation techniques and rapid tranquilisation), which may occur in psychiatric, general medical or other settings.

√ √ S

8.Identify which physical investigations should be carried out when patients present with psychiatric symptoms and when starting psychotropic medication.

√ √ P

9.Demonstrate an awareness of the potential to do psychological harm to patients, for example, by providing untrained or unsupervised psychotherapeutic interventions or fostering inappropriate doctor-patient attachments.

√ Prof

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Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

10. Construct an appropriate referral to psychiatric services. √ √ P

11. Recognise the importance of multidisciplinary teamwork in the field of mental health. √ Prof

Other topics

1.Use clinical cases encountered on placement as a basis for in depth reading, and critical appraisal, and apply this to your practice in an evidenced based way.

√ S/P

2.Evaluate the strengths and weaknesses of the current diagnostic approach to psychiatry and what constitutes a relevant ‘disorder’.

√ √ √ √ S

3. Contrast between mental illness and the range of normal responses to stress and life events (including bereavement). √ √ √ S

4.Evaluate the genetic contribution to psychiatric disorders and the major approaches and recent findings to have emerged in psychiatric genetics.

√ √ S

5. Evaluate the relationship between mental illness and the social, economic and physical environment. √ √ S

6. Examine the role of diversity in mental health in terms of service access and patient outcomes. √ √ S

7. Assess the causes and consequences of stigma and discrimination in relation to mental illness. √ √ √ S

8.

Demonstrate an awareness of ethical dilemmas in psychiatry (for example, compulsory treatment; ethical issues related to the detention and treatment of a patient against their will).

√ √ √ S

40

Learning Outcomes

At the end of the psychological medicine block you should

Covered/Achieved during Scholarship/Science;Practice;Professionalism.Lectures

Small group teaching

Placement Tutorials

SDL

e-learning

9.

Demonstrate an understanding of how disorders of the brain/mind are of equal importance to disorders of other parts of the body.

√ √ √ S

10.

Demonstrate an understanding of why psychiatric patients deserve the same high standard of medical care as all other patients.

√ √ √ S

11.

Evaluate the impact of mental illness on an individual and those around them. √ √ √ S

12.

Reflect on how working in health settings may impact upon your own health and that of colleagues. √ √ √ Prof

13.

Recognise the importance of seeking professional help if you yourself develop mental health problems. √ √ √

Prof

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