Mental health issues in Lincolnshire

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Mental health issues in Lincolnshire
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The Big Picture
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Viewpoint
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• Psychiatry has been described as 1 molecular
  biology and 99 gossip
• For some people thats not nearly enough gossip.

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Perspectives on the world

• Constructivist versus Positivist battle rages on
  in research, education, psychology and management

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Positivism Constructivism

• World exists independently of our ability to know
  it
• True knowledge about the world is possible and
  achieved by use of scientific method

• World does not exist independently and is
  constructed by human beings as part of an
  interaction
• True knowledge not possible, only an
  understanding of different constructions and
  interpretations

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Lincs Partnership Foundation Trust
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Adult Division
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• Modern life is rubbish

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Is there a future for psychiatry as a profession?

• Despite Psychology being one of the most popular
  undergraduate choices, within medicine only 3 of
  graduates choose Psychiatry as a career
• Following MMC many of our training posts are
  vacant
• Many roles are being delegated or transferred to
  others

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Societys Fear of Chemistry

• Rise of complementary therapies
• Rise of organic and health foods
• Poor compliance with prescribed drugs
• Careless uses of medication
• Low risk taking in prescribing
• Persecution of illicit drug users
• Rehash of anti-psychiatry movement
• Suspicion of big drug companies

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Post colonial position of psychiatrists

• Psychiatrists are handing over power to others
  (e.g. RMO status, admitting rights)
• Managerialists are the new secular rulers
• There is still fierce fighting between tribes,
  both in the capital and countryside

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New ways of working

• Inpatient/ acute care specialists
• Abolition of old style outpatient clinics
• Delegation of caseloads to non medical staff
• Frees up time for urgent, complex cases and
  liaison
• Separate services for AOT and early intervention
  in psychosis

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Education, education and education

• a subject is something you 'take' and when you
  have taken it, you have 'had' it, and if you have
  'had' it, you are immune and need not take it
  again.
• (The Vaccination Theory of Education?) -
  'Independent' Editorial 7/1/00

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education education education

• It is in fact nothing short of a miracle that
  the modern methods of instruction have not yet
  entirely strangled the holy curiosity of inquiry
  for this delicate little plant, aside from
  stimulation, stands mainly in need of freedom
  without this it goes to wrack and ruin without
  fail

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Education, education, education

• Relaxed alertness
• Orchestrated immersion
• Active processing

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Concerns about the New Orthodoxy in medical
education

• Learner centred approach
• Portfolios, formative assessments, workplace
  based assessments, 360 etc may not be brain
  friendly
• Psychometric properties of soft assessment are
  dubious impact may be reduced to obtain
  validity or reliability
• Mental health skills particularly difficult to
  assess

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Predicting the future
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SWOT
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Strengths

• New mental health and mental capacity acts
• Growth of CBT and IAPT services in primary care
• Stepped managed care in milder illness
• NICE guidelines for Personality Disorder
• New Care program approach
• New ways of working for psychiatrists

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Teenagers

• UNICEF survey shows that UK children are the
  unhappiest in Europe

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Early intervention

• Based on notion that early intervention may
  reduce the trajectory of the illness and reduce
  future disability
• Duration of Untreated Psychosis (DUP) is related
  to severity and outcome
• Effect of DUP may be predominantly socially
  mediated rather than due to nature of illness or
  cerebral damage

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Mental health act

• Mental disorder not defined or categorised
• Available treatment concept replaces
  treatability
• People other than doctors can be responsible
  clinician
• People other than social workers can be AMPs
• Community treatment order

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Available treatment

• Medical treatment concept has gradually expanded
• Includes manifestations and consequences of
  illness, such as self harm
• Includes general care
• Need only prevent a deterioration
• Needs only to have the purpose of treatment, not
  the likelyhood of success
• 
  
  
  

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Weaknesses

• Product pipeline stenosis (drugs, specialisms)
• Buildings not fit for purpose
• Geographical radius problems with increased
  specialisation
• Demarcation disputes between specialities
• Discrimination against the elderly
• Isolation of community specialists
• Recruitment and training future specialists

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Opportunities

• IAPT and primary care services
• Risk assessment and Forensic services
• Further penetration of basic services such as CPA
  programs and first generation drug treatments
• New generation of acute care environments
• Third wave cognitive therapies

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IAPT

• Improving access to psychological treatments
• Following NICE guidelines for depression and
  anxiety and Layard report
• Conflation with primary mental health care
  services

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Layard report 1
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Layard Report 2
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Low Intensity Workers

• Similar to existing Graduate Mental Health
  Workers
• Training 1 day a week for one year University
  of Nottingham
• Deliver assessment, CCBT, self help, guided
  self help, groups

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High Intensity

• Cognitive behaviour therapists
• Training 2 days a week for a year Derby
  University
• Deliver CBT for anxiety disorders, depression,
  OCD PTSD
• Straightforward step 3

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The teams

• Primary Care Mental Health workers (low
  intensity/GMHWs)
• CPNs
• Counsellors
• CBT therapists
• Psychologists link with each team

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Hybrids
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Retro

• In the absence of new treatments some older
  treatments are being revived in new ways
• Combination drug therapies such as Mirtazapine,
  Lithium, Venlafaxine
• Hybrids between CBT and mindfulness
• Anticonvulsants and Pregabalin
• Penfluridol

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Threats

• Antidepressant bubble has probably burst
• CBT bubble may burst soon
• Professions ability to add value may be
  declining
• Political pressures may conflict with economy of
  scale

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Enterprises that failed to predict the effects of
the internet

• Currys
• WH Smith
• Banks
• Music industry
• Postal service
• Bingo, gambling
• Universities
• Professions and experts

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Trad-jazz musicians were introduced in an effort
to kickstart the local music scene. Everything
seemed to go to plan... unfortunately the jazz
musicians had no natural enemies, and in this
predator free zone of the New Town, they
started to breed like wildfire. Before long
they were taking over, and Milton Keynes was
plunged - into trad-jazz hell!
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How good is CBT?

• Relapse rate for schizophrenia reduced from
  45(treatment as usual) to 31 (at 24 months)
• Only 10 of psychotic patients achieved a 25
  reduction in PANSS score
• Long term follow up shows high morbidity rates in
  anxiety disorders, only 36 recovering.

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3rd wave CBT

• Wave one was Behavioural therapy
• Wave two was conventional CBT focusing on
  identifying and countering negative automatic
  thoughts
• Wave three attempts to avoid the mental
  battlefield by emphasising acceptance of ones
  thoughts as mindful observer

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Sell

• CBT
• Dynamic psychotherapy
• SSRIs apart from sertraline
• Atypical antipsychotics
• ECT
• Organised day services
• Low impact assessments

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Hold

• Client centred therapy
• Tricyclics
• Typicals and depots
• Assertive outreach
• Early intervention
• Multiple choice assessments

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Buy

• Stepped managed care
• 3rd wave CBT
• Neuroscience influenced therapies
• Forensic and secure
• New inpatient environments
• Generalists
• Apprenticeship learning

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beware

• unexpected items in the bagging area

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Back to the future?
Tower of Fools (Narrenturm), Vienna, 1784