Clinical Psychologists and Psychiatrists

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Clinical Psychologists and Psychiatrists

• How They Work Together to Produce Better Outcomes
• Simone Pica
• Chief Psychologist The Melbourne Clinic

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Areas to be Covered

• Clinical Psychologists and Psychiatrists - Health
  Providers
• The Melbourne Clinic- The Treatment Setting
• Onset of Mental Disorders and types
• How we work together- Treatment Specialisations,
  Assessment,Treatment Planning, Provision of
  Treatment and Ongoing Challenges

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Clinical Psychologists

• Psychologists are specialists in human behaviour,
  development and functioning. They have expertise
  in conducting research and applying research
  findings in order to reduce distress, address
  behaviour and psychological problems, and to
  promote good mental health.
• Today, most psychologists tend to specialise in
  one or more areas. To date the APS has 9 colleges
  including Clinical Neuropsychology Clinical
  Psychology. Couselling Psychology, Educational
  Psychologists and Forensic Psychologists

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• Of these specialties, Clinical Psychologists are
  trained to work with people with mental disorders
• IN brief, Clinical Psychologists are specialists
  in the assessment, diagnosis and treatment of
  psychological problems and mental illness.
• They work with children, adolescents, adults and
  the elderly in a range of agencies including
  public and private hospitals, private practice
  and general medical services

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Skills and Competencies of Clinical Psychologists

• 1. Psychological assessment and diagnosis
• Clinical psychologists have specialist training
  in the assessment and diagnosis of major mental
  illnesses and psychological problems. Clinical
  psychologists are qualified to provide expert
  opinion in clinical, compensation, educational
  and legal jurisdictions.

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Clinical Psychologists cont.

• 2. Treatment
• Clinical psychologists are trained in the
  delivery of a range of (non-drug) techniques,
  strategies and therapies with demonstrated
  effectiveness in treating mental health
  disorders. They are specialists in applying
  psychological theory and scientific research to
  solve complex clinical problems requiring
  individually tailored interventions.
• 3. Research, teaching and evaluation

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Psychiatrists

• Psychiatrists are specialist medical doctors who
  diagnose and treat mental disorders.
• Qualifying as a psychiatrist involves first
  obtaining a medical degree and then undertaking a
  minimum of 5 years postgraduate specialisation
  in psychiatry.

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• The nature of their training means that
  psychiatrists have a strong grounding in both
  biological and psychological frameworks for
  understanding mental disorders. They are trained
  both to recognise and treat the effects of
  emotional disturbances on the body as a whole, as
  well as the effects of physical conditions on the
  mind

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Differences between Clinical Psychologists and
Psychiatrists

• A Psychiatrist is required to complete a medical
  degree prior to specialising in mental disorders
  including biological conditions (psychiatrists
  are physicians)
• A Psychiatrist can prescribe medication a
  Clinical Psychologist cannot.
• Clinical Psychologists have specialist training
  in non-medical interventions (psychological) and
  work closely with Psychiatrists
• Psychiatrists should be able to provide
  biological, psychological and social treatments

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The Melbourne Clinic The Treatment Setting

• The Melbourne Clinic (TMC) is a purpose built
  psychiatric hospital established in the 1970s
  and was initially privately owned by a group of
  psychiatrists. Since 1985 it has been managed by
  Healthscope Limited
• TMC is the largest and longest established
  private psychiatric hospital in Australia. It has
  106 beds, well over 100 accredited psychiatrists
  and employs a multi-disciplinary team including
  psychiatrists, nurses, psychologists, social
  workers, occupational therapists and dieticians

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Inpatient Programs - TMC

• TMC provides a comprehensive range of inpatient
  and day programs as well as an outreach program
• The Inpatient Programs include
• General Psychiatry (Living Well Program group
  interventions)
• Intensive Psychiatric Care
• Older Persons Psychiatry Unit
• Professorial Unit
• Anxiety and Depression Program
• Obsessive Compulsive Disorder Program
• Eating Disorders Program
• Substance Withdrawal Program

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Day Programs - TMC

• The Day Programs Include
• Life strategies program
• Sills-based Psychosocial Program
• Anxiety Day Treatment Program
• Depression Management Program
• Managing Bipolar Disorder Program
• Mindfulness Based Cognitive Therapy
• Dialectical Behaviour Therapy Program
• Eating Disorders Program
• Outreach Program -The outreach program provide
  assessment, support, rehabilitation and treatment
  in their own home and local community

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Onset of Mental Disorders

• One in 5 Australians will suffer from a mental
  disorder at some point in their lives. 
• A mental disorder is a health problem that
  significantly affects how a person thinks,
  behaves and interacts with other people and
  functions in their daily life.
• Mental disorders are diagnosed according to
  standardised criteria. One of the major wordwide
  classificatory systems is the Diagnostic and
  Statistical Manual of Mental Disorders (DSM

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What causes Mental Disorders?

• Mental illness results from complex interactions
  between the mind, body and environment.
• Factors which can contribute to mental disorders
  are
• Biological factors
• Including genetics, neurochemistry, diseases of
  the brain, physical illness drugs affecting the
  brain (use of alcohol, drugs and other substances
  ),
• Psychological factors
• Including cognitive styles such as constant
  negative thoughts about the self and the world,
  personality styles including avoidance, low self
  esteem and confidence, poor coping styles and
  poor problem solving approaches

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What Causes Mental Disorders cont.

• Social factors
• Including life events, long-term and acute stress
  in all areas of ones life (e.g. personal.
  family, work, relationships, financial), trauma,
  violence
• Work stress is categorized under social factors.
  Apart from major physical injuries and exposure
  to or involvement in a traumatic event, patients
  often report work stress as the significant
  contributing factor which was an ongoing event
  which wasnt addressed nor resolved.
• Common examples include harassment, bullying,
  little or no supervision or training, work
  overload, poor communication/support or
  difficulties with managers/supervisors.

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Types of Mental Disorders

• Mental disorders are of different types and
  degrees of severity. Some of the major types of
  mental disorders include
• Depression
• Bipolar Disorder
• Anxiety Disorders
• Schizophrenia
• Drug and Alcohol Disorders

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Mood DisordersDepression

• The term depression is used to describe feelings
  of sadness and grief, which many people
  experience at some stage.
• Reactive Depression - depression in response to a
  distressing event, such as bereavement,
  relationship breakdown or loss of a job. The
  feelings are more severe or persistent than
  normal unhappiness and symptoms often include
  anxiety, sleep problems and changes in eating
  habits.

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Mood Disorders cont.

• Endogenous or Major Depression - more severe than
  in reactive depression and there may or may not
  be a triggering event.
• Symptoms include sleep disturbance, appetite or
  weight changes, sadness or irritability, loss of
  interest in work or hobbies, loss of sexual
  interest, fatigue, poor concentration, difficulty
  making decisions, guilt and poor self-esteem or
  suicidal thoughts. Symptoms are persistent and
  severe and may leave the person unable to
  function or care for themselves.

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Mood Disorders cont.

• Bipolar Mood Disorder (previously called Manic
  Depression) - extremes in mood, with periods of
  depressed mood alternating with periods of mania.
  The manic phase may involve extreme happiness,
  overactivity, rapid speech, reduced need for
  sleep, a lack of inhibition, irritability with
  those who question them, and grandiose plans and
  beliefs

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Anxiety Disorders

• Anxiety refers to the physical, mental and
  behavioural changes we feel in response to a
  threat.
• These changes are sometimes referred to as the
  'fight or flight' response, because they prepare
  us to respond to danger.
• Some anxiety is inevitable in today's society and
  in many situations it is an appropriate and
  reasonable response. Anxiety disorders are
  different from 'everyday' anxiety in being more
  intense and persistent, to a degree which
  interferes with a person's life.

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Anxiety Disorders cont.

• Panic attack - a sudden feeling of panic
  associated with physical symptoms like shortness
  of breath, dizziness, chest pain, an urge to
  flee, difficulty gathering thoughts, fear of
  dying or losing control
• Some anxiety disorders include panic disorder,
  agoraphobia, phobias

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Anxiety Disorders cont.

• Obsessive-Compulsive Disorder - a person
  experiences obsessions (persistent, unwanted
  thoughts) and compulsions (being driven to
  perform a ritual or behaviour) and causes
  disruption to their everyday life.
• Generalised Anxiety Disorder - excessive
  general worry and anxiety and is very difficult
  for the person to control.
• Post-traumatic Stress Disorder (PTSD) -
  recurrent feelings of terror, frightening dreams
  or relived memories which result from a previous
  traumatic event memories or flashbacks may be
  triggered by a particular event and are
  intrusive, interfering with everyday life.

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Schizophrenia

• Schizophrenia is characterised by unusual or
  bizarre thoughts and emotions that others
  consider inappropriate. Schizophrenia is not a
  'split personality. The term refers to changes
  in the person's mental and social functioning,
  when their thoughts and perceptions become
  disordered.
• Symptoms of schizophrenia include hallucinations,
  delusions and problems with feelings, behaviour,
  motivation and speech. People may have
  disorganised thoughts and difficulty
  concentrating. A collection of such symptoms is
  sometimes termed psychosis, and can occur in
  other disorders as well, for example in severe
  depressive illnesses

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Substance Use Disorders

• People with substance use disorders have
  generally taken one or more drugs of abuse over
  an extended period, and are showing various
  behavioural, physical and psychological symptoms.
  
• People may develop substance use disorders for a
  number of reasons, such as anxiety or depressive
  disorders, a family history of substance abuse,
  being prone to the effects of stress and tension,
  or experiencing psychosocial problems (e.g. work
  stress, family problems, and relationship
  breakdown). Addiction may have both physiological
  and psychological components

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Overview of Psychological and Medical Treatments

• Psychological Treatments
• Psychotherapy is a useful treatment for may
  mental disorders including depression and anxiety
  disorders
• There are many types of psychotherapies including
  Cognitive Behavioural Therapy (CBT) which is an
  evidence based treatment that has been evaluated
  and proven to be effective.
• Historically, this treatment was viewed as two
  separate therapies which today are used in
  combination to treat mental disorders

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Psychological Treatments cont.

• Cognitive Therapy- the aim of cognitive therapy
  is to help individuals realise that they can
  influence their emotions by identifying and
  changing their thoughts and beliefs.
• when people are depressed, for example, they
  often think very negative thoughts about
  themselves, their lives and the future. This in
  turn further worsens their mood.
• Cognitive Therapy focuses on discovering and
  challenging unhelpful assumptions and beliefs and
  developing balanced thoughts, more realistic,
  rational ones

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Psychological Treatments cont.

• Behaviour Therapy focuses often maladaptive
  behaviours that occur during an episode of mental
  disorder.
• Behaviour therapy aims to identify and change
  aspects of behaviour that may perpetuate or
  worsen a persons mental disorder.
• Some behavioural strategies include skills
  training, goal setting, activity scheduling and
  structured problem solving
• These 2 therapies, more commonly known as CBT,
  have been found to be effective either on their
  own for certain disorders or in combination with
  psychiatric medications

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Psychiatric Medications

• Psychiatrists are experts in prescribing and
  monitoring psychiatric medications.
• Medications are the cornerstone of treatment for
  most mental disorders. Medications will alleviate
  or ease symptoms for most people. The ongoing use
  of medications will assist in stabilising
  symptoms and preventing relapse.
• Medications have both desired effects (e.g.
  reducing symptoms) and undesired effects commonly
  called side effects (e.g. drowsiness).
• The aim is to find medications that are tolerable
  and have the least number of side effects as well
  as effectively reducing symptoms. Adherence to
  medications is much more likely when it is clear
  that the benefits of taking the medication
  outweigh the costs.

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Psychiatric Medications cont.

• A feature of most psychiatric medications is that
  they may only begin to have a beneficial effect
  over several weeks. It is useful for the
  psychiatrist to provide information about
• The name of the medication, what it is supposed
  to do, and when it should begin to take effect
• How it is taken and for how long this might be
  necessary
• Any food, drinks, other medicines the person
  should avoid while taking this medication
• Possible side effects and what should be done
  if they occur
• Sources of information about this medication
  (e.g. pamphlets).

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Medications for Depression

• These are used for treating symptoms of
  depression, such as persistent sadness,
  hopelessness, poor appetite, insomnia, lack of
  energy, difficulty in concentrating and
  diminished interest in usually pleasurable
  activities.
• Selective serotonin reuptake inhibitors are most
  commonly prescribed because of their safety and
  tolerability.
• Selective serotonin re-uptake inhibitors (SSRIs)
• Generic name Common brand names
• citalopram Cipramil, Celapram, Talam, Talohexal
• escitalopram Lexapro
• fluoxetine Genrix, Fluohexal, Lovan,
• Prozac, Zactin
• Fluvoxamine Faverin, Luvox, Movox
• paroxetine Aropax, Oxetine, Paxetine
• sertraline Xydep, Zoloft

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Mood Stabilisers

• Medications for mood disorder
• Mood stabilizers are medicines that reduce the
  symptoms of acute manic and depressive episodes.
  They also prevent the recurrence of mania and
  depression in bipolar disorder
• when taken regularly over an extended period of
  time.
• Generic name Common brand names
• carbamazepine Tegretol, Teril
• lithium carbonate Lithicarb, Quilonum SR
• sodium valproate Epilim, Valpro

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Medications for Anxiety Disorders-anxiolytic
medications

• They are also useful in helping to manage
  agitation. Some are used to help people to sleep.
• Antidepressant medications, particularly the
  SSRIs, are used to treat a range of anxiety
  disorders without the tolerance and dependence
  problems associated with benzodiazepines (Valium
  and drugs like it).
• Benzodiazepine medications
• Generic name Common brand names
• Alprazolam Kalma, Xanax Alprax
• Diazepam Atenex, Ducene, Valium
• lorazepam Ativan
• oxazepam Alepam, Murelax, Serapax

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Antipsychotic Medications

• Medications for psychosis
• Antipsychotic medications are used for treating
  schizophrenia,
• schizophreniform psychosis, schizoaffective
  disorder, substance induced psychosis and other
  conditions where psychotic symptoms
• (ie. hearing voices, hallucinations
  disorganised thinking or
• delusional ideas) are present.

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Antipsychotic medications cont.

• Atypical antipsychotic medications
• Generic name Common brand names
• Amisulpride Solian
• Aripiprazole Abilify
• clozapine Clozaril,Clopine
• olanzapine Zyprexa

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Working Together The Assessment and Management
of Mental Disorders

• 1.To engage the patient in the treatment process
  from the initial stage, beginning with the
  initial interview. Failure to do so often results
  in an incomplete assessment which will then limit
  how management should proceed
• 2.To conduct a thorough psychiatric,
  psychological, social and medical assessment
  (including a suicide assessment)
• 3. Decide where the patient should be treated, in
  hospital or the community and give a thorough
  explanation to the patient if they need to be
  hospitalised

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• 4.To provide education and support for the
  individual and family
• 5.To treat the mental disorder, e.g. depression
  and associated depressive features with
  psychiatric medication and CBT
• 6.To address and improve overall behavioural
  functioning and always aim to treat the person
  for return to their employment
• 7.To monitor the persons condition and work
  toward preventing relapse or recurrence of their
  mental disorder

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2. The Assessment

• What are the sign and symptoms of the illness?
• What is the risk of self-harm, or harm to others?
• How disabling is the illness?
• The individuals general level coping and
  functioning
• Is their any evidence of a previous or ongoing
  mental disorder?
• Whether there is any family history of mental
  disorders

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The Assessment cont.

• Whether there were any triggers to the disorder,
  and if there were, what was their meaning to the
  individual
• If there were triggers, did they entirely cause
  the mental disorder, or did they trigger or
  worsen the persons exisiting condition
• The nature of family or friendship supports
• Their personality style
• Their drug and alcohol history
• Whether there are any relevant medical problems
• What is their understanding/explanation of their
  current condition?

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Clinical Psychologists Assessments

• A well know test which is used worldwide is the
  MMPI
• The MMPI is composed of 567 true/false items.
  Personality inventories like the MMPI are
  intended to discover what the individual is like
  as a person. A number of areas are assessed by
  the MMPI to answer such questions as "Who is
  this person and what would they typically feel,
  think and behave? What psychological problems and
  disorders are relevant to this person right now?
  What is the prognosis likely to be and what
  difficulties will they experience in their
  recovery

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Psychiatrists Assessments

• Psychiatrists must perform a medical assessment
  in addition to the psychiatric interview. Various
  test and investigations are used to determine if
  there is a medical problem causing/contributing
  to the mental disorder
• Some tests include relevant special
  investigations bloods, ECG, CT or MRI scans

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3. Where should the person be treated?

• Most people prefer not to go to hospital and the
  majority of the time people can be treated in the
  community.
• In some instances hospitalisation will be both
  necessary and beneficial. Especially if the
  person cannot guarantee their safety of if they
  are seriously unwell and are unable to care for
  themselves without assistance.
• People may also be admitted to hospital for
  specialised medical and psychological treatments.

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4. Psychoeducation and Support for the Family

• The main goal of education is to facilitate
  understanding about the disorder and its
  management
• A mental disorder is an illness, not a sign of
  weakness. Recovery is the rule, not the
  exception.
• Treatment is effective and there are many
  treatment options available.
• The goal of treatment is to get well and minimise
  relapse.

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4.Psychoeducation and Support for the Family cont.

• Treatment options (i.e., psychotherapy,
  medication) and relevant information about each
  alternative (e.g., side effects, duration,
  costs).
• Recognising and acting upon early warning signs
• Managing ongoing stressful problems that directly
  impact on recovery

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5. Medical and Psychological treatments in
combination

• The essential features of the management of most
  mental disorders involve physical treatments
  and/or psychotherapy. Physical treatments involve
  the administration of psychiatric medication.
  Psychotherapy includes CBT.
• The choice of psychiatric medication is based on
  a number of factors but is best made in
  consultation with specialist psychiatric opinion.

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Cognitive Therapy

• Individuals who are depressed or anxiously show a
  style of thinking that focuses on negative views
  of the world, themselves as individuals, of their
  experiences, and of their future. They come to
  think of themselves as worthless and of the world
  as being a bad or unfair place, without hope of
  their lives improving in the future.
• Some classic irrational beliefs which depressed
  or anxious people believe include I will never
  get better, If I were a better/smarter person
  this would never had happened to me, I wont be
  able to cope when I return to work, People dont
  wont to be with me because I am crazy, nothing
  can help me, If I did things perfectly then
  everything would be OK
• The aim of cognitive therapy is to help
  individuals identify, challenge or test their
  belief and correct their distorted and
  negatively-biased thoughts with a more reasonable
  and realistic thought.

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6. Improving Behavioural Functioning

• In addition to tackling the symptoms of mental
  disorders, the challenge to a full recovery often
  relies on the person being able to pick up and
  carry on at the level they did before becoming
  unwell.
• Mental disorders lead to a decline in
  functioning where the person may not be able to
  look after themselves as well as they did before,
  stop them form returning to work, a general
  slowing in their performance of activities and
  avoidance of family and friends.
• It is vital to monitor and tackle these problems
  from the beginning which can get worse over time
  and the individual struggles enormously to
  overcome.
• Behavioral strategies are vitally important in
  addressing these problems by addressing what
  problems the individual is experiencing and
  planning how to tackle them.

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6. Improving Behavioural Functioning cont.

• Patients will often show signs of getting worse
  when faced with ongoing stressors such making
  claims for their work injuries which is a painful
  and protracted process.
• Ongoing therapy and skills training (e.g. dealing
  with difficult situations, maintaining good
  physical health, exercise, learning how to
  communicate and assert oneself more effectively,
  overcoming inactivity, planning activities in
  advance, engaging in pleasant events with other
  people) are all important strategies.
• Monitoring the use of poor coping strategies is
  also important such as the use of drugs and
  alcohol, not taking medications regularly,
  missing appointments
• Improving the individuals ability to function is
  important to avoid demoralization and the person
  giving up

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7. Preventing Relapse

• Ongoing treatment involves the identification of
  conditions where the person may relapse or have a
  set back. In general the following need to be
  monitored and addressed by the patients Clinical
  Psychologist and Psychiatrist
• The first step is to identify high risk
  situations. These situations may include
  relationship break-ups, moving house, illness,
  or financial and status losses e.g.loss of a job,
  loss of a role

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7. Preventing Relapse cont.

• It is vital to help the person plan how they can
  respond most effectively in these situations. One
  aim of planning is to encourage individuals to
  realise that they can cope with these situations
  if they do indeed occur
• As with many mental disorders it is likely that
  some individuals will be able to identify changes
  in their thoughts, feelings, or behaviours which
  may signify that they are becoming unwell again.
  By being aware of early warning signs and acting
  immediately on these signs it may be possible for
  the individual to decrease the potential severity
  and duration of the episode.
• Ongoing adherence to medication and psychological
  treatment is likely to minimise relapse