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Recent Advances & Current Challenges in Psychiatry

Recent Advances & Current Challenges in Psychiatry. Dr. Naresh K. Buttan M.B.B.S., D.P.H., D.P.M., D.N.B. (Psy), C.C.S.T., Sec 12 (2) Approved Consultant Psychiatrist (Gen. Adult)- PCH CIC TPD (CPT)- HE SW Peninsula PGME Hon’ Fellow, AT & Locality Psych Lead- PCMD N.Buttan@nhs.net.

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Recent Advances & Current Challenges in Psychiatry

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  1. Recent Advances & Current Challenges in Psychiatry Dr. Naresh K. Buttan M.B.B.S., D.P.H., D.P.M., D.N.B. (Psy), C.C.S.T., Sec 12 (2) Approved Consultant Psychiatrist (Gen. Adult)- PCH CIC TPD (CPT)- HE SW Peninsula PGME Hon’ Fellow, AT & Locality Psych Lead- PCMD N.Buttan@nhs.net

  2. Psychiatry • Medical Specialty- subspecialties • Holistic view- Biopsychosocial model • Healthcare Services (NHS/ Pvt) – priorities • 3rd Sector – Insurance/ pharmaceuticals • Patients/ carers/ family- expectations • Society- understanding/ stigma • Stakeholders- plenty… Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  3. Recent Advances • Illness: • Epidemiology • Nosology/ diagnosis • Investigations: Aetiopathogenesis • Treatments: • Pharmacological • Psychological • Others Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  4. Recent Advances • Service models: • NHS • Social • Private • Legislations: • MHAct/ MCA/ DoLS • CQC/ IMCA/ IMHAs Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  5. Recent Advances-Epidemiology • Move from Descriptive to Analytical. • Community Epidemiological Surveys: • US – UK Mental Health Hospital Project 1965-70 • WHO- IPSS (International Pilot Study of Schizophrenia), 1968-74, 9 countries. • ECA (USA)- DIS (Diagnostic Interview Schedule- Structured tool); 1980-85. • National Comorbidity Surveys- (NCS, 1990-92), NCS- 2 (2001- 02), NCS – R (‘02), NCS – A. • WHO (ICD- DCR)- CIDI (Composite International Diagnostic Interview)- ICPE (International Consortium of Psychiatric Epidemiology, 1997). Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  6. Recent Advances- Epidemiology • WMH 2000 - World Mental Health 2000 initiative- CIDI surveys in 20 countries, findings: • Mental disorders- most prevalent chronic (Life Time to date- 50%, 12 months- 15-25 %) • Earlier onset (anxiety disorders- teenage) • Mental disorders- most impairing. • Most severe in surveys- diagnosable. • Of these only minority received treatments & only small minority received long treatments. • Underreporting- common, lower bound estimates Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  7. Recent Advances- Epidemiology • Modifiable determinants of illness onset: • Emerging evidence: Obstetric complications (Scz), Exposure to famine during childhood (ASPD), Early exposure to Pb (Alz.) • Non- specific risk factors: SLEs, Stress Buffering, Coping mechanisms • Modifiable determinants of illness course: • Primary prevention – impossible/ unrealistic. • Secondary Prevention (Health promotion) –school based interventions at young age, stress buffering skills. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  8. Recent Advances- Epidemiology • Genetic epidemiology: • Family, twin & adoption studies: higher rates in offsprings & 1st deg relatives (Scz, BPAD) • Chromosomal: deletions, mutations (Trisomy 21, Klinefelter XXY synd., Turner XO synd.) • Genetic: • Polymorphism→ molecular fn → behaviours • DNA sequence variation→ differences • STG (Serotonin Transporter Gene)- modulates influence of SLE on risk of Depression (3X Gen population) • Linkage or association studies. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  9. Recent Advances- Aetiopathogenesis • Older theories: structural or functional brain derangements, psychological/ behavioural, social. • Newer theories: recent advances in imaging→ subtle brain morphological changes (white matter, functional MRI, PET, SPECT- different rates of glucose uptake- specific brain areas), Neurohormones (HPA- stress response, HVA levels), genetics (STG, SNVs), biochemical changes in body, others (psychosocial). Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  10. Aetiology- Stress Diathesis Model CMDs Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  11. Recent Advances- Treatments • Biological: • Antipsychotics: SDAs (atypical), LAIs (depots), receptors- DA, MA, HT, GABA, NMDA. • Antidepressants: SSRIs, SNRI, NARI, NASSA, RIMA, 5HTagonist, ketamine, DBS. • Others- AEDs, GABAnergic, Z drugs, CEIs • Psychological: DBT, mindfulness, newer indications for known therapies. • Social: Nidotherapy, IPSERT Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  12. Recent Advances- Service Models • Socio- politico- economic drives: • NHS: ‘Liberating the NHS’ - April’13, DoH, 10 SHAs/ 152 PCTs- disappearing replaced by NHS CB (4 Regional Offices & 13 Area Teams), 152 Las, 211 Clinical Commissioning Groups (CCGs), HEE – 13 LETBs, PHE (4 regional & 1 local centres). • Social: SEs/ CICs, Social housing, others. • Private: healthcare - contractual issues, competition, Monitors in Foundation Trusts Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  13. Recent Advances- Laws • MHAct 1983- amendments 2007: • Changes in definitions, roles • Changes in sections & procedures • Addition of SCT (CTO), safeguards for patients • MCAct 2007/ DoLS 2009: safeguarding vulnerable • Bodies: • CQC & AIMS (RCPsych)- accreditations, checks, responsible for coordinating MHRTs, SOADs. • LAs/ NHS to arrange IMHAs/ IMCAs. • Court of Protection: Financial receivership/ appointee, Public Guardian or displacing /appointing Nearest Relative. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  14. Current Challenges • Needs. • Climate. • Resources. • Professional • Illness & treatments. • Social. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  15. Current Challenges- Needs • Demography: • Aging population: demands on services, shrinking workforce, complex needs, early diagnosis & treatment. • Nuclear families- single parents, urbanization, industrialization, early adversities. • Move to community: • Reduction of hospital beds- single rooms, separate sex wards, delayed admissions, early discharges, revolving door admissions • Community Based Interventions: CRHTs, Crises House, TCs • Expectations: • Patients: autonomy, respect, choices, rights • Society: humane, responsive, responsible • Professional: satisfaction, respect, autonomy, growth. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  16. Current Challenges- Climate • Social: • Availability, accessibility & approachability. • Diversity, globalization, information technology. • Political: • Governmental policies & priorities (‘No health without Mental Health’- DoH 2011) • Neighbourhood, migration, media, EWTD. • Economic: • Recession- cuts in funding • Currency of services- Payment by Results (PbR) • Cost- effectiveness: closures of specialist centres. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  17. Current Challenges: Resources • Manpower: • Shortage across spectrum: Centre for Workforce Intelligence (CfWI) report, Aug’11 • Poor recruitment, retention & early retirement. • Money: total cost to economy £32 bn (~ Defense budget) by mental health problems (The Sainsbury Centre for Mental Health, 2001) • Spending cuts- public sector/ services • Efficiency drive- current mantra. • Material: • Efficiency, efficacy, reliability. • Use of advanced technology, IT. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  18. Current Challenges- Professional • Changing roles: • New Ways of Working’05- consultant- now a part of MDT, distributed responsibility/ leadership in team. • Changes in laws- MHAct- Approved/ Responsible Clinicians, Approved Mental Health Professionals. • New roles: Clinical nurse prescribers (CNP/CNC), associate practitioner, STR workers. • Changing expectations: • Collaborative & flexible approach • Multitasking- doctor, team player, leader etc. • External agencies: Local authorities, courts, police, CQC, Commissioners, media etc. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  19. Current Challenges- Illness & Treatment • Illness: • Multifactorial - no single specific cause. • Diagnosis – syndromal not etiological, investigations – non specific. • Variations – symptoms, phenomenology, psychopathology (Inter & Intra). • Predictability – difficult as no concrete markers • Treatment: • Symptomatic – not always specific to illness. • Long lag period – effects delayed, side effects-early. • Relief – not permanent, need on long term, relapses delayed after stopping these. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  20. Current Challenges- Social • Individual: • Stigma – shame, isolation, delays help seeking. • Impact – on all areas: work, relation, self esteem. • Family/ carers: • Service models – confidentiality, autonomy • Laws – better defined role, rights & responsibility • Society: • Discrimination – understanding, less tolerance • Burden of illness – complex needs, severe disability, limited resources. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  21. Role of Consultant Psychiatrist - RCPsych, OP 74, June 2010 • Good Doctor- Good Medical Practice, GMC June 2010 • Good Psychiatric Practice RCPsych, 2009 • CanMEDS Model of Royal College of Physicians & Surgeons in Canada, 2007. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

  22. Recent Advances & Current Challenges in Psychiatry- Summary • Psychiatry – medical specialty. • Advances – illness & treatments. • Challenges – service delivery in current & future times. • Patient centred & holistic approach. • Evidence based, ethical, professional & reflective practice. • Psychiatrists – Leaders, vehicles of change. Dr. N. Buttan, HESW Peninsula PGME, MRCPsych Course, Sept'14

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