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Introduction: crisis – what crisis?

Introduction: crisis – what crisis?. Professor Chris Packham Associate Medical Director.

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Introduction: crisis – what crisis?

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  1. Introduction: crisis – what crisis? Professor Chris Packham Associate Medical Director

  2. Burden of diseaseMental health issues and musculoskeletal problems make up 75% of all self-reported causes of illness from work Self harm accounts for 6% of all working age years of lost life Depression leading worldwide cause of Years lost to Disability and more than CVD in UK

  3. Physical healthcare issues People with a severe mental illness are:5 times as likely to suffer from diabetes4 times as likely to die from cardiovascular or respiratory disease (shortening their life by 15 - 20 years)up to 20 times as likely to have HIV or Hepatitis C

  4. Getting the most out of crisis teams Dr Graham Worwood Consultant Psychiatrist Highbury Hospital

  5. Crisis team referral criteria What to expect when making a referral Evaluating and managing suicide risk in primary care – what you can do and the benefits of this. Case examples - discussion

  6. Crisis team Referral criteria The patient has a mental disorder that is leading to a high imminent risk in one or more domains*. The level of this risk is such that the patient needs to be further assessed +/- managed by a specialist mental health team as an emergency – defined as within the next 72 hours. Mental disorder includes personality disorder and “adjustment disorders” but excludes primary alcohol/substance misuse disorders, learning disability and organic disorders. Nb Emergency – 72 hours Urgent – 10 days Routine – 8 weeks * Suicide, dangerous self harm, marked self neglect, marked aggression/violence

  7. Focus on suicide risk and risk of dangerous self harm Risk of completed suicide and of engaging in self harm that leads to severe and potentially permanently damaging physical consequences e.g. vigorous head banging, severe bodily mutilation, highly dangerous Ods without true intent to die.

  8. What information do we need from you? A description of the patients mental disorder (brief hx, pptents, impact on life, key symptoms) Your evaluation of the risks presented and how you came to that view Relevant past history Your plans for managing/reviewing the patient Key demographic details Given the emergency (72 hr) criteria we believe that as a referrer the patient should have been seen face to face for the presenting mental disorder within the last 72 hours.

  9. Assessing/managing suicide risk in primary care. The continuum of self harm – distinguishing motives for self harm Suicidal thoughts, planning, intent Views re future Patients coping skills in face of suicidal thinking Protective factors – what has prevented you acting so far? Supporting safety – further appointments, communication with others, careful prescribing, therapeutic alliance etc

  10. Benefits of high quality assessment: Improves therapeutic alliance which can impact on risk and influences likelihood of obtaining help in the future. Enables high quality referral Is highly protective (both) Nb – pts at times do not want to engage with us or we are unable to get hold of them. Issues of transferring risks fully into secondary care

  11. Case study 1 You are seeing a 25 year old woman with a long history of self harm mainly by cutting and burning herself. She tells you that her self harm has recently increased since the break up of a relationship one month ago and she is feeling out of control. She has some suicidal thoughts and occasionally has considered taking an overdose but has no clear intent. She presents as tearful and a little low but is not severely depressed and would like help and support

  12. Case study 2 You are seeing a 45 year old married lady with 2 children. She presents as low and distressed and describes a 3 month history of increasing difficulties coping. She reports that she cannot see any future for herself and feels that she has let her family down very badly. She admits to experiencing suicidal thoughts with a consistent plan. You are not able to identify any definite intent to act on this during the assessment.

  13. Case study 3 You are seeing a 40 year old man who has a long history of intermittent alcohol dependence and is unemployed. He has in the last 2 days been rated as fit for work and is losing his entitlement to ESA. He tells you that he will kill himself if not given help immediately. When directly asked he suggests a number of different plans including hanging himself or walking in front of a train but it is clear that there is no consistent preformed plan. He is a little distressed but mainly presents as angry in the consultation.

  14. Three Key learning points Crisis teams are set up to accept emergency referrals with emergency being defined as a need to be seen within 72 hours. Understanding motives for self harm is of key importance when considering risks presented. It is of key importance to enquire about suicidal thoughts, planning and intent and to be able to provide this information when making a referral.

  15. Questions/discussion

  16. Managing Emerging Psychosis Dr Bert Park AMH Clinical Director

  17. Updated NICE SCZ guidelines Feb 2014 • 1.2 Preventing psychosis • 1.2.1 Referral from primary care • 1.2.1.1 If a person is distressed, has a decline in social functioning and has: • transient or attenuated psychotic symptoms or • other experiences or behaviour suggestive of possible psychosis or • a first-degree relative with psychosis or schizophrenia • refer them for assessment without delay to a specialist mental health service or an early intervention in psychosis service because they may be at increased risk of developing psychosis. [new 2014]

  18. Which question should you ask? • How are you feeling? • What are the voices saying to you? • Why are you feeling so _____? • What happened?

  19. What is the diagnosis? • Sudden onset of auditory hallucinations. Mood fluctuates markedy during the course of the day. Significant anxiety, but also periods of elation. Perplexity, at times appears confused. Periods of increased motor activity which can appear purposeless • What else would you like to know? • Differential diagnosis?

  20. How do you work with the family? • Invite them to the initial appointment • Observe through a one way mirror • Chit chat in the kitchen • Be prepared to challenge the family to get more involved. Build bridges • Psycho-education, referral to the Recovery College

  21. They are struggling to keep their house clean. What do you do? • Leave them to it, they need to learn to look after themselves • Employ a cleaner • Get them a job volunteering, helping other people • Ask family/friends to support them with the cleaning

  22. The salience network

  23. Binding through synchrony Gamma 25-100 Hz Phonological features ‘Mississippi 1’ Theta 4-8 Hz Lexical parsing Delta 1-4 Hz Emotional Prosody

  24. Cross spectral phase coherence

  25. Key messages • Try to answer the question ‘What happened?’ • DSM V has dropped the idea of schizophrenia subtypes • Updated Feb 2014 NICE schizophrenia guidelines includes the option of initial CBT/Family therapy for those who do not want medication • Link for Recovery College Prospectus http://www.nottinghamshirehealthcare.nhs.uk/our-services/local-services/adult-mental-health-services/nottingham-recovery-college/

  26. Safer Lithium Therapy John Lawton Clinical Pharmacy Services Manager Pharmacy Department Wells Road Centre and Highbury Hospital

  27. What do you knowabout lithium? Q1: The atomic number of lithium is: 3 , 4 , 11 or 12 ? Q2: Lithium is named after the Greek word 'lithos' which means: writing , light , stone or layered? Q3: Lithium is a member of which group in the periodic table: alkaline earth , alkali metal , transition metal or semi-metals? Q4:The element symbol for lithium is: L , Lm , Li or Lt? Q5: What colour does lithium burn in a flame test: bright green , dark orange, purple or red? Q6: The appearance of pure lithium metal is: black , pink , yellow or silvery white? Q7: Lithium metal is: less dense than water , more dense than water , less dense than air or the same density as water? Q8: Who sang the 1992 UK Top 11 single “Lithium”?

  28. Answers at… http://www.periodicvideos.com/

  29. Paid out £5m in compensation over the period 2008-12 and £400,000 in legal costs. Largest payout on behalf of a GP was £1.2m to a patient who was left severely disabled after a failure to monitor levels of a long-term prescription for lithium, resulting in lithium toxicity. http://www.themdu.com/press-centre/press-releases/gp-medication-error-cases-reported-to-mdu-increase-by-nearly-60-per-cent

  30. Examples of medication incident reports to NRLS • Lithium level of 0.97mmol/L treated as normal in a 61 year old with symptoms of lithium toxicity, as this fell within the local lab range of 0.6-1.2mmol/L. The patient later developed life threatening toxicity/renal failure. • Emergency admission of patient for lithium toxicity in a critical condition requiring ventilation. Unfortunately his lithium levels were out of date. The last level (5 months old) was within the therapeutic range, hence his lithium was re-authorised on repeat. Unfortunately, it appeared his out-patient appointments had been subject to cancellations hence his lithium levels were not being regularly monitored. • Patient on treatment for depression with lithium which was monitored by his GP. The lithium level had gone up but it was still within therapeutic levels (but may have been toxic for him). He had a stroke and died as a result but his clinical state may have been worsened by the effects of a high lithium level. The concern was that if the lithium level is not above normal it is not flagged up on the system even thought it may have doubled in reality. • Patient on lithium for many years. Discharged on diuretic but lithium dose was not reduced. Readmitted three weeks later with life threatening lithium toxicity. NRLS (National Reporting and Learning System) 11/03 to 12/08

  31. 1. What is lithium and what is it used for? 2. Checks needed before you start to take lithium 3. How to take lithium 4. Blood tests after starting taking lithium 5. What side effects can lithium cause? 6. What happens if the level of lithium in my blood is too high? 7. What can make the lithium level in my blood get too high? £60 for pack of 50 from https://www.nhsforms.co.uk

  32. NHCT Lithium Audit June 2013 Wells Road Centre Pharmacy N=62 (AMH=54, MHSOP=5, SMS=1, LSF=2) 46 community patients 16 in-patients 97% Rx Priadel tablets NUH Pathology NOTIS Results Database Look for evidence of recommended monitoring checks: - 3 monthly Li+ level - 6 monthly eGFR - 6 monthly TSH - Annual calcium

  33. NHCT Lithium Audit June 2013 - 3 monthly Li+ level - 98% - 6 monthly eGFR - 97% - 6 monthly TSH - 95% - Annual calcium - 85% - All within normal ranges Next step? How many patients have been given a purple NPSA Handbook? Quick practice audits in primary care?

  34. NAPC approved lithium guidelines (AMBER 2) on Nottinghamshire Joint Formulary website http://www.nottinghamshireformulary.nhs.uk/

  35. ECG every 3 months, or after each dose increase • If the QTc is above upper limit of normal, but genuine indication for the antipsychotic at this dose and no alternative, then providing the patient has no symptoms (pre-syncope or syncope) the treatment can be continued and the patient monitored at regular intervals. • If symptoms of pre-syncope/syncope, a history of syncope or TdP, or is co-prescribed any other medication that can prolong the QT interval then expert cardiology advice should be sought. • A QTc of >500msec is always abnormal and a cardiology opinion sought immediately and drug regimen reviewed without delay.

  36. THANK YOU!

  37. Clinical management of Acute Alcohol Withdrawal within Primary Care DrDavidRhinds ConsultantPsychiatristinSubstanceMisuse NottinghamshireHealthcareNHSTrust

  38. Dr David Rhinds Consultant Psychiatrist in Substance Misuse Nottinghamshire Healthcare NHS TRust Clinical management of Acute Alcohol Withdrawal within Primary Care: an Addiction Psychiatrist’s Perspective: Dr David Rhinds Consultant Psychiatrist in Substance Misuse Nottinghamshire Healthcare NHS Trust

  39. Goals of Treatment Reduction psychological, social and physical problems related to alcohol use Reduction “risky” or harmful behaviour associated with alcohol use Attainment of controlled, non-problematic alcohol use Abstinence

  40. Presentation of Acute Alcohol Withdrawal Usually in environments where alcohol no longer freely available: Hospital Care Homes Custody Patient presents having made decision to stop or forced withdrawal by family friends ? Drug seeking behaviour

  41. Alcohol Withdrawal Onset 6-24 h after last drink Peak: 24-48 h Duration: 5-7 days Clinical Features Autonomic hyperactivity: Sweating Tremor Tachycardia Raised blood pressure Raised temperature Apprehension, anxiety, irritability, agitation, insomnia Gastrointestinal: Nausea Vomiting Wernicke’s encephalopathy→Korsakoff’s

  42. Delirium Tremens Onset: 48-72 h after last drink (may occur up to 5 days after) Duration 3-10 days Clinical features As per severe alcohol withdrawal: Autonomic hyperactivity Severe anxiety, marked agitation Dehydration, electrolyte disturbance Plus: Clouding of consciousness Hallucinations Paranoid delusions Untreated mortality of up to 15%

  43. Epidemiology Only about 50% alcohol dependent patients develop clinically relevant symptoms of alcohol withdrawal (Sannibale et al., 2005) Less than 1 in 20 people who are alcohol dependent have a grand mal seizure, or severe agitated confusion (DT’s) (Schukit 2009) Majority of patients withdrawing from medication do not require medication (Whitfield, 1980) High as 85% in ED patients (Naranjo et al, 1983)

  44. Evidence Base Two studies in General Practice Naik PC, Lawton J & Brownell LW (1993); Comparing General Practitioners and Specialist Alcohol Services in the Management of Alcohol Withdrawal. Psychiatric Bulletin 24, 214-215. A Comparative Study investigating the outcome of prescribing attenuation medication to patients awaiting assessment by a Specialist Alcohol Service (Rhinds 2003) Only 12% GPs prescribed attenuation medication For the majority of patients (43%) drinking behaviour was unchanged on assessment

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