Concepts in psychiatric review
Model of care
Care programme approach:
Care Plan
Care co-ordinator CCO
Community Psychiatrist:
For individuals with a severe mental disorder, recently sectioned, at high risk of suicide/self-harm/harm to others, or under a Community Treatment Order (CTO).
Care Plan covers: medications, financial, housing and employment support and a programme activities to education and restore life skills needed for independent living.
Regular outpatient review at local CMHT by psychiatrist with referral to other services (such as psychology or employment or addiction services).
Review Care Plan at least once a year
Care preferences written and signed when the patient was well.
Crisis Card
Advance statement
Emergency contact numbers and clear advice for the patient should health concerns materialise.
Notably, the Mental health Act can be used to override decisions in advance statements If it is deemed in the patient's best interests.
Diagnosis
Principal diagnosis (and differential diagnosis) according to ICD-10
Current Mental Health
Remission or relapse of psychiatric symptoms characteristic of the principal diagnosis
Co-existing psychiatric symptoms: psychosis, depression, mania and anxiety
Any significant increase in alcohol or substance misuse
Assess for post-traumatic stress disorder (PTSD) and other reactions to trauma
Seep disturbance
Appetite
Energy levels
Drug treatment
- List prescribed psychiatric and non-psychiatric medications
- Check compliance
- Evaluate side-effects, particularly any weight gain and extrapyramidal symptoms such as akathisia (motor restlessness), dystonia (involuntary movements and sustained muscle action such as torticollis or trismus) and Parkinsonism (muscle rigidity, tremor, bradykinesia)
- Check any drug interactions, particularly with co-prescribed medication for diabetes, cardiovascular and cerebrovascular disease.
- Consider need to modify dosage
- Check need to initiate clozapine. This is considered where there is inadequate treatment response despite sequential trial of at least 2 adequately dosed different antipsychotic drugs, where at least 1 of the drugs should be a non-clozapine second-generation antipsychotic.
- Serial bloods to monitor clozapine or lithium drug levels and their effects upon haematological and biochemical parameters
Other Treatments (psychodynamic)
- Cognitive behavioural therapy (CBT) with or without family intervention
- CBT-based trauma reprocessing intervention may reduce PTSD symptoms and related distress
Physical health
- General physical health and wellbeing (including any weight, smoking, nutrition, physical activity and sexual health)
- Coexisting neurological (such as epilepsy, Parkinson's disease, dementia) and neurodevelopmental disorders
- Physical illnesses that predisposes to organic brain disorders (e.g. alcohol or substance misuse)
- Screening for the heightened risk of metabolic syndrome (obesity, type 2 diabetes, hypercholesterolaemia), cardiovascular and respiratory disease.
All patients should be offered programmes for:
- combined healthy eating and physical activity
- smoking cessation (including nicotine replacement therapy)
A physical health review, including history, clinical examination, blood pressure and blood testing is performed at least annually by the GP.
Blood testing includes: full blood count, iron/B12.folate, renal, liver function, calcium & vitamin D, prolactin, thyroid function, HBA1C, lipids
A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care notes.
Social history (consider positive/negative impact on mental and physical health)
- Activities of daily living (work, leisure activities or responsibilities for children/elderly as a carer)
- Degree of independence (is patient dependent on carer support)
- Employment (including voluntary and pre-vocational training)
- Attitude to education, peer support and self-management activities
- Significant changes to financial, employment, housing circumstances
- Significant social/partner relationships and history of trauma
- Quality of life
- Economic status
Substance misuse
- Smoking
- Alcohol consumption and dependency symptoms
- Substance misuse and any associated dependency
Forensic history
May be antecedent or a consequence of alcohol dependency and substance misuse behaviour
Mental State Examination
Including Insight and Mental Capacity
Risk assessment
- Risk of harm to self: physical injury, self-neglect, alcohol and substance misuse, sexual promiscuity (sexually transmitted infections) or financial ('manic' spending)
- Risk of harm to others: threatening behaviour, aggression or violence or neglect of people dependent on them for care (particularly family members and children)
- Risk of harm from others: domestic violence, assault, vulnerability, safeguarding or exploitation
Risk of suicide
Active: suicidal ideation, intent, planning and lethality
Predisposing risk factors: previous suicide attempts, hopelessness, family history of suicide, impulsiveness, recent psychiatric admission (within last 3months), >5 in-patient admissions, predominance of depressive symptoms, comorbid anxiety or eating disorder, alcohol and substance misuse, childhood physical and sexual abuse and personality disorder
Protective risk factors: effective mental health care interventions, connectedness to individuals, family and community, skills in problem-solving and conflict resolution, contacts with caregivers, cultural and religious beliefs that discourage suicide and support instincts for self-preservation
Formulation
[Age] with known/provisional diagnosis of [ICD-10] being treated by [Drug] presents with ....
Patient is compliant/non-compliant with medication and risk of relapse is low/moderate/high given concurrent alcohol/substance misuse/physical co-morbidities.
The prevailing psychosis/depression/anxiety syndrome involves....
The risk of suicide is considered extremely low.