the primary-secondary care interface dr rob waller consultant psychiatrist bradford district care...
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The Primary-Secondary Care Interface
Dr Rob WallerConsultant Psychiatrist
Bradford District Care [email protected]
Outline
What are you saying to the client?Is a diagnosis the best way to meet their
needs?Getting more assistance:
Antidepressant medication Secondary care Counselling
Are questionnaires any use?How not to get depressed yourself!
Clinical Depression
ICD-10 Depressive Episode Lowering of mood, reduction of energy, and
decrease in activity Little variation Two-weeks
Somatic Symptoms – dictates severity
Other types of depression
Brainstorm: think of as many forms of depression as you can
Non-medical depressions: Dysthymia/Cyclothymia/Personality Baby-blues Economic depression Psychodynamic depression The Great Depression
Responses to a diagnosis
Relief – help is at handStigma – people will think…Regression – I am a failure after allAttribution – how can I change things?Anger – how can you know?Anti-medical – I don’t want pillsDependant – It’s up to you nowReductionism – so that’s what it is…
Seven levels of understanding
One-line Diagnosis – ICD-10Differential DiagnosisBio-psycho-social formulation3x3 Aetiological GridCross-sectional formulation:5-AreasLongitudinal formulation: Beliefs/RulesWhy has this person developed this illness
at this point in their lives?
Aetiological Grid
Bio Psycho Social
Antecedents
Behaviour
Consequences
Cross-sectional Formulation
ENVI
RONMENT
Mood
Thoughts
BiologyBehaviour
Trigger
Longitudinal Formulation
Cognitive Biases
Mood
Thoughts
BiologyBehaviour
Trigger
Activating Events
Core Beliefs Early Events
ENVI
RONMENT
This person, This illness, This time
Genes
IUE
Perinatal
Tabla Rasa?
Oral
Anal
Genital
Latent
Demands Resources
Life
The eighth level
Do we need a diagnosis?
Problem-focussed Bio: medication, diet, exercise Socio: debt, CAB, community groups Psycho: counselling, guided self help
Solution-focussed Where do you want to be in six months? What steps are needed to get there? Can you do one before I see you next week?
NICE management
NICE GPs
Watchful WaitingComputerised CBTGuided Self HelpBrief Psychological Interventions
Two of these !
Secondary Care Options
Counselling [may well be PCT based]Psychiatry
Out-patient - complexity In-patient - risk
Therapy Psychotherapy – dynamic factors Psychology – circular factors
One Stop Shop?
When to Refer
Complexity Needs longer than seven minutes Needs more than Counselling Needs careful diagnosis & formulation
Risk Risk-spotting [hunches] Risk-assessment [dynamic/static] Risk-management [self + others + residual]
Questionnaires - QOF vs Usefulness
Group WorkIn threes:
Which ones do you use? How do you use them? Why do you use them?
Five mins
Feedback
Making Questionnaires Work
Time: They fill them inDiagnosis vs Change MeasureCopyright: the PHQDiscussion: eg BDI item 9Symptom Targeting: eg sleep
Depressed GPs
Doctors on the Edge: General Practitioners, Health and Learning in the Inner-City
Linden West
“Gritty realism, observational style, vastly helpful but also depressing”
http://www.bmj.com/cgi/content/full/322/7294/1128
How not to become depressed
Groups of five
What ways do you personally use to stop yourself from becoming depressed?
Do these work?What can we learn from this how we talk
to clients?
Feedback
What is mental HEALTH? And what can we do to increase it?
Work-life balance? Or should we go for integration?
Research findings for mental health Static: supportive upbringing, education, etc Dynamic:
Marriage / confiding relationship Intrinsic faith Personal development opportunities
The Primary-Secondary Care Interface
Dr Rob WallerConsultant Psychiatrist
Bradford District Care [email protected]