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
Psychiatry
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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
2
Recent Advances
 Illness:
1) Epidemiology
2) Nosology/ diagnosis
3) Investigations: Aetiopathogenesis
 Treatments:
1) Pharmacological
2) Psychological
3) Others
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
3
Recent Advances
 Service models:
1) NHS
2) Social
3) Private
 Legislations:
1) MHAct/ MCA/ DoLS
2) CQC/ IMCA/ IMHAs
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
4
Recent Advances-Epidemiology
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1)
2)
3)
4)
5)
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 ScheduleStructured 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
5
Recent Advances- Epidemiology
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WMH 2000 - World Mental Health 2000 initiative- CIDI
surveys in 20 countries, findings:
1)
Mental disorders- most prevalent chronic (Life Time to
date- 50%, 12 months- 15-25 %)
2)
Earlier onset (anxiety disorders- teenage)
3)
Mental disorders- most impairing.
4)
Most severe in surveys- diagnosable.
5)
Of these only minority received treatments & only small
minority received long treatments.
6)
Underreporting- common, lower bound estimates
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
6
Recent Advances- Epidemiology
• Modifiable determinants of illness onset:
a) Emerging evidence: Obstetric complications (Scz),
Exposure to famine during childhood (ASPD), Early
exposure to Pb (Alz.)
b) Non- specific risk factors: SLEs, Stress Buffering,
Coping mechanisms
• Modifiable determinants of illness course:
a) Primary prevention – impossible/ unrealistic.
b) Secondary Prevention (Health promotion) –school
based interventions at young age, stress buffering
skills.
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
7
Recent Advances- Epidemiology
• Genetic epidemiology:
1) Family, twin & adoption studies: higher rates in
offsprings & 1st deg relatives (Scz, BPAD)
2) Chromosomal: deletions, mutations (Trisomy 21,
Klinefelter XXY synd., Turner XO synd.)
3) Genetic:
a) Polymorphism→ molecular fn → behaviours
b) DNA sequence variation→ differences
c) STG (Serotonin Transporter Gene)- modulates
influence of SLE on risk of Depression (3X
Gen population)
d) Linkage or association studies.
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
8
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
9
Aetiology- Stress Diathesis Model
• Early Adverse
Life
Experiences.
• Genetic
Predispositi
on
Bio.
Vulnerability
Personality/
Temperament
Bio. Changes
in Brain Fn.
CMDs
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
Traumas/
SLEs
D&A
Physical
Illnesses
10
Recent Advances- Treatments
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Biological:
1)
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
2)
3)
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Psychological: DBT, mindfulness, newer
indications for known therapies.
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Social: Nidotherapy, IPSERT
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
11
Recent Advances- Service Models
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Socio- politico- economic drives:
A. 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).
B. Social: SEs/ CICs, Social housing, others.
C. Private: healthcare - contractual issues,
competition, Monitors in Foundation Trusts
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
12
Recent Advances- Laws
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MHAct 1983- amendments 2007:
1)
2)
3)
Changes in definitions, roles
Changes in sections & procedures
Addition of SCT (CTO), safeguards for patients
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MCAct 2007/ DoLS 2009: safeguarding vulnerable
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Bodies:
1)
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.
2)
3)
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
13
Current Challenges
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Needs.
Climate.
Resources.
Professional
Illness & treatments.
Social.
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
14
Current Challenges- Needs
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Demography:
a)
Aging population: demands on services, shrinking
workforce, complex needs, early diagnosis & treatment.
Nuclear families- single parents, urbanization,
industrialization, early adversities.
b)
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Move to community:
a)
b)
Reduction of hospital beds- single rooms, separate sex wards, delayed
admissions, early discharges, revolving door admissions
Community Based Interventions: CRHTs, Crises House, TCs
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Expectations:
a)
b)
c)
Patients: autonomy, respect, choices, rights
Society: humane, responsive, responsible
Professional: satisfaction, respect, autonomy, growth.
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
15
Current Challenges- Climate
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Social:
a)
b)
Availability, accessibility & approachability.
Diversity, globalization, information technology.
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Political:
a)
b)
Governmental policies & priorities (‘No health without
Mental Health’- DoH 2011)
Neighbourhood, migration, media, EWTD.
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Economic:
a)
b)
c)
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
16
Current Challenges: Resources
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Manpower:
a)
b)
Shortage across spectrum: Centre for Workforce
Intelligence (CfWI) report, Aug’11
Poor recruitment, retention & early retirement.
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Money: total cost to economy £32 bn (~ Defense
a)
b)
budget) by mental health problems (The Sainsbury
Centre for Mental Health, 2001)
Spending cuts- public sector/ services
Efficiency drive- current mantra.
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Material:
a)
b)
Efficiency, efficacy, reliability.
Use of advanced technology, IT.
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
17
Current Challenges- Professional
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Changing roles:
a)
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.
b)
c)
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Changing expectations:
a)
b)
c)
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
18
Current Challenges- Illness & Treatment
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Illness:
a)
b)
d)
Multifactorial - no single specific cause.
Diagnosis – syndromal not etiological, investigations – non
specific.
Variations – symptoms, phenomenology, psychopathology
(Inter & Intra).
Predictability – difficult as no concrete markers
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Treatment:
a)
b)
c)
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.
c)
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
19
Current Challenges- Social
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Individual:
a)
b)
Stigma – shame, isolation, delays help seeking.
Impact – on all areas: work, relation, self esteem.
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Family/ carers:
a)
b)
Service models – confidentiality, autonomy
Laws – better defined role, rights & responsibility
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Society:
a)
b)
Discrimination – understanding, less tolerance
Burden of illness – complex needs, severe disability,
limited resources.
Dr. N. Buttan, HESW Peninsula PGME,
MRCPsych Course, Sept'14
20
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
21
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
22