Mental Health Pathway

Transcription

1 Mental Health Pathway Triggers for Mental Health Pathway Information for professionals Consider mainstream Mental Health Services (Green light Toolkit) Clinical Interface Protocol Clinical Assessment Information for service users/carers DIAGNOSIS Anxiety Obsessive Compulsive Disorder Depression Bipolar Disorder Psychosis Plan interventions/organise treatment goals Agree expected outcomes with patients and carers Consider other MDT involvement to facilitate outcomes MANAGEMENT/ TREATMENT Anxiety OCD Depression Bipolar Disorder Psychosis Significant Reduction in Symptoms No Significant Reduction in Symptoms Treatment resistance protocols Consider in patient assessment REVIEW Monitor improvement Monitor for side effects Promote recovery Enable rehabilitation Discharge Plan

2 Triggers HONOS-LD items to consider as triggers for discussion whether mental health assessment needed Anxieties/phobias/obsessive compulsive behaviour (score 2) Behaviour(s) sufficiently frequent and severe to produce some disruption of and impact on own or other people s functioning Problems with hallucinations or delusions (score 1) Occasional odd or eccentric beliefs or behaviours suggestive of hallucinations or delusions Problems associated with mood changes (score 2) Mood change producing significant impact on self or others (e.g. weeping spells, decrease in skills, withdrawal and loss of interest

3 Information for Professionals People with Learning Disability are likely to have a higher prevalence of mental health problems. Mental health problems are complex in presentation and can present a diagnostic challenge. Therefore, people with Learning Disability are more likely to have unmet mental health needs. Some flexibility is advised with the assessment approach, in that the assessment may need to be done over a period of time (rather than in one setting) and information from carers is very valuable. Caution is advised with diagnoses especially when there are other issues such as diagnostic overshadowing, cognitive distortion in difficult life situations and when there are symptoms related to other developmental disorders. Specific information for the following disorders: Anxiety Obsessive compulsive disorder Depression Bipolar disorder Psychosis

4 Information for Service Users and Carers Depression Leaflet Anxiety Leaflet Psychosis Leaflet Bipolar Disorder Leaflet

5 Clinical Assessment Full Psychiatric History Developmental History History of Presenting Illness Consider Co-morbid Illnesses Past Psychiatric History Past Treatment History (Consider Side Effects of Medications) Significant Medical History Family History Drugs and Alcohol Relationship History Forensic History Full MSE Investigations (For baseline and to monitor for side effects of medications) Full Blood Count Vitamin B12 Thyroid Functions Liver Functions U&Es

6 DRAFT last updated 01 July 2010 LEARNING DISABILITY AND MENTAL HEALTH SERVICES CLINICAL INTERFACE PROTCOL BETWEEN ADULT MENTAL HEALTH SERVICES AND LEARNING DISABILITY SERVICES 1. INTRODUCTION 1.1 This Clinical Interface Protocol has been jointly developed and agreed between Adult Mental Health Services and Learning Disability Services. The fundamental principles are to direct resources as appropriate to the mental health needs of adults with a learning disability. The protocols are set in the context of: - Valuing People A New Strategy for Learning Disability for the 21st Century Valuing People Now New Horizons: a shared vision for mental health (2009) 2. CONTEXT 2.1 The White Papers (Valuing People (2001) and Valuing People Now (2009) emphasises that mainstream services should be accessed for people who have a learning disability in the same way as the rest of the population. In particular it makes reference to the mental health needs of people with a learning disability. 2.2 The NSF for Mental Health and New Horizons (2009) apply to all adults of a working age. 2.3 A key aspect of the White Paper relates to the importance of close collaboration between Adult Mental Health Services and Learning Disability Services with the provisions of clear protocols outlining joint working. It also states that each local service should have access to an assessment and treatment resource for people with significant learning disability and mental health needs who cannot be appropriately admitted to general psychiatric wards, even with the provision of specialist learning disability support. 3. CURRENT POSITION 3.1 Learning Disability Service (LD Service) is one of the five business units in the Leicestershire Partnership NHS Trust. The LD community service is being redesigned using care pathway model to work in collaboration with other services such as adult mental health service, mental health services for older people, social service, voluntary sector etc. There are eight clinical care pathways identified one which is mental health care pathway. Mental health care pathway is based on a stepped care model which emphasises both the health facilitation of people with LD (supporting people with LD to access mainstream services) as well as providing direct intervention to those with most complex needs. Agnes unit is a 20 bedded inpatient unit providing 12 assessment and treatment beds and 8 step down beds. 3.2 Developments in Adult Mental Health Services to support people with learning disability and mental health problems: - DRAFT last updated 01 July 2010 Acute Mental Health Inpatient Reprovision Project (AMHIRP) includes inpatient provision for people with mild learning disabilities. Mental Health Improvement Partnership (MHIP) includes service redesign to provide mental health services for people with learning disabilities. Forensic Services case-by-case agreement on joint assessment and joint working. 3.2 There is now a requirement for the development of joint protocols to underpin the joint working.

7 DRAFT last updated 01 July 2010 Clinical Interface Protocol Between Adult Mental Health Services and Learning Disability Services 1. PRINCIPLES 1.1 All service users should be treated by the service which best suits their needs. 1.2 The determination as to which service best suits their needs should be ascertained through the application of this Clinical Interface Protocol and mental health care pathway for people with LD. 1.3 On occasion the needs of a service user referred to one of the services may mean that they require transfer to the other. Any passing on of a referral from a Learning Disability service to an Adult Mental Health Service and vice versa should be done with a minimum of disruption and upset to the service user involved with careful planning and discussion between the teams. The original receiver of a referral takes responsibility for the initial assessment and instigates the process to transfer the care. Any decisions made in regard to which service would best meet the service user needs should be conducted in a way that is least disruptive to the patient and their carers and also to the referrer which would often be the General Practitioner. 1.4 Any transfer or support between services should be arranged in accordance with this Clinical Interface Protocol where possible during normal working hours unless there is good justification to do otherwise. 1.5 Joint assessments will usually determine complex issues of who should treat and where. Any joint assessments should be planned in a person-centred manner which meets the needs of the service user and utilises the skills and services available within both Learning Disability and Adult Mental Health services. 1.6 Emergency referrals i.e. those out of hours should adhere to the same principles in this Clinical Interface Protocols as first entry to services. 1.8 This Clinical Interface Protocol will require regular monitoring and audit to evaluate and respond to local and national policy, practice guidelines and the needs and views of service users and carers. Any review would be undertaken jointly by both services. 2. GUIDANCE ON ASSESSING NEED 2.1 The accessibility criteria for people with learning disability and mental health problems should be based on needs rather than an artificial divide of IQ. It is assumed that those with reasonable verbal skills who are able to communicate their needs effectively along with good adaptive behaviour skills (including having the ability to care for self and maintain self-hygiene) should be able to access generic mental health services. It is also important to ensure, at least initially, that none of these individuals suffer from significant sensory or motor impairment, i.e. they should be reasonably mobile and should not have high dependency needs. The caveat may be that some of the skills highlighted above may be temporarily affected due to active mental health problems, i.e. regression in skills usually seen in depressive illness. Should this be the case and there is a risk of exploitation or harm to this person accessing generic inpatient settings, then support should be provided for them to access generic services through health workers and

8 Consultants from the Learning Disability Service. 2.2 Anyone with very limited communication skills (i.e. verbal ability limited to use of few words and inability to speak in sentences) along with significant sensory/motor DRAFT last updated 01 July impairment (mobility restricted to 50 yards or wheelchair-bound) and dependency needs for care should be accessing specialist learning disability service for their mental health problems. 2.3 Conversely, those with Mild Learning Disability, pervasive development disorders and mental health problems whose needs may be more of a maintenance of routine, structure, boundaries and clear communication strategies, may benefit from accessing Learning Disability Services. 2.4 It is imperative that staff working in a generic mental health setting should be trained to identify and manage the potential risks of abuse and exploitation of patients with learning disability in the generic setting. 3. STARTING THE INTERFACE CRITERIA 3.1 The team within the service who initially receive the referral will process that referral as usual, undertaking an initial screening of the referral and assessment. 3.2 The team will hold the case and progress with it as much as possible unless there is a decision made that a joint assessment may be necessary. 3.3 Referrals will not be redirected back to the referrer where there is a debate as to which service would best meet the service user s needs. It is the responsibility of the initial receiving team to follow the Clinical Interface Protocol 3.4 If the receiving team deem that their service is not the most appropriate, that team will initiate local discussion between the other service to discuss the referral. This local discussion can take a number of formats. In the main it is likely to be a clinician to clinician discussion over the telephone. This is likely to be the most successful and will hopefully speed up response rate to progress the referral further. 3.5 This local discussion between services may result in three pathways for the service user: 1) After the initial discussion, the service who initially received the referral (first service) agrees to provide the care. It would then proceed in the normal manner. 2) The referral is passed onto the second service by agreement and that service then takes the lead and responsibility in managing the referral. 3) After the initial discussion, an agreement is made that a joint assessment is required. The outcome of the joint assessment would then be discussed at a multi-disciplinary meeting. This may then result in a number of other options: That one service accepts the referral and proceeds as normal Joint working is agreed. However it is important for one service will have responsibility for leading the joint working (providing care coordination). If there continues to be a disagreement as to who should take the lead and provide the service then this would have to be forwarded to a DRAFT last updated 01 July Dispute Resolution Panel (clinical directors and locality general managers of both services). 4) The final pathway for referral is that the referral is deemed not appropriate for either service and is required to be passed on to services outside the Partnership Trust, such as the voluntary sector or primary care.

9 4. REFERRAL PATHWAYS 4.1 Non urgent referral: Please see Appendix Urgent Referrals for potential Interface patients to Adult Mental Health and Learning Disability Services Urgent referral Local discussion between Adult Mental Health Services and Learning Disability Services Insufficient information to make an informed decision Admission or other intervention agreed and which team to lead Refer to Crisis Resolution Learning Disability Outreach Remain at home with agreement for the following day OR Joint assessment Joint working An urgent referral is received by the service. As with the first entry to service, it is the responsibility of the receiving team to screen the referral and initiate any local discussion between other services if it is deemed necessary Local discussion takes place between the Adult Mental Health service and Learning Disability services which is likely to be through clinicians In the event of this being an urgent referral and out of hours, this would need to take into account on-call arrangements. Following the local discussion a number of options may present themselves: The local discussion has not resolved which service would best meet the needs; therefore a joint assessment is required. The joint assessment is undertaken and the options to progress further are as those in the first entry to service i.e. one service accepts the referral, there is joint working with one service leading or referral onto a service outside of the Trust. There is an agreement that the patient needs admitting and a decision is made between the services as to which service is to lead this process. If admission is required the site based Consultant team provide care, joint working should be considered. Referral to Crisis Resolution or Learning Disability Outreach service

10 OR There may also be the opportunity for joint working between Crisis Resolution and Learning Disability Outreach services. Responsibility for leading this would be with one service There is joint agreement at local discussion that the patient can be discharged home with agreement as to how to follow up the next day. Where possible all supporting information should be available to the receiving service. It is the responsibility therefore for the referral to be screened and that information gathered as much as possible by the first service which receives the referral. If the patient is seen by Crisis Resolution or the Learning Disability Outreach service, it does not automatically mean that other aspects of joint working should cease. 4.3 The majority of people with a dual diagnosis of learning disability and mental health problems are to be enabled to use Adult Mental Health Services, with the support of Learning Disability Services and should have their needs assessment in the most appropriate setting community or hospital. 4.4 Admission into adult mental health in-patient/ward areas should only be considered when there is an acute clinical need requiring assessment and/or treatment and they cannot be safely managed and treated elsewhere in the community. DRAFT last updated 01 July ARBITRATION PROCESS 5.1 If, having followed this Clinical Interface Protocol, there is still dispute between the services as to which service would best meet the needs; the process will be to defer to the Dispute Resolution Panel. The panel would comprise of clinical directors and general managers from both the services who would hear all the information that had been gathered and then use the opportunity to make a decision with representatives from the services as to which would be the best outcome for the individual. 6. REVIEW OF THE PROTOCOL 6.1 This Clinical Interface Protocol will be audited and reviewed by representatives of the Learning Disability services and Adult Mental Health services within six months of its instigation.

11 Anxiety diagnosis (ICD-10 ) Generalized Anxiety Disorder Anxiety that is generalized and persistent but not restricted to, or even strongly predominating in, any particular environmental circumstances (i.e. it is "free-floating"). The dominant symptoms are variable but include complaints of persistent nervousness, trembling, muscular tensions, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort. Fears that the patient or a relative will shortly become ill or have an accident are often expressed. Panic Disorder [Episodic Paroxysmal Anxiety] The essential feature is recurrent attacks of severe anxiety (panic), which are not restricted to any particular situation or set of circumstances and are therefore unpredictable. As with other anxiety disorders, the dominant symptoms include sudden onset of palpitations, chest pain, choking sensations, dizziness, and feelings of unreality (depersonalization or derealization). There is often also a secondary fear of dying, losing control, or going mad. Panic disorder should not be given as the main diagnosis if the patient has a depressive disorder at the time the attacks start; in these circumstances the panic attacks are probably secondary to depression. Social Phobias Fear of scrutiny by other people leading to avoidance of social situations. More pervasive social phobias are usually associated with low self-esteem and fear of criticism. They may present as a complaint of blushing, hand tremor, nausea, or urgency of micturition, the patient sometimes being convinced that one of these secondary manifestations of their anxiety is the primary problem. Symptoms may progress to panic attacks. Agoraphobia A fairly well-defined cluster of phobias embracing fears of leaving home, entering shops, crowds and public places, or travelling alone in trains, buses or planes. Panic disorder is a frequent feature of both present and past episodes. Depressive and obsessional symptoms and social phobias are also commonly present as subsidiary features. Avoidance of the phobic situation is often prominent, and some agoraphobics experience little anxiety because they are able to avoid their phobic situations.

12 OCD Diagnosis (ICD-10) The essential feature is recurrent obsessional thoughts or compulsive acts. Obsessional thoughts are ideas, images, or impulses that enter the patient's mind again and again in a stereotyped form. They are almost invariably distressing and the patient often tries, unsuccessfully, to resist them. They are, however, recognized as his or her own thoughts, even though they are involuntary and often repugnant. Compulsive acts or rituals are stereotyped behaviours that are repeated again and again. They are not inherently enjoyable, nor do they result in the completion of inherently useful tasks. Their function is to prevent some objectively unlikely event, often involving harm to or caused by the patient, which he or she fears might otherwise occur. Usually, this behaviour is recognized by the patient as pointless or ineffectual and repeated attempts are made to resist. Anxiety is almost invariably present. If compulsive acts are resisted the anxiety gets worse.

13 Depression Diagnosis Depressive Episode In typical mild, moderate, or severe depressive episodes, the patient suffers from lowering of mood, reduction of energy, and decrease in activity. Capacity for enjoyment, interest, and concentration is reduced, and marked tiredness after even minimum effort is common. Sleep is usually disturbed and appetite diminished. Self-esteem and selfconfidence are almost always reduced and, even in the mild form, some ideas of guilt or worthlessness are often present. The lowered mood varies little from day to day, is unresponsive to circumstances and may be accompanied by so-called "somatic" symptoms, such as loss of interest and pleasurable feelings, waking in the morning several hours before the usual time, depression worst in the morning, marked psychomotor retardation, agitation, loss of appetite, weight loss, and loss of libido. Depending upon the number and severity of the symptoms, a depressive episode may be specified as mild, moderate or severe. Mild Depressive Episode Two or three of the above symptoms are usually present. The patient is usually distressed by these but will probably be able to continue with most activities. Moderate Depressive Episode Four or more of the above symptoms are usually present and the patient is likely to have great difficulty in continuing with ordinary activities. Page 1 of 2

14 Severe Depressive Episode Without Psychotic Symptoms An episode of depression in which several of the above symptoms are marked and distressing, typically loss of self-esteem and ideas of worthlessness or guilt. Suicidal thoughts and acts are common and a number of "somatic" symptoms are usually present. Severe Depressive Episode With Psychotic Symptoms An episode of depression as described in F32.2, but with the presence of hallucinations, delusions, psychomotor retardation, or stupor so severe that ordinary social activities are impossible; there may be danger to life from suicide, dehydration, or starvation. The hallucinations and delusions may or may not be mood-congruent. Recurrent Depressive Disorder A disorder characterized by repeated episodes of depression as described for depressive episode (F32.-), without any history of independent episodes of mood elevation and increased energy (mania). There may, however, be brief episodes of mild mood elevation and overactivity (hypomania) immediately after a depressive episode, sometimes precipitated by antidepressant treatment. The more severe forms of recurrent depressive disorder (F33.2 and F33.3) have much in common with earlier concepts such as manic-depressive depression, melancholia, vital depression and endogenous depression. The first episode may occur at any age from childhood to old age, the onset may be either acute or insidious, and the duration varies from a few weeks to many months. The risk that a patient with recurrent depressive disorder will have an episode of mania never disappears completely, however many depressive episodes have been experienced. If such an episode does occur, the diagnosis should be changed to bipolar affective disorder (F31.-). Page 2 of 2

15 Bipolar Disorder Diagnosis Bipolar Affective Disorder A disorder characterized by two or more episodes in which the patient's mood and activity levels are significantly disturbed, this disturbance consisting on some occasions of an elevation of mood and increased energy and activity (hypomania or mania) and on others of a lowering of mood and decreased energy and activity (depression). Repeated episodes of hypomania or mania only are classified as bipolar. Bipolar Affective Disorder, Current Episode Hypomanic The patient is currently hypomanic, and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past. Bipolar Affective Disorder, Current Episode Manic Without Psychotic Symptoms The patient is currently manic, without psychotic symptoms (as in F30.1), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past. Bipolar Affective Disorder, Current Episode Manic With Psychotic Symptoms The patient is currently manic, with psychotic symptoms (as in F30.2), and has had at least one other affective episode (hypomanic, manic, depressive, or mixed) in the past. Bipolar Affective Disorder, Current Episode Mild Or Moderate Depression The patient is currently depressed, as in a depressive episode of either mild or moderate severity (F32.0 or F32.1), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past. Page 1 of 2

16 Bipolar Affective Disorder, Current Episode Severe Depression Without Psychotic Symptoms The patient is currently depressed, as in severe depressive episode without psychotic symptoms (F32.2), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past. Bipolar Affective Disorder, Current Episode Severe Depression With Psychotic Symptoms The patient is currently depressed, as in severe depressive episode with psychotic symptoms (F32.3), and has had at least one authenticated hypomanic, manic, or mixed affective episode in the past. Bipolar Affective Disorder, Current Episode Mixed The patient has had at least one authenticated hypomanic, manic, depressive, or mixed affective episode in the past, and currently exhibits either a mixture or a rapid alteration of manic and depressive symptoms. Bipolar Affective Disorder, Currently In Remission The patient has had at least one authenticated hypomanic, manic, or mixed affective episode in the past, and at least one other affective episode (hypomanic, manic, depressive, or mixed) in addition, but is not currently suffering from any significant mood disturbance, and has not done so for several months. Periods of remission during prophylactic treatment should be coded here. Page 2 of 2

17 Psychosis Diagnosis Schizophrenia The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and affects that are inappropriate or blunted. Clear consciousness and intellectual capacity are usually maintained although certain cognitive deficits may evolve in the course of time. The most important psychopathological phenomena include thought echo; thought insertion or withdrawal; thought broadcasting; delusional perception and delusions of control; influence or passivity; hallucinatory voices commenting or discussing the patient in the third person; thought disorders and negative symptoms. The course of schizophrenic disorders can be either continuous, or episodic with progressive or stable deficit, or there can be one or more episodes with complete or incomplete remission. The diagnosis of schizophrenia should not be made in the presence of extensive depressive or manic symptoms unless it is clear that schizophrenic symptoms antedate the affective disturbance. Nor should schizophrenia be diagnosed in the presence of overt brain disease or during states of drug intoxication or withdrawal. Similar disorders developing in the presence of epilepsy or other brain disease should be classified under F06.2, and those induced by psychoactive substances under F10-F19 with common fourth character.5.

18 Anxiety Management and Treatment Broad Approach To Treatment In Anxiety Disorders Consider the full range of possible co-morbidities when planning treatment Actively consider psychological approaches to treatment When making a decision about the first line of treatment (talking therapies or medication), consider severity of illness, distress and impairment in functioning. The duration of waiting to uptake a talking therapy would also be significant Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase Psychoeducation Return to baseline level of functioning Anxiety Management and Treatment Guidelines for Treatment with Medication The Frith algorithms Panic Disorder Generalised Anxiety Disorder NICE Guidelines

19 Panic disorders Algorithm 15.2 Treatment of panic disorders in adults with LD Try cognitive behaviour therapy or anxiety management Continue treatment Partial or poor response Try an SSRI or SNRI eg paroxetine, sertaline, escitalopram or venlafaxine Continue treatment Partial or poor response Try imipramine Continue treatment Partial or poor response Try propranolol Continue treatment Partial or poor response Try benzodiazepines Continue treatment but limit to 4 weeks

20 Algorithm 15.3 Treatment of generalised anxiety disorder in adults with LD Generalised anxiety disorder Cognitive behavioural therapy or anxiety management training where applicable continue Poor or partial response Predominantly somatic symptoms Minimal somatic symptoms Propranolol up to 120mg/day [Note 1] Poor response or side effects Continue treatment Stop propanolol Start an SSRI (preferably with a long half-life) or venlafaxine or pregabalin Poor response Continue treatment [Note 3] Try another SSRI or a tricyclic antidepressant or a small dose of antipsychotc or buspirone or a benzodiazepine [Note 2]

21 OCD Management and Treatment Broad Approach To Treatment In OCD Consider the full range of possible co-morbidities when planning treatment. Consider pervasive developmental disorders in the differential diagnosis, or as a co-morbidity. Actively consider psychological approaches to treatment When making a decision about the first line of treatment (talking therapies or medication), consider severity of illness, distress and impairment in functioning. The duration of waiting to uptake a talking therapy would also be significant Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Consider exposure response prevention as part of the CBT approach. Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication o o The Frith Algorithms NICE Guidelines

22 Algorithm 15.1 Treatment of obsessive compulsive disorder (OCD) in adults with LD OCD Not associated with autistic spectrum disorder Associated with autistic spectrum disorder Try psychological approaches Try psychological approaches Poor response Poor response Continue treatment Try an antidepressant eg paroxetine or fluoxetine or sertraline a high dose if required upto BNF limits Try a small dose of antipsychotic eg haloperidol or risperidone or olanzapine Continue treatment Poor response or side effects Withdraw antipsychotic Try high dose of antidepressant if required upto BNF limits eg paroxetine or fluoxetine or sertraline or clomipramine Continue treatment Poor response or side effects Try a combination of small doses of an atypical antipsychotic and SSRI eg risperidone and paroxetine Continue treatment

23 Depression Management and Treatment Broad Approach To Treatment In Depressive Disorders Consider the full range of possible co-morbidities when planning treatment Actively consider psychological approaches to treatment When making a decision about the first line of treatment (talking therapies or medication), consider severity of illness, distress and impairment in functioning. The duration of waiting to uptake a talking therapy would also be significant Consider whether part of a recurrent depressive disorder or bipolar disorder Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase Consider prophylaxis if recurrent depression or bipolar disorder Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication The Frith Algorithms NICE Guidelines

24 Algorithm 17.1 Treatment of depression in adults with LD Depression [Note 1] Try a tricyclic antidepressant if previous history of successful treatment with this medication Severe psychotic depression or serious suicide risk. Consider ECT with concomitant antidepressant treatment ± antipsychotic Newer antidepressants eg SSRIs at therapeutic dose or for at least 4 weeks Effective, well tolerated Ineffective Ineffective Continue treatment for 6-9 months if first episode; 2-5 years if recurrent Increase dose. Re-assess after 4 weeks Review diagnosis Change antidepressant Change antidepressant consider SNRIs, NARIs, or a NASSA Ineffective, poorly tolerated Continue treatment for 6-9 months if first episode; 2-5 years if recurrent Effective, well tolerated Ineffective, poorly tolerated Change class of antidepressant Ineffective, poorly tolerated Consider lithium augmentation or ECT Monitor thyroid function tests 6-9 months Effective, well tolerated Effective Ineffective, poorly tolerated Augmentation with T3 Try reversible MAOIs [Note 2] Ineffective Effective, well tolerat Maintain dietary restric Ineffective Putative treatments [Note 3]

25 Bipolar Disorder Management and Treatment Broad Approach To Treatment In Bpad Consider whether part of a recurrent depressive disorder or bipolar disorder. Due consideration to prophylaxis Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase. Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication The Frith Algorithms NICE Guidelines

26 Algorithm 17.3 Treatment of mania/hypomania associated with bipolar affective disorder in adults with LD Rapid tranquillisation [Note 8] Commence antimanic medication, one of the following eg olanzapine, quetiapine, divalproex sodium, sodium valproate, carbamazepine or risperidone [Note 2] Poor response Continue mood stabiliser. In not alr on one consider prophylaxis with lit or carbamazepine or sodium valpr [Notes 3,4,5,6] With aggression Poor response/not on lithium or other mood stabiliser Add benzodiazepine [Note 7] Mania/hypomania Continue Poor response Without aggression If already on lithium/other mood stabiliser augment the dose if permissible [Note 1] Commence mood stabiliser/ antipsychotic if not already started Attempt to withdraw antipsychotic drug Poor response Consider combination of mood stabilisers eg lithium+sodium valproate+/-antipsychotic drug Continue Consider other drugs such as clozapine, lamotrigine or topiramate NB Committee on Safety in Medicine warning

27 Psychosis Management and Treatment Broad Approach To Treatment In Psychotic Disorders Focus on containing risks Consider joint working with teams like PIER Acute Phase Of Treatment Agree with service user/carers on treatment goals Offer appropriate doses as per guidelines to achieve a significant reduction in symptoms Once reduction in symptoms is achieved, move to maintenance phase Maintenance Phase Of Treatment Focus on maintaining improvement Review dose of medication to maintenance phase. Psychoeducation Return to baseline level of functioning Guidelines for Treatment with Medication The Frith Algorithms NICE Guidelines

28 Algorithm 18.1 Drug treatment of schizophrenia and other psychotic disorders in adults with LD Tolerated but ineffective. Positive/negative symptoms Atypical emerge/persist. antipsychotic [Note 2] Poorly tolerated and ineffective Poorly tolerated but effective Within BNF limits Outside BNF limits Ineffective and/or Ineffective poorly tolerated Consider another Ineffective/poor Is the patient on class of atypical tolerance typical antipsychotic Effective, continue antipsychotics? treatment Maximise dose (If the patient is antipsychotic within naïve BNF or if limits a new assessment see below try an atypical antipsychotic as first choice and skip to appropriate step in this algorithm.) Tolerated Effective but poorly tolerated Atypical antipsychotic [Note 2] Titrate dose of anticholinergic [Note 3] Effective and well tolerated Consider dose titration and anticholinergics Effective Explain and long-term side effects to patients and relatives; document such in notes. Continue well tolerated Follow advice of RCP in BNF [Note 1] eg ECG where possible and repeat periodically; document and discuss if ECG not possible If side effects persist If side effects improve Continue treatment Poorly tolerated Consider drug resistance Try clozapine Continue treatment [Note 9] Change atypical antipsychotic Effective, conti [Not Ineffective Consider augmentation [Note 7] Acute aggression or violence First diagnosis or antipsychotic- naive Consider Non-pharmacological rapid tranquillisation with a typical or an interventions atypical antipsychotic (lorazepam Atypical IM/oral) antipsychotic [Note 6] [Note 5] For a new diagnosis or for the first episode of schizophrenia NICE guidance recommends a trial of an atypical antipsychotic as being preferable to a typical antipsychotic No aggression Atypical antipsychotic [Note 4] Typical or atypical antipsychotic antipsychotic- naive [Note 8] New patient who may/may not be NB Committee on Safety in Medicine warning

29 Approach to Treatment Resistant Conditions o o o o o Review history Review diagnosis Review doses of medication Review compliance to treatment Consider undiagnosed co-morbidites Review investigations: consider neuro-imaging Consider exploring for other developmental disorders o o o Consider influence of environmental factors Consider other classes of drugs, augmentation strategies Consider a period of assessment in the inpatient unit

30 Discharge Planning Ensure global outcomes achieved Agree on discharge with service user/carer Letter to GP Reason for referral Outcome of assessment Outcome of intervention Advice on management of condition in primary care Advice on early symptoms/signs of recurrence Advice on re-referral