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  • © Henk Parmentier 2005 © Henk Parmentier 2005
  • World Health Organization January 28, 2011

Transcript

  • 1. Look Listen & Test: Mental Health Assessment In Primary Care Dr Gabriel Ivbijaro MBBS, FRCGP. FWACPsych, MMedSci, DFFP, MA Family Doctor Chair Wonca Working Party on Mental Health
  • 2. International Reference Group Culturally Sensitive Depression Guideline www.globalfamilydoctor.com
    • G Ivbijaro, L Kolkiewicz, E Palazidou, H Parmentier, A Abyad, B Ali, A Al-khatami, K Aswani, S Bammeke, H Bell-Gamm, J Benson, A Bideman, M Carmi, A Cohen, I Crabbe, C Dorwick,
    • J Gensichen, M Grenville, S Gupta, S Hiew, N Jackson, R Jenkins, A Khan, T Khoja, M Lee, F McMillan, L Risdale, H Rodenberg, T Swanwick, A Tylee, I Wilson, H Yaman, F Zizzo
  • 3. Look, Listen And Test: Mental Health Assessment – The WONCA Culturally Sensitive Depression Guideline Primary Care Mental Health 2005; 3: 145 -147
  • 4. Goldberg Huxley Model Level Filter Filter description Rate (per 1000) 1 Community (total) 250 1 st Filter Illness Behaviour 2 Primary Care (total) 230 2 nd Filter Ability to detect 3 Primary Care (identified) 140 3 rd Filter Willingness to refer 4 Mental Illness Services (total) 17 4 th Filter Factors determining admission 5 Mental Illness (admissions) 6
  • 5. Scope Of Psychiatric Problems In Primary Care
    • 1 in 3 primary care consultations in UK psychiatric
    • Primary care clinics very busy
    • 5 -15 minute consultations compared with 45 -60 minute assessments in secondary care
    • A good psychiatric assessment underpins the process of diagnosis and treatment
  • 6. Barriers To Making A Psychiatric Assessment In Primary Care
    • Lack of emphasis on psychiatry in Continuing Professional Development (CPD) Plans in primary care
    • Psychiatric terminology daunting
    • Short consultation times
    • Variable expression of symptoms across cultures (class, ethnicity, gender, sexuality, age)
  • 7. Qualities That Primary Care Physicians Bring To Psychiatric Assessment
    • Knowledge of patients longitudinal history
    • Knowledge of patients personality over time
    • Knowledge of patients family and social context
    • Time – the opportunity for GP to ask patient to come back repeatedly for further assessment (unless patient presenting in an emergency)
  • 8. Standardised Psychiatric Assessments
    • SCAN (WHO Schedules For Clinical Assessment in Neuropsychiatry)
    • European gold standard for assessment
    • Very detailed
    • Needs specialised training
    • Time consuming
    • Good for research
    • Unsuitable for day to day GP clinics
  • 9. Look, Listen, Test (LLT)
    • A generic schema
    • Informs consultation process regardless of pathology presented
    • Supports a holistic view by providing a psychological element to the formulation
    • Helpful schema for a primary care consultation
    • Useful for medical students
  • 10. Look, Listen, Test – How Does It Work?
    • Utilises the holistic observational and history taking skills routinely used in primary care
    • You look at your patient
    • You listen to what they say
    • You carry out appropriate tests which may be verbal probing through questions or physical investigations
    • You record your findings
  • 11. Cross-cultural implementation of a Chinese version of SCAN in Taiwan Cheng ATA, Tien AT, Chang CJ et al . British Journal of Psychiatry 2001 178, 576 - 572
  • 12. SCAN Symptom Look Listen Test Worry √ √ √ Nervous tension √ Restlessness √ Anxiety √ Cannot get breath √ √ Heart pounding √ √ Depressed mood √ √ √ Anhedonia √ √ Loss of hope √ √ Concentration √ √ Loss of interest √ √ Loss of energy √ √ Change in appetite √ √
  • 13. SCAN Symptom Look Listen Test Sleep problems √ √ Difficulty dropping off √ √ Expansive mood √ √ √ Irritable mood √ √ √ Over talkative √ √ Frequency of alcohol use √ √ Tolerance to drugs √ √ Derealisation √ √ Auditory hallucinations √ √ √ Voice commenting √ √ Thought broadcasting √ √ Being spied upon √ √ √ Unusual sensations √ √
  • 14. LLT
    • A practical schema
    • Can record symptoms and signs from SCAN
    • Taps into skills already developed in primary care
    • Has face validity
    • Jargon free & descriptive
    • Developed within primary care
  • 15. Definition of schizophrenia – reminder
    • Thought echo, thought withdrawal, thought broadcasting
    • Delusions of control influence or passivity clearly referred to body or limb movements or specific thoughts actions or sensations. Delusional perception
    • Hallucinatory voices giving running commentary or discussing the patient among themsleves
    • Persistent delusions of other kinds that are culturally inappropriate and completely impossible
    • Persistent hallucinations in any modality, accompanied by fleeting or half formed delusions without clear affective content or by persistent over-valued ideas, or when occurring every day for weeks on end
    • Breaks or interpolations in the train of thought resulting in incoherence , irrelevant speech or neologisms
    • Catatonic behaviour eg excitement, posturing, waxy flexibility, negativism, mutism and stupor
    • ‘ negative’ symptoms eg marked apathy, paucity of speech, blunting or incongruity of emotional response, usually resulting in social withdrawal
    • Significant and consistent change in overall quality of asome aspects of personal behaviour including loss of interest, aimlessness, idleness, a self absorbed attitude and social withdrawal
    • Clear cut symptoms
    • Other symptoms
  • 16. Schizophrenia- making the diagnosis
    • To make a diagnosis:
    • A minimum of one symptom from the category ‘clear cut’ or
    • At least two symptoms from the category ‘other’
    • And
    • Symptoms should have been present for most of the time during a period of one month or more
    • Diagnosis should not be made in the presence of extensive manic or depressive symptoms unless it is clear schizophrenic symptoms antedated affective symptoms
  • 17. Case 1
    • 85 year old lady
      • Consulting he doctors since she can not go to sleep at night
    • Lost husband 4 years ago, living herself, son living 45 minutes drive away
    • Medical history: diet controlled diabetes, hypothyroidism, polymyalgia rheumatica, hyprtension
    • Medication: prednisolone 10 mg, levothyroxine 75 mic, ramipril 5 mg, aspirin 75 mg
  • 18. HISTORY +LLT
    • Mental health diagnosis?
    • Social factors?
    • Medication?
    • Possible co-morbidity factors?
    • Other factors?
  • 19. EXAM
    • HISTORY
    • LONGITUDINAL BACK GROUND
    • CURRENT PROBLEMS
    • MSE
    • L
    • L
    • T
    • FORMULATIO
    • TREAT
  • 20.  
  • 21.
  • 22. Thank you! [email_address]