General Management principles- Investigations & Treatment Modalities Dr Alok Rana Consultant Old Age Psychiatrist

Management O Assessment Formulation O Investigation O Treatment

Investigation Traditional O Bloods O Scans: CT, special CTs,MRI, PET, fMRI, O ECG Other O Collateral history O Corroboration O Previous notes O Other specialities

Treatment O BioPsychoSocial O - Formulation to identify what to treat Holistic Approach: Whole person Symptomatic Treat the cause Preventing the consequences

Biological/Somatic O Drug/Physical element based treatment: O Routes: - Oral - Injectibles - Patches - PR - long acting inestions or depots

Pharmacological Somatic Tt O Anxiolytics O Antidepressants O Mood Stabilisers O Antipsychotics O Drugs for cognitive disorder O Drugs for addictions O Hypnotics

Non Pharmacological Somatic Tt O ECT: Electro Convulsive Therapy: Depression, Mania, Schizophrenia, Post partum psychosis O Phototherapy O TMS: Transcranial Magnetic Stimulation O DBS: Deep Brain Stimulation O Neurosurgery for psychiatric disorder

Psychological O Talking therapy: O Who delivers O Psychologists O Psychiatrists O CPNs O Other staff- trained

Psychological therapies O Counselling O Psychodynamic: Brief individual to Psychoanalysis O CBT: for anxiety, depression, eating disorder, schizophrenia O Family Therapy

Psychological therapies O CAT O DBT O Therapeutic Community O CST

Treatment by professions O Rehabilitation techniques: Ots O Art therapy O Aromatherapy O Dramatherapy

Social aspect of treatment O Identify predisposing, precipitating & perpetuating factors O Make formulation O Identify need: housing/family/support/finances/ O Social services O CAB

Illness based Somatic Psychological O Depression:Mild to Mod O Anxiety O Mania/Bipolar O Schizophrenia O Psychosis/delusional disorder O Dementia O Mild Depression O Anxiety O Eating disorder O Personality disorder O Mild dementia

Factors to consider Pharmacological Treatment Stages in life Drug Factors O Children O Elderly O Pregnancy O Breast feeding O Pharma ceuticals/ co- kinetics/dynamics O Drug side effects O Drug-drug interaction O Timing & frequency O Mode of administration

Prescribing O Establish and inform indication- diagnosis/ symptom based/ treat the cause etc O Discuss options and explain O Help patient to make an informed decision O Give information as leaflet if needed O Explain side effects, MOA, contraindications, what to expect and how to seek help

Drugs – what to know O MOA O Indications O Doses O Exception to normal dosing O Side effects – serious and other; early and late; warning signs. O Half life O Metabolism site O Interactions O Know the individual O Red/Amber drugs O Hospital initiation only drugs O Specialist formulary drugs & costs.

Limitations O Knowing your expertise O Acknowledging your limitations O Stepping over the boundary O Ever-changing medicine – life long learning O Joint working with other specialists

Early vs definite treatment I believe in early I will treat only if I am confidant O Better response O Better prognosis O Quick recovery O Less chronicity O Eg Early psychosis, depression, mania O Labelling & medico legal O Unnecessary exposure & Side effects O Consequence on career& personal life. O Eg Schizophrenia, Bipolar, Dementia

Psychotropics Anxiolytics: -Antidepressants: O TCAs O SSRIs (1 st line) O Mirtazapine O Trazodone O SNRIs - BZD, Antipsychotics O Typical/FGA: Haloperidol, Chlorpromazine (S/E) O Atypical/SGA: Olanzapine, Risperidone, Quetiapine Aripiprazole Clozapine

Psychotropics Mood Stabilisers: O Lithium O Sodium Valproate O Carbamazepine O Olanzapine O Dementia medication: O CHI medication O Donepezil O Rivastigmine O Galantamine NMDA Antagonist: Memantine