General Management principles-

Investigations & Treatment Modalities

Dr Alok Rana Consultant Old Age

Psychiatrist

ManagementO Assessment Formulation

O Investigation

O Treatment

Investigation

Traditional

OBloodsOScans: CT, special CTs,MRI, PET, fMRI,OECG

Other

OCollateral historyOCorroborationOPrevious notesOOther specialities

TreatmentO BioPsychoSocial

O - Formulation to identify what to treat

Holistic Approach:Whole personSymptomaticTreat the causePreventing the consequences

Biological/SomaticO Drug/Physical element based

treatment:O Routes:

- Oral- Injectibles- Patches- PR- long acting inestions or depots

Pharmacological Somatic Tt

O AnxiolyticsO AntidepressantsO Mood StabilisersO AntipsychoticsO Drugs for cognitive disorder O Drugs for addictionsO Hypnotics

Non Pharmacological Somatic Tt

O ECT: Electro Convulsive Therapy: Depression, Mania, Schizophrenia, Post partum psychosis

O PhototherapyO TMS: Transcranial Magnetic

StimulationO DBS: Deep Brain StimulationO Neurosurgery for psychiatric disorder

PsychologicalO Talking therapy:O Who delivers

O PsychologistsO PsychiatristsO CPNsO Other staff- trained

Psychological therapies

O CounsellingO Psychodynamic: Brief individual to

PsychoanalysisO CBT: for anxiety, depression, eating

disorder, schizophreniaO Family Therapy

Psychological therapiesO CATO DBTO Therapeutic CommunityO CST

Treatment by professions

O Rehabilitation techniques: OtsO Art therapyO AromatherapyO Dramatherapy

Social aspect of treatment

O Identify predisposing, precipitating & perpetuating factors

O Make formulationO Identify need:

housing/family/support/finances/O Social servicesO CAB

Illness based Somatic Psychological

O Depression:Mild to Mod

O AnxietyO Mania/BipolarO SchizophreniaO Psychosis/delusional

disorderO Dementia

O Mild DepressionO AnxietyO Eating disorderO Personality

disorderO Mild dementia

Factors to consider Pharmacological Treatment

Stages in life Drug Factors

O ChildrenO ElderlyO PregnancyO Breast feedingO Pharma ceuticals/

co-kinetics/dynamics

O Drug side effectsO Drug-drug

interactionO Timing &

frequencyO Mode of

administration

PrescribingO Establish and inform indication-

diagnosis/ symptom based/ treat the cause etc

O Discuss options and explainO Help patient to make an informed

decisionO Give information as leaflet if neededO Explain side effects, MOA,

contraindications, what to expect and how to seek help

Drugs – what to knowO MOAO IndicationsO DosesO Exception to

normal dosingO Side effects –

serious and other; early and late; warning signs.

O Half lifeO Metabolism siteO InteractionsO Know the individualO Red/Amber drugsO Hospital initiation

only drugsO Specialist

formulary drugs & costs.

LimitationsO Knowing your expertiseO Acknowledging your limitationsO Stepping over the boundaryO Ever-changing medicine – life long

learningO Joint working with other specialists

Early vs definite treatment

I believe in early I will treat only if I am confidant

O Better responseO Better prognosisO Quick recoveryO Less chronicityO 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:OTCAsOSSRIs (1st line)OMirtazapineOTrazodoneOSNRIs- BZD,

AntipsychoticsOTypical/FGA: Haloperidol, Chlorpromazine (S/E)OAtypical/SGA: Olanzapine, Risperidone, QuetiapineAripiprazoleClozapine

Psychotropics

Mood Stabilisers:OLithiumOSodium ValproateOCarbamazepineOOlanzapine

O Dementia medication:

O CHI medicationO DonepezilO RivastigmineO GalantamineNMDA Antagonist:Memantine