REVERSIBLE MILD COGNITIVE IMPAIRMENT - A CASE REPORT

With an increased general practitioner and public awareness, patients are being referred on to Memory Clinics earlier and Mild Cognitive Impairment (MCI) is often a conclusion of the assessment. The function of memory clinics is to facilitate early and accurate diagnosis of dementia and its management. Mild Cognitive Impairment is an organic condition which in significant proportion of cases, progresses to Dementia. In Bedfordshire and Luton, patients with MCI are followed up at nine months to yearly intervals and detailed neuropsychological assessments are carried out to monitor cognitive functions in order to detect dementia early and plan care at an early stage in line with the NICE guidance CG42. An interesting patient presented to the Memory Clinic. He suffered from bipolar disorder with age of onset after 50 years. He was successfully treated with a combination of antidepressants, antipsychotics and lithium carbonate. He started complaining of memory difficulties and the initial memory assessment concluded that he had MCI. He was followed up by the clinical psychologist at memory assessment services at yearly intervals. There were no active cognitive interventions done by the psychologist. In the meanwhile the patient developed Parkinson’s disease and was treated successfully with levodopa. Following this, neuropsychological tests demonstrated a significant improvement in cognitive functions. The patient was assessed as having recovered from mild cognitive disorder. In this article the authors discuss the possible differential diagnosis and causative factors for the presentation of MCI in this patient. Furthermore the possible reasons for recovery are explored. This also raised interesting questions as to the pharmacological management of mild cognitive disorder secondary to neurological conditions and as to how the course of mild cognitive disorders could be modified by effective interventions

REVERSIBLE MILD COGNITIVE IMPAIRMENT - A CASE REPORT

With an increased general practitioner and public awareness, patients are being referred on to Memory Clinics earlier and Mild Cognitive Impairment (MCI) is often a conclusion of the assessment. The function of memory clinics is to facilitate early and accurate diagnosis of dementia and its management. Mild Cognitive Impairment is an organic condition which in significant proportion of cases, progresses to Dementia. In Bedfordshire and Luton, patients with MCI are followed up at nine months to yearly intervals and detailed neuropsychological assessments are carried out to monitor cognitive functions in order to detect dementia early and plan care at an early stage in line with the NICE guidance CG42. An interesting patient presented to the Memory Clinic. He suffered from bipolar disorder with age of onset after 50 years. He was successfully treated with a combination of antidepressants, antipsychotics and lithium carbonate. He started complaining of memory difficulties and the initial memory assessment concluded that he had MCI. He was followed up by the clinical psychologist at memory assessment services at yearly intervals. There were no active cognitive interventions done by the psychologist. In the meanwhile the patient developed Parkinson’s disease and was treated successfully with levodopa. Following this, neuropsychological tests demonstrated a significant improvement in cognitive functions. The patient was assessed as having recovered from mild cognitive disorder. In this article the authors discuss the possible differential diagnosis and causative factors for the presentation of MCI in this patient. Furthermore the possible reasons for recovery are explored. This also raised interesting questions as to the pharmacological management of mild cognitive disorder secondary to neurological conditions and as to how the course of mild cognitive disorders could be modified by effective interventions

Cannabis and psychosis

Several studies have established a link between cannabis and psychosis. However the causal role of cannabis in schizophrenia is still not clear. The aim of this paper is to summarise the literature pertaining to whether cannabis causes psychosis, whether the continued use of cannabis by patients with schizophrenia affects the course of the disease and its treatment, and whether it is possible to reduce cannabis use in patients who have a psychotic disorder.peer-reviewe

Cannabis and Psychosis

Abstract Several studies have established a link between cannabis and psychosis. However the causal role of cannabis in schizophrenia is still not clear. The aim of this paper is to summarise the literature pertaining to whether cannabis causes psychosis, whether the continued use of cannabis by patients with schizophrenia affects the course of the disease and its treatment, and whether it is possible to reduce cannabis use in patients who have a psychotic disorder

STUDY ON LITHIUM MONITORING AMONGST PATIENTS IN A COMMUNITY MENTAL HEALTH AND PRIMARY CARE SETTING IN RURAL ENGLAND

Background: Lithium is widely used as a mood stabilizer in managing Bipolar Disorder. It is also licensed as an augmenting agent for recurrent depression and treatment resistant depression. However, it has a narrow therapeutic index with potentially significant side effects and adverse drug interactions. Toxicity is one of the main concerns for prescribers and serum levels should be checked regularly. Also, due to the adverse effects on Kidneys and Thyroid, there are strict guidelines to monitor the kidney as well as thyroid functions periodically. Whilst the need to monitor blood biochemistry is well established, less well recognized is the need to monitor patients’ physical health by means of annual checks of Body Mass Index (BMI) and waist circumference. Aim: The purpose of this study was to investigate compliance against the NICE CG185 guidelines. Hereford is a rural town in England with a population of about 180000. Currently, the Herefordshire part of 2gether Mental Health NHS Foundation Trust does not have clearly agreed shared care protocols for Lithium monitoring. Lithium monitoring is done by GPs as part of QOF targets. As Psychiatrists recommend treatment with lithium, they have the responsibility to have an updated results and act on these appropriately. Therefore, an important aspect of this audit was to identify monitoring gaps that may result from the dual ownership of patient care. Results: We found that 80% of cases complied with NICE guidance as regards blood monitoring however, only 40% of cases were compliant as regards checks on the physical health parameters of BMI and weight. Conclusion: The blood biochemistry of patients on lithium is generally well monitored however, physical health assessment is rarely completed with the required annual frequency and, waist circumference is almost never measured; either on initiation of lithium therapy or, on an on-going basis. More needs to be done to promote awareness of the need to monitor the physical health of patients on lithium and, in particular, to ensure that these checks include measurement of waist circumference. We believe that to improve monitoring of patients on lithium, shared care protocols should be developed between mental health services and GP services

ANTIDEPRESSANTS AND HYPONATREMIA IN A PATIENT WITH COLECTOMY – A CASE REPORT

Antidepressants are routinely used by General Practitioners (GP) as well as Psychiatrists to treat Depression. They are tolerated well. However, in certain patient populations, they are associated with SIADH (Syndrome of Inappropriate Anti-Diuretic Hormone Secretion) and Hyponatremia. Various research studies have shown that all antidepressants are associated with Hyponatremia. Hyponatremia as a side effect of antidepressant therapy is more commonly seen in old age, chronic Kidney disease and Hypothyroidism. Untreated Hyponatremia could lead to life threatening emergencies including Cerebral oedema, brain damage and coma. In this article, the authors discuss a 63 year old patient who suffered from Bipolar Disorder Type 2. He was treated with antidepressants (mainly Paroxetine) on and off for 30 years, without much side effects, until 2014. In July 2012, he underwent subtotal colectomy with ileorectal anastomosis as a management of adeno carcinoma of Colon. In April 2013, Paroxetine was stopped as he was well. He developed first episode of mania in July 2014. This was managed with Olanzapine. However, he soon developed a Depressive episode and severe Anxiety. He was restarted on Paroxetine and the dose was increased up to 50 mg along with Olanzapine 15 mg per day. As he did not improve, he was switched to Sertraline with which he developed Hyponatremia. Further to this, he was tried on Venlafaxine and Lofepramine and he developed Hyponatremia with both of them. Considering the severity of Depression, he was started on Mirtazapine and the dose was titrated to 45 mg. With this dose his serum Sodium levels were stable but his Depression persisted. Fluoxetine augmentation at this stage by the GP led to another episode of Hyponatremia. Hence, he was started on Aripiprazole 5 mg as an augmentation agent. His Depression improved reasonably (though he did not remit fully). Recently, he has been started on Vortioxetine and the dose has been titrated to 15 mg OD and in addition, he is on Mirtazapine 45 mg OD and Aripiprazole 5 mg OD. His Sodium levels have been stable and his Depression has improved. This is the first time we have come across a patient with colectomy developing severe Hyponatremia. In this article, we have discussed possible reasons for Hyponatremia following colectomy and the management strategies that could help

STUDY ON THE PRESCRIBING PATTERNS OF ANTIPSYCHOTIC MEDICATION IN A RURAL ENGLAND COMMUNITY MENTAL HEALTH TEAM

Introduction: Providing comprehensive services for about 400 patients in the South Herefordshire area, the community mental health team manages cases of varying severity and complexity, ranging from Schizophrenia, to neuroses and disorders of adult personality. Antipsychotic medication remains a mainstay of treatment and management for patients under the team case load; hence a need exists for a detailed look into the prescription patterns of such medications. Aim: The aim of this study was to look into the prescribing patterns of antipsychotics for a sample of 50 patients in the South Herefordshire community team during the year of 2016 (from Jan 2016 to Dec 2016), as well as investigate whether these antipsychotics were licensed to be used for the corresponding diagnoses of these patients. We also looked into whether patients were prescribed antipsychotics within BNF limits. As a part of this audit we looked into whether patients were made aware that they were on unlicensed antipsychotics or on above the BNF maximum doses of antipsychotics. Methodology: A random sample of 50 patients was taken from the case load of the South community team as is documented on RIO. The mean age of the patients in the sample was 46.1 (SD= +14.6) Sample selection was done by selecting every seventh patient in the patient case load (if not using antipsychotics the next patient was chosen). Patients studied involved those with F1-F19 Mental and behavioural disorders due to psychoactive substance use, F20-F29 Schizophrenia/Schizotypal/Delusional disorder, F31 Bipolar affective disorders, F32 Depression, F40-F48 Anxiety Neurotic and stress related disorders and somatoform disorders, F50-F59 Behaviour syndromes associated with physiological disturbances and physical factors, F60-F69 Disorders of adult personality and behaviour. The patients selected had to be followed up by the recovery team during the year 2016 and they had to be on an antipsychotic medication at any point during that time period. A scale was utilized to help the orderly collection of information as dose, patient diagnoses, comorbid substance use etc. SPC was relied upon for investigating the licensing of the different antipsychotics. Results: It was found that the most commonly prescribed antipsychotic was Quetiapine (28.07%) followed by Olanzapine (24.56%), Aripiprazole (14.04%) and Depot drugs (12.28%). It was found that the most commonly used depot drugs were Modecate and Depixol. It was also found that 14% of our patients were prescribed two antipsychotics at the same time. Unlicensed antipsychotics made up 17.54% of all prescribed antipsychotics. It was also found that no documentation on the system evidenced that patients were told about the use of unlicensed antipsychotics. Quetiapine and olanzapine made up 60 % of the unlicensed antipsychotics followed by risperidone and aripiprazole 40%. The conditions that were found to be given unlicensed medications were anxiety neurotic and stress related disorders and somatoform disorders (F40-48), disorders of adult personality and behaviour (F60-F69) and multiple conditions. The most common daily doses prescribed for Aripiprazole were found to be 5, 10 and 15 mg doses. For Quetiapine, it was the 300mg dose and for Olanzapine it was found to be the 10mg dose. In all but one patient antipsychotics were prescribed within BNF limits. One patient was prescribed Olanzapine 25 mg (BNF maximum dose 20 mg). Polypharmacy was found to be used more in the multiple diagnosis and schizophrenia conditions. Patients with schizophrenia and adult personality disorders were found to be the most patients who abused alcohol, cannabis and prescription opioid analgesic medications. Conclusion: Antipsychotics have a range of central nervous system effects and there are situations where it becomes necessary to use them off-license. However, it is essential to explain to the patient about the unlicensed use of antipsychotics and document this on the system. The effects of unlicensed antipsychotics need to be carefully monitored and their benefits regularly assessed and recorded. Antipsychotics interact with physical health medication and could adversely affect the physical health condition. Hence it is necessary to look into healthier means of pain management and review the long term prescription of opioid analgesics. It is important to investigate more into how to manage comorbidities such as substance misuse of alcohol and cannabis and whether cross referral between services is the best way to address this issue. Further audits can look into the follow up of patients on polypharmacy, and on the general effect on disease prognosis, and physical health side effects of such regimens

ANTIDEPRESSANTS AND HYPONATREMIA IN A PATIENT WITH COLECTOMY – A CASE REPORT

Antidepressants are routinely used by General Practitioners (GP) as well as Psychiatrists to treat Depression. They are tolerated well. However, in certain patient populations, they are associated with SIADH (Syndrome of Inappropriate Anti-Diuretic Hormone Secretion) and Hyponatremia. Various research studies have shown that all antidepressants are associated with Hyponatremia. Hyponatremia as a side effect of antidepressant therapy is more commonly seen in old age, chronic Kidney disease and Hypothyroidism. Untreated Hyponatremia could lead to life threatening emergencies including Cerebral oedema, brain damage and coma. In this article, the authors discuss a 63 year old patient who suffered from Bipolar Disorder Type 2. He was treated with antidepressants (mainly Paroxetine) on and off for 30 years, without much side effects, until 2014. In July 2012, he underwent subtotal colectomy with ileorectal anastomosis as a management of adeno carcinoma of Colon. In April 2013, Paroxetine was stopped as he was well. He developed first episode of mania in July 2014. This was managed with Olanzapine. However, he soon developed a Depressive episode and severe Anxiety. He was restarted on Paroxetine and the dose was increased up to 50 mg along with Olanzapine 15 mg per day. As he did not improve, he was switched to Sertraline with which he developed Hyponatremia. Further to this, he was tried on Venlafaxine and Lofepramine and he developed Hyponatremia with both of them. Considering the severity of Depression, he was started on Mirtazapine and the dose was titrated to 45 mg. With this dose his serum Sodium levels were stable but his Depression persisted. Fluoxetine augmentation at this stage by the GP led to another episode of Hyponatremia. Hence, he was started on Aripiprazole 5 mg as an augmentation agent. His Depression improved reasonably (though he did not remit fully). Recently, he has been started on Vortioxetine and the dose has been titrated to 15 mg OD and in addition, he is on Mirtazapine 45 mg OD and Aripiprazole 5 mg OD. His Sodium levels have been stable and his Depression has improved. This is the first time we have come across a patient with colectomy developing severe Hyponatremia. In this article, we have discussed possible reasons for Hyponatremia following colectomy and the management strategies that could help

HOW CAN WE MAKE THE CURRENT UK PSYCHIATRIC TRAINING SCHEME TRULY TRAINEE CENTRED?

Introduction. UK Psychiatric training is popular worldwide and IMG from throughout the world come to UK. Psychiatric training has undergone significant changes but this has not reflected in the outcomes. There is a need to refocus on trainee centred teaching principles. Current Psychiatric Training: Current training scheme started in 2007 as run-through programme spanning six years. Till 2005, examinations decided the progression of trainees through the training scheme with development of Work Place Based Assessments. Following Tooke’s report,training was uncoupled and examinations regained importance in deciding the progress of trainees to higher training. Factors affecting psychiatric training: EWTD, budget cuts, service priorities lead to a sense of lack of importance among trainees. Surveys focussing on clinical supervision pointed to the inadequacy and poor quality of supervision. Training has lost trainee centeredness. It is important to make the training maximally effective to deliver safer services. Trainees are major work forces and the future consultants who lead and manage services. Conclusion: Student centred teaching is a highly skilled educational process. Adapting these principles into psychiatric training could help trainees learn successfully