Building a Dual Diagnosis Service In a Private Hospital Setting

Transcription

1 Building a Dual Diagnosis Service In a Private Hospital Setting

2 Background The historical neglect of those with ID in the public hospital arena Queensland experience The Carter Enquiry & report The recent Qld health / DSQ experience The possibility of building an psychiatric service for those with ID through a private hospital, linked to other sectors

3 A day in the clinic 40 year old male, 150kg, moderate to severe ID, presents with aggression, tearfulness and self-harm.very limited verbal expression except for repeating the plane, the plane.eventually found to have gallstones, harmatoma and testicular hydrocele that the surgeons decline to remove because risk complicated by active epilepsy (absence seizures) as well as aggressive polydipsia had an historical diagnosis of BPAD A 25 year old Downs girl presents with her mother 4 years following death of father from cancer, complains of bad dreams, worries about her deceased father s health, refusing to go to work at KFC because of a man there.was fatuous, shy at times, and seemed to be thought disordered. A 30 year old female with a relatively high IQ (70!) describes feelings of depression and paranoia about the motives of others she is articulate and has a history of sexual abuse in the family she appears to lose consciousness in the waiting room and faints to the floor with eyes staring, leading to a medical emergency.

4 A Queensland perspective Neglect and mismanagement of those with ID & mental illness / challenging behaviour Culture of rejection, avoidance and misunderstanding The public hospital Emergency Department Misdiagnosis & underdiagnosis The emergence of massive polypharmacy Long stay patients

5 A Qld experience The Carter Enquiry & Report Restrictive practices highlighted & defined Emphasis on behavioural analysis The Specialist Response Service (SRS) The Mental Health Assessment & Outreach Service (the MHAOT) The Positive Behaviour Support Plan (PBSP) The dichotomy : chemical restraint OR treatment of a mental illness Who is doing the treatment?

6 The private psychiatrist The new legislation envisages the SRS liaising with private psychiatrists However, few private psychiatrists, and even fewer public, have much interest in ID psychiatry An obvious clinical lacuna, despite lots of $$$

7 Possibilities in the Private sector Clinicians still connected to general adult psychiatry / psychology In clinically diverse practice Primarily clinicians Self-sufficient practices Self-employed & independent Fee for service

8 referrals NGOs GPs Family Adult Guardian Forensic services Public mental health services

9 funding NGO Family Medicare safety net Public mental health out-sourcing

10 Our service Currently based in Toowong Private Hospital in central Brisbane Individual & group treatment Applied behavioural anaysis (incl. home visit) Assessment & management reports Follow-up and liaison with carers / families Psychiatry, psychology, community nursing and allied health NGO / carer / family education seminars

11 groups Anger management Sex offenders group Art group DBT group In setting of non-id group treatment for PTSD & depression / anxiety

12 Individual Rx CBT for OCD, anxiety, depression, psychosis etc The possibility of applying foundations of psychodynamic and existential psychotherapies to those with (mild) ID Biological treatment for Axis 1 disorders Medical treatment where necessary Or liaison with medical specialists

13 Service development Attracting psychiatrists & registrars Involvement in registrar training What is interesting about ID psychiatry?

14 Whats interesting about ID psychiatry? ID in psychiatric training is only an after though Really only touched on in cognitive assessment & in the the context of autism Crossover with physical medicine, epilepsy, and esoteric conditions The emergency department culture

15 What s interesting about ID Clinical aspects : psychiatry? Importance of affect and behaviour over the subtleties of language & thought The elusive quality of thought, thought form, delusions, perceptual abnormalities Response to treatment, psychological & biological Personality structure in ID A true empirical approach

16 The empirical approach When knowledge of brain and effect of medication in the individual is limited Relies on close observation by carers and family And everyone else Reflects limits of theory of brain and medications Hard to apply if hidden agendas in observers or assumptions in psychiatrist Defeated by polypharmacy Requires a tolerance for uncertainty Needs reasonable adherence to principle of Do No Harm, but also entails risk of harm

17 What s interesting Philosophical aspects Theory of mind Narrative Transference / counter-transference at the boundary of ID Recovery & resilience in this population Family dynamics, exhausted parents The carers Ethics & power imbalance

18 Forensic aspects Referrals from Corrections and from AMHSs re patients on forensic orders & involuntary treatment orders Risk assessments Combined psychiatrist / psychologist reports Risk management Opinions as to criminal responsibility

19 Limits of the private system Clinical workload issues Availabilty of private hospital beds Availability of closed wards / seclusion in acute mental illness The waiting room scenario.. your patient caused mine to have a panic attack out there!