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1 www.blackdoginstitute.org.au The Black Dog Institute’s Contribution to the Assessment and Management of Mood Disorders in Rural Areas. ACRRM Conference, October 2008. Gordon Parker, Executive Director, Black Dog Institute, and Scientia Professor, UNSW.

2 Mood Disorders.  Distributed widely  Deadly  Disabling  Discriminating  Detection problems  Dumbed down in a Dimensional model

3 Distributed Widely? Lifetime chance of a mood disorder =  25% for women;  15% for men

4 Deadly?  Lifetime chance of suicide = 15%.  Of those who commit suicide, at least 80% are depressed.

5 Disabling  A study undertaken by the World Health Organization, Harvard University and World Bank established that depression was the most disabling – and Bipolar Disorder the 6 th most disabling – of all medical and psychiatric conditions.  Why? Young onset, repeated and often lengthy episodes.  How? Not getting to work and difficulty in working if at work.

6 Discriminating?  General destigmatization.  Lack of appreciation by non- sufferers.  Employers – particularly those that are downsizing.  Insurance companies.

7 Detection Problems.  Depression commonly undetected.  80% of those with Bipolar Disorders miss receiving the correct diagnosis. If received – 10-15 years after onset. [Failure to detect leads to collateral damage].  Why?  Denial, pride, stoicism (esp in males, rural regions)  Failure to screen and ask sub-typing questions.

8 Dumbed Down by a Dimensional Model.  While we argue that there are several distinct types of depressions, and that the differing ‘types’ respond quite differently to differing treatments, ours is not the dominant view.  Instead, a ‘dimensional’ ‘single cause’ view dominates.

9 Dumbed down?  Depression is an ‘it’ – and ‘it’ is then interpreted as sufficient to dictate treatment.  Treatment is then shaped more by the practitioner’s discipline and training than by characteristics of the disorder (i.e. the patient is ‘fitted’ to the practitioner’s treatment model rather than the treatment being fitted to characteristics of the depressive condition).

10 Imagine if…. We treated ‘major breathlessness’ according to a similar model…..

11 The Black Dog Institute. Structure Function Models Strategies

12 Institute building

13 Courtyard

14 Organisational Model

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16 Depressive Disorders – Multiple ‘Types ’

17 Depressions ■Some (e.g. psychotic depression, melancholic depression) are categorical ‘diseases’, others more environmental reflecting stressors alone, or in conjunction with certain personality styles. Psychotic: Rare 1-2% Melancholic: Less common 2-10% Non-melancholic: Common >90%

18 CLINICAL FEATURE Psychotic features Psychomotor disturbance Depressed mood DEPRESSIVE SUB-TYPE Psychotic depression Melancholia Non-melancholic depression

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21 NEUROTRANSMITTER DA NA 5-HT CLINICAL FEATURE Psychotic features Psychomotor disturbance Depressed mood DEPRESSIVE SUB-TYPE Psychotic depression Melancholia Non-melancholic depression

22 By Contrast…. A range of non-melancholic disorders reflecting the impact of certain stressors on certain personality styles.

23 Stressors Contributing to Non- Melancholic Depression.  Acute reactive scenarios where affront to individual’s self-esteem. [Stress itself or stress may build on earlier stressors – ‘key and lock’ phenomenon].  Chronic stressors are ones that undermine the individual’s self-esteem in an ongoing way.

24 An ICONnoclastic ‘Neuronal’ Line-up Relevant to the Non-melancholic Depressive Disorders

25 ‘Meaningful conditions?’ ■The Bipolar Disorders: ups and downs, with melancholic depression in the ‘down’ phases. Mania Melancholia Hypomania Mania Hypomania Melancholia

26 Bipolar Disorder – Some Facts.  Up to 6% lifetime risk in the general population.  Onset generally in adolescence – years 10-12 of ‘high’ school the highest risk period.

27 Depression Clinic

28 The BDI Clinic.  Initial assessment involves the computerised MAP, which provides  Socio-demographic details  Lifetime and current details on depression, anxiety and family.  Life history of risk (medical and non-medical) factors; personality profile  Details on all previous treatments  Diagnostic algorithms to determine (a) melancholic vs non- melancholic, and (b) bipolar vs unipolar.  Then interview by intake psychiatrist, who presents history to consultant psychiatrist. Patient reinterviewed by both to clarify diagnosis and management plan (with or without relatives).  Detailed letter to referring practitioner.  Review at 12 weeks.

29 Clinical Services  Impact – weighted to new onset and ‘treatment resistant’ disorders. Paradigm change to diagnosis and management in 80% of referrals.  Reviews show substantive improvement, high satisfaction with service and facility ambience. Too successful in terms of waiting list. Costly.  Thus, establishment of MAP centres in Sydney and rural areas.

30 Mood Assessment Program-MAP ■Computerised assessment and diagnostic tool for patients with mood disorders ■Based on BDI model of depression ■Identifies depression, subtypes it (including bipolar), defines personality style and identifies comorbid anxiety diagnoses

31 Specific Aims of the MAP ■To assist with the sub-typing of depressive disorders (e.g. psychotic, melancholic or non-melancholic depression) ■To improve the detection, and therefore treatment, of bipolar disorder ■To identify relevant factors that are likely to have contributed to the onset or maintenance of the disorder (e.g. stressful events, personality, anxiety conditions, drug or alcohol use)

32 PILOT MAP Centres ■Pilot MAP Centres are opening around the state in a range of settings ■These centres are testing the acceptance of the MAP as a credible tool in diagnosis and management of depression and bipolar ■First MAP centre opened end October 07 – already over MAP 1,000 assessments completed ■Positive feedback received from referring clinicians

33 GP Education Programs

34 GP Education Website

35 Workshops for GPs and GP registrars ■Demystifying Depression: Managing Depression in General Practice. ■Troubled Teens: Managing Adolescent Mood Disorders in General Practice. ■Ups and Downs: An Introduction to Managing Bipolar Disorder ■Psychological Treatments of Depression ■Psychological Toolkit ■Making the Most of Mental Health Care Plans ■The Psychological Treatment Team: GPs, Psychologists and Others… ■Dealing with Life-Threatening Depressions ■Dealing with Difficult Consultations In General Practice All fully accredited by the RACGP and ACRRM

36 BDI Bush Bash 2008 ■Bowral Tulip Festival ■Deniliquin Ute Muster ■Andrew Johns walk ■Tamworth Bush Bash Depression Between 5-9 November, 2008, the Institute will be visiting Tamworth to conduct a range of programs in Tamworth. The theme of the pilot Black Dog Institute initiative is Let’s talk about depression. During the visit, the Institute will undertake: –Public forums on mood disorders and happiness –School Talks –Rural Ambassador presentations –Picnic information sessions –Workshops for health professionals.

37 Black Dog Institute Bus

38 Andrew Johns Walks for the Black Dog

39 Website

40 Online Self-testing MOOD ELEVATION DISINHIBITION MYSTICISM IRRITABILITY More confident See things in new light Creative ideas & plans Things vivid/crystal clear Spend more money Increased libido Say outrageous things Feel ‘high as a kite’ Laugh more Do outrageous things Lots of coincidences Feel at one with nature See special meaning in things Mystical experiences Talk over people Feel angry Thoughts race Feel irritated

41 Online Bipolar Disorder Educational Program

42 Online Depression Education Program

43 ‘The Horses for Courses’ Model. Logic:  What type of mood disorder does this person have?  What are its underlying causes?  Given such information, what management strategies will be appropriate for this person at this time?

44 Our Community Initiatives ■C■Consumer & Community Resource Centre

45 Institute Books

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48 ‘06 v ‘07 v ‘08 Website Statistics

49 Less Discriminating?  Changes in Australia relatively unique  Largely reflective of several overlapping strategies:  Committed organizations.  Political investment (Economic argument)  The ‘stories’ of prominent people (especially politicians and sportsmen).  The ‘stories’ of ‘everyday heroes’ (our books).  Conferences like this.

50 Supporters

51 Thus, our Model…  There are differing meaningful conditions.  Using a non-specific approach (i.e. drugs for all ‘depressions’, counselling for ‘all depressions’), some people will be ‘under-treated’ and others ‘over-treated’.  The differing conditions benefit from differing therapeutic approaches.  Thus, the need to identify those differing mood disorders.


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