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By Q. Vak. Southeast College of Technology. 2018.

Case A1: innovating in mental health services through establishing provider alliances There was clear unmet need in mental health provision malegra dxt 130 mg, but alongside this was fragmented provision with a range of different statutory and voluntary sector providers treating different levels of severity in Child and Adolescent Mental Health Services (CAMHS) and offering psychological therapies for adults (PTA) generic malegra dxt 130mg fast delivery. It was in this context that a particular GP who occupied a clinical lead role in the CCG began to design a new approach to all these services by taking a collaborative approach with a range of service providers discount 130 mg malegra dxt otc. This case reveals the power of distributed leadership when used in combination with an initial vision, top-down determination and associated funding activity. Following the launch of the collaborative alliances the leadership and ownership was transferred, in the main to the collaborating partners. Initiation of mental health provider alliances The mental health programme board of the CCG worked with existing mental health providers in the statutory and voluntary sectors to form a set of alliances. These were seen as having the potential to offer a more co-ordinated and holistic approach. They drew on non-recurrent funding and convened meetings of diverse current providers to form shadow alliance boards. They challenged these boards to identify a number of objectives and discrete projects that would contribute to better integration over a funding period. A proportion of the funding was earmarked as dependent on successful progress, providing a basis for further funding of activities. As is evident from the listing of the various alliance member bodies, the CCG had within its territory a very complex array of mental health services. Each of the new alliances was steered by an alliance provider board. Each of these had a senior clinical and managerial representative from each provider. In addition, there were CCG representatives in the form of the mental health programme director and transformation director. Each alliance met monthly and were, from time to time, attended by the CCG mental health programme board clinical chairperson. Governance came from the represented bodies, but the initial impetus and vision came from the clinical leadership from within the CCG. Implementation Over a 15-month period, each of the three provider alliances completed a number of collaborative projects, which were formulated and agreed during the first quarter of alliance activity. The psychological therapies alliance worked on an improved system for managing referrals. It also worked on joint projects with the third sector concerned with improving access for particular ethnic groups and with preparation for employment. The dementia alliance worked on reminiscence pods, awareness training and treatments for improving cognitive abilities. The CAMHS worked on more consistent use of clinical outcome measures, clarifying referral pathways, and offering targeted training and professional development workshops. This alliance also designed a new common triage system. The three initiatives were viewed as successful, at least to the extent that they merited continued support. Clinical leadership within the programme board, an operational commissioning arena, supported by a dedicated manager, was seen as effective in bringing some order and coherence to a complicated set of activities and services which had grown in a disorderly manner and which resulted in overlap and duplication. At the same time, leadership within this operational commissioning arena needed to be matched by clinical leadership within various provider bodies involved in implementing alliance working. Achievements reported From the interviews with participants across the alliance membership, it was evident that the alliance initiative was viewed in a highly positive manner. Here, clinicians from different providers brought cases they felt the need to be referred on elsewhere. These meetings were seen as producing rich professional discussion that would not otherwise have happened and a greater sense of connection between clinicians in different services. Clinicians reported much greater confidence in referring patients on now that they understand better how colleagues elsewhere work. Clinical psychologist Alliance activities were widely felt to have built confidence for further collaboration. The collection of outcome measures for these pilots contributed to this sense of achievement. Challenges encountered Some board members in all three alliances expressed concerns about the short-term focus. Delivery of the specific projects detailed in the alliance specifications was supposed to happen in just 15 months. This short-term focus was experienced as sapping energy from thinking about how longer-term and deeper collaboration could further overall service delivery and pursuit of alliance objectives. However, this view was often held alongside a seemingly contradictory perspective that the achievements of these limited collaborative projects had built trust and confidence between alliance members and stimulated their appetite for further collaboration. There was also recognition that the CCG had a legitimate role in asserting the kinds of areas and priorities for collaboration that are most important for service users in the longer term. Clinical leadership across different arenas Interviews revealed the exercise of clinical leadership in a number of ways across the different kinds of arena identified in Figure 24. The initial basis for the alliances was established by a leadership dyad at the apex of the CCG, operating within an operational commissioning arena, a programme board. This consisted of the GP clinical chairperson of the mental health programme board and her managerial counterpart, the mental health programme director. The clinical chairperson articulated the objectives and mechanisms of the alliances in terms of providers working out together how best to meet the needs of their user population rather than each provider defensively retreating to the scope and categories of patients specified in their existing provider contracts. As the CCG clinical lead stated: Our mantra as commissioners is assess and then treat, because for years as a GP I watched how patients get bounced around. CCG clinical lead The CCG GP clinical leader had a vision of how the complex array of mental health services could work better and had a theory of how to bring this about. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 43 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising.

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In contrast generic 130mg malegra dxt amex, Gilbert and co- investigation by Szesko and colleagues (107) using criteria workers (76) demonstrated significantly increased thalamic from postmortem histologic analysis (129) with a semiauto- volume as measured by volumetric MRI in 21 treatment- mated computerized system (130) demonstrated bilateral naive quality 130 mg malegra dxt, pediatric OCDpatients compared to 21 age- and reductions in amygdala volume in OCDpatients as com- sex-matched healthy controls (Fig purchase malegra dxt 130mg visa. No significant differences be- callosum and anterior cingulate cortex, volumetric abnor- tween OCDpatients and controls were observed in the hip- malities in the thalamus were particularly pronounced in pocampus. After mono- Recent investigation in pediatric OCDpatients has also drug therapy with the SSRI, paroxetine, thalamic volumes implicated the amygdala (87,91). Specifically, Rosenberg decreased to levels comparable to those observed in healthy and associates (87) reported reduced putamen but not cau- children. Reduction in thalamic volume was positively cor- date volumes in treatment-naive pediatric OCDpatients. In contrast, served after temporal lobe lesions (131). In pediatric OCD thalamic volume did not decrease after 12 weeks of CBT patients, a positive correlation was observed between puta- in 11 treatment-naive pediatric OCDpatients who received men and amygdala volumes but not amygdala and caudate no adjunctive medication treatment (133). Subsequent investigation also revealed signifi- changes were observed in total brain volume, the striatum, cant differences between pediatric OCDpatients and con- or anterior cingulate cortex with either CBT or paroxetine trols in the size of the splenium, the region of the corpus treatment. How- tical development and activity (134), thalamic volumetric ever, direct measurement of whole temporal lobe, amygdala, reductions in pediatric OCDpatients may be specific to and hippocampal and superior temporal gyrus volumes SSRI treatment as opposed to a generalized treatment re- failed to reveal any significant differences between pediatric sponse or spontaneous resolution of symptoms. Per- It should be noted that the techniques utilized in these haps, volumetric abnormalities of the amygdala only be- investigations were unable to discriminate specific subdivi- come apparent later in development. Thus, we were unable to localize methods may not have been sensitive enough to distinguish changes to specific thalamic target fields. The dorsomedial 1630 Neuropsychopharmacology: The Fifth Generation of Progress A B C FIGURE 113. A: Corpus callosum area (A) in pediatric (left [•, MMM, normal controls; , ----------, OCD patients. Reprinted from Rosenberg DR, Keshavan MS, Dick EL, et al. Corpus callosal morphology in treatment naive pediatric obsessive-compulsive disorder. Prog Neuropsychopharmacol Biol Psychiatry 1997;21: 1269–1283. Retrocallosal white matter abnormalities in patients with obsessive-com- pulsive disorder. B: Anterior cingulate volume in pediatric (left [ , ⋅⋅⋅⋅⋅⋅⋅⋅⋅⋅, controls (r. Toward a neurodevelopmental model of obsessive-compulsive disorder. Orbital frontal and amygdala volume reduc- tions in obsessive-compulsive disorder. C: Response suppres- sion failures as a function of age for nondepressed, psychotropic medication-naive pediatric pa- tients with OCD and normal controls performing the antisaccadic task. Note the marked inverse correlation between age and total number of response suppression errors in patients with OCD and a trend for such an effect in controls. Oculomotor response inhibition abnormalities in pediatric obsessive-compulsive disorder. D: Thalamic volume in pediatric (left [•, MMM, healthy control (r. Adapted from Gilbert AR, Moore GJ, Keshavan MS, et al. Decrease in thalamic volumes of pediatric obsessive-compulsive disorder patients taking paroxetine. Cerebral structural abnor- malities in obsessive-compulsive disorder. A quantitative morphometric magnetic resonance imag- ing study. Morphometric analysis of shavan (88) have hypothesized that a dysplasia in postnatal regional subdivisions of the thalamus is currently an active synaptic pruning may be involved resulting in excess prun- area of investigation in our laboratory. The neural network dys- plasia of reduced striatal volumes and increased ventral pre- frontal and thalamic volumes in treatment-naive pediatric FIGURE 113. Thalamic volume by diagnostic and treatment FIGURE 113. Decrease in thalamic volume associated with re- condition. Adapted from Gilbert AR, Moore GJ, Kesha- Brown Obsessive-Compulsive Scales. Decrease in thalamic volumes of pediatric obsessive- Moore GJ, Keshavan MS, et al. Decrease in thalamic volumes of compulsive disorder patients taking paroxetine. Arch Gen Psy- pediatric obsessive-compulsive disorder patients taking paroxe- chiatry 2000;57(5):449–456. Although morphometric brain to minutes during single session studies so that the temporal imaging studies are instructive, functional neuroimaging dimension has been relatively unexplored. Recent advances studies that actively drive the system and can measure brain are beginning to permit 'real-time' analysis of brain func- chemistry and receptor function may be more sensitive in tion in response to differential stimulation and diagnostic their ability to detect more subtle and localized abnormali- and treatment conditions. This allows for a connectionist ties in brain circuitry (79). Such an approach is especially promising for FUNCTIONAL NEUROIMAGING STUDIES OF repeated longitudinal assessment of OCDpatients before, OCD during, and after treatment intervention.

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Although most studies involve case reports or series buy malegra dxt 130 mg cheap, PG (115) discount 130mg malegra dxt with mastercard. The authors also reported an increase in heterozy- larger-scale discount malegra dxt 130 mg on-line, placebo-controlled trials are emerging. Discrepancies in the findings of the Mood Stabilizers two groups may be explained by genetic heterogeneity, or Lithium, a salt with mood stabilizing properties believed to the genetic contributions from these loci may be additive modulate 5-HT systems (136), has been examined in the or modest. Taken together, the findings support a potential treatment of PG (137). In three men with PG and comorbid role for the D4R in PG, and further studies are warranted to cycling mood disorders, lithium, at daily doses reported up clarify the relationship. Comings and colleagues also found a to 1,800 mg per day, was found to be at least partially decrease in heterozygosity of the Msc I allele of the D3 effective in controlling gambling, cycling mood, hypomania Chapter 120: Pathologic Gambling and Impulse Control Disorders 1731 TABLE 120. PSYCHOPHARMACOLOGIC TRIALS IN PATHOLOGIC GAMBLING Catagery Reference Drug Sample Design Outcome Mood stabilizers Moskowitz, Lithium 3 males with comorbid Open-label Improved control 1980 (137) cycling mood of gambling, cycling disorders mood, risk taking, and mania/hypomania Haller & Hinterhuber, Carbemazepine 1 male Placebo-controlled, Decreased gambling 1994 (138) double-blind, behavior maintained crossover at 30 wk Serotonin reuptake inhibitors Hollander, et al. Durations of treat- mood disorder may respond better to an alternate pharma- ment were not clearly specified, although at least one patient cotherapy. Further studies are warranted to investigate this was maintained for up to 11⁄ years. The author concluded that lithium may target Hollander and colleagues performed a randomized dou- 'an affective component with excitability and impulsive- ble-blind, placebo-controlled crossover study of fluvoxa- ness-explosiveness. The trial lasted 16 ranted and are currently ongoing to determine the tolerabil- weeks after a 1-week placebo lead-in phase, with subjects ity and efficacy of lithium, particularly in groups of randomized to receive either active medication or placebo individuals with PG and cycling mood disorders. Fifteen subjects treatment of a 37-year-old man with PG has been described meeting the criteria for PG but not for active substance (138). The gambler had a 16-year history of significant gam- use disorders or past or present major axis I disorders were bling, with periods of abstinence lasting only 2 to 3 months enrolled, and 10 individuals (all male) completed the study. A placebo-controlled, double-blind trial of in phase, one during placebo treatment in phase I, and two carbamazepine was undertaken, with no improvement during phase I treatment with fluvoxamine (one for non- noted in gambling behavior over the 12-week placebo phase. Study drug dosing was initiated at 50 mg per day, creased to 600 mg per day, with blood levels of 4. Gambling behaviors decreased 2 weeks second and third weeks, respectively. Thereafter, the dose into treatment, and gains were maintained at 30 months. Mean Given the efficacy of SRIs in targeting OC behaviors in endpoint dose of fluvoxamine was 195 50 mg per day OCD (139) and the data supporting 5-HT dysregulation (range, 100 to 250 mg per day). Adverse effects documented in PG, trials of SRIs have been performed. The first of during fluvoxamine treatment were of only mild intensity these studies involved a 31-year-old woman with PG and and were consistent with SSRI treatment, and they were not comorbid social phobia and OC personality traits who had associated with early withdrawal from the study. Outcome been gambling persistently despite multiple prior treatments measures included scores from the PG-CGI and PG- (140). Clomipramine was administered in double-blind, YBOCS, as earlier. Data from the investigation demon- placebo-controlled fashion in a crossover design. Minimal strated active drug to be superior to placebo in targeting improvement was seen after 10 weeks of placebo treatment. Both the groups receiving After initiation of active drug at 25 mg per day with an active medication and placebo showed improvement in con- increase up to 175 mg per day, gambling behavior was dis- trol of gambling behaviors during the first 8 weeks, and the continued at week 3, with absence of gambling remaining most significant difference in response was observed at the at 38 weeks. The adverse effect of increased irritability was end of the second 8-week block (Fig. In other words, effectively treated with a temporary decrease in dose. Sixteen group were more likely to persist over time, whereas initial subjects entered the 16-week trial (8-week placebo lead-in, gains observed in the fluvoxamine-placebo treatment group 8-week active), with seven of ten completers judged to be declined. These findings are consistent with a high initial responders by (a) a score of 'much improved' or 'very rate of placebo responders and suggest that acute trials of much improved' on the Clinical Global Impression score longer duration may be important in better distinguishing for gambling severity (PG-CGI) and (b) greater than 25% response to placebo and active drug. Of the the treatment of PG was reported by an independent group completers, four were female and six were male. In their study, 34 patients were treated for 6 months cation was well-tolerated, and the average dose for complet- with placebo or fluvoxamine at 200 mg per day. Outcome ers was 220 mg per day at endpoint, with responders tend- was measured by quantification of time and money spent ing to be treated with a slightly lower dose (207 mg per on gambling. The authors found no statistically significant day on average). Noncompleters left the study during the differences in response rates to placebo as compared with placebo phase (four for noncompliance, two for lack of re- active drug for the overall sample. Of the three nonresponders, two were the only observing a statistically significant superiority of fluvoxa- completers with histories of cyclothymia, a finding raising mine as compared with placebo in the male and younger- the possibility that individuals with a comorbid cycling aged subgroups of individuals with PG in the study. Strik- Chapter 120: Pathologic Gambling and Impulse Control Disorders 1733 FIGURE 120. Changes in gambling symptom severity of patients with pathologic gambling (PG) in response to fluvoxamine. Changes in PG–Clinical Global Impression (CGI) scores are shown for subjects completing a 16-week pla- cebo-controlled, double-blind study of fluvoxa- mine for the treatment of PG. Measures are shown for individuals receiving placebo in phaseIfollowedbyfluvoxamine inphaseII(dia- monds) or fluvoxamine in phase I followed by placebo in phase II (squares). The study com- promising results and to define better the short- and long- pared the results of treatment with fluoxetine at 20 mg per term efficacies and tolerabilities of specific SRIs in groups day with support psychotherapy (n 11) as compared of individuals with PG.

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Steven Pryjmachuk contributed to the protocol for the study buy generic malegra dxt 130 mg online, assessed studies for inclusion and contributed to the writing of the report malegra dxt 130 mg amex. Susan Kirk contributed to the protocol for the study generic malegra dxt 130mg with visa, assessed studies for inclusion, facilitated PPI contributions and contributed to the writing of the report. Peter Bower contributed to the study protocol, guided review procedures, extracted study outcome data, led data analysis and contributed to the writing of the report. Data sharing statement This is a secondary research study and, therefore, no primary data have been generated. Further information can be obtained from the corresponding author. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that 49 suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. The Global Burden of Disease: A Comprehensive Assessment of Mortality and Disability from Diseases, Injuries, and Risk Factors in 1990 and Projected to 2020. Boston, MA: Harvard School of Public Health on behalf of the World Bank; 1996. Improving the quality of health care for chronic conditions. The Mandate: A Mandate from the Government to the NHS Commissioning Board: April 2013 to March 2015. The NHS Improvement Plan: Putting People at the Heart Of Public Services. Supporting People with Long Term Conditions: An NHS and Social Care Model to Support Local Innovation and Integration. Self Care: A Real Choice – Self-Care Support – A Practical Option. Our Health, Our Care, Our Say: A New Direction for Community Services. Supporting People with Long Term Conditions to Self Care: A Guide to Developing Local Strategies and Good Practice. Securing Our Future Health: Taking a Long-Term View. Supporting Self-Care: The Contribution of Nurses and Physicians. A Rapid Review of the Current State of knowledge Regarding Lay-Led Self-Management of Chronic Illness: Evidence Review. London: National Institute for Health and Care Excellence; 2005. Lorig KR, Sobel DS, Stewart AL, Brown BW Jr, Bandura A, Ritter P, et al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that 51 suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Griffiths C, Foster G, Ramsay J, Eldridge S, Taylor S. How effective are expert patient (lay led) education programmes for chronic disease? Guendelman S, Meade K, Benson M, Chen YQ, Samuels S. Improving asthma outcomes and self-management behaviors of inner-city children: a randomized trial of the Health Buddy interactive device and an asthma diary. Stevens CA, Wesseldine LJ, Couriel JM, Dyer AJ, Osman LM, Silverman M. Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial. McPherson AC, Glazebrook C, Forster D, James C, Smyth A. A randomized, controlled trial of an interactive educational computer package for children with asthma. Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice. Richardson G, Bojke C, Kennedy A, Reeves D, Bower P, Lee V, et al. What outcomes are important to patients with long term conditions? State sponsored self-care policy and the Chronic Disease Self-management Programme. Panagioti M, Richardson G, Murray E, Rogers A, Kennedy A, Newman S, et al. Reducing Care Utilisation through Self-management Interventions (RECURSIVE): a systematic review and meta-analysis.