PROJECT EVIDENCE for Treatment of Mental Disorders. The project coordinator is Dr Allan Mawdsley. The version can be amended by consent. If you wish to contribute to the project, please email admin@mhyfvic.org
[6] Standard Treatment
a) Outpatient psychotherapies, medication and procedures
b) Inpatient psychotherapies, medication and procedures
c) Ancillary support services
[6 a ] Outpatient psychotherapies, medication and procedures
Specialist mental health services should offer a range of therapeutic programs for disabling mental health problems in the community. Service provision, clinical research and training are closely linked in the Tier Three facilities (see PE5c) but the practice guidelines published by those services should be implemented at all levels of their service delivery facilities.
These are grouped under nine headings: (i) organic brain disorders, (ii) substance abuse disorders, (iii) psychotic disorders, (iv) mood disorders, (v) anxiety disorders, including stress-related, somatoform and obsessive-compulsive disorders, (vi) physiological disorders, including eating, sleeping and sexual, (vii) personality disorders, (viii) intellectual disability and developmental disorders including autism spectrum disorders, (ix) behavioural and relationship disorders of childhood.
All disorders in childhood require wholistic management involving caregivers. See PE4 for a general outline of case identification and assessment and PE2a(i) for infant mental health. See PE6a(ix) for a general outline of case management for young people.
PE6a (i) Organic Brain Disorders
Insofar as consciousness and all cognitive, language and emotional processes are mediated by brain functions, it could be argued that all psychological disorders are brain disorders. However, an arbitrary categorisation separates those which are shown or presumed to reflect biologically-based abnormal brain processes from those functional disturbances without demonstrated brain abnormalities.
There remain many ambiguous examples, such as psychotic disorders and developmental disorders, where there are abnormal brain mechanisms that are nevertheless not included as organic brain disorders.
The included categories are delirium, dementia, epilepsy, brain damage and mental disorders due to medical conditions. See PE3a(i) for further discussion of Brain Injury.
DELIRIUM
ICD-10 (World Health Organization, 2015) defines delirium as an etiologically nonspecific organic cerebral syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe.
This definition covers a wide range of disturbances of brain function from a wide variety of causes, and the consequence of this is that a strong emphasis has to be put on clarifying the cause.
Delirium has a high prevalence; it affects 10% to 30% of general hospital patients and up to 80% in tertiary intensive care units (ICUs). Delirium in adults and the elderly is strongly associated with increased length of hospital stay, morbidity and mortality. In the elderly it is associated with a faster cognitive decline, loss of independence, and increased mortality in the year following hospital discharge. Delirium is the most important predictor of the proximity of death in the elderly and in oncological patients, young or old (terminal delirium).
The reported prevalence of delirium in critically ill children varies from 20% to 30%. Rates depend on age (more common in younger children), severity of the illness, number of medications, diagnostic tools used, and group under study (e.g., paediatric ICU patients, general ward). Mental retardation and a previous episode of delirium are also known risk factors.
According to seriousness, paediatric delirium can be benign and non-benign. There are two types of benign paediatric delirium: emergence delirium and the common delirium seen in general practice.
Emergence delirium, also known as emergence agitation, is a well-documented phenomenon occurring in children—and adults—in the immediate postoperative period, after the withdrawal of anaesthetic drugs.
In general practice paediatric delirium frequently occurs in the context of an infection (febrile delirium).
There are important clinical reasons for assessing pediatric delirium and taking it seriously:
The acute occurrence of a disturbance of cognition, emotions, consciousness, or a behavioural disturbance in a critically ill child should raise the suspicion of paediatric delirium and the need for thorough medical assessment.
Apart from involvement in the daily care of their hospitalized child, parents can have a major role in the prevention, detection and treatment of delirium. A model that recognizes and respects the uniqueness of each family and empowers and encourages them to partner with health care providers is useful.
Symptoms associated with delirium, such as delusions or hallucinations, may come as a complete surprise, something the family has never encountered before, and can be very frightening for both child and parents. This may lead to parents not recognizing their child’s behaviour, becoming afraid that neurological damage has occurred or that their child is going to die.
Not knowing how to cope with these behaviours in their child makes parents insecure and anxious; this in turn can influence the child, causing the delirium to worsen. A soothing stimulation of all the five senses of the child with delirium is advocated. The constant presence of one parent during the hospitalization, hearing parents’ voices, readily visible photographs of parents or other well-known family members, and favourite toys decrease the severity of delirium.
Reference
Schieveld JNM, Ista E, Knoester H, Molag ML. Pediatric delirium: A practical approach. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2015.
DEMENTIA
Dementia is a disorder of significant mental decline in multiple cognitive functions from the individual’s previous intellectual level. This includes memory problems, aphasia (impaired verbal communication), apraxia (impaired performance of fine motor tasks), agnosia (impaired recognition of objects or tasks) and impaired executive functioning (planning, judgment, tactfulness and impulse control). The disturbance is severe enough to interfere with work, social activities and relationships. It is ongoing, in contrast to the transience of delirium.
Amnestic disorders characterised by memory impairment and more limited cognitive impairments may occur in cases of brain damage.
Management involves long-term care and specific treatments depending upon the different causes.
EPILEPSY
Epilepsy is a group of chronic neurological disorders characterized by seizures, which are the result of abnormal, excessive or hypersynchronous neuronal activity in the brain. Epilepsies can be classified by the:
Epilepsy is a worldwide problem that affects between 2% and 3% of the population, 75% of the cases begin before adolescence. Epilepsy can be caused by genetic, structural, metabolic or unknown factors. Among the structural factors, the most common causes in developing countries are infectious and parasitic diseases (especially neurocysticercosis), perinatal brain damage, vascular disease, and head trauma – all preventable (Barragan, 2004). The prognosis of epilepsy depends on the etiology of the illness as well as on early and sustained treatment.
About one in 200 children has epilepsy. One in 20 children will have at least one seizure during their childhood – often a febrile convulsion (associated with high temperature). Such a once-off seizure is not considered epilepsy.
It is estimated that up to 70% of people with epilepsy can live normal lives if they receive proper care.
Reference
Barragan E. Epilepsy and related psychiatric conditions. In Rey JM (ed), IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatry and Allied Professions 2012.
Royal Children’s Hospital fact sheet: https://www.rch.org.au/kidsinfo/fact_sheets/Epilepsy_an_overview/..
Last updated 15/1/2022
POLICIES for Treatment of Mental Disorders. The project coordinator is Dr Allan Mawdsley. The version can be amended by consent. If you wish to contribute to the project, please email admin@mhyfvic.org
[6] Standard Treatment
a) Outpatient psychotherapies, medication and procedures
b) Inpatient psychotherapies, medication and procedures
c) Ancillary support services
[6 a ] Outpatient psychotherapies, medication and procedures
MHYFVic advocates that Specialist mental health services should offer a range of therapeutic programs for disabling mental health problems in the community. All disorders in childhood require wholistic management involving caregivers.
Service provision, clinical research and training should be integrated in the Tier Three facilities, with the practice guidelines published by those services implemented at all levels of their service delivery facilities. The baseline standard of case assessment required is that outlined in PE4 (and PE2a(i) for infant mental health)
POL6a (i) Organic brain disorders
MHYFVic advocates that Specialist mental health services should offer treatment programs for children with organic brain disorders. Such services would require collaboration with paediatric and neurology specialists and include ongoing collaboration with families and consultative support to other agencies involved in the management plan. It would also include lifestyle and social components.
Last updated 10/2/2022
PROJECT EVIDENCE for Treatment of Mental Disorders. The project coordinator is Dr Allan Mawdsley. The version can be amended by consent. If you wish to contribute to the project, please email admin@mhyfvic.org
[6] Standard Treatment
a) Outpatient psychotherapies, medication and procedures
b) Inpatient psychotherapies, medication and procedures
c) Ancillary support services
[6 a ] Outpatient psychotherapies, medication and procedures
All disorders in childhood require wholistic management involving caregivers. See PE4 for a general outline of case identification and assessment and PE2a(i) for infant mental health. See PE6a(ix) for a general outline of case management for young people.
BP6a (i) Organic brain disorders
The general principles of clinical assessment and case planning mentioned in the preceding paragraph are modified in each of the subgroupings because of the need for specialist expertise in the management of specific disorders. This is described in the Project Evidence subsections.
An arbitrary categorisation separates disorders which are shown or presumed to reflect biologically-based abnormal brain processes from those functional disturbances without demonstrated brain abnormalities. The included categories are delirium, dementia, epilepsy, brain damage and mental disorders due to medical conditions. See PE3a(i) for further discussion of Brain Injury.
DELIRIUM
ICD-10 (World Health Organization, 2015) defines delirium as an etiologically nonspecific organic cerebral syndrome characterized by concurrent disturbances of consciousness and attention, perception, thinking, memory, psychomotor behaviour, emotion, and the sleep-wake schedule. The duration is variable and the degree of severity ranges from mild to very severe.
According to seriousness, paediatric delirium can be benign and non-benign. There are two types of benign paediatric delirium: emergence delirium and the common delirium seen in general practice.
Emergence delirium, also known as emergence agitation, is a well-documented phenomenon occurring in children—and adults—in the immediate postoperative period, after the withdrawal of anaesthetic drugs.
In general practice paediatric delirium frequently occurs in the context of an infection (febrile delirium).
The acute occurrence of a disturbance of cognition, emotions, consciousness, or a behavioural disturbance in a critically ill child should raise the suspicion of paediatric delirium and the need for
thorough medical assessment. It is important because it is accompanied by risks such as pulling out of IV lines and catheters, auto-detubation, stepping or falling out of bed etc. It may also lead to a post-traumatic stress disorder (PTSD).
DEMENTIA
Dementia is a disorder of significant mental decline in multiple cognitive functions from the individual’s previous intellectual level. This includes memory problems, aphasia (impaired verbal communication), apraxia (impaired performance of fine motor tasks), agnosia (impaired recognition of objects or tasks) and impaired executive functioning (planning, judgment, tactfulness and impulse control). The disturbance is severe enough to interfere with work, social activities and relationships. It is ongoing, in contrast to the transience of delirium.
Amnestic disorders characterised by memory impairment and more limited cognitive impairments may occur in cases of brain damage.
Management involves long-term care and specific treatments depending upon the different causes.
EPILEPSY
Epilepsy is a group of chronic neurological disorders characterized by seizures, which are the result of abnormal, excessive or hypersynchronous neuronal activity in the brain. There are various subtypes requiring specialist neurological assessment and management.
Last updated 10/2/2022
We welcome discussion about any of the topics in our Roadmap epecially any wish to develop the information or policies.
Please send your comments by email to admin@mhyfvic.org
Speak about issues that concern you such as gaps in services, things that shouldn’t have happened, or things that ought to happen but haven’t; to make a better quality of service…….
Help achieve better access to services & better co-ordination between services together we can…….
Mental Health for the Young & their Families in Victoria is a collaborative partnership between mental health & other health professionals, service users & the general public.
MHYFVic
PO Box 206,
Parkville, Vic 3052
