RESUMO
In this case study, we present a novel approach to care within a Home Treatment Team, using a behavioural contract. This is a signed, written agreement that targets specific behaviours for change. The concept draws on social learning theory in that it requires social interaction and a relationship to work. In psychiatric settings, the behavioural contract often finds use in Democratic Therapeutic Communities but rarely in crisis or acute services. In this case study, we attempted to use a behavioural contract within our Home Treatment Team to help a patient address his alcohol dependence and its subsequent effect on his daily living activities. The behavioural contract provided an alternative way to manage a crisis episode. We hope that other crisis service staff reading this case study may use a behavioural contract in their work to a similar beneficial effect.
RESUMO
There is still much to learn about the predictors of therapeutic response in psychiatry, but progress is gradually being made and precision psychiatry is an exciting and emerging subspeciality in this field. This is critically important in the treatment of refractory psychotic disorders, where clozapine is the only evidence-based treatment but only about half the patients experience an adequate response. In this case report, we explore the possible biological mechanisms underlying treatment failure and discuss possible ways of improving clinical outcomes. Further work is required to fully understand why some patients fail to respond to the most effective treatment in refractory schizophrenia. Therapeutic drug monitoring together with early pharmacogenetic testing may offer a path for some patients with refractory psychotic symptoms unresponsive to clozapine treatment.
RESUMO
OBJECTIVES: Statins are a well-known primary and secondary prevention drug for cardiovascular disease and NICE guidelines have been issued to identify key indicators for their use. An audit looking into statin prescribing for medical inpatients was carried out in two geographically distinct London hospitals. DESIGN: A prospective inpatient audit of medical prescription charts was performed. Blood results were reviewed for the inpatients during their admission to identify any contraindications for statin usage (rhabdomyolysis). The medical notes were also reviewed for patient refusal of statin therapy. SETTING: The study was carried out at two distinct hospitals in London. Whipps Cross University Hospital (WCUH) and Chelsea & Westminster Hospital (CWH) are located in East London and West London, respectively. Acute medical, surgical, obstetrics and gynaecology, paediatric and palliative wards were excluded. PARTICIPANTS: A total of 309 inpatient medical notes and prescription chart data were collected from WCUH (n = 211) and CWH (n = 98). MAIN OUTCOME MEASURES: High percentage of hospitalized patients are not prescribed statins despite clear clinical indications for their use. Regardless of geographical and socioeconomic factors between hospitals, statin prescribing remains suboptimal. RESULTS: The patient demographics in both hospitals were very similar; the mean age at WCUH was 78 ± 15 1SD while at CWH the mean age was 74 ± 15 1SD. The results showed that approximately one-third of patients (30% at WCUH and 33% at CWH) had at least one indication for statin therapy according to NICE guidelines and yet they were not prescribed a statin. Ten percent of patients at WCUH and 13% of patients at CWH had ischaemic heart disease (IHD) and yet were not prescribed statins. CONCLUSION: Statin prescription is often overlooked in secondary care with patients being discharged without the appropriate assessment (NICE guidelines), which subsequently means repeat prescriptions are not provided by the GP. This study is the first to show that this problem is not due to resources or geography, but is inherent within the NHS system. Consequently, a revised prescription chart checking system has been suggested for pharmacists and junior doctors.
