MRCPsych

Passing the CASC Exam, Second Edition

Justin Sauer, Malarvizhi B. Sandilyan

• Publisher: CRC Press
• Year: 2016
• ISBN:
  9781315353692
• Edition: 2
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

This is a fully-updated, comprehensive guide for trainees preparing for the MRCPsych CASC exam (Clinical Assessment of Skills and Competencies). Success in the CASC is the final step in being awarded the MRCPsych qualification, which signifies the physician has fulfilled the necessary training requirements and has passed the membership exams conducted by the Royal College of Psychiatrists. The book is presented in a clear layout and covers the full range of psychiatry subspecialties likely to be encountered on exam day.

Chapter 1
Old age psychiatry

Oliver Bashford

○ LINKED STATIONS

STATION 1(a): TREATMENT-RESISTANT DEPRESSION

INSTRUCTION TO CANDIDATE

Mr Jones is a 74-year-old depressed patient. He has not responded to therapeutic doses of lofepramine and sertraline and, more recently, a combination of venlafaxine and mirtazapine. A worsening of mood and the emergence of psychotic features led to a compulsory admission to hospital under the Mental Health Act. He has been seen by the ward psychologist but is too depressed currently to engage with cognitive behavioural therapy (CBT). The nursing staff are concerned with his dietary intake, which has declined since his admission. Over the last week, fluid intake has reduced and blood tests show abnormal urea and electrolytes consistent with dehydration. His wife wonders if he should be transferred to a medical ward. In the absence of the consultant, you see this gentleman on the ward.

Explain to Mr Jones how you wish to manage him further and what this is likely to involve.

DO NOT INCLUDE A RISK ASSESSMENT.

ACTOR (ROLE-PLAYER) INSTRUCTIONS

You are withdrawn and relatively unforthcoming.

You do not recall the details of current or past treatments.

You are somewhat fearful and upset by the prospect of electro-convulsive therapy (ECT), but want to know more about it.

You recognise that you have not been eating or drinking well, but you are not delirious.

You do not actively want to end your life, but do not care if you die.

You would quite like to be left alone (halfway through the station), but you allow the candidate to continue if they are polite.

SUGGESTED APPROACH

Setting the scene

Begin the task by addressing the patient by name and introducing yourself. Acknowledge his current circumstances and explain the purpose of your meeting: ‘Hello Mr Jones, I am Dr______, a psychiatrist. I am sorry that things have been difficult for you lately; I understand your depression hasn’t improved despite treatment with several antidepressants…’

Allow the patient to respond to your introduction and maintain a flow in your conversation.

Then explain your concerns: ‘I can see that you haven’t been able to eat and drink well lately; is something stopping you from eating or drinking?’ ‘Do you remember you had some recent blood tests? Well, the results are concerning because they are abnormal, probably because you aren’t drinking very much.’

Explain the purpose of your discussion and offer him any clarifications: ‘I would like to discuss with you the various treatment options available to help you recover from this depression. Please do interrupt me if you want to ask me anything in-between.’

Medical treatment

Here, you have to explain your concerns about his physical health and how you are planning to manage this: ‘Mr Jones, it is very important that we talk about your physical health. Your recent blood tests were abnormal (deranged kidney function and salt levels in the blood), indicating that you are dehydrated. We will need to closely monitor this as, unless you are drinking, we might need to transfer you to the general hospital so they can rehydrate you with fluids. So we will be keeping a very close eye on your daily food and fluid intake over the next 24 hours to make sure your general health is satisfactory. We will need to take further blood tests and check your blood pressure and pulse rate frequently on the ward and I will be asking the nursing staff to encourage you to eat and drink at frequent intervals. Though all of this may seem like we are disturbing you quite often, these are important measures to support your general wellbeing.’

Psychological treatment

Here, you can briefly explore the outcome of the psychological assessment: ‘I understand that you met with the psychologist to work out ways of overcoming your depression. Can you tell me how it went?’ Then you can briefly explain the rationale of CBT and why it may not be suitable for him right now: ‘Cognitive behavioural therapy aims at modifying your thoughts and behaviours which contribute to depression. However, it may take up to several weeks to achieve this, and given the severe nature of your depression, we may have to leave it for the future and not consider it as an option right now.’

Pharmacological treatment

Here, briefly explain the options available for treatment-resistant depression. You will have to familiarise yourself with the literature evidence for the various drugs (see ‘Further Reading’).

You should explain that changes to medication will depend on him being physically well and appropriately hydrated. If the patient is somewhat unresponsive, it might seem inappropriate to discuss the detail of particular drugs; but you can talk in broad terms: ‘Mr Jones, there are further changes to your medication that might help you. Adding medication can have a positive effect on mood; however, this often takes some time to see a positive effect.’

Possibilities here for discussion include lithium, tri-iodothyronine or quetiapine.

ECT

ECT should be considered as an option when the effects of depression are potentially life threatening, such as through poor fluid or dietary intake. It will be important to demonstrate to the examiner that you recognise the severity of the depression and the risks faced by the patient and that ECT may be an appropriate treatment option. You should be familiar with the mental health law surrounding the administration of ECT in a consenting/non-consenting patient in principle, but are unlikely to be asked specifics in relation to the Mental Health Act law in a CASC station.

‘Mr Jones, unfortunately, you remain very depressed despite treatment and it is seriously affecting your general health now. We are concerned that your physical health will deteriorate further without appropriate treatment. Taking all of this into consideration, one option that we need to discuss is ECT.’ At this point, you should ask if he has heard about ECT or knows anyone who has been treated with ECT. This will help to address any preconceptions that he may have about ECT.

How does ECT work?

‘The treatment is well established and its role has been well recognised in treating depression for many years. Because of the advances in medicine, it has become safer over the years. ECT involves passing a mild electric current through the brain whilst you are asleep under anaesthesia. This will artificially create a fit, and during this fit, there is a release of natural brain chemicals or neurotransmitters which help improve the symptoms of depression.’

What is the process like?

‘Before we begin ECT, we have to check your physical health. This involves a thorough clinical examination, further blood tests, a tracing of your heart (ECG) and a chest x-ray if necessary. The anaesthetist will want to examine you and will also be at your bedside monitoring you throughout the procedure itself. I will go through all of this with you again in detail if you decide to proceed with ECT. You will have to sign a form to indicate that you are happy to go ahead with ECT. But of course, you can change your mind at any time before the procedure itself. The treatment is usually given twice a week and may last up to 12 sessions.’

What are the side effects?

‘There are some short-term side effects following ECT; the common ones are headache, muscular pain, nausea and confusion. The risk of serious harm such as death is 1 in 100,000, which is very rare and is related to anaesthetic complications. This risk is reduced by having a proper anaesthetic fitness check prior to the procedure. In the longer term, about a third of people complain of loss of memory for life events often surrounding the period of depression. This is something we would have to monitor in the future.’

Rapport and communication

The patient will show a degree of psychomotor retardation, being somewhat withdrawn and slow to talk. It is important not to rush the patient, to give him enough time to absorb all the information you give and to check he understands what you say. Give him opportunities to ask questions and for there to be a dialogue. Addressing the patient by name personalises the interview and makes him feel valued. Whilst explaining all the risks, it is important to simultaneously explain how you are going to manage the risks so as to not alarm the patient. It is very important to give realistic and honest hope and reassurances, which will instil confidence in him (and the examiner).

Conclusion

Here, you can summarise what you have discussed, any ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Preface
• Acknowledgements
• Editors
• Contributors
• Exam guidance
• 1 Old age psychiatry
• 2 Anxiety disorders
• 3 Child and adolescent psychiatry
• 4 Eating disorders
• 5 Addiction disorders
• 6 Forensic psychiatry
• 7 Learning disability psychiatry
• 8 Liaison psychiatry
• 9 General adult psychiatry
• 10 Neuropsychiatry
• 11 Personality disorder
• 12 Perinatal psychiatry
• 13 Psychotherapy
• 14 Physical examinations
• 15 Investigations and procedures
• 16 Miscellaneous disorders
• Index