Pattern-based formulation: clinical case 5.

OBJECTIVE:: To demonstrate how the Pattern-based Formulation can be used to integrate biological, psychological and sociocultural factors in constructing the case formulation in a patient who developed schizophrenia and post-psychotic depression. CONCLUSIONS:: Three new patterns are introduced and used to construct a comprehensive case formulation. This expands the suite of patterns in the pattern-based method of psychiatric case formulation, and further demonstrates its broad utility as an educational resource in psychiatry training.

Case formulation using pattern-based formulation methodology: clinical case 3.

OBJECTIVE: The objective of this study is to determine if pattern-based formulation (PBF) can accurately contribute to case formulation. CONCLUSIONS: The application of three PBFs accurately contributed to the development of this patient's case formulation. The case formulation demonstrated here, and the patterns introduced in this paper, will serve as educational materials for teaching psychiatric case formulation.

Case formulation using pattern-based formulation (PBF) methodology: clinical case 4.

OBJECTIVES: To provide a further example of the utility of the pattern-based model in formulation, and to introduce some further patterns. METHODS: A case study was carried out using the Pattern-based Formulation (PBF). RESULTS: Based on the case of a patient with a past history of trauma who developed late onset somatic symptoms, post-traumatic stress disorder and major depression, the PBF approach enabled development of a comprehensive formulation to explain the patient's current presentation. Four patterns were utilised. CONCLUSIONS: The PBF method of using patterns as building blocks enables development of a psychobiological formulation that can accommodate considerable complexity. PBF represents a broadly applicable method that may assist psychiatry trainees and others to develop good quality formulations.

Case formulation using Pattern-based Formulation (PBF) methodology: clinical case 2.

OBJECTIVES: To teach psychiatric case formulation; to build a repertoire of patterns that can be reused as building blocks in constructing case formulations. METHOD: Pattern-based Formulation. RESULTS: Demonstration of a case formulation and introducing three patterns. CONCLUSION: The demonstration will assist learning case formulation using the Pattern-based Formulation, while the three patterns introduced can be reused when formulating relevant cases.

Predicting serum drug level using the principles of pharmacokinetics after an overdose: a case of lithium overdose.

OBJECTIVE: In cases of drug overdose, clinicians often find it challenging to predict serum drug level and decide the optimum time for recommencing the overdosed drug. METHOD: This paper describes how to predict serum drug level using the principles of pharmacokinetics. RESULTS: The proposed method and recommencement of the overdosed drug is demonstrated using a clinical case of lithium overdose. CONCLUSION: The proposed method can assist clinicians in predicting serum drug levels and deciding the optimum time for recommencing the overdosed drug safely. Therefore, it may reduce unnecessary repeat serum drug level procedures.

Evaluating complex medical treatment options: a case report.

OBJECTIVE: Complex treatment decisions can be suboptimal due to lack of a reliable decision-making model, a need this paper aims to meet. METHOD: A model for making complex treatment decisions is introduced. RESULTS: The utility of the proposed method is demonstrated by making a complex treatment decision involving evaluation of clozapine treatment in a treatment-resistant patient. CONCLUSION: The proposed method implemented as a software tool can provide a framework for shared decision-making involving the patient.

A case report using the mental state examination scale (MSES): a tool for measuring change in mental state.

OBJECTIVE: There is a need for a simple and brief tool that can be used in routine clinical practice for the quantitative measurement of mental state across all diagnostic groups. The main utilities of such a tool would be to provide a global metric for the mental state examination, and to monitor the progression over time using this metric. METHOD: We developed the mental state examination scale (MSES), and used it in an acute inpatient setting in routine clinical work to test its initial feasibility. RESULTS: Using a clinical case, the utility of MSES is demonstrated in this paper. When managing the patient described, the MSES assisted the clinician to assess the initial mental state, track the progress of the recovery, and make timely treatment decisions by quantifying the components of the mental state examination. CONCLUSION: MSES may enhance the quality of clinical practice for clinicians, and potentially serve as an index of universal mental healthcare outcome that can be used in clinical practice, service evaluation, and healthcare economics.

Case formulation and management using pattern-based formulation (PBF) methodology: clinical case 1.

OBJECTIVE: A tool for psychiatric case formulation known as pattern-based formulation (PBF) has been recently introduced. This paper presents an application of this methodology in formulating and managing complex clinical cases. METHOD: The symptomatology of the clinical presentation has been parsed into individual clinical phenomena and interpreted by selecting explanatory models. RESULTS: The clinical presentation demonstrates how PBF has been used as a clinical tool to guide clinicians' thinking, that takes a structured approach to manage multiple issues using a broad range of management strategies. In doing so, the paper also introduces a number of patterns related to the observed clinical phenomena that can be re-used as explanatory models when formulating other clinical cases. CONCLUSION: It is expected that this paper will assist clinicians, and particularly trainees, to better understand PBF methodology and apply it to improve their formulation skills.

Investigating the effect of an online enhanced care program on the emotional and physical wellbeing of patients discharged from hospital with acute decompensated heart failure: Study protocol for a randomised controlled trial: Enhanced care program for heart failure.

Objective: Depression is highly prevalent and associated with increased hospitalisations and mortality among patients with heart failure (HF). This study will evaluate the effectiveness and cost-effectiveness of an online wellbeing program for patients discharged from hospital with acute decompensated heart failure (ADHF) in (i) improving emotional and physical wellbeing, and (ii) decreasing healthcare utilisation. Methods: Two-arm randomised controlled trial. Eligible patients with ADHF will be recruited pre-discharge from two hospitals. Five hundred and seventy participants will be randomised to receive the intervention (online enhanced care program for HF: 'Enhanced HF Care') or usual care. Enhanced HF Care includes health education (11 micro-learning modules) and monitoring of depression and clinical outcomes via fortnightly/monthly surveys for 6 months, with participants offered tailored advice via video email and SMS. Cardiac nurses track real-time patient data from a dashboard and receive automated email alerts when patients report medium- or high-risk levels of depression or clinical symptoms, to action where needed. General practitioners also receive automated alerts if patients report medium- or high-risk survey responses and are encouraged to schedule a patient consultation. Results: Sixty-five participants enrolled to-date. Co-primary outcomes ('Minnesota Living with Heart Failure Questionnaire' Emotional and Physical subscales) and healthcare utilisation (secondary outcome) at 1- and 6-month post-recruitment will be compared between treatment arms using linear mixed effects regression models. Conclusions: This study has the potential to reduce the burden of depression for patients with HF by prioritising urgent mental health needs and clinical symptoms while simultaneously empowering patients with self-care knowledge. Trial registration: The trial was prospectively registered via the Australian New Zealand Clinical Trials Registry: ACTRN12622001289707. Issue date: 4 October 2022.

A systematic approach to clinical reasoning in psychiatry.

OBJECTIVE: Clinical reasoning in psychiatry may be considered to be more challenging than in other branches of medicine because of its highly subjective nature. The literature on systematic approaches to the teaching of clinical reasoning in psychiatry is lacking, and we propose an approach that may assist educators and learners. METHOD: A systematic approach with a theoretical underpinning in logical inferences will be proposed as a teaching and learning tool. CONCLUSION: This paper complements our previous paper on psychiatric case formulation and expands our model of a theoretical framework for diagnostic reasoning and case formulation in psychiatry. Our approach also serves as a tool to assist in integrating the diverse clinical knowledge base in psychiatry.

Pattern-based formulation: a methodology for psychiatric case formulation.

OBJECTIVE: Psychiatric formulation is often considered a challenging task, particularly for trainees and students in psychiatry. The process of arriving at a good psychiatric formulation involves identifying major issues of the patient, and developing an explanatory system, which can be derived using known theoretical models in psychiatry. A good explanatory system should provide a high degree of coherence by linking the most relevant data, justification for the proposed management plan, and its feasibility. Unfortunately, the literature on 'how' to develop psychiatric formulation is limited, and for the trainees, psychiatric formulation remains a challenging task. METHOD: Based on the clinical reasoning strategy known as pattern recognition, a methodology for psychiatric case formulation has been proposed. The methodology uses a repository of templates, which are derived from major theoretical models in psychiatry. Developing a formulation involves a process of selecting, prioritising and combining templates according to the elicited set of main issues or psychopathology. The pattern resulting from the combination of different templates provides a degree of uniqueness to the explanatory system. CONCLUSION: It is expected that this methodology will help trainees and students to develop a broader understanding and skills in psychiatric formulation.