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    20221026劉震鐘老師 Community Psychiatry

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    蘇永泓
    This document discusses community psychiatry. It begins by explaining why community-based approaches are important, focusing on prevention, humanity, longitudinal care, and economic perspectives. It then covers social networks and their impact on health through various social, psychosocial, and physiological pathways. Conceptual models of disease progression and the natural history of illness are presented. The document also discusses preventive approaches based on risk levels, clinical trajectories of at-risk individuals, community rehabilitation settings, the roles of various organizations in a community mental health network, services beyond chronic psychosis, the community mental health care team, principles of community psychiatry, and challenges in the field.

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    20221026劉震鐘老師 Community Psychiatry

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    蘇永泓
    22 views21 pages
    This document discusses community psychiatry. It begins by explaining why community-based approaches are important, focusing on prevention, humanity, longitudinal care, and economic perspectives. It then covers social networks and their impact on health through various social, psychosocial, and physiological pathways. Conceptual models of disease progression and the natural history of illness are presented. The document also discusses preventive approaches based on risk levels, clinical trajectories of at-risk individuals, community rehabilitation settings, the roles of various organizations in a community mental health network, services beyond chronic psychosis, the community mental health care team, principles of community psychiatry, and challenges in the field.

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    This document discusses community psychiatry. It begins by explaining why community-based approaches are important, focusing on prevention, humanity, longitudinal care, and economic perspectives. It then covers social networks and their impact on health through various social, psychosocial, and physiological pathways. Conceptual models of disease progression and the natural history of illness are presented. The document also discusses preventive approaches based on risk levels, clinical trajectories of at-risk individuals, community rehabilitation settings, the roles of various organizations in a community mental health network, services beyond chronic psychosis, the community mental health care team, principles of community psychiatry, and challenges in the field.

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    22 views21 pages

    20221026劉震鐘老師 Community Psychiatry

    Uploaded by

    蘇永泓
    This document discusses community psychiatry. It begins by explaining why community-based approaches are important, focusing on prevention, humanity, longitudinal care, and economic perspectives. It then covers social networks and their impact on health through various social, psychosocial, and physiological pathways. Conceptual models of disease progression and the natural history of illness are presented. The document also discusses preventive approaches based on risk levels, clinical trajectories of at-risk individuals, community rehabilitation settings, the roles of various organizations in a community mental health network, services beyond chronic psychosis, the community mental health care team, principles of community psychiatry, and challenges in the field.

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    Community 

    Psychiatry

    劉震鐘 醫師
    Laurens van Lieshout (User:LaurensvanLieshout) - CC BY-SA3.0,
    https://commons.wikimedia.org/w/index.php?curid=1423431

    2
    Why “Community”

    • In contrast to institution
    • Preventive perspectives
    • Humanity perspectives
    • Longitudinal perspectives
    • Resource/economics perspectives

    3
    Social
    Structural Social Psychosocial
    Conditions Networks Mechanisms Pathways

    Culture: Social support: Behavioral pathways:


    norms/values Social network structure instrumental/financial smoking
    social cohesion size informational diet
    racism range appraisal exercise
    sexism density emotional adherence to medical
    competition boundedness treatments
    proximity Social influence: help-seeking behavior
    Socioeconomic homogeneity constraining/enabling
    factors: reachability direction of norms
    inequality Psychological pathways:
    peer pressure
    discrimination self-efficacy
    conflict Characteristics of self-esteem
    Social engagement:
    labor market network ties: coping effectiveness
    cognitive exercise
    poverty face-to-face contact depression/distress
    meaningful social role
    non-visual contact sense of well-being
    bonding
    Politics: organization participation
    laws reciprocity of ties Person-to-person Physiological pathways:
    public policy multiplexity contact HPA axis response
    participation duration allostatic load
    political culture intimacy immune system function
    Access to resources:
    job opportunities cardiovascular reactivity
    Social change access to health care cardiopulmonary fitness
    institutional contact transmission of diseases

    Conceptual Models of How Social Networks Impact Health


    4
    Berkman LF & Glass T 2000
    The Natural History of Disease

    Preclinical Clinical
    phase phase
    Outcome

    Biological Symptoms Diagnosis Therapy


    onset

    5
    Onset and progression of schizophrenia in relation to risk factors and 
    developmental processes affected by the disorder

    Millan et al. (2016) Nature Reviews Drug Discovery 6


    Concepts of preventive medicine

    • Primary prevention: health promotion; reduce risk 
    factors/enhancing host resistance: minimize 
    incidence
    • Secondary prevention: early detection and prompt 
    treatment: minimize prevalence
    • Tertiary prevention: rehabilitation: minimize 
    disability

    7
    Preventive approaches based on level of risks

    • Universal 
    • Selective 
    • Indicated

    8
    精神健康知能
    Aug 12 2007 China Times daily

    50
    45
    Registered
    40
    Recruited
    35
    30
    25
    20
    15
    10
    5
    0
    11/1/06 12/1/06 1/1/07 2/15/07 3/15/07 4/15/07 5/15/07 6/15/07 7/15/07 8/15/07 10/1/07 11/1/07 12/1/07

    9
    病人如何界定/辨識自已問題 問題呈現
    病人/家屬的背景及過去史 疑似精神病前期
    首次發生的精神病
    影響專業特質的因子 精神醫療專業：
    年齡、性別 態度/信念/ 問題辨識/
    訓練背景 知識/經驗 暫時診斷
    次專科、資歷
    工作場域 風險/期程/
    治療的考量：
    本次就診型式 給付結構 症狀層面評估
    是否有其他需求 執行實務
    執業結構
    病人期待
    繼續教育課程 新知的認識

    轉介系統 轉介 治療 暫時處理 忽略

    後續發展: 臨床成效、病人滿意度、專業
    成就感、 轉介與否等等

    圖一、影響第一線精神醫療專業人員處置的可能因素
    Clinical trajectories of young individuals seeking help who are at high 
    risk for developing schizophrenia
    Millan et al. (2016) Nature Reviews Drug Discovery

    11
     

    憂鬱性疾患 具精神病風險狀態  焦慮性疾患

    雙相情緒疾患  強迫性疾患 

    人格障礙或人格特質問題 適應性/成長階段困擾  個案後來可能發展


    成各種不一樣的精
    精神病光譜疾患  神疾病，也可能只
    是成長過程中的風
    圖二、示意圖：以「跨診斷」(transdiagnostic)的模式來看待「具 暴，一陣子過後自
    精神病風險狀態」個案在追蹤時，可能出現的變化 然就好了
    改編自Liu et al. Journal of the Formosan Medical Association (In
    press)
    參考原始文獻McGorry et al. World Psychiatry 2018, 17(2):133-
    142. 12
    Hospital services for psychiatric patients

    • Outpatient care
    • Emergency care
    • Acute inpatient care
    • Day care
    • Chronic inpatient rehabilitation
    • Chronic nursing care

    13
    Community rehabilitation settings

    • Home care
    • Halfway house
    • Sheltering training programs
    • Community rehabilitation center

    14
     
    中央主管機關 

    學校系統  地方衛生單位  勞動系統 

    社區心理  精神醫療網 
    衛生中心  核心醫院 
    (個管師)  (個管師) 

    個案 

    基層精神醫療  綜合醫院 

    摘自衛福部「精神病早期介入處置臨床參考指引」，各層級社區精神醫療網絡在早期介入的角色與連結
    15
    Services other than chronic psychosis
    • Early intervention for children
    • Long‐term care of elderly
    • Domestic violence: aggressors and victims
    • Sexual abuse: perpetrators and victims
    • Substance misuse
    • Post‐traumatic stress follow‐up
    • Suicide/depression prevention
    • Health education/promotion campaigns 
    • Public mental health in the era of global pandemic

    16
    Mental Health Care Team

    • Psychiatrists
    • Clinical psychologists
    • Social workers
    • Psychiatric nurses
    • Occupational therapists
    • Employment specialist
    • Administrative and clerical staff members
    • Links to other human services groups
    • Case managers

    17
    Focused on 
    • Outreaches rather than center‐based
    • Active participants rather than passive recipients
    • Strengths rather than weakness
    • Resources rather than limitations
    • Dynamic adjustment rather than static implement

    18
    Challenges in community psychiatry
    • Stigmatization
    • Revolving door phenomenon
    • Changes in psychosocial environment
    • Inadequate support systems 
    • Diversity of mental health problems
    • Priority of mental health issues in public policies
    • Legal aspects
    • NEET (Not in Employment, Education or Training) 

    19
    Student project

    20
    報告寫作重點

    ‧儘量以病歷報告的方式呈現
    • 練習coding精神症狀(情緒Affect、行為Behavior、
    認知Cognition、驅力Drive等的變化)
    • 練習和bio‐psycho‐social factors串連記錄或討論病
    情的變化
    • 討論著重在精神疾病相關的內容、不需對整部電
    影或小說討論
    ‧科學性的文章：文字通順、條理清楚
    ‧避免使用文學性的詞藻堆疊、含糊糾結的描述
    ‧切勿抄襲
    21

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