Evidence Based Medicine Y1 T2

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What is evidence based medicine?
The integration of best research evidence with clinical expertise and patient values.
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Fill in the gaps: The ______ of best research evidence with _____ _____ and ____ ______.
The integration of best research evidence with clinical expertise and patient values.
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Name three reasons why we need EBM
1. To deliver the best possible care with the best evidence 2. Contribute to good clinical governance 3. To have clear reasons to guide clinical practice
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What are the five steps of evidence based medicine?
1. Formulate a question 2. Track down the best evidence 3. Critically view the evidence for validity and applicability 4. Individualise 5. Evaluate your own performance
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What does non-maleficence mean?
First do no harm.
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Name an example of a drug which explains why we need EBM.
Thalidomide - Effective sleeping pill sold in late 50s, caused serious birth defects when taken in pregnancy.
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What is ethnic matching?
The patient asks to be matched to a therapist of the same ethnicity as them
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Why is client preference important?
Informed consent is incredibly important, shared decision making, ultimately their decision, their care.
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Define clinical expertise.
Non-specific therapy factors that predict the outcome of therapy. EG. Relationship building skills.
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What is the translational gap?
When you learn something but it's difficult to apply to real world clinical practice.
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Name the three elements of NICE relapse prevention
1. Medication 2. CBT 3. Mindfulness
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Outline three aspects of the NICE framework for psychological therapies
1. Provide appropriate therapy 2. Reduce gap between research and practice 3. Multi-disciplinary panel and come to a consensus using structured method
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Outline the four factors in the hierarchy of evidence
1. Systematic reviews 2. Secondary evidence on other factors 3. Gaps in evidence addressed 4. Expert and user consensus used when no research
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Outline the NICE stepped care model for depression.
See word document.
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Name five criticisms of EBM.
1. The definition is narrow 2. Focuses on scientific theory 3. It isn't 'evidence based' 4. Doesn't account for individuality 5. Undermines the autonomy of the doctor-patient realtionship
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How is the definition of EBM too narrow?
It struggles to consider non-statistical forms of medical information
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What is a con of focusing on scientific theory?
Scientific observations can contain their own biases, such as those of the observer.
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How is EBM not Evidence based?
There is very little evaluation as to whether working in an EBM way actually works.
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How could EBM potentially undermine the autonomy of the doctor-patient relationship?
Limits patient's right to choose what is best in their individual circumstances
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What is 'just in time learning'?
A method to gather evidence that focuses on current patient problems and is relevant to your practice and is UP TO DATE.
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What are 'foreground questions'?
Questions to ask evidence: PICO
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What does the P in PICO stand for?
Patient, problem and population
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What does the I in PICO stand for?
Intervention
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What does the C in PICO stand for?
Comparison (what is the main alternative)
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What does the O in PICO stand for?
(clinical) OUTCOMES - What do you hope to accomplish
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What is a case report?
'A detailed report of symptoms, signs, diagnosis, treatment or follow-up of an individual'
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Name three pros of a case report.
1. Can move practice forward 2. Emphasises individuality 3. Useful educationally
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Name three cons of a case report
1. Limited generalisation 2. Author bias 3.Anecdotal
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What is a case series?
A series of cases which are reported, tracking patients with a known condition.
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Name a pro of a case series.
1. More generalisable than a case report
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Name a con of a case series
1. Author bias
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What is a cohort study?
Usually a longitudinal study where they follow a group of people over time.
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Name two pros of a cohort study.
1. Large sample size 2. Can determine causal relationships
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Name two cons of a cohort study.
1. Participant attrition 2. Can't control confounds
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What is a controlled trial?
Where a psychotherapy is compared to a no treatment/medication/other treatment group. Placebos can be used.
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Name three pros of a controlled trial.
1. High level of control 2. Considers spontaneous recovery or worsening 3. Very strong form of evidence
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Name four cons of a controlled trial.
1. Expensive 2. Time consuming 3. Can't generalise 4. Favours treatment approaches that can afford to run them
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What is a review?
Gathering together several studies that address a related hypothesis and interpreting them.
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Name a pro of a review
It can give an accurate summary of a field
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Name two cons of a review
1. Bias or inaccurate reporting 2. Can dismiss relevant evidence as not appropriate.
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What is a mediation study?
A study which measures change in the mechanism pre and post therapy, and sees if this predicts clinical outcomes
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What is a dismantling study?
This is where you remove a component of the treatment and compare it to the full element.
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What is a process-outcome study?
Measure change on a week to week basis in therapy to try and understand how it works.
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What is a clinical audit?
A systematic review of criteria that seeks to improve patient care and outcomes.
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Name two examples of a clinical audit
1. Patient survey and focus group 2. Critical incident monitoring
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Name two pros of a clinical audit.
1. Can improve clinical practice 2. Can bring in service user perspective
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Name two cons of a clinical audit.
1. Rarely published 2. Results don't tend to generalise beyond the setting
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What are qualitative methods?
Research where we can't statistically analyse the data we collect as it isn't quantifiable.
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Name two pros of qualitative methods.
1. Rich data can generate new insights 2. Can explore topics indepth
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Name two cons of qualitative methods.
1. Time consuming/expensive 2. Can't easily generalise.
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What does health economics do?
Determines if the clinical benefits a treatment delivers is 'value for money'
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What is the T1 gap?
Where we have good treatments but they aren't good enough.
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What is the T2 gap?
Where the best treatments are only available to a small proportion of sufferers.
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What MUST someone with depression have to fit the DSM diagnostic criteria?
Low mood or Anhedonia (absence of positive mood)
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What else must someone with depression have to fit the DSM Diagnostic criteria?
Five of the following: -Changes in weight and appetite -Fatigue -Insomnia -Inappropriate guilt -Difficulty concentrating -Recurrent thoughts of death
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Does NICE recommend anti-depressants for low intensity depression?
Only if they have a past history of mod-severe depression or symptoms that persist after treatment or initial presentation has been over 2 years.
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List two facts regarding the prevalence of depression.
Blazer et al (1994) - At least 5% of the population has depression Lewinsohn et al (1993) - By the age of 18 20% of them will have depression
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What must you discuss when considering medication at a HI level?
1. Perception of efficacy 2. Previous history 3. The choice 4. Any anticipated adverse effects.
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Name four criticisms of anti-depressants.
1. Over prescription 2. Little evidence that supports SSRIs 3. Not depression specific and treat many disorders 4. Drug exert chemical effect in hours but mood effects in weeks
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Name three potential adverse effects of antidepressants.
1. Weight gain 2. Sexual dysfunction 3. Elevated suicide rates
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Outline a main piece of research into SSRIs and depression.
STAR*D Publicised results: By the end of the study 67% went into remission. Half way through 63% in remission. On citalopram 33% met remission. Drugs can work but need to try different ones.
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Outline the cognitive theory of depression.
Depression can be due to dysfunctional beliefs we have established and they are activated by events.
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Outline the negative triad.
Negative personal world view, Negative view of the future, Negative personal view.
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What does cognitive therapy do?
It helps clients identify and re-evaluate distorted cognition and beliefs. Identify and correct a range of 'thinking errors'.
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Is cognitive therapy based in the present?
True.
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Outline the cognitive model.
See word document.
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Name two elements behaviour therapy add if included in cognitive therapy.
1. Includes goal setting in sessions 2. Introduces work to do outside of sessions
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What did Huntley et al (2012) find?
Meta-analysis: Group CBT is effective
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What did Jacobson et al (1996) find?
CT elements don't add anything to behaviour therapy outcomes.
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What are the three main factors of interpersonal therapy?
1. Interpersonal relationships 2. Distress of those around them 3. Behaviours within relationships
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What are the three main aims of interpersonal therapy?
1. Relieve psychiatric symptoms 2. Manage relationship challenge 3. Make the best use of social support
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Who support IPT?
Cuiipers (2011)
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What is IPT built upon?
Attachment theory, communication and social theory. Focuses on the present.
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Name three IPT techniques.
1. Therapeutic alliance 2. Interpersonal inventory 3. Communication analysis
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Name four problems IPT tries to combat
1. Disputes 2. Role transitions 3. Grief and loss 4. Interpersonal sensitivity
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What three things does BA aim to do?
1. Increase engagement in adaptive activities 2. Decrease engagement in maintenance activities 3. Solve problems that limit reward access or maintains aversive control
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Which research mainly supports BA?
Ekers et al (2011)
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Outline the behavioural model of depression
Low mood --> Decreased activity --> Decreased pleasurable activity --> LOOP
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Outline the idea of couples therapy.
Bidirectional relationship: Depression and relationship discord. It involves both partners.
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Which research supports couples therapy?
Barbato et al (2008) - Meta analysis, it is as effective as drug treatments and individual psychotherapy.
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Name three issues with couples therapy.
1. Both partners have to be co-operative 2. What if they're in an abusive relationship 3. Difficult therapeutic relationship to master
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Who mainly promotes person lead counselling?
Carl Rogers.
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Name three types of counselling
Psychodynamic, interpersonal and behaviour therapies.
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What is the main aim of counselling?
It's based around catharsis and can help with interpersonal conflict. It is meant to be conscious raising.
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What must counsellors have/be?
'Genuineness, warmth, empathy and positive regard'
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Name the four stages of change in counselling.
Contemplation --> Preparation --> Action --> Maintenance
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Name two predisposing factors for anxiety
1. Pre-existing beliefs 2. Having no believable alternative explanation
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Name two maintenance factors for anxiety
1. Automatic reactions (eg. heart racing) 2. Strategic reactions (Safety behaviours)
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Define anxiety.
'A preoccupation with the concept of danger and an underestimation of ability to cope'
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What is classical conditioning?
Where you repeatedly associate a pair of stimuli.
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What is operant conditioning?
When you re-enforce a behaviour
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Outline the DSM-IV for panic disorder.
Must have recurrent and unexpected panic attacks and a month or more of one of the following: 1. Persistent worry about additional attacks 2. Worry about the implications of the attack 3. Significant change of behaviour related to attacks
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Name the C's for panic disorder
1. Review recent panic attacks 2. Identify and challenge evidence 3. Substitute more realistic alternatives
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Name the B's for panic disorder
1. Dropping safety behaviours 2. Entering feared situations to disconfirm beliefs 3. Exposure is a key part
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Outline Clark's cognitive model of panic.
External/internal trigger --> Perceived threat --> Anxiety --> Physical/cognitive symptoms --> Misinterpretation --> Anxiety loop
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Define social phobia
'A fear of social situations, where upon the individual avoids these situations or endures them with considerable distress'
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Outline Mowrer's two factor model.
Traumatic social interaction takes place --> Individual acquires a conditioned response of anxiety to similar situations --> this re-enforces the avoidance behaviours
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Outline Clark & Wells model of social phobia.
Social situation triggers beliefs --> Person monitors themselves not situation --> This confirms belief as not watching others to unconfirm --> Self focus impedes performance --> Engages in safety behaviours worsens situations --> ProcessinDistortion
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Sum up the diagnostic criteria for social phobia
Persistent fear of social situations, and exposure to this provokes anxiety and the fear is excessive and unreasonable. Avoidance interferes with the person's life.
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What do the NICE guidelines recommend about the treatment of social phobia?
Individual CBT --> CBT-based self help --> SSRIs --> Psychodynamic approaches
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What did Clark et al (2006) find out about social phobia?
CBT was superior in the treatment compared to exposure or wait list - this was maintained after 12 months.
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What is IAPT?
A NHS programme rolled out across England offering NICE approved treatments for depression and anxiety.
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Name two issues with having such accessible IAPT therapy.
1. Are we pathologising 'misery'? 2. Are we taking away people's ability to solve problems
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What did Glover et al (2014) find out about equality of access?
Both genders well represented, older adults UR, ethnic minorities UR, Depression OR, Anxiety disorders UR.
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Define physical activity.
Any movement of the body that results in the energy expenditure above that of resting level.
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Define exercise.
Physical activity in which the activity is purposefully undertaken to maintain or improve fitness or health
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What are the key features of NICE intervention of PA and depression.
Establish link --> Increase patients PA --> Focus on control, companionship not fitness --> Use motivational strategies --> Signpost patient to PA opportunities
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Name four elements most tCBT providers have in common.
1. Weekly/fortnightly 2. Over 16 3. Free 4. GP Referral
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Name the four benefits of tCBT.
1. Accessible 2. Low drop out rates 3. Lack of judgement 4. Time and cost effective
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Name five drawbacks of tCBT.
1. High relapse rate 2. Not always appropriate 3. Impersonal 4. Limited evidence base 5. Contributes to avoidance behaviours?
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What did Bee et al (2010) find out about tCBT?
Medium-large effect on work productivity and symptom reduction on employees off work with depression who engaged in tCBT.
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What did Northernwest university find out about tCBT?
Relapse rates significantly higher, nearly double of face-face CBT.
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What is the aim of books on prescription?
To allow patients to continue to help themselves outside and after therapy, and to prevent relapse.
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What do books on prescription consist of?
Worksheets, anecdotes, problem solving breakdowns, signposting and LOW READING AGES
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Name four benefits of books on prescription.
1. 24 hour support 2. Low level of commitment 3. Clear 4. Cheap
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Name four cons of books on prescription.
1. Patronising 2. Motivation 3. Evidence base 4. Reluctance to prescribe solely
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What did Kahn et al (2007) find about books on prescription?
Reduces the stigma of mental health and helps people who need it.
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What did Gellatly et al (2007) find?
Giving patients information on their problems isn't enough to foster change for most.
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What are the NICE guidelines for books on prescription?
30 min suitability assessment - book prescribed, 20 min support session every 14 days, follow up appointment after 3 months of treatment
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What is a long term condition?
'A condition for which there is currently no cure, and it is managed by drugs or other treatment'
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Give three examples of long term conditions
1. Chronic Pain 2. HIV/AIDs 3. Diabetes
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Explain why collaborative working is key for people with long term conditions.
Services must be integrated, especially mental and physical health, as LTC's have mental health side e effects. Collaboration ensures successful management and treatment.
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Name five common issues people with LTC's suffer with.
1. Managing symptoms 2. Lack of peer understanding 3. Loss of independence 4. Acceptance of their condition 5. Difficulty coming to terms with the daily implications
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What do NICE recommend for people with LTC's?
Offer group physical activity programmes or peer support self help programmes. cCBT or guided self help based on CBT.
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What did Davies et al find out about LTC's?
Heart attack sufferers have a 30% chance of suffering from depression
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What did Fenton & Stover (2006) find out about LTC's?
25% of people with diabetes suffer from depression
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