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By P. Ressel. Bryn Mawr College.

She remained overweight and talkative but she was able to largely abstain from alcohol buy cheap benicar 20 mg online blood pressure information. The Practice of Electroconvulsive Therapy: Recommendations for Treatment discount benicar 20 mg otc hypertension 16090, Training and Privileging: A Task Force Report of the American Psychiatric Association. Washington, DC: American Psychiatric Association; 2001Treatment procedures; 125-196 Avery D, Winokur G. Suicide, attempted suicide, and relapse rates in depression. Controlling stimulation strength and focality in electroconvulsive therapy via current amplitude and electrode size and spacing. Continuation and maintenance electroconvulsive therapy for the treatment of depressive illness: a response to the national institute for clinical excellence report. Gagne G, Furman M, Carpenter L, Price L, Efficacy of continuation ECT and antidepressant drugs compared to long-term antidepressants alone in depressed patients. Practical considerations in the use of ultrabrief ECT in clinical practice J ECT Sep 30 [Epub ahead of print] Gangadhar B, Kapur R, Kalyanasundaram S. Comparison of electroconvulsive therapy with imipramine in endogenous depression: a double blind trial. Attitudes toward electroconvulsive therapy among Hungarian psychiatrists. A double-blind comparison of bilateral, unilateral and simulated ECT in depressive illness. Low-dose right unilateral ECT: effectiveness of the first treatment. J ECT 2013, in press Lisanby S, Electroconvulsive Therapy for Depression. New England Journal of Medicine 2007; 357:1939-1945. International Journal of Neuropsychopharmalcology 2008; 11:883-890. Papakosta V, Zervas I, Pehlivanidis A, Papadimitriou G, Papakostas Y. A survey of attitudes of Greek medical student toward electroconvulsive therapy. Indications for electroconvulsive treatment in schizophrenia: a systematic review. Response rate to catatonia to electroconvulsive therapy and its clinical correlates. European Archives of Psychiatry and Clinical Neurosciences 2012. Distinctive neurocognitive effects of repetitive transcranial magnetic stimulation and electroconvulsive therapy in major depression. Sackheim H, Prudic J, Devanand D, Kiersky J, Fitzimons L, Moody B, McElhiney M, Coleman E, Settembrino J. Effects of stimulus intensity and electrode placement on the efficacy and cognitive effects of electroconvulsive therapy. Small J, Klapper M, Kellams J, Miller M, Milstein V, Sharpley P, Small I. ECT compared with lithium in the management of manic states. Electroconvulsive therapy and complaints of memory dysfunction: a prospective three year follow up study. Seizure threshold determination for electroconvulsive therapy: stimulus dose titration versus age-based estimations. Australian and New Zealand Journal of Psychiatry 2006; 40:188-192. A comparison of clinical response to electroconvulsive therapy in puerperal and non-puerperal psychoses. Efficacy and safety of electroconvulsive therapy in depressive disorders: a systematic review and meta-analysis.

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There is also a continued high-demand pressure on hospitals discount benicar 10mg mastercard blood pressure medication for sleep. Literature on Clinical Commissioning Groups The literature on CCGs comprises reports on the predecessor bodies to the CCGs cheap benicar 10 mg otc hypertension 4th report, which included early forms of GP fundholding and commissioning; literature on CCGs while they were in shadow form leading up to April 2013; and reports on the actual operation of CCGs since they became statutory bodies in April 2013. Since the original purchaser–provider split in the NHS, introduced by the National Health Service and Community Care Act of 1990,21 there have been many variants of clinical commissioning. The GP fundholding scheme was voluntary and it allowed GP practices to take control of a budget for certain defined services along with funds for a practice management allowance. Most notably, the pilots and experiments included GP commissioning using fundholding (from 1991), total purchasing (from 1995 to 1998), primary care groups (PCGs) (1999) and the authorisation of PCTs. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 5 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. INTRODUCTION PCTs; the latter research group also, to an extent, studied the transition into shadow CCGs and, in so doing, revealed a number of important features of the way it operated in England and to a degree in other countries. The 23-year period from 1990 to 2013 included numerous pilots and new forms. There are many relevant lessons to be drawn from the experiments and from the related literature. Studies of CCGs in shadow form again reported much uncertainty around the link between the governance/assurance level and the operational level; about links with the wider GP membership; about how to resolve conflicts of interest; and about who could make decisions about what. These reports, although providing clear descriptions of aspects of governance and engagement, paid less focused attention to actual examples of service redesign activity by CCGs and the precise work of clinical leaders – themes that we address below. Leadership, clinical leadership and engagement The body of literature on leadership in the English NHS, and in health services more widely, reflects the themes and concerns across many industry sectors. The literature on leadership in health services and on clinical leadership is extensive and we have reviewed it fully elsewhere – most notably for the NHS Leadership Academy. Other literature has highlighted the merits of having medics, and clinicians more generally, involved in taking up leadership 42 43, positions in health services and, relatedly, in investigating the required competences. This project showed, as with other studies, some considerable distance between many medics and the leadership teams. As explained, our prime focus was rather different, namely to trace the extent and nature of clinical leadership using the platform afforded by the CCGs. Thus, our prime focus was on active leadership of service redesign. Often this was undertaken by informal leaders, as well as those occupying formal roles within CCGs. Attempting to lead changes in service redesign across the complex boundaries in primary and secondary care is a very different challenge. Another central theme in the literature has been the perceived tension between, on the one hand, professional autonomy and established notions of professional practice and, on the other, the cluster of notions attached to organisational practice. Hence, the various ways in which doctors have resisted managerial attempts at organisational change and re-engineering have been extensively researched and reported in the literature. Much of this research, however, has been located in acute hospital settings where issues of competing hierarchies are at stake. As our scoping research had indicated, the more salient issues in the context of CCGs were aspects of interorganisational leadership and interprofessional leadership. Given that the policy thrust, as seen in The wider context and the policy intent, is ostensibly towards devolved leadership, then questions are inevitably raised as to where this leadership will be located and how it will be exercised in practice. Much of the leadership work seems to get done by combinations of managers and clinicians. Indeed, sometimes managers are clinicians who hold hybrid roles. Some researchers have emphasised and illustrated the pluralistic nature of organisational leadership. Extending out from this are 46–48 studies which point to much wider forms of distributed leadership throughout organisations. Informal leadership seems to be an attractive idea for some clinicians and is associated with the identity formation of leaders who practise leadership and then reflect on that practice. Instead of seeking leaders who, supposedly, know all the answers and issue these from on high, advocates such as Heifetz50 contend that leaders should be encouraged and developed who can stimulate changes in attitudes, behaviours and values.

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Fortunately generic 10 mg benicar blood pressure meaning, analogous measures can also be monplace to use approach/avoidance conflict tests to exam- valuable cheap benicar 10 mg fast delivery arteria circumflexa femoris lateralis. It is because of the assumption of homology, or ine the possibility that gene knockout mice exhibit altera- at least analogy, among the physiological and behavioral tions in what is called 'anxiety. The estab- dark box, have been widely used in rodent studies of anxio- lishment of multiple forms of validation for a particular lytic drugs. Anxiolytic drugs increase approach behavior in model provides convergent evidence in support of the pos- such paradigms, presumably because they reduce the anxiety tulate of cross-species homology. Investigators often begin by attempting to identify as ketamine or phencyclidine (PCP). Hence, studies of keta- the core features of the particular disorder of interest. Never- mine effects in either human or animal preclinical models theless, it is clear that appreciable diversity of both etiologies may aid in the identification of additional atypical antipsy- and symptom profiles exists within each of the major psychi- chotics having efficacy in the treatment of patients who are atric diagnostic categories. Furthermore, very few specific nonresponsive to typical antipsychotics. Indeed, in the PPI symptoms are unique to any specific diagnosis, but occur models of schizophrenia, the disruptive effects of glutamate in multiple diagnostic categories. Hence, it is most produc- antagonists on PPI of startle are reversed by atypical, but tive to focus on specific features observed in patients as not by most typical, antipsychotics (67). Interestingly, this endpoints for use in the development of animal models, effect of clozapine-like antipsychotics is mimicked by the rather than on clusters of symptoms. A related implication putative antipsychotic M100907, a selective serotonin-2A of this reasoning is that multiple different animal models, antagonist (68). In general, one goal of translational research in terms of the endpoint used, may all be useful in parallel. The endpoints in animals, which in turn can be translated back to the used in such models could be in vivo behaviors, biological human clinical studies. In the present example, this strategy markers, or in vitro behaviors of biological systems or prepa- would suggest that further studies could now determine rations. Operational definitions, especially of in vivo behav- whether M100907 reverses disruptions in PPI produced by ioral measures, assist in determining the theoretic relation- ketamine in healthy human volunteers. Furthermore, clini- ship between the observable and the construct of interest cal trials of the efficacy of M100907 in schizophrenia could (62,63). Finally, the observables should be measured objec- be designed to test the hypothesis that only schizophrenic tively and reliably. This admittedly speculative example illus- Human Preclinical Models: Relationship trates some of the potential advantages derived from the use between Animal and Human Phenomena of homologous, or at least analogous, measures in animal Human preclinical models can also contribute significantly and human preclinical models as well as in clinical trials. Unfortunately, such human models Such translational research is needed in the field of psychiat- appear to be underutilized, and relatively little effort is fo- ric disorders in order to guide both the refinement of the cused on the development of such human models. An ad- animal models and the development of new drugs. Nevertheless, even with human models, questions re- DRUG DISCOVERY AND DEVELOPMENT: garding the etiology of the disorder or the relationship be- PRECLINICAL MODELS AND CLINICAL tween the dependent measure and the symptoms still need TRIALS to be addressed using the same principles as when extrapo- lating across species. Relative to animal models, human pre- An emerging belief is that animal preclinical models repre- clinical models are necessarily more constrained by the addi- sent a bottleneck in psychotropic drug discovery (69). Com- tional ethical considerations regarding the use of humans pared to high-speed chemical synthesis, high-throughput in research. Nevertheless, such pre- to mimic some aspects of a disorder of interest. For example, clinical models of human psychopathology are required to the glutamate antagonist ketamine is used to induce a state provide initial assessments of the functional effects of novel that mimics some aspects of acute schizophrenia in healthy compounds in the integrated organism. Then, using brain imaging, psychologi- functional measures can confirm predictions about the po- cal assessments, and pharmacologic interactions, the neuro- tential effects of psychotropic drugs in patients. It is unreal- biology of this drug-induced state can be studied to gain istic to attempt to go from the 'test tube' to the clinic insight into the possible substrates underlying the psychotic when attempting to treat complex mental, cognitive, and state in schizophrenia patients. Such a human preclinical emotional disturbances that do not yet have clearly defined model can also play an important role in assessing novel neurobiological substrates, or even correlates. For example, it has been found that the atypical paucity of preclinical behavioral models predictive of clini- antipsychotic clozapine reduces the exacerbation of symp- cal efficacy' (69) reflects the paucity of our quantitative toms in schizophrenic patients given ketamine (66).

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