gpvts academic programme common psychiatric problems jim bolton consultant liaison psychiatrist st...
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GPVTS Academic Programme
Common psychiatric problems
Jim Bolton
Consultant Liaison Psychiatrist
St Helier Hospital
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Who should give this talk?
• Majority of mental health problems managed in primary care
• Only 10% referred to specialist services
• Mood disorders in an average list (2000)– 60-100 with depression– 70-80 with anxiety– 50-60 “situational disturbance”
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Introduction
• What would you like to talk about?
• Depression
• Anxiety
• Medically unexplained symptoms
• Mental health services
• Mental Health Act
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Depression
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Depression
• Part of normal experience
• A symptom, not a diagnosis
• When does depressed mood become an illness?
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Appropriate distress or psychiatric disorder?
• Normal distress (adjustment disorder)– brief change in mood
• Psychiatric disorder (depression)– persistent– extreme– disabling
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Depressive disorder - epidemiology
• Depends on how you look for it
• Lifetime risk 15-20%
• One month prevalence 5-10%
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Depressive disorder - classification
• Current episode– Mild– Moderate– Severe (+ psychotic symptoms)
• Pattern of episodes– Single episode– Recurrent depressive disorder
• Dysthymia• Mixed anxiety & depression
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Depressive disorder –symptoms
• Mood • Motivation
– energy, interest, pleasure, concentration• Thinking
– guilt, worthlessness, self-blame– hopelessness, suicidal ideation
• Biological symptoms– appetite, weight, sleep, libido
• Persistent
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Depressive disorder - aetiology
• Physical– genetics?– alcohol & drugs
• Psychological– past psychiatric history– personality and coping
• Social– stresses– support
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Depressive disorder – primary care
• Patients rarely present with neat clusters of symptoms
• Often combination of physical, psychological, social problems
• Somatic presentation common
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Depressive disorder - management
• Physical– antidepressants
• Psychological– counselling / psychotherapy
• Social– social support– practical advice, e.g. exercise, caffeine, alcohol
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Disorders of the puerperium
The “blues” Postnatal Puerperal depression psychosis
Onset: 4-5 days 2-4 weeks 1-3 weeks
Frequency: 50% 10-15% 0.2%
Duration: 2-3 days 4-6 weeks 6-12 weeks
(1 year)
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Postnatal depression- clinical features
• Commonly– tearfulness, irritability,
poor sleep
• Note– inadequacy– loss of confidence– anxieties– thoughts of harm
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Postnatal depression - aetiology
Summary– most support for psychosocial rather than
biological factors– similar to depression at other times– subgroup?
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Postnatal depression - treatment• Physical
– Antidepressants– Hormones
• Psychological– Counselling– Brief psychotherapies
• Social– maximise available support– voluntary groups
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Postnatal depression - prognosis
• 1:3 recurrence after subsequent birth
• Without treatment 30% ill at 1 year
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Anxiety
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Anxiety• Part of normal human experience
– “fight or flight”– motivational drive / performance
• Components– Cognitive– Autonomic– Motor tension
• Disorders– Anxiety as primary component (anxiety-related
disorders)– Occurs as part of many other disorders
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Anxiety-related disorders - classification
• Generalised anxiety disorder
• Panic disorder
• Phobic anxiety disorder
• OCD
• PTSD
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Anxiety-related disorders - epidemiology
• Lifetime prevalence– Generalised anxiety disorder 30%– Panic disorder 5%
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Anxiety-related disorders - aetiology
• Biological– Constitutional predisposition?– Caffeine, alcohol, drugs
• Psychological– Individual interpretation, past experiences,
coping resources
• Social
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Anxiety-related disorders - management
• Biological– Benzodiazepines– Antidepressants
• Psychological– CBT– Relaxation– Anxiety management
• Social
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Medically unexplained symptoms
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How common are MUS?
• Primary care: 20%
• Medical outpatient clinic: 25-50%
• Medical inpatients: 1-2%
• Liaison psychiatry: common referral
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Symptoms which commonly remain medically unexplained
• Muscle and joint pain• Low back pain• Tension headaches• Fatigue• Chest pain• Palpitations• Irritable bowel
• Why are so many symptoms not explained by organic disease?
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Back to basics:what is a symptom?
• “A phenomenon... arising from and accompanying a disease.”
Oxford English Dictionary
Disease
Symptom
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Perception
Interpretation
Symptom
What is a symptom?
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What is a symptom?
Perception
Interpretation
Symptom
• Many symptoms are due to the perception of organic disease.
• But many remain medically unexplained.
• What factors are associated with MUS?
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What factors are associated with MUS?
• Vulnerability factorsExperiences of illness
Illness beliefs
• Precipitating factorsLife events
Stress
• Maintaining factorsAnxiety and depression
Reactions of others
Iatrogenic
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PerceptionExperience of illness Stress
InterpretationReactions of others
Symptom
A model of MUS
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Management
Stepped care:
• 1) Basic management
• 2) Specialist management
• 3) “Damage limitation”
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Physical examination & investigation
• As much as is appropriate
• Over-investigation can reinforce the patient’s conviction that there must be something physical wrong
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Assessment
• What are the patient’s concerns and beliefs?
• How does the patient cope?
• Are there any background problems?
• Screen for anxiety and depression– antidepressant?
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Reassurance
• Most patients are reassured
• Bland reassurance is unhelpful
• Address the patient’s fears and beliefs
• Correct any misconceptions
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Explanation
• Give a positive explanation
• Explain how physical, psychological and social factors interact
• Give practical advice on coping and returning to normal activity
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Further management
Stepped care:
• 1) Basic management
• 2) Specialist management
• 3) “Damage limitation”
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Mental health services
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Mental health services
• Separation of acute and mental health
• Divided by age:
Child ------ Adult ------ Older adults
• …& speciality:– e.g. substance misuse, psychotherapy
• Crisis & Home Treatment Teams
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Community mental health team
• Often GP aligned
• Multidisciplinary team
• Management of “SMI”
• Care Programme Approach
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Making a referral
• Get to know your CMHT– Routine & emergency referrals
• Information to include– Past history– Social background– Risk
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Mental Health Act 1983
• Some people refuse help, even though this puts their own health or safety, or that of others, at risk.
• Legislation enables us to treat people against their will.
• Balance of benefit of treatment against infringement of civil liberties.
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Mental Health Act 1983
• Compulsory treatment of psychiatric (but not physical) disorder.
• “Sections”
• GPs involved in most sections.
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Implementing the MHA
• Individual must have refused voluntary treatment
• Individual must be at risk of harm to self or others
• Behaviour must be the result of known or suspected psychiatric disorder (but not addiction per se)
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Who’s involved in a “section”?
• Application by an Approved Mental Health Professional (AMHP) or the nearest relative (rarely used)
• + Recommendation from a doctor (usually a psychiatrist) approved under Section 12 of the MHA
• + Recommendation from another independent doctor (usually the GP)
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Section 2: Admission for assessment
• Assessment of suspected psychiatric disorder• 28 days• Right of appeal within 1st 14 days• Applied for by AMHP in consultation with
nearest relative• 2 medical recommendations• Treatment can be given without consent, but
switch to Section 3 once this becomes the main reason for inpatient care
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Section 3: Admission for treatment
• Treatment of severe and persistent psychiatric disorder
• 6 months in first instance – can be renewed• One appeal per 6 months• Statutory responsibilities for aftercare• Applied for by AMHP – cannot normally
proceed if nearest relative objects• 2 medical recommendations
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Section 4: Emergency admission
• When delay in finding another doctor would be dangerous
• AMHP plus 1 medical recommendation
• 72 hours
• Allows time for assessment for
section 2 or 3
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Depressive disorder - symptoms• Core symptoms• Depressed mood• Loss of interest and
enjoyment• Reduced energy
and fatigability
• Other common symptoms• Reduced concentration• Reduced self-esteem & self-
confidence• Ideas of guilt & unworthiness• Bleak and pessimistic views
of the future• Disturbed sleep• Diminished appetite
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Depressive disorder - symptoms
• Severity of depression
• Mild: 2 core plus 2 other symptoms
• Moderate: 2 core plus 3 other symptoms
• Severe: 3 core plus 4 other symptoms
• Remember – suicidal ideation