GPVTS Academic Programme

Common psychiatric problems

Jim Bolton

Consultant Liaison Psychiatrist

St Helier Hospital

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”

Introduction

• What would you like to talk about?

• Depression

• Anxiety

• Medically unexplained symptoms

• Mental health services

• Mental Health Act

Depression

Depression

• Part of normal experience

• A symptom, not a diagnosis

• When does depressed mood become an illness?

Appropriate distress or psychiatric disorder?

• Normal distress (adjustment disorder)– brief change in mood

• Psychiatric disorder (depression)– persistent– extreme– disabling

Depressive disorder - epidemiology

• Depends on how you look for it

• Lifetime risk 15-20%

• One month prevalence 5-10%

Depressive disorder - classification

• Current episode– Mild– Moderate– Severe (+ psychotic symptoms)

• Pattern of episodes– Single episode– Recurrent depressive disorder

• Dysthymia• Mixed anxiety & depression

Depressive disorder –symptoms

• Mood • Motivation

– energy, interest, pleasure, concentration• Thinking

– guilt, worthlessness, self-blame– hopelessness, suicidal ideation

• Biological symptoms– appetite, weight, sleep, libido

• Persistent

Depressive disorder - aetiology

• Physical– genetics?– alcohol & drugs

• Psychological– past psychiatric history– personality and coping

• Social– stresses– support

Depressive disorder – primary care

• Patients rarely present with neat clusters of symptoms

• Often combination of physical, psychological, social problems

• Somatic presentation common

Depressive disorder - management

• Physical– antidepressants

• Psychological– counselling / psychotherapy

• Social– social support– practical advice, e.g. exercise, caffeine, alcohol

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)

Postnatal depression- clinical features

• Commonly– tearfulness, irritability,

poor sleep

• Note– inadequacy– loss of confidence– anxieties– thoughts of harm

Postnatal depression - aetiology

Summary– most support for psychosocial rather than

biological factors– similar to depression at other times– subgroup?

Postnatal depression - treatment• Physical

– Antidepressants– Hormones

• Psychological– Counselling– Brief psychotherapies

• Social– maximise available support– voluntary groups

Postnatal depression - prognosis

• 1:3 recurrence after subsequent birth

• Without treatment 30% ill at 1 year

Anxiety

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

Anxiety-related disorders - classification

• Generalised anxiety disorder

• Panic disorder

• Phobic anxiety disorder

• OCD

• PTSD

Anxiety-related disorders - epidemiology

• Lifetime prevalence– Generalised anxiety disorder 30%– Panic disorder 5%

Anxiety-related disorders - aetiology

• Biological– Constitutional predisposition?– Caffeine, alcohol, drugs

• Psychological– Individual interpretation, past experiences,

coping resources

• Social

Anxiety-related disorders - management

• Biological– Benzodiazepines– Antidepressants

• Psychological– CBT– Relaxation– Anxiety management

• Social

Medically unexplained symptoms

How common are MUS?

• Primary care: 20%

• Medical outpatient clinic: 25-50%

• Medical inpatients: 1-2%

• Liaison psychiatry: common referral

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?

Back to basics:what is a symptom?

• “A phenomenon... arising from and accompanying a disease.”

Oxford English Dictionary

Disease

Symptom

Perception

Interpretation

Symptom

What is a symptom?

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?

What factors are associated with MUS?

• Vulnerability factorsExperiences of illness

Illness beliefs

• Precipitating factorsLife events

Stress

• Maintaining factorsAnxiety and depression

Reactions of others

Iatrogenic

PerceptionExperience of illness Stress

InterpretationReactions of others

Symptom

A model of MUS

Management

Stepped care:

• 1) Basic management

• 2) Specialist management

• 3) “Damage limitation”

Physical examination & investigation

• As much as is appropriate

• Over-investigation can reinforce the patient’s conviction that there must be something physical wrong

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?

Reassurance

• Most patients are reassured

• Bland reassurance is unhelpful

• Address the patient’s fears and beliefs

• Correct any misconceptions

Explanation

• Give a positive explanation

• Explain how physical, psychological and social factors interact

• Give practical advice on coping and returning to normal activity

Further management

Stepped care:

• 1) Basic management

• 2) Specialist management

• 3) “Damage limitation”

Mental health services

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

Community mental health team

• Often GP aligned

• Multidisciplinary team

• Management of “SMI”

• Care Programme Approach

Making a referral

• Get to know your CMHT– Routine & emergency referrals

• Information to include– Past history– Social background– Risk

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.

Mental Health Act 1983

• Compulsory treatment of psychiatric (but not physical) disorder.

• “Sections”

• GPs involved in most sections.

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)

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)

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

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

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

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

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