Dr Janet Obeney-WilliamsDr Janet Obeney-Williams

Staff Grade Liaison PsychiatryStaff Grade Liaison Psychiatry

Former GP principle in General PracticeFormer GP principle in General Practice

Top tips for GPs- Top tips for GPs- Psychiatry from two Psychiatry from two perspectivesperspectives

What is general practice like?What is general practice like?

'It is a world where thedoctor is frequently in the dark, getting glimpses of his patients from time to time, being careful not to find out too much, being content to find out the right distance for the patient and for himself.’ -Dr Andrew Elder

What is a psychiatrist?What is a psychiatrist?

‘‘Psychiatrists are Psychiatrists are medical doctors who must evaluate patients to who must evaluate patients to determine whether or not their determine whether or not their symptoms are the result of a symptoms are the result of a physical illness, a combination of physical illness, a combination of physical and mental, or a strictly physical and mental, or a strictly psychiatric one.’ -Wikipedia one.’ -Wikipedia

10,000 hours10,000 hours

Psychologist Dr Nick Psychologist Dr Nick Bayliss is famous for stating Bayliss is famous for stating that it takes 10,000 hours to that it takes 10,000 hours to become an EXPERT-5 become an EXPERT-5 years of full time workyears of full time work

Liaison PsychiatryLiaison Psychiatry

ExpertsExperts

GP’s are expertsGP’s are expertsWe are experts at evaluating and We are experts at evaluating and

treating in SHORT consultations treating in SHORT consultations over (sometimes) LONG periods over (sometimes) LONG periods of timeof time

We treat most problems without We treat most problems without specialistsspecialists

Only 1 in 20 GP consultations Only 1 in 20 GP consultations results in a referral to results in a referral to specialists-Kings Fund 2010specialists-Kings Fund 2010

No Health Without Mental Health No Health Without Mental Health (2011)(2011)

Mental ill health represents up to Mental ill health represents up to 23% of the total burden of ill 23% of the total burden of ill health in the UK-largest single health in the UK-largest single cause of disabilitycause of disability

No health without mental healthNo health without mental health –HM Government 2011–HM Government 2011

Almost half of all adults will Almost half of all adults will experience at least one episode of experience at least one episode of depression during their lifetimedepression during their lifetime

At least one in four people will At least one in four people will experience a mental health experience a mental health problem at some point in their life problem at some point in their life and one in six adults has a mental and one in six adults has a mental health problem at any one timehealth problem at any one time

Self-harming in young people is not Self-harming in young people is not uncommon (10–13% of 15–16-year-olds uncommon (10–13% of 15–16-year-olds have self-harmed)have self-harmed)

About one in 100 people has a severe About one in 100 people has a severe mentalmental health problemhealth problem

One in ten new mothers One in ten new mothers experiences postnatal experiences postnatal depressiondepression

Healthy Lives, Healthy People Healthy Lives, Healthy People (2010)(2010)

-White Paper-White Paper

First public health strategy that First public health strategy that gives equal weight to both mental gives equal weight to both mental and physical health:.and physical health:.

A preventive approach to mental A preventive approach to mental healthhealth

White Paper 2010White Paper 2010

Britain is now the most obese nation in Britain is now the most obese nation in EuropeEurope

By improving maternal health, we could By improving maternal health, we could give our children a better start in life, give our children a better start in life, reduce infant mortality and the reduce infant mortality and the numbers of low birth-weight babies. numbers of low birth-weight babies.

White Paper 2010White Paper 2010

In one study, the children of women In one study, the children of women who were depressed at 3 months after who were depressed at 3 months after giving birth had significantly lower IQ giving birth had significantly lower IQ scores at 11 yearsscores at 11 years

Taking better care of our children’s Taking better care of our children’s health and development could improve health and development could improve educational attainment and reduce the educational attainment and reduce the risks of mental illness, unhealthy risks of mental illness, unhealthy lifestyleslifestyles, ,

Health and Social Care Act (2012)Health and Social Care Act (2012)

““Parity of esteem” between physical Parity of esteem” between physical and mental healthand mental health

NHS Mandate 2012 NHS Mandate 2012 to tackle to tackle disparities between physical and disparities between physical and mental health caremental health care

TopicsTopics

Medically unexplained Medically unexplained symptomssymptoms

Schizophrenia and metabolic Schizophrenia and metabolic syndromesyndrome

The ‘new psychoses’The ‘new psychoses’

Medically unexplained Medically unexplained symptomssymptoms

Medically unexplained symptoms are Medically unexplained symptoms are physical symptoms that lack a medically physical symptoms that lack a medically identifiable organic cause.identifiable organic cause.

Some studies suggest that one-fifth of Some studies suggest that one-fifth of initial appointments with GPs concern initial appointments with GPs concern symptoms of this kind (Burton 2003). symptoms of this kind (Burton 2003).

Medically unexplained Medically unexplained symptoms in primary caresymptoms in primary care

Adult patients with medically unexplained Adult patients with medically unexplained symptoms (somatisation) in primary care symptoms (somatisation) in primary care are numerous and make are numerous and make disproportionately high demands on health disproportionately high demands on health services. Most of these individuals are services. Most of these individuals are open to the suggestion that their illness open to the suggestion that their illness reflects psychological needs. (Else reflects psychological needs. (Else Guthrie-Guthrie-Advances in Psychiatric Advances in Psychiatric Treatment (2008)Treatment (2008)

ExpertiseExpertise

Irritable bowel syndrome Irritable bowel syndrome

Chronic pelvic painChronic pelvic pain

Fibromyalgia Fibromyalgia

Chronic fatigue syndrome Chronic fatigue syndrome

ExplanationExplanation RejectingRejecting The doctor denies the reality of the The doctor denies the reality of the

patients’ symptoms andpatients’ symptoms and implies that the implies that the problem is imaginary or related to a psychological problem is imaginary or related to a psychological problem.problem.

ColludingColluding The doctor acquiesces to the The doctor acquiesces to the explanation offered by the patientexplanation offered by the patient

EmpoweringEmpowering The doctor provides a physical The doctor provides a physical mechanism of causationmechanism of causation The doctor removes The doctor removes any sense of blame from the patientany sense of blame from the patient The doctor The doctor strengthens the relationship with the patient, strengthens the relationship with the patient, enabling them to resolve the problem togetherenabling them to resolve the problem together

Source: Salmon Source: Salmon et al et al (1999)(1999)

ExplanationExplanation

RejectingRejecting-as GP’s we are experts in -as GP’s we are experts in knowing this is unlikely to work!knowing this is unlikely to work!

ColludingColluding-we know this can -we know this can undermine our patient’s confidence in undermine our patient’s confidence in our skillsour skills

EmpoweringEmpowering-we know this our best -we know this our best optionoption

EmpoweringEmpowering

GP’s do this for our patients GP’s do this for our patients all the timeall the time We explore our patients We explore our patients Health BeliefsHealth Beliefs-a -a

core competence in our Royal College core competence in our Royal College examinations examinations CSACSA

We areWe are Generalists Generalists so we can turn our so we can turn our hand to most explanations from the hand to most explanations from the increased gastric acid in increased gastric acid in DyspepsiaDyspepsia or the or the reduced serotonin in reduced serotonin in DepressionDepression

ExploringExploring

Another core competence for us-Another core competence for us-Cue’s,Cue’s, We have our own cohort of We have our own cohort of EXPERTS EXPERTS

who’ve helped us become skilled at using who’ve helped us become skilled at using our consultations to the best effect-our consultations to the best effect-Balint, Balint, Pendleton, Neighbour, the Cambridge-Pendleton, Neighbour, the Cambridge-Calgarry group and BATHE Calgarry group and BATHE (relayed to (relayed to us only this morning)us only this morning)

Our Our Primary CarePrimary Care Inheritance Inheritance

PhysicalPhysical

GP’s are used to explaining GP’s are used to explaining physical illness, in all systems of physical illness, in all systems of the bodythe body

Our patients often appreciate the Our patients often appreciate the detail we give themdetail we give them

PsychosocialPsychosocial

As GP’s, when we’ve picked up our As GP’s, when we’ve picked up our cues, cues, hidden agenda’s hidden agenda’s we go on to address we go on to address this with our patients-we’re probably this with our patients-we’re probably ExpertsExperts

GP’s when surveyed have been shown to GP’s when surveyed have been shown to believe we should manage believe we should manage MOST MUPSMOST MUPS

GP’s are still GP’s are still Gatekeepers Gatekeepers and, I would and, I would argue, argue, EXPERTSEXPERTS

When to refer?When to refer?

Appropriate and timely Appropriate and timely investigationsinvestigations--sometimes essential to exclude organic sometimes essential to exclude organic causescauses

When attendance is too frequent??When attendance is too frequent?? When someone develops an alarming When someone develops an alarming

symptom-we’ve all had that symptom-we’ve all had that One Case One Case who defied all the advice who defied all the advice

When we are When we are stuck stuck

EvidenceEvidence

The children of parents who present The children of parents who present with medically unexplained symptoms with medically unexplained symptoms are at greater risk of developing such are at greater risk of developing such symptoms than are the offspring of symptoms than are the offspring of parents with organic medical parents with organic medical conditions (Levy conditions (Levy et alet al, 2001; Craig , 2001; Craig et et alal, 2002). , 2002).

IBS-25% more visitsIBS-25% more visits

EvidenceEvidence

Children with more aches and pains, Children with more aches and pains, tiredness and fatigue are more likely tiredness and fatigue are more likely than their peers to develop anxiety than their peers to develop anxiety and depression (Campo and depression (Campo et alet al, 2004). , 2004).

Social learning theory is thought to be Social learning theory is thought to be the most likely explanationthe most likely explanation

EvidenceEvidence

A history of childhood adversity is common A history of childhood adversity is common in patients with medically unexplained in patients with medically unexplained symptoms in primary care (Schilte symptoms in primary care (Schilte et alet al, , 2001). 2001).

Depressive symptoms were the major Depressive symptoms were the major predictor of frequent attendance in primary predictor of frequent attendance in primary care populations in the UK and Spain care populations in the UK and Spain (Dowrick (Dowrick et al, et al, 2000). 2000).

EvidenceEvidence

A group in the USA conducted an RCT of A group in the USA conducted an RCT of multidimensional stepped care consisting multidimensional stepped care consisting of cognitive–behavioural, pharmacological of cognitive–behavioural, pharmacological and other treatment modalities. During the and other treatment modalities. During the 12-month trial, which involved 206 12-month trial, which involved 206 patients, 48 in the treatment group patients, 48 in the treatment group improved compared with 34 in the control improved compared with 34 in the control group (Smith group (Smith et alet al, 2006). , 2006).

EvidenceEvidence

Consensus of the evidence seems to be Consensus of the evidence seems to be that if your patients will agree-CBT, that if your patients will agree-CBT, treatment with anti-depressants (even if treatment with anti-depressants (even if lack of a clear diagnosis of depression) lack of a clear diagnosis of depression) can be helpful can be helpful

Refer for psychological therapiesRefer for psychological therapies

Factors associated with poor Factors associated with poor progprognosisnosis

Somatic symptoms that have lasted Somatic symptoms that have lasted for more than 2 yearsfor more than 2 years

Childhood physical or sexual abuseChildhood physical or sexual abuse History of psychiatric disorderHistory of psychiatric disorder Ongoing severe psychosocial Ongoing severe psychosocial

stressorsstressors

PsychiatryPsychiatry

Patients who come to a liaison psychiatry Patients who come to a liaison psychiatry clinic have already had clinic have already had ‘all’ ‘all’ their their investigationsinvestigations

Patients who’ve had Imaging, EEG’s, Patients who’ve had Imaging, EEG’s, Telemetry, after spending time with many Telemetry, after spending time with many EXPERTSEXPERTS

What can What can PsychiatryPsychiatry add? add?

Some terms for MUPSSome terms for MUPS

PsychogenicPsychogenicPsychosomaticPsychosomatic

Non organicNon organic ConversionConversion

Unexplained medical symptomsUnexplained medical symptomsHysteriaHysteria

Somatoform disordersSomatoform disordersFunctionalFunctional

DissociativeDissociative

PsychiatryPsychiatry

Sometimes management of Sometimes management of RiskRisk As a way into more complex psychological As a way into more complex psychological

therapiestherapies Treatment of difficulty to manage co-Treatment of difficulty to manage co-

morbid mood disordersmorbid mood disorders Patients see us as not being able to Patients see us as not being able to

arrange investigationsarrange investigations

Non-epileptic seizuresNon-epileptic seizures

Between 1-15% of general neurology Between 1-15% of general neurology patients, up to 50% of patients patients, up to 50% of patients referred to specialist epilepsy centres.referred to specialist epilepsy centres.

Acute onset might be associated with Acute onset might be associated with a specific traumatic life event.a specific traumatic life event.

Can present in people who also have Can present in people who also have epilepsyepilepsy

Non-epileptic seizuresNon-epileptic seizures

> in women, 75%:25%> in women, 75%:25% Usual onset in the 20sUsual onset in the 20s History of childhood sexual abuse in up to History of childhood sexual abuse in up to

50%50% Co-morbid epilepsy 15%Co-morbid epilepsy 15% Co-morbid personality disorder up to 40% Co-morbid personality disorder up to 40%

(10% in epilepsy)(10% in epilepsy) Co-morbid anxiety and depression high in Co-morbid anxiety and depression high in

both groupsboth groups

Non-epileptic seizuresNon-epileptic seizures

Patients need neurological assessment with Patients need neurological assessment with EEG and possible video-telemetryEEG and possible video-telemetry

The nonexistence of epilepsy is best confirmed The nonexistence of epilepsy is best confirmed by the neurologistby the neurologist

Non-epileptic seizures can result in overdose of Non-epileptic seizures can result in overdose of benzodiazepines and patients can end up in ITUbenzodiazepines and patients can end up in ITU

Can be easier to obtain negative results than Can be easier to obtain negative results than some more non-specific illnesses such as some more non-specific illnesses such as fibromyalgiafibromyalgia

Non-epileptic seizuresNon-epileptic seizures

History and examination give indications of non-History and examination give indications of non-epileptic seizureepileptic seizure

Type of seizure – prolonged and frequent in the Type of seizure – prolonged and frequent in the face of normal inter-ictal intellectual functionface of normal inter-ictal intellectual function

Seizures in public places, especially clinics or Seizures in public places, especially clinics or hospitalshospitals

Heightened distress after seizures e.g. Heightened distress after seizures e.g. prolonged cryingprolonged crying

Tongue biting, or or incontinence are less useful Tongue biting, or or incontinence are less useful in distinguishing from epilepsyin distinguishing from epilepsy

SchizophreniaSchizophrenia

Annual incidence in UK is 15-50 per 100,000 Annual incidence in UK is 15-50 per 100,000 (same statistic as DVT on oral contraceptive in (same statistic as DVT on oral contraceptive in women)women)

Strong evidence emerging for association of Strong evidence emerging for association of schizophrenia with complications during schizophrenia with complications during pregnancy and birthpregnancy and birth

Increase in schizophrenia in late winter and Increase in schizophrenia in late winter and spring births, thought to be associated with spring births, thought to be associated with influenza virus contact in mid-trimester of influenza virus contact in mid-trimester of pregnancypregnancy

Schizophrenia & IQSchizophrenia & IQ

Hutton and Joyce 1998, 2002 studies 136 Hutton and Joyce 1998, 2002 studies 136 people with schizophrenia and 81 controls people with schizophrenia and 81 controls showing cognitive impairment is there at showing cognitive impairment is there at First First Episode Episode and it is and it is Generalised Generalised

Pre-Morbid IQ tested by Pre-Morbid IQ tested by National Adult National Adult Reading TestReading Test

Pre-Morbid IQ Pre-Morbid IQ is is linearly associated linearly associated withwith presentation presentation of of SchizophreniaSchizophrenia

Lower Lower thethe IQ IQ the the earlier earlier thethe first age first age of of presentation presentation

Relevance?Relevance?

Both Both GrayGray and and WhiteWhite matter are affected matter are affected in people with schizophreniain people with schizophrenia

Leeson et al 2009 studied cognition at 1 Leeson et al 2009 studied cognition at 1 and 4 years in relation to social outcomeand 4 years in relation to social outcome

Only Only GlobalGlobal IQ :No other specific IQ :No other specific measure could predict global social measure could predict global social functionfunction

Can anything be done?Can anything be done?

2005, Richard and Deary2005, Richard and Deary Boosting cognitive reserve in adulthoodBoosting cognitive reserve in adulthood Educational attainment, community collegeEducational attainment, community college ExerciseExercise Cardiorespiratory functionCardiorespiratory function Modern Imaging has shown us that the adult Modern Imaging has shown us that the adult

brain is more plastic than we originally brain is more plastic than we originally thought, recruiting new neuronal pathwaysthought, recruiting new neuronal pathways

What does this add?What does this add?

Encouragement in outcome Encouragement in outcome modificationmodification

Some rigorous explanations which Some rigorous explanations which can be meaningful to patients and can be meaningful to patients and their familiestheir families

Under-pins other work such as Under-pins other work such as importance of ante-natal nutritionimportance of ante-natal nutrition

All areas where GP’s are involvedAll areas where GP’s are involved

Schizophrenia and CHDSchizophrenia and CHD

All cause mortality in people with All cause mortality in people with schizophrenia is >twice that in the general schizophrenia is >twice that in the general populationpopulation

CHD is a main player here and GP’s are CHD is a main player here and GP’s are expert at detecting and modifying thisexpert at detecting and modifying this

There is, however, evidence that even There is, however, evidence that even when BMI and other variables are when BMI and other variables are controlled for, schizophrenia and insulin controlled for, schizophrenia and insulin resistance are relatedresistance are related

Schizophrenia and CHDSchizophrenia and CHD

GP’s are GP’s are Experts Experts in lifestyle in lifestyle modification workmodification work

GP’s are experts at Interventions To GP’s are experts at Interventions To modify CHD modify CHD and addressing the and addressing the complexity of the metabolic syndrome complexity of the metabolic syndrome and insulin resistance (psychiatrists and insulin resistance (psychiatrists are not)are not)

Schizophrenia and DiabetesSchizophrenia and Diabetes

Prevalence likely 15-18%Prevalence likely 15-18% Up to 1/3 may have impaired glucose Up to 1/3 may have impaired glucose

tolerancetolerance High prevalence pre-dates the anti-High prevalence pre-dates the anti-

psychotic erapsychotic era GP’s are GP’s are Experts Experts at explaining risks at explaining risks

to patients and working with to patients and working with motivation and concordancemotivation and concordance

Schizophrenia and DiabetesSchizophrenia and Diabetes

The relationship between schizophrenia The relationship between schizophrenia and diabetes is not fully understood. An and diabetes is not fully understood. An association between the two conditions association between the two conditions was recognised in the pre-antipsychotic was recognised in the pre-antipsychotic era. Schizophrenia and diabetes may era. Schizophrenia and diabetes may share a common aetiology and/or share a common aetiology and/or pathogenic mechanisms. pathogenic mechanisms.

Cochrane review 2010Cochrane review 2010

Results indicate that regular exercise Results indicate that regular exercise programmes are possible in this population, and programmes are possible in this population, and that they can have health benefits on both the that they can have health benefits on both the physical and mental health and well-being of physical and mental health and well-being of individuals with schizophrenia.individuals with schizophrenia.

Larger randomised studies are required before Larger randomised studies are required before any definitive conclusions can be reachedany definitive conclusions can be reached

The ‘new psychoses’The ‘new psychoses’

Potentially treatable psychoses which Potentially treatable psychoses which have been recognised in the last decadehave been recognised in the last decade

Can present with evident confusion and Can present with evident confusion and neurological symptoms, making diagnosis neurological symptoms, making diagnosis challengingchallenging

Some patients present with predominantly Some patients present with predominantly psychiatric symptoms and have been psychiatric symptoms and have been diagnosed with schizophreniadiagnosed with schizophrenia

The ‘new psychoses’The ‘new psychoses’

anti-NMDA receptor encephalitisanti-NMDA receptor encephalitis can have additional features of can have additional features of

dyskinesias, seizures and catatonia dyskinesias, seizures and catatonia Can be associated with ovarian Can be associated with ovarian

pathologypathology diagnosis requires a positive finding diagnosis requires a positive finding

of antibodies to the NMDA receptorof antibodies to the NMDA receptor

The ‘new psychoses’The ‘new psychoses’

There are distinct prodromal, psychotic, There are distinct prodromal, psychotic, unresponsive, hyperkinetic and recovery unresponsive, hyperkinetic and recovery phases phases

Recovery is not always to the pre-morbid Recovery is not always to the pre-morbid levellevel

High mortality rate (25% in a case study of High mortality rate (25% in a case study of 100)100)

Diagnosis is made by detecting the Diagnosis is made by detecting the antibodies in serum-Oxford antibodies in serum-Oxford

The ‘new psychoses’The ‘new psychoses’

Treatment is immunomodulatory agents, Treatment is immunomodulatory agents, including plasmapheresis or high-dose including plasmapheresis or high-dose steroids steroids

Anti-psychotics and benzodiazepines have Anti-psychotics and benzodiazepines have a supportive role in treatmenta supportive role in treatment

unclear whether there is a pure psychiatric unclear whether there is a pure psychiatric presentation associated with lower presentation associated with lower antibody titres. antibody titres.

NMDANMDA

N-methyl-D-aspartateN-methyl-D-aspartate receptorreceptor (also (also known as the known as the NMDA receptorNMDA receptor a a glutamate receptor, is the predominant receptor, is the predominant molecular device for controlling molecular device for controlling synaptic plasticity and and memory function function

Hypo-function of Hypo-function of GlutamateGlutamate is emerging is emerging as a likely cause of schizophrenia, as a likely cause of schizophrenia, alongside the Dopamine hypothesisalongside the Dopamine hypothesis

In SummaryIn Summary

Potentially treatable psychosisPotentially treatable psychosisRole of investigations pivotal to Role of investigations pivotal to

diagnosisdiagnosisOngoing research in this area-Ongoing research in this area-

epidemiological and investigativeepidemiological and investigative

To summariseTo summarise

Mental illness is beginning to be Mental illness is beginning to be recognised as the huge public health recognised as the huge public health concern that we concern that we ‘experts’‘experts’ know only too know only too well that it iswell that it is

Some of the well known causes of poor Some of the well known causes of poor health-nutrition, Obesity, metabolic health-nutrition, Obesity, metabolic syndrome and the range of unformulated syndrome and the range of unformulated symptoms which present in primary caresymptoms which present in primary care

To summariseTo summarise

GP’s are managing majority of mental illness GP’s are managing majority of mental illness without involving specialistswithout involving specialists

Evidence supports the impact of the holistic Evidence supports the impact of the holistic care in the areas we’ve looked atcare in the areas we’ve looked at

When to or why refer?When to or why refer?

The public health challengesThe public health challenges

Some new scienceSome new science

ThanksThanks