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Presentation on theme: "THE DISTRESSED/ANXIOUS/ DEPRESSED PATIENT Lia Ali Jane Hutton."— Presentation transcript:


2 Journal Club

3 1. Why might meta-analyses be useful? 2. What are the benefits of meta-analysis? 3. What are the limitations of meta-analysis? 4. How might the findings of a meta-anlysis like this influence or impact your clinical practice?




7 45 yo divorced man is in for a gall bladder operation. On the ward he is quiet, makes poor eye contact and at times appears tearful. He only talks when asked direct questions, but has said he sees no point in having the operation because he does not deserve it. Vignette 1

8 Vignette 2 The patient is a 30 year old single mother of two. She presents to A&E having taken an overdose of prescription diazepam.

9 She is observed overnight and declared medically fit. There is a three month history of low mood contemporaneous with a relationship breakdown and yesterday she found out she may be evicted from her home. The diazepam was from the GP. No other meds. Vignette 2

10 The patient’s mother has suffered with depression and her father died young from complications of alcoholism. OD now regretted. Patient now resolved to address her difficulties. Vignette 2

11 82 year old man admitted through A&E for an exacerbation of COPD Sats are good but continues to complain of breathlessness and call for a nurse frequently This is his fourth such admission over the last year, and they are becoming more frequent The team are planning for discharge, but he is reluctant for this Vignette 3

12 The staff are becoming impatient with him. He knows this, but views his continuing breathlessness as a sign that something has been missed. He is married with 2 children. He has no personal history of mental health problems but has a family history of alcoholism and anxiety problems. Vignette 3

13 Upon questioning, he reveals that he gets very anxious about going to bed at night. Vignette 3


15 Depression Someone who is depressed might feel… Sad, low, weepy, guilty, despairing, overwhelmed or numb Fed up and irritable, and snap at those closest to them Lonely, even when they are with other people Particularly low in the morning Tired all the time Preoccupied and find it hard to enjoy things Hopeless about the future They might also… Find it hard to get out of bed and to get going Be restless and unable to settle to anything Have trouble with concentration or memory Eat and sleep more or less Stopping seeing people and doing things they enjoy Lack confidence in self Be harsh on self “ not good enough” Think negatively about the world Think about self-harm

16 Anxiety Pain or tightness in the chest Fast, shallow breathing Fast or pounding heart beat Feeling dizzy or faint Tense or aching muscles Headaches Sweating Stomach churning Needing to go to the toilet Trembling Pins and needles or numbness Fearing the worst Worrying Can’t concentrate Fidgety, can’t relax Irritable Avoid feared situations

17 Unhelpful health beliefs Difficulty adjusting to situation Also…

18 Symptoms may be difficult to distinguish from symptoms of physical illness and may interfere with investigations or interventions. Depression and anxiety may lead to poorer outcomes through direct physiological mechanisms, by decreasing adherence to treatment and by increasing unhealthy behaviour such as smoking, poor diet and lack of exercise Predict increased length of hospital stay, more outpatient visits, poorer quality of life (Koenig and Kuchibhatla, 1998), greater disability (Pohjasvaara et al, 2001), increased admissions and health care costs, poorer concordance with treatments (NHS, 2009) and poorer health outcomes, for example, increased death rate after a heart attack (DH, 2009) Often predict functioning better than medical variables do Impact of anxiety and depression

19 Bi-directional association with diabetic complications, which may induce low mood, self- blame and helplessness, but also be influenced by poorer self-care and physiological mechanisms Depression in diabetes

20 Smoking post-MI doubles risk of cardiac death, and is predicted by depression (Taylor et al, 1998). Self-efficacy predicts functioning and treatment adherence in heart failure (Mumby, 1995; Schweitzer et al, 2007). Perceived control and role maintenance are important (Fowers, 1994; Vale, 1998). Optimism predicts success in changing risk factors and more adaptive coping (Shepperd et al, 1996; Desharnais et al, 1990). Belief vigorous activity will evoke another MI predicts poorer prognosis (Reigel, 1993). Cardiac illness

21 Depression is associated with poorer survival, longer admissions, continued smoking and poorer physical and social functioning (Ng et al, 2007) Anxiety is common and leads to avoidance of exercise, reduced fitness and greater disability Unsurprising; most people find breathlessness frightening Fears about deterioration and death also understandable But psychological distress is not inevitable consequence of COPD, but complication which increases disability and reduces capacity to engage in treatment Can be successfully treated, with benefits for quality of life and probably physical functioning COPD (Hynninen et al, 2005)


23 This is as difficult for you as asking someone about their bowel habit once was. Practice will help. This will soon not be a big deal. Your confidence rubs off on patients and other staff. Asking about mental health

24 Your own form of words (eg): “How are you?” “Have you had any problems with your mental health?” “How are you in yourself?” Authentic phrasing not the Mac Tilt! Asking about mental health


26 Exercise: Pair up. Ask your partner about their mental health. (Use a history from a patient you know) Reflect back. Asking about mental health

27 Talking points: Concerns about being intrusive. Asking for permission. Fears about opening up and not being able to fix (a problem for health staff). Upsetting/frightening to hear about mental health problems. Asking about mental health



30 HADS (Zigmond and Snaith, 1983) 0-3 scales,cut-off of 8, ?unidimensional I feel tense or wound up I get a sort of frightened feeling as if something bad is about to happen Worrying thoughts go through my mind I can sit at ease and feel relaxed I get a sort of frightened feeling like butterflies in the stomach I feel restless and have to be on the move I get sudden feelings of panic I still enjoy the things I used to enjoy I can laugh and see the funny side of things I feel cheerful I feel as if I am slowed down I have lost interest in my appearance I look forward to enjoyment with things I can enjoy a good book or radio or TV programme

31 Over the last 2 weeks, how often have you been bothered by the following problems? 0-3: not at all, several days, more than half the days, nearly every day Feeling nervous, anxious or on edge Not being able to stop or control worrying Worrying too much about different things Trouble relaxing Being so restless that it is hard to sit still Becoming easily annoyed or irritable Feeling afraid as if something awful might happen 5-9 mild, 10-14 moderate, 15-21 severe anxiety GAD-7

32 Last 2 weeks, same 0-3 scales Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself or that you are a failure or have let yourself or your family down Trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed? Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual Thoughts that you would be better off dead or of hurting yourself in some way Scores of 5, 10, 15, and 20 are cut-off points for mild, moderate, moderately severe and severe depression PHQ-9


34 Listening and being ready to be surprised Asking about concerns Simple need for information/problem- solving Acute v chronic Detection

35 Problem 1 Symptoms exist on a continuum. Disorder-labels are binary. (decision to treat is binary) (well/sick is also binary) Cut-offs are arbitrary but necessary. 1. Challenges of detection

36 Problem 2 There are no investigations in mental health care. 1. Challenges of detection

37 Problem 3 Common mental disorders have physical (somatic) symptoms and cognitive/affective symptoms. Should somatic symptoms be disregarded? 1. Challenges of detection

38 Problem 4 Anxiety and depression are very comorbid (~60%). They are grouped: Common Mental Disorder. 1. Challenges of detection

39 Common mental disorders are chronic and remitting and relapsing illnesses. Diagnosis should take into account history and also impairment. 1. Challenges of detection

40 Active detection Passive detection

41 Depression in palliative care: In the absence of physical symptoms, depression is v unlikely. In the presence of physical symptoms, depression may or may not be present. 1. Challenges of detection Rayner L, Lee W, Price A, Monroe B, Sykes N, Hansford P, Higginson IJ, Hotopf M. The clinical epidemiology of depression in palliative care and the predictive value of somatic symptoms: Cross-sectional survey with four-week follow-up. Palliative Medicine 2011;25(3):229.


43 1.Organic, especially: a.Delirium b.Dementia c.Substances 2.Psychosis. 3.Ordinary sadness / grief. 2. Alternative diagnoses

44 1.Delirium – investigate/treat urgently. 2.Dementia – refer. 3.Substances – refer. 4.Psychosis – refer urgently (not delirium). If delirium, investigate/treat urgently. 5.Ordinary sadness / grief – you may be able to manage this, but if not, refer. 2. Alternative diagnoses

45 Patients don’t come with diagnostic labels. They come to your attention via behaviours: Lost or agitated > Think organic especially delirium. Mad > Think psychosis or organic. Sad > Think depression or psychosis or organic. Afraid > Think anxiety or depression or psychosis or organic. [Bad > Think personality or anxiety or depression or psychosis or organic.] 2. Alternative diagnoses

46 Role Play – Michael’s story continues



49 Balancing open and closed questions Using more specific questions e.g. How are your symptoms? How are you in yourself? Letting the patient know how much time you have, and that they have your undivided attention for that time Unless there is an emergency, sticking to this planned time Be clear about the purpose of the appointment Set an agenda together and check you have included everything the patient wants to cover Ask them to prioritise the problems which are most important to tackle today, if it seems likely there won’t be time to cover them all 3. Assessment

50 Could you tell me a bit more about that? What troubles you the most about that? (this can be a good question to interrupt a long account, some details of which don’t seem relevant) Is this something you’d like some help with? Is there anything you’d like me to do? Are there any other problems we haven’t talked about yet? Useful Questions

51 Once referral made: Interview. Usually 60-90 mins. May also review notes, speak to staff, speak to family, etc. 3. Assessment

52 1.Presenting complaint/Hist of PC 2.Past Psych History/P Medical Hist 3.Family History 4.Personal History/Occup/Relationships 5.Tobacco Drugs Alcohol 6.Mental State Examination 7.Formulation (differential diagnosis) 8.Plan 9.Review 3. Assessment

53 Self Management – Psychoeducation + exercise Psychotherapy – Many approaches. Pharmacotherapy - Antidepressants Combination of above approaches. 4. Management

54 Pharmacological: Refer. Antidepressants (TCA/SSRI/other). Work in days. Work in physical illnesses. Work best in severe depression. Serious interactions and side effects. Antipharmacological: Steroids 4. Management

55 General Approach to Treatment of Major Depressive Disorder in Patients With Comorbid Medical Conditions Based on PHQ-8 or PHQ-9 Score and Degree of Functional Impairmenta. Whooley, M. A. JAMA 2012;307:1848-1857

56 Interplay of bodily sensations, external events, thoughts, feelings and (lack of) actions Focus on changing thoughts and actions Evidence for anxiety and depression, even in context of medical problems (van Straten et al, 2010) 4. Management: CBT

57 Keeping active Social support Eating well, avoiding alcohol Rest and sleep Social support and being listened to Meaningful activity Coherent understanding of situation Hope 4. Management

58 NICE Guidance

59 NICE: Key priorities for implementation Identifying depression in people with chronic illness (PHQ-9, GAD-7) Comprehensive assessment - functional impairment and/or disability & duration of episode Stepped care: LI and HI interventions ? Use of medication for mild depression Choice of anti-depressants Collaborative care if depression has not responded to initial HI or anti-depressants All interventions should be delivered by competent practitioners

60 Low-intensity psychosocial interventions For patients with mild to moderate depression or sub-threshold depressive symptoms which are persistent or complicate the care of the medical problem … ≥1 Consider offering ≥1 of the following, guided by patient preference: structured group physical activity group-based peer support individual guided CBT-based self-help computerised CBT

61 High-intensity psychosocial interventions For patients with initial presentation of moderate depression, offer the following choice of high intensity psychological interventions:  group-based CBT or  individual CBT or  behavioural couples therapy or  medication or  combined CBT and medication


63 Suicidal thoughts are common (10%/week) Suicide is rare (~0.01%/year). Suicidality fluctuates moment to moment. 5. Suicidality

64 Preventing suicides is mostly by addressing the means. 5. Suicidality Many suicides occur in people with no prior contact with mental health services. Most (~95%) people who kill themselves are diagnosable with a psych disorder.

65 Some structure: Ideation - Thinking about it. Intent & plan – Preparing for it. Access – How it might be done. History – Attempted it before. 5. Suicidality

66 Red flags: 1.Threatening to hurt or kill himself or herself 2.Looking for ways to kill himself or herself 3.Seeking access to pills, weapons, or other means 4.Talking or writing about death, dying, or suicide. Curr Psychiatry Rep. 2008 Feb;10(1):87-90. Suicide warning signs in clinical practice. practice/monograph/1016/diagnosis /step-by-step.html

67 Some answers 5. Suicidality (Self harm) Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250

68 DSH is rising but suicide is falling (until recently). 1:5 repeat within a year. 1:10 repeat 5 or more times in a year. Usually an attempt to escape from an intolerable situation. Young – relationships. Old – health / bereavement. 5. Suicidality (Self harm) Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250

69 What to do: Immediate risk assessment… …by a mental health professional (NICE) …by a health professional (RCPsych) Mental health problems? What is the risk? Medical or social problems?. 5. Suicidality (Self harm) Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250

70 What to do: Allow for ‘processing’ and discussion. Manage MH problems. Manage risk. Signpost or refer to services. If input available, use it. 5. Suicidality (Self harm) Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250

71 Role play – Michael’s story continued


73 Case discussions


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