1. GPVTS Academic Programme Common psychiatric problems Jim Bolton Consultant Liaison Psychiatrist St Helier Hospital

2. 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”

3. Introduction What would you like to talk about? Depression Anxiety Medically unexplained symptoms Mental health services Mental Health Act

4. Depression

5. Part of normal experience A symptom, not a diagnosis When does depressed mood become an illness?

6. Appropriate distress or psychiatric disorder? Normal distress (adjustment disorder) –brief change in mood Psychiatric disorder (depression) –persistent –extreme –disabling

7. Depressive disorder - epidemiology Depends on how you look for it Lifetime risk 15-20% One month prevalence 5-10%

8. Depressive disorder - classification Current episode –Mild –Moderate –Severe (+ psychotic symptoms) Pattern of episodes –Single episode –Recurrent depressive disorder Dysthymia Mixed anxiety & depression

9. Depressive disorder – symptoms Mood Motivation –energy, interest, pleasure, concentration Thinking –guilt, worthlessness, self-blame –hopelessness, suicidal ideation Biological symptoms –appetite, weight, sleep, libido Persistent

10. Depressive disorder - aetiology Physical –genetics? –alcohol & drugs Psychological –past psychiatric history –personality and coping Social –stresses –support

11. Depressive disorder – primary care Patients rarely present with neat clusters of symptoms Often combination of physical, psychological, social problems Somatic presentation common

12. Depressive disorder - management Physical –antidepressants Psychological –counselling / psychotherapy Social –social support –practical advice, e.g. exercise, caffeine, alcohol

13. Disorders of the puerperium The “blues”Postnatal Puerperal depressionpsychosis Onset:4-5 days2-4 weeks1-3 weeks Frequency:50%10-15%0.2% Duration:2-3 days4-6 weeks6-12 weeks (1 year)

14. Postnatal depression - clinical features Commonly –tearfulness, irritability, poor sleep Note –inadequacy –loss of confidence –anxieties –thoughts of harm

15. Postnatal depression - aetiology Summary –most support for psychosocial rather than biological factors –similar to depression at other times –subgroup?

16. Postnatal depression - treatment Physical –Antidepressants –Hormones Psychological –Counselling –Brief psychotherapies Social –maximise available support –voluntary groups

17. Postnatal depression - prognosis 1:3 recurrence after subsequent birth Without treatment 30% ill at 1 year

18. Anxiety

19. 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

20. Anxiety-related disorders - classification Generalised anxiety disorder Panic disorder Phobic anxiety disorder OCD PTSD

21. Anxiety-related disorders - epidemiology Lifetime prevalence –Generalised anxiety disorder 30% –Panic disorder 5%

22. Anxiety-related disorders - aetiology Biological –Constitutional predisposition? –Caffeine, alcohol, drugs Psychological –Individual interpretation, past experiences, coping resources Social

23. Anxiety-related disorders - management Biological –Benzodiazepines –Antidepressants Psychological –CBT –Relaxation –Anxiety management Social

24. Medically unexplained symptoms

25. How common are MUS? Primary care: 20% Medical outpatient clinic: 25-50% Medical inpatients: 1-2% Liaison psychiatry: common referral

26. 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?

27. Back to basics: what is a symptom? “A phenomenon... arising from and accompanying a disease.” Oxford English Dictionary Disease Symptom

28. Perception Interpretation Symptom What is a symptom?

29. Perception Interpretation Symptom Many symptoms are due to the perception of organic disease. But many remain medically unexplained. What factors are associated with MUS?

30. Vulnerability factors Experiences of illness Illness beliefs Precipitating factors Life events Stress Maintaining factors Anxiety and depression Reactions of others Iatrogenic

31. Perception Experience of illness Stress Interpretation Reactions of others Symptom A model of MUS

32. Management Stepped care: 1) Basic management 2) Specialist management 3) “Damage limitation”

33. Physical examination & investigation As much as is appropriate Over-investigation can reinforce the patient’s conviction that there must be something physical wrong

34. 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?

35. Reassurance Most patients are reassured Bland reassurance is unhelpful Address the patient’s fears and beliefs Correct any misconceptions

36. Explanation Give a positive explanation Explain how physical, psychological and social factors interact Give practical advice on coping and returning to normal activity

37. Further management Stepped care: 1) Basic management 2) Specialist management 3) “Damage limitation”

38. Mental health services

39. Separation of acute and mental health Divided by age: Child ------ Adult ------ Older adults …& speciality: –e.g. substance misuse, psychotherapy Crisis & Home Treatment Teams

40. Community mental health team Often GP aligned Multidisciplinary team Management of “SMI” Care Programme Approach

41. Making a referral Get to know your CMHT –Routine & emergency referrals Information to include –Past history –Social background –Risk

42. 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.

43. Mental Health Act 1983 Compulsory treatment of psychiatric (but not physical) disorder. “Sections” GPs involved in most sections.

44. 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)

45. 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)

46. Section 2: Admission for assessment Assessment of suspected psychiatric disorder 28 days Right of appeal within 1 st 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

47. 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

48. 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

50. 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

51. 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