1. Physical and mental health Dr Alan Cohen FRCGP

2. Presentations The presentation of mental illness with physical symptoms The association between mental illness and physical illness

3. General Practice Disorganised/Chaotic Poor at identifying people with mental heath problems Not interested in mental health

4. General Practice 280 million consultations annually 30% have a mental health component 91% of all mental health problems are managed entirely in primary care 25% of people with severe mental health problems are managed entirely in primary care

5. What is General Practice? The art of general practice is “organising the chaos of the first presentation” People usually present with somatic symptoms A more acceptable ticket of entry Easier to explain Stigma Difficult sometimes to distinguish a psychological cause from a physical cause

6. Medically Unexplained Symptoms 5 – 10% of all primary care consultations 50% of out patient attendances Associated with increased health care consumption Consultations in primary and secondary care Increased use of medication Associated with increased dissatisfaction in the consultation Both patient and GP

7. Distinguishing between physical and mental health problems... Reasons to refer: We don’t know what to do The diagnosis The management We know what to do but can’t do it ourselves Investigations Procedures A second opinion “The dump” – transfer of care

8. Prevalence of unexplained symptoms in consecutive attendees at a UK teaching hospital Clinic% Chest59% Cardiology56% Gastroenterology60% Rheumatology58% Neurology55% Dental49% Gynaecology57%

9. What this means.... The wrong patient getting the wrong treatment at the wrong time Costs the NHS a great deal of money Increases disatisfaction of both patient and doctor

10. Associations Common Mental Health Problems Depression Anxiety Severe and Enduring Mental Health Problems Schizophrenia Bi-polar disorder

11. Depression Diabetes Ischaemic Heart Disease Stroke Other chronic neurological conditions Cancer

12. Diabetes Depression is 2 – 3 times as common in people with diabetes Associated with Increased health care consumption Increased self perceived symptom load NOT associated with improved glycaemic control QOF Indicator

13. Diabetes Cost of treating co-morbid diabetes and depression is 250% Cost of all treatment is 400% Proportion of NHS hospital expenditure on diabetes is 10% of total spend

14. Ischaemic Heart Disease Depression is 2 – 3 times as common in people with ischaemic heart disease The best predictor of death following MI is the presence of depression QOF indicator

15. Ischaemic Heart Disease 40% of admissions can be prevented by providing psychological treatments 50% of revascularisation procedures (CABG and PTCA) can be prevented by providing psychological treatments

16. Anxiety Anxiety occurs in 25% of people with COPD People with COPD make up the largest group of “frequent flyers” A fear of becoming of short of breath, or actually becoming short of breath?

17. Schizophrenia and Bi- polar disorder  Few Papers  Most studies are by Psychiatrists, about in- patient populations  There are some large epidemiological studies which look at co-morbidity  There are no papers on the characteristics (physical or mental) of the SEMI not in contact with the secondary services

18. Characteristics In a study* of 101 patients in the community 26 were obese (BMI > 30) 53 were current smokers 11 were hypertensive (BP systolic >160, diastolic >100) SMR 150 (all causes)** *Kendrick 1996 B J Psych **Harris and Barraclough 1998 B J Psych

19. SMR by cause of death Respiratory disease SMR 250 Infectious disease SMR 500 Cardiovascular disease SMR 250

20. Characteristics: Health Promotion Consultation rate 13 -14* Data that is recorded smoking23% BP38% Cx smear28% Mammography8% Alcohol use20% Weight27% Cholesterol2.5% *Burns and Cohen BJGP 1998

21. Schizophrenia co- morbidity  Cardiovascular disease – lifestyle  Smoking: 80-90% are smokers  Respiratory disease - lifestyle  Diabetes – lifestyle, medication, genetics  Hepatitis C and HIV - lifestyle  Drug related movement disorders - iatrogenic  Cancer colon - ???  Rheumatoid Arthritis ???

22. Bipolar co-morbidity  As for schizophrenia plus:  Smoking: 25 – 30% are smokers  Drug related thyroid & renal disorder - Lithium

23. What to do? Burns and Kendrick* recommend “A proactive approach, closed questions for physical symptoms, and regular screening” Examine BP, chest, skin, side effects and urine analysis Investigations: CXR, ECG, FBC, ESR, TFTs Vision and Hearing tests * Psychiatry and General Practice Today 1994 (RCGP/RCPsych)

24. (More) What to do? GP Guide from the Institute of Psychiatry* -BP, IHD, cerebro-vascular disease -Chronic Bronchitis, infections -Obesity -Chiropody, vision and hearing problems -diabetes mellitus, thyroid disease -Drug side-effects -Family planning including cervical smears -Smoking, alcohol, exercise

25. (Even more) What to do NICE guidance: physical health is the responsibility of primary care Registers are needed Regular physical health checks, including endocrine disorders, cardiovascular disorders, life style risk factors Explicit recording of responsibility to monitor health care

26. What GPs get paid to do... Do you really want to know???

27. A brief overview of the GP contract Describes three levels of care: Essential care Has to be provided by all general practices Additional care May be provided in addition to essential services (vaccinations etc) Enhanced care Provides care above and beyond that which is considered to be “essential”

28. Essential Care Incentives exist to deliver high quality, evidence based outcomes for essential care The Quality and Outcome Framework (QOF) Points based incentive system Delivers a total of 1000 points 655 points are available for delivering clinical outcomes Outcomes divided into a number of clinical domains “Points means ££££££ !!”

29. The clinical areas covered CHD Heart Failure Stroke and TIA BP DM COPD CKD AF LD Asthma Dementia Depression Mental Health Obesity Smoking Palliative care Cancer Hypothyroidism Epilepsy

30. Mental Health Domain The practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses 4 The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status 23 The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months 1 The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months 2 The percentage of patients on the register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate 6 The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance 3

31. Mental Health Domain Delivers a total of 39 points (out of 655) Specifies a particular set of clinical diagnoses to be included in the “register” Schizophrenia Bi-polar disorder Other psychoses Excludes dementia, childhood behaviour disorders etc

32. Mental Health Domain 2 nd Indicator (MH9) The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status What does this mean in practice?

33. Mental Health Domain The user/patient is called for an appointment Some interventions are offered There is not yet a requirement as to which investigations/interventions should be offered.

34. Proposed changes Specify that the following interventions are recorded for everybody on the electronic list: Blood pressure recorded Peak flow recorded Urine analysis/fasting blood glucose recorded Height and weight recorded (BMI recorded) Smoking habits recorded Drug and alcohol use Flu vaccination offered annually

35. Further proposals Cervical screening as appropriate Drug and alcohol advice as appropriate Smoking cessation advice as appropriate Should this group be offered regular screening for bowel cancer – a priority group for bowel screening programme? Should this group be screened for Hepatitis C and HIV status?

36. In Summary Distinguishing mental from physical illness is not straightforward Managing the mental health problems of people with long term conditions will have a cost benefit Managing people with MUS will have a cost benefit There are significant associations between people with SMI and physical health problems

37. Thank you Alan.cohen@scmh.org.uk