CUH Liaison Psychiatry Lecture for medical students 2011

Download Report

Transcript CUH Liaison Psychiatry Lecture for medical students 2011

PSYCHOLOGICAL MEDICINE
Dr Eugene M Cassidy
MD, MRCPsych, MMedSc (Physiol.)
Consultant Liaison Psychiatrist
CUH
[email protected]
CUH Liaison Psychiatry
Outline
•
•
•
•
•
•
Mental Health Problems in General Hospital - Overview
Psychological Adjustment to illness
Depression in Medical Illness
Alcohol Problems
Somatisation
Management
CUH Liaison Psychiatry
Mental Health in the General Hospital
• Deliberate self-harm
• Drug and alcohol misuse
• Acute organic disorders (delirium)
• Psychological adjustment to illness
• Physical and psychiatric co-morbidity
• Medically unexplained symptoms
• Behavioural problems (e.g. non-adherence to
treatment, capacity issues)
CUH Liaison Psychiatry
Psychological adjustment to illness
CUH Liaison Psychiatry
Stress and Physical illness
• Major health problems are stressful
• Response to this stress dependent upon individual
– Perception / Beliefs of illness
– Vulnerability
– Coping ability
– Response of others
CUH Liaison Psychiatry
Illness Perception / Beliefs
•
•
•
•
•
Illness identity
Cause
Consequences
Course
Cure/controllability
• Influenced by
– Medical Communication, Personal experience, Norms
CUH Liaison Psychiatry
Individual Vulnerability
• Personality traits (e.g. tendency to worry about illness)
• Prior experience of illness within a family
• An individual’s psychological state at the time of the
illness
• Previous experience of trauma, or a neglected or
abusive childhood
CUH Liaison Psychiatry
Helpful Coping
•
•
•
•
•
•
Seeking information
Seeking practical and social support
Learning new skills
Developing new interests
Helping others
Emotion-focused coping
CUH Liaison Psychiatry
Less Helpful Coping
•
•
•
•
Hoping the condition will just disappear
Denial
Obsessively focusing on minute details of the disorder
Seeking others to blame
CUH Liaison Psychiatry
Response of Others to illness
•
•
•
•
Closing in
Drifting away
Infantilising
Depersonalising
• Guthrie
CUH Liaison Psychiatry
Physical and Psychiatric Co-morbidity
CUH Liaison Psychiatry
Psychological Medicine
• Applies bio-psychosocial model to medical care (irrespective of
psychiatric morbidity)
• Involves all staff and all patients
• More than just Liaison Psychiatry & Health Psychology
• Is there a need?
– Psychiatric disorders in medical illness
– Benefits most obvious in Somatoform disorder
CUH Liaison Psychiatry
Depression in Medical Illness
• Vulnerability – Stress model
• Bio-psycho-social
• Dimensional (significant depressive symptoms)
• Categorical (Major Depression)
CUH Liaison Psychiatry
Depression is common in medical illness
• Major Depressive disorder 8%
• All depressive disorders 15-36%
Magni et al, 1986, Feldman et al, 1987, Koenig et al, 1997, Von Ammon et al, 2001
CUH Liaison Psychiatry
Depression is under recognised
•
Physicians have been found to recognise depression in only one fourth
to one half of their depressed medical outpatients
Wells et al, 1989; Schulberg et al, 1985; RCP/RCPsych, 1995
CUH Liaison Psychiatry
Detection of Depression in Medical Setting
• Be vigilant
– Depression is common
• Ask about it:
• If positive, look for:
– mood and motivation symptoms
– cognitive changes (always enquire about suicidal
thoughts)
– biological symptoms
– Disability or physical symptoms in xs of expected
CUH Liaison Psychiatry
Screening for Major Depression
Please ask the following:
1.
During the past month have you been bothered by feeling down, depressed
or hopeless? No
Yes
2.
During the past month have you been bothered by little interest or pleasure in
doing things?
No
Yes
If Yes to either of the above 2 questions, please ask:
3.
Is this something with which you would like help?
No
Yes, but not today Yes
Likelihood Ratio for MDD = 17.5
(ST elevation in MI 11.2; D-Dimers>1092ng/ml 3.1)
Depression affects medical outcome
• Morbidity
• Survival
• Length of hospital stay
• Cost of medical care
• Compliance with therapy,
• Quality of life
Creed et al, 2002; Katon et al, 2003
CUH Liaison Psychiatry
Frasure-Smith et al, 1993
CUH Liaison Psychiatry
Lesperance et al, 2002
CUH Liaison Psychiatry
Impact of depression on DM
•
•
•
•
More complications
Poorer glycemic control
Reduced dietary / oral hypoglycemic adherance
More typical DM symptoms even when severity of
DM controlled for
• Poorer quality of life
• Increased healthcare costs x 4.5 (Egede et al, 2002)
CUH Liaison Psychiatry
Depression is treatable
….. But it isn’t always treated
• Beware empathy and understanding
• Antidepressants
• Psychological therapies
CUH Liaison Psychiatry
CUH Liaison Psychiatry
Gill & Hatcher, 2000
CUH Liaison Psychiatry
The Burden of Alcohol Misuse on emergency inpatient hospital admissions among residents
from a health board region in Ireland
O’Farrell, S. Allwright, J. Downey, D Bedford, F. Howell.
Addiction (2004): 99, 1279-1285
Acute Alcohol intoxication
• 2.0% all emergency admissions
• 203/100,000 population
CUH Liaison Psychiatry


PREVALENCE
147/759 (19.4%) CAGE +
19% DSM-IV Abuse / Dependence
•
30% male
•
8% female
DETECTION
80% doctors enquire
46% record consumption
1% recorded CAGE
18% recognised by medic
•64% discharge summaries
•37% referred on
CUH Liaison Psychiatry
PHARMACOTHERAPY
OF WITHDRAWAL
Pharmacological Management
of Alcohol Withdrawal:
Evidence-based
practice guideline
Mayo-Smith et al, JAMA, 1997
Benzodiazepines
•Reduce symptoms
•Prevent seizures
•Prevent delirium
CUH Liaison Psychiatry
Fixed Dose
or
Symptom Triggered
Withdrawal
Scales
Thiamine for Wernicke-Korsakoff Syndrome in
people at risk from alcohol abuse
Day E, Bentham P, Callaghan R, Kuruvilla T, George S
Cochrane Review (2004)
+
CUH Liaison Psychiatry
A Good place to Intervene
60
50
40
gen hosp
gen populn.
30
20
10
0
pre-cont
action
CUH Liaison Psychiatry
Rumpf et al, 1987
Feedback Helps!
• Health Consequences Feedback increases the
proportion of patients willing to accept brief advice by
@¼
R Patton, MJ Crawford, R Touquet. Emerg Med J (2003)20: 451-452
CUH Liaison Psychiatry
“With respect to alcohol abuse,
our charge is straightforward:
first we must ask something, then
we must do something.”
CUH Liaison Psychiatry
Somatisation
• See other PPT PRESENTATION as part of this lecture series
CUH Liaison Psychiatry
Management of Mental Health Problems
in Medical Illness
CUH Liaison Psychiatry
Framework for Psychological Support
Specialist psychological/
psychiatric interventions
Counselling
Self- Help interventions
Effective information giving and communication
Stepped care approach (1)
• Prevention
• Information and Communication
• Involve and Support families / carers
CUH Liaison Psychiatry
Stepped care approach (2)
•
•
•
•
Simple advice and problem-solving
Self-help
Relaxation techniques
Counselling – problem focussed
CUH Liaison Psychiatry
Stepped care approach (3)
• Drug treatments
– Drug interactions
– Benefits in co-morbid illness symptomatology
• Specific psychological therapies
– CBT
– Marital therapy
– Family therapy
CUH Liaison Psychiatry
Biopsychosocial Management
INTERESTED IN A CAREER IN PSYCHIATRY ???
• Please contact me at : [email protected]
• Tel: 021-4920007
CUH Liaison Psychiatry