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
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Mental Health Problems in General Hospital - Overview
Psychological Adjustment to illness
Depression in Medical Illness
Alcohol Problems
Somatisation
Management
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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)
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Psychological adjustment to illness
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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
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Illness Perception / Beliefs
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Illness identity
Cause
Consequences
Course
Cure/controllability
• Influenced by
– Medical Communication, Personal experience, Norms
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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
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Helpful Coping
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Seeking information
Seeking practical and social support
Learning new skills
Developing new interests
Helping others
Emotion-focused coping
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Less Helpful Coping
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Hoping the condition will just disappear
Denial
Obsessively focusing on minute details of the disorder
Seeking others to blame
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Response of Others to illness
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Closing in
Drifting away
Infantilising
Depersonalising
• Guthrie
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Physical and Psychiatric Co-morbidity
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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
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Depression in Medical Illness
• Vulnerability – Stress model
• Bio-psycho-social
• Dimensional (significant depressive symptoms)
• Categorical (Major Depression)
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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
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Depression is under recognised
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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
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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
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Screening for Major Depression
Please ask the following:
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During the past month have you been bothered by feeling down, depressed
or hopeless? No
Yes
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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:
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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
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Frasure-Smith et al, 1993
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Lesperance et al, 2002
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Impact of depression on DM
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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)
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Depression is treatable
….. But it isn’t always treated
• Beware empathy and understanding
• Antidepressants
• Psychological therapies
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Gill & Hatcher, 2000
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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
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PREVALENCE
147/759 (19.4%) CAGE +
19% DSM-IV Abuse / Dependence
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30% male
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8% female
DETECTION
80% doctors enquire
46% record consumption
1% recorded CAGE
18% recognised by medic
•64% discharge summaries
•37% referred on
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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
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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)
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A Good place to Intervene
60
50
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gen hosp
gen populn.
30
20
10
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pre-cont
action
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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
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“With respect to alcohol abuse,
our charge is straightforward:
first we must ask something, then
we must do something.”
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Somatisation
• See other PPT PRESENTATION as part of this lecture series
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Management of Mental Health Problems
in Medical Illness
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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
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Stepped care approach (2)
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Simple advice and problem-solving
Self-help
Relaxation techniques
Counselling – problem focussed
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Stepped care approach (3)
• Drug treatments
– Drug interactions
– Benefits in co-morbid illness symptomatology
• Specific psychological therapies
– CBT
– Marital therapy
– Family therapy
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Biopsychosocial Management
INTERESTED IN A CAREER IN PSYCHIATRY ???
• Please contact me at : [email protected]
• Tel: 021-4920007
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