Transcript Depression beyond “Functional Hai”

Psychiatry in General Practice
Dr. Achal Bhagat
MBBS MD MRCPsych
APOLLO HOSPITAL
SAARTHAK
Psychiatric Disorder is common
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25% of general population
40-50% of general practice population
Psychosocial Issues more common in
women
Depression becoming more common in
younger men
HOW IS PSYCHIATRIC
DIAGNOSIS DIFFERENT?
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No External Validation
What is Normalcy?
Culture
Interview is a key skill
HOW DO YOU ARRIVE AT
PSYCHIATRIC DIAGNOSIS?
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ESTABLISH RAPPORT
OBTAIN INFORMATION
ASSESS FOR PSYCHIATRIC SIGNS
COMPARE PRESENT FUNCTIONING
WITH DEVELOPMENTAL STAGE
GOALS
ANALYSE
Diagnosis: When to explore
further?
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Unexplained multiple somatic symptoms
Multiple visits
Biological Symptoms
Irritability
Hopelessness
Fatigue
A depressed look
KEY DISORDERS
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MINOR PSYCHIATRIC DISORDERS
MAJOR PSYCHIATRIC DISORDERS
MAJOR DISORDER
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MOOD DISORDER
SCHIZOPHRENIA
MINOR DISORDERS
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ANXIETY
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Apprehension about future, On the edge, Somatic
Symptoms, Avoidance
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DEPRESSION
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Sustained Change of Mood, Inability to enjoy, Negative
Cognitions, Lack of Interest, Sleep and Appetite
Disturbance
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OBSESSIVE COMPULSIVE DISORDER
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Repetitive intrusive thoughts recognized to be absurd have
to be controlled by either doing something or avoiding
something
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DISORDER OF SEXUAL FUNCTION
DIAGNOSING PSYCHIATRIC
DISORDER
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APPEARANCE AND BEHAVIOR
SPEECH
MOOD
THOUGHT
PERCEPTION
COGNITION
HOW TO ANALYSE?
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WHAT ARE THE AREAS OF DISTURBANCE?
IN WHAT AREA IS THE KEY DISTURBANCE?
WHAT AREA DID THE DISTURBANCE
START FROM?
WHAT AREA IS THE MOST DISTRESSING?
ARE THERE ANY CAUSATIVE
RELATIONSHIPS?
HISTORY
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I/D
CHIEF COMPLAINTS IN
CHRONOLOGICAL ORDER
HOPI
SPONTANEOUS CHRONOLOGICAL ACCOUNT
 COMPLETE THE SYNDROME
 NEGATIVE HISTORY
 TREATMENT HISTORY
HISTORY
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PAST PSYCHIATRIC HISTORY
PAST MEDICAL HISTORY
FAMILY HISTORY
PERSONAL HISTORY
BIRTH
CHILDHOOD
ADULT
RELATIONSHIPS WORK LEISURE
PRESENT LIVING CIRCUMTANCES
PRESENT FAMILY
SPEECH
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REACTION TIME
QUANTITY
COHERENT
COMPREHENSIBLE
PROSODY
MOOD
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QUALITY
SUBJECTIVE
OBJECTIVE
RANGE
REACTIVITY
INAPPROPRIATE / INCONGRUENT
THOUGHT
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FLOW
FORM
CONTENT
OVERVALUED IDEAS
DELUSIONS
OBSESSIONS
PERCEPTION
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ILLUSIONS
HALLUCINATIONS
BODY IMAGE
DEREALISATION/
DEPERSONALISATION
COGNITIVE FUNCTIONS
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ORIENTATION
ATTN/CONC
MEMORY
INTELLIGENCE
JUDGEMENT
ABSTRACT THINKING
INSIGHT
BASICS
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ALWAYS TRY TO EXPLAIN ALL SYMPTOMS
WITH ONE DIAGNOSIS/HYPOTHESIS
 BUT CO-MORBIDITY IS A REALITY
 CONSIDER A DIAGNOSIS OF PERSONALITY
DISORDER IF THERE IS NO CLEAR CUT
ONSET/ THERE ARE PATTERNS IN INTER
PERSONAL RELATIONSHIPS
BASICS
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RULE OUT LEARNING DISORDER
RULE OUT ORGANIC DIAGNOSIS
RULE OUT SUBSTANCE ABUSE
RULE OUT MOOD DISORDER
RULE OUT SCHIZOPHRENIA
CONSIDER MINOR PSYCHIATRIC
DISORDER
WHAT WORKS?
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MEDICINE
PSYCHOLOGICAL TREATMENTS
SOCIAL SUPPORTS
How to explore?
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Active Listening
Explore triggers and patterns in
psychosocial context
Do not ask why
Do not suggest that symptoms are
functional
Look out for key symptoms
Depression is treatable
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Antidepressants and not benzodiazepines
Adequate dosages
Adequate time
When to refer?
Which antidepressant?
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Conventional
Least side effects
Same as the one that worked last time
Different from the ones which have already
been tried without a positive result
Explore causes of non response
Is psychotherapy possible at the
level of general practice?
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Yes
 What methods?
 Cognitive Behaviour Therapy
 Supportive Therapy
Cognitive Behaviour Therapy
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We Think
We Feel
We Act
If we change the way we think we can
change the way we act
How to change thinking?
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Identify negative thoughts
Identify patterns in them
Learn methods of challenging the patterns
Replace these with lesser negative thoughts
Physician heal thyself
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What are my needs?
What are my need fulfilling activities and
how much time do I spend in trying to do
them?
What are the obstacles?
What can I do about the obstacles?