Transcript Alan Cohen`s presentation

Physical and mental
health
Dr Alan Cohen FRCGP
Presentations
The presentation of mental illness with physical
symptoms
The association between mental illness and physical
illness
General Practice
Disorganised/Chaotic
Poor at identifying people with mental heath
problems
Not interested in mental health
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
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
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
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
Prevalence of unexplained symptoms
in consecutive attendees at a UK
teaching hospital
Clinic
%
•
•
•
•
•
•
•
59%
56%
60%
58%
55%
49%
57%
Chest
Cardiology
Gastroenterology
Rheumatology
Neurology
Dental
Gynaecology
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
Associations
Common Mental Health Problems
Depression
Anxiety
Severe and Enduring Mental Health Problems
Schizophrenia
Bi-polar disorder
Depression
Diabetes
Ischaemic Heart Disease
Stroke
Other chronic neurological conditions
Cancer
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
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
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
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
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?
Schizophrenia and Bipolar disorder
Few Papers
Most studies are by Psychiatrists, about inpatient 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
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
SMR by cause of death
Respiratory disease
SMR 250
Infectious disease
SMR 500
Cardiovascular disease
SMR 250
Characteristics:
Health Promotion
Consultation rate
Data that is recorded
smoking
BP
Cx smear
Mammography
Alcohol use
Weight
Cholesterol
13 -14*
23%
38%
28%
8%
20%
27%
2.5%
*Burns and Cohen BJGP 1998
Schizophrenia comorbidity
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 ???
Bipolar co-morbidity
As for schizophrenia plus:
Smoking: 25 – 30% are smokers
Drug related thyroid & renal disorder Lithium
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)
(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
(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
What GPs get paid to
do...
Do you really want to know???
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”
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 ££££££ !!”
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
Mental Health Domain
The practice can produce a register of people with schizophrenia, bipolar disorder and
other psychoses
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
4
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
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
Mental Health Domain
2nd 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?
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.
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
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?
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
Thank you
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