19: PSYCHIATRY

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CHAPTER 19 PSYCHIATRY

DEPRESSION

Depression is the most common psychiatric problem of general practice. There are well over 5000 suicides in the UK each year, three-quarters of them among men.

Diagnosis

Management

• Assess the risk of suicide (see p. 300).

• Explain the diagnosis to the patient:

– depression is an illness

– one might liken it to a deficiency state of chemical in the brain

– the prognosis is excellent.

Non-drug treatment

• Continued GP support (offer follow-up with the same doctor).

• Family and friends, self-help groups.

• Counselling (e.g. with marital problems).

• Psychologist (e.g. for cognitive behavioural therapy).

• Community psychiatric nurse.

Prescribing

• Negotiate the use of drugs with the patient:

– antidepressants are not addictive

– they correct the chemical imbalance that is causing the patient’s symptoms.

• Prescribe a selective serotonin reuptake inhibitor (SSRI), e.g. fluoxetine 20 mg od or citalopram 20 mg od. SSRIs should be used with caution in children and adolescents. Paediatric prescribing should only be initiated by a specialist child psychiatrist.

– Warn the patient that the therapeutic benefit will not be felt for the first 10–14 days.

– Side-effects: common side-effects which usually settle within the first 2 weeks include nausea, nervousness and insomnia.

– Contraindications: avoid if the patient enters a manic phase.

• If response is poor, consider second-line antidepressants, e.g. venlafaxine, trazodone.

• Duration of treatment with antidepressants: 4 months to 2 years. After the patient is feeling well, continue treatment for 3 or 4 months. Treatment should not be discontinued if the patient is approaching an emotionally challenging time. Abrupt withdrawal of SSRIs should be avoided by reducing the dose to one tablet or capsule on alternate days for 1 month before stopping completely.

Referral.

Referral to a psychiatrist is indicated with:

• uncertain diagnosis

• poor response to treatment at adequate doses

• suicide risk (immediate admission, see below)

• psychotic features

• behaviour disturbance, e.g. psychomotor retardation.

Administration

ANXIETY

True anxiety neurosis interferes with the patient’s normal daily activities. Milder forms of anxiety are extremely common, may accompany physical illness and can cause a variety of symptoms.

Management

• Exclude physical disease at the initial consultation. Thereafter avoid overinvestigating, as this reinforces anxiety rather than relieving it.

• Treat any underlying depression (see p. 292).

• Symptomatic hyperventilation may be relieved by rebreathing expired air via a paper bag.

Prescribing

• For the acute, short-term relief of severe anxiety, e.g. in panic attacks, use diazepam 2–5 mg tds, as required. The maximum duration of treatment should be 14 days. Alternatively, prescribe propranolol 10–40 mg tds, as required.

• For chronic anxiety consider an SSRI, e.g. citalopram 20 mg od, or a tricyclic, e.g. clomipramine 10–75 mg od.

• For chronic agitation, e.g. in dementia, chlorpromazine 25–50 mg nocte is more appropriate.

OBSESSIVE–COMPULSIVE DISORDER

Obsessive–compulsive disorder (OCD) is a neurobiological condition that causes the patient to feel compelled repeatedly to think, speak or act-out irrational rituals, such as hand washing, touching objects or chanting mantras. The spectrum of severity is wide, with the mildest form almost going unnoticed by the patient and family. The most severe cases are disablingly time-consuming and can provoke extreme anxiety.

• OCD affects about 1% of children and adolescents.

• It tends to run in families.

• Children often keep their symptoms a secret.

Management

In mild cases the patient and family need reassurance that the condition is usually self-limiting.

Referral

• Patients who are upset by the OCD.

• Patients who take more than an hour a day to perform their rituals.

• Patients in whom the rituals interfere with everyday life.

Treatment.

The SSRI group of antidepressants are the most useful, e.g. fluoxetine 20–60 mg od. The other effective treatment for OCD is cognitive behavioural therapy. A combination of the two is usually offered by the psychiatrists.

INSOMNIA

Insomnia can be divided into acute and chronic. The chronic variety is more common in the elderly.

Management

• Explain that insomnia is not a disease.

• Treat the underlying cause, if any (see above).

• Try to avoid prescribing for chronic insomnia.

• Offer self-help leaflet.

• Advise a regular bedtime routine.

• Advise avoidance of stimulants, e.g. caffeine, alcohol.

• Are the patient’s expectations unrealistic?

• For short-term treatment requiring rapid relief of symptoms, i.e. no longer than 2 weeks, prescribe, e.g.:

– temazepam 10–20 mg nocte, or

– zopiclone 7.5–15 mg nocte.

Addiction to benzodiazepines

Explain the addiction potential of benzodiazepines to the patient and record in the notes that this has been discussed. A number of successful litigation cases against doctors over the prescribing of benzodiazepines have hinged on the fact that the patients were not informed of the addiction potential of these drugs. State the maximum safe duration of treatment (2 weeks) to the patient and explain that drugs are not a long-term cure.

PSYCHOSOMATIC ILLNESS

Patients with psychosomatic illnesses all share the belief that they are physically unwell. The frequent attender, chronic somatiser and heartsink patient may all come under this heading.

The GP may have negative feelings towards such patients. Recognising this is an important step in coping.

Diagnosis

History.

Psychosomatic illnesses may be difficult to distinguish from organic disease initially. The patient with globus hystericus, for example, may present with a straightforward sore throat.

However, a number of suspicious features make the possibility of a psychosomatic illness increasingly likely: multiple, unconnected physical symptoms; ‘vague’ symptoms such as spasms, churning or pressure; impossible symptoms, such as pain all over; and symptoms that defy treatment, such as wind, bloating and electric shocks.

Examination.

Satisfy yourself that the physical symptoms have been adequately explored by examination, investigation and referral, if indicated.

Management

• Gently, but firmly, inform patients that their symptoms, while real, are not due to physical disease. Many patients are difficult to reassure, but an unwavering message is important. The slightest doubt in the doctor’s mind is soon picked up by patients and used to reinforce their neurosis.

• Many patients will have emotional, social or family problems. Some may be clinically depressed (see p. 292). Some patients may have a justifiable phobia, e.g. after losing a close friend to cancer. Attempt to explore these areas.

• Encourage the patient to expect less of the doctor’s abilities to cure the physical symptoms.

• Encourage the patient to lead a normal life despite the symptoms, rather than be dominated by them.

The above process is often spread over many consultations and may be repeated as patients ‘relapse’.

Referral.

Referral to a specialist to exclude organic disease can be a useful way of reassuring patients that they are not physically unwell.

Referral to a psychiatrist is sometimes necessary to lighten the load on the GP. Some psychiatrists have an interest in hypochondriasis. The community psychiatric nurse or social worker can help explore emotional, social and family problems. The clinical psychologist may be able to provide the patient with training in behavioural methods of coping with physical and mental symptoms.

FATIGUE

Fatigue is a common presenting symptom in general practice. It is often described as: tired all the time, exhausted, lacking energy, sleepy, worn out.

Depression and anxiety are probably the commonest causes. Exclude physical causes initially.

Physical causes of fatigue:

• acute infection (e.g. flu-like illness)

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