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

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.

Tip

• 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.

Tip

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.

Tip

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.

Tip

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

Physical causes of fatigue:

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

• postviral

• alcohol abuse

• heart failure

• malignancy (e.g. lung, breast, bowel, lymphoma)

• diabetes

• hypothyroidism

• degenerative neurological disease (usually described as weakness)

• chronic infection (e.g. TB, bronchiectasis)

• anaemia.

Management

• If the history suggests depression, explore and treat (see p. 292).

• Explain to the patient that a physical cause has not been found. Acknowledge the patient’s problem of fatigue.

• If family or social problems emerge, it may be helpful to pursue these over time.

• It may be necessary to correct the patient’s expectations of the doctor, e.g. ‘I need a tonic, Doctor.’

• Chronic fatigue is best managed with empathy and encouragement. The ME Society is a valuable source of support. Medical certificates should be issued to the patient who claims to be too fatigued to work. The Benefits Agency generally takes a sympathetic view of this condition.

Referral.

Referral is indicated if:

• a physical disease is suggested but cannot be ruled out (e.g. a suspicion of bowel cancer)

• depression proves difficult to treat (see p. 292)

• help is needed with psychosocial problems (e.g. family therapy)

• anxiety cannot be treated successfully in general practice.

SUICIDE

There are over 5000 deaths per year in the UK due to suicide. The majority of victims have consulted a GP shortly before death.

Tip

Most suicide patients suffer from a mental illness:

• depression (most common)

• alcoholism

• schizophrenia.

Management

• Consider the possibility of suicide when dealing with mental illness.

• An open discussion with the patient of the risk of suicide is very useful, e.g. ‘Do you ever think life is not worth going on with?’ Most suicidal patients are grateful for this.

• Consider risk factors (see above).

• Try to establish the level of risk.

• Try to achieve a psychiatric diagnosis in simple terms: depression, psychosis, alcoholism, etc.

• Treat the underlying disorder:

– depression (see p. 292)

– alcoholism (see p. 310)

– psychosis (see p. 305).

• Avoid overprescribing large quantities of drugs when seeing patients in a depressed state. Drug overdose with recently dispensed antidepressants is common.

• Consider admission to hospital:

– via A&E if the patient has taken a drug overdose

– via a psychiatric unit, by voluntary or compulsory admission (see p. 307).

• Frequent follow-up of depressed or disturbed patients enables smaller quantities of drugs to be dispensed, is good clinical practice, and enables the GP more accurately to assess a rising suicide risk.

EATING DISORDERS

ANOREXIA NERVOSA

Anorexia nervosa is most common in upper social class women, between the ages of 15 and 25. It affects up to 2% in this group. The mortality is 5–10%.

Management

Admit the patient to hospital if:

• severe depression is present (see p. 292)

• weight loss has been rapid and persistent

• the weight is below 60% of normal for sex and height.

Compulsory admission may be necessary (see p. 307).

Ask about emotional difficulties with e.g. parents, peers, sexual partner. Discuss aspects of adolescence such as sexual maturation, leaving home, adult responsibilities.

Frequent follow-up is important if the patient is to be managed in general practice. Check C&Es. Consultations should include weight, BP and pulse, food intake and attitudes to food and weight gain. If amenorrhoea is prolonged, consider arranging bone densitometry (increased risk of osteoporosis). Less severe cases commonly resolve with time, encouragement and support. Consider referral to a psychiatric department or specialist eating disorder unit (if available).

BULIMIA NERVOSA

Bulimia nervosa is characterised by avoidance of calorie intake by vomiting or purgation after overeating in binges. It is difficult to diagnose as the weight is often normal and the behaviour secretive. Half of patients with bulimia have previously suffered anorexia nervosa.

Management

Management is as for anorexia nervosa (see p. 302).

DEMENTIA

About 5% of people over 65 have moderate to severe dementia. The majority of cases are due to Alzheimer’s-type or multi-infarct dementia. The prevalence increases with age.

Seventy-five per cent of patients with Alzheimer’s disease die within 2–4 years of diagnosis.

Diagnosis

History.

Dementia is characterised by slowly progressive deterioration in cognitive function:

• memory difficulties (particularly short-term)

• speech difficulties

• personality changes

• uncharacteristic behaviour

• loss of abstract reasoning.

These are often noticed first by a relative or neighbour.

There should be no change in conscious level.

Investigations (dementia screen)

• FBC and ESR

• C&Es, LFTs and glucose

• TFTs

• vitamin B₁₂ and folate

• VDRL (or equivalent).

Management

All new cases should be referred to a neurologist if the diagnosis is uncertain or unusual (for a CT brain), or to a psychogeriatrician, if available. The patient should be accompanied by a relative.

Long-term problems

• Depression: treat in the usual way (see p. 292).

• Aggression (see p. 305).

• Loss of driving licence: advise patient/relative to inform the Driver and Vehicle Licensing Agency.

• Wandering and other safety aspects: Medic Alert bracelet.

• Financial difficulties: suggest early application for enduring power of attorney (see solicitor).

Prescribing.

Treatment with major tranquillisers reduces the risk of self-harm:

• Agitation at night: e.g. promazine (Sparine) 25–75 mg on.

• Aggression: e.g. risperidone 1 mg od or bd.

• Nocturnal wakefulness: haloperidol 2 mg bd.

• Depression: (see p. 292).

• Sexual disinhibition: benperidol 0.25 mg od to 0.5 mg tds.

• Anticholinesterase inhibitors, e.g. donepezil or galantamine, may slow the progression of the disease and can be used in selected patients with moderate Alzheimer’s disease on specialist advice.

Administration

Quality and Outcomes Framework for Dementia

• Review the care of the patient with dementia once every year.

DISTURBED BEHAVIOUR

The GP may be called to attend a patient whose behaviour or speech is abnormal and characterised by delusions, hallucinations or acute confusion.

This behaviour may have:

• Psychiatric causes: e.g. schizophrenia, mania, depressive psychosis.

• Organic causes: e.g. acute infection, hypoglycaemia, head injury, brain tumour, encephalitis, drug side-effects, septicaemia, alcoholism.

Management

The first priority is to gain control of the situation. The patient may already be calm and willing to try and answer questions, but some patients may be aggressive or give the impression of being frightened and ready to strike out at the doctor. (For violent behaviour, see below.)

Sedation.

If sedation is necessary to gain control, the patient should be given haloperidol 10 mg im. The dose may be repeated up to three times if necessary.

Gain as much information as possible about the patient from a relative, the medical records, other health professionals, the community psychiatric nurse or receptionist, and obtain details of current medication.

Admission to hospital?

Consider admission if the patient is likely to self-harm or is a danger to others, or there is serious physical illness or an undiagnosed acute mental disorder.

The patient may not need admitting if there has been a gradual deterioration in mental function (e.g. dementia) or there is a minor physical illness (e.g. delirium due to fever of UTI).

Medical or psychiatric admission?

A patient with an acute psychiatric emergency should look generally well physically. There should be no suggestion of an acute medical problem and the predominant features of the illness should be a disturbance of thought or behaviour.

If the patient is unwilling to go into hospital, consider compulsory admission (p. 307).

Disturbed behaviour after psychiatric discharge from hospital may remain within socially acceptable limits. The community psychiatric nurse should review the patient regularly. Acute worsening of the patient’s condition will probably warrant readmission.

Administration

Quality and Outcomes Framework for Schizophrenia, Bipolar Disorder and Other Psychoses

• Review general health once a year.

• Achieve therapeutic lithium levels every 6 months.

• Check TSH and creatinine annually in lithium patients.

• Document an agreed care plan.

• Follow up non-compliers for annual review within 14 days.

VIOLENCE

Violence against doctors is increasing. It can be verbal as well as physical. Some violence is due to psychiatric illness, e.g. schizophrenia, or organic diseases, e.g. hypoglycaemia and cerebral events. Some patients are simply violent people.

Some hints for preventing violence

• Have a written procedure for dealing with complaints.

• Listen sympathetically. Do not get defensive.

• Avoid physical confrontation. Talk to the person firmly but calmly, and do not provoke them.

Tip

If violence is threatened in the surgery and the situation seems likely to escalate, call for help and telephone the police on 999.

If violence appears likely while on a visit, leave immediately. Call by telephone and tell the person you will only return to the house with a police escort.

After an episode of threatened or actual violence

• Record the details of the episode accurately in the notes.

• Discuss the events with your colleagues. Similar episodes with the same patient may be revealed.

• Removing a person from the practice’s list is the only way of guaranteeing safety for doctors and staff in the future. Inform the primary care organisation of your decision; they will contact the patient.

• Before removing a patient from the list, ensure there are no reasonable grounds to suspect an underlying illness to account for the behaviour.

• If a complaint was involved, inform your defence organisation.

• Consider criminal proceedings in cases of assault.

SECTIONING

The compulsory admission of a patient to hospital is most often used for suicide risk and acute psychosis. It allows the GP to admit a person, against their will, to a psychiatric unit under the Mental Health Act 1983.

Before seeing the patient

• Prior knowledge of the patient is useful. Obtain the GP records.

• Consider your own safety. Call the police if in doubt. See violence, p. 306.

• The patient may need sedating. Check you have a major tranquilliser, e.g. haloperidol 30 mg im.

Requirements of the Act

• The patient must be suffering from a mental illness, e.g. depression or psychosis, and not just be antisocial, drunk, etc.

• Admission is in the interest of the patient’s health or safety or to protect others, e.g. if there is a high risk of suicide or the patient is dangerous.

• Voluntary admission is preferred if possible.

How to organise a compulsory admission

• Telephone the duty psychiatrist to discuss the case and request formal admission.

• A psychiatrist, an approved social worker (ASW) and a doctor who knows the patient (usually the GP) each need to assess the patient in order to admit under Section 2 (28-day compulsory admission for assessment and treatment). Arrangements are usually coordinated by the ASW. If the GP is unable to attend, the ASW will ask for a Section 2-approved doctor.

• On the patient’s discharge from hospital, ensure that a suitable follow-up plan is in place.

Mental Health Act (MHA) 1983

Section 2: Admission for assessment and treatment up to 28 days.

Section 3: Admission for treatment for up to 6 months initially.

Section 4: Emergency admission for up to 72 hours.

Section 136: Removal from a public place to a place of safety by the police.

Administration

Complete the appropriate MHA form as arranging compulsory admission attracts a fee.

BENZODIAZEPINE ADDICTION

Many patients in general practice, especially the elderly, may have been on long-term repeat prescriptions for benzodiazepines.

Management

Patients who do not want to stop

• A patient’s commitment to stopping may fluctuate.

• Explain the risks as above and record the discussion in the notes. (Recent cases of litigation have made this more important.)

• Offer help with psychiatric problems.

• Try at a future date to encourage patients to stop, e.g. by including with their repeat prescription an invitation to discuss the issue with the doctor.

OPIATE ADDICTION

There are two new cases of opiate addiction per GP per year in the UK on average. The trend is increasing and there are higher rates in city practices. Opiate addiction is associated with a 20-fold excess mortality for age.

Diagnosis

History.

Opiate addiction presents in a variety of ways to the GP, but most commonly:

• The patient admits to drug abuse and wants help.

• The patient wants a prescription to prevent or treat withdrawal symptoms.

• Drug abuse complicates or leads to other medical conditions: pain, hepatitis, HIV, depression and suicide, sepsis, overdose.

Tip

Some addicts present with withdrawal symptoms in an attempt to gain a prescription for opiates or benzodiazepines. It is wise to resist, especially if they are not known to the GP and if this is the first consultation.

Take a history of drug use to distinguish between the intermittent drug misuser and the physically dependent addict. Validate the history, as necessary, by telephoning the patient’s usual GP and consultant psychiatrist.

Examination.

Examine for evidence of injection, hepatitis, sepsis.

Investigations

• Urine sample for drug screen.

• Blood tests for hepatitis B and C and HIV status.

Management

• Deal with any urgent medical problems not requiring a prescription for opiates or other psychotropic medication, e.g. sepsis.

• Offer a longer consultation within the next 2–3 days, to provide a more thorough evaluation of the problem, before deciding on long-term management.

• Patients requesting opiates may become aggressive if refused. The management of the aggressive patient is dealt with on p. 306.

• Counsel for HIV testing if appropriate (see p. 201). Offer hepatitis B immunisation (see p. 342).

• The occasional drug misuser may only need advice, support and referral to the local drug counselling service or self-help groups.

• Patients with a short history of drug abuse may require the above, but with prescriptions and advice on the treatment of withdrawal symptoms: Imodium for diarrhoea, clonidine for sweating and propranolol for anxiety.

Advice

• Offer continuing medical support for general health matters.

• Advise about not sharing needles, safe injection techniques and needle-exchange programmes.

• Advocate smoking rather than injecting.

Tip

For the established opiate addict a withdrawal programme should be devised, based on the gradual reduction of methadone. This should be provided by the local specialist in drug addiction, who determines the prescribing and follow-up schedule for the patient. Writing out the prescriptions can be shared with the GP.

Prescribing controlled drugs.

(For the main rules, see p. 319.)

Additional rules for addicts include:

• There should be a written contract from the specialist outlining the duration of treatment and rate of withdrawal. No extra drugs should be given. Lost drugs are the patient’s responsibility. The commonest drug used for controlled withdrawal is methadone.

• Discuss with the pharmacist or dispenser. Daily dispensing of the daily ration helps prevent the patient taking it all at once or from selling it. The prescription should be marked ‘daily supervised consumption’. This ensures that the patient has to consume each daily ration in front of the pharmacist and should be continued for the first 3 months of treatment or until compliance is assured. It is easier to use a blue FP10, as there is space for the pharmacist to record up to 14 daily doses dispensed. Dispense 2-days’ supply on Saturday if the chemist closes on the Sunday.

• Write ‘Methadone mixture 1 mg/ml’ on the prescription.

• Inform other GPs in the practice. Aim for care by one GP.

• Ongoing support from the drug counsellor is vital.

Tip

Dealing with drug abusers can be very difficult and specialist help should be sought early in most cases. As with tobacco and alcohol abuse, relapse is common.

ALCOHOL ABUSE

Alcohol abuse affects women as well as men, the elderly as well as the young, and all social classes. On a national basis the average GP will probably have 5–10 alcoholic patients per 2000 population per year.

High-risk groups include:

• publicans

• caterers

• members of the armed forces

• business executives.

Diagnosis

Alcohol abuse presents in a number of ways:

• a complaint from a relative or friend

• a request from the patient for help with drinking

• an incidental finding.

Examination.

If appropriate, look for:

• hypertension

• obesity/malnourishment

• encephalopathy (tremor)

• polyneuropathy.

Investigations.

Investigations are not always necessary. However, the following are useful:

• FBC for the macrocytosis of chronic alcohol excess

• γ-GT

• LFTs

• urine to screen for other drugs.

Management

Crisis intervention.

Occasionally the patient presents with an acute medical or psychiatric problem due to alcohol abuse:

• Severe depression: there is a high risk of suicide in this group of patients. Admit to a psychiatric unit, by compulsory admission if necessary (see p. 307).

• Acute withdrawal complications, such as fitting, atrial fibrillation and delirium tremens: admit under the medical team.

• Acute complications of chronic alcohol abuse: these include pancreatitis, hepatitis, bleeding oesophageal varices and encephalopathy. Admit under the medical team.

Tip

As alcoholism is not considered to be a psychiatric disease by itself, any treatment given must be with the consent of the patient. Often the cry for help comes from the spouse, in which case try to support the spouse also.

Planned intervention

Detoxification

• Establish the patient’s motivation to detoxify.

• Underline to patients that they are responsible for their drinking and for the success of the detoxification.

• Refer for inpatient detoxification if any of the following applies:

– history of withdrawal fits or delirium tremens

– there are coexisting medical problems

– any psychiatric condition

– inadequate domestic support

– misuser of other drugs.

SMOKING

Smoking is now recognised as an addiction treatable at the expense of the NHS.

Treatment should be offered to smokers who express a desire to quit, and should form part of an advice and encouragement programme.

NRT (nicotine replacement therapy) and bupropion are two forms of treatment available on the NHS.

Formulations

• Nicotine skin-patches, gum, lozenges, sublingual tablets, inhalators or nasal spray.

• Bupropion tablets. Generally, patients should be prescribed bupropion only after unsuccessful attempts at quitting with NRT.

Contraindications

• Age under 15 years.

• Unstable cardiovascular disease.

NRT patch

Choosing a patch.

Smokers of over 20 cigarettes a day need the strongest patch to start with; smokers of 10 cigarettes or less a day can start with the medium-strength patch. Smokers who start smoking first thing in the morning need a 24-hour patch (e.g. Nicotinell or NiQuitin); later starters can use a 16-hour patch (Nicorette).

Using the patches.

Prescribe 3 weeks supply on an NHS prescription and get the patient to set a quit date. The patient stops smoking on the quit date and uses one patch every day. If they are still abstinent after 3 weeks then a further prescription for 3 weeks can be issued. Each brand of patch has its own schedule for dose reduction and total duration of use.

Bupropion

Bupropion is prescribed on the NHS for 4 weeks initially and a further 4 weeks if abstinence is maintained. The patient’s quit date is set for 2 weeks after the medication is started. The starting dose is 150 mg a day, increased to 150 mg bd after the first 6 days. Avoid bupropion if there are risk factors for seizure.

Further attempts to quit using NRT or bupropion should not be funded by the NHS within 6 months.

Each practice should have access to a lead person in smoking who can offer support to patients attempting to quit. Practice nurses and health visitors are valuable resources in this role.

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