Psychiatry and psychological medicine

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chapter 40 Psychiatry and psychological medicine

INTRODUCTION AND OVERVIEW

Psychiatric disorders are highly prevalent. Depressive and anxiety disorders occur in up to 25% of primary care patients.1 The World Health Organization Global Burden of Disease Project (cited in Davies 20002) identified that psychiatric illnesses in developed economies account for over 20% of years of life lost through premature mortality and years lived with a disability. The economic impact is enormous in direct costs to the healthcare system and indirect costs to the community.

The National Survey of Mental Health and Wellbeing found a one-year prevalence of 20% of adults surveyed with a psychiatric illness and noted that, while only a third of those suffering from a psychiatric disorder sought treatment, most of those presented to their general practitioner (GP). Indeed, of patients who seek help for their psychiatric symptoms, 75–90% see a GP.4 A GP seeing 40 patients a day could expect that eight would require support or treatment for anxiety or depression.5

Given the size of the problem, it is clearly beyond the scope of this chapter to do more than provide a framework for the GP in the assessment and understanding of patients who present with psychiatric disorders, and then to briefly describe the management of some of the conditions that present in general practice, emphasising high-prevalence disorders.

The most common psychiatric disorders presenting to GPs are depression, anxiety, adjustment disorders, and alcohol abuse and dependence (dealt with in Ch 62). The prognoses of anxiety, depression and psychotic disorders are all improved by early detection and intervention, and so the GP’s role is pivotal in improving the level of functioning and quality of life of their patients. The GP is uniquely positioned to assess psychiatric symptoms, because they will have often seen a patient over an extended timeframe and so will have access to information about the patient and their premorbid functioning.

OBJECTIVE OF THE CONSULTATION

With every patient there are three questions that the GP is endeavouring to answer:

• What is wrong (or what is the diagnosis)?
• Why did whatever is wrong with the patient go wrong with them?
• What are we going to do about it (treatment approach)?

Like any other branch of medicine, to answer these questions requires an adequate history and examination, followed by the GP using the information and data available to answer the above three questions.

PSYCHIATRIC HISTORY

A standard psychiatric history requires information in a number of categories. Although, obviously, in general practice it is difficult to obtain all the information, much of the history may already be known.

A psychiatric interview includes:

• demographics
• presenting complaint (including current symptoms)
• past history (both medical and psychiatric)
• medication and medication history
• alcohol, cigarette and drug history
• forensic history
• family history
• developmental history and personal history
• premorbid personality
• level of functional impairment.

The interview is described in most psychiatric texts, including Foundations of Clinical Psychiatry.6

EXAMINATION

Both a mental state examination and a physical examination are indicated.

MENTAL STATE EXAMINATION

Unlike the physical examination, the mental state examination occurs throughout the consultation, as the patient’s emotional, behavioural and thinking states are observed by the GP. It helps to make notes about the patient’s mental state throughout the interview, particularly in noting affective changes and any thought disorder.

• Appearance and behaviour—describe what is observed.
• Speech—describe the quality and process of speech, which can range from mute, to the slowed speech of psychomotor-retarded depression, to the very rapid and pressured speech of mania.
• Affect—observe the patient’s emotional state during the interview, noting fluctuations and whether it is congruent or incongruent with the content of the conversation. For example, the tearfulness of a patient describing the recent death of their parent would be mood congruent.

In patients with schizophrenia or post-traumatic stress disorder, affect is sometimes blunted, with a reduction in the intensity that would normally be anticipated. For example, a patient may say he or she is being watched by aliens in a rather ‘matter of fact’ fashion, in contrast to the extreme level of agitation and anxiety you would expect were such a delusional belief to be true.

• Thought process—does the history flow in a normal conversational fashion? Manic thoughts are so fast that the conversation appears to take jumps, and there appears to be little connection between sentences. In schizophrenia the conversation may not be understandable. It is difficult to recall such disorganised thought unless you have recorded it at the time.
• Thought content—thought content includes the depressed themes of depressive disorders, the nihilistic delusions and descriptions of hopelessness, helplessness and guilt in psychotic depression, and the ruminations of obsessive compulsive disorder. The delusional beliefs of psychosis are described here, as is suicidal or homicidal ideation.
• Perception—perception most commonly relates to auditory hallucinations, although all sensory modalities can be involved.
• Cognitive testing or cognition—assessment of a patient’s cognition is an important aspect of a mental state examination and a number of commonly used instruments are available, such as the mini-mental state examination (MMSE).7 If a patient has come to the appointment on their own and on time, their cognition is probably intact. The MMSE is particularly important where there is a history of alcohol abuse or when dementia-like disorders are suspected.
• Insight—probably the most practical assessment of insight is whether the patient believes they have an illness that is treatable and is amenable to such treatment.
• Judgment—judgment is best assessed by asking what the patient plans to do next. For example, a patient with depression who plans to resign because they believe they are hampering their employer’s business opportunities probably has impaired judgment.

For further details about mental state examination, see The psychiatric mental state examination by Trzepacz and Baker.8

HINTS TO ENHANCE A PSYCHIATRIC CONSULTATION

• Set aside time—in an often busy consulting day it is sometimes difficult to take the time to elicit psychiatric symptoms, and so if suspicious of psychological symptoms, making arrangements for a longer consultation is a priority. It is important to keep interruptions to an absolute minimum and ensure privacy.
• Opening the interview—psychiatric interviews are usually best started with neutral subjects such as details of current circumstances, while listening with an empathic ear and observing the patient’s emotional and behavioural responses. Gentle encouragement, such as asking the patient, ‘What do you mean?’ or perhaps repeating the patient’s last phrase as a question, can help to clarify symptoms. For example, if a patient has described feeling very sad, the GP might say, ‘You mention that you have been feeling really sad—have you ever thought that life is not worth living?’.
• Summarise back to the patient—it is helpful to reflect back to the patient the history that they have given to you and also to clarify whether you have correctly identified relevant features of the history.
• Concluding the interview—it is often useful when completing any patient interview to ask if there is anything they believe to be important that has not yet been raised.

COMMON INTERVIEW DIFFICULTIES

Most interactions with patients are relatively straightforward; however, sometimes difficulties arise. Some of these are discussed below.

• Lack of trust—trust is essential in any successful interaction. Usually a patient is seeing a GP who they already trust; however, if it is evident that the patient is not being open, tact and reassurance are required, as is the ability to tolerate deficits in the history.

Possible reasons for a lack of trust are suspiciousness due to developing persecutory ideation, embarrassment about things they have either done or imagined doing, or believing that emotional symptoms reflect a weakness of character.

• Tearfulness—in the context of a busy general practice, an emotionally distressed patient presents a challenge. However, such demonstrations of emotional distress can be usefully reflected back to the patient, such as saying, ‘I can see this has been very upsetting for you’.
• Anger and hostility—aggression and anger can be prejudicial to an effective interview. Management of anger and hostility will be discussed later.
• Over-familiarity—some patients, particularly those with maladaptive personality styles, require the GP to be on their guard. It is important not to take compliments at face value—for example, when a patient says that they have finally found someone who understands them.

DIAGNOSIS

(or: What is wrong with the patient?)

While patients and healthcare professionals want to know the ‘diagnosis’, it is important not to be lulled into a false sense of understanding. In psychiatry, a categorical classification diagnostic system is used, most commonly the Diagnostic and Statistical Manual of Mental Disorders (DSM IV-TR).9 Such a diagnostic system has a number of benefits, including enhanced communication between professionals and facilitating evidence-based research.

However, a categorical classification system does not have a dimensional capacity and patients with symptoms that do not meet the full criteria for the application of a label can often have marked distress and significant functional impairment. In some ways the use of such a labelling system is akin to a patient presenting with a sore throat and, after a thorough examination, being diagnosed with ‘sore throat disorder’. Diagnostic labels are useful as long as these limitations are recognised and with an awareness that they often change over time as more becomes known about the patient’s symptoms.

FORMULATION

(or: Why did whatever is wrong with the patient go wrong with them?)

Why is the patient here with these symptoms at this particular time? It is the formulation that reflects the integrative nature of psychiatry. It reflects the complexities of a biological, psychological and social paradigm.

It may help to conceptualise patients as being like a three-legged kitchen stool. One leg of the stool represents the biological brain, the second leg represents their psychology (the way they think, process and react to things) and the third leg represents the world in which they live. There is no such thing as a patient whose presentation does not reflect the complexity of the abovementioned stool.

The biological perspective includes family history and any genetic vulnerability. Previous episodes increase the risk of subsequent episodes. Medical illnesses, concomitant medication and substance use and abuse can also influence the reason for a patient presenting.

From a psychological perspective, the developmental history may suggest vulnerabilities. Personality style, coping strategies (both adaptive and maladaptive), loss issues and the patient’s patterns of thinking and behaviour also help understanding.

Also, patients live in a real world with relationships and concerns that need to be taken into account in understanding them. For example, it is more difficult to treat a depressed woman with antidepressants and psychotherapy if she is in a violent domestic relationship.

TREATMENT

(or: What are we going to do about it?)

Treatment is predicated on the abovementioned biological, psychological and social understanding. It requires use of evidence-based interventions targeting the biological brain and the psychological make-up of the patient, and taking into consideration the realities of their environment. The rationale for the three-legged stool metaphor is that a treatment intervention failing to address one or other dimensions is unlikely to be successful.

It is this that makes psychiatric presentations a paradigm of the integrative approach itself, in that the whole of the person, in all their dimensions, needs to be considered in order to treat symptoms, maximise function and enhance quality of life.

PSYCHIATRIC EMERGENCIES: RISK TO SELF AND OTHERS

Before dealing with some of the common conditions in general practice, suicide and violence will be addressed.

SUICIDAL PATIENTS

Managing a suicidal patient is highly stressful. Suicide is not random or pointless but, rather, a way out of a problem or a crisis that is invariably causing intense suffering.

Suicide was the eleventh leading cause of death in the United States in 2006.10 An estimated 12–25 suicides are attempted, for every suicide death.11 Recently the suicide rate in Australia has decreased, but it continues to be a significant problem. Since 1990, more male deaths in Australia have been attributed to suicide than to non-intentional motor traffic fatalities. The overall rate has remained relatively stable, at 11 per 100,000 of population per year in the United States and Australia. It is a rare occurrence with a very low base rate, while each of the risk factors is common. This makes prediction and prevention of suicide a difficult task. The majority of patients who suicide have seen their GP in the month before.12

Risk factors for suicide

The most significant risk factor for suicide is previous attempts. Other risk factors are:

• sense of hopelessness
• age—risk rises with age; peak in males is between 15 and 24 years
• gender—males are much more likely to suicide than females, in a ratio of about 4:113 (young women have an increased risk of self-harm compared with young men)
• marriage/partnered status—risk is increased for those who are separated, divorced, widowed, single or living alone
• unemployment and retirement
• physical illness
• psychiatric disorder—the risk is significantly higher than in the general population in patients with severe major depressive disorder, bipolar affective disorder, schizophrenia or borderline personality disorder
• current relationship difficulties
• history of sexual abuse
• availability of means (e.g. firearms in the home)
• alcohol and other substance abuse
• incarceration.

Suicide assessment

The most important aspect of management is to ask. Initially this can be relatively indirect—for example, ‘Does it ever seem that life is not worth living?’. Then ask more directly. There is little evidence that asking about suicide gives the idea to the patient—indeed, current popular culture mentions suicide in both literature and music. But be prepared to follow up the question with a discussion of alternative solutions to the person’s problems.

Assess the plans, intention or organisation of the suicide plan. Ask about future activities. Document things they plan to do in the next few weeks. Assess underlying psychiatric disorders.

If the patient is suicidal but wanting help, it may be possible to manage them at home, provided they have social supports. Alternatively, they may agree voluntarily to be assessed by public or private psychiatry services.

If concerned about the person’s safety, use the appropriate local mental health legislation to ensure that the patient is first and foremost given ‘asylum’ and assessed by a psychiatrist or crisis team.

VIOLENCE AND AGGRESSION

Aggression is a major problem in society today, and dealing with it is certainly one of the most difficult tasks facing GPs. Management begins with treating the aggression first.

Aggression may be adaptive and may be triggered by environmentally appropriate and highly specific stimuli. It may be a normal reaction to a realistic threat, or a maladaptive reaction. It may be out of proportion to the stimuli or aimed at unrealistic or inappropriate stimuli. It may be impulsive or uncontrolled and it may be non-specific.

Violence, like suicide, is very difficult to predict. The most robust risk factor is a history of violence. Fear of violence by psychiatric patients probably contributes to societal stigma. Patients with depression and anxiety are probably less dangerous than the general community; patients with schizophrenia have a risk of violence approximately equal to that in young men in the general population. Dementia patients also have an increased risk of being violent towards their carers.

While psychiatric disorders alone are a poor predictor of violence, some psychiatric disorders have a higher risk. These are:

• delirium and acute brain syndromes
• psychotic and related disorders
• personality and related disorders
• alcohol and drug intoxication/withdrawal.

Risk factors

Risk factors for violence/aggression are:

• statement of intent
• specific plan
• means
• male
• youth
• history of violence and antisocial acts
• low socioeconomic status
• poor social support
• recent psychosocial stress.

Mental state assessment of aggressive patients

Formal testing is usually not possible. General appearance can be noted, as can the level of behavioural activity. The mainstay of the mental state assessment is to determine whether you can establish adequate communication with the patient.

It may be possible to determine the intellectual level of the patient, their mood state, emotional control, reality orientation, presence or absence of intoxication or withdrawal and potential for insight.

Management of potentially violent patients

• Keep yourself safe.
• Know of past violence.
• Be alert.
• Assume that aggression is possible.
• Keep the environment safe. (Don’t have objects that could be used as weapons easily accessible.)
• Keep a safe distance.
• Have an escape route and help at hand.
• Trust your instincts—if you feel afraid, make any excuse to leave the room.

Approaching an aggressive patient

People who are aggressive or angry tend to cause us to feel angry. It is important to control your anger or fear, and demonstrate respectful control of the situation. To that end, try to understand where the patient ‘is at’, using a non-aggressive stance.

• Recognise the patient’s fear and insecurity, but show that you are in calm control.
• Set appropriate limits. For example, accept that the patient may be talking loudly but tell them that you want to listen to them and are unable to do so when they shout.
• Admit that you feel fearful or concerned.
• Be humane and respectful, recognising that the aggression has an underlying meaning. Nevertheless, the patient needs to know that violence is not acceptable.
• Avoid making outright refusals or concrete promises. Rather, establish that decisions may be able to be made once the situation has calmed down.
• If aggression is related to a specific situation or person, try and separate them.
• Restrict access to weapons.
• There is no place for heroics.
• If there are identifiable potential victims, the duty to warn them takes priority over confidentiality.
• Treat mental disorders, possibly using mental health legislation.
• If there is no evidence of a mental disorder, ask the person to leave, and if necessary call the police.

The rest of this chapter briefly discusses some of the more common disorders presenting in general practice.

DEPRESSION

Up to 10% of people who see a GP have depression, often with anxiety. Patients with depressive disorders can present with a range of symptoms that may or may not fulfill the criteria for a label of major depressive disorder, but patients with a severe depressive syndrome always have anhedonia (loss of interest in usually enjoyed activities).

Other neurovegetative symptoms include insomnia, often with early-morning wakening, diminished appetite, diurnal mood variation, impaired energy and motivation, diminished libido, and poor memory and concentration. Patients will often describe a sense of hopelessness, helplessness and guilt. With hopelessness it is important to ask whether the patient has plans for the future. An absence of such plans increases the suicide risk.

General practice patients often present with comorbid physical illness. It is not always easy to identify symptoms of depression in the context of physical illness.

Particular patient groups with an increased risk of depression include:

• chronic illness
• central nervous system illnesses (stroke or Parkinson’s disease)
• pain and fatigue syndromes with no clear diagnosis
• the elderly
• people living alone
• comorbid substance abuse, including alcohol and amphetamines
• postpartum women
• recent losses
• transitional changes
• adolescents with behavioural changes.

INVESTIGATION

In the vast majority of patients with depression there is no underlying medical explanation. However, there are a number of neurological and medical causes of depression symptoms. These include thyroid disorders, Parkinson’s disease, malignancies, infections such as infectious mononucleosis, rheumatoid arthritis and sleep apnoea. If the history and examination suggest it, then appropriate investigations may be indicated. These can include thyroid function tests, complete blood picture, electrolytes and brain CT scan.

If the depression proves to be treatment refractory, investigations need to be considered.

It is important to review pharmacotherapy, as a number of drugs can cause depression symptoms. There are many of these, including indomethacin, griseofulvin, tetracyclines, beta-blockers and levodopa.

SCREENING INSTRUMENTS (DEPRESSION AND ANXIETY)

General practice is busy, and GPs have substantial time constraints. Patients presenting to GPs with depression will commonly complain of somatic symptoms rather than emotional symptoms. These can include joint pain, headache, fatigue, muscle aches, gastrointestinal upset and dizziness. This probably reflects the fact that patients perceive that doctors are mostly interested in their physical complaints, as well as the reality that it is probably easier to articulate physical symptoms than psychological ones.

The use of screening instruments in these patients can be a helpful way of identifying the level of psychological distress and possibly the need for intervention, and also set a baseline measure.

Questionnaires like the Depression Anxiety Stress Scales (DASS, developed by Lovibond SA and Lovibond PF) or the SPHERE can be helpful. (The DASS and SPHERE instruments can be obtained from the web addresses in the Resources list at the end of this chapter.)

But the GP’s clinical impression is still the primary assessment tool. And don’t forget that asking, ‘Are you feeling depressed?’ works.

TREATMENT

As the causes of depression arise from a wide range of biopsychosocial factors, the integrated management of depression needs to attend to all these factors if it is to optimise outcomes. An over-reliance on any one aspect of patient care to the exclusion of the others risks inadequate management or mismanagement of the mental health problem. For example, the management of mental health problems is often overly reliant on pharmacological strategies alone, sometimes marginalising the importance of psychological strategies, other potential therapies and lifestyle factors. Conversely, if a patient with severe mental health problems were to be denied the use of pharmacological therapies because of personal or practitioner preferences, there would be a greater risk of sub-optimal outcome for the patient. Therefore, any holistic management strategy will not be an either/or approach but will use all safe and effective therapies available and tailor them according to the patient’s needs and wishes. This section therefore presents a range of possible strategies from which the clinician can draw, starting with general and supportive measures such as lifestyle management and psychological approaches, which should be included in the management of all patients, and then considering the rational and judicious use of pharmacological and other therapies.

Mental healthcare

Lifestyle management: the ESSENCE model

Education

Psychoeducation is essential. It is helpful to explain the physiological basis of symptoms, and to discuss the high prevalence of depression and that it is not a ‘personality weakness’.

Stress management

While many theories about the psychological understanding of depression exist, and proponents of different psychological theories claim effectiveness in depression, in general practice the therapy with the widest utility and best evidence for efficacy is cognitive behaviour therapy (CBT).

People develop particular ways of thinking about the world that may or may not predispose them to the development of psychological symptoms. CBT endeavours to elucidate the negative thoughts people have when they are evaluating the events that occur in their lives, and helps them to learn more constructive ways of evaluating the event. It also seeks to use behavioural approaches to help improve functioning, develop skills and overcome behaviours such as avoidance, which often reinforce unhelpful thought patterns.

For example, a ‘perfectionistic’ patient may believe that only doing things perfectly is adequate and that anything less than perfect is a failure. While this thinking style can be adaptive—for example, an accountant needs the books to balance—a patient may find that with a new baby she is unable to control the baby’s sleeping, eating and punctuality, and consequently believes that she is a failure as a mother, which may precipitate a depressive episode.

Cognitive therapy is a guided process whereby patients learn to recognise links between their emotions and thoughts, evaluate the evidence supporting their initial thoughts, and then find alternatives.

For example, a depressed patient may expect a telephone call from a friend. When the call doesn’t occur, they personalise this, thinking, ‘My friend no longer likes me. I must have done something wrong’, which exacerbates their depression. Cognitive therapy helps the patient to recognise that the escalation of depression symptoms is related to their thoughts and to find alternative explanations, such as that their friend is forgetful or may have had another appointment or perhaps has a faulty telephone. The intensity of the psychological symptoms is reduced. And the patient develops a sense of power over their emotions.

CBT is available from trained GPs, psychologists and psychiatrists. There are also internet-based programs, including Mood Gym and Climatetv (see Resources list).

Despite its attractiveness, CBT does not suit everybody. Some patients want a therapist who will do the work for them. It can be useful to give a patient some reading homework (such as a rationale of CBT). If, two weeks later, they say they haven’t had time to read it, the task can be reset. If at the next appointment they still haven’t read it, they probably won’t take an active role in therapy and it is likely to be unsuccessful. A more behavioural approach might be indicated in such patients.

Behavioural therapeutic interventions for depression, while easier to recommend than cognitive approaches, are nevertheless not always easy to implement. A range of CBT-based strategies can be used, including structured problem-solving, anger management and assertiveness training, interpersonal therapy and activity scheduling. It is beyond the scope of this textbook to outline these approaches in detail but these strategies can be easily learned by GPs, and can increase the range of options available to suitably trained and motivated GPs in the primary care management of mental health problems.

Managing insomnia is also vital for managing mental health problems, particularly depression. In fact, some patients with depression will find that their depression resolves if they use and maintain effective behavioural strategies for improving sleep.14

The other approach to therapy that is gaining particular attention among medical practitioners and psychologists alike is the mindfulness-based approach. Originally pioneered in the health setting by Jon Kabat-Zinn’s mindfulness-based stress reduction (MBSR), mindfulness has made a transformation from a complementary to a mainstream approach within a relatively short space of time. This has been driven in large part by recent research particularly in the fields of mental health and neuroscience.

Psychologists Teasdale, Williams and Segal took the work of Kabat-Zinn a step further when they used mindfulness principles to underpin a new approach to cognitive therapy—mindfulness-based cognitive therapy (MBCT). Other variations of mindfulness-based approaches include dialectical behavioural therapy (DBT), acceptance commitment therapy (ACT) and the Stress Release Program (SRP).

MBCT has been shown to significantly reduce depressive relapse.15,16 Mindfulness, as opposed to conventional cognitive therapy, does not seek to change the content of thought but instead seeks to change the relationship a person has to their thoughts (and emotions and sensations also).17 When, for example, we experience a thought, emotion or sensation that we dislike, our habitual reaction is to become highly judgmental of it and therefore to try and suppress it or become reactive to it. Experience, however, teaches us that the more reactive we become to an unpleasant experience, the more it monopolises our attention, thereby accentuating its impact. Furthermore, through habitual rumination, particularly about the past and the future, we create or replay stressors and negative situations, often without realising that we are doing it. Therefore, through cultivating a greater capacity to focus on present-moment reality, and by fostering meta-cognitive awareness (the capacity to objectively stand back from one’s thoughts and just see them as events, rather than facts), people with anxiety and depression can more fully engage with life (through greater focus on the present moment), undo the tendency to amplify the impact of unpleasant experiences and minimise the unconscious tendency to ruminate.

The various approaches to mindfulness-based therapies are based on mindfulness meditation. It is important to recognise that mindfulness meditation is not a distraction; quite the opposite. It is a mental discipline used to help train the capacities and cognitive insights that will help the person to undo the processes driving their depression or anxiety for the vast majority of the day when they are not meditating.

Another area where mindfulness is proving important is in the training of healthcare professionals. It has been found not only to reduce burnout and improve general wellbeing, coping and mental health among medical students and doctors,18,19 but also to assist in the development of communication, empathy and emotional intelligence.20 Overall, mindfulness-based approaches seem to be extremely safe.21

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