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 Caution should be exercised when using mindfulness with patients with a history of psychosis. It should only be used in remission, if at all, and only by experienced practitioners. It may also be better not to try to commence mindfulness therapy for people with acute and severe depression and anxiety. Generally it is better to wait until the person has stabilised to some extent before commencing mindfulness therapy. People should also be cautious in doing intensive or prolonged practice when new to the approach.

Spirituality

Having an active search for meaning, including having a religious or spiritual dimension to one’s life, appears to be protective against mental health problems.22,23 It can also help a person to recover more quickly or to cope better if mental health problems do arise.

Exercise

Regular exercise has antidepressant benefits and should be recommended to all patients with depression.24 A strategy is to write a prescription for a 30-minute walk, five days per week. Being written on a prescription pad can increase the patient’s perception of the treatment’s validity, and encouraging them to walk with a friend can help them commit to the activity.

In order for exercise to be a successful intervention for mental health problems it needs to be done regularly. Unfortunately, finding and maintaining motivation to undertake a regular exercise program is a major challenge for many people with depression and anxiety. For these people, encouragement, structured programs, regular guidance and exercising with the support of others is very important and can be instrumental to the success of any exercise-based interventions. Exercise is a powerful, accessible and attractive approach that is ideal for adolescent depression, and it can be effective at any age. Physical exercise also provides help for a range of symptoms associated with depression, including lack of vitality and concentration, as well as improved physical health outcomes.25

Elevation of mood is universally seen with various exercise programs, independent of disease; however, aerobic exercise appears to be most effective in improving mental health. A number of studies have demonstrated that regular physical exercise results in mood elevation in both healthy and clinically depressed people. A large proportion of these studies have reported antidepressant and anxiolytic (anxiety-relieving) effects of exercise.26 Higher-intensity exercise seems to be more effective than low-intensity exercise. Exercise has also been useful in the management of alcohol and substance abuse, which commonly accompany mental health problems. The mechanism of action in depression and anxiety is not completely clear, but some of the likely mechanisms include:

• increased cerebral neurotransmitters, such as serotonin27
• improvement in sleep and help with insomnia28
• increase in self-esteem by giving a sense of achievement and mastery
• acting as a therapeutic distraction to reduce rumination about worries and concerns
• improvement in general health, vitality and physical fitness
• release of pent-up anger, frustration and hostility
• increase in social engagement, particularly in team sports
• reduced need for medications associated with depression (e.g. beta-blockers, sedatives).

Nutrition

Nutrition has not generally been thought of as a core element in the management of mental health issues, but it should be. Poor nutrition can play a causative role in some patients’ mood changes, or may exacerbate symptoms if left unaddressed. For example, adolescents in the lowest quintile of diet quality have an odds ratio of 1.79 for developing depression, compared to those in the highest quintile for diet quality (e.g. whole food, balanced, adequate fruits and vegetables, not calorie dense).29 Unfortunately, for many people food is a source of loathing and guilt, especially when one is dealing with eating addiction or eating disorders, or is locked in a pitched battle to control weight. Before considering the particular foods that might be useful for mental health, it is important to remember the following:

• Food is to be enjoyed.
• The foods found to be beneficial for depression or anxiety may be helpful for other mental health problems including bipolar disorder and schizophrenia.
• Some foods have a therapeutic effect on depression and anxiety, but others will also be important in offsetting some of the symptoms and physical health-related problems associated with poor mental health.
• Mental health is a complex, multifactorial area of health, and diet is one piece of the jigsaw.

The Medical Journal of Australia reviewed the evidence regarding the direct effects of food on mood and drew the following conclusions:30

• Eating breakfast regularly leads to improved mood, better memory, more energy and feelings of calmness.
• Eating regular meals and nutritious afternoon snacks may improve cognitive performance.
• Slow weight reduction in overweight women can help to elevate mood.
• High levels of refined sugar consumption were found to be linked to a greater prevalence of depression.

Food and depression

The role of nutrition in the management of depression is currently far from mainstream, but the GP needs to consider its use on the back of a growing body of research and an increasing interest among patients wishing to self-manage mental health problems. A few examples of the role of food for the management of mental health problems are given below, with the caution that this is still a relatively new field and should not replace the use of other psychological and pharmacological therapies when they are indicated.

One key study31 conclusively showed that low dietary intake of fish and seafood is associated with higher incidence of depression. Omega-3 fatty acid supplementation reduces symptoms of depression in unipolar and bipolar mood disorders.32 Regular omega-3 fatty acid consumption is associated with a 30% reduction in risk of mental health problems.33

Chocolate has now been confirmed as a food that improves mood, but probably only in the short term.34 It does not seem to be so useful when consumed in excess as a comfort food rather than in moderation. Dark chocolate is preferable.

High levels of saturated fat consumption may be linked to a greater prevalence of depression.35

Supplements

Some specific nutritional supplements show promise as therapeutic agents that should be considered in depression, although, as with other categories of illness, a nutritionally rich diet is far more beneficial than a poor diet boosted with nutritional supplements.

• Folate—it has been estimated that 15–38% of depressed people also have a folate deficiency.36 Dietary folate below median,37 low folate and a MTHFR C677T genotype are all independently associated with increased risk of depression.38 There is evidence of a reduced response to fluoxetine with declining folate levels.39 Preliminary studies have also shown it to be useful in the treatment of major depressive disorders.40 Food sources include tomato juice, green beans, broccoli, spinach, asparagus, okra, black-eyed peas, lentils, navy, pinto and garbanzo beans. Dose: 500 μg/day.
• SAMe (s-adenosyl-L-methionine)—400–1600 mg daily may raise levels of the brain chemical dopamine. Meta-analyses have concluded that SAMe is superior to placebo, as effective as tricyclic antidepressants, and better tolerated in the treatment of depressive disorders, but may have significant side effects.41,42 SAMe is not to be taken without medical supervision. The body usually manufactures all the SAMe it needs from the amino acid methionine, which is found in ordinary dietary sources such as meats, soybeans, eggs, seeds and lentils.
• Foods high in B vitamins, particularly B6, have long been thought to help with prevention of depression. Foods rich in a range of B vitamins include potatoes, bananas, lentils, chilli peppers, tempeh, liver, turkey, spinach, broccoli, mushrooms and tuna.
• 5-HTP (5-hydroxytryptophan)43 is an amino acid that is used to make serotonin and melatonin, and can enhance mood and sleep. Foods that contain the amino acid tryptophan can help raise levels of 5-HTP. Such foods include red meats (beef, pork, lamb and wild game), poultry (chicken and turkey) and seafood (tuna, salmon, halibut and shrimp), as well as cottage cheese, Swiss cheese, peanuts, cashews and avocados. Vitamin C assists in the production of 5-HTP and is an excellent antioxidant. 5-HTP, 100 mg three times per day, may also help. Caution must be exercised, as combination with antidepressant medication may cause serotonin syndrome.

Food and anxiety

Much of the nutritional information on depression applies for anxiety also. During times of anxiety and increased stress (high allostatic load), there are greater demands on the body’s nutrients. They are used more rapidly to meet the increased biochemical needs of metabolism, and so there is an increased need for many nutrients.

One particular aspect of the stress placed on the body is an increase in oxidation and free-radical production, and so antioxidants are an extra important part of the diet. Licorice also provides adrenal support and can help as an antioxidant.44 There is some evidence to suggest that omega-3 fatty acids may also reduce symptoms of anxiety.45

Magnesium46 is a mineral with many uses in the body, including relaxing tense muscles, maintaining normal nerve function and cardiac rhythm, and helping to maintain stable blood sugar levels and immune function.

As in depression, the B vitamins47 are considered helpful in general, but B6 seems to be particularly important. Vitamin B6 can be found in potato, banana, chicken breast, sunflower seeds, trout, spinach and avocado.

Hypoglycaemia can make an anxious person feel more anxious, because there are similarities between some of the symptoms associated with each. This can be avoided by eating regularly (possibly every 3 hours) and snacking on healthy low-GI foods. Ensure adequate fluid intake.

Removing stimulants from the diet is important for many patients, as these can add to the level of anxiety. Typical stimulants include coffee, tea, chocolate and caffeine-based soft drinks. Coffee and other caffeine-containing foods increase alertness but can increase heart rate and aggravate agitation and depression, which is particularly important to note in relation to the increasing numbers of adolescents attempting to use caffeine as a mood-enhancing drug.48

Connectedness

Relationships, upbringing and social circumstances profoundly influence the way we think and cope, and this can sensitise a person to the development of depression or anxiety disorders later in life. Social isolation, relationship break-up, educational status, disadvantage, unemployment and socioeconomic conditions can all influence one’s susceptibility and response to mental health problems.

The sub-cultures we identify with in society and the music we listen to can create an atmosphere that is therapeutic or reinforces depression and anxiety.

The importance of supportive and stable relationships (e.g. marriage, family and friends) cannot be over-emphasised. Consciously seeking and nurturing such relationships has a flip-side in that patients may need to be prepared to leave behind those relationships that consistently undermine their efforts at growth.

Connectedness is also nurtured through community engagement and involvement with groups such as clubs and interest groups. Attending these can be therapeutic in itself, apart from any other benefits. Connectedness and support can be fostered in other ways as well, including via healthcare professionals, support groups and group therapy, and via information technology (IT). There are increasing numbers of IT-based mental health interventions that provide information, self-help strategies and links to healthcare interventions. Connectedness and support will not only have a beneficial effect on mood and self-esteem but, depending on the group, can also help to support us in making other healthy changes such as improving diet or exercise.

Developing a regular, structured activity schedule with regular pleasurable activities is a most useful strategy for patients with depression. Explaining to patients with symptoms of depression that developing a structured day has significant antidepressant benefits can be significantly empowering to a patient. Listed websites and books such as the Management of Mental Disorders (WHO; see Resources list) have easy-to-follow instructions on how to do this.

Patients often have difficulty being motivated. In mild to moderate depression, it is helpful to encourage the patient by explaining that feeling like doing something will often come after doing it, and that this is preferable to waiting until we feel like doing something before doing it.

Environment

Environment can have a range of beneficial or deleterious effects on emotional state. It is not hard to observe the effect of a sports crowd on mood, or the effect of a beautiful garden or park. It is hard to maintain good mental health if one lives in a war zone, and living in an overcrowded or noisy environment can be a significant stressor for many people. Positive and safe environments can foster health behaviours, such as exercise, that can be important for good mental health.

Environment influences a person at every stage of the life cycle. For example, the intrauterine environment during pregnancy can influence development in later life in profound ways. A mother who is smoking during pregnancy increases the risk of mental health problems in her offspring later in life.49 Extreme stress, particularly in the first semester of pregnancy, can significantly increase the incidence of schizophrenia in the offspring. Elderly people who are living in a non-stimulating environment will have declining mental health as a result. Environment can foster and support social interaction, opportunities and learning, and influence safety, particularly in the workplace.

Environment can also have an impact in other ways. Air pollution, for example, may be another factor in exacerbating depression.50 Climate change and drought affect economies and communities, and these can have secondary effects on the mental health of the farmers and communities involved.

Sunlight is an important modulator of mood. There is a natural rise and fall in mood with the seasons, but for some the fall is enough to lead to depression. Regular, moderate sun exposure has been found to be beneficial for mental health, particularly those with seasonal affective disorder (SAD), which is a type of depression.51 Light stimulates brain chemicals and mood, which is probably a hangover from evolution, when we would have gone into a relative hibernation when food was scarce. Exposure to sunlight may also have a beneficial effect on schizophrenia.52

Pharmacological

Antidepressant medications represent the most established treatment for major depressive disorder and few would argue with their use, particularly for severe depression, but there is some controversy over their effectiveness and widespread use particularly for mild to moderate depression and in children and adolescents. Meta-analyses have questioned whether they have a therapeutic effect greater than placebo for patients with less severe depression.53 Despite their popularity, a meta-analysis found that the magnitude of benefit of antidepressant medication compared with placebo may be minimal or nonexistent, on average, in patients with mild or moderate symptoms, but increasing with severity of depression symptoms; that is, for patients with very severe depression, the benefit of medications over placebo is clear.

It is likely that patients with a strong preference for an integrative approach will be less inclined towards a pharmacological solution, but any patient with moderate to severe depression, whether they are sympathetic to integrative medicine or not, should certainly think very carefully before declining the use of antidepressants as at least a part of their total management approach.

In general, the first-line pharmacological antidepressant is a selective serotonin reuptake inhibitor (SSRI). However, if the patient has a depressive disorder with loss of interest in almost all activities, and melancholic features such as early morning wakening, marked diurnal mood variation, significant psychomotor retardation, marked anorexia or weight loss and marked excessive/inappropriate guilt, a dual-action antidepressant such as a selective serotonin and norepinephrine reuptake inhibitor (SNRI) can also be considered as a first-line biological treatment. If the first drug is not effective after an adequate trial (with dose optimisation as described below), an alternative SSRI or an SNRI can be used. Ensure that the first agent is slowly ceased and that the appropriate washout time is observed. The Therapeutic Guidelines: Psychotropic version 5 (2003) provides an excellent guide to choosing an antidepressant.54

The GP should become familiar with a couple of antidepressants in each class, with knowledge of side effects and possible drug interactions. If a patient has previously responded to a particular antidepressant, unless some new contraindication has arisen it is sensible to use that agent again, although it will not necessarily have the same efficacy in a separate episode.

The most important goal of pharmacotherapy is ensuring dose optimisation. Wait 4–6 weeks at each dose before increasing. A drug has not failed until a 6-week trial at maximum recommended dose, balanced against the incidence and acceptability of side effects. The MIMS and the Australian Medicines Handbook provide advice on maximum doses.55,56

For a first episode of depression, when in remission treat for a minimum of 12 months. For a second episode treat for 2–5 years, and after a third episode treat indefinitely.

The use of antidepressant drugs in children and adolescents is controversial. Because of ethical considerations in research there is very little high-quality evidence on efficacy and tolerability in this patient group. Nevertheless, depression can occur and can have a substantially deleterious effect on the social and academic function of the young person. Anecdotally, careful treatment with SSRIs can be effective in remitting symptoms and improving function. Such prescribing needs careful discussion and informed consent from the young person and their parents.

The younger the child, the more caution should be applied, and seeking a second opinion from a child and adolescent psychiatrist early is preferable.

There has been some recent controversy about antidepressants increasing the risk of suicide in young people. The reliability of the evidence for this is being debated but it is prudent for a doctor prescribing antidepressant drugs for all age groups, and particularly the young, to be vigilant about suicidal risk.

Herbal (St John’s wort)

A Cochrane review57 found that the available evidence suggests that the Hypericum extracts tested in the included trials:

• are superior to placebo in patients with major depression
• are similarly effective as standard antidepressants, and
• have fewer side effects than standard antidepressants.

The association of country of origin and precision with size of effects complicates the interpretation, however. Because of its low incidence of side effects, it is not unreasonable to begin with a therapeutic trial of St John’s wort, particularly in patients who are resistant to taking pharmaceutical antidepressant medications. St John’s wort is a well-tolerated medicine with few side effects; however, drug interactions are possible. For a patient already taking antidepressant medication or other medicines in general, check to make sure that no untoward drug interactions will occur with the introduction of this medicine.

ANXIETY DISORDERS

Anxiety disorders are the most common psychiatric illnesses, with a one-year prevalence of 9.7%,3 and can cause significant distress for large numbers of patients.

Fear is the response to a realistic and immediate danger, whereas in anxiety the fearful response, with the same physiological arousal, occurs in the absence of any specific danger or in the anticipation of problems or challenges. The behavioural response to anxiety is a modification of the fight-or-flight response, but in the absence of something that is easily fought, patients respond with avoidant behaviour, withdrawal from functional activities and self-medication with drugs or alcohol. Patients also present with a range of physical symptoms including fatigue, headache and nausea. Different anxiety disorders share significant similarities in both understanding and management.

SOME OF THE ANXIETY DISORDERS

• Panic and related disorders—the first panic attack often occurs in the late teens. While 20% of adults will experience one panic attack in their lives, in any one year only about 2% of the population experience significant panic attacks. The fear is of either dying or losing control. Agoraphobia, where the anxiety is of being in a situation or place from which escape might be difficult, affects about 2% of the population per year, with an onset in the mid to late twenties.
• Social phobia—fear of scrutiny is as common as the combined prevalence of panic disorder and agoraphobia, and occurs equally commonly in men and women.
• Specific phobia—at least 8% of the population have a diagnosable specific phobia, although only about 10% of these people seek treatment.
• Generalised anxiety disorder—persistent, generalised and excessive feelings of anxiety are relatively common, affecting 2–8% of the population, with age of onset between 20 and 40 years of age.
• Obsessive–compulsive disorder—this disorder presents with obsessive, intrusive, unwanted thoughts that the individual finds difficult to control, and/or persistent and uncontrollable compulsions or urges to perform certain behaviours. It affects approximately 0.6% of the population. It generally first occurs in childhood or early adolescence in a fluctuating pattern.
• Post-traumatic stress disorder—this disorder presents with a range of specific symptoms, most notably featuring re-experiencing and avoidant behaviours developing after exposure to a significant traumatic event.

INVESTIGATIONS

In patients presenting with anxiety disorders in middle and late age, similarly to patients with depression, organic aetiologies need to be searched for more aggressively than in patients who present with their first episodes in late teenage or early adulthood.

Cardiac arrhythmias may produce symptoms of anxiety, and hyperthyroidism and hypoglycaemia can present with anxiety. Substance abuse and intoxication must be considered, and caffeine use not uncommonly can produce a chronic anxiety pattern or may precipitate a panic attack.

The use of investigations is determined by the findings in the history and physical examination.

MANAGEMENT

Check for symptoms of depression and risk of suicide.

Certain strategies are applicable to all anxiety disorders. The provision of reassurance, explanation and education is imperative. Remove physical factors contributing to the symptoms, and manage caffeine, cigarette smoking and alcohol use.

For most anxiety disorders seen in general practice, psychological interventions are probably sufficient. These include assisting patients to recognise the normal adaptiveness of anxiety and the negative consequences of avoidance (physical or pharmacological, including alcohol) in exacerbating anxiety. There are many resources teaching relaxation training, structured problem solving as for depression and cognitive and behavioural therapy. Resources on the internet can be helpful.

Often the most helpful treatment is a behavioural therapeutic exposure intervention. Patients are fearful of situations that provoke their anxiety. Use the analogy of the person who wants to ride a horse but who has fallen off. If you ask a patient to tell you the best way to help a person who has fallen off a horse but who wants to ride again to bring about that outcome, most will tell you that they need to get back on the horse. Obviously, if one has fallen off a horse, the thought of riding is extremely anxiety provoking. However, if they want to ride again, a graded exposure is required. Using blinkers, having somebody sit with them, tethering the horse or even using a Shetland pony are strategies that are still likely cause to anxiety and have no guarantee of safety; however, such a strategy has the best likelihood of getting them riding again.

Alternatively, seeing someone regularly to talk about the original fall and about how anxious they feel might seem caring to the patient because ‘somebody understands’, but such an approach risks perpetuating the avoidance. With this rationale, patients are far more receptive to the development and implementation of exposure-based behavioural therapeutic interventions. Books such as Management of Mental Disorders by the WHO58 or websites such as Climatetv (see Resources list) help patients develop exposure-based interventions.

Biological

Pharmacotherapy has a role in disabling anxiety. In a crisis, benzodiazepines are extremely useful but have a high risk of dependency; therefore, they are reserved for short-term use. Ongoing benzodiazepine use is an avoidance strategy and risks dependency.

Most anxiety disorders respond to the newer SSRIs, although anxiety may be exacerbated by these medications in some patients. The therapeutic drug guidelines provide details of doses and indications.

The same maxim applies as in the use of these drugs for patients with depression, in that dose optimisation is an imperative, with doses being increased according to tolerability and efficacy until the maximum therapeutic dose necessary is reached.

Lifestyle: the ESSENCE approach

All the key points mentioned above in the ESSENCE section on depression are relevant in the management of anxiety. For patients with anxiety it is also advisable to avoid abuse of alcohol, tobacco and caffeine.

Herbal

Patients with anxiety and depression commonly self-prescribe herbal medicines. It is advisable for a health practitioner to have training in the use of any herbs and formulas before prescribing them, and to have a reliable source of information available when concerns about interactions with medications arise.

In patients suffering from anxiety and sleep disturbances, phytomedicines may have a valid place alongside synthetics, and GPs will at least need to be equipped for conversations with patients about the potential benefits and risks.

Many herbs have anxiolytic effects and a broad mechanism of action.

One review59 reported that commonly used traditional herbs with varying levels of evidence for alleviating anxiety include the following:

• kava (Piper methysticum)60
• chamomile (Matricaria recutita)
• valerian (Valeriana officinalis), often combined with lemon balm (Melissa officinalis) or with St John’s wort (Hypericum perforatum)
• passionflower (Passiflora incarnata)61
• rhodiola (Rhodiola rosea)
• Bacopa monnieri
• Centella asiatica
• Withania somnifera
• Ziziphus jujuba var. spinosa.

Acupuncture

There is some evidence that acupuncture can help reduce the symptoms of anxiety, especially when combined with behavioural desensitisation (including psychotherapy).62 One study showed that benefits continued for as long as one year after treatment. Treatment is based on an individualised assessment of the excesses and deficiencies of qi located in various meridians. In traditional Chinese medicine, it is considered that a qi deficiency is often detected in the kidney or spleen meridians in anxiety states.

Social

Functional impairment is significant because often the anxiety and its associated avoidance has resulted in a patient withdrawing from the workplace or from their social network. The rationale of an exposure-based intervention to facilitate the patient returning, in a graded fashion, to the workplace and to a social role is an important aspect of therapy.

It needs to be constantly remembered that patients with anxiety disorders will often self-medicate and, unless asked, the use of agents, particularly alcohol and benzodiazepines, can be under-appreciated.

PSYCHIATRIC DISORDERS IN THE ELDERLY

The number of people aged over 65 years is likely to double by 2040. While most elderly people are fit, active and healthy, old age is often a time of loss and disability, where many are widowed and alone and where serious physical, sensory and mental conditions can have a significant impact on independence and autonomy. The elderly therefore require increasing levels of support and extensively use primary care and specialist medical services.

Allow for deafness, poor vision and frailty, and in elderly patients with confusion keep questions brief and simple. Do not shout or patronise.

Collateral history is also essential where there is confusion or memory deficit.

GENERAL PRINCIPLES OF MANAGEMENT

Symptoms have often evolved over time and there is generally no need to rush. Quickly resorting to pharmacological interventions can be inappropriate; the importance of a biological, psychological and social approach is paramount.

When using psycho-pharmacotherapy, consider the reduction in body water, renal clearance and plasma albumin in the elderly that can heighten bioavailability, increase the time of storage and also delay excretion of drugs with the potential for side effects. Many elderly people take other medications and have concomitant physical illnesses that can interact with psycho-pharmacotherapy.

DEMENTIA

Dementia is a syndrome involving changes in memory, intellect, behaviour and personality, often noted by others. Its prevalence is 1% of the population at age 65 years, doubling every 5 years until at age 85 years, 25% of elderly people have dementia. The common dementias are Alzheimer’s dementia (50%), cerebrovascular dementia (15%) and Lewy body dementia (15%).

The time of onset of cognitive impairment and the pattern of progression is crucial.

Delirium versus dementia

Differences between the symptoms of dementia and those of delirium are listed in Table 40.1. Delirium can occur at any age and is a medical emergency, with the primary objective being to identify the cause. It is more common in older people and can superimpose on a developing dementia.

TABLE 40.1 Differential diagnosis of delirium and dementia

Clinical feature Delirium Dementia
Onset Abrupt, possibly with a precise date Gradual (unless vascular)
Duration Acute (days to weeks) Chronic (months to years)
Reversible? Usually Generally irreversible; decline may be progressive
Disorientation Early and pronounced in most cases Later in illness (months to years)
Consistency Varies from moment to moment, hour to hour More stable day to day
Consciousness Clouded, fluctuating Not usually affected
Attention span Strikingly short Not particularly affected
Psychomotor changes Striking: hyperactive or hypoactive Usually only occur in late dementia

Source: Gauthier, Burns & Pettit 199763

When assessing cognitive impairment there can sometimes be a mismatch between symptoms as presented and observed cognitive function. For example, a loyal spouse may minimise symptoms in order to keep a patient at home, or a child may exaggerate the degree of cognitive impairment in order to get assistance. Patients suspected of having dementia can often blame lack of knowledge of what day it is and other pertinent observations or orientation on retirement, poor vision or hearing and social isolation, but most cognitively intact people are aware of these things.

Not uncommonly, patients developing dementia suddenly reach a time where the demand on them exceeds their coping capacity, leading to marked anxiety or agitation—the so-called ‘catastrophic reaction’.

Cognitive testing needs to take into account issues such as poor vision, hearing, comorbid depression, educational level, language and lack of cooperation. Short, structured questionnaires such as the Mini-Mental State Examination are useful, but often it is the tone of the answers that reveals much. For example, when asking an elderly patient about what day it is, a bland response such as ‘one day seems much like another’ or, in a person who has previously described an interest in world affairs who is asked about recent events, the remark ‘I don’t follow the news any more’ is revealing.

Tact and sensitivity are essential.

Investigations

Having determined that a patient has dementia, it is imperative to exclude treatable causes. Differential diagnosis of dementia includes:

• urinary tract infection
• adverse effects of prescribed medication
• alcohol excess
• depression
• eyesight or hearing problems
• diabetes
• thyroid disease
• renal disease
• hyponatraemia
• poor nutrition
• brain tumour
• head injury
• infection.

After the history and a thorough physical examination, including neurological assessment (gait etc), a number of investigations may be appropriate, depending on the clinical context. These could include:

• full blood count
• B12, and folate and iron studies
• biochemistry
• thyroid function tests
• urinalysis
• CT scan
• ECG
• chest X-ray
• sexually transmitted disease screen
• brain MRI.

Management

Do not be nihilistic: advice, education and carer support are essential.

Acetyl cholinesterase inhibitors can delay cognitive decline, but most psychotropic drugs can worsen confusion. Atypical antipsychotic drugs can help behavioural symptoms of dementia.

One of the important aspects of managing patients with cognitive deficits is involving families and carers, and clarifying legal issues such as Power of Attorney, Will and Enduring Power of Guardianship. Careful assessment of testamentary capacity is important. Essentially the question is whether the patient can comprehend in adequate detail the nature of a decision and its consequences. It is not essential that the doctor agrees with the decision, but it is important that the GP documents their opinion and, if asked to provide an opinion of a patient’s testamentary capacity, provides a caveat that any such determination, in the absence of any significant medical event, is valid only for a limited period.

Medication

There is no known cure for senile dementia but some medications have a small effect in slowing progression of the disease or providing some relief of symptoms.

• Cholinesterase inhibitors (donepezil (Aricept®), rivastigmine (Excelon®), galantamine (Razadyne®)) may offer symptom relief for a short time in patients with mild to moderate depression.
• Memantine (Ebixa®/Namenda®) is currently indicated for use for people with moderately severe to severe Alzheimer’s disease, but the effect is likely to be small.
• Antipsychotics (haloperidol (Serenace®)) are used to control agitation, aggression, delusions and hallucinations.

An integrated approach has been shown to slow cognitive decline.64

Lifestyle: the ESSENCE model

• Education—having an education and an engaged mind actively involved with stimulating pastimes has been found to be protective against dementia. Even engaging in these activities when elderly is protective and can slow the progression. Having inadequate stimulation and unstimulating pastimes such as excessive television watching increases risk and accelerates dementia.
• Stress management—poor mental health is a risk factor in itself for dementia. Evidence is also accumulating that a range of psychological strategies, and in particular mindfulness, not only have the capacity to enhance mental health but also improve focus and memory, and stimulate neurogenesis in the hippocampus and prefrontal cortex.65
• Spirituality—any improvements in mental health or coping related to meaning and spirituality are likely to be important for preventing, managing or coping with dementia, for the patient and their family.
• Nutrition—nutritional deficiencies should be corrected. Healthy nutrition, omega-3 fatty acids, reduced saturated fat intake and avoidance of excessive alcohol are all preventive for dementia and look to slow the progression of it.
• Exercise—regular exercise as tolerated can both prevent and slow the rate of progression of dementia. Exercise, among other things, helps to stimulate neurogenesis (including in the hippocampus), improve memory and concentration and improve mental health.
• Connectedness—relationships and social interaction significantly protect against dementia, and can assist in slowing progression and in coping.
• Environment—the importance of a stimulating and engaging physical and social environment cannot be overstated.

Herbal

Ginkgo biloba and brahmi (Bacopa monnieri) are popular herbs that have long been used for improving cognitive impairment, but the evidence is inconsistent.

PSYCHOTIC DISORDERS

The main psychotic disorders are schizophrenia and bipolar affective disorder I. These are low-prevalence disorders, schizophrenia occurring in 1% and bipolar affective disorder I in 1.2% of the population. Both have a significant genetic vulnerability.

In psychotic illnesses there is often a significant delay of over 12 months between first symptoms and treatment, and at least 75% of these patients will have seen a GP during that period. The longer the time to treat, the worse the prognosis. It is conceptualised that the psychotic illness itself is neurotoxic, similarly to the way in which prolonged coma or lengthy post-traumatic amnesia worsens the prognosis.

The hallmark of psychotic disorders are delusions (false ideas about reality), perceptual abnormalities and disorganised thinking. There is often a history of prodromal deterioration in patients diagnosed with schizophrenia in the 2–5 years before presentation. Nevertheless, 25–40% of patients with DSM IV-TR schizophrenia will only have one episode. Good prognostic indicators are a rapid onset of symptoms, rapid recovery, presence of affective symptoms and stable premorbid personality.

Schizophrenia begins in late adolescence or early adulthood in men, and in the early to mid twenties in women. If a patient presents with unusual thinking or changes in mood or behaviour, it is useful to at least consider the possibility that it is a prodrome, to use structured problem-solving techniques, to enlist supports such as drug and alcohol agencies if there is a substance problem, and to elicit family education and support.

The presence of one manic episode is sufficient to diagnose bipolar disorder I. Manic patients have elevated or irritable mood for a period of one week, with decreased sleep, increased self-esteem, increased energy, and rapid and jumping thoughts (flight of ideas). They are distractible and impulsive, and often risk damaging their reputation or incurring financial loss or legal problems.

INVESTIGATIONS FOR PATIENTS WITH A FIRST EPISODE OF PSYCHOSIS

The recommendations of clinical guidelines on the management of psychosis are that a number of investigations to exclude treatable pathology, as indicated by the history and physical examination, are indicated. These can include:

• an EEG if temporal lobe epilepsy is considered
• CT scan of the brain
• thyroid function test
• syphilis serology
• HIV serology
• B12 and folate
• ESR, complete blood picture, electrolytes
• fasting blood sugar
• serum calcium and phosphate
• urine and blood drug screens.

ROLE OF ILLICIT SUBSTANCES

It is worth briefly noting the contribution of illicit substances, most notably cannabis, to schizophrenia. There is controversy as to the role of cannabis in the development of psychotic disorders; however, it is probably best to consider that cannabis, while not causative of psychosis, can unmask symptoms in a vulnerable brain. This conceptualisation tends to reduce the risk of both patients and their families blaming the patient for causing the psychosis. It can also help in encouraging the patient to avoid illicit substances. The concept that, for the person with a predisposition to psychosis, the patient is ‘allergic’ to cannabis and needs to avoid it and other drugs in a similar fashion to the person with an allergy to penicillin having to avoid that drug, enables the doctor to advise the patient strongly to avoid the substance, without having to adopt a moralistic view.

MANAGEMENT

Schizophrenia-type psychosis

If a patient with a psychotic illness can be managed at home, the maxim is to go slowly and start with a low dose of atypical antipsychotic. The dose can be increased in the first week to the initial target dose (for example: risperidone 2 mg, olanzapine 10 mg, quetiapine 300 mg). After 3 weeks, if there has been response, the dose can be increased slowly over the next month to 4 mg, 20 mg and 800 mg respectively.15,16

Agitation can settle in hours or days but the positive symptoms of schizophrenia can sometimes take weeks or even months. Once first-episode symptoms are in remission, it is reasonable to try and stop medication, with vigilant observation of the mental state after 1 or 2 years.

After a second episode of psychosis, treatment needs to continue for at least 5 years after remission; after a third episode, treatment should be considered lifelong.

Manic-type psychosis

For mania, the treatment of choice is mood stabilisers. (Seek advice in patients during the reproductive years due to the problems of both teratogenicity and effects on the newborn of drugs like sodium valproate and lithium.)

A major part of managing psychotic illnesses is to help the patient and their family identify warning signs of and triggers that may precipitate an illness relapse. For example, sleep deprivation (from, for instance, a patient doing excessive overtime or night shifts) may be a trigger for an episode of illness. However, reduction in sleep requirement may be the first indicator of an evolving manic episode.

Encourage the patient to keep a mood and sleep diary, to identify both triggers and warning signs. Try to involve the family. The relapse signature varies from individual to individual and can be used to assist the GP to develop a management plan. GPs can help provide continuity of care and to monitor mental state. Strategies such as going for walks, exercising, talking and watching television can help manage symptoms such as hallucinations.

The GP can monitor side effects of both the illness and its treatment, including weight gain and emergent diabetes. Patients with schizophrenia and bipolar disorder have increased morbidity and mortality from general medical conditions compared to the normal population, even in the absence of treatment with atypical antipsychotics and other drugs.

PATIENTS WITH CHRONIC PHYSICAL SYMPTOMS FOR WHICH NO ORGANIC CAUSE IS IDENTIFIED

This includes patients with chronic pain. These patients challenge both GPs and psychiatrists. The principles of management are described below.

MEDICAL EXAMINATION AND NECESSARY INVESTIGATIONS

Explain the results of investigations and examination carefully and then, importantly, explain how emotional states can modulate pain perception. To avoid excessive and unnecessary procedures and investigations, it helps to set regular, time-limited appointments. Encourage the patient not to see multiple doctors. Only refer the patient if there is a clear reason, but ensure that all reasonable measures have been undertaken to diagnose treatable underlying pathology.

DIAGNOSING CONCOMITANT PSYCHIATRIC ILLNESS

In acknowledging ongoing pain symptoms, the focus is on the management of the pain. For example, it is helpful to explain to the patient that any reduction in tension can lead to a reduction in pain and that the focus is on rehabilitation rather than cure.

It is important to identify psychosocial precipitants and to help the patient to problem-solve these. Often it is important to involve the family where previously there has been a focus on the symptoms, instead switching the focus to the need to reinforce appropriate coping strategies.

Such patients cause significant frustration for doctors. It is important to be aware of that frustration and to have a clear plan, which, in the absence of any abnormal findings and investigations, can sometimes best be viewed as palliative, albeit for the long term. Sometimes it helps to refer the patient for a psychiatric assessment, but always tell the patient that you are doing so.

PERSONALITY DISORDERS

The personality and coping style of the patient can have an impact, both positive and negative, on the assessment, treatment efficacy and prognosis. It can also have an impact on the health of the doctor.

A person with a healthy personality copes with the environment and interpersonal relationships by first trying to manipulate the factors to best suit themselves. They then have the capacity to recognise when this is no longer feasible, and the flexibility to adapt to inflexible external demands. In order to do this, a person needs an innate ability to take responsibility for their own cognitions, emotions and behaviour. They need to be of sufficient maturity and to demonstrate adequate intelligence.

Personality disorder diagnoses are purely descriptive and do not eliminate the need to understand the entirety that is the person. For that reason, such patients often have significant comorbid anxiety, depression and substance abuse problems.

Personality disorders are not in themselves inherently untreatable; however, they often cause significant frustration for GPs. They can lead to diagnostic difficulties such as the ‘diagnosis’ being incorrect or missed, or comorbid conditions also being missed. In general, patients with personality disorders are not ‘good’ patients, and it is not uncommon for patients with maladaptive personality styles to cause interpersonal problems between the clinician and the patient. These then become the focus of attention.

MANAGEMENT

The most important initial task in managing patients with disordered personalities is to engage them in a therapeutic relationship. You cannot assume that the patient has the capacity to be engaged; even if the GP wishes it, engagement requires active collaboration between both the GP and the patient. A lack of adequate engagement can lead to major diagnostic and treatment difficulties.

Common obstacles to engagement include unrealistic expectations of the patient and the clinician, basic mistrust of the professionals by the patient, and ambivalence from the patient about both seeking out and receiving help.

Correctable reasons for treatment failure in patients with personality disorders include:

• inadequate engagement in treatment
• unrealistic treatment expectations
• unrealistic timeframe for treatment
• inconsistent delivery of treatment
• unresolved covert staff disagreements
• inadequate inter-staff communication
• undue delay in response to a deterioration or improvement in the patient’s clinical status.

Patients with maladaptive personalities often precipitate ‘splitting’ of staff, for which the most important pre-emptive strike is education of the staff. It is important to be clear with the patient, possibly using treatment contracts that specify what particular staff are able to provide and/or tolerate. Regular meetings of all the relevant clinicians to identify and resolve differing attitudes to treatment can be helpful. Not infrequently, patients with significant personality disorders will tell the GP a different version of events to that given to the psychiatrist or mental health teams, and communication between the members of the treating team is essential.

Patients with the diagnostic label borderline personality disorder can be difficult to manage and are often treated rather dismissively. Nevertheless, these patients have a significant mortality rate by suicide of approximately 10%.

Borderline personality disorder patients have difficulties with ‘here and now’ and generally the focus of therapy is on current problems and stressors rather than past problems. The GP can have problems with counter-transference, and such patients often demonstrate idealised transference versus devalued transference, in that one moment the doctor is the ‘best in the world’ and the next they are being denigrated for being the worst. Such patients are frequently those with whom doctors have boundary transgressions.

The strategy for managing displays of over-familiarity and idealisation is to be objective and careful, and unambiguous in your response. It is important with these patients to set clear limits of both what you can and cannot do, and your availability and accessibility. Be open and discuss these issues with the patient. Acknowledge the individual’s responsibility for their behaviour, but also acknowledge the need for such behaviour and to assist the patient to find alternative behaviours and responses using structured problem-solving techniques.

It can be useful to ask for a second opinion with patients who have difficult personality styles. Usually the outcome of such opinions is that the GP is doing an excellent job and that it is reasonable to continue to see a dependent patient on a regular basis, and that it is acceptable to set limits with the patient with a borderline personality style.

GET TO KNOW YOUR LOCAL PSYCHIATRIC RESOURCES

As is the case in all specialities, it is helpful for the GP to develop a working relationship with a psychiatrist or two who, at the very least, are available to give telephone advice. Get to know private psychiatrists and their billing practices.

The public mental health sector varies from state to state and area to area, but GPs who clarify local referral protocols and systems will often find that a little effort pre-emptively can save a great deal of time when dealing with an acute or complex patient.

RESOURCES

Australian Centre for Posttraumatic Mental Health. http://www.acpmh.unimelb.edu.au/.

Australian Medicines Handbook. http://www.amh.net.au/.

Beyondblue. http://www.beyondblue.org.au.

Black Dog Institute (mood disorders and depression resource). http://www.blackdoginstitute.org.au/.

BluePages (depression resource). http://bluepages.anu.edu.au/home/.

Climate GP (CBT for anxiety and depression). http://www.climate.tv/.

Depression Anxiety Stress Scales. http://www2.psy.unsw.edu.au/groups/dass/.

Mental Health First Aid. http://www.mhfa.com.au/program_overview.shtml.

MoodGYM (online CBT for depression). http://www.moodgym.anu.edu.au/.

Organization of Teratology Information Specialists (information on drugs in pregnancy). http://www.otispregnancy.org/.

RANZCP (clinical practice guidelines). http://www.ranzcp.org/.

Reach Out (for younger people). http://www.reachout.com.au.

Reach Out Central. http://www.reachoutcentral.com.au/.

SPHERE. http://www.spheregp.com.au/. (can also be accessed from the Beyondblue website)

University of Adelaide Library, Treatment Guidelines for Mental Health. http://www.adelaide.edu.au/library/guide/med/menthealth/guidelines.html.

WHO Treatment Protocol Project. Management of mental disorders, 4th edn. Vols 1 & 2. Sydney: WHO Collaborating Centre for Evidence in Mental Health Policy, 2004.

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