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.

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.

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.

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

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.

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

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:

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:

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

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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