1. Chickens and eggs: mental health and chronic disease
Professor of Primary Medical Care
University of Liverpool
2. Iain 67
retired restaurant manager
married with three children
3. Presenting problems painful feet
difficult to walk
3 or 4 in last 2 weeks
currently c500ml vodka/day
4. Chronic diseases Diabetes (Type II)
BP 148/92 (n=<140/80)
Fasting blood sugar 11.8 (n= <8)
medication - Gliclazide
mainly in feet
5. Mental health worried about blackouts, drinking
poor sleep, irritable
loss of interest
can’t be bothered to see his children….
‘What’s the point of getting up in the morning?’
6. How you make sense of all this.... .. influences what you might do about it
7. Chickens and eggs A B
A = B
B A B A
C A & B
A = chronic disease
B = mental health problems
8. A B Diabetes increases likelihood of depression
(though less than cardiovascular disease)
Paile-Hyvärinen et al, Ann Med 2007
Arthritis increases likelihood of depression
Kothe et al, Pain 2007
9. B A Alcohol use increase incidence and persistence of diabetes
Depression may predict incident diabetes
Engum et al J Psychosom Res 2007
Depression and anxiety linked with increased risk of developing low back pain
Croft et al, Spine 1995
10. A = B Medical perspectives
Overlap of symptom patterns e.g. fatigue, weight loss, can ‘lead to double counting’
Wagena et al, Eur Resp J 2005
Mind and body are the same
therefore makes no sense to differentiate
Ayuverdic tradition, or pre-Cartesian
11. A B A B Anxiety increases blood pressure
Increased blood pressure increases risk of heart disease or stroke
Awareness of risk of heart disease or stroke increases anxiety
Which further increases BP and hence risk of disease....
and so on....
12. C A & B Both physical and mental problems have a common cause
e.g. RTA, assault
e.g. existential concerns
13. Deciding what to do....
14. Intervening at the psychological level Enhanced depression treatment for people with arthritis may
reduce depressive symptoms
reduce pain severity
improve functional status
Salerno et al, Arch Int Med 2002
Lin et al, JAMA 2003
15. Intervening at the psychological level But enhanced depression treatment for people with diabetes had little impact on
Katon et al, Arch Gen Psych 2004
Lin et al, Ann Fam Med 2006
16. Risks and benefits (Number needed to treat)
Number needed to harm
antidepressants may be cardiotoxic
losing sense of autonomy
Berry et al, PEC 2006
17. Intervening at the physical level Does improved medical care lead to improved mental health?
Little direct research on this
18. What do patients want?
19. What do patients want? Doctors assume (or fear) they want
lots of investigations and referrals
20. In reality….. patients with complex problems
are most likely to want emotional support
are more likely to seek explanation and reassurance
are no more likely than others to seek investigation and treatment
have few expectations of cure
Salmon et al J Psychosom Res 2005
21. Screening tools Feeling down, depressed or hopeless?
Little interest or pleasure in doing things?
Is this something with which you would like help?
Arroll et al, BMJ 2005
22. What does Iain want?
23. ‘Why bother to get up in the morning?’ loss of ability
diabetes and its complications
loss of purpose
work and children
slow, inexorable path to death…...
24. ‘What do you enjoy?’
25. ‘I can talk to you, doc’ still problems with alcohol, and painful feet
but a basis for conversation, and mutual respect
26. Sysiphus and his rock
This universe seems to him neither sterile nor futile.. .The struggle itself toward the heights is enough to fill a man's heart.
We must imagine Sysiphus happy.
Sysiphus is happy. He is happy because his fate belongs to him. He remains its master, his mind and body fully engaged in his chosen activity: This universe …. seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart.Sysiphus is happy. He is happy because his fate belongs to him. He remains its master, his mind and body fully engaged in his chosen activity: This universe …. seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart.