Top tips for GPs- Psychiatry from two perspectives

1. Dr Janet Obeney-Williams Staff Grade Liaison Psychiatry Former GP principle in General Practice Top tips for GPs- Psychiatry from two perspectives

2. What is general practice like? 'It is a world where the doctor is frequently in the dark, getting glimpses of his patients from time to time, being careful not to find out too much, being content to find out the right distance for the patient and for himself.’ -Dr Andrew Elder

3. What is a psychiatrist? • ‘Psychiatrists are medical doctors who must evaluate patients to determine whether or not their symptoms are the result of a physical illness, a combination of physical and mental, or a strictly psychiatric one.’ -Wikipedia

4. 10,000 hours • Psychologist Dr Nick Bayliss is famous for stating that it takes 10,000 hours to become an EXPERT-5 years of full time work

5. Liaison Psychiatry

6. Experts • GP’s are experts • We are experts at evaluating and treating in SHORT consultations over (sometimes) LONG periods of time • We treat most problems without specialists

7. Only 1 in 20 GP consultations results in a referral to specialists-Kings Fund 2010

8. No Health Without Mental Health (2011) • Mental ill health represents up to 23% of the total burden of ill health in the UK-largest single cause of disability

9. No health without mental health –HM Government 2011 • Almost half of all adults will experience at least one episode of depression during their lifetime

10. At least one in four people will experience a mental health problem at some point in their life and one in six adults has a mental health problem at any one time

11. Self-harming in young people is not uncommon (10–13% of 15–16-year-olds have self-harmed) • About one in 100 people has a severe mentalhealth problem

12. One in ten new mothers experiences postnatal depression

13. Healthy Lives, Healthy People (2010)-White Paper • First public health strategy that gives equal weight to both mental and physical health:. • A preventive approach to mental health

14. White Paper 2010 • Britain is now the most obese nation in Europe • By improving maternal health, we could give our children a better start in life, reduce infant mortality and the numbers of low birth-weight babies.

15. White Paper 2010 • In one study, the children of women who were depressed at 3 months after giving birth had significantly lower IQ scores at 11 years • Taking better care of our children’s health and development could improve educational attainment and reduce the risks of mental illness, unhealthy lifestyles,

16. Health and Social Care Act (2012) • “Parity of esteem” between physical and mental health • NHS Mandate 2012 to tackle disparities between physical and mental health care

17. Topics • Medically unexplained symptoms • Schizophrenia and metabolic syndrome • The ‘new psychoses’

18. Medically unexplained symptoms • Medically unexplained symptoms are physical symptoms that lack a medically identifiable organic cause. • Some studies suggest that one-fifth of initial appointments with GPs concern symptoms of this kind (Burton 2003).

19. Medically unexplained symptoms in primary care • Adult patients with medically unexplained symptoms (somatisation) in primary care are numerous and make disproportionately high demands on health services. Most of these individuals are open to the suggestion that their illness reflects psychological needs. (Else Guthrie-Advances in Psychiatric Treatment (2008)

20. Expertise Irritable bowel syndrome Chronic pelvic pain Fibromyalgia Chronic fatigue syndrome

21. Explanation • Rejecting The doctor denies the reality of the patients’ symptoms and implies that the problem is imaginary or related to a psychological problem. • Colluding The doctor acquiesces to the explanation offered by the patient • Empowering The doctor provides a physical mechanism of causation The doctor removes any sense of blame from the patient The doctor strengthens the relationship with the patient, enabling them to resolve the problem together • Source: Salmon et al (1999)

22. Explanation • Rejecting-as GP’s we are experts in knowing this is unlikely to work! • Colluding-we know this can undermine our patient’s confidence in our skills • Empowering-we know this our best option

23. Empowering • GP’s do this for our patients all the time • We explore our patients Health Beliefs-a core competence in our Royal College examinations CSA • We are Generalists so we can turn our hand to most explanations from the increased gastric acid in Dyspepsia or the reduced serotonin in Depression

24. Exploring • Another core competence for us-Cue’s, • We have our own cohort of EXPERTS who’ve helped us become skilled at using our consultations to the best effect-Balint, Pendleton, Neighbour, the Cambridge-Calgarry group and BATHE (relayed to us only this morning) • Our Primary Care Inheritance

25. Physical • GP’s are used to explaining physical illness, in all systems of the body • Our patients often appreciate the detail we give them

26. Psychosocial • As GP’s, when we’ve picked up our cues, hidden agenda’s we go on to address this with our patients-we’re probably Experts • GP’s when surveyed have been shown to believe we should manage MOST MUPS • GP’s are still Gatekeepers and, I would argue, EXPERTS

27. When to refer? • Appropriate and timely investigations-sometimes essential to exclude organic causes • When attendance is too frequent?? • When someone develops an alarming symptom-we’ve all had that One Case who defied all the advice • When we are stuck

28. Evidence • The children of parents who present with medically unexplained symptoms are at greater risk of developing such symptoms than are the offspring of parents with organic medical conditions (Levy et al, 2001; Craig et al, 2002). • IBS-25% more visits

29. Evidence • Children with more aches and pains, tiredness and fatigue are more likely than their peers to develop anxiety and depression (Campo et al, 2004). • Social learning theory is thought to be the most likely explanation

30. Evidence • A history of childhood adversity is common in patients with medically unexplained symptoms in primary care (Schilte et al, 2001). • Depressive symptoms were the major predictor of frequent attendance in primary care populations in the UK and Spain (Dowrick et al, 2000).

31. Evidence • A group in the USA conducted an RCT of multidimensional stepped care consisting of cognitive–behavioural, pharmacological and other treatment modalities. During the 12-month trial, which involved 206 patients, 48 in the treatment group improved compared with 34 in the control group (Smith et al, 2006).

32. Evidence • Consensus of the evidence seems to be that if your patients will agree-CBT, treatment with anti-depressants (even if lack of a clear diagnosis of depression) can be helpful • Refer for psychological therapies

33. Factors associated with poor prognosis • Somatic symptoms that have lasted for more than 2 years • Childhood physical or sexual abuse • History of psychiatric disorder • Ongoing severe psychosocial stressors

34. Psychiatry • Patients who come to a liaison psychiatry clinic have already had ‘all’ their investigations • Patients who’ve had Imaging, EEG’s, Telemetry, after spending time with many EXPERTS • What can Psychiatry add?

35. Some terms for MUPS • Psychogenic Psychosomatic • Non organic Conversion • Unexplained medical symptoms Hysteria • Somatoform disorders Functional • Dissociative

36. Psychiatry • Sometimes management of Risk • As a way into more complex psychological therapies • Treatment of difficulty to manage co-morbid mood disorders • Patients see us as not being able to arrange investigations

37. Non-epileptic seizures • Between 1-15% of general neurology patients, up to 50% of patients referred to specialist epilepsy centres. • Acute onset might be associated with a specific traumatic life event. • Can present in people who also have epilepsy

38. Non-epileptic seizures • > in women, 75%:25% • Usual onset in the 20s • History of childhood sexual abuse in up to 50% • Co-morbid epilepsy 15% • Co-morbid personality disorder up to 40% (10% in epilepsy) • Co-morbid anxiety and depression high in both groups

39. Non-epileptic seizures • Patients need neurological assessment with EEG and possible video-telemetry • The nonexistence of epilepsy is best confirmed by the neurologist • Non-epileptic seizures can result in overdose of benzodiazepines and patients can end up in ITU • Can be easier to obtain negative results than some more non-specific illnesses such as fibromyalgia

40. Non-epileptic seizures • History and examination give indications of non-epileptic seizure • Type of seizure – prolonged and frequent in the face of normal inter-ictal intellectual function • Seizures in public places, especially clinics or hospitals • Heightened distress after seizures e.g. prolonged crying • Tongue biting, or or incontinence are less useful in distinguishing from epilepsy

41. Schizophrenia • Annual incidence in UK is 15-50 per 100,000 (same statistic as DVT on oral contraceptive in women) • Strong evidence emerging for association of schizophrenia with complications during pregnancy and birth • Increase in schizophrenia in late winter and spring births, thought to be associated with influenza virus contact in mid-trimester of pregnancy

42. Schizophrenia & IQ • Hutton and Joyce 1998, 2002 studies 136 people with schizophrenia and 81 controls showing cognitive impairment is there at First Episode and it is Generalised • Pre-Morbid IQ tested by National Adult Reading Test • Pre-Morbid IQ is linearly associated with presentation of Schizophrenia • Lower the IQ the earlier the first age of presentation

43. Relevance? • Both Gray and White matter are affected in people with schizophrenia • Leeson et al 2009 studied cognition at 1 and 4 years in relation to social outcome • Only GlobalIQ :No other specific measure could predict global social function

44. Can anything be done? • 2005, Richard and Deary • Boosting cognitive reserve in adulthood • Educational attainment, community college • Exercise • Cardiorespiratory function • Modern Imaging has shown us that the adult brain is more plastic than we originally thought, recruiting new neuronal pathways

45. What does this add? • Encouragement in outcome modification • Some rigorous explanations which can be meaningful to patients and their families • Under-pins other work such as importance of ante-natal nutrition • All areas where GP’s are involved

46. Schizophrenia and CHD • All cause mortality in people with schizophrenia is >twice that in the general population • CHD is a main player here and GP’s are expert at detecting and modifying this • There is, however, evidence that even when BMI and other variables are controlled for, schizophrenia and insulin resistance are related

47. Schizophrenia and CHD • GP’s are Experts in lifestyle modification work • GP’s are experts at Interventions To modify CHD and addressing the complexity of the metabolic syndrome and insulin resistance (psychiatrists are not)

48. Schizophrenia and Diabetes • Prevalence likely 15-18% • Up to 1/3 may have impaired glucose tolerance • High prevalence pre-dates the anti-psychotic era • GP’s are Experts at explaining risks to patients and working with motivation and concordance

49. Schizophrenia and Diabetes • The relationship between schizophrenia and diabetes is not fully understood. An association between the two conditions was recognised in the pre-antipsychotic era. Schizophrenia and diabetes may share a common aetiology and/or pathogenic mechanisms.

50. Cochrane review 2010 • Results indicate that regular exercise programmes are possible in this population, and that they can have health benefits on both the physical and mental health and well-being of individuals with schizophrenia. • Larger randomised studies are required before any definitive conclusions can be reached