Mood disorder and physical illness: impact and interventions

1. Leeds Institute of Health Sciences Mood disorder and physical illness: impact and interventions Allan House Professor of liaison psychiatry Academic Unit of Psychiatry and Behavioural Sciences

2. A workshop in 3 parts Characterising the emotional state Determining the relationship between emotional state and physical illness Considering intervention strategies in the general hospital (�..and something interspersed to keep the delta waves at bay)

3. A hierarchy of mental disorders (after Foulds)

4. A hierarchy of mental disorders (after DSM or ICD)

6. Characterising emotional disorder: three approaches Distress as symptom burden Common mental disorders as specific syndromes The central importance of individual features (such as cognitions or behaviours)

7. Some common measures of symptom burden Hospital Anxiety and Depression Scale: HAD 14 items General Health Questionnaire: GHQ 12, 28, 30, 60 items Beck Depression Inventory: BDI 21 items Center for Epidemiological Studies: CES-D 20 items

9. Leeds Institute of Health Sciences

10. Trying to differentiate states of distress How many factors? Undifferentiated distress Depression Anxiety Somatoform disorder (somatic distress)

12. Major depression: depressed mood or loss of interest or pleasure and during the same 2 week period >3 from: Weight loss or weight gain, or marked change in appetite Insomnia or hypersomnia Agitation or retardation Fatigue or loss of energy Worthlessness or guilt Poor concentration or indecisiveness Thoughts of death or suicidal thinking

13. Trying to differentiate syndromes How many syndromes? Depressive disorders: major depression; minor depression; dysthymia; adjustment disorders Anxiety disorders: generalised anxiety disorder; panic disorder; social phobia; agoraphobia; specific monophobias Somatoform disorders: symptom states (pain; fatigue); hypochondria/health anxiety; conversion disorder

15. What cognitions really count? Is it the presence of negative ones? Hopelessness Sense of personal worthlessness Sense of life not worth living Suicidal ideas Or the absence of positive ones? Positive forward directed thinking Optimism Ikigai Pleasure, or enjoyment in life

16. Course of depressive symptoms after stroke

17. The example of maternal mental health: the usual problems Postnatal depression discussed as if it�s a disease (like post-stroke depression) Somatic distress written out of the picture (Edinburgh postnatal depression scale) Very little attention to depression-congruent cognitions

18. Mothers in Born in Bradford have GHQ-28 administered at booking GTT; Postnatal depression discussed as if it�s a disease GHQ-28 a 28 item measure of symptom burden Somatic distress written out of the picture (Edinburgh postnatal depression scale) GHQ-28 includes somatic sub-scale Very little attention to depression-congruent cognitions GHQ-28 depression subscale has mainly cognitive items

19. Depressive symptoms in GHQ-28: Items in the GHQ-D subscale thinking of yourself as a worthless person life is entirely hopeless life isn�t worth living wishing you were dead and away from it all at times you couldn�t do anything because your nerves were too bad idea of taking your own life kept coming into your mind possibility that you might make away with yourself

20. Some questions from BiB: for all women and by ethnicity The relation between emotional distress and somatic distress in pregnancy The relation between self-reported emotional and somatic distress and conventionally-defined mental disorder (CIS-R) The prevalence of negative cognitions in pregnancy The meaning given to symptoms by women in pregnancy

21. Some questions to discuss What questions should we invite non-specialists to ask: routinely of patients in difficulty with their disease What standardised measures should we invite non-specialists to use, and how should they use the responses? note: the lesson from QoF in the UK On what aspects of the presentation should we concentrate as psychiatrists?

23. What sorts of experience are stressful?Characteristics of the event imminent and strong demands life transitions ambiguity undesirability uncontrollability

24. What sorts of experience are stressful?Characteristics of the event Loss Threat Dilemma Note � an experience can be both a loss and a gain.

25. Components of the ILLNESS REPRESENTATION identity cause consequences course (natural history) cure/controllability

26. Illness Identity Pain Nausea Breathlessness Weight Loss Fatigue Stiff joints Sore Eyes Headaches Upset Stomach Sleep difficulties Dizziness Loss of Strength

27. Cause A germ or virus caused my illness. Diet played a major role in causing my illness. Pollution of the environment caused my illness. My illness is hereditary - it runs in my family. It was just by chance that I became ill. Stress was a major factor in causing my illness.

28. Consequences My illness is a serious condition My illness has had major consequences on my life My illness has become easier to live with� My illness has not had much effect on my life. � My illness has strongly affected the way others see me.

29. Course (timeline) My illness will last a short time� My illness is likely to be permanent rather than temporary My illness will last a long time

30. Control/Cure My illness will improve in time There is a lot which I can do to control my symptoms. There is very little that can be done to improve my illness. � My treatment will be effective in curing my illness. Recovery from my illness is largely dependant on chance or fate. � What I do can determine whether my illness gets better or worse.

31. Two main components of the earlyexperience of physical illness Perceptions of disease and disability: Controllability Locus of control Sense of coherence Helplessness/hopelessness Perceptions of healthcare: Quality Co-ordination Continuity Information received Satisfaction with care

33. Some influences on illness perceptions Medical communication Personal (typically family) experience Subjective norms (widely held beliefs) gender differences eg genetic causes defensive biases eg in perception of risks

34. The social network Quantity [ size , contact] Quality [intimacy, composition]

36. Stress and illness: the response of others Closing in �it�s our problem now� Drifting away Infantilising �I�ll look after you� Depersonalising �Does he take sugar?�

37. Some questions to discuss Do illnesses have any unique or relatively specific characteristics as life events or difficulties? Should we think less about illness representations and more about healthcare representations? And if so what are the main components of the latter? Does illness create particular interpersonal problems, or needs for social support? Or can we continue to borrow our thinking from other areas of psychiatry?

38. Lessons for assessment You need to know about both burden and specific symptoms, so: - routine use of a symptom measure - follow up with an interview You need to know about persistence of symptoms, so: - ask about symptoms before illness, and chart trajectory after illness You need to know how the patient understands symptoms in relation to: - life before illness; - illness; - experience of treatment of illness You need to know what impact on health-related behaviours depression is having You need to know how others in the social network are responding

40. Stepped care and depression: NICE Guidelines

42. Average recovery rates in reviews of antidepressant v placebo RCTs

43. Evidence for antidepressants in psychiatric practice: a summary Most RCTs provide outcomes at 6-8 weeks Total dropouts at 6-8 weeks are 30% for TCA, and 27% for SSRI Placebo response is 30-40% AD response is 50-60% with no clear difference between classes of AD

44. Leeds Institute of Health Sciences

46. Total and class- specific prescriptions of antidepressants (millions) 1975-98.

48. NICE guidelines for non-specialist management of depression in primary care Step 2 Watchful waiting* Guided self-help (manual-based)* Computerised CBT Exercise Brief psychological intervention++ Step 3 Medication Social support

49. People have their own ways of coping 1 AIMS problem-focussed emotion-focussed 2 STYLE approach/avoidance active/passive 3 TECHNIQUES cognitive e.g. reframing, seeking knowledge behavioural e.g. exercising, drinking emotional e.g. crying, grieving

52. Some questions for discussion How can we develop and implement policies for more rational prescribing of antidepressants in physical illness? Where is the best pay-off likely to be in Step 2 and Step 3 interventions for depression associated with physical illness? Is there a way of organising our specialist services so that we offer something between the consultation/referral model and the liaison model?

53. A plan to curb therapeutic zeal? Watchful waiting � 1/3 depressive episodes will recover spontaneously or with placebo treatment within a month Don�t start an AD without a clear (written) stopping protocol Only use AD in moderate or severe depression and only as part of a therapeutic programme��.

54. Depression and stroke: what should be on offer? Something for everyone (on the team) Problem-solving Activity scheduling/behavioural activation Motivational interviewing Strong on engagement/acceptability Practical/pragmatic Easy to learn

55. Two levels of service? A team training programme Activity scheduling Motivational interviewing Problem-solving A specialist referral policy CBT Interpersonal therapy/family therapy CAT