Top Tips for GPs - Royal College of Psychiatrists

Top tips for GPsPsychiatry from two
Dr Janet Obeney-Williams
Staff Grade Liaison Psychiatry
Former GP principle in General Practice
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
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
10,000 hours
Dr Nick
Bayliss is famous for stating
that it takes 10,000 hours to
become an EXPERT-5
years of full time work
Liaison Psychiatry
 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
1 in 20 GP consultations
results in a referral to
specialists-Kings Fund 2010
No Health Without Mental Health
 Mental
ill health represents up to
23% of the total burden of ill
health in the UK-largest single
cause of disability
No health without mental health
–HM Government 2011
 Almost
half of all adults will
experience at least one episode of
depression during their lifetime
 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
 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
mental health problem
 One
in ten new mothers
experiences postnatal
Healthy Lives, Healthy People
-White Paper
 First
public health strategy that
gives equal weight to both mental
and physical health:.
 A preventive approach to mental
White Paper 2010
 Britain
is now the most obese nation in
 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.
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
Health and Social Care Act
 “Parity
of esteem” between physical
and mental health
 NHS Mandate 2012 to tackle
disparities between physical and
mental health care
Schizophrenia and metabolic
The ‘new psychoses’
Medically unexplained
 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).
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)
Irritable bowel syndrome
Chronic pelvic pain
Chronic fatigue syndrome
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
 Source: Salmon et al (1999)
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
 Rejecting-as
 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
 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 CambridgeCalgarry group and BATHE (relayed to
us only this morning)
 Our Primary Care Inheritance
 GP’s
are used to explaining
physical illness, in all systems of
the body
 Our patients often appreciate the
detail we give them
 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
 GP’s when surveyed have been shown to
believe we should manage MOST MUPS
 GP’s are still Gatekeepers and, I would
argue, EXPERTS
When to refer?
 Appropriate
and timely investigationssometimes essential to exclude organic
 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
 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
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
history of childhood adversity is common
in patients with medically unexplained
symptoms in primary care (Schilte et al,
 Depressive symptoms were the major
predictor of frequent attendance in primary
care populations in the UK and Spain
(Dowrick et al, 2000).
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).
 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
Factors associated with poor
 Somatic
symptoms that have lasted
for more than 2 years
 Childhood physical or sexual abuse
 History of psychiatric disorder
 Ongoing severe psychosocial
 Patients
who come to a liaison psychiatry
clinic have already had ‘all’ their
 Patients who’ve had Imaging, EEG’s,
Telemetry, after spending time with many
 What can Psychiatry add?
Some terms for MUPS
 Psychogenic
 Non organic
 Unexplained
medical symptoms
 Somatoform disorders
 Dissociative
 Sometimes
management of Risk
 As a way into more complex psychological
 Treatment of difficulty to manage comorbid mood disorders
 Patients see us as not being able to
arrange investigations
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
Non-epileptic seizures
in women, 75%:25%
 Usual onset in the 20s
 History of childhood sexual abuse in up to
 Co-morbid epilepsy 15%
 Co-morbid personality disorder up to 40%
(10% in epilepsy)
 Co-morbid anxiety and depression high in
both groups
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
Non-epileptic seizures
History and examination give indications of nonepileptic seizure
Type of seizure – prolonged and frequent in the
face of normal inter-ictal intellectual function
Seizures in public places, especially clinics or
Heightened distress after seizures e.g.
prolonged crying
Tongue biting, or or incontinence are less useful
in distinguishing from epilepsy
Annual incidence in UK is 15-50 per 100,000
(same statistic as DVT on oral contraceptive in
 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
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
 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 Global IQ :No other specific
measure could predict global social
Can anything be done?
2005, Richard and Deary
Boosting cognitive reserve in adulthood
Educational attainment, community college
Cardiorespiratory function
Modern Imaging has shown us that the adult
brain is more plastic than we originally
thought, recruiting new neuronal pathways
What does this add?
 Encouragement
in outcome
 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
Schizophrenia and CHD
 All
cause mortality in people with
schizophrenia is >twice that in the general
 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
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)
Schizophrenia and Diabetes
 Prevalence
likely 15-18%
 Up to 1/3 may have impaired glucose
 High prevalence pre-dates the antipsychotic era
 GP’s are Experts at explaining risks
to patients and working with
motivation and concordance
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.
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
The ‘new psychoses’
 Potentially
treatable psychoses which
have been recognised in the last decade
 Can present with evident confusion and
neurological symptoms, making diagnosis
 Some patients present with predominantly
psychiatric symptoms and have been
diagnosed with schizophrenia
The ‘new psychoses’
 anti-NMDA
receptor encephalitis
 can have additional features of
dyskinesias, seizures and catatonia
 Can be associated with ovarian
 diagnosis requires a positive finding
of antibodies to the NMDA receptor
The ‘new psychoses’
 There
are distinct prodromal, psychotic,
unresponsive, hyperkinetic and recovery
 Recovery is not always to the pre-morbid
 High mortality rate (25% in a case study of
 Diagnosis is made by detecting the
antibodies in serum-Oxford
The ‘new psychoses’
 Treatment
is immunomodulatory agents,
including plasmapheresis or high-dose
 Anti-psychotics and benzodiazepines have
a supportive role in treatment
 unclear whether there is a pure psychiatric
presentation associated with lower
antibody titres.
 N-methyl-D-aspartate
receptor (also
known as the NMDA receptor a
glutamate receptor, is the predominant
molecular device for controlling synaptic
plasticity and memory function
 Hypo-function of Glutamate is emerging
as a likely cause of schizophrenia,
alongside the Dopamine hypothesis
In Summary
 Potentially
treatable psychosis
 Role of investigations pivotal to
 Ongoing research in this areaepidemiological and investigative
To summarise
 Mental
illness is beginning to be
recognised as the huge public health
concern that we ‘experts’ know only too
well that it is
 Some of the well known causes of poor
health-nutrition, Obesity, metabolic
syndrome and the range of unformulated
symptoms which present in primary care
To summarise
GP’s are managing majority of mental illness
without involving specialists
Evidence supports the impact of the holistic
care in the areas we’ve looked at
When to or why refer?
The public health challenges
Some new science