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CUH Liaison Psychiatry
PSYCHOLOGICAL MEDICINE
Dr Eugene M Cassidy
MD, MRCPsych, MMedSc (Physiol.)
Consultant Liaison Psychiatrist
CUH
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CUH Liaison Psychiatry
Outline
• Mental Health Problems in General Hospital - Overview• Psychological Adjustment to illness• Depression in Medical Illness• Alcohol Problems• Somatisation• Management
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CUH Liaison Psychiatry
Mental Health in the General Hospital
• Deliberate self-harm• Drug and alcohol misuse• Acute organic disorders (delirium)
• Psychological adjustment to illness• Physical and psychiatric co-morbidity• Medically unexplained symptoms
• Behavioural problems (e.g. non-adherence to treatment, capacity issues)
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CUH Liaison Psychiatry
Psychological adjustment to illness
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CUH Liaison Psychiatry
Stress and Physical illness
• Major health problems are stressful
• Response to this stress dependent upon individual– Perception / Beliefs of illness– Vulnerability– Coping ability– Response of others
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CUH Liaison Psychiatry
Illness Perception / Beliefs
• Illness identity• Cause• Consequences• Course• Cure/controllability
• Influenced by– Medical Communication, Personal experience, Norms
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CUH Liaison Psychiatry
Individual Vulnerability
• Personality traits (e.g. tendency to worry about illness)• Prior experience of illness within a family• An individual’s psychological state at the time of the
illness• Previous experience of trauma, or a neglected or
abusive childhood
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CUH Liaison Psychiatry
Helpful Coping
• Seeking information• Seeking practical and social support• Learning new skills• Developing new interests• Helping others• Emotion-focused coping
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CUH Liaison Psychiatry
Less Helpful Coping
• Hoping the condition will just disappear• Denial• Obsessively focusing on minute details of the disorder• Seeking others to blame
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CUH Liaison Psychiatry
Response of Others to illness
• Closing in• Drifting away• Infantilising• Depersonalising
• Guthrie
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CUH Liaison Psychiatry
Physical and Psychiatric Co-morbidity
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CUH Liaison Psychiatry
Psychological Medicine
• Applies bio-psychosocial model to medical care (irrespective of
psychiatric morbidity)
• Involves all staff and all patients
• More than just Liaison Psychiatry & Health Psychology
• Is there a need?
– Psychiatric disorders in medical illness
– Benefits most obvious in Somatoform disorder
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CUH Liaison Psychiatry
Depression in Medical Illness
• Vulnerability – Stress model• Bio-psycho-social
• Dimensional (significant depressive symptoms)• Categorical (Major Depression)
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CUH Liaison Psychiatry
Depression is common in medical illness
• Major Depressive disorder 8%
• All depressive disorders 15-36%
Magni et al, 1986, Feldman et al, 1987, Koenig et al, 1997, Von Ammon et al, 2001
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CUH Liaison Psychiatry
Depression is under recognised
• Physicians have been found to recognise depression in only one fourth to one half of their depressed medical outpatients
Wells et al, 1989; Schulberg et al, 1985; RCP/RCPsych, 1995
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CUH Liaison Psychiatry
Detection of Depression in Medical Setting
• Be vigilant– Depression is common
• Ask about it: • If positive, look for:
– mood and motivation symptoms– cognitive changes (always enquire about suicidal
thoughts)– biological symptoms– Disability or physical symptoms in xs of expected
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Screening for Major Depression
Please ask the following:
1. During the past month have you been bothered by feeling down, depressed or hopeless? No Yes
2. During the past month have you been bothered by little interest or pleasure in doing things? No Yes
If Yes to either of the above 2 questions, please ask:
3. Is this something with which you would like help? No Yes, but
not today Yes
Likelihood Ratio for MDD = 17.5
(ST elevation in MI 11.2; D-Dimers>1092ng/ml 3.1)
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CUH Liaison Psychiatry
Depression affects medical outcome
• Morbidity
• Survival
• Length of hospital stay
• Cost of medical care
• Compliance with therapy,
• Quality of life
Creed et al, 2002; Katon et al, 2003
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CUH Liaison PsychiatryFrasure-Smith et al, 1993
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CUH Liaison PsychiatryLesperance et al, 2002
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CUH Liaison Psychiatry
Impact of depression on DM
• More complications• Poorer glycemic control• Reduced dietary / oral hypoglycemic adherance• More typical DM symptoms even when severity of
DM controlled for
• Poorer quality of life• Increased healthcare costs x 4.5 (Egede et al, 2002)
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CUH Liaison Psychiatry
Depression is treatable
….. But it isn’t always treated
• Beware empathy and understanding
• Antidepressants
• Psychological therapies
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CUH Liaison Psychiatry
Gill & Hatcher, 2000
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CUH Liaison Psychiatry
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CUH Liaison Psychiatry
The Burden of Alcohol Misuse on emergency in-patient hospital admissions among residents
from a health board region in Ireland
O’Farrell, S. Allwright, J. Downey, D Bedford, F. Howell.
Addiction (2004): 99, 1279-1285
Acute Alcohol intoxicationAcute Alcohol intoxication• 2.0% all emergency admissions2.0% all emergency admissions• 203/100,000 population203/100,000 population
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CUH Liaison Psychiatry
PREVALENCEPREVALENCE 147/759 (19.4%) CAGE +147/759 (19.4%) CAGE + 19% DSM-IV Abuse / Dependence 19% DSM-IV Abuse / Dependence
• 30% male 30% male • 8% female8% female
DETECTIONDETECTION80% doctors enquire 80% doctors enquire 46% record consumption46% record consumption1% recorded CAGE 1% recorded CAGE 18% recognised by medic18% recognised by medic
•64% discharge summaries 64% discharge summaries •37% referred on37% referred on
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CUH Liaison Psychiatry
Pharmacological Management
of Alcohol Withdrawal:
Evidence-based practice guideline
Mayo-Smith et al, JAMA, 1997
Benzodiazepines
•Reduce symptoms
•Prevent seizures
•Prevent delirium
Fixed Doseor
Symptom Triggered
Withdrawal
Scales
PHARMACOTHERAPY
OF WITHDRAWAL
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CUH Liaison Psychiatry
Thiamine for Wernicke-Korsakoff Syndrome in people at risk from alcohol abuse
Day E, Bentham P, Callaghan R, Kuruvilla T, George S
Cochrane Review (2004)
+
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CUH Liaison Psychiatry
A Good place to Intervene
0
10
20
30
40
50
60
pre-cont action
gen hosp
gen populn.
Rumpf et al, 1987
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CUH Liaison Psychiatry
Feedback Helps!
• Health Consequences Feedback increases the proportion of patients willing to accept brief advice by @ ¼
R Patton, MJ Crawford, R Touquet. Emerg Med J (2003)20: 451-452R Patton, MJ Crawford, R Touquet. Emerg Med J (2003)20: 451-452
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CUH Liaison Psychiatry
““With respect to alcohol abuse, With respect to alcohol abuse, our charge is straightforward: our charge is straightforward:
first we must ask something, then first we must ask something, then we must do something.”we must do something.”
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CUH Liaison Psychiatry
Somatisation
• See other PPT PRESENTATION as part of this lecture series
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CUH Liaison Psychiatry
Management of Mental Health Problemsin Medical Illness
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Framework for Psychological Support
Counselling
Self- Help interventions
Effective information giving and communication
Specialist psychological/ psychiatric interventions
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CUH Liaison Psychiatry
Stepped care approach (1)
• Prevention• Information and Communication• Involve and Support families / carers
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CUH Liaison Psychiatry
Stepped care approach (2)
• Simple advice and problem-solving• Self-help• Relaxation techniques• Counselling – problem focussed
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CUH Liaison Psychiatry
Stepped care approach (3)
• Drug treatments– Drug interactions– Benefits in co-morbid illness symptomatology
• Specific psychological therapies– CBT– Marital therapy– Family therapy
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Biopsychosocial Management
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CUH Liaison Psychiatry
INTERESTED IN A CAREER IN PSYCHIATRY ???
• Please contact me at : [email protected]• Tel: 021-4920007