PSYCHOLOGICAL MEDICINE

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PSYCHOLOGICAL MEDICINE

• Dr Eugene M Cassidy
• MD, MRCPsych, MMedSc (Physiol.)
• Consultant Liaison Psychiatrist
• CUH
• Eugene.Cassidy_at_hse.ie

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Outline

• Mental Health Problems in General Hospital -
  Overview
• Psychological Adjustment to illness
• Depression in Medical Illness
• Alcohol Problems
• Somatisation
• Management

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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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Psychological adjustment to illness
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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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Illness Perception / Beliefs

• Illness identity
• Cause
• Consequences
• Course
• Cure/controllability
• Influenced by
• Medical Communication, Personal experience, Norms

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Individual Vulnerability

• Personality traits (e.g. tendency to worry about
  illness)
• Prior experience of illness within a family
• An individuals psychological state at the time
  of the illness
• Previous experience of trauma, or a neglected or
  abusive childhood

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Helpful Coping

• Seeking information
• Seeking practical and social support
• Learning new skills
• Developing new interests
• Helping others
• Emotion-focused coping

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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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Response of Others to illness

• Closing in
• Drifting away
• Infantilising
• Depersonalising
• Guthrie

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Physical and Psychiatric Co-morbidity
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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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Depression in Medical Illness

• Vulnerability Stress model
• Bio-psycho-social
• Dimensional (significant depressive symptoms)
• Categorical (Major Depression)

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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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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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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
• 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
• 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-Dimersgt1092ng/ml 3.1)
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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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Frasure-Smith et al, 1993
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Lesperance et al, 2002
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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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Depression is treatable

• .. But it isnt always treated
• Beware empathy and understanding
• Antidepressants
• Psychological therapies

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Gill Hatcher, 2000
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The Burden of Alcohol Misuse on emergency
in-patient hospital admissions among residents
from a health board region in Ireland OFarrell,
S. Allwright, J. Downey, D Bedford, F.
Howell. Addiction (2004) 99, 1279-1285

• Acute Alcohol intoxication
• 2.0 all emergency admissions
• 203/100,000 population

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• DETECTION
• 80 doctors enquire
• 46 record consumption
• 1 recorded CAGE
• 18 recognised by medic
• 64 discharge summaries
• 37 referred on

• PREVALENCE
• 147/759 (19.4) CAGE
• 19 DSM-IV Abuse / Dependence
• 30 male
• 8 female

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PHARMACOTHERAPY OF WITHDRAWAL
Pharmacological Management of Alcohol
Withdrawal Evidence-based practice
guideline Mayo-Smith et al, JAMA, 1997
Fixed Dose or Symptom Triggered

• Benzodiazepines
• Reduce symptoms
• Prevent seizures
• Prevent delirium

Withdrawal Scales
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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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A Good place to Intervene

Rumpf et al, 1987
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Feedback Helps!

• Health Consequences Feedback increases the
  proportion of patients willing to accept brief
  advice by _at_ ¼

R Patton, MJ Crawford, R Touquet. Emerg Med J
(2003)20 451-452
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With respect to alcohol abuse, our charge is
straightforward first we must ask something,
then we must do something.
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Somatisation

• See other PPT PRESENTATION as part of this
  lecture series

CUH Liaison Psychiatry
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Management of Mental Health Problemsin Medical
Illness
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Framework for Psychological Support

 
Specialist psychological/ psychiatric
interventions
Counselling 
  Self- Help interventions
Effective information giving and communication
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Stepped care approach (1)

• Prevention
• Information and Communication
• Involve and Support families / carers

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Stepped care approach (2)

• Simple advice and problem-solving
• Self-help
• Relaxation techniques
• Counselling problem focussed

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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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INTERESTED IN A CAREER IN PSYCHIATRY ???

• Please contact me at Eugene.Cassidy_at_hse.ie
• Tel [phone]