CUH Liaison Psychiatry PSYCHOLOGICAL MEDICINE Dr Eugene M Cassidy MD, MRCPsych, MMedSc (Physiol.)...

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CUH Liaison Psychiatry

PSYCHOLOGICAL MEDICINE

Dr Eugene M Cassidy

MD, MRCPsych, MMedSc (Physiol.)

Consultant Liaison Psychiatrist

Eugene.Cassidy@hse.ie

Outline

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

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)

Psychological adjustment to illness

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

Illness Perception / Beliefs

• Illness identity• Cause• Consequences• Course• Cure/controllability

• Influenced by– Medical Communication, Personal experience, Norms

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

Helpful Coping

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

Less Helpful Coping

• Hoping the condition will just disappear• Denial• Obsessively focusing on minute details of the disorder• Seeking others to blame

Response of Others to illness

• Closing in• Drifting away• Infantilising• Depersonalising

• Guthrie

Physical and Psychiatric Co-morbidity

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

Depression in Medical Illness

• Vulnerability – Stress model• Bio-psycho-social

• Dimensional (significant depressive symptoms)• Categorical (Major Depression)

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

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

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

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)

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

CUH Liaison PsychiatryFrasure-Smith et al, 1993

CUH Liaison PsychiatryLesperance et al, 2002

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)

Depression is treatable

….. But it isn’t always treated

• Beware empathy and understanding

• Antidepressants

• Psychological therapies

Gill & Hatcher, 2000

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

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

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

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)

A Good place to Intervene

pre-cont action

gen hosp

gen populn.

Rumpf et al, 1987

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

““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.”

Somatisation

• See other PPT PRESENTATION as part of this lecture series

Management of Mental Health Problemsin Medical Illness

Framework for Psychological Support

Counselling

Self- Help interventions

Effective information giving and communication

Specialist psychological/ psychiatric interventions

Stepped care approach (1)

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

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

• Drug treatments– Drug interactions– Benefits in co-morbid illness symptomatology

• Specific psychological therapies– CBT– Marital therapy– Family therapy

Biopsychosocial Management

INTERESTED IN A CAREER IN PSYCHIATRY ???

• Please contact me at : Eugene.Cassidy@hse.ie• Tel: 021-4920007

CUH Liaison Psychiatry PSYCHOLOGICAL MEDICINE Dr Eugene M Cassidy MD, MRCPsych, MMedSc (Physiol.)...

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