MRCPsych Leicester 2008

Alex Mitchell, Consultant in LiaisonPsychiatry

Alex Mitchell, Consultant in LiaisonPsychiatry

MRCPsych -Update on Liaison Psychiatry

MRCPsych -Update on Liaison Psychiatry

Five Questions for AudienceFive Questions for Audience

• List any medical disorder with a high rate of

(A) Depression (B) Psychosis (C) Cognitive Impairment (d) Anxiety

• List a psychiatric condition with an organic basis

• List 1 neurological & 1 psychiatric disorder that has a

diagnosis test available

• What causes most disability worldwide?

What is Liaison Psychiatry?

Simple Definition: Psychiatric care in medical settings

UK Definition: Psychiatric Complications of Medical illness

organic conditions=>

How are Psychiatric Disorders Classified?How are Psychiatric Disorders Classified?

MoodPsychosis

Cognition

Unipolar Depression

Bipolar Affective Disorder

Adjustment Disorder

Anxiety Disorders

Post-Partum Affective Disorders

Organic Affective Disorders

Brief Reactive Psychosis

Schizophrenia

Persistent Delusional Disorder

Organic Psychosis

Delirium

Dementia

Organic Amnesic Syndrome

Authors Comments – Psychiatric disorders may be reduced to these three presenting clusters

How do Psychiatric Disorders Present?How do Psychiatric Disorders Present?

TransientRelapsing

Chronic

Acute Stress Reaction

Normal Grief

Adjustment disorder

Brief Reactive Psychosis

Mild Depression

Delirium

Major Depression

Bipolar Affective Disorder

Obsessive-Compulsive Disorder

Schizophrenia

Dementia

Anorexia Nervosa

Personality Disorders

Authors Comments – The presentation of psychiatric disorders can be conceptualized in the following time periods

MoodPsychosis

Cognition

Unipolar Depression

Bipolar Affective Disorder

Adjustment Disorder

Anxiety Disorders

Post-Partum Affective Disorders

Organic Affective Disorders

Brief Reactive Psychosis

Schizophrenia

Persistent Delusional Disorder

Organic Psychosis

Delirium

Dementia

Organic Amnesic Syndrome

Neurological Disease

Parkinson’sEpilepsyMultiple Sclerosis

Alzheimer’s Disease

Head Injury

Stroke

NUS

CNS Tumours

HIV/AIDs

Huntington’s

Tourette’s

CJD

Toxins

MND

Alcohol

Systemic

What Causes Most Disability?What Causes Most Disability?

• Acute lower respiratory infections• Cancer• Cerebrovascular disease• Childhood diseases• Chronic obstructive pulmonary disease• Depression• Diarrhoeal diseases• Falls • Ischaemic heart disease• HIV/AIDS • Malaria• Road traffic accidents• Tuberculosis

Burden of Neuropsychiatric Disease - DALYsBurden of Neuropsychiatric Disease - DALYs

The Impact of Mental HealthThe Impact of Mental Health

Worldwide Causes of Disability

Disease % of All DisabilityAcute lower respiratory infections 7%

HIV/AIDS 6%

Diarrhoeal diseases 5%

Depression 4%

Ischaemic heart disease 4%

Childhood diseases 3.8%

Cerebrovascular disease 3.5%

Malaria 3.1%

Road traffic accidents 2.8%

Chronic obstructive pulmonary disease 2.6%

Tuberculosis 2.3%

Falls 2.1%

Murray CJL, Lopez AD (1997) Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 349 (9063): 1436-1442.

Western Causes of Disability

Disease % of All DisabilityIschaemic Heart Disease 12%

Smoking 10%

Physical Inactivity 7%

High Blood Pressure 6%

Obesity 5%

Dementia 4%

Depression 4%

Lung Cancer 4%

Poor Diet 3%

High Cholesterol 2%

Illicit Drugs 2%

Murray CJL, Lopez AD (1997) Global mortality, disability, and the contribution of risk factors: Global Burden of Disease Study. Lancet 349 (9063): 1436-1442.

Comments – Psychiatric illness are among the most important causes of disability in young people, and their prevalence is increasing

What Psych Conditions Have A Diagnostic Test?What Psych Conditions Have A Diagnostic Test?

Functional Psychiatric Disorders?Organic Psychiatric Disorders?Neurological Disorders?

Neurosyphilis

Hydrocephalus

SuicidalityMisc. Poisoning Syndromes

Factitious DisorderCarbon Monoxide Poisoning

MalingeringDegenerative DementiasWilson’s Disease

Bulimia NervosaPost-partum psychosisKluver Bucy Syndrome

Somatization DisorderPost-natal depressionNon-degenerative dementia

HypochondriasisMaternity BluesDelirium (often)

Adjustment DisorderAlcohol DependencySleep Apnoea

Acute Stress ReactionAlcohol WithdrawalNarcolepsy

Personality DisordersDrug WithdrawalHuntington’s Chorea

Generalised Anxiety DisorderGilles de la TouretteAlcohol Intoxication or Harmful Use

Mild Depression??Melancholic DepressionIllicit Drug Intoxication

Separation AnxietyPanic AttacksSydenham’s chorea

School RefusalAnorexia NervosaLesch-Nyhan Syndrome

ADHDAutismFragile X

Conditions that have little chance of a diagnostic test

Conditions that NEARLY have a diagnostic test

Conditions with a Diagnostic Test

Examples of Psychiatric Complications

Audience Examples?

CNS Disorder Depression (all types)

Cognitive Deficits

Dementia Psychosis

Alcohol 15% 80% 15% 5%

Epilepsy 20% Unknown rare 5%

Alzheimer’s disease 30% 100% 100% 30%

Head Injury 35% 3% Unknown 3%

HIV dementia 25% 40% 25% 6%

Huntington’s Disease 25% 40% Unknown 8%

Multiple Sclerosis 50% 50% 5% 10%

Parkinson’s Disease 50% 80% 30% 20%

Stroke 50% 50% 20% 5%

Subarachnoid Haemorrhage 20% 30% Unknown Unknown

Normal Control 10% 5% 2% 1%

Examples of Causation

Aetiology of stroke?

Risk FactorsHypertensionSmokingHyperlipidaemiaExerciseGenetic FactorsMedical Illness

Risk FactorsHIV ExposureUnsafe SexBlood transfusionImmunosuppression

Primary PathologyAtheromaEmboli

Primary PathologyHIV in CNS

DiseaseCerebrovascular Accident

PathogenesisMetabolic dysregulation

PathogenesisHypoxia

SyndromeDelirium

ComplicationsAgitationHallucinationsHigh mortality ratePoor Compliance

ComplicationsFallsIncontinenceHigh mortality rateMemory Loss

Aetiology of Ischemic Stroke

Aetiology of Depression in Parkinson’s disease

Risk FactorsParkinson’s diseaseStressful life-eventsGenetic FactorsDisability & handicapMedication

Primary Pathology? Basal ganglia disease

Pathogenesis? Stress hormone dysregulation? Psychological mechanisms

DisorderDepression

ComplicationsParasuicidePoor ComplianceSelf-neglectSocial isolation

Aetiology of HIV Related Delirium

Risk FactorsAlcohol ConsumptionNutritional CompromiseLiver DiseaseMedical Illness

Primary PathologyNeuronal LossSynaptic Degeneration

DiseaseDementia

PathogenesisDirect neurotoxicity

ComplicationsLoss of functionSelf-neglectSocial isolationUnemploymentDisintegration of personality

Aetiology of Alcohol Induced Dementia

Aetiology is ComplexAetiology is ComplexAuthors Comments – Understanding the cause of psychiatric disorders is difficult because they are multifactoral

Classification

Some Important Neuropsychiatric Conditions

Alzheimer’s diseaseAlzheimer’s disease

Fronto-temporal DementiaFronto-temporal Dementia

Huntington’s ChoreaHuntington’s Chorea

Multiple SclerosisMultiple Sclerosis

Vascular Dementia - SPECTVascular Dementia - SPECT

Head InjuryHead Injury

Parkinson’s DementiaParkinson’s Dementia

Cerebral Tumour - MetastasesCerebral Tumour - Metastases

Alcohol – Wernicke KorsakoffsAlcohol – Wernicke Korsakoffs

Questions?

Easily Overlooked SyndromesEasily Overlooked Syndromes

Alcohol Problems

Illicit Drug Problems

Anxiety Disorders

Anger & Irritability

Delirium

Early Dementia

Eating Disorders

Not volunteered?

Not diagnosed?

Not referred?

Not treated?

Symptoms

OccurHelp

SeekingSymptoms

Recognized

Referral

Occurs

Symptoms

Validated

Treatment

Occurs

Authors Comments – Many syndromes are easily overlooked by health professionals leading to unnecessary delays in treatment

Lag time Lag time Lag time Lag time Lag time

years months weeks weeks days

Illness

BeginsIllness

Resolves

Recognition of Depression x 256Recognition of Depression x 256

• Depressed Patients Do Not Seek Help1 in 4 patients seek help

• Depressed Patients Are Not Diagnosed1 in 4 depressed patients are diagnosed

• Depressed Patients Are Not Treated1 in 4 depressed patients are offered treatment

• Depressed Patients Are Not Adequately Treated1 in 2 depressed patients are given appropriate dose

• Depressed Patients May Not Respond1 in 3 only pick up one prescription1 in 3 do not respond to their first antidepressant

Authors Comments – Depression (and other disorders) may or may not be recognized in the community for various reasons