A Bird’s Eye View of depression and unexplained somatic symptoms in primary care Wanchai, Hong...

A Bird’s Eye View of depression A Bird’s Eye View of depression and unexplained somatic and unexplained somatic symptoms in primary caresymptoms in primary care

Wanchai, Hong Kong2nd March 2005

David GoldbergDavid GoldbergInstitute of PsychiatryInstitute of PsychiatryKing’s College, LondonKing’s College, London

Six parts to the lecture:Six parts to the lecture:1) How common is depression, and how likely

is it to be detected, and how it presents in primary care?

2) What kinds of depression should you recognise?

3) How should depression best be detected?

4)How is it best assessed?

5)How is it best treated?

6)How are unexplained somatic symptoms best treated?

1. How common is depression is, and how likely it is to be detected, and how it presents in primary care?

Mental disorders in primary care Mental disorders in primary care WHO study : South Manchester 1991WHO study : South Manchester 1991

male female both

Depression 13.9 18.3 17.0

General fatigue 6.1 11.3 9.7

Generalised anxiety 4.9 8.1 7.1

Agoraphobia 2.1 4.6 3.8

Alcohol problems 9.4 0.9 3.6

Panic disorder 3.4 3.6 3.5

Any mental Dx 23.5 27.5 26.2

rates / 100 consultations

Mental disorders in primary care Mental disorders in primary care WHO study :Manchester & ShanghaiWHO study :Manchester & Shanghai

manchester shanghai

Depression 17.0 4.0

General fatigue 9.7 2.0

Generalised anxiety 7.1 1.9

Agoraphobia 3.8 0.1

Alcohol problems 3.6 2.7

Panic disorder 3.5 0.2

Any mental Dx 26.2 9.7


Detection of Mental disorders by GP Detection of Mental disorders by GP Manchester & ShanghaiManchester & Shanghai

manchester shanghai

Depression 17.0 (70.0%) 4.0 (21.0%)

General fatigue 9.7 (49.8%) 2.0 (21.7%

Generalised anxiety 7.1 (72.3%) 1.9 (19.9%)

Agoraphobia 3.8 (69.6%) 0.1 ( 0.0%)

Alcohol problems 3.6 (63.0%) 2.7 (38.7%)

Panic disorder 3.5 (70.6%) 0.2 ( 0.0%)

Any mental Dx 26.2 (62.9%) 9.7 (15.9%)


Self rated overall health by patientSelf rated overall health by patientDiagnosable mental disorders only!Diagnosable mental disorders only!

manchester shanghai

Excellent 3.9% 0.0%

Very good 19.0% 4.7%

Good 27.1% 6.3%

Fair 39.3% 33.0%

Poor 22.4% 55.9%

Presenting complaints of mental Presenting complaints of mental disorders: Manchester & Shanghaidisorders: Manchester & Shanghai

manchester shanghai

Psychological 29.5% 1.0%

Both psych.& physical 69.0% 22.0%

Pain 23.2% 34.0%

Physical complaints 24.3% 44.0%

Miscellaneous 14.3% 3.0%

Size of group 222 102

ICD -10 mental disorders only

Treatment of recognised cases Treatment of recognised cases of depressionof depression

Any drug treatment 55% 21.4%

sedatives 13% 14.3%

antidepressants 39% 0.0%

other 18.8% 7.1%

Any non-drug 85% 0.0%

discussion 78%

referral 9%

physical tests 8%

No treatment prescribed 5% 78.6%

Manchester Shanghai

In summary:In summary:

Depression appears to be much less common in Shanghai than in Manchester

It is even more likely to present as somatic symptoms in Shanghai

Shanghai doctors are not very good at detecting depression

Shanghai doctors are much less likely to treat depression

Depressed patients in Shanghai are much more likely to rate themselves in poor health than those in Manchester

2: What kinds of depression should you recognise in

primary care?

Classification of depression Classification of depression for primary carefor primary care

DEPRESSION

i - presenting as unexplained somatic symptoms

ii - with physical disease

iii - presenting psychological symptoms

iv. CHRONIC ANXIOUS DEPRESSION

i. Depression presenting with i. Depression presenting with unexplained somatic symptomsunexplained somatic symptoms

Easily the commonest presentation (57%!)

Diagnosis often missed – GP distracted by possible physical causes of symptoms

Physical symptom may be part of the depression; maybe a pre-existing minor symptom; maybe quite new

Most of these patients do not think of themselves as depressed, but are aware of their physical symptoms, and want you to deal with them

ii: Depression accompanyingii: Depression accompanyingdefinite physical disordersdefinite physical disorders

About 10% of depression in general medical practice

GP often misses it, since the presence of real physical disorder demands attention

However, depression often exacerbates pains and other physically caused discomforts – and treatment of this often very rewarding in terms of symptom relief.

Response to treatment proportional to severity of the depression – not to whether there is an understandable cause for the depression [eg cancer]

Body

Mind

PAINPre-existing physical illness

In steady state….

Body

Mind

STRESSFUL LIFE EVENT

PAIN

gets

worse

Pre-existing physical illness

Body

Mind


DEPRESSION

Much worse

PAIN!


Body

Mind


DEPRESSION

Much worse

PAIN!


Depression gets even worse

iii. Depression presenting iii. Depression presenting psychologicallypsychologically

Only 5% of cases in Manchester

95% detected by their GP

Not really a problem

Detection most likely if psychological symptoms are mentioned early in the interview

iv: Chronic mixed anxious iv: Chronic mixed anxious depressiondepression

100% detected by the GP in Manchester

Management different from a discrete episode of depression

3: How should depression best be detected?

3:3: How should mental disorders be How should mental disorders be detected in general medical practice?detected in general medical practice?

First, by the doctor modifying his/her interview techniques to make it more likely that the patient displays CUES suggesting distress

Second, by routinely using two screening questions when a CUE is detected, or in three other circumstances

Sensitive doctors:Sensitive doctors:

Make eye contact with the patientMake eye contact with the patient

Make empathic commentsMake empathic comments

Pick up verbal cuesPick up verbal cues

Pick up non-verbal cuesPick up non-verbal cues

Do not read notes while patient is Do not read notes while patient is speakingspeaking

Deal with over-talkativenessDeal with over-talkativeness

Ask fewer questions about the pastAsk fewer questions about the past

Making eye contactMaking eye contact

Make it at the beginning, and when the patient is telling you something

Don’t look in the notes, or at your computer, unless you stop the patient:

“Excuse me a moment, I need to look something up in your record”

Draw attention to both Draw attention to both verbal and non-verbal cues:verbal and non-verbal cues:

Verbal:

“You mentioned that you felt quite low after your mother died. Tell me about that”

Non-verbal:

“You look quite sad”

“You sound very upset about this”

“You’ve got quite a tremor when you talk about this”

Make supportive comments Make supportive comments when needed:when needed:

“ You’ve been going through a bad time”

“Things have been very difficult for you”

“That must have been really frightening”

Deal with Deal with emotionemotion by drawing by drawing attention toattention to it: it:

OBVIOUS DISTRESS:

“ You still seem very upset by your mother’s death”

ANGER:

“ You seem very angry about this. Tell me about it”

EMBARRASSMENT:

“ This is something that is difficult for you to talk about”

How should depression be How should depression be detected if there are cues?detected if there are cues?

Screening with 2 routine questions.

In the past week: have you been feeling in low spirits or depressed? have you been feeling in low spirits or depressed?

have had less pleasure from your usual activities?have had less pleasure from your usual activities?

ALSO, in certain high risk groups. do they haveALSO, in certain high risk groups. do they have

o a past history of depression

o a significant physical illness causing disability

o some other mental health problems (e.g. dementia)

3: Detection Skills3: Detection Skills

IN SUMMARYIN SUMMARY:: Sensitive doctors are Sensitive doctors are good good

communicatorscommunicators, and good detectors of , and good detectors of depressiondepression

Especially important to detect Especially important to detect depression with depression with unexplained somatic unexplained somatic symptomssymptoms, and when depression , and when depression accompanies definite physical diseaseaccompanies definite physical disease

Use Use screening questionsscreening questions routinely in 3 routinely in 3 other high risk groupsother high risk groups

4: Assessment of Severity4: Assessment of Severity

3: Assessment Skills….3: Assessment Skills….

Today, we will deal only withToday, we will deal only with

Assessing severity of depressionAssessing severity of depression

Making the link between somatic Making the link between somatic symptoms and emotional arousalsymptoms and emotional arousal


Today, we will deal first withToday, we will deal first with


Why does this matter?Why does this matter?

- because different degrees of - because different degrees of depression should be treated depression should be treated differentlydifferently


Today, we will deal first withToday, we will deal first with


If either of your screening questions If either of your screening questions is positive, routinely go on to ask is positive, routinely go on to ask the following additional questions:the following additional questions:

Assessing Severity of DepressionAssessing Severity of Depression

Persistent sadness or low mood; and/orPersistent sadness or low mood; and/orLoss of interests or pleasureLoss of interests or pleasure

Disturbed sleepDisturbed sleepPoor concentrationPoor concentrationLow self confidenceLow self confidenceFatigue or low energyFatigue or low energyPessimism or hopelessness about the futurePessimism or hopelessness about the futurePoor appetitePoor appetiteLow libidoLow libidoSuicidal thoughts or actsSuicidal thoughts or actsAgitation or slowing of movementsAgitation or slowing of movementsGuilt or self-blameGuilt or self-blameMay be diurnal variation of moodMay be diurnal variation of mood

Must be present:

Plus at least four of:

5: Treatment of depression 5: Treatment of depression in primary carein primary care

4. Management Skills….4. Management Skills….Ventilation of feelingsVentilation of feelingsProvision of information/educationProvision of information/educationMaking links - how symptoms relate to Making links - how symptoms relate to social & interpersonal problemssocial & interpersonal problemsNegotiationNegotiationMotivating change in behaviourMotivating change in behaviourProblem solvingProblem solvingRestoring sleep rhythmsRestoring sleep rhythmsNegotiating acceptable treatmentNegotiating acceptable treatment

Today, we will deal only Today, we will deal only withwith

Management of DepressionManagement of Depression

Making links - how symptoms Making links - how symptoms relate to social & interpersonal relate to social & interpersonal problemsproblems

MILD DEPRESSIONMILD DEPRESSION5 or 6 symptoms on ICD-105 or 6 symptoms on ICD-10

Many treatments are equally effectiveMany treatments are equally effective::HypericumHypericum (St John’s Wort) (St John’s Wort)Problem solvingProblem solving from GP or nurse from GP or nurseRestoration of Restoration of sleepsleep Moderate Moderate exerciseexerciseself helpself help materials, bibliotherapy materials, bibliotherapyComputerised CBTComputerised CBTand, of course, and, of course, case management + case management + PBOPBO

MODERATE & SEVERE MODERATE & SEVERE DEPRESSIONDEPRESSION

(7 - 12 symptoms on ICD-10)(7 - 12 symptoms on ICD-10)

Find an Find an AD drugAD drug that suits the that suits the individual patient, and/orindividual patient, and/or

Problem solving, IPT or CBTProblem solving, IPT or CBT if if availableavailable

Computerised CBTComputerised CBT also effective also effective

+ Regular follow up+ Regular follow up - can be - can be carried out by practice nursecarried out by practice nurse..

Anti-depressants in primary Anti-depressants in primary carecare

All the drugs are EQUALLY effective (or All the drugs are EQUALLY effective (or ineffective) ineffective)

Studies claiming to show differences Studies claiming to show differences between them are usually NOT carried out between them are usually NOT carried out with primary care patientswith primary care patients

Some are more Some are more toxictoxic that others that others

Some are more likely to be Some are more likely to be taken taken regularlyregularly

The The costscosts are very different, use generic are very different, use generic drugs when you can!drugs when you can!

First line anti-depressants in First line anti-depressants in primary careprimary care

fluoxetine and citalopram are both cheap, fluoxetine and citalopram are both cheap, not that toxic, as effective as any others, not that toxic, as effective as any others, and well toleratedand well tolerated

sertraline is best in heart diseasesertraline is best in heart disease

Lofepramine, mirtazepine & reboxetine are Lofepramine, mirtazepine & reboxetine are safer in overdosesafer in overdose

AvoidAvoid paroxetine as 1 paroxetine as 1stst line treatment line treatment

AvoidAvoid dothiepin in ischaemic heart disease dothiepin in ischaemic heart disease

Do not useDo not use venlafaxine as 1 venlafaxine as 1stst line Rx line Rx

Drug treatments in PCDrug treatments in PCThe patient fails to respond…The patient fails to respond…

check drug taken regularly & in check drug taken regularly & in prescribed doseprescribed dose

increase dose within permitted range, increase dose within permitted range, only modest, incremental increasesonly modest, incremental increases

if poorly tolerated switch to another if poorly tolerated switch to another drugdrug

switch to 2switch to 2ndnd AD if no response in 1/12 AD if no response in 1/12

Drug treatments in PCDrug treatments in PCSecond line treatmentsSecond line treatments

Try another SSRITry another SSRIMirtazepine acceptable (but sedation & weight Mirtazepine acceptable (but sedation & weight

gain)gain)Moclobemide acceptable (but wash out Moclobemide acceptable (but wash out

previous AD)previous AD)

Combined treatments Combined treatments (lithium (lithium

augmentation and AD combinations), also augmentation and AD combinations), also phenelzine, and venlafaxinephenelzine, and venlafaxine should should notnot be be initiated in PCinitiated in PC

Chronic anxious depressionChronic anxious depression(mainly seen in primary (mainly seen in primary

care)care)

Remember social & I-P causes

Combined AD and CBT

Consider befriending

Telephone support

Enhanced care

A simple management for chronic A simple management for chronic anxious depressionanxious depression

Regular structured visits; plan activities – relaxing or distracting; problem-solving; avoid negative thoughts

Exercise may be helpful, also sleep management

Keep referrals and investigations to a minimum

Poly-pharmacy to be avoided; so simplify medication

Sick role may be unhelpful; encourage self-help & confidence building

TREATMENT RESISTANT TREATMENT RESISTANT DEPRESSIONDEPRESSION

Try a different drug, from a different Try a different drug, from a different groupgroup

Problem solving, IPT or CBT if availableProblem solving, IPT or CBT if available

Consider referral to a psychiatrist for Consider referral to a psychiatrist for other treatmentsother treatments

((Try venlafaxine if patient won’t go?)Try venlafaxine if patient won’t go?)

..

What doesn’t seem to work?What doesn’t seem to work?

Lots of thingsLots of things..

Supportive counselling; aroma therapy; Supportive counselling; aroma therapy; avoiding coffee and chocolate; Colour avoiding coffee and chocolate; Colour therapy; dance therapy; fish oils; ginkgo; therapy; dance therapy; fish oils; ginkgo; ginseng; glutamine; homoeopathy; lemon ginseng; glutamine; homoeopathy; lemon balm; meditation; music; painkillers; balm; meditation; music; painkillers; keeping a pet; selenium; avoiding sugar; keeping a pet; selenium; avoiding sugar; tyrosine; vervain.tyrosine; vervain.

Many of these are harmless, but there is no Many of these are harmless, but there is no evidence that they are effectiveevidence that they are effective

WHO NEEDSWHO NEEDSPSYCHOTHERAPY?PSYCHOTHERAPY?

those who won’t take drugs at allthose who won’t take drugs at all

those who won’t persist with drugsthose who won’t persist with drugs

those who relapse despite drugsthose who relapse despite drugs

those who don’t respond to drugsthose who don’t respond to drugs

effects may be additiveeffects may be additive

Psychotherapy for Psychotherapy for depressiondepression

in primary carein primary careSpecial training needed for IPT & Special training needed for IPT & CBTCBT

GPs find CBT unfamiliar & difficultGPs find CBT unfamiliar & difficult

usually no-one else to do the usually no-one else to do the treatmentstreatments

but both GPs and nurses can be but both GPs and nurses can be trained to do trained to do problem solvingproblem solving

How to decide in each case?How to decide in each case? (Patient-based Evidence)(Patient-based Evidence)

What is time course of the disorder?What is time course of the disorder?

Is there a family history of Is there a family history of depression?depression?

Is there a past history of depression?Is there a past history of depression?

Is there social support? Is there social support?

How severe is the depression now?How severe is the depression now?

Is severity increasing?Is severity increasing?

How to decide in each case?How to decide in each case?(Patient-based Evidence)(Patient-based Evidence)


Less than 2 weeks, or

Symptoms intermittent

- general advice, watch & wait

How to decide in each case?How to decide in each case?



If YES, favours active treatment





If YES, favours active treatment





Is there good social support? Is there good social support?

NO – active treatment

YES, and MILD:

favours advice, watch & wait





Is there social supportIs there social support? ?

How severe is the depression now?How severe is the depression now?

Is severity increasing?Is severity increasing?

≥7 symptoms or ≤ 6 deteriorating: treat

≤6, improving - advice, watch & wait

Problem SolvingProblem Solving1. Ask the patient to identify their MAIN problem

2. Ask them to think of possible solutions

3. Suggest any you can think of they haven’t mentioned

4. Prioritise the list; allow them to strike out impossible solutions

5. List advantages and disadvantages of each solution

6. Settle on their preferred solution: break it down into steps

7. They are to work on the first step of their preferred solution and report progress

to you

Some relative costs….Some relative costs….

For drugs, assume 4 sessions, 10 minsFor drugs, assume 4 sessions, 10 mins

Amitryptiline 100mg……..…… £67.10Amitryptiline 100mg……..…… £67.10

Prozac 20mg………………….. £114.00Prozac 20mg………………….. £114.00

Venlafaxine 75mg…………… £159.50Venlafaxine 75mg…………… £159.50

Problem solvingProblem solving, , 6 x 30 mins6 x 30 mins

By GP ………………………… £273.00By GP ………………………… £273.00

By nurse………..…………… £183.00By nurse………..…………… £183.00

In Summary….In Summary….

People consulting us need to receive People consulting us need to receive patient based evidencepatient based evidence, which is more , which is more than “evidence based medicine”than “evidence based medicine”

In mild depression, drugs are In mild depression, drugs are unnecessary provided you give good unnecessary provided you give good advice and follow-up the patientadvice and follow-up the patient

No drug is superior to another in No drug is superior to another in primary careprimary care

Differences between them are in Differences between them are in tolerability, toxicity and coststolerability, toxicity and costs

6: Treatment of 6: Treatment of UnexplainedUnexplained

Somatic SymptomsSomatic Symptoms

6. Treatment of USS:6. Treatment of USS:

Making linksMaking links - how symptoms - how symptoms relate to social & relate to social & interpersonal problemsinterpersonal problems

Some characteristicsSome characteristicsof consultations which of consultations which

encourage somatisationencourage somatisationBridges & Goldberg 1987Bridges & Goldberg 1987

Somatisation seen as a feature of Somatisation seen as a feature of dyadic exchange between doctor & dyadic exchange between doctor & patient:patient:

Doctor confines consultation to physical causes

(Patients collude with this)

Doctor avoids dealing with embarrassing or difficult material

Doctor may lack alternative strategies

Body

Mind


ANXIETY

What sort of symptoms?

Body

Mind


ANXIETY

Abdominal pain

tachycardia

dyspnoeaHow?

Body

Mind


ANXIETY

Abdominal pain

tachycardia

dyspnoea

Spasm in circular muscles of gut

Sympathetic stimulation

Bronchospasm

Body

Mind


PAIN gets worse

Depression/

anxiety not

invariably

present


Vigilance,

catastrophising

Autonomic

arousal

MEDICAL

ILLNESS

symptoms

Health care utilisation

ANXIETY


Vigilance,

catastrophising

Autonomic

arousal

MEDICAL

ILLNESS

symptoms

Health care utilisation

Body

Mind


DEPRESSION

How can depression cause physical symptoms?

Examples?


Rumination,

Lowered pain threshold

Depressive convictions about own health

Autonomic

arousal

symptoms

DEPRESSION

GP needs to:

make appointments to see the patient regularly,

each time to physically examine patient; and

NOT say “it’s your nerves”.

(It may help, if the patient is also depressed, to prescribe an anti-depressant).

A simple Management of Unexplained Somatic

symptoms

GP needs to physically examine patient; carry out all reasonable investigations; then reattribute the physical symptom.

(It may also be necessary to prescribe an anti-depressant).

A more complex management of Unexplained Somatic

symptoms

A more complex A more complex management: management: “reattribution“reattribution””

1)1) Feeling understoodFeeling understood: patient feels : patient feels doctor has understood his doctor has understood his symptomssymptoms

2)2) Changing the attributionChanging the attribution: the : the patient must “re-frame” symptoms patient must “re-frame” symptoms - see them in a different way- see them in a different way

3)3) Making the linkMaking the link: how emotion can : how emotion can cause the symptomscause the symptoms

Three stages:

Feeling understoodFeeling understood

Take a full history, clarify complaintTake a full history, clarify complaint Elicit associated symptomsElicit associated symptoms Respond to mood cues, probe mood Respond to mood cues, probe mood

statestate Explore social & family factorsExplore social & family factors Clarify health beliefsClarify health beliefs Perform a focused physical Perform a focused physical

examinationexamination

Changing the attributionChanging the attribution

Feedback the results of physical Feedback the results of physical examination & investigationsexamination & investigations

Acknowledge the reality of the Acknowledge the reality of the patient’s symptomspatient’s symptoms

Reframe the patients complaintsReframe the patients complaints: : remind them of other symptoms and remind them of other symptoms and life eventslife events

Making the linkMaking the link

EXPLANATIONEXPLANATION: linked to depression : linked to depression or anxietyor anxiety

DEMONSTRATIONDEMONSTRATION: Practical; “here : Practical; “here and now”; linked to life eventsand now”; linked to life events

IDENTIFICATIONIDENTIFICATION: other family : other family membersmembers

PROJECTIONPROJECTION: family member - : family member - learned behaviourlearned behaviour

Negotiating TreatmentNegotiating Treatment

Explore patient’s viewsExplore patient’s views

Acknowledge patient’s worries and Acknowledge patient’s worries and concernsconcerns

Problem-solving and coping Problem-solving and coping strategiesstrategies

RelaxationRelaxation

Appropriate treatment of depressionAppropriate treatment of depression

Specific plans for follow-upSpecific plans for follow-up

What do all effective treatments What do all effective treatments have in common?have in common?

A healer is prepared to see the patient A healer is prepared to see the patient and and support him or hersupport him or her through the through the crisis.crisis.

The healer must believe in what he or The healer must believe in what he or she is doing, to produce and she is doing, to produce and expectancyexpectancy that improvement will occur, and some that improvement will occur, and some hopehope for the future. for the future.

ALL successful healers do this!ALL successful healers do this!((Remember – different approaches suit Remember – different approaches suit

different people).different people).

That’s all today, but I’ll take questions

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A Bird’s Eye View of depression and unexplained somatic symptoms in primary care Wanchai, Hong...

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