a bird’s eye view of depression and unexplained somatic symptoms in primary care wanchai, hong...
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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
rates / 100 consultations
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%)
rates / 100 consultations
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
STRESSFUL LIFE EVENT
DEPRESSION
Much worse
PAIN!
Pre-existing physical illness
Body
Mind
STRESSFUL LIFE EVENT
DEPRESSION
Much worse
PAIN!
Pre-existing physical illness
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
3: Assessment Skills….3: Assessment Skills….
Today, we will deal first withToday, we will deal first with
Assessing severity of depressionAssessing severity of depression
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
3: Assessment Skills….3: Assessment Skills….
Today, we will deal first withToday, we will deal first with
Assessing severity of depressionAssessing severity of depression
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)
What is time course of the disorder?What is time course of the disorder?
Less than 2 weeks, or
Symptoms intermittent
- general advice, watch & wait
How to decide in each case?How to decide in each case?
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?
If YES, favours active treatment
How to decide in each case?How to decide in each case?
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?
If YES, favours active treatment
How to decide in each case?How to decide in each case?
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 good social support? Is there good social support?
NO – active treatment
YES, and MILD:
favours advice, watch & wait
How to decide in each case?How to decide in each case?
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 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
STRESSFUL LIFE EVENT
ANXIETY
What sort of symptoms?
Body
Mind
STRESSFUL LIFE EVENT
ANXIETY
Abdominal pain
tachycardia
dyspnoeaHow?
Body
Mind
STRESSFUL LIFE EVENT
ANXIETY
Abdominal pain
tachycardia
dyspnoea
Spasm in circular muscles of gut
Sympathetic stimulation
Bronchospasm
Body
Mind
STRESSFUL LIFE EVENT
PAIN gets worse
Depression/
anxiety not
invariably
present
STRESSFUL LIFE EVENT
Vigilance,
catastrophising
Autonomic
arousal
MEDICAL
ILLNESS
symptoms
Health care utilisation
ANXIETY
STRESSFUL LIFE EVENT
Vigilance,
catastrophising
Autonomic
arousal
MEDICAL
ILLNESS
symptoms
Health care utilisation
Body
Mind
STRESSFUL LIFE EVENT
DEPRESSION
How can depression cause physical symptoms?
Examples?
STRESSFUL LIFE EVENT
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