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Module: Health Psychology
Lecture: Psychological Medicine
Date: 23 February 2009
Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick
Tel: +44(24) 761 50222 Email: [email protected] www.warwick.ac.uk/go/hpsych
Aims and Objectives
Aim: To provide an overview of psychological medicine in the context of clinical practice
Objectives: You should be able to describe … the common somatic symptom presentations driven by
psychological problems the key features of BPI and different psychotherapies available
in the NHS the symptoms, prevalence and consequence of depression in
different populations, and appropriate screening methods the components of a stepped care model for depression,
including treatment options and their relative effectiveness BPI techniques for patients with mild-moderate depression
Of the most common physical complaints in primary care, what % are explained organically?
85%
15%
Organic Basis Found
No Organic Basis Found
(Kroenke & Mangelsdorff, 2001)
40, 50, 60, 70%? What do you think?
0
1
2
3
4
5
6
7
8
9
10
organic cause 3 yr incidence (%)
3-Year Incidence of Common Symptoms and the proportion for which an organic cause was Suspected
(Kroenke & Mangelsdorff, 2001)
Inci
den
ce (
%)
Organic cause
A pervasive issue for clinical practice
Specialty Problem / Symptom
Orthopedics - Low back pain
Obs/Gyn - Pelvic pain, PMS
ENT - Tinnitus
Neurology - Dizziness, headache
Cardiology - Atypical chest pain
Pulmonary - Hyperventilation, dyspnea
Rheumatology - Fibromyalgia, Pain
Internal Medicine - Chronic Fatigue Syndrome
Gastroenterology - Irritable Bowel Syndrome
Rehabilitation - Closed head injury
Endocrinology - Hypoglycemia
Patients with a wide range of somatic symptoms are encountered not only in
primary care, but within (all) the specialities also
What % of primary care visits are driven by psychological factors?
5, 10, 20, 40%?
30%
70%
Medical Reason
Psychological Reason
(Cummings & VandenBos,1981; 2001)
Psychological Medicine in Clinical Practice
A 20-year study found 60% of all primary care visits were attributable to
psychological factors …
… later replication estimated 70%!
Most patients (>90%) did not perceive psychological issues as relevant to
themselves / their visit
What does this mean?
Clinicians treat more patients with psychological conditions
than do mental health professionals
… but …
recall what we know about patient presentations and their
related beliefs
The Clinical Problem
Patients with psychological conditions often present with somatic (i.e. physical/bodily) symptoms, disclose only physical complaints, and do not recognise link between psychological
factors are physical health
Consequently … many patients with psychological conditions receive treatment only for their somatic symptoms
… thus … many patients with treatable psychological conditions remain undetected, inaccessible and untreated
… until … they come back, probably to consult for the same ‘treatment resistant’ somatic complaint!
What psychological problems bring patients into primary care?
25%Chronic Pain / Somatization
10%Family
Problems
10%Job Stress
Anxiety20%
Depression 25%
Miscellaneous10%
(Tulkin & Gordon, 1998)
Depression: What is it?
Depression is a disorder of emotion, i.e. affective-disorder
At least two types: Unipolar: focus of this session Bipolar: involves (rapid) transition between depressive and
manic phases – ~25% of all depression cases
Unipolar has high incidence – 5% of population will suffer at least one episode of depression
Average age of onset ~30 years, and is recurring illness for ~70% of people
Prevalence is especially high in clinical populations
Biggest cause of morbidity in the world (WHO)
ABC of Depressive Symptoms
Symptoms of depression clustered by ABC
Affect, e.g. persistently lowered mood, diminished interest or pleasure in activities
Behaviour, e.g. not eating (appetite loss), sleep disturbance, lowered libido, social withdrawal
Cognition, e.g. depressive ideation (guilt), suicidal thoughts, fatalistic (hopelessness)
Depression: Prevalence
0
5
10
15
20
25
30
Pre
vale
nce
(%
)
General Primary Medical Chronic Elderly Elderly Population Care Inpatients Illness (Own Home) (Care Home)
(DoH, 2004)
Prevalenceunderestimated
by ~30%
Health Effects of Depression
Depressive symptomatology predicts: Development of physical illness (Lett et al., 2004)
Onset of co-morbid complications (Lustman et al., 2005)
Functional recovery after stroke (Parikh et al 1990)
Mortality / survival …
after myocardial infarction (Donahoe et al., 2007)
after stroke and at 10 years (Morris et al., 1993)
in unstable angina (Frasure-Smith et al., 2000)
in general medical inpatients (Herrmann et al., 1998)
Mechanisms of Action
Direct pathway Endocrine stress
response
HPA axis over-activity
Platelet stickiness
Autonomic instability
Metabolic dysfunction
Indirect pathway Physical inactivity; Poor
diet
Social withdrawal
Smoking; Alcohol use
Poor treatment adherence
Impaired self-care
Poor quality / Ineffective medical care
Improving Care
Recognition: Screening
Targeted screening, e.g. non-organic cause, chronic illness, medical patient, etc.
Screening based on questions about affect and motivation within a specified time period
Two questions:
During the past month have you often been bothered by feeling down, depressed or hopeless?
During the past month have you often been bothered by little interest or pleasure in doing things?
Positive Screen
Yes to either question is a positive screen
Positive screen followed by more detailed assessment to determine
Symptom severity: common measures can be helpful, e.g. HADS; GHQ; BDI; CES-D
Suicide risk: suicidal ideation / thoughts; suicide planning; previous self-harm
Differential diagnosis: Bi-polar disorder; Alcohol misuse; Substance abuse; Generalised anxiety, Acute psychosis
Treatment Types
All treatments aim to promote personal change
Change can occur in 3 domains
Affect: How we feel
Behaviour: How we actCognition: How we think
Treatment strategies target different mechanisms to promote change
Two principle types of treatment strategy: Psychological and Pharmacological
Psychological
Psychotherapy Remediation of mental
health problems and symptoms
Structured multi-session interventions
Specific ‘stand-alone’ treatment
Delivered by qualified professional
Brief Psych Intervention
Mental health promotion
1 / <5 brief sessions (<10 mins)
Integrated with usual care as indicated
Delivered by any competent health professional in frequent contact with patients
Two broad types of treatment strategy
Brief Psychological Intervention
BPIs are effective for mild depression
Each should include scheduled, short-term follow-up
Common strategies include: Watchful waiting: Reassurance and social facilitation -
~30% recover within 6 weeks
Guided self-help: Manual-based info and activities
CCBT: Several packages available, e.g. Beating the Blues
Exercise: Enhance motivation for behaviour change
Life skills: Promoting adaptive coping processes
Psychotherapies in the NHS
Psychotherapy is indicated for more severe and/or complex depressive symptomatology
Numerous types of psychotherapy
Widely available psychotherapies in NHS include: Cognitive behaviour therapy
Psychoanalytic therapies
Systemic therapy
Cognitive Behaviour Therapy (CBT)
CBT aims to identify, change and / correct negative thought patterns, beliefs, and behaviours by combining
Behavioural techniques (e.g. activity scheduling, rewards, desensitisation) used to change unwanted behaviours
Cognitive techniques (e.g. dichotomous reasoning, overgeneralisations, personalisation) used to challenge negative automatic thoughts
Personal change occurs as a result of specific techniques delivered on the basis of a therapeutic relationship, i.e. techniques are instrumental
Psychoanalytic Therapies (PAT)
Several types of PAT, e.g. psychodynamic therapy and psychoanalytic psychotherapy
Mental health problems reflect unconscious / unresolved conflicts that are being re-enacted in adult life
Therapy provides opportunity for emotional assimilation, insight and interpretation
Personal change occurs as a result of a therapeutic relationship delivered through the vehicle of specific techniques, i.e. the clinical relationship is instrumental
Systemic therapy
Seeks to understand individual problems in relation to social roles and relationships - often involves family
Aims to identify, explore and change patterns of unhelpful beliefs and behaviours in roles and relationships
Short-term intervention where providers actively intervene to enable people to decide where change would be
desirable to facilitate the process of establishing new, more fulfilling
and useful patterns Personal change occurs as a result of developing social
relations guided by techniques delivered by therapist, i.e. the social relationship is instrumental
Summary of Psychotherapies
Core therapies are available in NHS
Aim to promote personal change in ABC domains
CBT is most used, researched and evidence-based
Effectiveness varies according to condition CBT: Disorders related to depression, generalised
anxiety, eating, CFS, and management of chronic pain
PAT: Depression, anxiety disorders, phobias, anger / emotional expression
Systemic therapy: mental health problems caused and / or exacerbated by problematic social relationships
Pharmacological Interventions
Different classes of antidepressants available, e.g. Tricylics, MOIs and SSRIs
~2-week lag before minimal symptom improvement, and 6 weeks for maximum effect
Average AD response is ~55%, whilst average placebo response is ~35%
High rate of AD treatment discontinuation, ~30% Patients worry about side-effects, e.g. weight gain, addiction, non-
reversible physiological changes
Ending treatment is problematic Fear of relapse - psychological if not physiological dependence Ambiguity about treatment duration / completion from outset
Problematic Prescribing of ADs
Year All Ages Aged <70 Aged >70
20025648 / 81221
(6.9%)
4631 / 73795
(6.3%)
1017/7426
(13.7%)
20045812 / 83859
(6.9%)
4904 / 77190
(6.3%)
908 / 6669
(13.6%)
48% prescribed an AD in 2002, still prescribed an AD in 2004
11 general practices in the West Midlands
Practical techniques to help you to help your mild-moderately depressed patients
Enhance Adaptive Coping
Activity Scheduling
Monitoring
Behavioural Activation
Enhancing Adaptive Coping
Coping Processes:
Facilitate appraisal, e.g. education, information,
discussion
Mobilising resources, e.g. increase social support
Re-appraise success, e.g. active follow-up
Problem-Solving Tasks:
Identify all problems
Break down into components
Set priorities
Generate possible solutions
Identify solution to try
Assess its effect on problem
Activity Scheduling
Monitor current activity Involves patient in planning Teaches that everything’s an activity
Assess activity experience Mastery – sense of achievement Pleasure – personal reward / satisfaction
Schedule new activities Break down activities – essential ingredients Schedule new, high yield activities
Activity Scheduling
Time Monday Tuesday Wednesday
09-1000Went back to bed
M0 P0
Asleep
M0 P0
Hospital
M2 P0
10-1100Still in bed
M0 P0
Went to shops
M3 P0
Watch telly
M0 P1
11-1200 Watch telly
M0 P1
Shops
M3 P0
Called friend
M0 P2
12-1300Went to shop
M1 P0
Lunch in town
M0 P3
Washing
M3 P0
13-1400Made lunch
M2 P2
Watch telly
M0 P0
Made lunch
M2 P1
Activity Experience
Mastery
Generates hopefulness / reduces helplessness
Increases self-esteem and future orientation
Develops self-efficacy and goal orientation
Creates favourable appraisal context
Pleasure
Provides immediate reinforcement
Builds expectation for repeatable reward
Enhances behavioural motivation
Increases probability of generalisation
Behavioural Activation
Move beyond activity scheduling
Focused activation
Graded task assignment
Avoidance modification
Routine self-regulation
Attention to experience
Benefits of These BPI Techniques
Don’t need major expertise in mental health care Any health professional can / should learn and practise
these techniques
Proven clinical and cost-effectiveness 3-4 brief sessions can ameliorate symptom burden,
prevent further decline and reduce future resource use
Consistent with contemporary clinical practice Offer immediate, patient-centred support / intervention
focused on problem that is important / relevant to patient
Enhance the Dr–Patient relationship Context for biopsychosocial discussion of patients lives and
enhanced understanding of mind-body interactions
Summary
This session would have helped you to understand …
the common somatic symptom presentations driven by psychological problems
the key features of BPI and different psychotherapies available in the NHS
the symptoms, prevalence and consequence of depression in different populations, and appropriate screening methods
the components of a stepped care model for depression, including treatment options and their relative effectiveness
BPI techniques for patients with mild-moderate depression
Any questions?
What now?
Obtain / download one of the recommended readings
ABC: Depression in Medical Patients
In your small groups consider today’s lecture in relation to your tutorial tasks:
a) integrated template
b) ESA question
Tutorial begins at 3.15