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PSYCHOLOGICAL MEDICINE

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PSYCHOLOGICAL MEDICINE Dr Eugene M Cassidy MD, MRCPsych, MMedSc (Physiol.) Consultant Liaison Psychiatrist CUH Eugene.Cassidy_at_hse.ie CUH Liaison Psychiatry – PowerPoint PPT presentation

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Title: PSYCHOLOGICAL MEDICINE


1
PSYCHOLOGICAL MEDICINE
  • Dr Eugene M Cassidy
  • MD, MRCPsych, MMedSc (Physiol.)
  • Consultant Liaison Psychiatrist
  • CUH
  • Eugene.Cassidy_at_hse.ie

2
(No Transcript)
3
Outline
  • Mental Health Problems in General Hospital -
    Overview
  • Psychological Adjustment to illness
  • Depression in Medical Illness
  • Alcohol Problems
  • Somatisation
  • Management

4
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)

5
Psychological adjustment to illness
6
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

7
Illness Perception / Beliefs
  • Illness identity
  • Cause
  • Consequences
  • Course
  • Cure/controllability
  • Influenced by
  • Medical Communication, Personal experience, Norms

8
Individual Vulnerability
  • Personality traits (e.g. tendency to worry about
    illness)
  • Prior experience of illness within a family
  • An individuals psychological state at the time
    of the illness
  • Previous experience of trauma, or a neglected or
    abusive childhood

9
Helpful Coping
  • Seeking information
  • Seeking practical and social support
  • Learning new skills
  • Developing new interests
  • Helping others
  • Emotion-focused coping

10
Less Helpful Coping
  • Hoping the condition will just disappear
  • Denial
  • Obsessively focusing on minute details of the
    disorder
  • Seeking others to blame

11
Response of Others to illness
  • Closing in
  • Drifting away
  • Infantilising
  • Depersonalising
  • Guthrie

12
Physical and Psychiatric Co-morbidity
13
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

14
Depression in Medical Illness
  • Vulnerability Stress model
  • Bio-psycho-social
  • Dimensional (significant depressive symptoms)
  • Categorical (Major Depression)

15
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

16
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

17
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

18
Screening for Major Depression
  • Please ask the following
  • 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
  • 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-Dimersgt1092ng/ml 3.1)
19
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

20
Frasure-Smith et al, 1993
21
Lesperance et al, 2002
22
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)

23
Depression is treatable
  • .. But it isnt always treated
  • Beware empathy and understanding
  • Antidepressants
  • Psychological therapies

24
Gill Hatcher, 2000
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The Burden of Alcohol Misuse on emergency
in-patient hospital admissions among residents
from a health board region in Ireland OFarrell,
S. Allwright, J. Downey, D Bedford, F.
Howell. Addiction (2004) 99, 1279-1285
  • Acute Alcohol intoxication
  • 2.0 all emergency admissions
  • 203/100,000 population


27
  • DETECTION
  • 80 doctors enquire
  • 46 record consumption
  • 1 recorded CAGE
  • 18 recognised by medic
  • 64 discharge summaries
  • 37 referred on
  • PREVALENCE
  • 147/759 (19.4) CAGE
  • 19 DSM-IV Abuse / Dependence
  • 30 male
  • 8 female

28
PHARMACOTHERAPY OF WITHDRAWAL
Pharmacological Management of Alcohol
Withdrawal Evidence-based practice
guideline Mayo-Smith et al, JAMA, 1997
Fixed Dose or Symptom Triggered
  • Benzodiazepines
  • Reduce symptoms
  • Prevent seizures
  • Prevent delirium

Withdrawal Scales
29
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)

30
A Good place to Intervene

Rumpf et al, 1987
31
Feedback Helps!
  • Health Consequences Feedback increases the
    proportion of patients willing to accept brief
    advice by _at_ ¼

R Patton, MJ Crawford, R Touquet. Emerg Med J
(2003)20 451-452
32
With respect to alcohol abuse, our charge is
straightforward first we must ask something,
then we must do something.
33
Somatisation
  • See other PPT PRESENTATION as part of this
    lecture series

CUH Liaison Psychiatry
34
Management of Mental Health Problemsin Medical
Illness
35
Framework for Psychological Support

 
Specialist psychological/ psychiatric
interventions
Counselling 
  Self- Help interventions
Effective information giving and communication
36
Stepped care approach (1)
  • Prevention
  • Information and Communication
  • Involve and Support families / carers

37
Stepped care approach (2)
  • Simple advice and problem-solving
  • Self-help
  • Relaxation techniques
  • Counselling problem focussed

38
Stepped care approach (3)
  • Drug treatments
  • Drug interactions
  • Benefits in co-morbid illness symptomatology
  • Specific psychological therapies
  • CBT
  • Marital therapy
  • Family therapy

39
Biopsychosocial Management
40
INTERESTED IN A CAREER IN PSYCHIATRY ???
  • Please contact me at Eugene.Cassidy_at_hse.ie
  • Tel 021-4920007
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