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Module: Health Psychology Lecture: Psychological Medicine Date: 23 February 2009

This lecture provides an overview of psychological medicine in clinical practice, including the common somatic symptom presentations driven by psychological problems and the symptoms, prevalence, and consequences of depression. It also discusses appropriate screening methods and treatment options for depression.

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Module: Health Psychology Lecture: Psychological Medicine Date: 23 February 2009

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  1. Module: Health PsychologyLecture: Psychological MedicineDate: 23 February 2009 Chris Bridle, PhD, CPsychol Associate Professor (Reader) Warwick Medical School University of Warwick Tel: +44(24) 761 50222 Email: C.Bridle@warwick.ac.ukwww.warwick.ac.uk/go/hpsych

  2. 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

  3. Of the most common physical complaints in primary care, what % are explained organically? 40, 50, 60, 70%? What do you think? (Kroenke & Mangelsdorff, 2001)

  4. 3-Year Incidence of Common Symptoms and the proportion for which an organic cause was Suspected Incidence (%) Organic cause (Kroenke & Mangelsdorff, 2001)

  5. A pervasive issue for clinical practice Patients with a wide range of somatic symptoms are encountered not only in primary care, but within (all) the specialities also

  6. What % of primary care visits are driven by psychological factors? 5, 10, 20, 40%? 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 (Cummings & VandenBos, 1981; 2001)

  7. 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

  8. 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!

  9. What psychological problems bring patients into primary care? Anxiety 20% Depression 25% Miscellaneous 10% 10% Job Stress 25% Chronic Pain / Somatization 10% Family Problems (Tulkin & Gordon, 1998)

  10. 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)

  11. 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)

  12. Depression: Prevalence Prevalence underestimated by ~30% Prevalence (%) General Primary Medical Chronic Elderly Elderly Population Care Inpatients Illness (Own Home) (Care Home) (DoH, 2004)

  13. 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)

  14. Mechanisms of Action • Indirect pathway • Physical inactivity; Poor diet • Social withdrawal • Smoking; Alcohol use • Poor treatment adherence • Impaired self-care • Direct pathway • Endocrine stress response • HPA axis over-activity • Platelet stickiness • Autonomic instability • Metabolic dysfunction Poor quality / Ineffective medical care

  15. Improving Care

  16. 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?

  17. 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

  18. Treatment Types • All treatments aim to promote personal change • Change can occur in 3 domains Affect: How we feel Behaviour: How we act Cognition: How we think • Treatment strategies target different mechanisms to promote change • Two principle types of treatment strategy: Psychological and Pharmacological

  19. Psychological Two broad types of treatment strategy 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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

  26. 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

  27. Problematic Prescribing of ADs 11 general practices in the West Midlands 48% prescribed an AD in 2002, still prescribed an AD in 2004

  28. Practical techniques to help you to help your mild-moderately depressed patients Enhance Adaptive Coping Activity Scheduling Monitoring Behavioural Activation

  29. 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

  30. 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

  31. Activity Scheduling

  32. Activity Experience • Pleasure • Provides immediate reinforcement • Builds expectation for repeatable reward • Enhances behavioural motivation • Increases probability of generalisation • Mastery • Generates hopefulness / reduces helplessness • Increases self-esteem and future orientation • Develops self-efficacy and goal orientation • Creates favourable appraisal context

  33. Behavioural Activation • Move beyond activity scheduling • Focused activation • Graded task assignment • Avoidance modification • Routine self-regulation • Attention to experience

  34. 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

  35. 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

  36. 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

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