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

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