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: C.Bridle@warwick.ac.uk 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