Common Psychiatric

Conditions

Dr Imran WaheedConsultant Psychiatrist

Birmingham Central Home Treatment Team

27th January 2011

Overview

• Managing depression

• Assessing deliberate self harm/suicide

• Violence and aggression

The Challenges in Primary Care

• Time constraints

• Training – only one third of GPs had any mental health training in the last 5 years

• 70 % of practice nurses have had no mental health training in the last 5 years

Depression

Managing Depression

Do antidepressants work?

Benefits of treating depression

Sweden: Two year educational programme (GPs on Gotland)

• Increased antidepressant use

• Reduced referral, sick leave and in-patient days for depression

• Significantly reduced suicide

(Rutz et al, Acta Psych Scand 1989;80:151-4)

Sweden: Annual on-going educational programme (GPs in Jämtland county)

• Antidepressant use increased from 25% below national average to the same level

• Suicide decreased to the national average

(Henriksson and Isacsson, Acta Psychiatr Scand 2006;114:159-67)

Denmark:

• Suicide rate (1995-1999) has dropped in all groups

• More markedly in people prescribed SSRIs or older antidepressants (n=438,625)

▫ Compared to those not treated with antidepressants (n=1,199,057)

(4yrs, Søndergård et al, Acta Psychiatr Scand 2006;114:168-76)

10% increase in SSRIs reduced suicide rate by 1.4%

10% increase in 2nd genn reduced suicide rate by 1.2%

Physical Symptoms in Psychiatric

Patients

Data from Kellner R, Sheffield BF. The one-week prevalence of symptoms in neurotic patients and normals.

Am J Psychiatry 1973;130:102–105

Psychiatric Healthy

Symptom Patients % Subjects %

Tiredness, lack of energy 85 40

Headache, head pains 64 48

Dizziness or faintness 60 14

Feeling of weakness in parts of body 57 23

Muscle pains, aches, rheumatism 53 27

Stomach pains 51 20

Chest pains 46 14

Deliberate Self Harm &

Suicide

Overview

• Every week 10% of the UK population aged 16-65 report significant depressive symptoms, and one in 10 of these admits to suicidal thinking

• But fewer than two people in a million will kill themselves.

• A typical primary care group of 100 000 expects 10 suicides a year.

• Depressive disorders are therefore common, while suicide remains rare.

Suicide Statistics

• Among the 10 leading causes of death in most countries

• Over past 2 decades considerable increase in young men committing suicide

• 1 % of all deaths• 6000 suicides a year• For every suicide there are more than 30

episodes of non fatal self-harm• In 2003 men accounted for 75% of all suicides

Copyright ©2005 BMJ Publishing Group Ltd.

Hawton, K. et al. BMJ 2005;330:891-894

Suicide and undetermined deaths in England and Wales in 15-19 year olds and 20-24 year olds between 1968 and 2000. Data source: Office for National Statistics. Twentieth century

mortality: 100 years of mortality data in England and Wales by age, sex, year and

underlying cause. CD Rom. London: ONS, 2003.

Case Scenario

• A 33 year old HCA presents in primary care.

• She is having repeated thoughts of taking her own life by taking an overdose or crashing her car.

• Her two daughters have been placed with her ex-partner – ongoing custody battle.

• She says she wants to die.

• She has just broken up with a new partner.

• She is having problems at work – service users have made complaints about her.

Risk factors

• Previous attempts – 1 % who attempt suicide die from suicide within a year & repetition rate is 100 times greater than the general population

• Suicidal ideation (communicated by 60 % of those attempting suicide)

• Presence of psychiatric disorders – 15 % of people with depression kill themselves, schizophrenia (10%), PD (5-25%) and drugs/alcohol (20%).

• Chronic physical illness e.g. cancer patients have risk twice that of general population

• Approximately 50 % of those who commit suicide have seen a doctor in the past month.

Demographic/social factors

• Age over 40, but rising in younger men

• Male sex

• More females attempt, more men succeed

• Single/unmarried/divorced

• Occupation (doctors, pharmacists, farmers)

• Unemployed

• Recent life crises

Assessment

• Asking a patient about suicide does not increase risk of suicide

• Those who talk about suicide do not commit suicide - nonsense

• Use graded questions – open and closed• Explore suicidal ideas – is there a plan?• What are the means? (e.g. guns – greater risk)

Seriousness• Intent• Planned vs. impulsive• Final acts• Attempts made to prevent discovery• How discovered and how brought to medical

attention?• Use graded questions – open and closed• Explore suicidal ideas – is there a plan?• What are the means? (e.g. guns – greater risk)• How do they feel now?

Other features

• Evidence of mental illness?

• What would stop the person committing suicide?

• Excessive guilt and loss of self-esteem

• What social support do they have?

Violence and Aggression

Overview

• Despite public concern about violence perpetrated by those with mental disorders, the number of homicides in the UK carried out by people with mental disorders has remained constant over the past 38 years as the total number of homicides has increased.

• There is no evidence that the killing of strangers has increased.

• Evidence does suggest that rates of all types of violencein mentally disordered offenders have increased since the 1970s, but this is matched by the rise in violence in community controls.

• There are high rates of mental disorder among prisoners, and people with schizophrenia are more likely than controls to be convicted of any offence, including violence.

• Does not necessarily mean that mental disorder is itself associated with offending. It could mean that people with mental disorders are more likely to be caught or convicted.

Risk factors

• Young male• Previous/recent Hx of violence• Psychopathic personality traits• Brain impairment –

disinhibition/impulsiveness• Use of drugs/alcohol• Long waiting times• Psychiatric disorder – esp. paranoid delusions,

command hallucinations

Warning signs

• Recent/previous history of violence

• Patient grievance

• Threats being made

• Possession of an object that could be used as a weapon

• Signs of anger/irritability

• Patient making interviewer fearful

• Intoxication/withdrawal state

Safety

• Small minority of patients can be potentially dangerous

• Does the patient have a history of violence?

• Make sure someone knows where you are

• Ensure that you can call for help if needed

• Avoid challenging confrontations and stay calm

• Arrange furniture so you can leave quickly

• Remove any potential weapons

• If you feel threatened, leave and seek help

Common Psychiatric

Conditions

Dr Imran WaheedConsultant Psychiatrist

Birmingham Central Home Treatment Team

27th January 2011