MANAGING PATIENTS WITH CHRONIC MENTAL HEALTH PROBLEMS IN PRIMARY CARE

Transcription

1 MANAGING PATIENTS WITH CHRONIC MENTAL HEALTH PROBLEMS IN PRIMARY CARE Dr Ilyas Mirza Psychiatric Consultant Barnet Enfield & Haringey Mental Health Trust

2 CHRONIC MENTAL HEALTH Anxiety disorders PROBLEMS Affective disorders depression, bipolar Schizophrenia (s) Personality disorders Chronic diseases are diseases which current medical interventions can only control not cure. The life of a person with a chronic condition is forever altered there is no return to normal.

3 ISSUES

4 SCENARIOS 1. Supporting patient while waiting for response to referral 2. Supporting patient while waiting for appointment after assessment 3. Patient discharged back to care of GP 4. Patient stopping medication 5. Existing Trust patient deteriorating

5 SCENARIO 1 - Supporting patient while waiting for response to referral Patient with moderate - severe depression who has recently deteriorated. Treated by the Trust five years ago but not seen since. Non-urgent referral made but no assessment expected for at least 13 weeks. What to do for the patient in the meanwhile?

6 SCENARIO 2 Supporting patient while waiting for appointment after assessment Patient has been assessed and is waiting for an outpatient appointment and remains intermittently suicidal. GP has increased medication and sees patient every two weeks to try and hold him. What to do?

7 SCENARIO 3 Patient discharged back to care of GP Patient with schizophrenia discharged from inpatient care back to care of GP. Came to see GP and seemed psychotic and depressed with suicidal ideation, using paracetamol and alcohol. Carer extremely concerned and ringing GP frequently. How to treat them to promote recovery?

8 SCENARIO 4 Patient stopping medication Patient decides to stop antipsychotic medication because of subtle extrapyramidal effects. GP prescribed 15mg mirtazapine to try and help his mood/sleep pattern. Patient did not turn up for last review and has now run out of medication. How to get him to a review? How to motivate him to restart medication?

9 SCENARIO 5 Existing Trust patient deteriorating Existing Trust patient diagnosed as schizotypal with depression. GP now finds the patient to have paranoid delusions, lack of sleep and appetite and suicidal ideation. GP hears this from husband as wife has very little English. What to do to get him seen? How to treat them in the meanwhile?

10 DEPRESSION - DRUG TREATMENT Tricyclics e.g. Amitriyptyline, Dosulepin MAOIs- Moclobamide SSRIs- Fluoxetine, Sertraline, Citalopram NARI- Reboxetine SNRI- Venlafaxine, Duloxetine Others- Mirtzapine, Trazadone

11 A proposed model of symptoms mediated by 5-HT & NA* *Hypothetical neuro-behavioural model using several data sources based mostly on animal studies 1. Lucki I. Biol Psychiatry 1998; 44: Frazer A. J Clin Psychiatry 2001; 62(Suppl 12): Jones CL. Prog Brain Res 1991; 88: Ressler KJ, Nemeroff CB. Depress Anxiety 2000; 12(Suppl 1): 2 19.

12 Recovery Rates Diminish with Duration of Major Depressive Episode

13 A 5 Yr Prospective Follow Up of 431 Patients % R ate R ecoveryy % 16% 11% 6% 1% 6 Months 1 Year 2 Years 4 Years 5 Years The effect of decline in the level of depressive symptoms on the time to recovery was highly significant (P<0.0001). Recovery=8 weeks of Psychiatric Status Rating (PSR) 1 (no symptoms) or 2 (minimal symptoms, no impairment). Recovery=sustained remission. Keller MB et al. Arch Gen Psychiatry 1992;49(10): UKCYB00506 January 2010

14 Patients who do Receive Treatment with Antidepressants Response to initial monotherapy 2 Patients (%) % No 62% Yes Remission 1 HAM-D17 Score 7 Only about 30% of patients actually achieve full remission 1, Response *HAM-D17, 17-item Hamilton Rating Scale for Depression 1. Adapted from O Reardon JP et al. Psych Ann 1998;28: Adapted from Fawcett J, Barkin R L. J Clin Psych 1997;58(Suppl 6);32 9 UKCYB00506 January 2010

15 THE STAR*D STUDY Remission Rates With Open Label Treatment. % % of R Patients e m is s io n in (H Remission A M D -1 7 < 7 ) Level % Level % Mono = single Rx regimen Level % Mono Mono Mono n= 3,671 n= 789 n=226 Remission was defined as a score of <5 on the Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR16), equivalent to HAM-D17 score of <7. Rush AJ et al. American Journal of Psychiatry 2006;163 (11): UKCYB00506 January 2010

16 PSYCHO-SOCIAL TREATMENT Exercise Changes in endorphin and monoamine levels Increased self esteem due to social contact and sense of mastery. Sleep hygiene Social support Activity scheduling Problem solving approach

17 COGNITIVE BEHAVIOUR THERAPY Thoughts Behaviour Mood Physiological Reactions Socratic thinking Early experience Core beliefs Dysfunctional assumptions Critical incidents Depression

18 PSYCHO-SOCIAL TREATMENT Interpersonal Psychotherapy Interpersonal skill deficit underlying problem- role play, video feedback and methods to improve social skill Relationship conflict dealt with using systematic ideas. Clear communication, ownership and conflict resolution. Unresolved loss - guided mourning, reminiscence. Psychosocial transitions - balance sheets of losses and gains.

19 Positive symptoms Delusions Hallucinations Disorganised speech Disorganised behaviour Negative symptoms Blunt effect Emotional withdrawal Avolition Alogia Anhedonia.

20 COGNITIVE Thought disorder Incoherence Impaired attention Impairment in information processing.

21 Aggression or hostility Verbal aggression Hostility Self injurious behaviour. Depressive or anxious Irritability Guilt Tension Worry

22 ATYPICAL ANTIPSYCHOTICS Clozapine Amisulpiride Aripiprazole Olanzapine Quetiapine Risperidone

23 SIDE EFFECTS PROFILE EFFECT on QTc Hyperprolactinaemia Additional info/comments DRUG Weight Gain Sedation EPSE hypotension # Anticholinergic Postural Zuclopenthixol Atypical Antipsychotics (by BNF Listing) Amisulpride Aripiprazole /+ (akathisia) Clozapine Olanzapine /+ -/+ + Paliperidone Quetiapine Risperidone For treatment resistant schizophrenia,mandatory regular FBC tests, and registration with monitoring agency Primary active metabolite of risperidone Sertindole / Reintroduced after earlier suspension due to concerns about arrhythmias; its use is restricted to patients who are enrolled in clinical studies and who are intolerant of at least one other antipsychotic Zotepine / # This effect is dose related; EPSE: Extra Pyramidal side-effects? Not sufficiently active by mouth to be used as an antipsychotic, only licensed for short term management of agitation and restlessness Incidences: +++ High, ++ Moderate, + Low, - Little or Minimum,? Unknown

24 FORMULATIONS AVAILABLE DRUG Zuclopenthixol Amisulpride Aripiprazole Clozapine Olanzapine Paliperidone Quetiapine Risperidone Sertindole Zotepine FORMULATION (as acetate Acuphase) lasting 3 days Tablets, liquid Tablets, oro-dispersible tablets, liquid, short-acting injection Tablets Tablets, oro-dispersible tablets, liquid, short-acting injection Tablets Tablets (for twice daily use) and XL tablets (for once daily use) Tablets, oro-dispersible tablets, liquid, long acting IM injection for administration every two weeks Tablets Tablets

25 RECOVERY

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