Physical and mental health

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Physical and mental health

• Dr Alan Cohen FRCGP

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Presentations

• The presentation of mental illness with physical
  symptoms
• The association between mental illness and
  physical illness

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General Practice

• Disorganised/Chaotic
• Poor at identifying people with mental heath
  problems
• Not interested in mental health

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General Practice

• 280 million consultations annually
• 30 have a mental health component
• 91 of all mental health problems are managed
  entirely in primary care
• 25 of people with severe mental health problems
  are managed entirely in primary care

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What is General Practice?

• The art of general practice is organising the
  chaos of the first presentation
• People usually present with somatic symptoms
• A more acceptable ticket of entry
• Easier to explain
• Stigma
• Difficult sometimes to distinguish a
  psychological cause from a physical cause

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Medically Unexplained Symptoms

• 5 10 of all primary care consultations
• 50 of out patient attendances
• Associated with increased health care consumption
• Consultations in primary and secondary care
• Increased use of medication
• Associated with increased dissatisfaction in the
  consultation
• Both patient and GP

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Distinguishing between physical and mental health
problems...

• Reasons to refer
• We dont know what to do
• The diagnosis
• The management
• We know what to do but cant do it ourselves
• Investigations
• Procedures
• A second opinion
• The dump transfer of care

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Prevalence of unexplained symptoms in
consecutive attendees at a UK teaching hospital

• Clinic
• Chest 59
• Cardiology 56
• Gastroenterology 60
• Rheumatology 58
• Neurology 55
• Dental 49
• Gynaecology 57

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What this means....

• The wrong patient getting the wrong treatment at
  the wrong time
• Costs the NHS a great deal of money
• Increases disatisfaction of both patient and
  doctor

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Associations

• Common Mental Health Problems
• Depression
• Anxiety
• Severe and Enduring Mental Health Problems
• Schizophrenia
• Bi-polar disorder

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Depression

• Diabetes
• Ischaemic Heart Disease
• Stroke
• Other chronic neurological conditions
• Cancer

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Diabetes

• Depression is 2 3 times as common in people
  with diabetes
• Associated with
• Increased health care consumption
• Increased self perceived symptom load
• NOT associated with improved glycaemic control
• QOF Indicator

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Diabetes

• Cost of treating co-morbid diabetes and
  depression is 250
• Cost of all treatment is 400
• Proportion of NHS hospital expenditure on
  diabetes is 10 of total spend

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Ischaemic Heart Disease

• Depression is 2 3 times as common in people
  with ischaemic heart disease
• The best predictor of death following MI is the
  presence of depression
• QOF indicator

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Ischaemic Heart Disease

• 40 of admissions can be prevented by providing
  psychological treatments
• 50 of revascularisation procedures (CABG and
  PTCA) can be prevented by providing psychological
  treatments

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Anxiety

• Anxiety occurs in 25 of people with COPD
• People with COPD make up the largest group of
  frequent flyers
• A fear of becoming of short of breath, or
  actually becoming short of breath?

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Schizophrenia and Bi-polar disorder

• Few Papers
• Most studies are by Psychiatrists, about
  in-patient populations
• There are some large epidemiological studies
  which look at co-morbidity
• There are no papers on the characteristics
  (physical or mental) of the SEMI not in contact
  with the secondary services

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Characteristics

• In a study of 101 patients in the community
• 26 were obese (BMI gt 30)
• 53 were current smokers
• 11 were hypertensive (BP systolic gt160, diastolic
  gt100)
• SMR 150 (all causes)
• Kendrick 1996 B J Psych
• Harris and Barraclough 1998 B J Psych

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SMR by cause of death

• Respiratory disease
• SMR 250
• Infectious disease
• SMR 500
• Cardiovascular disease
• SMR 250

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Characteristics Health Promotion

• Consultation rate 13 -14
• Data that is recorded
• smoking 23
• BP 38
• Cx smear 28
• Mammography 8
• Alcohol use 20
• Weight 27
• Cholesterol 2.5
• Burns and Cohen BJGP 1998

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Schizophrenia co-morbidity

• Cardiovascular disease lifestyle
• Smoking 80-90 are smokers
• Respiratory disease - lifestyle
• Diabetes lifestyle, medication, genetics
• Hepatitis C and HIV - lifestyle
• Drug related movement disorders - iatrogenic
• Cancer colon - ???
• Rheumatoid Arthritis ???

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Bipolar co-morbidity

• As for schizophrenia plus
• Smoking 25 30 are smokers
• Drug related thyroid renal disorder - Lithium

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What to do?

• Burns and Kendrick recommend
• A proactive approach, closed questions for
  physical symptoms, and regular screening
• Examine BP, chest, skin, side effects and urine
  analysis
• Investigations CXR, ECG, FBC, ESR, TFTs
• Vision and Hearing tests
• Psychiatry and General Practice Today 1994
  (RCGP/RCPsych)

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(More) What to do?

• GP Guide from the Institute of Psychiatry
• BP, IHD, cerebro-vascular disease
• Chronic Bronchitis, infections
• Obesity
• Chiropody, vision and hearing problems
• diabetes mellitus, thyroid disease
• Drug side-effects
• Family planning including cervical smears
• Smoking, alcohol, exercise

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(Even more) What to do

• NICE guidance
• physical health is the responsibility of primary
  care
• Registers are needed
• Regular physical health checks, including
  endocrine disorders, cardiovascular disorders,
  life style risk factors
• Explicit recording of responsibility to monitor
  health care

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What GPs get paid to do...

• Do you really want to know???

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A brief overview of the GP contract

• Describes three levels of care
• Essential care
• Has to be provided by all general practices
• Additional care
• May be provided in addition to essential services
  (vaccinations etc)
• Enhanced care
• Provides care above and beyond that which is
  considered to be essential

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Essential Care

• Incentives exist to deliver high quality,
  evidence based outcomes for essential care
• The Quality and Outcome Framework (QOF)
• Points based incentive system
• Delivers a total of 1000 points
• 655 points are available for delivering clinical
  outcomes
• Outcomes divided into a number of clinical
  domains
• Points means !!

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The clinical areas covered

• CHD
• Heart Failure
• Stroke and TIA
• BP
• DM
• COPD
• CKD
• AF
• LD

• Asthma
• Dementia
• Depression
• Mental Health
• Obesity
• Smoking
• Palliative care
• Cancer
• Hypothyroidism
• Epilepsy

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Mental Health Domain
The practice can produce a register of people with schizophrenia, bipolar disorder and other psychoses 4
The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses with a review recorded in the preceding 15 months. In the review there should be evidence that the patient has been offered routine health promotion and prevention advice appropriate to their age, gender and health status 23
The percentage of patients on lithium therapy with a record of serum creatinine and TSH in the preceding 15 months 1
The percentage of patients on lithium therapy with a record of lithium levels in the therapeutic range within the previous 6 months 2
The percentage of patients on the register who have a comprehensive care plan documented in the records agreed between individuals, their family and/or carers as appropriate 6
The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who do not attend the practice for their annual review who are identified and followed up by the practice team within 14 days of non-attendance 3
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Mental Health Domain

• Delivers a total of 39 points (out of 655)
• Specifies a particular set of clinical diagnoses
  to be included in the register
• Schizophrenia
• Bi-polar disorder
• Other psychoses
• Excludes dementia, childhood behaviour disorders
  etc

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Mental Health Domain

• 2nd Indicator (MH9)
• The percentage of patients with schizophrenia,
  bipolar affective disorder and other psychoses
  with a review recorded in the preceding 15
  months. In the review there should be evidence
  that the patient has been offered routine health
  promotion and prevention advice appropriate to
  their age, gender and health status
• What does this mean in practice?

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Mental Health Domain

• The user/patient is called for an appointment
• Some interventions are offered
• There is not yet a requirement as to which
  investigations/interventions should be offered.

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Proposed changes

• Specify that the following interventions are
  recorded for everybody on the electronic list
• Blood pressure recorded
• Peak flow recorded
• Urine analysis/fasting blood glucose recorded
• Height and weight recorded (BMI recorded)
• Smoking habits recorded
• Drug and alcohol use
• Flu vaccination offered annually

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Further proposals

• Cervical screening as appropriate
• Drug and alcohol advice as appropriate
• Smoking cessation advice as appropriate
• Should this group be offered regular screening
  for bowel cancer a priority group for bowel
  screening programme?
• Should this group be screened for Hepatitis C and
  HIV status?

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In Summary

• Distinguishing mental from physical illness is
  not straightforward
• Managing the mental health problems of people
  with long term conditions will have a cost
  benefit
• Managing people with MUS will have a cost benefit
• There are significant associations between people
  with SMI and physical health problems

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Thank you

• Alan.cohen_at_scmh.org.uk