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THE
DISTRESSED/ANXIOUS/
DEPRESSED PATIENT
Lia Ali
Jane Hutton
THE
DISTRESSED/ANXIOUS/
DEPRESSED PATIENT
Lia Ali
Jane Hutton
INTRODUCTORY ROLE
PLAY &
VIGNETTES
Vignette 1
45 yo divorced man is in for a gall bladder
operation. On the ward he is quiet, makes poor
eye contact and at times appears tearful.
He only talks when asked direct questions, but has
said he sees no point in having the operation
because he does not deserve it.
Vignette 2
The patient is a 30 year old single
mother of two. She presents to A&E
having taken an overdose of
prescription diazepam.
Vignette 2
She is observed overnight and declared medically
fit.
There is a three month history of low mood
contemporaneous with a relationship breakdown
and yesterday she found out she may be evicted
from her home.
The diazepam was from the GP. No other meds.
Vignette 2
The patient’s mother has suffered with
depression and her father died young from
complications of alcoholism.
OD now regretted. Patient now resolved to
address her difficulties.
Vignette 3
82 year old man admitted through A&E for an
exacerbation of COPD
Sats are good but continues to complain of
breathlessness and call for a nurse frequently
This is his fourth such admission over the last year,
and they are becoming more frequent
The team are planning for discharge, but he is
reluctant for this
Vignette 3
The staff are becoming impatient with him.
He knows this, but views his continuing
breathlessness as a sign that something has
been missed.
He is married with 2 children. He has no personal
history of mental health problems but has a
family history of alcoholism and anxiety
problems.
Vignette 3
Upon questioning, he reveals that he gets
very anxious about going to bed at night.
INTRODUCTION TO
ANXIETY AND
DEPRESSION
Depression
Someone who is depressed might feel…
•Sad, low, weepy, guilty, despairing,
overwhelmed or numb
•Fed up and irritable, and snap at those
closest to them
•Lonely, even when they are with other
people
•Particularly low in the morning
•Tired all the time
•Preoccupied and find it hard to enjoy
things
•Hopeless about the future
They might also…
•Find it hard to get out of bed and to get
going
•Be restless and unable to settle to anything
•Have trouble with concentration or
memory
•Eat and sleep more or less
•Stopping seeing people and doing things
they enjoy
•Lack confidence in self
•Be harsh on self “ not good enough”
•Think negatively about the world
•Think about self-harm
Anxiety
•Pain or tightness in the chest
•Fast, shallow breathing
•Fast or pounding heart beat
•Feeling dizzy or faint
•Tense or aching muscles
•Headaches
•Sweating
•Stomach churning
•Needing to go to the toilet
•Trembling
•Pins and needles or
numbness
•Fearing the worst
•Worrying
•Can’t concentrate
•Fidgety, can’t relax
•Irritable
•Avoid feared situations
Also…
• Unhelpful health beliefs
• Difficulty adjusting to situation
Impact of anxiety and depression
• Symptoms may be difficult to distinguish from symptoms of physical
illness and may interfere with investigations or interventions.
• Depression and anxiety may lead to poorer outcomes through direct
physiological mechanisms, by decreasing adherence to treatment and
by increasing unhealthy behaviour such as smoking, poor diet and lack
of exercise
• Predict increased length of hospital stay, more outpatient visits, poorer
quality of life (Koenig and Kuchibhatla, 1998), greater disability
(Pohjasvaara et al, 2001), increased admissions and health care costs,
poorer concordance with treatments (NHS, 2009) and poorer health
outcomes, for example, increased death rate after a heart attack (DH,
2009)
• Often predict functioning better than medical variables do
Depression in diabetes
• Bi-directional association with diabetic
complications, which may induce low mood, selfblame and helplessness, but also be influenced by
poorer self-care and physiological mechanisms
Cardiac illness
• Smoking post-MI doubles risk of cardiac death, and is
predicted by depression (Taylor et al, 1998).
• Self-efficacy predicts functioning and treatment
adherence in heart failure (Mumby, 1995; Schweitzer et
al, 2007) .
• Perceived control and role maintenance are important
(Fowers, 1994; Vale, 1998).
• Optimism predicts success in changing risk factors and
more adaptive coping (Shepperd et al, 1996;
Desharnais et al, 1990).
• Belief vigorous activity will evoke another MI predicts
poorer prognosis (Reigel, 1993).
COPD (Hynninen et al, 2005)
• Anxiety and depression are associated with hospitalisation,
length of stay and post-discharge mortality
• Depression is associated with continued smoking and poorer
physical and social functioning, and is untreated in a majority of
cases (Ng et al, 2007; Pooler and Beech, 2014)
• Anxiety is common and leads to avoidance of exercise, reduced
fitness and greater disability
• Unsurprising; most people find breathlessness frightening
• Fears about deterioration and death also understandable
• But psychological distress is not inevitable consequence of
COPD, but complication which increases disability and reduces
capacity to engage in treatment
• Can be successfully treated, with benefits for quality of life and
probably physical functioning
ASKING ABOUT
MENTAL HEALTH
Asking about mental health
• This is as difficult for you as asking
someone about their bowel habit once
was.
• Practice will help.
• This will soon not be a big deal.
• Your confidence rubs off on patients and
other staff.
Asking about mental health
Your own form of words (eg):
“How are you?”
“Have you had any problems with your
mental health?”
“How are you in yourself?”
Authentic phrasing not the Mac Tilt!
Asking about mental health
Exercise:
Pair up.
Ask your partner about their mental health.
(Use a history from a patient you know)
Reflect back.
Asking about mental health
Talking points:
Concerns about being intrusive.
Asking for permission.
Fears about opening up and not being able
to fix (a problem for health staff).
Upsetting/frightening to hear about mental
health problems.
ASSESSMENT TOOLS
HADS (Zigmond and Snaith, 1983)
0-3 scales,cut-off of 8, ?unidimensional
•I feel tense or wound up
•I still enjoy the things I used to
enjoy
•I get a sort of frightened feeling as
if something bad is about to happen •I can laugh and see the funny side
of things
•Worrying thoughts go through my
mind
•I feel cheerful
•I can sit at ease and feel relaxed
•I feel as if I am slowed down
•I get a sort of frightened feeling like •I have lost interest in my
butterflies in the stomach
appearance
•I feel restless and have to be on the •I look forward to enjoyment with
move
things
•I get sudden feelings of panic
•I can enjoy a good book or radio or
TV programme
GAD-7
• Over the last 2 weeks, how often have you been bothered by the
following problems?
• 0-3: not at all, several days, more than half the days, nearly every day
• Feeling nervous, anxious or on edge
• Not being able to stop or control worrying
• Worrying too much about different things
• Trouble relaxing
• Being so restless that it is hard to sit still
• Becoming easily annoyed or irritable
• Feeling afraid as if something awful might happen
• 5-9 mild, 10-14 moderate, 15-21 severe anxiety
PHQ-9
•
Last 2 weeks, same 0-3 scales
•
Little interest or pleasure in doing things
•
Feeling down, depressed, or hopeless
•
Trouble falling or staying asleep, or sleeping too much
•
Feeling tired or having little energy
•
Poor appetite or overeating
•
Feeling bad about yourself or that you are a failure or have let yourself or your family
down
•
Trouble concentrating on things, such as reading the newspaper or watching television
•
Moving or speaking so slowly that other people could have noticed? Or the opposite,
being so fidgety or restless that you have been moving around a lot more than usual
•
Thoughts that you would be better off dead or of hurting yourself in some way
•
Scores of 5, 10, 15, and 20 are cut-off points for mild, moderate, moderately severe
and severe depression
DETECTION
Detection
• Listening and being ready to be
surprised
• Asking about concerns
• Simple need for information/problemsolving
• Acute v chronic
1. Challenges of detection
Problem 1
Symptoms exist on a continuum.
Disorder-labels are binary.
(decision to treat is binary)
(well/sick is also binary)
Cut-offs are arbitrary but necessary.
(>1 cut off = Stepped care)
1. Challenges of detection
Problem 2
There are no investigations in
mental health care.
1. Challenges of detection
Problem 3
Common mental disorders have physical
(somatic) symptoms and
cognitive/affective symptoms.
Should somatic symptoms be disregarded?
1. Challenges of detection
Problem 4
Anxiety and depression are very comorbid
(~60%).
They are grouped: Common Mental Disorder.
1. Challenges of detection
Common mental disorders are chronic
and remitting and relapsing illnesses.
Diagnosis should take into account
history and also impairment.
1. Challenges of detection
Passive detection
Active detection
Depression in palliative care:
In the absence of physical symptoms,
depression is v unlikely.
In the presence of physical symptoms,
depression may or may not be present.
Rayner L, Lee W, Price A, Monroe B, Sykes N, Hansford P, Higginson IJ, Hotopf
M. The clinical epidemiology of depression in palliative care and the predictive
value of somatic symptoms: Cross-sectional survey with four-week follow-up.
Palliative Medicine 2011;25(3):229.
1. Challenges of detection
ALTERNATIVE
DIAGNOSES
2. Alternative diagnoses
1. Organic, especially:
a. Delirium
b. Dementia
c. Substances
2. Psychosis.
3. Ordinary sadness / grief.
2. Alternative diagnoses
1. Delirium – investigate/treat urgently.
2. Dementia – refer.
3. Substances – refer.
4. Psychosis – refer urgently (not delirium).
If delirium, investigate/treat urgently.
5. Ordinary sadness / grief – you may be able to
manage this, but if not, refer.
2. Alternative diagnoses
Patients don’t come with diagnostic labels.
They come to your attention via behaviours:
Lost or agitated > Think organic especially delirium.
Mad > Think psychosis or organic.
Sad > Think depression or psychosis or organic.
Afraid > Think anxiety or depression or psychosis or
organic.
[Bad > Think personality or anxiety or depression or
psychosis or organic.]
Role Play – Michael’s story continues
ASSESSMENT
3. Assessment
•
•
•
•
•
•
•
Balancing open and closed questions
Using more specific questions e.g. How are your symptoms?
How are you in yourself?
Letting the patient know how much time you have, and that
they have your undivided attention for that time
Unless there is an emergency, sticking to this planned time
Be clear about the purpose of the appointment
Set an agenda together and check you have included
everything the patient wants to cover
Ask them to prioritise the problems which are most important
to tackle today, if it seems likely there won’t be time to cover
them all
Useful Questions
• Could you tell me a bit more about that?
• What troubles you the most about that? (this can
be a good question to interrupt a long account,
some details of which don’t seem relevant)
• Is this something you’d like some help with?
• Is there anything you’d like me to do?
• Are there any other problems we haven’t talked
about yet?
3. Assessment
Once referral made:
Interview. Usually 60-90 mins.
May also review notes, speak to staff,
speak to family, etc.
3. Assessment
1.
2.
3.
4.
5.
6.
7.
8.
9.
Presenting complaint/Hist of PC
Past Psych History/P Medical Hist
Family History
Personal History/Occup/Relationships
Tobacco Drugs Alcohol
Mental State Examination
Formulation (differential diagnosis)
Plan
Review
4. Management
Self Management – Psychoeducation + exercise
Psychotherapy – Many approaches.
Pharmacotherapy - Antidepressants
Combination of above approaches.
4. Management
Pharmacological:
Refer.
Antidepressants (TCA/SSRI/other).
Work in days.
Work in physical illnesses.
Work best in severe depression.
Serious interactions and side effects.
Antipharmacological:
Steroids. (not Beta blockers).
4. Management
General Approach to Treatment of Major Depressive Disorder in Patients With Comorbid
Medical Conditions Based on PHQ-8 or PHQ-9 Score and Degree of Functional Impairmenta.
Whooley, M. A. JAMA 2012;307:1848-1857
4. Management: CBT
• Interplay of bodily sensations, external
events, thoughts, feelings and (lack of)
actions
• Focus on changing thoughts and actions
• Evidence for anxiety and depression, even
in context of medical problems (van
Straten et al, 2010)
4. Management
Keeping active
Social support
Eating well, avoiding alcohol
Rest and sleep
Social support and being listened to
Meaningful activity
Coherent understanding of situation
Hope
NICE Guidance
NICE: Key priorities for implementation
Identifying depression in people with chronic illness
(PHQ-9, GAD-7)
Comprehensive assessment - functional impairment
and/or disability & duration of episode
Stepped care: LI and HI interventions
? Use of medication for mild depression
Choice of anti-depressants
Collaborative care if depression has not responded
to initial HI or anti-depressants
All interventions should be delivered by competent
practitioners
Low-intensity psychosocial interventions
For patients with mild to moderate depression
or sub-threshold depressive symptoms which
are persistent or complicate the care of the
medical problem…
Consider offering ≥1 of the following, guided
by patient preference:
• structured group physical activity
• group-based peer support
• individual guided CBT-based self-help
• computerised CBT
High-intensity psychosocial interventions
For patients with initial presentation of moderate
depression, offer the following choice of high
intensity psychological interventions:
 group-based CBT or
 individual CBT or
 behavioural couples therapy or
 medication or
 combined CBT and medication
5. Suicidality
Suicidal thoughts are common (10%/week)
Suicide is rare (~0.01%/year).
Suicidality fluctuates moment to moment.
5. Suicidality
Preventing suicides is mostly by
addressing the means.
Many suicides occur in people with no prior contact with mental
health services.
Most (~95%) people who kill themselves are diagnosable with a
psych disorder.
5. Suicidality
Some structure:
Ideation - Thinking about it.
Intent & plan – Preparing for it.
Access – How it might be done.
History – Attempted it before.
Red flags:
1. Threatening to hurt or kill himself
or herself
2. Looking for ways to kill himself or
herself
3. Seeking access to pills, weapons,
or other means
4. Talking or writing about death,
dying, or suicide.
Curr Psychiatry Rep.
2008 Feb;10(1):87-90.
Suicide warning signs in clinical practice.
http://bestpractice.bmj.com/bestpractice/monograph/1016/diagnosis
/step-by-step.html
Some answers
Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250
5. Suicidality (Self harm)
DSH is rising but suicide is falling (until
recently).
1:5 repeat within a year.
1:10 repeat 5 or more times in a year.
Usually an attempt to escape from an
intolerable situation.
Young – relationships.
Old – health / bereavement.
Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250
5. Suicidality (Self harm)
What to do:
Immediate risk assessment…
…by a mental health professional (NICE)
…by a health professional (RCPsych)
• Mental health problems?
• What is the risk?
• Medical or social problems?
.
Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250
5. Suicidality (Self harm)
What to do:
Allow for ‘processing’ and discussion.
Manage MH problems.
Manage risk.
Signpost or refer to services.
If input available, use it.
Emerg Med J 2006;23:251–255. doi: 10.1136/emj.2005.027250
5. Suicidality (Self harm)
Role play – Michael’s story continued
Case discussions