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
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Aim: To provide an overview of psychological medicine
in the context of clinical practice
Objectives: You should be able to describe …
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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?
40, 50, 60, 70%? What do you think?
85%
15%
Organic Basis Found
No Organic Basis Found
(Kroenke & Mangelsdorff, 2001)
3-Year Incidence of Common Symptoms and the
proportion for which an organic cause was Suspected
10
Incidence (%)
9
8
7
6
5
4
3
2
Organic 1
cause
0
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A
organic cause
3 yr incidence (%)
(Kroenke & Mangelsdorff, 2001)
A pervasive issue for clinical practice
Patients with a wide range
of somatic symptoms are
encountered not only in
primary care, but within
(all) the specialities also
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
Psychological Medicine in Clinical Practice
What % of primary care visits are
driven by psychological factors?
5, 10, 20, 40%?
70%
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
30%
Medical Reason
Psychological Reason
(Cummings & VandenBos,
1981; 2001)
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?
Anxiety
20%
Depression
25%
Miscellaneous
10%
10%
Job Stress
25%
Chronic Pain /
Somatization
10%
Family
Problems
(Tulkin & Gordon, 1998)
Depression: What is it?
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Depression is a disorder of emotion, i.e. affective-disorder
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At least two types:
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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
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Prevalence is especially high in clinical populations
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Biggest cause of morbidity in the world (WHO)
ABC of Depressive Symptoms
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Symptoms of depression clustered by ABC
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Affect, e.g. persistently lowered mood,
diminished interest or pleasure in activities
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Behaviour, e.g. not eating (appetite loss), sleep
disturbance, lowered libido, social withdrawal
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Cognition, e.g. depressive ideation (guilt),
suicidal thoughts, fatalistic (hopelessness)
Depression: Prevalence
30
Prevalence (%)
25
Prevalence
underestimated
by ~30%
20
15
10
5
0
General
Population
Primary
Care
Medical
Inpatients
Chronic
Illness
Elderly
(Own Home)
Elderly
(Care Home)
(DoH, 2004)
Health Effects of Depression
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Depressive symptomatology predicts:
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Development of physical illness
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Onset of co-morbid complications

Functional recovery after stroke
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Mortality / survival …
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after myocardial infarction

after stroke and at 10 years

in unstable angina

in general medical inpatients
(Lett et al., 2004)
(Lustman et al., 2005)
(Parikh et al 1990)
(Donahoe et al., 2007)
(Morris et al., 1993)
(Frasure-Smith et al., 2000)
(Herrmann et al., 1998)
Mechanisms of Action
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Direct pathway
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Endocrine stress
response
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Indirect pathway
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Physical inactivity; Poor
diet
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HPA axis over-activity
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Social withdrawal
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Platelet stickiness
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Smoking; Alcohol use
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Autonomic instability
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Poor treatment adherence
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Metabolic dysfunction
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Impaired self-care
Poor quality / Ineffective medical care
Improving Care
Recognition: Screening
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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:
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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
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Yes to either question is a positive screen
Positive screen followed by more detailed assessment
to determine
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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
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All treatments aim to promote personal change

Change can occur in 3 domains
Affect:
Behaviour:
Cognition:
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
How we feel
How we act
How we think
Treatment strategies target different mechanisms to
promote change
Two principle types of treatment strategy:
Psychological and Pharmacological
Psychological
Two broad types of treatment strategy
Brief Psych Intervention
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Mental health promotion
Psychotherapy
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1 / <5 brief sessions
(<10 mins)
Integrated with usual
care as indicated
Delivered by any
competent health
professional in frequent
contact with patients
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Remediation of mental
health problems and
symptoms
Structured multi-session
interventions
Specific ‘stand-alone’
treatment
Delivered by qualified
professional
Brief Psychological Intervention

BPIs are effective for mild depression

Each should include scheduled, short-term follow-up
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Common strategies include:
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Watchful waiting: Reassurance and social facilitation ~30% recover within 6 weeks
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Guided self-help: Manual-based info and activities
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CCBT: Several packages available, e.g. Beating the Blues
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Exercise: Enhance motivation for behaviour change
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Life skills: Promoting adaptive coping processes
Psychotherapies in the NHS
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Psychotherapy is indicated for more severe and/or
complex depressive symptomatology
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Numerous types of psychotherapy
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Widely available psychotherapies in NHS include:
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Cognitive behaviour therapy
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Psychoanalytic therapies
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Systemic therapy
Cognitive Behaviour Therapy (CBT)
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CBT aims to identify, change and / correct negative
thought patterns, beliefs, and behaviours by combining
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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)
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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
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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
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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
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Core therapies are available in NHS
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Aim to promote personal change in ABC domains
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CBT is most used, researched and evidence-based
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Effectiveness varies according to condition
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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
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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%
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Patients worry about side-effects, e.g. weight gain, addiction, nonreversible physiological changes
Ending treatment is problematic
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Fear of relapse - psychological if not physiological dependence
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Ambiguity about treatment duration / completion from outset
Problematic Prescribing of ADs
11 general practices in the West Midlands
Year
2002
2004
All Ages
Aged <70
Aged >70
5648 / 81221
4631 / 73795
1017/7426
(6.9%)
(6.3%)
(13.7%)
5812 / 83859
4904 / 77190
908 / 6669
(6.9%)
(6.3%)
(13.6%)
48% prescribed an AD in 2002, still prescribed an AD in 2004
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:
Problem-Solving Tasks:
Facilitate appraisal, e.g.
education, information,
discussion
Identify all problems
Mobilising resources, e.g.
increase social support
Re-appraise success, e.g.
active follow-up
Break down into components
Set priorities
Generate possible solutions
Identify solution to try
Assess its effect on problem
Activity Scheduling
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Monitor current activity
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Involves patient in planning
Teaches that everything’s an activity
Assess activity experience
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Mastery – sense of achievement
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Pleasure – personal reward / satisfaction
Schedule new activities
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Break down activities – essential ingredients
Schedule new, high yield activities
Activity Scheduling
Time
09-1000
10-1100
11-1200
12-1300
13-1400
Monday
Tuesday
Wednesday
Went back to bed
Asleep
Hospital
M0 P0
M0 P0
M2 P0
Still in bed
Went to shops
Watch telly
M0 P0
M3 P0
M0 P1
Watch telly
Shops
Called friend
M0 P1
M3 P0
M0 P2
Went to shop
Lunch in town
Washing
M1 P0
M0 P3
M3 P0
Made lunch
Watch telly
Made lunch
M2 P2
M0 P0
M2 P1
Activity Experience
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Mastery
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Generates hopefulness
/ reduces helplessness
Increases self-esteem
and future orientation
Develops self-efficacy
and goal orientation
Creates favourable
appraisal context
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Pleasure
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Provides immediate
reinforcement
Builds expectation for
repeatable reward
Enhances behavioural
motivation
Increases probability of
generalisation
Behavioural Activation
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Move beyond activity scheduling
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Focused activation
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Graded task assignment
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Avoidance modification
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Routine self-regulation
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Attention to experience
Benefits of These BPI Techniques
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Don’t need major expertise in mental health care
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Proven clinical and cost-effectiveness
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3-4 brief sessions can ameliorate symptom burden,
prevent further decline and reduce future resource use
Consistent with contemporary clinical practice


Any health professional can / should learn and practise
these techniques
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