Psychiatry in General Practice
Dr Almas Malik
ST2 GPVTS
Aims
• MSE
• Case scenario
• Risk
• Perinatal psychiatry
• Schizophrenia mx
• Ward interaction with PD
• Bipolar – when to refer
• Screening
Mental State Exam
A+B: eye contact, posture, psychomotor
Speech: rate, volume, tone
Mood: subjectively and objectively
Thoughts: content, flow, preoccupied, obsessive,
delusions
Perception: hallucinations
Risk
Insight
Case 1
• 39 yrs female, south Asian. Married, housewife, 2
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children 5 + 8. Previous consults non-specific hand pain
+ pre-menstrual sx’s + menorrhagia – (both
investigated)
Presents with hand pain + heavy periods
Not sleeping, tired all the time, husband doesn’t do
anything
Hand pain is so bad I want to kill myself
I can’t cope with looking after the children
Doctor please help me!
Assessing Risk
To self: superficial cutting, suicide, self-neglect
From others: Financial, Sexual, Physical. Contraception
To others: children in home, partners, family
Questions: thoughts of wanting to end their life, attempts
to end their life, plans to end their life – what, when,
how, plans for future, anything that would stop them
taking their own life – children. Superficial cutting –
frequency, intoxicated while harming
Past history of violence, suicide attempts, criminal records
• Social: home alone all day. Spends her time
doing housework and looking after children.
Doesn’t socialise, no friends. Husband works in
post office and pastor. No alcohol or drugs
• Why now – psychosocial triggers
Management of depression
• Assess risk + function
• Admission or manage in primary care
• Crisis plan to all patients: A+E, Samaritans + SLAM 24
hour line
• Non-pharmacological: self-help CBT Moodgym, MIND,
physical activity, regular reviews, SUN project –
emotional support group, Touchstone Centre – group
and individual psychotherapy
• Pharmacological – Moderate - severe
1. SSRI’s – citalopram 20mg od (r/w in first 2 weeks)
2. Different SSRI – sertraline 50mg od
3. Mirtazepine 30mg od (if sleep disturbance)
4. Venlafaxine 75mg od
Prevention – coping, social support, relaxation, exercise
Perinatal psychiatry
• Baby blues – in first week, lasting few
days. No tx
• Post-natal depression – in 6 months.
Sertraline or paroxetine, mother and baby
unit
• Puerperal psychosis
First 2 weeks, mood disturbance + delusions
+ hallucinations. Refer urgently.
antidepressant’s in pregnancy
• Sertraline preferred
• TCA’s lower risks in pregnancy, but
dangerous in O/D
• Paroxetine in first trimester fetal heart
defects - avoid
• Risk of mild, self-limiting withdrawal sx’s
in neonate with all anti-depressants
Management schizophrenia
Medication is mainstay of tx
single agent
Risperidone
Olanzapine – weight gain, cardiovascular risk,
diabetes risk
Role of CBT – hallucinations + delusions, improve
social functioning
Family therapy
Refer – risk issues, acutely distressed, decline of
functioning
Interesting interaction
• 39 yr old female, stood in corridor with bleeding arm
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from superficial cuts. Benzodiazepine reduced
Feeling anxious, boyfriend’s mum’s funeral coming up.
Wanted to support boyfriend but funeral was bringing
back memories of her own mother’s death. Couldn’t
cope with this additional stressor with current admission
+ medication changes
Wants benzodiazepine now as stressed and can’t cope
Bereavement counselling offered. Advised to speak to
her bf about how she was feeling. Commented disliked
Dr..
Seen a few times in the week, wanted to be seen more
Burdened, avoiding patient.
PD In GP
• Splitting
• Repeated - ‘heart-sink’
• Dependent nature
• Impulsive
• Instant gratification
• Poor-coping strategies
Management PD
• Medication has no role
• Help understanding of their diagnosis
• Talking therapies
• Touchstone group therapies to understand
actions and feelings
• SUN project – coping skills and support
• Negotiate how often patient is seen
• Admissions detrimental
Bipolar
Refer –
• acute relapses, risk, decline in functioning, non-
compliance
• Meds: antimanic – antipsychotics, valproate,
lithium
Preventing relapse:
• Patient education – recognise early symptoms of
relapse and seek help. Coping strategies
• Sleep hygiene, regular lifestyle. Shift work,
flights ax time zones
• Support during significant life events
‘ I think of the future it seems so bleak
I wish I could retain my high when at its peak
But I always seem to drop face first and hit the concrete
I feel like a prisoner of my own mind
I just wanna escape another identity, place and time
Anything to stop me feeling so confined
I used to think the answer would be in a bottle of wine
I feel so guilty for the burden placed on my daughter and hate myself for
having this mental disorder
I don’t want my daughter to care for her mum
I just wanted to perfect life for her
I have secret fears for her sanity as they say an illness like this can be
hereditary
Its a lonely feeling knowing you’re so misunderstood
I just want somebody to listen and fully understand
Offer me comfort and the support of a helping hand
Remind me I’m not alone and God still has a plan
Please Lord don’t let me slip from the grasp of your hand’
MH screening
At risk groups:
Chronic medical problems
Women – young, pregnancy, mother’s, menopause
Carers
Minority ethnic groups
Relapses:
Non-compliance
Social triggers
References
• NICE guidelines
• CSK website
• http://www.rcpsych.ac.uk/