Special interest: Mental health

Psychosis is broadly defined as the presence of delusions and hallucinations and can be organic or functional in nature. The former is secondary to an underlying medical condition, such as delirium or dementia, the latter to a psychiatric disorder, such as schizophrenia or bipolar disorder. Functional psychosis is relatively common in the general population, with epidemiological studies estimating its prevalence to be approximately 0.2-0.7%. However, this figure varies depending on a number of factors including the definition used and the age group. By some definitions up to a third of people have experienced psychotic symptoms in their lifetime. Prevalence in the elderly increases to 4.8% and is even higher in nursing home populations. The identification and treatment of psychosis is important as it is associated with a 10% lifetime risk of suicide and significant social exclusion. Delays in recognition can ultimately lead to a worse prognosis.

Only a small minority of patients receive effective treatment for depression. About 40% of patients do not seek medical help, and of those who do, between 30 and 50% are not recognised as being depressed, usually as a result of somatic presentations. Patients may not be offered the appropriate treatment if strict diagnostic criteria are not applied, and under half of those receiving treatment will complete a minimal treatment course.

Postnatal depression is known to have a detrimental effect on the mother, baby and the family. Antenatal depression is also important and GPs have a role in managing depression throughout this key period.Women have considerable contact with health professionals before, during and after childbirth. Midwives and GPs are encouraged to use this to identify mental health problems as early as possible in antenatal care and monitor or treat those with symptoms or risk of illness. Infants of mothers with postnatal depression, especially boys, have poorer emotional, behavioural and cognitive development. Infants of women with antenatal anxiety and depression also have altered stress responses, which persist after birth, and are more likely to be born preterm and have a low birth weight. Personal and social relationships can be strained and disrupted, and these women are at a increased risk of domestic violence.

Autism, like most psychiatric disorders, covers a spectrum of severity from severely disabling classic autism to milder forms of Asperger’s syndrome which border on normality. The term autism spectrum disorder (ASD) includes autism, atypical autism and Asperger’s syndrome. Some parents consult their GP worried that their child might have autism. Others may attend with a range of concerns that might point to the condition such as problems with hearing, vision, hypersensitivity to sensory stimuli, behaviour management, language impairment or repetitive behaviour. Autism conditions often co-exist with neurological disorders (particularly those including epilepsy), and more than 300 syndromes which include autism have been described.The new NICE guidelines, launched in September 2011, cover children, from birth up to 19 years, on the autism spectrum and build on the guidance published by SIGN in 2007.ASD was once believed to be relatively rare but is now thought to occur in about 1% of children. There is certainly increasing demand for diagnostic services for children and young people. Whether the apparent increasing prevalence signifies an epidemic or an epidemic of discovery is debatable.

Generalised anxiety disorder (GAD) is a common condition, with a point prevalence of 4.4% among the adult population in England. It is characterised by a persistent, unfocused sense of threat, associated with symptoms of tension, autonomic hyperactivity and vigilance. Patients repeatedly overestimate the danger of physical or social harm, and at the same time underestimate their ability to cope. As a result, they worry excessively about a wide range of activities and life events, such as work, family issues, financial difficulties and health problems. GAD is a chronic relapsing condition, with a remission rate of only 38% after five years. It is associated with even greater impairment of occupational and social functioning than that associated with major depression, and has a significant impact on quality of life. However, around two-thirds of patients are not recognised in primary care and only a third of those identified by the 2007 household survey in England were receiving any form of treatment. Both in research and in clinical practice, there has been an excessive focus on depression to the detriment of the anxiety disorders. This is unfortunate in view of the high prevalence of GAD, its substantial impact on functioning and its association with chronic physical health problems. It is to be welcomed that this imbalance is now being addressed.

Obsessive-compulsive disorder (OCD) is common, chronic and debilitating. The estimated worldwide prevalence is 1-2%. In the UK alone there are estimated to be more than a million people with OCD, many of whom are unaware that it is a treatable condition. OCD is characterised by intrusive unwanted thoughts (obsessions) and ritualistic behaviours (compulsions).It can occur in children as young as six, and most patients who develop OCD will have symptoms in childhood or adolescence. Some develop OCD in adult life, and there is a subgroup of patients who develop it for the first time in old age. There is an equal incidence in both sexes.

Individual music therapy improves outcomes in depression when combined with standard therapy, a randomised controlled trial from Finland has found. A total of 79 participants (62 women), aged 18 to 50, with an ICD-10 diagnosis of depression were recruited from psychiatric health centres and polyclinics. Thirty three were allocated to the intervention group and 46 received standard care only. The intervention consisted of 20 twice-weekly sessions, each session lasting for one hour. Both the therapist and patient were provided with a keyboard, percussion instrument and acoustic drum. A therapeutic musical relationship was developed by improvising music together.

A large cohort study from the UK has reached the surprising conclusion that tricyclics are the safest class of antidepressants in elderly people. The cohort comprised 60,746 primary care patients aged 65 and over (mean age 75) with a new diagnosis of depression recorded between January 1 1996 and December 31 2007. The cohort was followed up until December 31 2008. Comments Dr Phillip Bland,'Perhaps the most striking result from this study is that almost 90% of the patients were given antidepressants. For elderly patients with mild to moderate depression, the risks of antidepressant medication are likely to outweigh the benefits, and a psychosocial intervention may well be preferable.If we are to prescribe, I do not think there is sufficient evidence to justify prescribing very low dose tricyclics (<75mg amitriptyline). Venlafaxine is not a first-line treatment, and this study suggests that we should be wary of prescribing mirtazapine to elderly patients (although NICE concluded that this might be the most cost-effective drug for moderate to severe depression).6 NICE recommends SSRIs, but I think a strong case can be made for considering lofepramine as an alternative in elderly patients: compared with older tricyclics, it causes fewer side effects, is less cardiotoxic and is safer in overdose.'

Online messaging via an electronic medical record is an effective and efficient way of providing enhanced care for depressed patients, a primary care study from the United States has found. Patients were also more likely to be satisfied with their treatment than those who received standard care.