Special interest: Mental health

In bipolar disorder patients are intermittently severely ill and unable to function, but they usually return to their normally functioning self. The extremes of symptoms and experiences require intensive specialist care,  but the overall success of management will depend on an informed and complementary interaction between primary and secondary care. Bipolar disorder is at least twice as common as schizophrenia, and eminently treatable. It is perfectly suited to the well established outpatient model practised in general practice.

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.

Exercise has been suggested as a means to lift mood for many years, and there is increasingly strong evidence for its use as a treatment for depression. Several meta-analyses have produced robust evidence that exercise is effective as a monotherapy for depression. There is also some evidence that exercise is beneficial as an adjunct to pharmacotherapy.

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.

There are clinical descriptions of children with attention disorders dating back to the late 18th century. ADHD is the term most widely used to cover a group of common, chronic neurodevelopmental disorders characterised by developmentally abnormal and disabling levels of restlessness and overactivity (usually combined with impulsiveness) and/or inattention. ADHD is multifactorial in origin, with a strong genetic component and is four times more common in boys than girls. The prevalence of ADHD is at least 5% and that of the most severe form i.e. hyperkinetic disorder (HKD) 1-2%. However, a survey of services for ADHD in Scotland found that only 0.6% of children and adolescents were receiving treatment.

For patients with  a chronic condition and depression the prognosis is thought to be  worse. Comorbid depression is associated with increased pain, greater functional impairment and reduced quality of life. Depressed patients may lack the confidence to self-manage their condition, increasing the risk of long-term complications.

Around 1 in 400 adults suffer from bipolar disorder at some point during their lives although it is unusual for the condition to develop after the age of 40. The prevalence of bipolar disorder in the elderly is reported to be 1%.Medical management with lithium, valproate or olanzapine is recommended as first-line therapy by NICE. Careful monitoring of lithium levels is essential, in particular to prevent toxicity as lithium has a low therapeutic index. Older patients are especially vulnerable, with one study reporting that over a period of 9 years 4% of elderly patients on lithium were hospitalised because of lithium toxicity.

'Compared with consultant physicians, we are more than three times as likely to commit suicide. GPs have the highest incidence of work-related mental ill health of any profession, with a rate more than 15 times the overall average.'

A GP's willingness to act on clinical intuition and respond to family concerns can be key to early detection

A longitudinal cohort study from New Zealand has suggested a unidirectional cause and effect relationship between cigarette smoking and depression, in which smoking increases the risk of developing symptoms of depression. The Christchurch Health and Development Study has followed up a group of 1,265 children who were born in 1977. Participants were studied at ages 18, 21 and 25, when 79-81% of the original cohort attended. 'When case finding among patients with chronic conditions, smoking is yet another important risk factor to add to the list of functional impairment, previous depression, physical inactivity, obesity and maladjustment. More controversially, it has been suggested that we should routinely target smoking cessation when treating depressed smokers.'

The authors suggest that the simpler definition is preferable for two reasons. First, it is easier to remember and will reduce the time needed to make an assessment. Second, for patients with a chronic condition, it avoids the difficulty of deciding whether somatic symptoms are caused by depression or by the physical illness itself. Another group of patients for whom this is often a problem are antenatal and postnatal mothers.

Of those patients whose depression is recognised, less than half will complete a minimal treatment course (≥2 months' antidepressants or four psychotherapy sessions). Case management is a low-cost intervention which can improve outcomes as a result of better adherence and increased recognition of non-responders.