Special Interest: Mental health

Common mental health disorders affect around one in five women during pregnancy and the first year following childbirth. Depression and anxiety disorders are the most prevalent mental health disorders during this period as they are at other times of life. It is important to distinguish postnatal depression from baby blues, which is common and requires no treatment, although it is a potential risk factor for postnatal depression. Postpartum psychosis affects 1 in 1,000 women and can develop very quickly in the first two weeks postpartum, often requiring urgent admission to a specialised mother and baby unit. One in six women with bipolar disorder will develop postpartum psychosis. 

In patients with suspected dementia, the history should cover cognitive, behavioural and psychological symptoms, and the impact symptoms have on daily life. A physical examination is necessary to look for any focal neurological signs and to exclude any visual or auditory problems. Baseline blood tests should be carried out. A medication review should be undertaken as many commonly prescribed drugs have anticholinergic effects which can exacerbate cognitive impairment. A brief cognitive screening test should be performed before referral to a memory clinic.

Depression and dementia are both common conditions in older people, and they frequently occur together. Rather than a risk factor, depression with onset in later life is more likely to be either prodromal to dementia or a condition that unmasks pre-existing cognitive impairment by compromising cognitive reserve. The distinction between depression and early dementia may be particularly difficult. Detailed histories obtained from patients and their relatives as well as longitudinal follow-up are important. 

Common causes of memory loss in older people are mild cognitive impairment, the various types of dementia, and psychiatric illness, mainly depression. Around 10% of patients with mild cognitive impairment progress to dementia each year. NICE guidance suggests examination of: attention, concentration, short- and long-term memory, praxis, language and executive function.

Psychosis is a state of mind in which a person loses contact with reality in at least one important respect while not intoxicated with, or withdrawing from, alcohol or drugs, and while not affected by an acute physical illness that better accounts for the symptoms. Common positive symptoms of psychosis include delusions and hallucinations. These symptoms are strongly influenced by the underlying cause of the psychosis: delusions in schizophrenia tend to be bizarre; delusions in depression negative; delusions in mania expansive. When a patient presents with psychotic symptoms, it is important to take a full psychiatric history, perform a mental state examination and complete relevant investigations, as indicated in each individual case.

Co-occurring severe mental illness, usually schizophrenia or bipolar affective disorder, and substance misuse is termed dual diagnosis. Mental illness and its consequences may lead to substance misuse as a coping strategy. Substance misuse can lead to mental health problems, either by triggering a first episode in a susceptible person, or by exacerbating an existing disorder. However, substance misuse itself is unlikely to be the sole cause of a severe and enduring mental illness.

It is estimated that up to 80% of patients with Parkinson’s disease will eventually develop cognitive impairment over the course of their illness. Even at the time of diagnosis, cognitive impairment has been reported in 20-25% of patients. Commonly affected domains are executive function, visuospatial ability and attention control. In addition, patients with Parkinson’s disease dementia may present with deficits in language function and verbal memory.

The diagnosis of post-traumatic stress disorder (PTSD) differs from most psychiatric disorders as it includes an aetiological factor, the traumatic event, as a core criterion. The DSM 5 core symptoms of PTSD are grouped into four key symptom clusters: re-experiencing, avoidance, negative cognitions and mood, and arousal. Symptoms must be present for at least one month and cause functional impairment.

Type 2 or complex trauma results from multiple or repeated traumatic events occurring over extended periods. Complex trauma is often associated with other adversity and stressors such as neglect, loss or deprivation. For many individuals these traumas occur at a developmentally vulnerable time with the perpetrator often in a caregiving role. Patients who have experienced complex trauma should be assessed for the core symptoms of PTSD. In addition, patients should be assessed for disturbances in the three domains of emotional dysregulation, negative self-concept and interpersonal disturbances.

The symptoms of depression in adolescents are similar to those in adults. Depression in children of primary school age may be very subtle and symptoms include mood fluctuations, tearfulness, frustration or temper tantrums. If depression is suspected, it is essential to evaluate the degree of risk. Risk has two key aspects: the likelihood of a potentially harmful incident occurring and degree of potential harm.

Anxiety disorders are among the most common mental health disorders of childhood. Three quarters of anxiety disorders have their origins in childhood, with presentation often chronic in nature. Where the child is experiencing significant distress or functional impairment (e.g. missing school, not taking part in age-appropriate activity), then specialist input is likely to be needed.

A large Swedish study has suggested that gabapentinoid medications are associated with an increased risk of suicidal behaviour and unintentional overdose in adolescents and young adults.

Intensive blood pressure (BP) control reduces the risk of developing mild cognitive impairment, but not dementia, a US randomised trial has found.

Male doctors have a lower suicide risk than the general male population, an analysis of English death registrations from 2011 to 2015 has found. However, the risk for female doctors is comparable with that of the general female population, although the male preponderance of suicide meant that there were in fact more than twice as many male as female doctor suicides. There are differences between specialties: compared with physicians, GPs are more than three times as likely to commit suicide.

Postmenopausal women who take systemic hormone replacement therapy (HRT) are more likely to develop Alzheimer’s disease, although the increase in risk is modest, a Finnish nationwide case-control study has found.

The risk of dementia in old age is greater in individuals who abstain from alcohol and those who consume more than 14 units per week from midlife than for those who drink moderately, according to findings from a large prospective cohort study. For those drinking > 14 units/week, a 7 unit increase in weekly alcohol consumption was associated with a 17% increase in the risk of dementia.

All antidepressants are more efficacious than placebo in adults with major depressive disorder, a systematic review and meta-analysis has found. Double-blind, randomised controlled trials were identified from the Cochrane Central Register of Controlled Trials and other large databases. Placebo-controlled and head-to-head trials of 21 antidepressants (a selection of first-generation and all approved second-generation antidepressants) were included.

Sertraline is ineffective in patients with chronic kidney disease (CKD) and depression, a randomised controlled trial, from the USA, has found. This study suggests that the prescription of sertraline, and indeed any SSRI, to stage 3b-5 CKD patients with depression can no longer be justified. CBT is probably the best option and there is some evidence of its efficacy in end-stage CKD patients.

A study of patients with type 1 diabetes has shown an association between impaired awareness of hypoglycaemia and cognitive deficits such as diminished learning, memory and pattern separation. This study compared cognitive function in type 1 diabetes patients who had normal awareness of hypoglycaemia with patients who had impaired awareness of hypoglycaemia. The study authors state: ‘It is possible that people with impaired awareness of hypoglycaemia have a diminished ability to distinguish cues that are specifically associated with hypoglycaemia and hence are unable to take appropriate action to avoid severe hypoglycaemia.'