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PSYCHIATRY

 

Be vigilant for dementia in Parkinson’s disease

23 May 2017Paid-up subscribers

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.

Diagnosing and managing mild cognitive impairment

23 May 2017Paid-up subscribers

The prevalence of mild cognitive impairment in adults aged 65 and over is estimated to be 10-20%. It is likely that this figure will increase in line with trends in dementia diagnosis. In some cases, mild cognitive impairment may be a prodrome for dementia, and may be caused by any of the dementia pathology subtypes. It is important to obtain a history of cognitive changes over time, as well as information about the onset and nature of cognitive symptoms, confirmed by a reliable informant, if available.

Diagnosing young onset dementia can be challenging

23 May 2016Paid-up subscribers

The most common causes of young onset dementia are early onset forms of adult neurodegenerative conditions and alcohol. Vascular dementia is the second most common cause of young onset dementia after Alzheimer’s disease. Conventional vascular risk factors may be absent and diagnosis relies on imaging evidence of cerebrovascular disease. Those with suspected young onset dementia should be referred to a neurology-led cognitive disorders clinic where available as the differential diagnosis is considerably broader than in older adults and requires specialist investigation.

Be vigilant for post-traumatic stress reactions

23 May 2016Paid-up subscribers

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.

Depression in young people often goes undetected

21 May 2015Registered users

Major (unipolar) depression is one of the most common mental health disorders in children and adolescents, with an estimated one year prevalence of 4-5% in mid-late adolescence. Depression is probably the single most important risk factor for teenage suicide, the second to third leading cause of death in this age group and a forerunner of adult depressive disorder. Half of those with lifelong recurrent depression started to develop their symptoms before the age of 15 years.

Optimising the management of bipolar disorder

21 May 2015

NICE recommends that when adults present in primary care with depression, they should be asked about previous periods of overactivity or disinhibited behaviour. If this behaviour lasted for four or more days referral for a specialist mental health assessment should be considered. A diagnosis of bipolar disorder is supported by diagnostic criteria and usually confirmed by a psychiatrist. If a manic episode has been present during the history the diagnosis is bipolar I disorder, while a hypomanic episode is indicative of bipolar II disorder.

Depression in older people is underdiagnosed

22 May 2014Registered users

Depression is more common in old age than dementia yet is underdiagnosed and undertreated. It is important to recognise that patients may not always present in a typical way, features that may indicate depression include anxiety, a preoccupation with somatic symptoms, and a change in function. The presence of understandable triggers and causes should not deter GPs from offering treatment, as long as symptoms are pervasive and continuously persist beyond two weeks.

Improving the detection and treatment of schizophrenia

22 May 2014Paid-up subscribers

Schizophrenia is a debilitating, often chronic, psychotic disorder with early onset and a lifetime prevalence of 7.2/1,000. The longer the period without treatment, the worse the outcome. In the UK, the mean duration of untreated psychosis is one to two years. The new NICE guidelines for schizophrenia recommend that all patients who are distressed and have a decline in social functioning accompanied by psychotic symptoms or behaviour suggesting psychosis should be comprehensively assessed by a specialist mental health service.

Diagnosis and management of autism in adults

23 May 2013Paid-up subscribers

Autism affects 1.1% of the adult population. High-functioning individuals with autism, Asperger’s syndrome, may remain undiagnosed until adulthood. Autism is a life-long condition characterised by problems in two core dimensions: difficulties with social communication and strongly repetitive behaviour, resistance to change or restricted interests. The history should identify early developmental and behavioural problems in different settings e.g. at home, in education or employment. Sensory and GI problems are very common, and should be asked about. The Autism-Spectrum Quotient (AQ-10) is a 10-item questionnaire for people with suspected autism. It provides a time-efficient, structured way of ascertaining key symptoms and clearly signals those who should be referred for further assessment.

Managing disruptive behaviour disorders in children

23 May 2013Paid-up subscribers

The age at which individuals are most physically aggressive is 22 months. However, some children fail to inhibit this normal aggression and by the time they are three or four are showing signs of oppositional defiant disorder. In older children persistent antisocial behaviour is classified as conduct disorder. Epidemiological follow-up surveys show that the risk of poor outcomes in antisocial children is very high. The causes are multiple but two sets of factors stand out. First, genetic predisposition. Even children adopted away from violent or criminal parents have three or four times the rate of antisocial behaviour and second, poor parenting. [With external links to the evidence base]

Identifying patients at risk of perinatal mood disorders

23 May 2012Paid-up subscribers

In perinatal mental illness not only does the patient suffer, but obstetric outcomes, mother-baby interactions and hence longer term emotional and cognitive development of the child are also affected. Perinatal mental illness also has an impact on other family members. The UK Confidential Enquiry into Maternal and Child Health has consistently found psychiatric disorders to be one of the leading causes of maternal death, often through suicide. Postnatal depression and puerperal psychosis are two disorders most commonly associated with the perinatal period: the first, because of its high prevalence, 13% in the first few months following birth, the second because of its potentially disastrous consequences, including suicide, neglect of the baby and infanticide. [With external links to the current evidence base]

Primary care management of patients who self-harm

22 May 2012Paid-up subscribers

With a 10.5% lifetime risk, self-reported self-harm is common in the community: 5.6% have made a suicide attempt. Self-harm without lethal intent is slightly less common at 4.9%. Following an episode of self-harm the GP can offer assessment and practical support, for example, monitoring type and quantity of medication prescribed, and signposting or referral where relevant. GPs are ideally placed to support patients and their families following self-harm through an understanding and nonjudgmental approach which aims to alleviate distress.

Raising standards of care for patients with depression

25 May 2011Paid-up subscribers

Adults in the UK with a diagnosis of either ICD-10 depressive episode or ICD-10 mixed anxiety and depressive disorder have been estimated to have taken more than a quarter of the total number of days of sickness absence in one year. Few patients receive effective treatment. There are four reasons for this: failure to seek help (40% don't attend); failure of GPs to recognise depression (30-50% of cases); non-adherence or early cessation of treatment (only about 25% of patients complete a six-month course of antidepressant treatment);lack of treatment efficacy (50% with moderate depression don't respond to initial treatment). Only about one in ten patients receive effective treatment.

Diagnosing and managing psychosis in primary care

25 May 2011Paid-up subscribers

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%. Prevalence in the elderly increases to 4.8%. 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.

Borderline personality disorder often goes undetected

28 May 2010Paid-up subscribers

GPs play a crucial role in identifying patients who may be suffering from borderline personality disorder (BPD). All practitioners caring for patients with BPD  should work together in order to understand needs and risks and to provide patients with consistent support and help.BPD is associated with significant impairment of psychological, social and occupational functioning, with a suicide rate of almost 10%, a rate 50 times higher than in the general population.

Managing bipolar disorder in primary care

28 May 2010Paid-up subscribers

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.

Diagnosing depression in primary care

21 May 2009Paid-up subscribers

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.

GPs have a central role in managing schizophrenia

21 May 2009Paid-up subscribers

In recent decades the care of people with schizophrenia has shifted from hospital to the community. The GP's role has thus expanded, a fact reflected by the emphasis placed on primary care involvement in the recently updated NICE guideline on schizophrenia. On average GPs in the UK will have 7-12 people with schizophrenia on their lists, and for some of these patients they may be the sole provider of care.