Chickens and eggs: mental health and chronic disease

1. Chickens and eggs: mental health and chronic disease Christopher Dowrick Professor of Primary Medical Care University of Liverpool Duncan Society March 2008

2. Iain 67 retired restaurant manager married with three children

3. Presenting problems painful feet difficult to walk falls/blackouts 3 or 4 in last 2 weeks alcohol binge pattern currently c500ml vodka/day

4. Chronic diseases Diabetes (Type II) peripheral neuropathy recent tests BP 148/92 (n=<140/80) Fasting blood sugar 11.8 (n= <8) medication - Gliclazide Osteoarthritis mainly in feet

5. Mental health worried about blackouts, drinking poor sleep, irritable fatigue loss of interest social withdrawal can’t be bothered to see his children…. ‘What’s the point of getting up in the morning?’

6. How you make sense of all this.... .. influences what you might do about it

7. Chickens and eggs A B B A A = B B A B A C A & B A = chronic disease B = mental health problems

8. A B Diabetes increases likelihood of depression (though less than cardiovascular disease) Paile-Hyvärinen et al, Ann Med 2007 Arthritis increases likelihood of depression Kothe et al, Pain 2007

9. B A Alcohol use increase incidence and persistence of diabetes Depression may predict incident diabetes Engum et al J Psychosom Res 2007 Depression and anxiety linked with increased risk of developing low back pain Croft et al, Spine 1995

10. A = B Medical perspectives Overlap of symptom patterns e.g. fatigue, weight loss, can ‘lead to double counting’ Wagena et al, Eur Resp J 2005 Philosophical perspectives Mind and body are the same therefore makes no sense to differentiate Ayuverdic tradition, or pre-Cartesian

11. A B A B Anxiety increases blood pressure Increased blood pressure increases risk of heart disease or stroke Awareness of risk of heart disease or stroke increases anxiety Which further increases BP and hence risk of disease.... and so on....

12. C A & B Both physical and mental problems have a common cause e.g. RTA, assault e.g. existential concerns

13. Deciding what to do....

14. Intervening at the psychological level Enhanced depression treatment for people with arthritis may reduce depressive symptoms reduce pain severity improve functional status Salerno et al, Arch Int Med 2002 Lin et al, JAMA 2003

15. Intervening at the psychological level But enhanced depression treatment for people with diabetes had little impact on glycaemic control Patient self-care Medication management Katon et al, Arch Gen Psych 2004 Lin et al, Ann Fam Med 2006

16. Risks and benefits (Number needed to treat) Number needed to harm antidepressants may be cardiotoxic losing sense of autonomy Berry et al, PEC 2006

17. Intervening at the physical level Does improved medical care lead to improved mental health? Probably Little direct research on this Ethically complex!

18. What do patients want?

19. What do patients want? Doctors assume (or fear) they want lots of investigations and referrals effective treatment cure

20. In reality….. patients with complex problems are most likely to want emotional support are more likely to seek explanation and reassurance are no more likely than others to seek investigation and treatment have few expectations of cure Salmon et al J Psychosom Res 2005

21. Screening tools Feeling down, depressed or hopeless? Little interest or pleasure in doing things? Is this something with which you would like help? Arroll et al, BMJ 2005

22. What does Iain want?

23. ‘Why bother to get up in the morning?’ loss of ability painful feet diabetes and its complications loss of purpose work and children slow, inexorable path to death…...

24. ‘What do you enjoy?’

25. ‘I can talk to you, doc’ still problems with alcohol, and painful feet but a basis for conversation, and mutual respect

26. Sysiphus and his rock This universe seems to him neither sterile nor futile.. .The struggle itself toward the heights is enough to fill a man's heart. We must imagine Sysiphus happy. Sysiphus is happy. He is happy because his fate belongs to him. He remains its master, his mind and body fully engaged in his chosen activity: This universe …. seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart.Sysiphus is happy. He is happy because his fate belongs to him. He remains its master, his mind and body fully engaged in his chosen activity: This universe …. seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart.