Look Listen & Test: Look Listen & Test: Mental Health Mental Health Assessment In Assessment In Primary Care Primary Care

Dr Gabriel IvbijaroDr Gabriel Ivbijaro MBBS, FRCGP. FWACPsych, MMedSci, DFFP, MAMBBS, FRCGP. FWACPsych, MMedSci, DFFP, MA

Family DoctorFamily DoctorChair Wonca Working Party on Mental Health Chair Wonca Working Party on Mental Health

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International Reference International Reference GroupGroup

Culturally Sensitive Culturally Sensitive Depression Guideline Depression Guideline

www.globalfamilydoctor.comwww.globalfamilydoctor.com

• G Ivbijaro, L G Ivbijaro, L Kolkiewicz, E Kolkiewicz, E Palazidou, H Palazidou, H Parmentier, A Parmentier, A Abyad, B Ali, A Al-Abyad, B Ali, A Al-khatami, K Aswani, khatami, K Aswani, S Bammeke, H Bell-S Bammeke, H Bell-Gamm, J Benson, A Gamm, J Benson, A Bideman, M Carmi, Bideman, M Carmi, A Cohen, I Crabbe, A Cohen, I Crabbe, C Dorwick, C Dorwick,

• J Gensichen, M J Gensichen, M Grenville, S Gupta, Grenville, S Gupta, S Hiew, N Jackson, S Hiew, N Jackson, R Jenkins, A Khan, R Jenkins, A Khan, T Khoja, M Lee, F T Khoja, M Lee, F McMillan, L McMillan, L Risdale, H Risdale, H Rodenberg, T Rodenberg, T Swanwick, A Tylee, Swanwick, A Tylee, I Wilson, H Yaman, I Wilson, H Yaman, F ZizzoF Zizzo

Look, Listen And Look, Listen And Test: Mental Health Test: Mental Health Assessment – The Assessment – The WONCA Culturally WONCA Culturally

Sensitive Depression Sensitive Depression GuidelineGuideline

Primary Care Mental Primary Care Mental Health 2005; 3: 145 -147Health 2005; 3: 145 -147

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Goldberg Huxley ModelGoldberg Huxley ModelLevelLevel FilterFilter Filter Filter

descriptiondescriptionRate Rate

(per (per 1000)1000)

11 Community (total)Community (total) 250250

1st Filter Illness Illness BehaviourBehaviour

22 Primary Care (total)Primary Care (total) 230230

2nd Filter Ability to detectAbility to detect

33 Primary CarePrimary Care (identified)(identified)

140140

3rd Filter Willingness to Willingness to referrefer

44 Mental Illness Mental Illness Services (total)Services (total)

1717

4th Filter Factors Factors determining determining admissionadmission

55 Mental Illness Mental Illness (admissions)(admissions)

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Scope Of Psychiatric Scope Of Psychiatric Problems In Primary CareProblems In Primary Care

• 1 in 3 primary care consultations in 1 in 3 primary care consultations in UK psychiatricUK psychiatric

• Primary care clinics very busyPrimary care clinics very busy• 5 -15 minute consultations compared 5 -15 minute consultations compared

with 45 -60 minute assessments in with 45 -60 minute assessments in secondary caresecondary care

• A good psychiatric assessment A good psychiatric assessment underpins the process of diagnosis underpins the process of diagnosis and treatment and treatment

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Barriers To Making A Barriers To Making A Psychiatric Assessment In Psychiatric Assessment In

Primary CarePrimary Care• Lack of emphasis on psychiatry in Lack of emphasis on psychiatry in

Continuing Professional Development Continuing Professional Development (CPD) Plans in primary care(CPD) Plans in primary care

• Psychiatric terminology dauntingPsychiatric terminology daunting• Short consultation timesShort consultation times• Variable expression of symptoms Variable expression of symptoms

across cultures (class, ethnicity, across cultures (class, ethnicity, gender, sexuality, age)gender, sexuality, age)

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Qualities That Primary Care Qualities That Primary Care Physicians Bring To Physicians Bring To

Psychiatric Assessment Psychiatric Assessment • Knowledge of patients longitudinal historyKnowledge of patients longitudinal history• Knowledge of patients personality over Knowledge of patients personality over

timetime• Knowledge of patients family and social Knowledge of patients family and social

contextcontext• Time – the opportunity for GP to ask Time – the opportunity for GP to ask

patient to come back repeatedly for further patient to come back repeatedly for further assessment (unless patient presenting in assessment (unless patient presenting in an emergency) an emergency)

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Standardised Psychiatric Standardised Psychiatric AssessmentsAssessments

• SCAN (WHO Schedules For Clinical SCAN (WHO Schedules For Clinical Assessment in Neuropsychiatry)Assessment in Neuropsychiatry)

• European gold standard for European gold standard for assessment assessment

• Very detailedVery detailed• Needs specialised trainingNeeds specialised training• Time consumingTime consuming• Good for researchGood for research• Unsuitable for day to day GP clinicsUnsuitable for day to day GP clinics

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Look, Listen, Test (LLT)Look, Listen, Test (LLT)

• A generic schemaA generic schema• Informs consultation process Informs consultation process

regardless of pathology presentedregardless of pathology presented• Supports a holistic view by providing a Supports a holistic view by providing a

psychological element to the psychological element to the formulationformulation

• Helpful schema for a primary care Helpful schema for a primary care consultationconsultation

• Useful for medical students Useful for medical students

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Look, Listen, Test – How Look, Listen, Test – How Does It Work?Does It Work?

• Utilises the holistic observational and history Utilises the holistic observational and history taking skills routinely used in primary caretaking skills routinely used in primary care

• You look at your patientYou look at your patient

• You listen to what they sayYou listen to what they say

• You carry out appropriate tests which You carry out appropriate tests which may be verbal probing through questions may be verbal probing through questions or physical investigationsor physical investigations

• You record your findingsYou record your findings

Cross-cultural Cross-cultural implementation of a implementation of a Chinese version of Chinese version of

SCAN in TaiwanSCAN in Taiwan

Cheng ATA, Tien AT, Chang CJ Cheng ATA, Tien AT, Chang CJ et al .et al .

British Journal of Psychiatry British Journal of Psychiatry 2001 178, 576 - 572 2001 178, 576 - 572

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SCAN SymptomSCAN Symptom LookLook ListenListen TestTest

WorryWorry √√ √√ √√

Nervous tensionNervous tension √√

RestlessnessRestlessness √√

AnxietyAnxiety √√

Cannot get breathCannot get breath √√ √√

Heart poundingHeart pounding √√ √√

Depressed moodDepressed mood √√ √√ √√

AnhedoniaAnhedonia √√ √√

Loss of hopeLoss of hope √√ √√

ConcentrationConcentration √√ √√

Loss of interestLoss of interest √√ √√

Loss of energyLoss of energy √√ √√

Change in appetiteChange in appetite √√ √√

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SCAN SymptomSCAN Symptom LookLook ListenListen TestTest

Sleep problemsSleep problems √√ √√

Difficulty dropping offDifficulty dropping off √√ √√

Expansive moodExpansive mood √√ √√ √√

Irritable moodIrritable mood √√ √√ √√

Over talkativeOver talkative √√ √√

Frequency of alcohol Frequency of alcohol useuse

√√ √√

Tolerance to drugsTolerance to drugs √√ √√

DerealisationDerealisation √√ √√

Auditory hallucinationsAuditory hallucinations √√ √√ √√

Voice commentingVoice commenting √√ √√

Thought broadcastingThought broadcasting √√ √√

Being spied uponBeing spied upon √√ √√ √√

Unusual sensationsUnusual sensations √√ √√

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LLTLLT

• A practical schemaA practical schema• Can record symptoms and signs Can record symptoms and signs

from SCANfrom SCAN• Taps into skills already developed in Taps into skills already developed in

primary careprimary care• Has face validityHas face validity• Jargon free & descriptiveJargon free & descriptive• Developed within primary careDeveloped within primary care

Definition of Definition of schizophrenia – reminder schizophrenia – reminder

• Thought echo, thought withdrawal, Thought echo, thought withdrawal,

thought broadcasting thought broadcasting • Delusions of control influence or Delusions of control influence or

passivity clearly referred to body passivity clearly referred to body or limb movements or specific or limb movements or specific thoughts actions or sensations. thoughts actions or sensations. Delusional perceptionDelusional perception

• Hallucinatory voices giving Hallucinatory voices giving running commentary or discussing running commentary or discussing the patient among themslevesthe patient among themsleves

• Persistent delusions of other kinds Persistent delusions of other kinds that are culturally inappropriate that are culturally inappropriate and completely impossible and completely impossible

• Persistent hallucinations in any modality, Persistent hallucinations in any modality, accompanied by fleeting or half formed accompanied by fleeting or half formed delusions without clear affective content or delusions without clear affective content or by persistent over-valued ideas, or when by persistent over-valued ideas, or when occurring every day for weeks on endoccurring every day for weeks on end

• Breaks or interpolations in the train of Breaks or interpolations in the train of thought resulting in incoherence , thought resulting in incoherence , irrelevant speech or neologismsirrelevant speech or neologisms

• Catatonic behaviour eg excitement, Catatonic behaviour eg excitement, posturing, waxy flexibility, negativism, posturing, waxy flexibility, negativism, mutism and stupormutism and stupor

• ‘‘negative’ symptoms eg marked apathy, negative’ symptoms eg marked apathy, paucity of speech, blunting or incongruity paucity of speech, blunting or incongruity of emotional response, usually resulting in of emotional response, usually resulting in social withdrawalsocial withdrawal

• Significant and consistent change in overall Significant and consistent change in overall quality of asome aspects of personal quality of asome aspects of personal behaviour including loss of interest, behaviour including loss of interest, aimlessness, idleness, a self absorbed aimlessness, idleness, a self absorbed attitude and social withdrawalattitude and social withdrawal

Clear cut symptomsClear cut symptoms Other symptoms Other symptoms

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Schizophrenia- making the Schizophrenia- making the diagnosis diagnosis

To make a diagnosis:To make a diagnosis:• A minimum of one symptom from the category A minimum of one symptom from the category

‘clear cut’ or ‘clear cut’ or • At least two symptoms from the category ‘other’At least two symptoms from the category ‘other’

AndAnd• Symptoms should have been present for most of Symptoms should have been present for most of

the time during a period of one month or morethe time during a period of one month or more• Diagnosis should not be made in the presence of Diagnosis should not be made in the presence of

extensive manic or depressive symptoms unless extensive manic or depressive symptoms unless it is clear schizophrenic symptoms antedated it is clear schizophrenic symptoms antedated affective symptoms affective symptoms

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Case 1Case 1

• 85 year old lady85 year old lady– Consulting he doctors since she can not Consulting he doctors since she can not

go to sleep at nightgo to sleep at night• Lost husband 4 years ago, living herself, son living 45 Lost husband 4 years ago, living herself, son living 45

minutes drive awayminutes drive away• Medical history: diet controlled diabetes, hypothyroidism, Medical history: diet controlled diabetes, hypothyroidism,

polymyalgia rheumatica, hyprtensionpolymyalgia rheumatica, hyprtension• Medication: prednisolone 10 mg, levothyroxine 75 mic, Medication: prednisolone 10 mg, levothyroxine 75 mic,

ramipril 5 mg, aspirin 75 mg ramipril 5 mg, aspirin 75 mg

HISTORY +LLT HISTORY +LLT

• Mental health diagnosis?Mental health diagnosis?• Social factors?Social factors?• Medication?Medication?• Possible co-morbidity factors?Possible co-morbidity factors?• Other factors?Other factors?

EXAMEXAM

HISTORYHISTORY• LONGITUDINAL LONGITUDINAL

BACK GROUNDBACK GROUND

• CURRENT CURRENT PROBLEMSPROBLEMS

MSEMSE• LL

• LL

• TT• FORMULATIOFORMULATIO• TREATTREAT

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Thank you!gabriel.ivbijaro@gmail.com

Thank you!gabriel.ivbijaro@gmail.com