1y care management of common mental health disorders Flashcards

1
Q

how common is mental illness

A

1/4 people suffer from mental illness
40% of GP consultations have mental health component

most mental illness is managed exclusively in 1y care

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2
Q

impact of mental health on life expectancy

A

pts w/ major mental illness die 12 (F) - 16 (M) yrs earlier than background population

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3
Q

common patient complaints

A
feeling low 
no energy 
tired all the time 
struggling w/ motivation
can't stop crying 
struggling w/ sleep 
not enjoying things I used to 
not coping w/ things like I used to
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4
Q

when to be especially alert to the possibility of depression

A

PMH of depression
significant illnesses causing disability
other mental health problems e.g. dementia

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5
Q

2 screening questions for depression

A

during the last month, have you been bothered by feeling down, depressed or hopeless
during the last month have you been bothered by having little interest or pleasure in doing things

-ve score on both almost always rules out depression
+ve score to either signals possible depression w/ a +ve predictive value of either Qs being ~ 18-20% - further hx required

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6
Q

DSM IV/V depression classification

A

symptoms must have been present nearly every day for at least 2wks
at least 1 of the first 2 criteria and a total of 5 out of the 9 criteria in total:
- depressed mood
- loss of interest or pleasure (anhedonia)

  • significant weight loss/gain or change in appetite
  • sleep difficulties (incl hypersomnia)
  • psychomotor agitation or retardation
  • fatigue
  • feelings of worthlessness or inappropriate guilt
  • reduced concentration or indecisiveness
  • recurrent thoughts of death or suicidal thoughts
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7
Q

NICE depression guidelines

A

diagnosis should be based on DSM IV criteria
depression: 5/9 criteria required incl at least 1 of the first 2 criteria
subthreshold depressive symptoms are defined as those having <5 of the DSM IV criteria

severity is based on functional impairment, once the diagnostic criteria have been passed
mild - ≥5 symptoms but w/ mild functional impairment
severe - at least 5 symptoms (often most or all will be present) w/ marked functional impairment
moderate is in between

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8
Q

PHQ 9 for depression

A

5-9 mild
10-14 moderate
15-19 moderately severe
20-27 severe depression

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9
Q

NICE treatment guideline

A

stepped care model - least intrusive intervention to be provided first, if that is ineffective/declined then offer appropriate intervention from the next step

  1. recognition and initial management
  2. moderate depression or if step 1 not working
  3. moderate/severe depression or step 2 not working
  4. severe and complex depression

also consider fitness to work and drive

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10
Q

step 1 - depression management

A

recognition, assessment and initial management

  • all known and suspected presentations of depression
  • intervention options: assessment, support, psycho-education, lifestyle advice, active monitoring

offer advice on sleep hygiene
offer active monitoring (discuss concerns, provide info about depression, reassess within 2 wks, contact pt if they don’t attend follow up)

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11
Q

step 2 - depression management

- recognised depression, persistent subthreshold depressive symptoms or mild-mod depression

A

sleep hygiene advice

active monitoring - discuss concerns, provide info, reassess in 2wks, contact if they don’t attend

low intensity psychological and psychosocial interventions e.g. individual self-help based on CBT principles, computerised CBT, group CBT, group physical activity programmes

don’t routinely use antidepressants (risk-benefit ratio is poor) unless:

  • hx of moderate-severe depression OR
  • present w/ sub-threshold symptoms that have been present for ≥2y OR
  • sub-threshold symptoms for <2y but they don’t respond to other interventions
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12
Q

step 3 - depression management
- persistent subthreshold depressive symptoms or mild-mod depression with inadequate response to initial interventions, and moderate and severe depression

A

antidepressant (normally SSRI) OR

high intensity psychological intervention
- individual CBT, interpersonal therapy, behavioural activation, couples therapy where the relationship is a contributory factor

combined treatments (medication + high intensity psychological) preferred for moderate-severe depression

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13
Q

fitness to drive

A
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14
Q

follow-up from initial consultation (depression)

A

2 wks after starting at intervals of every 2-4wks for 3mths and then at longer intervals if the response is good

if pts <30y/o or considered greater risk, see after 1wk and as frequently thereafter as appropriate until risk no longer clinically important

encourage to take anti-depressants for at least 6mths after remission and for up to 2yrs if they are at risk of relapse

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15
Q

management of non-responders to depression treatment

A

if absent/minimal response after 3-4wks at therapeutic dose, increase level of support AND increase dose OR switch to another anti-depressant

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16
Q

switching anti-depressants

A

initially switch to a different SSRI or a better tolerated newer generation anti-depressant

subsequently to another class that may be less well tolerated (TCA, venlafaxine or MAOI) - MAOI specialist initiated only

combining and augmentation - using combinations should only normally be started in 1y care in consultation w/ psychiatrist (e.g. addition of another antidepressant e.g. mirtazapine or augmentation w/ another medication e.g. lithium, antipsychotic)

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17
Q

stopping/reducing antidepressants

A

advise re. risk of withdrawal symptoms and gradually reduce the dose

normally over a 4wk period

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18
Q

step 4 - depression management

A

severe and complex depression
risk to life
severe self-neglect

intervention options:
- refer for multi-professional and possible inpatient care for people w/ depression who are at significant risk of self-harm, have psychotic symptoms, require complex multiprofessional care or where an expert opinion is needed

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19
Q

how common is suicide

A

6000 people die p/a by suicide in the UK
one person dies by suicide every 40s

for every one person who commits suicide, 30 people attempt

biggest cause of death for:

  • aged 15-24
  • men <50y/o
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20
Q

suicide risk assessment

A

ALWAYS ask about suicidal thoughts

  • ideation, intent, plans - vague, fleeting, recurring, detailed, specific, in motion
  • previous attempts
  • impulsivity and self control
  • current stressors/triggers or sense of hopelessness
  • protective factors vs risk factors
  • assess whether the person has adequate social support and aware of sources of help
  • arrange help appropriate to the level of risk
  • if considerable immediate risk to self/others - urgent referral to specialist mental health services
  • advise person to seek further help if situation deteriorates
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21
Q

bipolar disorder

  • how common
  • when to refer
  • suicide risk
A

10% of adults taking antidepressants for ‘depression’ actually have features of bipolar disorder
Refer if suspected

Suicide risk in bipolar 20 times higher than general population

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22
Q

medication in bipolar disorder

A

Do not start SSRIs in depressed phase – refer/discuss with 2ry care
Stop antidepressants if patients become hypomanic

Beware sodium valproate in women of child-bearing age
2y care medication only – woman must be on effective contraception and signed agreement between prescriber and patient

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23
Q

what is generalised anxiety disorder

A

Excessive worry about a number of different events

Can exist in isolation or comorbid anxiety/depressive disorders

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24
Q

what is panic disorder

A

Recurrent panic attacks and persistent worry about further attacks

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25
Q

what is social anxiety disorder

A

persistent fear of, or anxiety about, one or more social or performance situations that is out of proportion to the actual threat posed

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26
Q

generalised anxiety disorder - DSM IV classification

A

A. Excessive anxiety and worry occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).

B. The person finds it difficult to control the worry

C. The anxiety and worry are associated with three or more of the following symptoms

  • Restlessness or feeling keyed up or on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
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27
Q

NICE management of GAD

A
  1. identification and assessment
  2. for those whom active monitoring is insufficient
  3. for those w/ marked functional impairment OR for those who haven’t improved w/ step 2 treatments
  4. specialist referral
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28
Q

step 1 - GAD management

when to consider the diagnosis of GAD

A

Those presenting with anxiety or significant worry.
Frequent attenders with a chronic health problem.
Frequent attenders without health problems but who are seeking reassurance about somatic symptoms (especially elderly people or those from minority ethnic groups).
Frequent attenders who are repeatedly worrying about a wide range of different issues.

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29
Q

step 1 - GAD management

what to include when assessing the severity of anxiety

A

Level of distress.
Functional impairment.
Number, severity and duration of symptoms.

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30
Q

step 1 - GAD management

what to look out for - may affect the development, course and severity of anxiety state

A

Other anxiety disorder in addition to generalised anxiety disorder (e.g. panic disorder).
Depression.
Substance misuse.
Physical health problems.
History of mental health problems.
Past experience and response to treatments.

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31
Q

step 1 - GAD management

if depression or other anxiety disorder present w/ GAD, what do we treat first

A

If depression or other anxiety disorder present, treat the primary disorder first eg co-morbid depression/anxiety – treat depression first.
Treat co-morbid substance misuse disorder first

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32
Q

step 1 - GAD management

what to offer for all identified w/ GAD

A

education about anxiety disorder
active monitoring of patient’s function and symptoms.

Discourage over-the-counter treatments (lack of evidence, interactions).

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33
Q

step 2 - GAD management

low intensity psychological interventions

A

Individual non-facilitated self-help
Individual guided self-help
Psychoeducational groups

  • used for those whom active monitoring is insufficient
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34
Q

step 2 - GAD management

what is Individual non-facilitated self-help

A

written material based on CBT principles, with instructions to work through material over at least 6 weeks.

35
Q

step 2 - GAD management

what is Individual guided self-help

A

written material as above, with support from a trained practitioner who offers 5–7 weekly/fortnightly face-to-face/phone sessions lasting 20–30mins each.

36
Q

step 2 - GAD management

what are Psychoeducational groups

A

usually 6 weekly sessions of 2 hours each with a group of patients and a therapist. Based on CBT principles; interactive and including self-help manual.

37
Q

step 3 - GAD management

- what is offered

A

high intensity psychological intervention or drug therapy

  • used for those w/ marked functional impairment OR for those who haven’t improved w/ step 2 treatment
38
Q

step 3 - GAD management

what is High-intensity psychological intervention

A
CBT (one-to-one sessions, each lasting 1 hour, run weekly for 12–15w). 
Applied relaxation (one-to-one sessions, each lasting an hour, run weekly for 12–15w).
39
Q

step 3 - GAD management

drug therapy - what do we use

A
40
Q

step 3 - GAD management

what drugs shouldn’t be used

A

Do not use benzodiazepines except for short-term measures during a crisis.
Do not offer antipsychotics for anxiety disorder in primary care.

41
Q

step 3 - GAD management

  • when to review
  • how long to continue drug therapy for
A

Review patients every 2–4w in the first 3m (more frequently in those under 30y, and 3-monthly thereafter.
Continue therapy for at least 12m after initiation to reduce the risk of relapse

41
Q

step 3 - GAD management

  • when to review
  • how long to continue drug therapy for
A

Review patients every 2–4w in the first 3m (more frequently in those under 30y, and 3-monthly thereafter.
Continue therapy for at least 12m after initiation to reduce the risk of relapse

if pt fails to respond to adequate drug treatment or to high-intensity psychological therapies, offer the alternative treatment

42
Q

step 4 - GAD management

- when to consider referral

A

Severe anxiety disorder with marked functional impairment and:
Risk of self-harm or suicide.
Significant comorbidity (substance misuse, personality disorder, complex physical health problems).
Self-neglect.
OR failure to respond to step 3 interventions.

43
Q

step 4 - GAD management

  • what should review include
  • what can also be considered
A

CMHT review should include a thorough assessment of the problem and risks, including the impact on family and carers, previous treatment and the development of a comprehensive care plan.
Consider offering combined drug and psychological interventions.

44
Q

panic disorder DSM classification

A

Recurring unforeseen panic attacks, followed by at least a month of persistent worry about having another attack and concern about its consequences OR a significant change in behaviour related to the panic attacks.

45
Q

what are panic attacks

A

Panic attacks are characterized by an abrupt surge of intense fear or physical discomfort, reaching a peak within a few minutes, in which at least 4 of the following symptoms are present:

Palpitations, pounding heart, tachycardia	
Sweating
Muscle trembling, shaking
Shortness of breath, sensations of smothering
Choking sensations
Chest pain or discomfort
Nausea, abdominal distress
Dizzy, lightheaded, instability, feeling faint
Derealization, depersonalization
Fears of losing control or going crazy
Fear of dying
Numbness, tingling sensations
Chills, hot flushes.
46
Q

NICE panic disorder management

  • mild-moderate
  • moderate-severe
A

Mild- Moderate

  • Self Help e.g. website, support groups
  • bibliotherapy based on CBT principles
  • info on support groups
  • review progress appropriately based on individual circumstances (every 4-8wks)

Mod-Severe

  • Psychological therapy
  • Drug treatment
47
Q

drug treatment for panic disorders

A

Offer an SSRI licensed for panic disorder (citalopram, sertraline, paroxetine, escitalopram but NOT fluoxetine

If unable to use SSRI or no response after 12w, consider imipramine or clomipramine (off-label indication for both) – beware both are dangerous in overdose.

48
Q

what drugs not to use for panic disorder

A

fluoxetine

Avoid benzodiazepines/sedating antihistamines/antipsychotics

49
Q

what to do if single therapy for panic disorder fails

A

If one therapy (CBT, drugs, self-help) fails to give adequate response, try an alternative from this list (citalopram, sertraline, paroxetine, escitalopram)

if no response, refer for specialist input (CMHT)

50
Q

social anxiety disorder - DSM

A

A. Persistent fear of social or performance situations…the individual fears that he or she will act in a way that will be embarrassing and humiliating.
B. Exposure to the situation provokes anxiety, which may take the form of a Panic Attack.
C. The person recognizes that this fear is unreasonable or excessive.
D. The feared situations are avoided or else are endured with intense anxiety and distress.
E. This interferes significantly with the person’s normal routine, occupational (academic) functioning, or social activities or relationships
F. The fear, anxiety, or avoidance is persistent, typically lasting 6 or more months.
G. The fear or avoidance is not due to direct physiological effects of a substance (e.g., drugs, medications) or a general medical condition not better accounted for by another mental disorder.

51
Q

what do people with social anxiety disorder often think about it

A

Often view it as a personal failing or flaw rather than a treatable condition.
Often avoid contact with health services.
Often have difficulty taking things in when things are explained to them.

52
Q

useful screening questions for social anxiety disorder

A

Do you find yourself avoiding social situations or activities?
Are you fearful or embarrassed in social situations?

53
Q

NICE treatment for social anxiety disorder

A

1st line: CBT
2nd line: Medication
- Sertraline or Escitalopram
- Continue for 6 months of treatment once treatment has become effective.

54
Q

what is grief and what symptoms may be experienced

A

Feelings of disbelief and difficulty comprehending the reality of the loss.
Bitterness/anger/guilt/blame.
Impaired functioning: within the family, socially, ability to work/go to school.
Intense yearning and sadness, and emotional and physical pain. There may be physical symptoms of anxiety.
Mental fogginess, difficulty concentrating, forgetfulness.
Loss of sense of self or sense of purpose in life.
Feeling disconnected from other people and ongoing life.
Difficulty engaging in activities or making plans for the future.

55
Q

differentiating grief from depression

A

Grief includes longing/yearning for the loved one
positive emotions can still be experienced
symptoms worst when thinking about the deceased person.
people often want to be with others, whereas people with depression tend to want to be alone.

56
Q

prolonged grief disorder

A

Marked distress and disability caused by the grief reaction.
AND the persistence of this distress and disability more than 6m after a bereavement.

57
Q

treatment options for prolonged grief disorder

A

Counselling eg Cruse
Antidepressants for comorbid depression
Behavioural/cognitive/exposure therapies
Refer if significant impairment in functioning

58
Q

OCD diagnosis

A

OCD is characterised by obsessions or compulsions (usually both) which must impair function.

To warrant a diagnosis of OCD, obsessions and compulsions must be time consuming >1hr , or cause significant distress or functional impairment.

59
Q

what are obsessions

A

unwanted intrusive thoughts, images or urges. Tend to be repugnant and inconsistent with a person’s values.

60
Q

what are compulsions

A

repetitive behaviours or mental acts the person feels driven to perform. Can be overt (checking they locked the door) or covert (mentally repeating a phrase in their head).

61
Q

OCD screening

A

Do you wash or clean a lot?
Do you check things a lot?
Is there any thought that keeps bothering you that you’d like to get rid of and can’t?
Do your daily activities take a long time to finish?
Are you concerned about putting things in a special order? Are you very upset by mess?
Do these problems trouble you?

62
Q

OCD 1st line treatment

A

CBT including Exposure and Response Prevention (asking people to resist their urges/compulsions)

63
Q

OCD 2nd line treatment

3rd line treatment

A

Medication ; SSRIs (sertraline/citalopram/fluoxetine/paroxetine)

  • Often required at higher doses for longer duration –up to 12 weeks to see a response
  • Under guidance from secondary care

medication - clomipramine (most SSRI like of TCAs)

64
Q

insomnia

  • how common
  • what % >65s prescribed drugs
A

Common GP problem
12% of over 65s were prescribed benzodiazepines or Z-drugs
Screen for 2ry causes

65
Q

2y causes for insomnia

A

Anxiety/depression.
Physical health problems (e.g. pain, dyspnoea).
Obstructive sleep apnoea
Excess alcohol or illicit drugs.
Parasomnias (restless legs, sleep walking/talking/sleep terrors/teeth grinding (bruxism), etc.).
Circadian rhythm disorder (especially in shift workers).

66
Q

insomnia treatments

A

sleep hygiene
sleep diaries
CBT
medications

67
Q

sleep hygiene for insomnia

A

Avoid stimulating activities before bed
Avoiding alcohol/caffeine/smoking or heavy meals before bed
Regular day time exercise
Same bedtime and relaxing bedtime routine each day – ensure separation of work from bedtime
Ensure bedroom environment promotes sleep e.g. dark, correct temp

68
Q

medications for insomnia

A
  • not routinely advised
  • Melatonin licensed >55yrs for short term insomnia <13 weeks use
  • Hypnotics : zopiclone)/temazepam – only in severe disabling insomnia causing marked distress; addictive potential, may interfere with next day tasks, avoid driving/operating machinery; Reduce time to fall sleep by only 22 minutes. Don’t maintain sleep
69
Q

eating disorders

- signs to recognise and refer to 2y care

A
  • menstrual or other endocrine disturbances, or unexplained gastrointestinal symptoms
  • physical signs of: compensatory behaviours, including laxative or diet pill misuse, vomiting or excessive exercise
  • abdominal pain that is associated with vomiting or restrictions in diet, and that cannot be fully explained by a medical condition
  • unexplained electrolyte imbalance or hypoglycaemia
  • atypical dental wear (such as erosion)
  • whether they take part in activities associated with a high risk of eating disorders (for example, professional sport, fashion, dance, or modelling).
  • faltering growth (for example, a low weight or height for their age) or delayed puberty.
70
Q

emerging psychosis

  • how common
  • when to recognise
A

Average GP sees one case a year
Easy to spot if frank psychosis

Often difficult to diagnose in early stages
Listen to family concerns
Look for increasing distress and declining function
Consider organic cause

Early diagnosis improves prognosis

71
Q

shared care for major mental illness

A
  • Medication monitoring
  • BMI/BP/smoking

Blood tests

  • Antipsychotics; Monitoring cardiovascular risk factors for 2nd generation; Monitoring ECG for QTC prolongation 1st generation
  • Lithium (bipolar/adjunct in depression): Thyroid / Kidney function tests 6monthly: Lithium levels 3 monthly – risk of lithium toxicity (Coarse tremor, D&V, poor coordination, slurred speech, blurred vision; Avoid nephrotoxic drugs eg ACE I/NSAIDs/diuretics if possible)
72
Q

3rd sector care

A

Collection of voluntary and community organisations
Locally available resources
Penumbra
ACIS counselling
Cairns Counselling
Cruse Bereavement Counselling
Alcohol and Drugs action
Momentum
ACVO – Aberdeen City Voluntary Organisations- 3rd sector interface
Link workers now more readily available in primary care can signpost patients to locally available services

73
Q

risk factors for depression

A
prev depression 
hx of other mental illness
hx of substance abuse
FHx depression/suicide
domestic violence
unemployment
poor social support network 
recent stressful life event
74
Q

ICD 10 depression diagnosis

A
Key symptoms: 
persistent sadness or low mood; and/or
loss of interests or pleasure
fatigue or low energy
at least one of these, most days, most of the time for at least 2 weeks
if any of above present, ask about associated symptoms: 
disturbed sleep 
poor concentration or indecisiveness
low self-confidence
poor or increased appetite
suicidal thoughts or acts
agitation or slowing of movements
guilt or self-blame
75
Q

ICD 10 severity of depression

A
the 10 symptoms then define the degree of depression and management is based on the particular degree 
mild depression (four symptoms) 
moderate depression (five to six symptoms) 
severe depression (seven or more symptoms, with or without psychotic symptoms)
76
Q

key things to ask about for suicidal risk factors

A
prev self-harm/suicidal behaviour
depression/other mental health problems 
substance misuse
physical illness - TBI are at 2x risk of suicide as general pop, increased to 4x risk in first 6mths after injury, still 2x as high 7yrs after injury
low socioeconomic status 
relationship breakdown
76
Q

key things to ask about for suicidal risk factors

A
prev self-harm/suicidal behaviour
depression/other mental health problems 
substance misuse
physical illness - TBI are at 2x risk of suicide as general pop, increased to 4x risk in first 6mths after injury, still 2x as high 7yrs after injury
low socioeconomic status 
relationship breakdown
76
Q

key things to ask about for suicidal risk factors

A
prev self-harm/suicidal behaviour
depression/other mental health problems 
substance misuse
physical illness - TBI are at 2x risk of suicide as general pop, increased to 4x risk in first 6mths after injury, still 2x as high 7yrs after injury
low socioeconomic status 
relationship breakdown
77
Q

key things to ask about for suicidal risk factors

A
prev self-harm/suicidal behaviour
depression/other mental health problems 
substance misuse
physical illness - TBI are at 2x risk of suicide as general pop, increased to 4x risk in first 6mths after injury, still 2x as high 7yrs after injury
low socioeconomic status 
relationship breakdown
78
Q

GAD-7

A

0-5 mild
6-10 moderate
11-15 moderately severe
15-21 severe anxiety

79
Q

psychological therapy for panic disorder

A

1-2hr sessions/wk
these should be completed within 4mths
7-14 h is usually optimal

sometimes more intense CBT over a shorter timeframe may be more appropriate

80
Q

expected side effects of lithium

A
fine tremor
dry mouth 
altered taste sensation
increased thirst
urinary frequency 
mild nausea
weight gain
81
Q

symptoms of lithium toxicity

A

MEDICAL EMERGENCY

vomiting and diarrhoea
coarse tremor - larger movements, esp hands 
muscle weakness
lack of coordination incl ataxia
slurred speech 
blurred vision 
lethargy
confusion 
seizured