1y care management of common mental health disorders Flashcards
how common is mental illness
1/4 people suffer from mental illness
40% of GP consultations have mental health component
most mental illness is managed exclusively in 1y care
impact of mental health on life expectancy
pts w/ major mental illness die 12 (F) - 16 (M) yrs earlier than background population
common patient complaints
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
when to be especially alert to the possibility of depression
PMH of depression
significant illnesses causing disability
other mental health problems e.g. dementia
2 screening questions for depression
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
DSM IV/V depression classification
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
NICE depression guidelines
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
PHQ 9 for depression
5-9 mild
10-14 moderate
15-19 moderately severe
20-27 severe depression
NICE treatment guideline
stepped care model - least intrusive intervention to be provided first, if that is ineffective/declined then offer appropriate intervention from the next step
- recognition and initial management
- moderate depression or if step 1 not working
- moderate/severe depression or step 2 not working
- severe and complex depression
also consider fitness to work and drive
step 1 - depression management
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)
step 2 - depression management
- recognised depression, persistent subthreshold depressive symptoms or mild-mod depression
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
step 3 - depression management
- persistent subthreshold depressive symptoms or mild-mod depression with inadequate response to initial interventions, and moderate and severe depression
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
fitness to drive
follow-up from initial consultation (depression)
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
management of non-responders to depression treatment
if absent/minimal response after 3-4wks at therapeutic dose, increase level of support AND increase dose OR switch to another anti-depressant
switching anti-depressants
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)
stopping/reducing antidepressants
advise re. risk of withdrawal symptoms and gradually reduce the dose
normally over a 4wk period
step 4 - depression management
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
how common is suicide
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
suicide risk assessment
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
bipolar disorder
- how common
- when to refer
- suicide risk
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
medication in bipolar disorder
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
what is generalised anxiety disorder
Excessive worry about a number of different events
Can exist in isolation or comorbid anxiety/depressive disorders
what is panic disorder
Recurrent panic attacks and persistent worry about further attacks
what is social anxiety disorder
persistent fear of, or anxiety about, one or more social or performance situations that is out of proportion to the actual threat posed
generalised anxiety disorder - DSM IV classification
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)
NICE management of GAD
- identification and assessment
- for those whom active monitoring is insufficient
- for those w/ marked functional impairment OR for those who haven’t improved w/ step 2 treatments
- specialist referral
step 1 - GAD management
when to consider the diagnosis of GAD
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.
step 1 - GAD management
what to include when assessing the severity of anxiety
Level of distress.
Functional impairment.
Number, severity and duration of symptoms.
step 1 - GAD management
what to look out for - may affect the development, course and severity of anxiety state
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.
step 1 - GAD management
if depression or other anxiety disorder present w/ GAD, what do we treat first
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
step 1 - GAD management
what to offer for all identified w/ GAD
education about anxiety disorder
active monitoring of patient’s function and symptoms.
Discourage over-the-counter treatments (lack of evidence, interactions).
step 2 - GAD management
low intensity psychological interventions
Individual non-facilitated self-help
Individual guided self-help
Psychoeducational groups
- used for those whom active monitoring is insufficient
step 3 - GAD management
drug therapy - what do we use
GAD-7
0-5 mild
6-10 moderate
11-15 moderately severe
15-21 severe anxiety
