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 2 - GAD management
what is Individual non-facilitated self-help
written material based on CBT principles, with instructions to work through material over at least 6 weeks.
step 2 - GAD management
what is Individual guided self-help
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.
step 2 - GAD management
what are Psychoeducational groups
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.
step 3 - GAD management
- what is offered
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
step 3 - GAD management
what is High-intensity psychological intervention
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).
step 3 - GAD management
drug therapy - what do we use
step 3 - GAD management
what drugs shouldn’t be used
Do not use benzodiazepines except for short-term measures during a crisis.
Do not offer antipsychotics for anxiety disorder in primary care.
step 3 - GAD management
- when to review
- how long to continue drug therapy for
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
step 3 - GAD management
- when to review
- how long to continue drug therapy for
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
step 4 - GAD management
- when to consider referral
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.
step 4 - GAD management
- what should review include
- what can also be considered
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.
panic disorder DSM classification
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.
what are panic attacks
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.
NICE panic disorder management
- mild-moderate
- moderate-severe
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
drug treatment for panic disorders
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.
what drugs not to use for panic disorder
fluoxetine
Avoid benzodiazepines/sedating antihistamines/antipsychotics
what to do if single therapy for panic disorder fails
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)
social anxiety disorder - DSM
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.
what do people with social anxiety disorder often think about it
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.
useful screening questions for social anxiety disorder
Do you find yourself avoiding social situations or activities?
Are you fearful or embarrassed in social situations?
NICE treatment for social anxiety disorder
1st line: CBT
2nd line: Medication
- Sertraline or Escitalopram
- Continue for 6 months of treatment once treatment has become effective.
what is grief and what symptoms may be experienced
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.
differentiating grief from depression
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.
prolonged grief disorder
Marked distress and disability caused by the grief reaction.
AND the persistence of this distress and disability more than 6m after a bereavement.
treatment options for prolonged grief disorder
Counselling eg Cruse
Antidepressants for comorbid depression
Behavioural/cognitive/exposure therapies
Refer if significant impairment in functioning
OCD diagnosis
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.
what are obsessions
unwanted intrusive thoughts, images or urges. Tend to be repugnant and inconsistent with a person’s values.
what are compulsions
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).
OCD screening
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?
OCD 1st line treatment
CBT including Exposure and Response Prevention (asking people to resist their urges/compulsions)
OCD 2nd line treatment
3rd line treatment
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)
insomnia
- how common
- what % >65s prescribed drugs
Common GP problem
12% of over 65s were prescribed benzodiazepines or Z-drugs
Screen for 2ry causes
2y causes for insomnia
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).
insomnia treatments
sleep hygiene
sleep diaries
CBT
medications
sleep hygiene for insomnia
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
medications for insomnia
- 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
eating disorders
- signs to recognise and refer to 2y care
- 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.
emerging psychosis
- how common
- when to recognise
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
shared care for major mental illness
- 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)
3rd sector care
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
risk factors for depression
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
ICD 10 depression diagnosis
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
ICD 10 severity of depression
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)
key things to ask about for suicidal risk factors
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
key things to ask about for suicidal risk factors
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
key things to ask about for suicidal risk factors
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
key things to ask about for suicidal risk factors
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
GAD-7
0-5 mild
6-10 moderate
11-15 moderately severe
15-21 severe anxiety
psychological therapy for panic disorder
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
expected side effects of lithium
fine tremor dry mouth altered taste sensation increased thirst urinary frequency mild nausea weight gain
symptoms of lithium toxicity
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
