Common Mental Disorders In Primary Care Flashcards
Mental Health Care in Primary Care
The provision of basic preventive and curative mental health care at the first point of contact of entry into the health care system
Reasons for low recognition of CMD in developing countries
High patient loads
Poor undergraduate training in psychiatry
Stigma associated with mental illness
Somatic presentation of mental disorders
Common mental disorders
Depressive disorders
Anxiety disorders
Define Depression/major depression
A persistent feeling of sadness and Los of interest.
Epidemiology of Depression
Third cause of burden of disease worldwide
Projected to be first by 2030
80% in low and middle income countries
16% in Africa
Major contributor to death by sucide
Course of Depression
Variable chronicity and remission
80% lifetime recurrence
Risk factors for depression
Family History and genetics
F:M 2:1
History of trauma/abuse
Chronic Stress
Unresolved grief or loss
Personality traits
Medication and substance use
History of other mental disorders
Chronic medical condition
Medications that can cause depression
Acyclovir
Phenytoin
Benzodiazepines
Barbiturates
Antihistamines
Calcium Channel blockers
Isotretinon
Opioids
Varenicline
Disease that can trigger depression
Hypothyroidism
Substance use disorder
Chronic illnesses ( DM, CVD, Athritis, kidney disease, HIV, lupus, MS)
Chronic pain
List the Depressive disorders according to DSM-V classification
Disruptive mood dysregulation disorder
MDD/ Clinical Depression
Persistent depressive disorders
Premenstrual dysphoric disorder
Substance/medicatio -induced depressive disorder
Depressive disorder due to another medical condition
Unspecified depressive dosorders
DSM-5 Criteria for MDD
Five or more out of 9 symptoms in >/=2 week
Each of these symptoms represents a change from previous functioning and needs to be present for nearly everyday
The Nine symptoms of DSM
- Depressed mood (can be irritable in children and adolescents)
- Loss of interest or pleasure most of the day
- Change in wt or appetite. Wt 5% change over 1 month
- Insomnia
- Psychomotor retardation or agitation
- Loss of energy or fatigue
- Worthlessness or guilt
- Impaired concentration or indecisiveness
- Recurrent thoughts of death or suicidal ideation or attempt.
Important point to note in diagnosis of MDD
Symptoms cause significant distress or impairment in daily function
Symptoms are not secondary to substance use or general medical condition
Clinical course
Untreated episodes last>= 6 months
Median time to recovery is 20 weeks with adequate txt
50% will have a chronic or recurrent
Increased risk of Suicide
Risk factors for suicide
I Ideation
A Substance use
P Purposelessness
A Anger
T Trapped
H Hopelessness
W Withdrawal
A Anxiety
R Recklessness
M Mood Change
Depression Rating scales
Patient health questionnaire
Hamilton depression rating scale
Beck depression inventory
Zung self-rated depression scale
Centre of epidemiological studies depression scale
Edinburgh postnatal depression scale
Daily rating of severity of problems
Collaborative assessment and management of municipality
Geriatric depression scale
Patient health questionnaire
9 items
Based of DSM-5
over 2 weeks
Uses of Patient Health Q.
Diagnostic tool
To monitor symptoms severity
To determine need for tx
Scoring of Patient Health questionnnaire
20-27 sever depression
15-19 moderately severe depression
10-14 Moderate depresion
5-9 minimal symptoms
<5 Symptoms absent
General principles of mgt of MDD
Therapeutic alliance
Pt centered
Tx comorbid
Guided by subtype
Not suicide ideation and suicidality
Multidisciplinary+ psychiatry
He’s Taking
Diagnosis is clinical - HXS + MSE
2 Major defining symptoms plus the 9 other symptoms
Ask:
Duration of symptoms
Associated disability
Past hxs of mood dxso
Family hxs of mood dxso
Availability of social support
Factors that favor general advice and active mgt
=<4 symptoms with little disability
Intermittent symptoms or < 2 weeks
Recent onset with identified stressor
No past or family hxs of depression
Social support available
Lack of suicidal thoughts
Factors that favour more active tx in
> = 5 or more symptom with asso disabilty
Persistent or long standing symptoms
Personal or family has
Low social support
Occasionally suicidal thoughts
Lab investigations
Tft
Free T4
Vit D
Non pharmacological tx
Lifestyle modification
Psychotherapy
Referral to support group
Phototherapy is standard for seasonal pattern
Pharmacotherapy of MDD
SSRI- (First line) Fluoxetine, sertraline, cotalopram, escitalopram, paroxetine, and fluvozamine.
SNRI - (+ comorbid pain) Venalafaxine, fluoxetine, levominacipran, molnacipran.
Serotonin modulators - trazodone, vilazodone and vortioxetine.
Atypical antid bupropion and mirtazapine
TCA amitriptyline, imipramine, clomipramine, doxepin, nortriptyline and desipramine
MAOI tranylcypromine, phenelzine, selegiline and isocarboxazid
Others membrane stabilizer, antid
Choice of Agent
Patient Preference
Prior response
Safety, tolerability and adverse effects
Comorbid disorders
Potential drug-drug interaction
Pharmacokinetics parameters
Cost
Side effects of pharmacotherapy
Sexual dysfunction
Sedation
GI disturbances
HBP (NE)
Insomnia
Hesitancy(NE)
Anticholinergic effects (NE, TCA)
Mania
Other treatment modalities
Vagal nerve stimulation - for chronic unresponsive cases> 2 years.
Mild impulse is sent to the vagus nerve which travels to the brain.
10 weeks for a response
Mixed rxn, invasive, side E
Improves mood
ECT- 80-90% effective
A better outcome with older pts
Tx of choice for suicidal, pregnancy, catatonic, severe psychosis
Transcranial Magnetic Stimulation(TMS)
. For refractory case
5 days a week for 4-6 weeks
Appears effective
?long term benefits
Depression in special population
Pregnancy
Single medication at the lowest effective dose
Paroxetine= septal wall defects
St. Johns wart contraindicated
Lactation
Monotherapy with sertraline or paroxetine at the lowest effective dose.
Fluoxetine is contraindicated due to its long half-life.
Pediatrics
Risk increase 2-4 times after puberty
Less verbalized feelings
Fewer melancholic symptoms and suicide attempts
TX
Psychotherapy 2-3months
SSRI- Fluoxetine most beneficial in age 8-18. Others citalopram or sertraline
Escitalopram <12yr
Elderly
Memory problem and confusion
25% prevalence in >60
TX
Lower doses + slow titration
Monotherapy>polytherapy
SSRI -First choice
Risk of SIADH and Hyponatremia
TCA not recommended - orthostatic Hypotension, Anticho, drug interactions
Factors that favors referal
Inadequate response to >= 2 interventions
Recurrent episode within 1 year
?bipolar dxso
Pt or relative
More persistent suicidal thoughts
Self neglect
Need for urgent referral
Active suicidal ideas or plans
Psycotic symptoms
Severe agitation accompanying severe symptoms
Severe self neglect
Prevention
Control stress
Support from family and friends
Early tx at the earliest possible sign of problem
Consider giving longterm maintenance tx
