Family Medicine JC127: Common Mental Health Problems In Primary Care

Question 1

Size of mental health problem

Answer 1

Psychological symptoms affect >50% of adults at some time
- Worry
- Tiredness
- Sleep disturbance

• ~1 in 7 may have diagnosable mental disorder, 2 most common:
  1. Depression
  2. Anxiety disorders (GAD, Panic disorder, OCD, PTSD, Phobia)
• Widespread under-detection of depression and anxiety disorders by doctors (>50% are missed, 75% missed in HK)

Question 2

PHQ9, GAD7

Answer 2

**Screening instruments designed to help clinicians enhance detection rates of common mental health disorders
- self-administered
- **not meant for diagnosis, ONLY for screening

PHQ9: Major Depressive Disorders
GAD7: Generalised anxiety disorders

Question 3

PHQ-2 screen

Answer 3

2 questions only, taken from first 2 criteria of DSM5
1. In the past month, have you been bothered by the fact that you **feel down, depressed, hopeless?
2. In the past month, have you been bothered by the fact that you have **little pleasure / interest in doing things

In HK (for Major Depressive Disorders):
- Sensitivity: 96.7%
- Specificity: 73.4%

Question 4

PHQ-9

Answer 4

• For ***Major Depressive Disorders
• 0-3 (not at all - nearly everyday)
• max score: 27
• all from criteria of DSM5
• over last **2 weeks whether patient been bothered by the **9 symptoms:
  1. Little interest / pleasure in doing things
  2. Feeling down, depressed, hopeless
  3. Trouble falling asleep, staying asleep, sleeping too much
  4. Feeling tired / having little energy
  5. Poor appetite / overeating
  6. Feeling bad about yourself, feeling that you are a failure, feeling that you have let yourself / your family down
  7. Trouble concentrating on things such as reading newspaper / watching television
  8. Retardation: Moving / speaking so slowly that other people could have noticed
  OR
  Agitation: being so fidgety / restless that you have been moving around a lot more than usual
  9. Suicidality: Thinking that you would be better off dead / that you want to hurt yourself in some way

0-4: No depression
5-9: **Mild —> Watchful waiting, Repeat PHQ-9 next FU (web)
10-14: **Moderate —> Counselling, FU +/- Pharmacotherapy (web)
15-19: **Moderately severe —> Pharmacotherapy + Psychotherapy (web)
20-27: **Severe —> Pharmacotherapy + Specialist referral (web)

PHQ-9 score ***>=10 (for Major depression):
- Sensitivity: 88%
- Specificity: 88%

Question 5

GAD-7

Answer 5

• For ***GAD
• 0-3 (not at all - nearly everyday)
• max score: 21
• over last **2 weeks whether patient been bother by the **7 symptoms:
  1. Feeling nervous, anxious / on edge
  2. Being unable to stop / control worrying
  3. Worrying too much about different things
  4. Trouble relaxing
  5. Being so restless that it is hard to sit still
  6. Becoming easily annoyed / irritable
  7. Feeling afraid as if something awful might happen

0-4: No anxiety
5-9: Mild
10-14: Moderate
15-21: Severe

GAD-7 score ***>=10 (for GAD):
- Sensitivity: 89%
- Specificity: 82%

Question 6

Questions to assess severity of depression

Answer 6

1. What do you think is the matter with you?
2. ***Do you think that your feelings are possibly caused by nerves, anxiety or depression?
3. Can you think of any reason why you feel this way?
4. Do you feel down in the dumps?
5. Do you feel that you are not coping well? Or ***how are you coping with this?
6. Do you have any good times?
7. Has anything changed in your life
8. ***How do you sleep? Do you wake early?
9. What time of the day do you feel at your worst?
10. Where would you put yourself between 0% and 100%
11. Have you felt hopeless?
12. What is your energy like?
13. What is your appetite like?
14. Are you as interested in sex as before?
15. Do you feel guilty about anything?
16. Do you cry when no one is around?

Question 7

Suicidal and Self harm assessment

Answer 7

• 45% people completed suicide had consulted a GP within 1 month
• People survived lethal suicide attempts have similar clinical and psychosocial profiles as suicide completes
• > 50% of those who complete suicide initially presented with self-harm
• Implications: Assess for Suicide + Self harm in ***every patient you suspect depression

Question 8

Screening for suicidal ideation

Answer 8

1. Do you feel that life is worthwhile?
2. Has the thought of ending your life occurred to you?

ASQ: Ask Suicide Screening Question Tool Kit
1. In the past few weeks, have you wished you were dead?
2. In the past few weeks, have you felt that you / your family would be better off if you were dead?
3. In the past week, have you been having thoughts about killing yourself?
4. Have you ever tried to kill yourself? (when + how)
5. Are you having thoughts of killing yourself right now? (If yes to any of above)
—> Yes to ***>=1 of above identified 97% of youth at risk of suicide

Question 9

Common mental health presentations

Answer 9

1. Tiredness
2. SOB
3. Palpitations

Question 10

1. Tiredness

Answer 10

Most common cause: ***Psychological distress
- Lifestyle stress
- Anxiety
- Depression
- Somatisation / Medically Unexplained Physical Symptoms (MUPS)

Other causes: ***Physiological fatigue
- Lifestyle issues
- Overwork
- Sleep deprivation
- Poor diet

***Medical causes of fatigue (still need to rule out)
- DM
- OSA
- Malignancy
- COPD
- Drugs
- etc.

History taking
1. History of present illness
- OPQRST

2. Global questions
   - General discomfort, aches, pains
   - Fever / sweats / appetite / weight loss
   - Sleep pattern
3. Focused systems review
   - Bleeding (anaemia)
   - CVS (chest pain, palpitations, SOB) (heart failure)
   - GI symptoms (reflux, heartburn, abdominal pain, bowel movements) (IBS, IBD, malignancy)
   - Neurological (dizziness, headache, syncope)
   - Endocrine (thirst, polyuria, frequency, nocturia) (DM, hyper / hypothyroidism)
4. Drug intake
   - alcohol, smoking, OTC medication (e.g. antihistamine), prescription medication, recreational drugs
5. Psychological
   - stresses, mood, sexual problems (e.g. low libido)
6. Social
   - work, home (kids, partners, parents), housing, finances
7. Routine background
   - diet, exercise, past medical history, family history
8. ICE’s and reason for consultation

Physical examination:
1. General inspection
- facial features, skin appearance and colour, conjunctival colour, lymphadenopathy
2. Vital signs
- HR, BP, RR, Temp
3. Anthropometric measurements
- BMI, waist circumference, WHR
4. Basic respiratory + CVS exam, ***thyroid exam
5. Abdominal exam (check for enlarged spleen, liver, Inguinal LN)
6. Urinalysis (renal impairment, DM)

Question 11

Clinical depression

Answer 11

Diagnosed when >=5 symptoms present for >2 weeks
1. **Low mood (must have either one)
2. **Loss of interest (must have either one)
3. Sleep disturbance (e.g. insomnia, early morning waking)
4. Lost concentration
5. Fatigue
6. Change in appetite / weight
7. Agitation / retardation
8. Feelings of worthlessness / guilt
9. Suicidal thoughts

Question 12

Generalised Anxiety Disorder

Answer 12

• Characterised by excessive anxiety / worry occurring more days than not for >=6 months about a number of events / activities
• Person finds it difficult to control the worry and it is associated with >=3:
  1. Restlessness / Feeling keyed up / on edge
  2. Easily fatigued
  3. Difficult concentrating / the mind going blank
  4. Irritability
  5. Muscle tension
  6. Sleep disturbance (difficult falling / staying asleep / restless unsatisfying sleep)

1. ***Physiological symptoms
   - irregular heart beat
   - SOB
   - fatigue
   - muscle tension
2. ***Emotional symptoms
   - irritability
   - feeling on edge
3. ***Cognitive symptoms
   - difficulty concentrating
   - frequent worries

Question 13

Summary

Answer 13

Tools:
- PHQ9: Major Depressive Disorders (score >=10 / >=5 symptoms, max score 27, 2 weeks)
- GAD7: Generalised anxiety disorders (score >=10, max score 21, 2 weeks)
- ASQ: Ask Suicide Screening Question Tool Kit (>=1 to any of questions)

1. Emotional symptoms are common but do not necessarily mean that sufferer has a diagnosable mood disorder
2. Many mood disorders are short lived responses to stresses in people’s lives such as work stress / bereavement
3. Cornerstone to the detection of a mood disorder is understanding of presenting symptoms and syndromes
4. Depression and anxiety are common in primary care but are missed by doctors in >=50% of cases
5. Screening tools e.g. PHQ-9, GAD-7 can be useful to enhance detection rates for depression and anxiety
6. Clinical depression is diagnosed when ***>=5 symptoms every day for >2 weeks
7. Patients with depression / anxiety often present with physical symptoms
8. Anxiety and Depression often occur together
9. Mental disorders can also occur together with other medical problems