GP psychiatry Flashcards
what should you do if someone is not responding to their anti-depressant in 3-4 weeks
increase level of support
increase dose OR switch to another antidepressant
what are 2 questions asked to screen for depression
“During the last month, have you often been botheredby feeling down, depressed or hopeless?” (low mood)
“During the last month, have you been botheredby having little interest or pleasure in doing things?” (anedonia)
are antipsychotics offered for anxiety disorder in primary care
no
what is the first line treatment for social anxiety disorder
CBT
what should you do if you think someone is an immediate risk to themselves or others
refer urgently to specialist mental health services
what things are on the 2nd list of the DSM 5 criteria for depression
Significant weight loss or gain, or change in appetite.
Sleep difficulties (including hypersomnia).
Psychomotor agitation or retardation.
Fatigue.
Feelings of worthlessness or inappropriate guilt.
Reduced concentration or indecisiveness.
Recurrent thoughts of death or suicidal thoughts
what is the first line treatment for mild to moderate depression
SSRI
individual CBT, interpersonal therapy, behavioural activation
what is different about the symptoms of grief from depression
positive emotions still experienced
symptoms worse when thinking about decreased
want to be social (depression alone)
what is some advice give regarding sleep hygiene
Avoid stimulating activities before bed
Avoiding alcohol/caffeine/smoking before bed
Avoid heavy meals/ strenuous exercise before bed
Regular day time exercise
Same bedtime each day
Ensure bedroom environment promotes sleep
Relaxation
what is the difference between obsessions and compuslions
Obsessions: unwanted intrusive thoughts, images or urges. Tend to be repugnant and inconsistent with a person’s values.
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).
what are treatment options for grief
¥ Counselling eg Cruse
¥ Antidepressants for comorbid depression
¥ Behavioural/cognitive/exposure therapies
¥ Refer if significant impairment in functioning
what things will impair a depressed person ability to drive
must not drive if significant memory or concentration problems, agitation, behavioural disturbance or suicidal thoughts
when should you be suspicious of emerging psychosis
increasing distress and declining function – employment, relationship, hygiene
listen to family concerns
how premature do people with major mental illness die
women 12 years
men 16 years
what % of GP consultations have a a mental health component
40%
what are the 3 things in the DSM 5 classification of anxiety
- excessive anxiety and worry about a number of different things
- difficult to control worry
- symptoms
what is the treatment of mil- moderate panic disorder
Self help – books bases on CBT principles, support groups, exercise benefits
Review progress every 4-8 weeks
how is acute grief characterised
¥ Feelings of disbelief and difficulty comprehending the reality of the loss.
¥ Bitterness/anger/guilt/blame.
¥ Impaired functioning
¥ Intense yearning and sadness, and emotional and physical pain.
¥ 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.
when should you consider anxiety for specialist CMHT 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.
what is the 3rd line treatment for OCD
clomipramine (most SSRI like of tricyclics)
what is requires for the diagnosis os panic disorder
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 is the DSM 5 classification for social phobia
A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others
Exposure provockes anxiety attacks
recognise fear is excessive
feared situations are avoided
what symptoms may be present during a pancake attack
- Palpitations, pounding heart, tachycardia - Dizzy, lightheaded, instability, feeling faint
- Sweating - derelealisation/ depersonalisation
- Muscle trembling, shaking - fears of losing control or going crazy
- Shortness of breath, sensations of smothering - fear of dying
- Choking sensations - numbness, tingling sensations
- Chest pain or discomfort - chills/ hot flushes
- Nausea, abdominal distress
if active monitoring is insufficient in managing anxiety, what are the next steps
low intensity psychological interventions - self help books, group counselling,
what are some examples of Low-intensity psychological andpsychosocial interventions used in primary care for depression
individual self-help based on CBT principles, computerised CBT, group CBT, group physical activity programme
what advice should be given to all those with generalised anxiety disorder
education about anxiety disorder, and active monitoring of patient’s function and symptoms.
Discourage over-the-counter treatments
what drugs should be considered if first line SSRI is not effective at managing anxiety
swap to an alternative SSRI or SNRI (venlafaxine/duloxetine)
pregabalin (beware abuse potential)
what is generalised anxiety disorder
Excessive worry about a number of different events
Can exist in isolation or comorbid anxiety/depressive disorders
where are the 2 most important criteria in the DSM 5 classification of depression
- Depressed mood.
- Loss of interest or pleasure (anhedonia).
who gets to decide if a depressed person is fit to work
doctor objective
what drugs may an anti-depressant be augmented wit
lithium
antipsychotic (e.g. quetiapine, aripriprazole etc)
another antidepressant such as mirtazapine
how long should anxiety medication be taken to prevent relapse
12 months
what are some screening questions used for OCD
¥ 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?
what are some hypnotics/ Z drugs licensed for severe insomnia
zolpidemzopiclone)
temazepam
(addictive potential, may interfere with next day tasks, avoid driving/operating machinery 8hrs after use)
what are sign symptoms of lithium toxicity
¥ Vomiting and diarrhoea ¥ Coarse tremor (larger movements, especially of hands) ¥ Muscle weakness ¥ Lack of coordination including ataxia ¥ Slurred speech ¥ Blurred vision ¥ Lethargy ¥ Confusion Seizures
what psychological therapy is offered for moderate - sever anxiety
1-2 hourly CBT sessions a week for 4 months
what are sub threshold depressive symptoms defined as
having <5 of the DSM IV criteria
what drugs may be considered in anxiety is no response to SSR
imipramine or clomipramine (TCA)
how is the severity of depression graded in DSM 5 classification
functional impairment (mild = mild functional impairment, severe = marked functional impairment)
how long have depression symptoms been happening for a diagnosis
almost every day for 2 weeks
why should SSRIs not be given to bipolar patients in a depressed phase
SSRIs - can precipitate a manic episode
how long should a person take their anti-depressant after remission if they are at severe risk of relapse
2 years
what other conditions may affect the development, course and severity of anxiety
¥ Other anxiety disorder in addition to generalised anxiety disorder (e.g. panic disorder). ¥ Depression. ¥ Substance misuse. ¥ Physical health problems. - chronic History of mental health problems
how long are anxiety symptoms present for a diagnosis
> 6 months
what is monitored for 1st and 2nd antipsychotics
1st - ECG for QT prolongation
2nd - cardiovascular risk footers
what kind of illnesses os depression commonly secondly to
chronic illness causing disability e.g. cancer
what should you think about when assessing the severity of anxiety
¥ Level of distress.
¥ Functional impairment.
¥ Number, severity and duration of symptoms.
what are screening questions for social anxiety disorder
¥ Do you find yourself avoiding social situations or activities?
¥ Are you fearful or embarrassed in social situations?
when prescribing venlafaxine, what must you do
monitor BP
what is panic disorder
Recurrent panic attacks and persistent worry about further attacks
what is featured on the 2nd list in the DSM 5 classification of depression
Significant weight loss or gain, or change in appetite.
Sleep difficulties (including hypersomnia).
Psychomotor agitation or retardation.
Fatigue.
Feelings of worthlessness or inappropriate guilt.
Reduced concentration or indecisiveness.
Recurrent thoughts of death or suicidal thoughts.
what are expected side effects of tlithium
¥ Fine tremor ¥ Dry mouth ¥ Altered taste sensation ¥ Increased thirst ¥ Urinary frequency ¥ Mild nausea ¥ Weight gain
what is step 3 in the management of vernalised anxiety
A high-intensity psychological intervention or drug therapy
what question should you always ask someone who is depressed
suicide risk assessment
Plans - vague, detailed, specific, already in motion
Previous attempts
what is the most dangerous anti-depressant class to overdose on
TCA
what can happen if you withdraw an antidepressant to fast
discontinuation symptoms
what is the 2nd line treatment for OCD
SSRIs (sertraline/ citalopram/ fluoxetine/ paroxetine)
Often required at higher doses for longer duration –up to 12 weeks to see a response
what is the follow up for depression
see people 2 weeks after starting, at intervals of every 2 to 4 weeks for 3 months and then at longer intervals if the response is good
what are secondary causes of insomnia
¥ Anxiety/depression.
¥ Physical health problems (e.g. pain, dyspnoea).
¥ Obstructive sleep apnoea (
¥ Excess alcohol or illicit drugs.
¥ Parasomnias
Circadian rhythm disorder (especially in shift workers
what is the 2nd line treatment for social anxiety disorder
sertraline or escitalopram
Continue for 6 months of treatment once treatment has become effective
what are panic attacks characterised by
an abrupt surge of intense fear or physical discomfort, reaching a peak
within a few minutes,
+ at least 4 symptoms are present
what is the first line drug treatment for generalised anxiety
SSRI - sertraline
what are non pharamacoglogical methods of managing mild depression in primary care
support, psycho-education, lifestyle advice, active monitoring and referral for further assessment and interventions (3rd sector counselling)
what are some short term drugs that can be used for insomnia in the elderly
melatonin
what is included in a CMHT review
assessment of the problem and risks, including the impact on family and carers, previous treatment and the development of a comprehensive care plan.
give some parasomnias that can give insomnia
restless legs, sleep walking/talking/sleep terrors/teeth grinding (bruxism), etc.
for an OCD diagnosis, what must the obsessions and compulsions be
time consuming >1hr, or cause significant distress or functional impairment.
what is the suicide risk in bipolar patients compared to the general population
20x higher
how long should a person take their anti-depressant after remission
6 months
what SSRI’s are licensed for panic disorder
citalopram, sertraline, paroxetine, escitalopram
how does the DSM 5 depression classification work in terms of 1st and 2nd lists of criteria
if 2 form 1st list you need 3 form second
is 1 from first list you need 4 form 2nd
(5 in total)
what is the 1st line treatment for OCD
CBT including Exposure and Response Prevention
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 by the situation
what are some symptoms of GAD in the DSM 5 classification
¥ Restlessness or feeling keyed up or on edge
¥ Being easily fatigued
¥ Difficulty concentrating or mind going blank
¥ Irritability
¥ Muscle tension
Sleep disturbance
what is defined at a 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.
when should you prescribe antidepressants in primary care for depression
PMH of moderate- severe depression
sub threshold symptoms > 2 years
don’t respond to other interventions
when switching anti-depressants, what should you switch an SSRI to
a different SSRI or a better tolerated newer generation antidepressant
what criteria for depression diagnosis does nice recommend in primary care
DSM 5
what is meant by A 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, based on manuals tested in clinical trials, run weekly for 12–15w).
