JC127 (Family Medicine) - Common Mental Health Problems in Primary Care

Question 1

Most common mental disorders in general population

Answer 1

1. Depression

2. Anxiety disorders (incl. generalized anxiety disorder, panic disorder, obsessive-compulsive disorder, PTSD, phobias)

Question 2

Screening tools for depression and anxiety disorder

Answer 2

PHQ-2 (Patient Health Questionnaire 2) depression scale - short version of PHQ-9

PHQ-9 (Patient Health Questionnaire) depression scale

GAD7 (Generalized Anxiety Disorder 7-item scale)

Question 3

Outline questions in the PHQ-2

Function of PHQ-2

Answer 3

first 2 questions asked on the PHQ-9:
o In the past 2 weeks, have you been bothered by the fact that you feel down, depressed or hopeless?
o In the past 2 weeks, have you been bothered by the fact that you have little pleasure or interest in doing things?

If either is positive then you should go to the following 7 questions on PHQ-9

Function: screen large groups of patients for undiagnosed depression

Question 4

Outline questions in the PHQ-9

Answer 4

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things
2. Feeling down, depressed, or hopeless
3. Trouble falling asleep, staying asleep, or sleeping too much
4. Feeling tired or having little energy
5. Poor appetite or overeating
6. Feeling bad about yourself, feeling that you are a failure, or feeling that you have let yourself or your family down

Question 5

Score interpretation for PHQ-9

Answer 5

Question 6

Outline GAD7 questions

Answer 6

Feeling nervous, anxious or on edge
Being unable to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen

(0 = not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day)

Question 7

Score interpretation for GAD7

Answer 7

Question 8

Questions to assess the severity of depression

Answer 8

 What do you think is the matter with you?
 Do you think that your feelings are possibly caused by nerves, anxiety or depression?
 Can you think of any reason why you feel this way?
 Do you feel down in the dumps?
 Do you feel that you are not coping well? Or how are you coping with this?
 Do you have any good times?

 Has anything changed in your life?
 How do you sleep? Do you wake early?
 What time of the day do you feel at your worst?
 Where would you put yourself between 0% and 100%?
 Have you felt hopeless?
 What is your energy like?
 What is your appetite like?
 Are you as interested in sex as before?
 Do you feel guilty about anything?
 Do you cry when no one is around?

Question 9

Questions for screening for suicidal ideation

Answer 9

 Do you feel that life is worthwhile?
 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 or 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 and how)
5. Are you having thoughts of killing yourself right now?
If yes&raquo_space; full mental health evaluation, do not let the patient go
home immediately

Question 10

Differential diagnosis for chronic fatigue and tiredness

Answer 10

Psychological distress (= most common cause):
o Lifestyle stress
o Anxiety
o Depression
o Somatization /Medically Unexplained Physical Illness (MUPS)

Physiological fatigue due to lifestyle issues (e.g. overwork, relative sleep deprivation, poor diet)

Medical/ organic causes of fatigue: anemia, hypothyroidism, diabetes, cancers, sleep apnea etc.

Question 11

Outline history taking questions for chronic fatigue

Answer 11

HPI: OPQRST

General:
o General discomfort, aches or pains
o Fever/ sweats/ appetite/ weight loss
o Sleep pattern

System:
o Bleeding (e.g. anemia)
o GI symptoms (reflux, heartburn, abdominal pain, bowel movements)
o CVS (chest pain, palpitations, SOB)
o Neuro (dizziness, headache, syncope)
o Endocrine (thirst, polyuria, frequency, nocturia, goiter)
o Apnea – snoring

Drug: alcohol, smoking, OTC meds, prescription meds and recreational drugs

Psychological: stresses, mood, sexual problems

Social: work, home (kids, partners and parents), housing, finances

Routine background: diet, exercise, PMHx, FHx

Question 12

Outline P/E for chronic fatigue

Answer 12

 General inspection: facial features, skin appearance (e.g. thyroid) and colour, conjunctival colour (pallor), lymphadenopathy (malignancy)

 Vital signs: HR (thyroid), BP, RR, Temp

 Anthropometric measurements: BMI, waist circumference, WHR

 Basic Resp (COPD) and CVS (CHF) exam, thyroid exam

 Abdominal exam (check for enlarged spleen, liver and inguinal lymph nodes)

 Urinalysis (renal impairment, DM)

Question 13

Clinical indicators of depression

Answer 13

Clinical depression is diagnosed when there are >5 symptoms present every day for over 2 weeks

1. Low mood
2. Loss of interest
3. Sleep disturbance
4. Lost concentration
5. Fatigue
6. Change in appetite or weight
7. Agitation/ retardation
8. Feelings of worthlessness or guilt
9. Suicidal thoughts

o Must have either 1 or 2

Question 14

Clinical indicators of anxiety

Answer 14

 Physiological symptoms: irregular heartbeat, shortness of breath, fatigue, muscle tension

 Emotional symptoms: irritability, feeling on edge

 Cognitive symptoms: difficulty concentrating, frequent worries

Question 15

Clinical features of generalized anxiety disorder

Answer 15

Characterized by excessive anxiety and worry occurring more days than not for >6 months about a number of events or activities

The person finds it difficult to control the worry and it is associated with >3 of:
 Restlessness/ feeling keyed up/ on edge
 Being easily fatigued
 Difficulty concentrating/ the mind going blank
 Irritability
 Muscle tension
 Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Screening: GAD 7