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GP > Mental Health > Flashcards

Mental Health Flashcards

1
Q

What is the difference between low mood and depression?

A

Low mood will tend to lift after a few days or weeks. A low mood that doesn’t go away can be a sign of depression.

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2
Q

What factors may increase risk of depression?

A
  • Chronic comorbidities
  • Medicines (for example, corticosteroids).
  • Female gender.
  • Older age.
  • Recent childbirth.
  • Psychosocial issues such as divorce, unemployment, poverty, homelessness.
  • Personal history of depression.
  • Genetic and family factors — a family history of depressive illness.
  • Adverse childhood experiences
  • Personality factors (for example, neuroticism).
  • A past head injury, including hypopituitarism following trauma.
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3
Q

What are the key symptoms of depression?

A
  • feeling down, depressed, or hopeless during the last month

- little interest or pleasure in doing things (anhedonia)

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4
Q

What are associated symptoms of depression?

A
  • Disturbed sleep (decreased or increased compared to usual).
  • Decreased or increased appetite and/or weight.
  • Fatigue/loss of energy.
  • Agitation or slowing of movements.
  • Poor concentration or indecisiveness.
  • Feelings of worthlessness or excessive or inappropriate guilt.
  • Suicidal thoughts or acts.
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5
Q

What part of the history should you ask about in depression?

A
  • symptoms of depression
  • past psychiatric history (previous episodes of depression)
  • screening for other psychiatric diagnosis
  • assess suicide risk
  • past medical history
  • drugs history
  • family history of psychiatric diseases
  • social history
  • does the patient have insight into what is going on?
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6
Q

What are some possible differential diagnosis for depression?

A
  • grief reaction
  • anxiety disorders
  • bipolar disorder
  • premenstrual dysphoric disorder
  • neurological conditions
  • substances and adverse drug effects
  • hypothyroidism
  • obstructive sleep apnoea
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7
Q

What neurological conditions may be differentials for depression?

A

Parkinson’s, multiple sclerosis, dementia

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8
Q

What substances/drugs can be differentials for depression?

A
  • CO poisoning can present with irregularities of the mental state
  • substance misuse (alcohol, steroids, cannabis, cocaine, narcotics)
  • centrally acting antihypertensives, lipi soluble beta blockers, CNS depressants, opioids, isotretinoin
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9
Q

What investigations can be done for depression?

A
  • TFTs to exclude hypothyroidism
  • electrolytes and serum calcium to rule out a metabolic disturbance
  • blood count and ESR to rule out systemic infection or chronic disease
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10
Q

Give an example of a screening tool for depression.

A

PHQ-9: a 9-item self-administered diagnostic screening and severity tool based on current diagnostic criteria for major depression

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11
Q

What are possible complications of depression?

A
  • exacerbation of pain, disability and distress associated with other conditions
  • reduced QOF for patient and family
  • increased morbidity and mortality in a range of comorbid conditions
  • impaired ability to function normally
  • increased risk of substance abuse
  • complications associated with use of antidepressants
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12
Q

What is the prognosis for depression?

A
  • with treatment, lasts 3-6 months
  • 50% recover within 6 months and nearly 75% within the year
  • recurrence likelihood is high
  • persistent subthreshold symptoms progress to the full criteria for depression in 70% of people
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13
Q

How should patients with mild depression or people with subthreshold depressive symptoms requesting treatment be managed?

A

Period of active monitoring

  • Discuss the presenting problems and any concerns they may have.
  • Provide information about the nature and course of depression.
  • Arrange follow up, normally within 2 weeks
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14
Q

How should people with persistent subthreshold depressive symptoms or mild-to-moderate depression be managed?

A
  • consider offering a low-intensity psychosocial intervention
  • group based CBT
  • avoid routine use of antidepressants but consider for:
    • history of moderate to severe depression
    • subthreshold symptoms that have persisted
    • persistence after interventions
    • complicating care of a chronic physical health problem
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15
Q

How should people with moderate or severe depression be managed?

A

Offer an antidepressant and a high-intensity psychological intervention

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16
Q

What are common side effects of SSRIs?

A
  • feeling agitated, shaky or anxious
  • feeling or being sick
  • indigestion
  • diarrhoea or constipation
  • loss of appetite and weight loss
  • dizziness
  • blurred vision
  • dry mouth
  • excessive sweating
  • sleeping problems (insomnia) or drowsiness
  • headaches
  • low sex drive
  • difficulty achieving orgasm during sex or masturbation
  • in men, difficulty obtaining or maintaining an erection (erectile dysfunction)
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17
Q

What advise would you give patients receiving treatment?

A
  • vigilant for worsening symptoms
  • usually takes 2-4 weeks for symptoms to improve
  • antidepressants should be taken for 6 months after remission of symptoms to prevent relapse
  • antidepressants are not addictive
  • may experience discontinuation symptoms if they miss doses (e/g/ sweating, restlessness, abdo symptoms, altered sensations)
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18
Q

What are different forms of low intensity psychological interventions?

A
  • Individual guided self-help, based on the principles of cognitive behavioural therapy (CBT) — this includes written material or other media relevant to reading age, and usually consists of 6-8 sessions (face-to-face and via telephone) over 9-12 weeks.
  • Computerized cognitive behavioural therapy (CCBT) — this can be provided via a stand-alone computer-based or web-based programme and usually takes place over 9-12 weeks.
  • Structured group-based physical activity programme — usually consists of 3 sessions per week of moderate duration (45 minutes to 1 hour) over 10-14 weeks.
19
Q

What are different forms of high intensity psychological interventions?

A
  • Individual CBT — usually given over 16-20 sessions over 3-4 months. For people with severe depression, two sessions per week might be provided for the first 2-3 weeks of treatment.
  • Interpersonal therapy — duration and number of sessions is similar to CBT.
  • Behavioural activation — duration and number of sessions is similar to CBT.
  • Couples therapy — usually consists of 15-20 sessions over 5-6 months.
20
Q

What is shift work disorder and jet lag?

A

Circadian rhythm sleep disorders

Due to a change in circadian rhythm and environmental factors altering timing or duration of sleep

21
Q

What is the classification of insomnia?

A

Short term - under 4 weeks duration
Long term - lasting over four weeks
Primary - no identifiable underlying cause
Secondary - due to other conditions

22
Q

What can cause insomnia?

A

Other sleep disorders - sleep apnoea, circardian rhythm disorders, parasomnias, narcolepsy
Stress - situational or noise
Psychiatric comorbidity e.g. depression, bipolar, GAD, panic disorder, PTSD
Medication and substance abuse
Medical comorbidity

23
Q

What are the investigations for insomnia?

A

History to establish underlying cause
Physical and psychological examination e.g. bloods for hypothyroidism, low ferritin associated with restless legs
Sleep diaries
Polysomnography

24
Q

What is the management of insomnia?

A

Sleep hygiene advice - limit caffeine, avoid napping, regular exercise, do not look at devices, avoid lie ins

CBT

Benzodiazepines and Z drugs such as zopiclone and short acting benzos e.g. loprazolam

25
Q

What are the risk factors for OSA?

A 
Obesity
Male sex
Increased collar size
Craniofacial abnormalities
Nasal congestion
Hypothyroidism
Acromegaly
Respiratory depressant drugs including alcohol
26
Q

What is narcolepsy?

A

When the brain loses its normal ability to regulate the sleep wake cycle
Types 1 and 2

Loss of orexin secreting neurones which regulate sleep, wakefulness and appetite. Due to autoimmunity.

27
Q

What are the symptoms of narcolepsy?

A 
Excessive daytime sleepiness
Disrupted nighttime sleep
Vivid dreams
Cataplexy - conscious collapse
Dream like hallucinations when entering or emerging from ram sleep
Sleep paralysis
28
Q

What is the management of narcolepsy?

A 
Good sleep hygiene
Scheduled naps
CNS stimulants e.g. modafinil
Antidepressants for cataplexy e.g. SSRIs
Support
29
Q

What is restless legs?

A

May involve brain iron deficiency and abnormal dopaminergic neurotransmission
Urge to move the legs

30
Q

What are the clinical features of restless legs?

A

Urge to move legs, worse when sitting or lying still
Involuntary jerks if legs still
Abnormal sensations e.g. pins and needles or burning
Symptoms relieved by movement or massaging
Secondary insomnia and fatigue
Look out for conjunctival pallor, angular cheilosis, koilonychia or atrophic glossitis due to iron deficiency

31
Q

What is GAD?

A

Generalised anxiety disorder, disproportionate pervasive uncontrollable and widespread worry

32
Q

What are the criteria for GAD?

A

DSM-V - core symptoms of excessive widespread worry for more days than not, difficult to control and present for 6 months

ICD-10 - present for most days for several months, with elements of apprehension, motor tension and autonomic overactivity.

33
Q

What are the risk factors of GAD?

A 
Female sex
Family history of psychiatric disorders
Childhood adversity e.g. maltreatment, parental problems, exposure to overprotection, bullying
Environmental stressors
Substance abuse
Chronic and/or painful illness
34
Q

What are the complications of GAD?

A

Serious disability, impaired quality of life
Impaired social and occupational functioning
Comorbidities
Suicidal ideation and attempts

35
Q

What is included in the GAD-7 questionnaire?

A

Over past 2 weeks been bothered by any of the following
Feeling afraid, as if something awful might happen
Becoming easily annoyed or irritable
Being so restless, hard to sit still
Trouble relaxing
Worrying too much about different things
Not being able to stop or control worrying
Feeling nervous, anxious or on edge

36
Q

What are the differentials of GAD?

A 
Situational anxiety
Adjustment disorder
Depression
Panic disorder
Social phobia
OCD
PTSD
Anorexia nervosa
Substance and alcohol misuse/withdrawal
Cardiac disease
Hyperthyroidism
Anaemia
Infection
Pulmonary disease
IBS
Phaeochromocytoma
37
Q

What is the management of GAD?

A 
Assess severity
Ask about comorbidities
Ask about environmental stressors
Treat disease which is most severe first e.g. depression
Substance misuse

Step 2 - not improved with interventions, off CBT:
Individual non-facilitated self help, guided self help, or psychoeducational groups

Step 3 - not improving with step 2 interventions
Individual high intensity psychological intervention e.g. CBT or drug treatment e.g. SSRIs

If pregnancy, a high intensity psychological intervention should be offered first

Step 4 - refer for specialist treatment if at risk of
self harm, self neglect, significant comorbidity e.g. substance misuse, suicide

38
Q

How can risk of suicide be assessed?

A 
Do they think about it
Evet made plans, do you have the means
Why have you not acted on these thoughts
Identify previous attempts, feelings of hopelessness
Male <30 years
Single or living alone
History of substance abuse
Antidepressant treatment
Psychosis
Anxiety, agitation, panic attacks
Severe depression
39
Q

What symptoms are often present in GAD?

A 
Autonomic arousal symptoms e.g. palpitations, sweating, shaking
Difficulty breathing, choking feeling, chest pain, nausea
Dizzy, faint, depersonalisation
Feeling of losing control
Fear of dying
Hot flushes, cold chills
Numbness, tingling
Restlessness
40
Q

What is loss of libido?

A

Sexual dysfunction relating to loss of sexual desire or sexual drive

41
Q

What questions need to be considered when assessing loss of libido?

A

What do they mean - loss of will or loss of way
Is there a problem with performance, what came first
How long ago did it start
Has it been progressive
How is the relationship
Has there been criticism
What sexual difficulties have been experienced e.g. ED or dyspareunia
Any other health problems
If appropriate ask about contraception - there may be a fear of pregnancy
Screen for depression - have you felt hopeless, little interest or pleasure in doing things

42
Q

What are the differentials for loss of libido?

A 
Mental illness e.g. depression
During cancer treatment
Overwork, chronic tiredness
Anxiety
Falling hormones
Prostate cancer treatment
Antihypertensives
After a baby
High intake of alcohol
Sex not fulfilling
Dyspareunia
Recurrent UTIs
Relationship problems
43
Q

What are the investigations?

A 
Hospital Anxiety and Depression Scale
FBC - MCV due to excessive alcohol consumption
U&Es - renal disease
LFTs
TFTs - hypothyroidism
FSH, LH, PL
44
Q

What is the management?

A 
Dependent on the cause
Relationship counselling
Lifestyle, work, financial matters
Depression treatment
Antipsychotics can raise prolactin which can cause dampened sexual arousal
Oestrogen

GP (2 decks)

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