Mental health

Question 1

definition depression

Answer 1

the absence of a positive affect (a loss of interest and enjoyment in ordinary things and experiences), low mood, and a range of associated emotional, cognitive, physical, and behavioural symptoms.

Question 2

NICE less severe depression

Answer 2

subthreshold and mild depression

Question 3

NICE more severe depression

Answer 3

moderate and severe depression

Question 4

diagnosis depression

Answer 4

risk factors
non specific sx
specific sx - disturbed sleep, decrease/increase in appetite and/or weight, fatigue or loss of energy; agitation or slowing down; poor concentration; worthlessness or guilt; suicidal ideas or plans.

Question 5

history depression

Answer 5

Assessing the onset, duration, pattern, and severity of symptoms; current lifestyle (alcohol, sleep, substance misuse); past depression and/or self-harm; coexisting mental or physical health conditions (bipolar, anxiety, OCD, PTSD); risk factors including family history and personal, social, or environmental factors (chronic physical health conditions, hx of domestic violence); suicidal ideas or plans; current and previous medication, any support?, recent traumatic life events
Use questionnaire
Assess mental state and cognitive function
Physical examination or additional investigations? (neuro)

Question 6

initial management

Answer 6

Providing advice on sources of information and support, including activities to improve sense of wellbeing. - exercise, healthy diet, alcohol and sleep
Offer support for any family/carers
Developing a treatment plan using shared decision-making depending on the person’s wishes and needs.
Discussing treatment options such as active monitoring, guided self-help, antidepressant treatment, and/or cognitive behavioural therapy (CBT) or other psychological interventions.
Providing advice on the risks and benefits of antidepressants, if indicated, including adverse effects and withdrawal symptoms, recommended duration of treatment, and how to switch or stop treatment safely (gradually tapering dose with regular monitoring for withdrawal symptoms and signs of relapse).
Arranging regular monitoring and follow-up, depending on the person’s age, risk of suicide, and clinical judgement.

Question 7

follow up depression

Answer 7

Asking about symptom response, adverse effects, concordance with treatment, risk factors for relapse, and any suicidal thoughts or ideas.
Managing any modifiable risk factors and reconsidering the diagnosis if clinically appropriate.
Giving advice about relapse prevention.

Question 8

further line management if no sx improvement depression

Answer 8

Switching to an alternative psychological therapy.
Adding in an antidepressant (if not already taking).
Increasing the antidepressant dose or switching to a drug in the same class or different class (using cross-tapering when clinically indicated).
Changing to a combination of psychological intervention and antidepressant medication.
Seeking specialist advice or arranging referral.

Question 9

referral to specialist mental health services depression

Answer 9

More severe depression and is at signficant risk of self-harm or suicide, harm to others, or self-neglect.
Psychotic symptoms or suspected bipolar disorder.
More severe depression or chronic depressive symptoms affecting personal and social functioning, which have not responded to treatment in primary care.

Question 10

two depression identification question

Answer 10

During the last month, have you often been bothered by feeling down, depressed, or hopeless?
During the last month, have you often been bothered by having little interest or pleasure in doing things?

Question 11

ddx depression

Answer 11

bereavement
anxiety
bipolar
psychotic - schizophrenia
PMS
neurological - demental, MS, parkinson’s
substance misuse
drug side effects - methyldopa, propranonol, COCP, omeprazole, opioids
hypothyroidism, OSAS, anaemia

Question 12

websites to give pt about depression

Answer 12

royal college of psychiatrists
MIND
depression UK
the samaritans
mental health foundation
SANEline

Question 13

new episode less severe depression

Answer 13

Offer active monitoring, with the option to consider treatment at any time if needed.
Ensure the person has adequate social support and is aware of sources of help if symptoms worsen.
Arrange an initial review, usually within 2–4 weeks, and ensure follow-up if the person does not attend
if wants tx - CBT, mindfulness, meditation, counselling

Question 14

mental health act depression

Answer 14

The Mental Health Act (MHA) 1983 allows compulsory admission of people who:
Have a mental disorder of a nature or degree that warrants assessment or treatment in hospital, and
Need to be admitted in the interests of their own health or safety, or for the protection of other people.

Question 15

if pt at risk of suicide anti-depressant

Answer 15

Avoid tricyclic antidepressants ([TCAs] except for lofepramine) and venlafaxine (a serotonin noradrenaline reuptake inhibitor [SNRI]) due to their risk of death from overdose.
limit amount available

Question 16

first line anti depressant

Answer 16

SSRI - safe and tolerable

Question 17

first line anti depressant chronic physical health condition

Answer 17

sertraline or ciralopram as lower likelihood of drug interactions

Question 18

counsel pt on anti depressant tx

Answer 18

Advise that symptoms of anxiety, agitation, hopelessness, or suicidal ideas may increase when starting treatment, and advise when to seek urgent review.
Arrange to review the person’s treatment if needed, depending on clinical judgement. See the section on Follow-up in the section Scenario: Ongoing management for more detailed information.
Ensure the person has a crisis plan identifying potential triggers and strategies to help.
Advise that medication usually starts to work within 4 weeks (if the antidepressant is going to work).
Advise that medication may be needed for at least 6 months after the remission of symptoms, to reduce the risk of relapse. People who are at high risk of relapse may need to take medication for longer.
Reassure that antidepressant drugs are not addictive but withdrawal symptoms may occur if medication is stopped abruptly, doses are missed, or the full dose is not taken as directed.
Advise that some antidepressant drugs may affect alertness and concentration, affecting the person’s ability to drive. This is particularly relevant when starting treatment or after increasing the dose.

Question 19

2 contraindications SSRI

Answer 19

In a manic phase of bipolar disorder.
With poorly controlled epilepsy.
With known QT interval prolongation, or congenital long QT syndrome (citalopram and escitalopram).

Question 20

2 contraindications of SNRI

Answer 20

Uncontrolled hypertension.
Hepatic impairment (duloxetine).

Question 21

2 contraindications of TCA

Answer 21

With arrhythmias.
With heart block.
With severe hepatic impairment.
With severe renal impairment (lofepramine).

Question 22

2 contraindications mirtazapine

Answer 22

Cardiac disorders.
Diabetes mellitus.
Hepatic impairment (risk of increased plasma concentration).
Hypotension.
Older age.
lots more

Question 23

2 contraindications of reboxetine

Answer 23

A history of bipolar disorder.
A history of cardiovascular disease.
A history of epilepsy.
Hepatic impairment (risk of increased exposure).

Question 24

questionnaire depression

Answer 24

PHQ9
past 2 weeks had:
- little interest or pleasure in doing anything
- feeling down, depressed or hopeless
- insomnia or sleeping too much
- feeling tired/little energy
- poor appetite, overreating
- feeling bad about yourself/let you or your family down
- trouble concentrating
- moving/speaking so slowly or more fidgety/restless
- thought you were better off dead/hurting yourself
20-27 - severe,
15-19 - moderately severe,
10-14 - moderate,
5-9 - mild

Question 25

definition GAD

Answer 25

haracterized by excessive worry about every day issues that is disproportionate to any inherent risk.

Question 26

at least 3 sx GAD diagnosis

Answer 26

present most of the time
restlessness or nervousness, being easily fatigued, poor concentration, irritability, muscle tension, or sleep disturbance.
Symptoms are present for at least 6 months and cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Question 27

clinical fx of GAD

Answer 27

chronic
fluctuate in severity
low rates of remission

Question 28

GAD classification systems

Answer 28

the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR), or the World Health Organization (WHO) International Classification of Diseases (ICD-11)

Question 29

most common ages GAD

Answer 29

35-55

Question 30

risk factors GAD

Answer 30

Female sex.
Comorbid anxiety disorders.
Family history of anxiety disorders.
Childhood adversity.
History of sexual or emotional trauma.
Sociodemographic factors.

Question 31

complications of GAD

Answer 31

Distress, substantial disability, and impaired quality of life.
Impaired social and occupational functioning.
Comorbidities.
Suicidal ideation and attempts.

Question 32

when GAD be suspected

Answer 32

a person who reports chronic, excessive worry which is not related to particular circumstances, and symptoms of physiological arousal such as restlessness, insomnia, and muscle tension.
Have a chronic physical health problem.
Do not have a physical health problem, but are seeking reassurance about somatic symptoms (particularly older people and people from minority ethnic groups).
Are repeatedly worrying about a wide range of different issues.

Question 33

stepped-care approach management of GAD

Answer 33

If comorbidities such as depression are present, the primary disorder should be treated first.
If the anxiety symptoms are mild, a period of active monitoring should initially be undertaken.
If symptoms have not resolved following a period of active monitoring, a low-intensity psychological intervention, such as individual facilitated or non-facilitated self-help or psychoeducational group therapy, should be offered.
In the presence of marked functional impairment, or if symptoms have not resolved with low-intensity psychological interventions, either a high-intensity psychological intervention (such as applied relaxation or cognitive behavioural therapy), or drug therapy should be offered, depending on the person’s wishes.
If the person chooses drug therapy, a selective-serotonin reuptake inhibitor (SSRI) should be offered first-line, or if this is not tolerated, a serotonin-noradrenaline reuptake inhibitor (SNRI). If SSRIs and SNRIs are contraindicated or not tolerated, pregabalin should be considered.
Referral for specialist treatment should be arranged if GAD is complex, if the person has treatment-refractory GAD, if there is very marked functional impairment, or a if there is a high risk of self-harm.
Regular follow up should be arranged to monitor treatment progress.

Question 34

hx GAD

Answer 34

The nature, severity, and duration of symptoms.
Current physical or emotional stress.
History of physical or emotional trauma.
History of mental health disorders, and family history of mental health conditions in first-degree relatives.
Comorbid conditions, such as chronic pain, arthritis, cancer, coronary heart disease, cerebrovascular accident, or chronic obstructive airway disease.
History of alcohol or substance abuse.
Other risk factors for GAD.
Past experiences of, and responses to, treatments if appropriate.
Repeated visits with the same physical symptoms which do not respond to treatment (for example insomnia, headache, or fatigue).
Use of over-the-counter or prescribed medications and herbal remedies.
Anxiety can be an adverse effect of some medicines, such as salbutamol, theophylline, beta-blockers, herbal medicines (including ma huang, St John’s wort, ginseng, guarana, belladonna), corticosteroids, and some antidepressants.
Availability of social and emotional support.
assess risk of suicide
questionnaire
physical examination - increased HR, SOB, trembling, exaggerated startle responsne

Question 35

GAD 7 questionnaire

Answer 35

(GAD-7) consists of seven questions. The score is calculated by assigning scores of 0, 1, 2, and 3, to the response categories of ‘not at all’, ‘several days’, ‘more than half the days’, and ‘nearly every day’ adding up to a possible total of 21. Scores of 5, 10, and 15 are taken as cut-off points for mild, moderate, and severe anxiety respectively. The person should be asked ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’:
Feeling afraid, as if something awful might happen.
Becoming easily annoyed or irritable.
Being so restless that it is 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.

Question 36

ddx GAD

Answer 36

situational anxiety, adjustment disorder, depression, panic disorder, social phobias, OCD, PTSD, somatoform disorders, anorexia nervosa, substance of drug induced anxiety disorder (salbutamol, theophylline, corticosteroids, antidepressants, herbal remedies, caffeine)
CNS depressant withdrawal, cardiac disease, pulmonary disease, hyperthyroidism, infection, IBS, phaeochromocytoma

Question 37

non pharmacological for GAD

Answer 37

individualised non facilitated self help (written or elctronic materials with minimal therapist constant), individual guided self help (written/electronic materials with 5-7 weekly or fortnightly face to face/teleophone for 20/30 mins
psychoeducational groups - one therapist to 12 pts
if still no help
individual high intensity CBT or applied relaxation - 12/15 weekly sessions
then drug tx

Question 38

drug tx GAD

Answer 38

SSRI first line
If sertraline is ineffective, offer an alternative SSRI, for example, paroxetine or escitalopram, or a selective serotonin-noradrenaline reuptake inhibitor (SNRI), such as duloxetine or venlafaxine.
If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin.

Question 39

drug advice GAD

Answer 39

Explain that adverse effects early in treatment with an SSRI or SNRI may include increased anxiety, agitation, and sleeping problems, and that there will be a gradual improvement in symptoms over 1 week or more before they experience the full anxiolytic effect.
Review the effectiveness and adverse effects of the drug every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter. Dose adjustment may be required. Modest benefit is usually seen within 6 weeks and continues to increase over time.
Advise people aged under 30 years that in a minority of people aged under 30 years, SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm. Anyone in this age group receiving an SSRI or SNRI should therefore be seen within 1 week of first prescribing, and the risk of suicidal thinking and self-harm should be monitored weekly for the first month.

Question 40

pregnant medication GAD

Answer 40

non pharma or pregablin

Question 41

primary care self care advice GAD

Answer 41

Sleep hygiene — such as going to bed and waking up at the same time each day, eliminating alcohol after 6 pm, avoiding caffeine after 3 pm, and getting out of bed if unable to fall asleep to avoid negative associations with the sleep environmen
regular exercise
OTC meds

Question 42

primary care self care advice GAD

Answer 42

Sleep hygiene — such as going to bed and waking up at the same time each day, eliminating alcohol after 6 pm, avoiding caffeine after 3 pm, and getting out of bed if unable to fall asleep to avoid negative associations with the sleep environmen
regular exercise
OTC meds

Question 43

SSRI contraindications GAD

Answer 43

n a manic phase of bipolar disorder.
Taking monoamine oxidase inhibitors (MAOIs), or who have recently discontinued an MAOI

Question 44

SNRI contraindications GAD

Answer 44

With uncontrolled hypertension.
Taking a monoamine oxidase inhibitor (MAOI), or who have recently discontinued an MAOI.

Question 45

caution pregablin GAD

Answer 45

substance abuse
Conditions that may precipitate encephalopathy.
Diabetes mellitus — pregabalin may cause weight gain. People with diabetes who gain weight on pregabalin may need to adjust their anti-diabetic medication.
Renal impairment — dose adjustments may be necessary.

Question 46

diazepam contraindications GAD

Answer 46

Acute pulmonary insufficiency, compromised airways, respiratory depression.
Chronic psychosis (as monotherapy), phobic or obsessional states, hyperkinesis, depression or anxiety associated with depression (as monotherapy).
Central nervous system depression.

Question 47

test for cognitive function

Answer 47

MMSE
GPCOG

Question 48

factors offering protection against suicide

Answer 48

social support
religious belief
being responsible for children

Question 49

conduct suicide risk assessment

Answer 49

is must be difficult to feel that way - is there ever a time when it feels so difficult that you’ve thought about death or even that you might be better off dead?
‘you seem very down to me’ - sometimes when people are very low in mood they have thoughts that life is not worth living - have you ever been troubled with thoughts like these
made plans?
told anyone about it?
carried out any acts in anticipation of death?
do they have the means?
is there any available support?

Question 50

similarities and differences between suicide and self harm

Question 51

risk factors for suicide

Answer 51

suffering from mental illness
family hx, genetic, biological
psychologial factors - aggression, impulsive
exposure to self harm/suicide
availability of method
negative life events and social problems
physical illness
recent discharge from psychiatric inpatient care

Question 52

resources suicide

Answer 52

NHS 111
samaritans
papyrus
MIND

Question 53

self harm define

Answer 53

when someone takes action to hurt of harm themselves
an expression of personal distress

Question 54

factors associated with self harm

Answer 54

young person
prisoners, asylum seekers, veterans
gay, lesbian, bisexual, transgender- discriminated against
knowing others who self harm/doing it together
neglect, physical, emotion or sexual abuse in childhood
mental illness - depression
low self esteem
relationship problems
unemployed
lack of support

Question 55

relationship of self harm to suicide

Answer 55

if harm yourself more likely to die through sicide

Question 56

short term management of self harm primary care ACUTE

Answer 56

<48 hrs
- empathy and sensitive
- examine any physical injuries
- assess emotional and mental state and fx increase risk (depression, suicidal intent, hopelessness, recent life changes etc)
- assess for protective factors
- any safeguarding concerns in children and vulnerable adults
- if physical or mental state significant risk - emergency departmet (if poison - every case to A+e)
- wound management
- urgent referral to secondary mental health service or community mental health team, or durg and alcohol services
- if not comply ->mental health act

Question 57

consulting approach self harm

Answer 57

similar to suicide

Question 58

short term management primary care CHRONIC

Answer 58

• risk assessments
• referral to community mental health services or CAHMS
• manage any psychosocial needs
• manage any mental health problems
• monitor physical health
• prevent access to means of self harm
• offer written and verbal info to pt and family
• routine follow up