Mental Health

Question 1

Low mood vs depression

Answer 1

• Feeling low is common after distressing events or major life changes
• Feeling down for several weeks (more than 2 weeks) and no longer getting pleasure from things you previoulsy enjoyed is more likely depression

Question 2

Management depression - signposting

Answer 2

• Royal college of psychiatrists website has patient info
• MIND website
• Depression UK website
• Mental health foundation website
• Samaritans website and helpline - 24hrs a day
• SANE line website and telephone - 4-10pm everyday

Question 3

When to refer depression?

Answer 3

• More severe depression - risk of self harm, self neglect, suicide - crisis resolution and home input team may be needed
• Psychotic symptoms

Question 4

Options for managing depression - not severe

Answer 4

• If someones depression is mild and does not want treatment - active monitoring and consider treatment if needed
• If mild but wants treatment - guided self help 1st line
• Don’t offer antidepressant 1st line, if someone wants medication offer SSRI
• others: CBT, Group therapy/minfulness, Meditation, Counselling

Question 5

Review after commencing depression treatment plan

Answer 5

2-4 weeks after have f/u
UNLESS 18-25 and started antidepressant - need f/u within 1 week due to risk of increased suicidal ideation

Question 6

Manageing depression - severe

Answer 6

• OFfer any options listed on other card
• Can offer SSRIs or SNRIs if want medication
• Must notidy DVLA if have significant memory, concentration, behavioural or suicidal thoughts
• DO NOT recommend St Johns Wort
• Use validated tool eg PHQ-9 to assess response to treatment

Question 7

Screening tool for depression in GP

Answer 7

• PHQ-9

Question 8

What does PHQ-9 involve?

Answer 8

Over the last 2 weeks have often have you been bothered about any of the following problems?:
* Little interest/pleasure in doing things
* Feeling down, depressed or hopeless
* Trouble falling/staying asleep or sleeping too much?
* Feeling tired or having little energy?
* Poor appetite or overeating?
* Feeling bad about yourself - or that you are a failure/let family down?
* Trouble concentrating on things eg reading/watching TV?
* Moving or speaking so slowly that others have noticed? - or the opposite - too fidgety?
* Thoughts that you would be better off dead, or hurting yourself in some way?

Total is out of 27, each point is scored not at all, several days(1), more than half days (2)or nearly every day (3)

Question 9

Depression severity from PHQ-9

Answer 9

• 0-4 = none
• 5-9 = mild
• 10-14 = moderate
• 15-19 = moderatley severe
• 20-27 = severe

Question 10

what is GAD?

Answer 10

• Most common type of all anxiety disorders
• Excessive and persistent worry and tension even without identifiable cause
• Can intefere with aspects of persons life and impair their ability to function normally
• Affects females:males 2:1
• Age onset usually adolescent

Question 11

Typical progression of GAD

Answer 11

• Symptoms start and progress more slowly than other anxiety disorders

Question 12

Stress vs GAD

Answer 12

• Stress - identifiable cause, feel relaxed after problem solved, exercise helps symptoms, transient, sleep undisturbed
• GAD - feels worried for unidentifiable reason, lack of appetite, question self worth, self doubt, over analyses past conversations, avoid social interactions, preoccupied by past for days, muscle tension, nausea, palpitations, SOB, headaches and exercise does not help symptoms, unable to concentrate, inability to sleep

Question 13

Experiences of GAD

Answer 13

• Tremoring hands
• Confused by feelings and thoughts
• Become withdrawn from others - isolate self
• Feeling like dying - palps, stomach pains, headaches, pins and needles
• Seek constant reassurance from others - only temporarily relief
• Perfection is minumum standard - not a goal
• Looking up symptoms on internet - causing more stress
• Depression alongside

Question 14

Experiences of GAD treatment

Answer 14

• CBT really helpful - discuss issues and what ifs
• Yoga, pilates
• Diary - write what time symptom dissapears - can reassure self when it next happens, this will pass, it does not define me
• Baby steps - walk to shop and back home
• Opening up for family is beneficial - supportive
• Talking about your feelings and opening up is beneficial - see how common it is

Question 15

Define GAD - NICE cks

Answer 15

excessive worry about a number of different events associated with heightened tension

Question 16

Clinical features of GAD

Answer 16

• Excessive and persistent worry about various events or activities, occurring more days than not for at least 6 months
• Difficulty controlling the worry
• Restlessness or feeling keyed up or on edge
• Fatigue
• Difficulty concentrating or mind going blank
• Irritability
• Muscle tension
• Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying sleep)
• The anxiety and worry are associated with significant distress or impairment in social, occupational, or other important areas of functioning

Question 17

Differentials for GAD

Answer 17

• Hyperthyroidism
• Cardiac disease
• Medication induced anxiety - eg salbutamol, theopylline, corticosteroids, antidepressants, caffeine

Question 18

Step wise approach to GAD

Answer 18

NICE suggest a step-wise approach:
1. education about GAD + active monitoring
2. low-intensity psychological interventions (individual non-facilitated self-help or individual guided self-help or psychoeducational groups)
3. high-intensity psychological interventions (cognitive behavioural therapy or applied relaxation) or drug treatment
4. highly specialist input e.g. Multi agency teams

Question 19

Drug treatment for GAD

Answer 19

• Sertraline should be considered the first-line SSRI
• If sertraline is ineffective, offer an alternative SSRI (paroxetine or escitalopram) or a serotonin–noradrenaline reuptake inhibitor (eg duloxetine and venlafaxine)
• If the person cannot tolerate SSRIs or SNRIs, consider offering pregabalin

Question 20

Warning for patients starting GAD medication and f/u

Answer 20

• For patients under the age of 30 years NICE recommend you warn patients of the increased risk of suicidal thinking and self-harm.
• Need to be seen within 1 week after initiating treatment if in this age group
• Weekly follow-up is recommended for the first month
• All other patients not in this group can be f/u within 4-6 weeks unless high risk

Question 21

Tools that can be used to assess response to GAD treatment

Answer 21

Anxiety screening questionnaires such as GAD-2 or GAD-7 to compare with previous scores.

Question 22

What is within GAD7 questionaire?

Answer 22

Over the last 2 weeks how often have you been bothered by any of the following problems?:
* Feeling nervous, anxious or on edge?
* Not being able to stop or control worrying?
* Worrying too much about different things?
* Trouble relaxing
* Being so restless it is hard to sit still
* Easily annoyed/irritable
* Feeling afraid as if something awful might happen?

Score out of 2, with not at all(0), several days (1). more than half days (2) nearly every day (3)

Question 23

GAD7 score meanings

Answer 23

• 5 or more mild
• 10 or more moderate
• 15 or more severe

When screening, further evaluation is recommended when score is 10 or more