Mental Health Flashcards
Depression diagnosis
Ask the two ‘depression identification questions’:
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?
If ‘yes’ to one of the questions and symptoms have been present most days, most of the time, for at least 2 weeks, ask about associated symptoms of depression:
Disturbed sleep (decreased or increased).
Decreased or increased appetite and/or weight.
Fatigue or loss of energy.
Agitation or slowing down of movements and thoughts.
Poor concentration or indecisiveness.
Feelings of worthlessness or excessive or inappropriate guilt.
Recurrent thoughts of death, recurrent suicidal ideas, or a suicide attempt or specific plan.
Depression history
The onset, duration, pattern, and severity of symptoms
Impact on work, on carer roles, on relationships including safeguarding concerns for children in their care.
Current lifestyle including diet, physical activity, sleep; alcohol, substance misuse.
Any past history of depression + episodes of self-harm.
Any current symptoms or history of coexisting mental health conditions.
Any learning disability or acquired cognitive impairment eg dementia.
Any risk factor eg family history of depression, suicide, or self-harm; chronic physical health conditions; domestic violence.
Supportive relationships including partner, family, friends, carers; and support from any other organisations.
Any recent or past stressful or traumatic life events.
Always ask about any thoughts, ideas, plans, or intent to self-harm or commit suicide, and any protective factors.
Depression 1st investigations to order
metabolic panel
FBC
thyroid function tests
Patient Health Questionnaire-9 (PHQ-9)
Also consider:
24-hour free cortisol
vitamin B12
folic acid
mild depression treatment
Consider anti-depressant - SSRI and SNRI
Follow up patients 1 to 2 weeks after initiating therapy, then monthly for the next 12 weeks.
Successful antidepressant therapy may be expected to take 6 to 8 weeks. A 50% decrease in symptom score constitutes an adequate response, and a 25% to 50% change in symptom score may indicate the need to modify treatment.
If discontinuation of antidepressant treatment is required, slowly decrease the dose to reduce the risk of unpleasant withdrawal symptoms; this may take several months at a rate that is tolerable to the patient.
Psychotherapy - CBT or IPT - The time to response is approximately 12 weeks.
Supportive interventions - Offer advice on activities to help wellbeing. Advise patients to maintain a healthy lifestyle.
2nd line - switch antidepressant - if no improvement has occurred within the first 2 weeks of treatment. First within class and then outside of class.
Continue successful antidepressant treatment for 9 to 12 months. However, some physicians recommend that patients with frequent previous recurrences who respond successfully to antidepressant, may require indefinite therapy.
If there is an inadequate response to two full-dose and duration antidepressants, the patient’s depression might be considered treatment resistant or refractory - more complex.
3rd line - St John’s Wort
moderate depression treatment
1ST LINE - antidepressant
CONSIDER - psychotherapy or other non-pharmacological treatment
CONSIDER - immediate symptom management with benzodiazepine ± antipsychotic
2ND LINEswitch to alternative antidepressant
Severe depression treatment
1ST LINEpsychiatric referral ± hospitalisation + antidepressant
CONSIDER-immediate symptom management with benzodiazepine ± antipsychotic
1ST LINE-psychiatric referral ± hospitalisation + electroconvulsive therapy (ECT)
PLUS-antidepressant
2ND LINE-switch to alternative antidepressant
typical presenting features of generalised anxiety disorder in adults. • Develop appropriate management plans for generalised anxiety disorder which incorporate the NICE
recommended “stepped approach”. •
excessive worry for at least 6 months
muscle tension
sleep disturbance
fatigue
restlessness
irritability
poor concentration
Other:
COMMON
headache
sweating
dizziness
gastrointestinal symptoms
muscle aches
increased heart rate
shortness of breath
trembling
exaggerated startle response
UNCOMMON - chest pain
Step 1 — for all people with GAD:
Provide information and treatment options.
Arrange active monitoring of the person’s symptoms at intervals based on clinical judgement.
Step 2 — for people with GAD whose symptoms have not improved:
Individual non-facilitated self-help — based on CBT principles - materials that the person works through over a period of at least 6 weeks.
Individual guided self-help — supported by a trained practitioner who facilitates the programme and reviews progress 5–7 weekly sessions.
Psychoeducational groups — ratio of one therapist to 12 participants and usually consist of 6 weekly 2-hour sessions.
Step 3 — An individual high-intensity psychological intervention such as CBT or applied relaxation. 12–15 weekly sessions each lasting 1 hour.
Drug treatment — offer SSRI first line.
If sertraline is ineffective, offer an alternative SSRI or a SNRI.
If cannot tolerate consider pregabalin.
Explain that adverse effects early in treatment may include increased anxiety, agitation, and sleeping problems. Gradual improvement in symptoms over 1 week or more before full effect.
Review every 2–4 weeks during the first 3 months of treatment and every 3 months thereafter. Modest benefit is usually seen within 6 weeks and continues to increase over time.
Advise people aged under 30 that in a minority SSRIs and SNRIs are associated with an increased risk of suicidal thinking and self-harm. 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.
Do not offer a benzodiazepine for the treatment of GAD in primary care, except as a short-term measure during crises.
Differentiate between stress and generalised anxiety disorder. • Use a GAD 7 questionnaire with a patient and interpret the score generated. •
Answer the typical questions asked by patients suffering from generalised anxiety disorder.
GAD is a long-term condition that causes you to feel anxious about a wide range of situations and issues, rather than 1 specific event.
Feeling nervous, anxious or on edge?
Not at all, Several days, More than half the days, Nearly every day
Not being able 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?
Anxiety severity scale:
0-4: No anxiety
5-9: Mild anxiety
10-14: Moderate anxiety
15-21: Severe anxiety
Topic 1: Mental State Assessment
• Perform a mini-mental state examination (MMSE) and GPCOG assessment and interpret the score generated.
MMSE - for assessing cognitive impairment in older adults
Orientation
5 - What is the (year) (season) (date) (day) (month)?
5 - Where are we (state) (country) (town) (hospital) (floor)?
Registration
3 - Name 3 objects: 1 second to say each. Then ask the patient
all 3 after you have said them. Give 1 point for each correct answer. Then repeat them until he/she learns all 3. Count trials and record.
Attention and Calculation
5 - Serial 7’s. 1 point for each correct answer. Stop after 5 answers. Alternatively spell “world” backward.
Recall
3 - Ask for the 3 objects repeated above. Give 1 point for each correct answer.
Language
2 - Name a pencil and watch.
1 - Repeat the following “No ifs, ands, or buts”
3 - Follow a 3-stage command:
“Take a paper in your hand, fold it in half, and put it on the floor.”
1 - Read and obey the following: CLOSE YOUR EYES
1 - Write a sentence.
1- Copy the design shown. Eg two pentagons interlocking
Total Score -
ASSESS level of consciousness along a continuum - Alert Drowsy Stupor Coma
GPCOG
Name and Address for subsequent recall test
1. “I am going to give you a name and address. After I have said it, I want you to repeat it. Remember this name and address because I am going to ask you to tell it to me again in a few minutes: John Brown, 42 West Street, Kensington.” (Allow a maximum of 4 attempts).
Time Orientation
2. What is the date? (exact only)
Clock Drawing – use blank page
3. Please mark in all the numbers to indicate the hours of a clock (correct spacing required)
- Please mark in hands to show 10 minutes past eleven o’clock (11.10)
Information
5. Can you tell me something that happened in the news recently?
(Recently = in the last week. If a general answer is given, eg “war”, “lot of rain”, ask for details. Only specific answer scores).
Recall
6. What was the name and address I asked you to remember?
Total correct (score out of 9)
If patient scores 9, no significant cognitive impairment and further testing not necessary.
If patient scores 5-8, more information required. Proceed with Step 2,
If patient scores 0-4, cognitive impairment is indicated. Conduct standard investigations.
STEP 2 - informant review:
These six questions ask how the patient is compared to when s/he
was well, say 5 – 10 years ago
Does the patient have more trouble remembering things
that have happened recently than s/he used to?
Does he or she have more trouble recalling conversations
a few days later?
When speaking, does the patient have more difficulty in
finding the right word or tend to use the wrong words
more often?
Is the patient less able to manage money and financial
affairs (e.g. paying bills, budgeting)?
Is the patient less able to manage his or her medication
independently?
Does the patient need more assistance with transport
(either private or public)?
(If the patient has difficulties due only to physical problems, e.g bad leg, tick ‘no’)
(To get a total score, add the number of items answered ‘no’, ‘don’t know’ or ‘N/A’)
Total score (out of 6)
If patient scores 0-3, cognitive impairment is indicated. Conduct standard investigations.
Topic 2: Suicide Risk • Describe the factors associated with an increased risk of a person committing suicide. • Describe the factors that might offer a person some protection against committing suicide. •
Inc risk:
psychiatric disorder, negative life events, Family history, psychological factors, alcohol genetic & and drug misuse, family biological factors
history of suicide, physical illness, exposure to suicidal behaviour of others, and access to methods of self- harm.
Possible protective factors
– Social support. – Religious belief. – Being responsible
for children (especially young children).
Topic 3: Self-harm • Describe the factors associated with self-harm. • Express the relationship of self-harm to suicide. •
It seems to happen more often in:
young people
prisoners, asylum seekers, and veterans of the armed forces
Lgbt people - this may be due to the stress of prejudice and discrimination
a group of young people who self-harm together - having a friend who self-harms may increase your chances of doing it as well
physical, emotional or sexual abuse during childhood.
Common problems include:
Feeling depressed.
Relationship problems with partners, friends and family.
Being unemployed, or having difficulties at work.
Many people who self-harm may also have alcohol or drug use problems
People who self-harm are not usually trying to die. But, if you do start to harm yourself, you are more likely than other people to die through suicide.
Explain how to conduct a suicide risk assessment.
PHQ9 - start with this and build up to asking about suicidal thoughts.
Broach suicidal thoughts in the context of other questions about mood or e.g. “It 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?”).
Reflect back to the patient your observations of their non-verbal communication (e.g. “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 been troubled by thoughts like this?”).
Starting with more general questions and gradually focusing on more direct ones:
– Are they feeling hopeless, or that life is not worth living?
– Have they made plans to end their life?
– Have they told anyone about it?
– Have they carried out any acts in anticipation of death (e.g. putting their affairs in order).
– Do they have the means for a suicidal act (do they have access to pills, insecticide, firearms…)?
– Is there any available support (family, friends, carers…)?
Whether they have any images about suicide (e.g. “If you think about suicide, do you have a particular mental picture of what this might involve?”).
• Direct colleagues and patients to appropriate resources for use when patients are experiencing suicidal ideation or the consequences of suicide attempts.
Patients should be informed how best to contact you in between appointments should an emergency arise.
Patients should also be given details of who to contact out of hours when you are not available.
If there is thought to be an immediate risk of self-harm or suicide — refer to a crisis resolution and home treatment team.
If there the person is experiencing high levels of distress — refer to a community mental health team / (CAMHS).
If there is misuse of recreational drugs or alcohol — refer to drug and alcohol services.
Useful contacts:
NHS 111 Website
SAMARITANS Website
PAPYRUS Website
MIND Website
AcuteFollow-up of self harm
When a person presents in primary care following an act of self-harm:
Establish the following as soon as possible:
The severity of the injury and how urgently medical treatment is needed.
Physical healthcare and a psychosocial assessment
Whether there is immediate concern about the person’s safety.
Whether there are any safeguarding concerns.
Whether the person has a care plan.
If the person’s physical injuries and/or acute mental state are not thought to necessitate referral to an emergency department:
Provide wound management as appropriate.
Determine the need for urgent referral to appropriate secondary mental health services
Arrange follow up for the person who has self-harmed, within 48 hours.
Establish the means of self-harm and discuss removing this with therapeutic collaboration.
Assess whether there are concerns about capacity, competence, consent or duty of care.
Seek consent to liaise with those involved in the person’s care to gather information to understand the context of and reasons for the self-harm.
Discuss and agree with the person, and carers the purpose, format, and frequency of initial aftercare and which services will be involved in their care.
If the person is being supported and given care in primary care, ensure that they have:
Regular appointments for review of self-harm.
A medicines review.
Information about available social care, voluntary and non-NHS sector support, and self-help resources.
Care for any coexisting mental health problems, including referral to mental health services as appropriate.
When planning treatment following self-harm, take into account any associated coexisting conditions and the psychosocial assessment.
Consider developing a safety plan in partnership with people who have self-harmed.
Establish the means of self-harm.
Recognise the triggers and warning signs of further self-harm, or a suicidal crisis.
Identify individualised coping strategies
Identify family members or friends to provide support
Include contact details for the mental health service, including out-of-hours services and emergency contact details.
Keep the environment safe by working collaboratively to remove or restrict lethal means of suicide.
Care plan should be held by the person, Be shared with the family, carers and relevant professionals.
Long term self-harm management
For people who have previously self-harmed and are at risk of repetition, ensure that a psychosocial assessment has been carried out.
The roles of a primary care physician may include:
Management of psychosocial needs, including offering support to facilitate any goals (such as employment) outlined in the care plan.
Managing any mental health problems that have been identified (possibly as part of a shared-care arrangement).
Monitoring the person’s physical health, including the physical consequences of self-harm.
Considering what medicines are prescribed - toxicity ( eg opiates and TCA), recreational drug and alcohol consumption.
Working with secondary health for routine sharing of risk management plans.
