Mental Health Flashcards
What are the three core symptoms of depression according to ICD-10 criteria?
Low mood
Anhedonia
Anergia/fatigue
Other than the core symptoms what are some other features of depression?
Disturbed sleep with early morning wakening Poor concentration Low self confidence Poor or increased appetite Suicidal thoughts or acts Psychomotor retardation Guilt or self blame
Important questions to ask in depression to rule out other things?
Hypomanic or manic episodes- bipolar disorder
Normal reaction to grief
Medical disorders - chronic eg hypothyroidism, MS, alcohol and substance abuse
Medication associated with depression
Corticosteroids Beta blockers Statins Oral contraceptives Isotretinoin
Manic symptoms
Symptoms that affect social or occupational functioning or psychosis or hospitalisation distinguishes it from hypomanic
Abnormally elevated, expansive or irritable mood
Abnormal and persistent increased activity or energy
Inflated self esteem, grandiosity, flight of thoughts
Unrestrained buying, spending or gambling sprees
No drugs or other causes
Side effects of sertraline
GI upset, dry mouth, decreased libido or sexual activity, reduced ability to orgasm, mild nausea, drowsiness
Uncommon- weight gain, tremor, palpitations, urinary incontinence, urinary retention
When to refer to psychiatric services ?
- significant perceived risk of suicide, harm to others or severe self neglect
- if there are psychotic symptoms
- if there is a history or clinical suspicion of bipolar disorder
- in all cases where child or adolescent is presenting with major depression
Assessing suicide risk
Thoughts of suicide or self harm What precipitated attempt Why then, there and now Planned or impulsive Suicide note left Intoxicated Any precautions against discovery Previous attempts at suicide or self harm How do they feel now Do a PHQ9 Is there support at home Any risks to anyone Are there children at home How do they feel about the future
What increases risk of suicide ?
Age over 45 Male Family history of depression, substance misuse or suicide Unemployed Physical illness Psychiatric illness Divorced or widowed or single Personal substance misuse Previous attempts
Treatment of mild depression
Do not routinely medicate but consider use if there is moderate to severe recurrent depression or depression has persisted for more than 2-3 months
Offer low intensity psychosocial intervention eg self guided CBT, computerised CBT, structured group physical activity programme
Treatment of moderate or severe depression
Provide a combo of antidepressant meds and high intensity psychological intervention such as CBT
- SSRI- sertraline or citalopram
- SNRI- venlafaxine, mirtazapine
- Add an augmenting agent eg second gen antipsychotic such as quetiapine or lithium
- Tri cyclic - amitriptyline
- MAOI
Important things to check in treatment resistant depression
Check diagnosis Check alcohol or drug abuse Further antidepressant trials ECT Neurosurgery
Electroconvulsive therapy
Most effective treatment for severe depression, life threatening depression, prolonged or severe mania, Catatonia
SE- memory loss, short term retrograde amnesia, confusion, headaches, clumsiness
Generalised anxiety disorder symptoms
Psychological- constant worries, pervasive feeling of apprehension or dread, poor concentration, frustration, instability to tolerate uncertainty
Physical- trembling, sweating, nausea, SOB, difficulty swallowing, hot flashes, headaches, muscle ache or tension, twitching, irritability, insomnia, feeling in the edge, restlessness
Behavioural-putting things off due to feeling overwhelmed, avoidance, drug taking
More than 6 months and not tied to specific situation or OCD
Things to exclude in GAD
Phobia Hyperthyroidism Angina Asthma Excessive caffeine Alcohol Drugs
Treatment for GAD
Simple lifestyle changes- increase exercise, improve work life balance, avoid excess caffeine and stimulant drugs, avoid excess alcohol
Long term interventions such as CBT, SSRI self help
Benzos not to be used for more than 2-4 weeks due to tolerance and dependence
Benzodiazepines
Symptoms of anxiety reduces in 30-90 minutes
SE- sedation, reps depression, tolerance, dependence, impaired cognition
Discontinuation of antidepressants
Do slowly over a period of at least four weeks to prevent withdrawals and a recurrence of symptoms
Stop at an appropriate time and not during times of stress
Antidepressant discontinuation syndrome
Common symptoms- dizziness, headache, nausea, lethargy
Rarer- ataxia, electric shock sensations, EPSE, hypomania or mania
Differentials of psychosis
Schizophrenia Bipolar Delirium Drug induced Encephalitis Thyroid disease Brain tumour Hugh dose steroids Temporal lobe epilepsy Dementia Brain injury Metabolic disorders Lupus Drug withdrawal
Treatment of psychosis
Antipsychotic medication
CBT
Social support
Questions to ask in psychosis
Describe experience When did last feel normal How have things changed since then Ask about social life, family, friends, interests Auditory hallucinations - describe the voice, what does it say, what does it sound like, Other strange or frightening experiences Tv or radio talking about or to you Paranoia Special powers?
Side effects of antipsychotics
Weight gain, diabetes. Metabolic syndrome, hyperlipidaemia Sedation Movement disorders Prolonged QT Raised prolactin (mainly in clozapine)
Monitoring with antipsychotics
Weight Waist circumference Pulse BP Fasting blood glucose Blood lipid profile Prolactin levels Assess for movement disorders ECG if necessary
What is section 2 of MHA?
Person can be detained under section two if suffering from mental health condition which warrants their detention in hospital with a view to the protection of themselves or others
Under section two if not assessed in hospital before or have not been assessed for a while
Lasts 28 days
Section 3 of MHA
Detained in hospital for treatment
Can follow a section two
Up to 6 months
Force treatment for first three months but needs reassessing after 3 months
Section 4 of MHA
72 hour emergency hold for treatment
Positive symptoms of schizophrenia
Delusions
Hallucinations
Negative symptoms of schizophrenia
Blunted mood
Reduced speech
Poor self care
Loss of volition
Thoughts changes in schizophrenia
Disorders of speech
Tangential
Knights move
Neologisms
Causes or increased risk of schizophrenia
Birth asphyxia, childhood encephalitis, sexual abuse, cannabis, separation from parent, born in city
Increased risk in Afro Caribbean and south Asian patients
Poor prognosis gradual onset, strong family history, low IQ, premorbid hisorur of social withdrawal and lack of obvious precipitation
Types of schizophrenia
Paranoid- commonest subtype, hallucinations and delusions
Hebephrenic- age of onset 15-25, poor organisms, flu testin
affect prominent with fleeting fragmented delusions and hallucinations
Catatonic- characterised by stupor, posturing, waxy flexibility, negativity
Simple and residual- negative symptoms predominant
Risk factors for delirium
CHIMPS PHONED Constipation Hypoxia Metabolic disturbance Pain Sleepnlessness Prescriptions Hypothermia or Pyrexia Organ dysfunction eg hepatic or renal failure Nutrition Environmental changes Drugs
What to ask in delirium history
History of dementia or depression
Look for infection
Medications- opiates or calcium supplements
Vascular problems-previous MI, limb ischaemia (vascular dementia RF)
Other presenting complaints
History of recurrent admissions
What is involved in a confusion screen?
Early warning score
BP and pulse (check for sepsis, dehydration, hypotension)
Obs
CT head- bleeds, strokes, SOL
Bloods- FBC (anaemia, WCC, MCV), U&Es (electrolyte imbalance high calcium, dehydration), LFT (alcohol intake, liver failure), TFTs, calcium, b12, glucose, CXR, blood cultures upfield query sepsis, urine dip for UTI
Differentials for memory problems
Alzheimer’s Vascular dementia Dementia with Lewy Bodies Traumatic brain injury Frontotemporal dementia Semantic dementia Creutzfeldt Jakob disease Normal pressure hydrocephalus Wernicke Korsakoff Pseudo dementia secondary to depression Confusion secondary to infection
Tests and tools to assess confusion and cognition
Addenbrookes cognitive assessment
Montreal cognitive assessment- MoCA
Mini mental state exam
Hospital anxiety and depression scale
Vascular dementia
Usually caused by an acute, such as stroke or TIA
Can also develop over time from small blockages or slowing of blood
Risk factors- diabetes, hypertension, high cholesterol, CHD, peripheral artery disease
Step like decline in memory or cognition
Lower the vascular risk- aspirin and statins
Alzheimer’s
Most common form of dementia
Usually Begins in 60s
Risk factors- age, genetics
Gradual downward slope decline, starting from memory, thought and language,
Clinical presentation of Alzheimer’s
Involvement in cortical function eg aphasia, agnosia, apraxia
Decrease of motivation and drive
Slow rate of progression
CT and MRI show cerebral atrophy
Hallucinations, delusions, anxiety, marked agitation, aggression, agitation, wandering, hoarding, sexual inhibition
Genetics with dementia
Early onset is autosomal dominant so 50% chance of getting it.
50% of those with Down’s syndrome who live to 60 will get AD
Late onset genetics- apolipoprotein E (E4 increases risk, E3 normal risk, E2 reduced risk)
Pharmacological management of Alzheimer’s and Lewy Body
Cholinesterase inhibitors - donepezil
Rivastigmine
Memantine- NMDA receptor blockers
Meds slow down progress of the disease
Delays worsening of dementia for 6-12 months
Non pharmacological treatment for dementia
CBT reminiscence therapy Aromatherapy Sensory stimulation Music therapy
Criteria for dementia
Decline in memory, decline in emotional control or motivation Apathy Coarsening of social behaviour Must not have delirium Must be present for at least 6 months Should be irreversible
Lewy body dementia
Memory impairment
Sleep disturbances- nightmares, aggressive movements, disturbed sleep cycle
Autonomic dysregulation
Variable cognition
Urinary incontinence
Visual spatial difficulties, language impairment, dyspraxia
Memory, motor and psychosis
Deposits of alpha synuclein
Memory difficulties and problems develop at least one year before motor
Give rivastigmine and maybe memantine
Parkinson’s dementia
One third with PD develop dementia
Memory and psychotic symptoms develop one year after motor difficulties
Also alpha synuclein deposits
Front- temporal dementia
Frontal lobe- behaviour, problem solving, executive function (planning)
Temporal lobe- language, recognising objects and people
Lost inhibitions, lose empathy, apathy, change in eating habits
Borderline personality disorder
Impulsive aggression, affective lability, self injury and identity diffusion
Unstable self image, fears of abandonment, transient psychotic symptoms,
Maladaptive patterns of thought and behaviour
Treatment- co morbidities such as anxiety and depression, CBT, DBT,
Mental state exam
Appearance- overall impression, physical conditions suitability of dress, cleanliness
Behaviour- appropriateness of behaviour, distractibility, eye contact, rapport
Speech- rate, rhythm, volume, tone, coherence, relevance, quantity and fluency, abnormal associations, flight of ideas
Mood
Perception- delusional perception, illusion, hallucination
Thought- form- linear, tangential, circumferential, derailment
Content- suicidal or violent thoughts, delusions, overvalued ideas
Cognition- alert, attention concentration, orientation to time and place, short term memory
Insight- recognition of illness and need for treatment
