Mental Health Flashcards
What is the definition of depression?
Depression is characterised by persistent low mood and/or loss of pleasure in most activities with a range of emotional, cognitive, physical and behavioural symptoms.
The American Psychiatric Association state there are nine defining symptoms.
An episode of depression serious enough to require treatment, occurs in how many men and women at some point in their lives?
1 in 4 women
1 in 10 men
What does sub-threshold depressive symptoms refer to?
It describes a situation when an individual has some of the 9 defining symptoms of depression, but they are insufficient in number or severity to meet the full criteria to diagnose depression
What is the cause/ what are the risk factors associated with depression? (6)
Although the cause of depression is unknown, it is believed to result from a complex interaction of factors. These factors being:
- Psychosocial issues such as unemployment, divorce and poverty
- Genetic factors
- Personality
- Failure of adaptive mechanisms to stressors
- Chronic co-morbidities e.g. diabetes, COPD, CVD, chronic pain
- A past head injury
What factors may place someone at a particularly high risk of depression? (5)
- History of depression, suicide attempt or abuse
- Significant physical illness
- Other mental health problems i.e. schizophrenia and dementia
- Family history of depression
- Frequent visits to GP or A&E
What are the complications of depression? (4)
- Exacerbates pain, disability and distress
- Increases mortality: from comorbid conditions and from suicide
- Impairs a person’s ability to function normally
- Increases the risk of substance abuse
What is the average length of an episode of depression?
6-8 months
What is the risk of recurrence after a first episode of depression?
50%
What is the risk of recurrence after a second episode of depression?
70%
What is the risk of recurrence after a third episode of depression?
90%
What % of people with sub threshold depressive symptoms progress to having depression?
70%
What diagnostic tool is used to help diagnose depression?
DSM-5
Diagnostic and statistical manual of mental disorders
How do you assess for the two ‘core’ symptoms of depression?
- During the last month, have you often been bothered by feeling down, depressed, or hopeless?
- Do you have little interest or pleasure in doing things?
What are the other typical symptoms of depression, important to ask about? (7)
- Fatigue/loss of energy
- Worthlessness/excessive or inappropriate guilt
- Recurrent thoughts of death, suicidal thoughts or actual suicide attempts
- Lack of concentration/indecisiveness
- Psychomotor agitation/retardation
- Insomnia/hypersomnia
- Significant appetite and/or weight loss
What are the symptoms of atypical depression? (5)
- Reactive mood
- Increased appetite
- Weight gain
- Excessive sleepiness
- Sensitivity to rejection
Of the nine defining symptoms of depression, how many does NICE suggest the patient must have before they are diagnosed with depression?
At least 5 symptoms, with at least one of these a ‘core’ symptom.
How is sub threshold depressive symptoms diagnosed?
If the patient has at least two, but less than five symptoms that are required for the diagnosis of depression.
What are the differential diagnoses for depression?
- Grief reaction (this can be distinguished based upon certain symptoms, for example in depression the patient may feel no sense of a positive future, and finds distress in all facets of life, whereas in grief, the individual may still look forward to the future, and their distress relates to a particular loss)
- Dementia
- Substances/adverse drug effects
- Hypothyroidism
If someone is newly diagnosed with depression, what bio-psychosocial assessment needs to be completed?
Quality and Outcomes Framework (QOF)
What does the QOF for depression assess for? (8)
- Risk of suicide
- Any safeguarding concerns for children/vulnerable adults
- Co-morbid conditions associated with depression
- The severity of depression
- Stresses contributing to the development of depression
- A persona/family history of depression
- Sources of support
- Past experience of/response to, treatment
What co-morbid conditions maybe associated with depression? (5)
- Alcohol/substance abuse
- Anxiety
- Eating disorders
- Psychotic symptoms
- Dementia
If a patient appears to be at a risk of suicide, what options are available to support them? (3)
- Contact the Crisis Resolution and Home Treatment (CRHT) team for an urgent assessment.
- Voluntary or compulsory admission may be required
- Review the patient frequently in primary care
What psychological interventions are available for people with depression? (3)
- Computerised cognitive behavioural therapy (CBT)
- Individual guided self-help based on CBT (usually includes face-to-face or telephone sessions)
- Structured group-based physical activity programme
Which herbal remedy is marketed towards targeting depression, however NICE does not recommend its use?
St John’s wort
Antidepressants are not indicated for use mild depression, however in moderate depression, what is the first-line drug of choice?
SSRIs: Citalopram Fluoxetine Paroxetine Sertraline
Which SSRI is preferred if the patient has multiple health problems, due to it having a lower risk of drug interactions?
Sertraline
In addition to SSRIs, what other drugs are indicated for the treatment of depression? (4)
- Tricyclic antidepressants: lofepramine, trazodone, amitriptyline
- Duloxetine
- Mirtazapine
- Venlafaxine
What is somatisation aka somatic symptom disorder?
Somatisation is when physical symptoms are caused by psychological or emotional factors.
It is a chronic condition in which there are numerous physical complaints. It is defined as multiple, recurrent and frequently changing physical symptoms usually present for several years before the patient is referred to a psychiatrist.
Somatic symptom disorder has been associated in people with what conditions? (2)
- IBS
- Chronic pain
- PTSD
Patients with somatic symptom disorder (SSD) often seek to take on the sick role. How does taking on this role help them?
In most societies this provides them with attention, care and sometimes monetary reward.
It can be a relief rom stressful or impossible interpersonal expectations.
Although patients with SSD may take on the sick role, why is this not malingering?
Patients with SSD genuinely experience these symptoms, and are not aware that the cause is not physical. The mental or emotional problem is being expressed physically, so the pain and other symptoms e.g. diarrhoea, are real.
When is somatisation very commonly experienced?
Tension headaches, neck pain, palpitations etc, due to stress and anxiety.
Somatoform disorders are extremes of somatisation, and tend to persist long-term with no physical disease explaining the symptoms. What are the somatoform disorders? (5)
- Somatisation disorder (SSD)
- Hypochondriasis (e.g. minor headache = brain tumour, or skin rash = skin cancer)
- Conversion disorder
- Body dysmorphic disorder
- Pain disorder
At what age does SSD tend to develop, and in which gender is it more common in?
The disorder tends to begin before the age of 30 and occurs more often in women
What are the cardiac symptoms associated with SSD? (3)
- SOB
- Palpitations
- Chest pain
What are the GI symptoms associated with SSD? (6)
- Vomiting
- Abdo pain
- Difficulty in swalloing
- Nausea
- Bloating
- Diarrhoea
What are the MSK symptoms associated with SSD? (3)
- Pain in the legs or arms
- Back pain
- Joint pain
What are the neurological symptoms associated with SSD? (5)
- Headaches
- Dizziness
- Amnesia
- Vision changes
- Paralysis or muscle weakness
How is SSD diagnosed?
Often thorough physical examinations and diagnostic tests are performed to rule out any physical causes before SSD is diagnosed.
What features of SSD may indicate a diagnosis of somatisation rather than a physical illness? (6)
- Multiple symptoms, often occurring in different organ systems
- Symptoms that are vague or exceed objective findings
- Chronic course
- Presence of a psychiatric disorder
- History of extensive diagnostic testing
- Rejection of previous physicians
How is the diagnosis of SSD explained to a patient, and why is this so important?
It is vital for the doctor-patient relationship that the doctor conveys an understanding of the patients symptoms, and avoids implications that the illness is psychosomatic and does not exist.
An example of explaining the diagnosis:
“The results of my examination and of the tests we conducted show that you do not have a life-threatening illness. However, you do have a serious and impairing medical condition, which I see often but which is not completely understood. Although no treatment is available that can cure it completely, there are a number of interventions that can help you deal with the symptoms better than you have so far”
There is often an underlying mood disorder associated with SSD. Therefore which drugs would the patient likely respond to?
Antidepressants
Why may patients with SSD refuse antidepressants?
They rarely accept that the symptoms are caused (at least in part) by mental health problems
What framework is useful to use when trying to explore psychosocial stressors related to SSD?
BATHE
B - background : “what is going on in your life?”
A - affect : “how do you feel about it?”
T - trouble : “what troubles you the most about that situation?”
H - handle : “what helps you handle that?”
E - empathy : “this is a tough situation to be in. Your reaction makes sense to me”.
What are the possible complications of SSD? (3)
- Break down in trust with medical profession/poor relationship with healthcare provider
- Invasive testing/investigations to look for causes
- Dependency of pain relief/sedatives
What is generalised anxiety disorder (GAD)?
GAD is characterised typically by disproportionate, pervasive, uncontrollable and widespread worry and a range of somatic, cognitive, and behavioural symptoms that occur on a continuum of severity.
There are two main classifications systems for GAD, what are they called?
- DSM-V (American Psychiatric Association)
2. ICD-10 (WHO)
GAD encompasses a range of anxiety disorders, what are they? (6)
- Acute stress disorder
- Obsessive-complsive disorder
- Panic disorder
- Post-traumatic stress disorder
- Social phobia
- Specific phobias
What factors are known to increased a person’s risk of developed GAD? (9)
- Female gender
- Family history of psychiatric disorders
- Childhood adversity e.g. maltreatment, parental problems, exposure to overprotective/harsh parenting styles, bullying
- Physical/emotional trauma
- Domestic violence
- Unemployment
- Low socioeconomic status
- Substance dependence
- Chronic/painful illness e.g. arthritis
Between which ages is GAD most common?
35 to 55 years of age
What are the complications associated with GAD? (4)
- Serious disability
- Impaired social and occupational functioning
- Co-morbidities
- Suicidal ideation/attempts
When should GAD be suspected? (2)
If a person reports:
- Chronic, excessive worry not related to particular circumstances
- Symptoms of physiological arousal - such as restlessness, insomnia, muscle tension
What does the DSM-V diagnostic criteria for GAD include? (3)
- At least 6 months of excessive, difficult to control worry about everyday issues, that is disproportionate to any inherent risk, and causes distress, or impairment
- The worry is not confined to features of another mental disorder
- The person experiences at least 3 of the following symptoms, most of the time:
- restlessness/nervousness
- fatigued
- poor concentration
- irritability
- muscle tension
- sleep disturbance
What does the ICD-10 criteria for GAD include? (3)
- Anxiety which is generalised and persistent but not restricted to any particularly environmental circumstances
- Variable dominant symptoms including:
- persistent nervousness
- trembling
- muscle tension
- sweating
- lightheadedness
- palpitations
- dizziness
- epigastric discomfort
- Expressions of fears, e.g. that the person or their relative will shortly become ill/have an accident
What is important to remember when taking a history from people solely presenting with physical symptoms?
People with GAD often present with physical symptoms such as headaches, muscle tension, GI upset and may not readily report worry or psychological distress. So it is therefore important to ask about these things.
What are the differential diagnoses for someone with suspected GAD? (10)
- Situational anxiety
- Adjustment disorder
- Depression
- Panic disorder
- Social phobia
- Anorexia
- Somatoform disorders
- IBS
- Phaeochromocytoma
- Infection
Which questionnaire assess the severity of GAD?
GAD-7
What is GAD-7?
It is a questionnaire consisting of 7 questions with scores ranging from 0 to 3. The questions are based on: over the last 2 weeks, how often have you had any of the following:
- Feeling afraid
- Become easily annoyed/irritable
- Restless
- Trouble relaxing
- Worrying too much
- Not being able to stop or control worrying
- Feeling nervous/anxious/on edge
What psychological interventions can be offered to help someone with GAD?
CBT in the form of non-facilitated self-help, individual guided self-help, psycho-educational groups.
What drug treatment options are available for people with GAD? (3)
- First line = SSRI e.g. sertraline, paroxetine, escitalopram
- SNRI (serotonin-noradrenaline reuptake inhibitor) e.g. venlafaxine, duloxetine
- Pregabalin
Which drugs should not be offered as treatment for GAD? (2)
Benzodiazepines / antipsychotics
How is alcohol dependence or problem drinking defined?
A regular consumption of alcohol above the recommended levels. Men and women are not meant to regularly drink more than 14 units per week.
How is harmful drinking defined, compared to alcohol dependence?
Harmful drinking is defined as a pattern of alcohol consumption causing health problems directly related to alcohol. e.g. acute pancreatitis, depression, alcohol-related accidents.
Alcohol dependence is characterised by a craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences
An alcohol disorder can be identified using the DSM-V questions. Although there are many, give examples of these questions?
In the past year have you:
- Had times when you ended up drinking more, or longer, than you intended?
- More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
- Spent a lot of time drinking? Or being sick/getting over the after effects?
- Wanted a drink so badly you couldn’t think of anything else?
- Continued drinking even though it was causing trouble with your family or friends?
In England, what % of men and women drinking alcohol levels above the recommended units per week?
Men - 31%
Women - 16%
What are the short-term complications of excessive drinking/alcohol misuse?
Death and illness from accident and injury, drowning, alcohol poisoning.
What are the long-term complications of excessive drinking/alcohol misuse? (7)
- Cancer
- Heart disease/arrhythmias/hypertension
- Liver disease
- Pancreatitis
- Psychiatric illness
- Wernicke’s encephalopathy
- Fetal alcohol disorders due to alcohol consumption during pregnancy
Which questionnaire can be used to assess the nature and severity of alcohol misuse in an individual?
AUDIT - alcohol use disorders identification test
If the results of the AUDIT questionnaire suggest an alcohol dependence, which other questionnaires can be used to assess the severity of this?
SADQ = severity of alcohol dependence questionnaires LDQ = leeds dependence questionnaire
What are the mild symptoms of alcohol withdrawal? (10)
- Hypertension
- Tachycardia
- Anorexia
- Anxiety
- Emotional lability
- Insomnia
- Irritability
- Diaphoresis
- Headache
- Fine tremor
What are the moderate symptoms of alcohol withdrawal? (3)
- Worsening mild symptoms
- Agitation
- Coarse tremor
What is the name given to a severe alcohol withdrawal?
Delirium tremens
How does delirium tremens present?
Worsening moderate symptoms, plus confusion/delirium, generalised tonic-clonic seizures, auditory, visual, or tactile hallucinations, hyperthermia subsequent to psychomotor agitation.
When should someone with alcohol dependence be admitted urgently to hospital?
- For medically assisted withdrawal particularly if they are at high risk of delirium tremens
- If they show signs of Wernicke’s encephalopathy
If harmful/dependent drinkers are malnourished or at risk of malnourishment, what should be offered?
Oral thiamine
What is the CAGE questionnaire?
C - have you ever felt you should CUT down on your drinking?
A - have people ANNOYED you by criticising your drinking?
G - have you ever felt GUILTY about your drinking?
E - have you ever had a drink first thing in the morning to steady your nerves (EYE OPENER)?
What is delirium?
It is an acute, fluctuating syndrome of disturbed consciousness, attention, cognition and perception.
When does delirium typically occur?
It tends to occur in people with predisposing factors such as advanced age, and multiple co-morbidities, when new precipitating factors such as medications or infection, are added to the mix.
What are the 3 classifications of delirium?
- Hyperactive delirium
- Hypoactive delirium
- Mixed delirium
What are the predisposing factors for delirium? (11)
- Older age (over 65)
- Cognitive impairment (e.g. dementia)
- Frailty/multiple co-morbidities (e.g. stroke/heart failure)
- Significant injuries e.g. hip fracture
- Functional impairment e.g. immobility or the use of restraints such as cot sides
- Iatrogenic events e.g. bladder catheterization, surgery
- History of/current intake of alcohol excess
- Sensory impairment e.g. hearing loss
- Poor nutrition
- Lack of stimulation
- Terminal phase of illness
What are the precipitating factors for delirium? (11)
- Infection e.g. UTI, pressure sore
- Metabolic disturbances e.g. hypoglycaemia, hyperglycaemia, dehydration
- Cardiovascular disorders e.g. heart failure
- Respiratory disorders e.g. P.E.
- Neurological disorders e.g. stroke, encephalitis
- Endocrine disorders e.g. thyroid dysfunction or Cushing’s syndrome
- Urological disorders e.g. urinary retention
- GI disorders e.g. hepatic failure, constipation
- Severe uncontrolled pain
- Alcohol intoxication
- Medication e.g. anti-Parkinsonian medication
How many people over the age of 65, in hospital, are thought to be affected by delirium?
At least 50%
What are the complications associated with delirium? (11)
- Increased mortality
- Increased length of stay in hospital
- Nosocomial infections
- Increased risk of admission to long-term care or re-admission to hospital
- Increased incidence of dementia
- Falls
- Pressure sores
- Continence problems
- Malnutrition
- Functional impairment
- Distress for the person/their family/carers
What pre-exising illnesses are associated with a poorer prognosis with delirium? (3)
- Dementia/cognitive impairment
- Hypoxic illness (such as severe pneumonia)
- Visual impairment
What sort of behavioural changes are seen in someone with delirium/how does delirium present? (8)
- Altered cognitive function - the patient may be disorientated, have memory and language impairment, worsened concentrations, slow response and confusion
- Inattention
- Disorganised thinking
- Altered perception
- Altered physical function - dependent on hyperactive or hypoactive delirium
- Altered social behaviour - changes in mood, fear, paranoia, anxiety, depression, irritability, apathy
- Altered level of consciousness
- Falling and loss of appetite (often warning sign of delirium)
What criteria is used to confirm a diagnosis of delirium?
CAM criteria - confusion assessment method
DSM-IV
What does the CAM criteria for delirium consist of?
- Confusion that has developed suddenly and fluctuates
- Inattention
- Disorganised thinking
- Altered level of consciousness
What targeted investigations based on findings from history and examinations, are necessary to carry out in someone with delirium? (13)
- Urinarlysis
- Sputum culture
- FBC
- Folate and B12
- U&Es
- HbA1c
- Calcium
- LFTs
- Inflammatory markers
- Drug levels
- TFTs
- CXR
- ECG
What are the differential diagnoses with delirium? (7)
- Depression
- Dementia
- Mental illness
- Anxiety
- Thyroid disease
- Non-convulsive epilepsy or temporal lobe epilepsy
- Charles Bonnet syndrome
What is the general management plan for someone with delirium?
Most people need to be admitted to hospital (if they aren’t there already) for urgent assessment and close monitoring
Although most people need admission to hospital for delirium, what are the benefits and negatives for them being treated in primary care?
The patient remains in a familiar environment so as not to exacerbate confusion, however they would need constant supervision and their symptoms must not be harmful to themselves or others.
What does the treatment of delirium include? (3)
- Correcting the underlying cause, e.g. treating infection, pain, cessation of causative drugs etc.
- Optimise treatment of co-morbidities
- Ensure patient is in a calm and safe environment and avoid physical restraints
- Pharmacological measures should be a last resort for severe agitation or psychosis
What pharmacological treatment can be used for severe delirium, as a last resort? (3)
- Short-term, low-dose haloperidol
- Low-dose lorazepam (if haloperidol is contraindicated e.g. for people with Parkinson’s disease, Lewy-body dementia or a prolonged QT interval)
…informed consent should be obtained and documented…
What is dementia?
Dementia is a typically progressive clinical syndrome of deteriorating mental function significant enough to interfere with activities of daily living. It affects cognitive domains such as memory, thinking, language, orientation, judgement and social behaviour.
For a diagnosis of dementia to be made, what must the person have?
An impairment in at least two cognitive domains; memory, language, behaviour etc, leading to significant functional decline (enough to affect ADLs) that cannot be explained by another disorder or adverse effects of medication
