Mental Health Problems

Question 1

What are the symptoms of psychosis?

Answer 1

Positive- disorganised behaviour, speech and/ or thoughts. Delusions and/ or hallucinations.
Negative- emotional blunting, reduced speech, loss of motivation, self-neglect, social withdrawal.

Question 2

What are the causes of psychosis?

Answer 2

Schizophrenia, medication, substance misuse

Question 3

What are the complications of psychotic disorders?

Answer 3

-Increased risk of premature death due to higher rates of suicide, cardiovascular disease and type 2 diabetes.
-Difficulties in social functioning
-substance misuse

Question 4

What is the prodromal phase of psychosis?

Answer 4

A period of emotional disturbance which precedes the development of a psychotic disorder.

Question 5

The prodromal phase of psychosis involves a person in distress with a deterioration in social functioning. What else is required to diagnose it?

Answer 5

• transient or low intensity psychotic symptoms or
• other experiences or behaviour suggestive of possible psychosis (suspicion, mistrust, or perceptual change) or
• a first- degree relative with a psychotic disorder

Question 6

What assessment should be made if psychosis is suspected to determine the appropriate referral?

Answer 6

Risk of harm to self or others

Question 7

Who should people with suspected psychosis be referred to?

Answer 7

If high risk of harm- same day mental health assessment by the early intervention in psychosis team, or crisis or home treatment team.
If not deemed to be high risk of harm- the early intervention in psychosis service.

Question 8

Should treatment be given whilst awaiting secondary care assessment for psychosis?

Answer 8

An antipsychotic drug should not be given unless under advice from a consultant psychiatrist.

Question 9

What happens if I patient with a known psychotic disorder has a relapse?

Answer 9

• if they have a treatment plan, follow the plan.
• If they are high risk of harm they should be referred for same day mental health assessment.
• if no care plan but no immediate risk- refer to community mental health services.

Question 10

If secondary care prescribes antipsychotic medication, how long are they responsible for it?

Answer 10

For the first 12 months or until the persons condition has stabilised. (Whichever is longer)

Question 11

What is adjustment disorder?

Answer 11

An extreme reaction of depressed mood or symptoms of anxiety to an identifiable psychosocial stressor. Can be a single or multiple events. Can be a one off or recurrent.

Question 12

What is the diagnostic criteria for adjustment disorder?

Answer 12

Marked distress out of proportion to the the severity of the stressor.
Significant impairment in function.
Symptoms do not meet the criteria for another mental health disorder.
The syndrome does not represent normal bereavement.

Question 13

What are common triggers of adjustment disorder?

Answer 13

Marital conflict/ divorce
Jon loss
Relocation
Conflict with friends/family/colleagues
Academic failure
Chronic illness

Question 14

What are some of the pitfalls in primary care in managing adjustment disorder?

Answer 14

Failing to recognise it
Treating as depression or anxiety (most has a self limiting prognosis and drug treatment is not indicated)
Failing to recognise depression or anxiety!
Forgetting there is an increased risk of suicide or attempted suicide.

Question 15

What is the prognosis in adjustment disorder?

Answer 15

Symptoms usually resolve within 6 months of the termination of the stressor.

Question 16

What are the treatment options in adjustment disorder?

Answer 16

Likely to improve without treatment once the stressor resolves.
Watchful waiting with supportive empathetic clinician may be all that is needed.
Focussed psychological therapy may be considered in some situations.
Drug treatment is not indicated

Question 17

What information does NICE recommend sharing before prescribing antidepressants?

Answer 17

1.Side effects- can occur before benefits. Usually ease over time.
2. What next if the medicine is ineffective
3. Issues around withdrawal- missing doses/ difficulty stopping.
4. Safe storage
5. Provide written info about drug and treatment plan.

Question 18

What are some side effects and benefits of mirtazipine?

Answer 18

Most likely antidepressant to cause weight gain, sedative particularly at lower doses, lowest incidence of sexual dysfunction.

Question 19

Can you use two antidepressants in conjunction?

Answer 19

Secondary care may do this but NICE is clear this shouldn’t happen in primary care.

Question 20

When should more frequent reviews of antidepressants take place?

Answer 20

• if they’re taking the drug for the first time
• following dose adjustments
• patient reported adverse effects
• if there is a change in the mental health condition or social circumstances
• if there are additional care needs such as a learning disability.

Question 21

What should you check if there has been no improvement in depressive symptoms on medication?

Answer 21

1. Check expectations- not likely to be suddenly back to normal.
2. What does improvement look like? (Often little patches of feeing better against a background of ongoing low mood)

Question 22

Which antidepressants cause the most withdrawal effects?

Answer 22

Those used in higher doses, for longer periods of time and with shorter half lives (such as paroxetine)

Question 23

What are the symptoms of SSRI withdrawal?

Answer 23

Restlessness, anxiety, insomnia, sweating, GI upset, palpitations, headaches, fatigue, myalgia, altered mood or sensation.

Question 24

Why is it important to recognise the withdrawal symptoms that occur post SSRI?

Answer 24

• so that we don’t misdiagnose a relapse of the original problem
• ## recognise patients may be fearful of stopping antidepressants leading to prolonged treatment.

Question 25

How can we distinguish SSRI withdrawal from a relapse?

Answer 25

1. Ask about symptoms unlikely to be caused by depression (nausea, muscle pain, sensory disturbance)
2. Establish the timeline- withdrawal usually starts within days of stopping treatment whereas relapse takes weeks to months.
3. Restarting the antidepressant usually rapidly relieves withdrawal symptoms whereas improvement usually takes weeks to months after a relapse.

Question 26

How can we reduce the risk of SSRI withdrawal?

Answer 26

Slowly taper the dose. Think about the half life of drugs. Short half life venlafaxine and paroxetine need slowest reductions. Fluoxetine has a long half life and may be reduced more quickly.