Mental Health Problems

Question 1

What is psychosis?

Answer 1

Abnormal thought patterns or perceptions which make it difficult for the person to recognise what is real and what is not.

Question 2

What causes psychosis?

Answer 2

Bipolar disorder, schizophrenia, secondary to brain injury, drug use or trauma.

Question 3

What are the positive symptoms of psychosis?

Answer 3

Hallucinations, delusions, thought disorder

Question 4

What are the negative symptoms of psychosis?

Answer 4

lack of motivation, flattened mood, social withdrawal, lack of pleasure, paucity of speech/thought.

Question 5

What are other symptoms of psychosis?

Answer 5

hyper or hypo excitability, memory impairment, attention impairment, loss of functioning (social, occupational, academic)

Question 6

What should you enquire about as risk factors for psychosis?

Answer 6

• Family history of mental illness
• Early life adverse experiences
• Alcohol, smoking, and other drugs (Cannabis, amphetamines, khat, phencyclidine and ketamine)
• Current stressors
• Pregnancy or recent delivery
• medication use- especially steroids

Question 7

Is insight important in psychosis?

Answer 7

Good insight improves engagement and treatment. Poor insight increases the risk of relapse

Question 8

What tests might you consider to investigate an organic cause of psychosis?

Answer 8

FBC, U+E, LFT, TSH, Urine drug test, HIV, Syphillis, B12, anti-NDMA receptors (encephalitis) if neurological features.

Question 9

What is the prognosis in acute psychosis?

Answer 9

4/5 symptoms resolve. Most (4/5) will have a relapse in the next 5 years. The longer symptoms go untreated, the more likely it is that people will have persisting positive and negative symptoms. Early referral is important for this reason.

Question 10

What are some non-psychotic causes of psychotic-type symptoms?

Answer 10

Personality disorders, dissociative disorder, PTSD, Anxiety disorders, Autism.

Question 11

Name some second generation antipsychotics

Answer 11

Risperidone, olanzapine, quetiapine, aripiprazole

Question 12

Why are second generation antipsychotics preferred to first generation?

Answer 12

Fewer extrapyramidal side effects- (dystonia, akathisia, Parkinsonian features and tardive dyskinesia)

Question 13

What is the aim of treatment in psychosis?

Answer 13

Treat acute psychotic symptoms, prevent relapse, manage chronic symptoms, reduce risk of worsening associated symptoms and loss of functioning, Severe untreated disease can result in self- harm/neglect/harm to others

Question 14

If two second generation antipsychotics fail what is tried next and what is the risk of this?

Answer 14

Clozapine- requires careful monitoring because of risk of agranulocytosis.

Question 15

How long should antipsychotics be continued?

Answer 15

At least two years as there is a risk of relapse if stopped prior to this

Question 16

What is the lifetime risk of depression for men and women?

Answer 16

Women 1 in 4
Men 1 in 10

Question 17

What is depression?

Answer 17

Loss of interest and enjoyment in everyday activities and experiences, low mood and range of emotional, cognitive, physical and behavioural symptoms.

Question 18

How long does the average episode of depression last?

Answer 18

6-8 months

Question 19

How common is relapse in depression?

Answer 19

Very common- 50% after first episode, 70% after 2nd and 90% after 3rd.

Question 20

List some risk factors for depression

Answer 20

• Recent stressful life events
• personal history of depression, other mental health problems and substance misuse
• Psychosocial problems (poverty, unemployment, being a carer, relationship breakdown, domestic violence)
• Chronic physical health conditions
• Perinatal period
• Family history of depression/ suicide
• Adverse childhood experiences
• Drugs including antihypertensives, antidepressants, hormones and corticosteroids.

Question 21

What is the two question screening test for depression?

Answer 21

In the past month:
-Have you often been bothered by feeling down, depressed or hopeless?
- Have you had little interest or pleasure in doing things?
Yes to either warrants further investigation.

Question 22

What are the diagnostic criteria for depression and how many are needed?

Answer 22

5 out of the following:
- Depressed mood
- Anhedonia
- Significant weight/appetite change
- Sleep difficulties
- Fatigue
- Feelings of worthlessness or guilt.
- Reduced concentration or indecisiveness
- Recurrent thoughts of death/suicidal thoughts.

Question 23

How can we determine the severity of depression?

Answer 23

NICE recommends using PHQ-9 and categorising as ‘less severe’ PHQ <16 or more severe if >16 (or equal to)

Question 24

What are the five lives to assess psychosocial situation?

Answer 24

1. Life at home (Home circumstances, relationships, employment, finances)
2. Life events (Stressors or traumatic events)
3. Lifestyle (Sleep, diet, exercise, drugs, alcohol)
4. Life before (PMH, response to previous treatments, history of elevated mood)
5. Life lost (risk of suicide, self harm/ harm to others)

Question 25

What percentage of people with depression present with somatic symptoms?

Answer 25

45-95% of depressed patients. Consider depression in repeat presentations of somatic symptoms without clear physical diagnosis. In all patients with long-term or chronic health conditions.

Question 26

Does PHQ-9 assess for anxiety?

Answer 26

No- worth asking about this separately and if symptoms of anxiety consider assessing with alternative score as well such as GAD-7

Question 27

What is the cycle of thoughts, behaviours, physical symptoms and feelings in depression?

Answer 27

-Negative thinking about self, the world, the future -Can lead to behaviours such as stopping doing enjoyable things, stopping exercising, reduced self care, social withdrawal, use of alcohol, drugs, self harm. - Can lead to physical symptoms of poor sleep, fatigue, poor memory and concentration, changes in appetite and weight and loss of libido. - Which can lead to feelings of sadness, low mood, anhedonia, anxiety, worry, shame, guilt, anger - Which can lead to negative thoughts about self, the world and the future.

Question 28

What can be missed when diagnosing depression?

Answer 28

- Depression in people with communication difficulties - Adjustment disorder - Vague somatic symptoms - Older people with memory problems (Dementia or depression?) -Eating disorders - Bipolar disorder

Question 29

What are the treatment options for less severe depression?

Answer 29

NICE has menu of options including: - Guided self help - Group CBT - Group exercise - Mindfulness and meditation - Counselling - SSRI's

Question 30

What is on the treatment menu for more severe depression?

Answer 30

- Individual CBT and antidepressants - Counselling - Individual problem solving or behavioural action - Short term psychodynamic psychotherapy. - Guided self help - Group exercise

Question 31

What does active monitoring mean in the treatment of depression?

Answer 31

Option to not start any specific treatment. -Listen to the person and their concerns -Inform them of the nature and course of depression - Follow up, normally at 2-4 weeks - Try to contact them if they don't engage with follow up actively

Question 32

Should we encourage physical activity in depression?

Answer 32

YES! studies have shown even small amounts of physical activity are associated with substantially reduced risk. Activity- particularly outdoors is likely to benefit wellbeing. Optimising sleep and diet and minimising alcohol are also helpful.

Question 33

What did the 2021 drugs and therapeutic bulletin conclude about the role of antidepressants?

Answer 33

- The evidence for the clinical efficacy of antidepressants remains uncertain. - Range of adverse effects include emotional numbing, sexual difficulties, fatigue and weight gain. - Withdrawal symptoms are common and can be severe and long lasting

Question 34

What is NICE's recommended first-line treatment for severe depression?

Answer 34

CBT with antidepressant therapy

Question 35

How do you decide which antidepressant to prescribe?

Answer 35

Take into account patient preference, previous treatments, and their effect. Citalopram and sertraline have fewer interactions but citalopram can affect QT interval.

Question 36

Which SSRI's have a longer and shorter half -life?

Answer 36

Paroxetine and venlafaxine may be harder to stop because of a shorter half-life. The opposite may be true of fluoxetine due to its longer half-life.

Question 37

What info should be given in a written depression management plan?

Answer 37

- Indication and intended outcomes of treatment - Starting dose and intervals between adjustments. - Time to onset of action (usually within 4 weeks) - Who to contact if there are problems - Anticipated duration of therapy and duration of each prescription - Risks of taking more than the prescribed dose + signs of overdose. - Plans for review

Question 38

When should you consider more frequent reviews for those on antidepressants?

Answer 38

- Patient taking drug for the first time - Following dose adjustments - If the patient reports adverse effects from medication - Change in a mental health condition or social circumstances - Patient has additional care needs such as a learning disability/ cognitive impairment.