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Question 1

What proportion of primary care provider visits are related to stress & lifestyle ?
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Answer 1

70% of primary care provider visits are related to stress & lifestyle

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Question 2

What is the relationship between [feeling] stress & engaging in healthy habits ?
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Answer 2

People who are stressed / overwhelmed are less likely to engage in healthy habits, even though healthy habits can improve mood

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Question 3

What are the effects of work stressors on CAD & diabetes ?

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Eu Heart J 2020:31(14):1737-1744

Am J Epidem 2012:176(7):586-596

Answer 3

1) Increased overtime (by 3-4 hrs/day) associated with 1.5 x multiple cardiovascular outcomes including CV death, angina. Increased in males.
2) Work stressors increase incidence of NIDDM in women by two fold over 15 yrs. Only decreased by 20% when adjusted for obesity & other health behaviours assoc w diabetes

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Question 4

List potential unhealthy responses to job characteristics which can affect the risk of obesity & hypertension

• what can this in turn lead to ?

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Answer 4

Potential unhealthy responses to job characteristics:

1) Stress
2) Smoking
3) Physical inactivity
4) Unhealthy diet
5) Heavy EtOH use

= #1 to #5 increase the risk of Htn, obesity which can in turn lead to the following risk factors for CV disease:

1) Sleep problems,
2) Decreased heart rate variability
3) Inflammation
4) Hypercoagulability, atherosclerosis
5) Decreased immune system functioning
6) HPA axis stimulation: inc cortisol & catecholamines

Question 5

What is the Perceived Stress scale ?

What is it used for ?

What are meaningful scores ?

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Answer 5

The Perceived Stress Scale:

• created by psychologist Dr Sheldon Cohen, 1983
• Ten questions on perceived stress
• Scoriing of perceived stress (note 13’s):

0 to 13 - low stress

14 to 26 - moderate stress

27 to 40 - high stress

Question 6

What are the Patient Health Questionnaire 2 questions screening tool (PHQ-2) & General Anxiety Disorder 2 question screening tool (GAD-2) ?
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More info here

Answer 6

Both consist of two questions which can EACH be scored 0-3. A TOTAL score of above 3 is positive and merits further screening.

PHQ-2 screens for depression, if (+) => PHQ-9 or Hamilton Depression Scale (HAM-D)

GAD-2 => GAD-7

Question 7

In terms of depression:

1) How is the diagnosis of major depressive disorder made ?
2) What makes it difficult to assess depressive symptoms ?
3) What role can gender play ?
4) What role can culture play ?

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Answer 7

1) Dx of Major depressive disorder is made using DSM-5 criteria (based on previous 2 weeks)
2) It may be difficult to delineate between depression & chronic illness somatic symptoms
3) Gender roles for men may not allow them to describe their emotional problems
4) Spanish speaking Latinos are MORE likely to endorse crying vs English speaking Latinos.

Question 8

What should you do before concluding that a patients symptoms are due to stress ?

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Answer 8

One should rule out anxiety before concluding that symptoms are due to stress.

Question 9

Is there an association between diabetes & depression ?

Possible mechanism ?

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Answer 9

There is a BIDIRECTIONAL assocation between diabetes & depresssion.

• ie they each predict the other.
• reason is unclear - ? role of inflammation ?

Question 10

What medical conditions is depression associated with an increased risk of ?

“In these diseases, depression is as strong an independent marker for mortality as __”

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Answer 10

Depresssion assoc w increased risk of:

1) Diabertes
2) Cardiac diseases
3) Stroke
4) Cancer risk

=> depression is as strong a risk factor as smoking

Mn: Lorraine - smoking + depression

Question 11

What are some implications of poor emotional health in a diabetic ?

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Answer 11

1) Increased anxiety/depression in presence of lower perceived control over diabetes
2) (-) emotional health assoc w (-) perceptions of DM including the seriousness of the illness & the severity of consequences.

Question 12

Name 3 risk factors for suicidal ideation on diabetics.

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Answer 12

3 risk factors for suicidal ideation on diabetics:

1) Insulin therapy
2) Duration of diabetes
3) Unsatisfactory glycemic control (HbA1c > 6.5%)

Mn: Severity x 3

Question 13

In terms of CAD & depression:

1) What is the relationship
2) What is the magnitude of CV complications in pts with major depressive disorder ?
3) List possible mechanisms (4) for #2

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Answer 13

1) Depression is an independent risk factor for cardiac events. See doubling of # of cardiac events even when controlling for EF & # of blocked arteries.
2) See 2.5 x risk cardiac complications (CV death, MI, arrest, revascularisation over 2 yr FU)
3) Pts with depression suffer from PERL:

P - abn Platelet function

E - Endothelial dysfunction

R - lowered heart Rate variability

L - dec adherence to Lifestyle changes

Mnemonic: PERL blocking the heart in figure w mime - sad lips split to two over heart.

Question 14

In terms of treatment of depression in pts with CAD:

1) Is it effective from the CV point of view ?
2) What drug(s) are relatively safe ?
3) What drugs(s) should be avoided ? why ?
4) What does optimal treatment include.

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Answer 14

1) See improved syx & QOL, no clear findings that Rx improves survival.
2) SSRI’s are relatively safe & early treatment may decrease CV events
3) Tricyclic antidepressants are unsafe due to QT prolongation & orthostatic hypotension.
4) Optimal Rx includes medication & psychotherapy

Question 15

List 5 self-managment techniques for emotional well-being

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Answer 15

P - develop Problem solving skills

A - learn Assertiveness techniques as appropriate

T - learn Time managment techniques

C - learn Cognitive behavioral skills

H - improve one’s sense of Humor

Mnemonic: PATCH (Adams)

Question 16

In terms of drug treatment of depression

1) What is first / second / third line drug Rx
2) What are the anticipated response rates (NNT) and need to discontinue Rx due to side-effects ?

3) Is there a role for combination therapy ?
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Answer 16

1) First line - SSRIs/SNRIs.

Second line - TCAs

MAOs - 3rd line - inc side-effects & more interactions with food

2) Response rates / discontinuation from side-effects

SSRI - (+) 1 in 7, stop 1 in 21 (1 in 20 to 90)

TCA - (+) 1 in 7 to 14, stop in 25% to 1 in 25

3) OK to use combo Rx:
- Physical activity + CBT
- SSRI + CBT

Question 17

In terms of Exercise + Depression:

1) Can exercise prevent or treat depression ?
2) How effective is exercise …
a) Compared to active therapies
b) Compared to no Rx or a control group Rx

3) Is there a role to encourage exercise in childhood ?
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Answer 17

1) Exercise can prevent or treat depression
2) It’s impact is comparable to cognitive behavioral therapy
3) Exercise is …
a) More effective than no Rx or control group Rx
b) Not more effective than Rx w psychological or pharmacological therapies.
4) Exercise in childhood may prevent depression in young adults if it’s regularly practiced starting in childhood.

Question 18

In terms of Mental health + nutrition:

1) Can we make general recommendations about mental health + nutrition ?
2) What does the evidence support ?

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Answer 18

1) The consistent evidence needed to make general recommendations about mental health and nutrition is not available
2) INTENSIVE lifestyle intervention is effective for depression & anxiety as shown by an improvement in Beck depression Index, social functioning scores, and mental health scores over 6 wks when there was a greater decrease in BMI

Question 19

In terms of Nutrients + mood:

1) “In __ [population], __ [nutrient deficiencies] were more common among depressed vs non-depressed subjects.
2) Name 2 nutrients which help treat depression when used as supplements.

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Answer 19

1) In child-bearing age women, deficiences of [FOB CISZ] was more common among depressed subjects:

F - folate

O - omega 3

B - vitamin B12

C - calcium

I - iron

S - selenium

Z - zinc

2) Supplementation with fish oil + folate helps treat depression

Question 20

In terms of types of foods + depression/anxiety

1) Name two type of food/diet association with depression

2) Is there a dose-response between types of fat intake & depression (2) ?
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Answer 20

1) Frequent fast food (Take out) intake assoc w 40% increased risk of developing depression; Unhealthy diets assoc w self-reported depression. Inc rates of depression w Fried foods, Refined grains, Sugary products.

Mnemonic: FURST.

2) Dose-response:

Higher trans fats => inc risk depression

Higher mono- & poly-unsaturated fats => lower rate depression.

Question 21

Among woment of childbearing age, list nutritional deficiencies which are more common among those who are depressed. (7)

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Answer 21

F - Fiber

O - Omega 3

B - B12

C - Calcium

I - Iron

S - Selenium

Z - Zinc

Question 22

List 4 types of foods associated with an increased rate of depression

Are some fats associated with a higher/lower rate of depression

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Answer 22

F - Fried foods

U - Unhealthy diet

R - Refined grains

S - Sugary products

T - Trans fats

UP - unsaturated (poly/mono) fats => lower rate

Mn: “In first depression, think of FURST’

Question 23

List the components for an action plan for emotional wellbeing

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Answer 23

T - Topic

I - Intervention

T - Time

U - follow Up

S - Support

eg “To improve my emotions I will begin exercising in one week, 3x/week for 20 min. My husband will walk with me and keep me accountable. I will follow up in 2 weeks by phone.

Question 24

List the practical techniques of positive psychology (7)
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Answer 24

I - Improve & find signature strengths

B - count Blessings

S - Savor the pleasing things in life

W - Write what one wants to be remembered for

E - Express appreciation

P - Practice kindness regularly

T - Think about ones happiest days frequently.

Question 25

In terms of positive emotions:

1) What is the ideal ratio of positive to negative emotions ? What is this predictive of ?
2) In terms of encouraging positive emotions - one can:
a) Promote activities that increase __ - __
b) View stress not as __ but rather as __

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Answer 25

1) A ratio of (+) to (-) emotions of 3:1 or more measures resilience & likelihood of overcoming obstacles
2) To encourage positive emotions:
a) Promote activities that increase self-efficacy
b) View stress not as a bad influence but as a signal to find more appropriate ways to satisfactorily react to stressors.