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Systems: Psychiatry AB > Primary Care Management > Flashcards

Primary Care Management Flashcards

1
Q

What impact does major mental illness have on mortality?

A

Patients with major mental illness die 12 (women) to 16 (men) years earlier than background population

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2
Q

When should you be especially alert of the possibility of depression?

A
  • A PMH of depression.
  • Significant illnesses causing disability.
  • Other mental health problems, e.g. dementia.
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3
Q

What are 2 key questions in screening for depression?

A
  • “During the last month, have you often been botheredby feeling down, depressed or hopeless?”
  • “During the last month, have you been botheredby having little interest or pleasure in doing things?”
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4
Q

What are the key symptoms in the ICD10 diagnosis of depression?

A
  • Persistent sadness or low mood; and/or
  • Loss of interests or pleasure
  • Fatigue or low energy
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5
Q

What are the associated symptoms in the ICD10 diagnosis of depression?

A
  • Disturbed sleep
  • Poor concentration or -Indecisiveness
  • Low self-confidence
  • Poor or increased appetite
  • Suicidal thoughts or acts
  • Agitation or slowing of movements
  • Guilt or self-blame
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6
Q

What are the different degrees of depression according to the ICD10 classification?

A
  • Mild depression (four symptoms)
  • Moderate depression (five to six symptoms)
  • Severe depression (seven or more symptoms, with or without psychotic symptoms)
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7
Q

What is the criteria for depression using the DSM IV/V classification?

A
  • Symptoms must have been present nearly every day for at least 2w.
  • At least one of the first 2 criteria, and a total of 5 out of the 9 criteria in total:
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8
Q

What are the key symptoms of depression in the DSM IV/V classification?

A
  • Depressed mood

- Loss of interest or pleasure (anhedonia)

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9
Q

What are the additional symptoms of depression in the DSM IV/V classification?

A
  • Significant weight loss or gain, or change in appetite.
  • Sleep difficulties (including hypersomnia).
  • Psychomotor agitation or retardation.
  • Fatigue.
  • Feelings of worthlessness or inappropriate guilt.
  • Reduced concentration or indecisiveness.
  • Recurrent thoughts of death or suicidal thoughts.
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10
Q

What do the scores on the PHQ 9 for depreesion mean?

A
  • 0-5 mild depression
  • 6-10 moderate depression
  • 11-15 moderately severe depression
  • 16-20 severe depression
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11
Q

What is the NICE guidelines for diagnosing depression?

A
  • Diagnosis should be based on DSM IV criteria
  • For depression:5/9 criteria are required, including at least 1 of the first 2 criteria (low mood/anhedonia).
  • Subthreshold depressive symptomsare defined as those having <5 of the DSM IV criteria.
  • Severity is based on functional impairment, once the diagnostic criteria have been passed (i.e. once you have 5 or more symptoms, one of which must be from the first two criteria).
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12
Q

What are the NICE guidelines for diagnosing mild depression?

A
  • 5 or more symptoms (one of which must be from the 1st 2 criteria)
  • With mild functional impairment
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13
Q

What are the NICE guidelines for diagnosing severe depression?

A
  • At least 5 symptoms (one of which must be from the 1st 2 criteria) and often most or all will be present
  • Marked functional impairment
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14
Q

What must be asked about when assessing suicide risk?

A
  • Suicidal thoughts
  • Ideation
  • Intent
  • Plans: vague, detailed, specific, already in motion
  • Previous attempts
  • Homicidal risk
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15
Q

How should you act on suicide risk?

A
  • Assess whether the person has adequate social support and is aware of sources of help
  • Arrange help appropriate to the level of risk
  • If considerable immediate risk to themselves or others, refer urgently to specialist mental health services
  • Advise the person to seek further help if the situation deteriorates
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16
Q

What model is suggested by the NICE guidelines for treatment of depression?

A

Stepped care model
-The least intrusive intervention to be provided first. If that intervention is ineffective, or declined, offer an appropriate intervention from the next step.

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17
Q

What is step 1 in the NICE treatment guidelines for depression?

A

Recognition, assessment and initial management

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18
Q

Who is step 1 of the NICE treatment guidelines indicated for?

A

All known and suspected presentations of depression

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19
Q

What interventions are suggested in step 1 of the NICE treatment guidelines for depression?

A
  • Assessment
  • Support
  • Psycho-education
  • Lifestyle advice
  • Active monitoring
  • Referral for further assessment and interventions
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20
Q

Who is step 2 of the NICE treatment guidelines indicated for?

A

Recognised depression

  • Persistent subthreshold depressive symptoms
  • Mild to moderate depression
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21
Q

What interventions are suggested in step 2 of the NICE treatment guidelines for depression?

A
  • Offer advice on sleep hygiene
  • Offer active monitoring(discuss concerns, provide information about depression, reassess within 2w; contact the person if they do not attend follow-up appointment).
  • Low-intensity psychological andpsychosocial interventions(e.g. individual self-help based on CBT principles, computerised CBT, group CBT, group physical activity programme).
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22
Q

In step 2 of the NICE guidelines for the treatment of depression when are antidepressants suggested?

A
  • They have a past history of moderate–severe depression
  • They present with subthreshold symptoms that have been present for 2y or more
  • They have subthreshold symptoms for <2 years but they don’t respond to other interventions
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23
Q

Who is step 3 of the NICE treatment guidelines indicated for?

A
  • Persistent subthreshold depressive symptoms
  • Mild to moderate depression with inadequate response to initial interventions
  • Moderate and severe depression
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24
Q

What interventions are suggested in step 3 of the NICE treatment guidelines for depression?

A
  • An antidepressant (normally a selective serotonin reuptake inhibitor [SSRI])or
  • A high-intensity psychological intervention (Individual CBT, interpersonal therapy, behavioural activation, couples therapy where the relationship is a contributory factor)

Combined treatments (medication + high intensity psychological) preferred for moderate to severe depression

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25
Q

What can the GP do if they assess someone as not being able to work?

A
  • Can complete a fitness to work assessment and sign them off for an appropriate length of time
  • Can facilitate return to work (staged return/ amendment of duties etc.)
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26
Q

Can depression affect ability to drive?

A
  • In severe depression the individual is not fit to drive

- The DVLA should be informed

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27
Q

Once treatment is initiated for depression, what follow-up should occur?

A
  • Normally see people 2 weeks after starting, at intervals of every 2 to 4 weeks for 3 months and then at longer intervals if the response is good
  • In patients aged under 30, or considered at greater risk, see after one week and as frequently thereafter as appropriate until risk considered no longer clinically important
  • Encourage to take for at least 6 months after remission, and for up to 2 years if they are at risk of relapse
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28
Q

What should be done if there is minimal or no response to medication for depression after 3-4 weeks?

A
  • Increase level of support

- Increased dose or switch to another antidepressant

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29
Q

How should antidepressants be switched?

A
  • Initially switch to a different SSRI or a better tolerated newer generation antidepressant
  • Subsequently to another class that may be less well tolerated e.g. TCA, venlafaxine or MAOI (MAOI specialist initiated only)
  • Combining and augmentation: Using combinations should only normally be started in primary care in consultation with a psychiatrist
  • Consider combining or augmenting an antidepressant with lithium, an antipsychotic (e.g. quetiapine, aripriprazole etc) or another antidepressant such as mirtazapine
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30
Q

How should antidepressants be stopped or reduced?

A
  • Refer to Maudsley guidelines

- Advise re risk of discontinuation symptoms and gradually reduce the dose, normally over a 4 week period

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31
Q

Who is step 4 of the NICE treatment guidelines indicated for?

A
  • Severe and complex depression
  • Risk to life
  • Severe self-neglect
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32
Q

What interventions are suggested in step 4 of the NICE treatment guidelines for depression?

A

Refer to multi-professional and possible inpatient care for people with depression who are at significant risk of self-harm, have psychotic symptoms, require complex multi-professional care or where an expert opinion is needed

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33
Q

How is bipolar generally managed?

A
  • Refer is suspected
  • Do not start SSRIs in depressed phase – refer/discuss with 2ry care
  • Stop antidepressants if patients become hypomanic
  • Suicide risk is greater
  • Beware of sodium valproate of women of child bearing age
  • 2ry care medication only – woman must be on effective contraception and signed agreement between prescriber and patient
34
Q

What is generalised anxiety disorder?

A
  • Excessive worry about a number of different events

- Can exist in isolation or comorbid anxiety/depressive disorders

35
Q

What is panic disorder?

A

Recurrent panic attacks and persistent worry about further attacks

36
Q

What is social anxiety disorder?

A

-Persistent fear of, or anxiety about, one or more social or performance situations that is out of proportion to the actual threat posed by the situation.

37
Q

What is the DSM IV classification for GAD?

A
  • Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
  • Difficult to control worry
  • Associated symptoms (3 or more)
38
Q

What are the GAD associated symptoms in the DMS IV classification?

A
  • Restlessness or feeling keyed up or on edge
  • Being easily fatigued
  • Difficulty concentrating or mind going blank
  • Irritability
  • Muscle tension
  • Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)
39
Q

When should you consider the diagnosis of GAD?

A
  • Those presenting with anxiety or significant worry.
  • Frequent attenders with a chronic health problem.
  • Frequent attenders without health problems but who are seeking reassurance about somatic symptoms (especially elderly people or those from minority ethnic groups).
  • Frequent attenders who are repeatedly worrying about a wide range of different issues.
40
Q

What should be included when assessing the severity of anxiety?

A
  • Level of distress.
  • Functional impairment.
  • Number, severity and duration of symptoms.
41
Q

What may affect the development, course of anxiety state?

A
  • Other anxiety disorder in addition to generalised anxiety disorder (e.g. panic disorder).
  • Depression.
  • Substance misuse.
  • Physical health problems.
  • History of mental health problems.
  • Past experience and response to treatments.
42
Q

What is step 1 in the NICE guidelines for GAD?

A

Identification and assessment

43
Q

How should co-morbid mental illness be treated?

A
  • Treat the primary disorder first as the secondary may resolve or improve
  • Treat any substance misuse first
44
Q

What treatments should be offered for all identified with GAD?

A
  • Education about anxiety disorders
  • Active monitoring of patient’s function and symptoms
  • Discourage over the counter treatments
45
Q

What do the scores on the GAD7 for anxiety mean?

A
  • 0-5 mild anxiety
  • 6-10 moderate anxiety
  • 11-15 moderately severe anxiety
  • 16-21 severe anxiety
46
Q

What should be offered to those for whom active monitoring is insufficient for their GAD?

A

Low intensity psychological interventions

  • Individual non-facilitated self-help: written material based on CBT principles, with instructions to work through material over at least 6 weeks.
  • Individual guided self-help: written material as above, with support from a trained practitioner who offers 5–7 weekly/fortnightly face-to-face/phone sessions lasting 20–30mins each.
  • Psychoeducational groups: usually 6 weekly sessions of 2 hours each with a group of patients and a therapist. Based on CBT principles; interactive and including self-help manual.
47
Q

Who is step 3 in the treatment of GAD indicated for?

A
  • For those with marked functional impairment

- For those who have not improved with step 2 treatments

48
Q

What should be offered for step 3 of the treatment of GAD?

A
  • High intensity psychological intervention

- Drug therapy

49
Q

What high intensity psychological interventions are offered as part of step 3 treatment of GAD?

A
  • CBT (one-to-one sessions, each lasting 1 hour, run weekly for 12–15w).
  • Applied relaxation (one-to-one sessions, each lasting an hour, based on manuals tested in clinical trials, run weekly for 12–15w).
50
Q

What drug therapy should be offered for GAD at step 3?

A
  • Offer SSRI first line. Eg sertraline (off label but most cost effective) /fluoxetine (BMJ 2011;342:d1199 SR/MA most effective)
  • If first-line SSRI is ineffective, swap to an alternative SSRI or SNRI (venlafaxine/duloxetine)
  • If an SSRI or SNRI cannot be tolerated, consider using pregabalin (beware abuse potential)
  • Do not use benzodiazepines except for short-term measures during a crisis.
  • Do not offer antipsychotics for anxiety disorder in primary care.
51
Q

What should happen once a patient is commenced on drug therapy for GAD?

A
  • Review patients every 2–4w in the first 3m (more frequently in those under 30y, and 3-monthly thereafter.
  • Continue therapy for at least 12m after initiation to reduce the risk of relapse (high if treatment stopped in first 12m).
  • If a patient fails to respond to adequate drug treatment or to high-intensity psychological therapies, offer the alternative treatment
52
Q

What is step 4 in the management of GAD?

A

Specialist (CMHT) referral

53
Q

When should a specialist referral be considered in the treatment of GAD?

A
  • Risk of self-harm or suicide.
  • Significant comorbidity (substance misuse, personality disorder, complex physical health problems).
  • Self-neglect.
54
Q

What is involved in step 4 of GAD management?

A
  • CMHT review should include a thorough assessment of the problem and risks, including the impact on family and carers, previous treatment and the development of a comprehensive care plan.
  • Consider offering combined drug and psychological interventions.
  • Consider augmentation of antidepressants or combinations of antidepressants
55
Q

What is the DSM classification for panic disorder?

A
  • Recurring unforeseen panic attacks, followed by at least a month of persistent worry about having another attack and concern about its consequences OR a significant change in behaviour related to the panic attacks
  • Panic attacks are characterised by an abrupt surge of intense fear, or physical discomfort, reaching a peak within a few minutes, in which at least 4 associated symptoms are present
56
Q

According to the DSM, what are the associated symptoms of panic attack?

A
  • Palpitations, pounding heart, tachycardia
  • Sweating
  • Muscle trembling, shaking
  • Shortness of breath, sensations of smothering
  • Choking sensations
  • Chest pain or discomfort
  • Nausea, abdominal distress
  • Dizzy, lightheaded, instability, feeling faint
  • Derealization, depersonalization
  • Fears of losing control or going crazy
  • Fear of dying
  • Numbness, tingling sensations
  • Chills, hot flushes.
57
Q

What treatments does the NICE guidelines recommend for panic disorders?

A

Mild- Moderate
-Self Help

Mod-Severe

  • Psychological therapy
  • Drug treatment
58
Q

What self-hep should be offered for panic disorder?

A
  • Offer bibliotherapy based on CBT principles
  • Offer information on support groups.
  • Discuss the benefits of exercise as part of good general health.
  • Review progress appropriately based on individual circumstances (often every 4–8w)
59
Q

What psychological intervention is recommended for use in panic disorder?

A
  • CBT: 1–2 hourly sessions weekly. These should be completed within 4 months. 7–14h is usually optimal. Sometimes, more intense CBT over a shorter timeframe may be appropriate.
  • Monitor outcomes using short self-completed questionnaires.
  • If this fails, consider an alternative therapy.
60
Q

What drug treatment is recommended in the treatment of panic disorder?

A
  • Offer an SSRI licensed for panic disorder (citalopram, sertraline, paroxetine, escitalopram but NOT fluoxetine,
  • If unable to use SSRI or no response after 12w, consider imipramine or clomipramine (off-label indication for both) – beware both are dangerous in overdose.
  • Avoid benzodiazepines/sedating antihistamines/antipsychotics
61
Q

What is social phobia?

A

A persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.

62
Q

What is the criteria for social phobia disorder?

A
  • Can have panic attacks with exposure to feared situation
  • Recognises the fear is unreasonable or excessive
  • Feared situations are avoided or endured with intense distress
  • Avoidance of situation interferes with person’s routine or relationships
  • Fear is persistent, typically lasting 6 months or more
  • Not due to physiological effects of substance or a general medical condition
63
Q

People with social anxiety disorder….

A
  • Often view it as a personal failing or flaw rather than a treatable condition.
  • Often avoid contact with health services.
  • Often have difficulty taking things in when things are explained to them.
64
Q

What is the treatment for social anxiety disorder?

A

1st line
-CBT

2nd line

  • Sertraline or escitalopram
  • Continue for 6 months of treatment once treatment has become effective
65
Q

What is normal grief characterised by?

A
  • Feelings of disbelief and difficulty comprehending the reality of the loss.
  • Bitterness/anger/guilt/blame.
  • Impaired functioning: within the family, socially, ability to work/go to school.
  • Intense yearning and sadness, and emotional and physical pain. There may be physical symptoms of anxiety.
  • Mental fogginess, difficulty concentrating, forgetfulness.
  • Loss of sense of self or sense of purpose in life.
  • Feeling disconnected from other people and ongoing life.
  • Difficulty engaging in activities or making plans for the future.
66
Q

How can grief be differentiated from depression?

A

In grief

  • Includes longing/yearning for the loved one
  • Positive emotions can still be experienced
  • Symptoms worst when thinking about the deceased person
  • People often want to be with others, whereas people with depression tend to want to be alone
67
Q

How is prolonged grief disorder characterised?

A

Marked distress and disability caused by the grief reaction.
AND the persistence of this distress and disability more than 6m after a bereavement.

68
Q

What are the treatment options or prolonged grief disorder?

A
  • Counselling eg Cruse
  • Antidepressants for comorbid depression
  • Behavioural/cognitive/exposure therapies
  • Refer if significant impairment in functioning
69
Q

What questions can be used in the screening of OCD?

A
  • Do you wash or clean a lot?
  • Do you check things a lot?
  • Is there any thought that keeps bothering you that you’d like to get rid of and can’t?
  • Do your daily activities take a long time to finish?
  • Are you concerned about putting things in a special order? Are you very upset by mess?
  • Do these problems trouble you?
70
Q

How is OCD characterised?

A

OCD is characterised by obsessions or compulsions (usually both) which must impair function.

  • Obsessions: unwanted intrusive thoughts, images or urges. Tend to be repugnant and inconsistent with a person’s values.
  • Compulsions: repetitive behaviours or mental acts the person feels driven to perform. Can be overt (checking they locked the door) or covert (mentally repeating a phrase in their head).

To warrant a diagnosis of OCD, obsessions and compulsions must be time consuming >1hr , or cause significant distress or functional impairment.

71
Q

What is the treatment for OCD?

A

1st line
-CBT including Exposure and Response Prevention (asking people to resist their urges/compulsions)

2nd line

  • Medication ; SSRIs (sertraline/citalopram/fluoxetine/paroxetine
  • Often required at higher doses for longer duration –up to 12 weeks to see a response

3rd line
-Medication; clomipramine (most SSRI like of tricyclics)

72
Q

What are potential secondary causes of insomnia?

A
  • Anxiety/depression.
  • Physical health problems (e.g. pain, dyspnoea).
  • Obstructive sleep apnoea (risk increased if BMI ≥30 or neck circumference ≥40cm).
  • Excess alcohol or illicit drugs.
  • Parasomnias (restless legs, sleep walking/talking/sleep terrors/teeth grinding (bruxism), etc.).
  • Circadian rhythm disorder (especially in shift workers).
73
Q

What are the treatments for insomnia?

A
  • Sleep hygiene
  • Sleep diaries
  • CBT-I
  • Medication is not routinely advised
74
Q

Although not routinely advised, what medications can be used in insomnia?

A
  • Melatonin licensed >55yrs for short term insomnia <13 weeks use
  • Hypnotics :Z-drugs (zolpidem/zopiclone)/temazepam – only in severe disabling insomnia causing marked distress
  • Addictive potential and may interfere with next day tasks
75
Q

What is sleep hygiene?

A
  • Avoid stimulating activities before bed
  • Avoiding alcohol/caffeine/smoking before bed
  • Avoid heavy meals or strenuous exercise before bed
  • Regular day time exercise
  • Same bedtime each day
  • Ensure bedroom environment promotes sleep
  • Relaxation
76
Q

What is the role of primary are in eating disorders?

A

Recognise them and refer them to secondary care

77
Q

What role does primary care play in emerging psychosis?

A
  • Average GP sees one case a year
  • Easy to spot if frank psychosis
  • Often difficult to diagnose in early stages
  • Listen to family concerns
  • Look for increasing distress and declining function
  • Consider organic cause
  • Early diagnosis improves prognosis
78
Q

What is involved in shared care for major mental illness?

A
  • Medication monitoring
  • BMI/BP/ smoking sttus
  • Blood tests
79
Q

Why do blood tests need to be carried out when on certain medications for mental illness?

A

Antipsychotics

  • Monitoring cardiovascular risk factors for 2nd generation
  • Monitoring ECG for QTC prolongation 1st generation

Lithium

  • Thyroid / Kidney function tests 6monthly
  • Lithium levels 3 monthly – risk of lithium toxicity
  • Fine tremor vs coarse tremor
  • Avoid nephrotoxic drugs eg ACE I/NSAIDs/diuretics if possible
80
Q

What are the expected side effects of lithium?

A
  • Fine tremor
  • Dry mouth
  • Altered taste sensation
  • Increased thirst
  • Urinary frequency
  • Mild nausea
  • Weight gain
81
Q

What are the symptoms of lithium toxicity?

A
  • Vomiting and diarrhoea
  • Coarse tremor
  • Muscle weakness
  • Lack of coordination including ataxia
  • Slurred speech
  • Blurred vision
  • Lethargy
  • Confusion
  • Seizures
82
Q

What 3rd sector support is there available?

A
  • Collection of voluntary and community organisations
  • Locally available resources
  • Penumbra
  • ACIS counselling
  • Cairns Counselling
  • Cruse Bereavement -Counselling
  • Alcohol and Drugs action
  • Momentum
  • ACVO – Aberdeen City Voluntary Organisations- 3rd sector interface

Systems: Psychiatry AB (18 decks)

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