Primary Care Management Flashcards
What is a screening tool used in primary care for depression?
PHQ-9
Questionnaire that patient rates with a scale and the higher they score, the more severe the depression
What is the stepped care model for treating depression?
The least intrusive intervention to be provided first. If that intervention is ineffective, or declined, offer an appropriate intervention from the next step
What is Step one in the stepped care model?
Recognition, assessment & initial management
All known and suspected presentations of depression
Intervention options: Assessment, support, psycho-education, lifestyle advice, active monitoring and referral for further assessment and interventions
What is step two of the stepped care model?
Recognised depression – persistent subthreshold depressive symptoms or mild to moderate depression
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
Donotroutinely use antidepressants
What is step three of the stepped care model?
persistent subthreshold depressive symptoms or mild to Moderate depression with inadequate response to initial interventions, and moderate and severe depression An antidepressant (normally a selective serotonin reuptake inhibitor [SSRI]) A high-intensity psychological intervention Combined treatments (medication + high intensity psychological) preferred for moderate to severe depression
How long should depressed patients be seen in practice?
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 for meds
What should be done when an antidepressant doesn’t have a response after 3-4 weeks? (switching and stopping)
Switching antidepressants: when switching
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
Stopping or reducing antidepressants
Advise re risk of discontinuation symptoms and gradually reduce the dose, normally over a 4 week period
What is step four of the stepped care model?
Severe and complex depression
Refer for multiprofessional and possible inpatient care for people with depression who are at significant risk of self-harm, have psychotic symptoms, require complex multiprofessional care or where an expert opinion is needed
What is a screening tool for GAD in primary care?
GAD-7
Patient rates questionnaire and the higher the score the worse the anxiety
What is the drug therapy used for GAD at stage three of the stepped care model?
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.
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)
What is panic disorder?
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
What are the symptoms of panic disorder?
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
What are the drug therapies used for panic disorder?
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
What are the symptoms of a lithium overdose?
Vomiting and diarrhoea Coarse tremor (larger movements, especially of hands) Muscle weakness Lack of coordination including ataxia Slurred speech Blurred vision Lethargy Confusion Seizures
