primary care management Flashcards
depression RF
Previous depression History of other mental illness History of substance misuse Family history of depression or suicide Domestic violence Unemployment Poor social support network Recent stressful life event – eg losses, bereavement, losing job
what should you think about when screening for depression?
A PMH of depression.
Significant illnesses causing disability.
Other mental health problems, e.g. dementia.
what are 2 key questions to ask when screening for depression?
“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?”
mild or moderate depression treatment?
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).
what criteria must they meet before u give antidepressants in depression?
They have a past history of moderate–severe depression OR
They present with subthreshold symptoms that have been present for 2y or more OR
They have subthreshold symptoms for <2y but they don’t respond to other interventions
how does follow up work in depression?
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
what to do if response absent or minimal after 3/4 weeks?
increase level of support and increase dose OR switch to another antidepressant
how to swap antidepressant?
first switch to diff SSRI
or switch to diff class (TCA< MAOI)
-combing and augmenting- speak to psychiatrist
-combining and augmenting with lithium
if sever and complex depression what do?
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.
how many people die a year from suicide?
6000 people die a year by suicide in the UK. Worldwide, one person dies by suicide every 40 seconds (BMJ 2015;351:h4978).
For every one person who commits suicide, 30 people attempt suicide (BMJ 2015;351:h4978).
suicide is the biggest cause of death for:
Those aged 15–24y.
Men under 50y.
suicide RA?
Must always ask about suicidal thoughts
Will not “plant the idea of suicide” in patient
Ideation/Intent/Plans - vague, detailed, specific, already in motion
Previous attempts
Also homicidal risk
Impulsivity/self control
Access to lethal methods
Current stressors/sense of hopelessness
Protective factors
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
in BP what should you NOT start if in depressed phase
Do not start SSRIs in depressed phase
if patients become hypomanic and on antidepressant what do?
STOP antidepressents
what med to be careful in pregnant ladies?
sodium valproate
treatment for mild-moderate panic disorders?
Self-help
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)
treatment for moderate-severe panic disorders?
Psychological therapy
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.
Drug treatment
drug prescribed in panic disorder?
-SSRI licensed for panic disorder (citalopram, sertraline, paroxetine, escitalopram
If unable to use SSRI or no response after 12w, consider imipramine or clomipramine
If one therapy (CBT, drugs, self-help) fails to give adequate response, try an alternative from this list; if no response, refer for specialist input (CMHT)
what drugs to avoid in panic disorder?
fluoxetine
benzodiazepines/sedating antihistamines/antipsychotics
social phobia defintion>
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
screening qs for/social anxiety disorder?
Do you find yourself avoiding social situations or activities?
Are you fearful or embarrassed in social situations?
treatment for social anxiety disorder?
1st line: CBT
2nd line:
sertraline or escitalopram
Continue for 6 months of treatment once treatment has become effective.
how to differentiate grief from depression?
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.
Prolonged grief disorder diagnosis
Marked distress and disability caused by the grief reaction.
AND the persistence of this distress and disability more than 6m after a bereavement
treatment for prolonged grief disorder?
Counselling eg Cruse
Antidepressants for comorbid depression
Behavioural/cognitive/exposure therapies
Refer if significant impairment in functioning
how to diagnose OCD?
obsessions and compulsions must be time consuming >1hr , or cause significant distress or functional impairment.
what is an obsession?
unwanted intrusive thoughts, images or urges. Tend to be repugnant and inconsistent with a person’s values
what is a compulsion?
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).
OCD screening qs?
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?
OCD treatment?
1st line: Exposure and Response Prevention (asking people to resist their urges/compulsions) in CBT
2nd line:
SSRIs (sertraline/citalopram/fluoxetine/paroxeti
3rd line: Medication; clomipramine (most SSRI like of tricyclics)
causes of Insomnia?
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).
Insomnia treatment
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
are meds used in insomnia`/
Medications not routinely advised
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, may interfere with next day tasks, avoid driving/operating machinery 8hrs after use
Reduce time to fall sleep by only 22 minutes
what to monitor in patient taking anti-psychotics?
Monitoring cardiovascular risk factors for 2nd generation
Monitoring ECG for QTC prolongation 1st generation
what to monitor in patients taking lithium (bipolar/adjunct in depression)
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
lithium toxicity symptoms
Fine tremor Dry mouth Altered taste sensation Increased thirst Urinary frequency Mild nausea Weight gain
what are signs of toxicity?
Vomiting and diarrhoea Coarse tremor (larger movements, especially of hands) Muscle weakness Lack of coordination including ataxia Slurred speech Blurred vision Lethargy Confusion Seizures
