Primary care management of common mental health conditions Flashcards
Mental health and primary care stats
40% gp consultations
most handled exclusively by gp
1 in 4 people
Major mental illness and death
women - 12 yrs earlier
men - 16 years earlier
Be alert to depression especially if…
PMH
significant illness - disability
other mental health problem eg dementia
2 key questions for depression
During the last month - feeling down, depressed or hopeless?
During last month - little interest or pleasure?
Recognising and diagnosing depression
ICD-10
DSM-5
PHQ-9
Suicide risk assessment
suicidal thoughts ideation intent plans previous attempts social support level of risk immediate risk - refer further help also homicidal risk
Stepped care model
Least intrusive intervention provided first
Ineffective/declined
offer appropriate intervention from next step
Stepped care model step 1
recognise, assess, initial management
step 1 - options
assessment support psycho-education lifestyle advice active monitoring
Step 2
sleep hygiene
active monitoring
CBT
(medication)
step 3
antidepressant - SSRI
CBT, IPT, behavioural activation
Follow up
see patients 2 weeks after starting
2-4 weeks interval for 3 months
under 30 at great risk - 1/week
6 months after remission take meds and up to 2 years if relapse risk
Do NOT routinely use anti-depressants unless
PMH of mod-severe depression
subthreshold symptoms for 2+years
Subthreshold for <2yrs but not respond to other interventions
Fitness for work
Med 3 forms
Fitness to drive - must not drive
significant memory or concentration problems, agitation, behaviour or suicidal thoughts
Non responders to anti-depressants
absent/minimal after 4 week
increase level of support and dose
OR switch to other
Switching anti-depressant
Switch to other SSRI
another class eg TCA
combine and augment
Lithium, antipsychotic or mirtazapine
Stopping or reducing anti-depressants
advise risk - discontinuation symptoms and gradually reduce dose over 4 weeks
Step 4
severe and complex depression
risk to life
severe self-neglect
Step 4 - interventions
multiprofessional - inpatient
self harm
psychotic symptoms
Antidepressants in bipolar
do not start SSRI in depressed phase
stop if become hypomanic
Panic disorder
Recurrent panic attacks and persistent worry about further attacks
Social anxiety disorder
Persistent fear of 1 or more social performance situations out of proportion to actual posed threat
GAD - DSM 5
excessive anxiety and worry for atleast 6 months
difficult to control worry
6 symptoms
6 part C symptoms in GAD DSM-5
restlessness easily fatigued difficult concentrating irritability muscle tension sleep disturbance
Step 1- GAD
education
active monitoring
Step 2 - GAD
CBT
guided self help
psychoeducational groups
Step 3 - GAD
CBT and applied relaxation
SSRI eg sertraline
SNRI
(pregabalin)
GAD - BZD
only in short term crisis
GBD - pregabalin
beware abuse potential
GBD - antipsychotics
do not offer for anxiety disorders
Step 4 - GAD
specialist referral
self harm, suicide
co-morbid eg substance misuse
self neglect
CMT review
assessment of problem and risks
impact on family and care plan
Step 4 - GAD treatment
drug and psychological
augmentation or anti-depressants
Symptoms of panic attacks
palpitations sweating shaking choking sensation chest pain nausea light headed fear of dying numbness
Panic disorder (mild-mod)
self help
mod-severe panic disorder
psychological therapy
drug treatment
Self help
bibliotherapy based on CBT
support groups
exercise benefits
Psychological interventions of panic disorder
CBT
self-completed questionnaires
alternative therapy if this fails
Panic disorder - drug treatment
citalopram, sertraline
NOT fluoxetine
clomipramine (no response to SSRI after 12wks)
avoid BZD, anti-psychotics
Screening questions in social anxiety
avoiding social situations?
fearful or embarrassed in social situations?
Treating social anxiety disorder
1st line = CBT
2nd line = sertraline/citalopram
Normal grief
disbelief anger/guilt/blame impaired functioning yearning and sadness difficult concentrating loss of purpose
Differentiating grief from depression
Grief - longing/yearning
+ve emotions still experienced
worst symptoms when thinking of person
want to be with others
Prolonged grief disorder
distress and disability
persistence - more than 6m
Prolonged grief disorder - treatment
counselling
anti depressant
CBT
refer if significant
Screening for OCD
do you wash or clean a lot?
do you check things a lot?
special order? upset by mess?
do these problems trouble you?
OCD diagnosis
obsessions and compulsions
obsession - intrusive thoughts, images
Compulsions - repetitive behaviour
>1hr or distress or functional impairment
overt behaviour - OCD
checking the locked door
Covert behaviour - OCD
mentally repeating a phrase in their head
OCD treatment
CBT - exposure+response
SSRI - up to 12 weeks to see a response
clomipramine
Insomnia - 2ry causes
anxiety/depression
obstructive sleep apnoea
excess alcohol/drugs
parasomnia eg restless legs, teeth grinding
circadian rhythm disorder (shift workers)
Insomnia treatments
sleep hygiene
sleep diaries - CBT
melatonin >55yrs
hypnotics if disabling
Sleep hygiene
avoid stimulating activities avoid alcohol/caffeine before bed avoid heavy meals regular day time exercise relaxation
Eating disorders - 1 care
recognise and refer
Shared care for major mental illness
medication monitoring BMI/Bp/smoking blood tests - antipsychotics (ECG) - lithium (thyroid/kidney every 6 months) - lithium levels 3 monthly
3rd sector
voluntary +community organisations
ACIS counselling
bereavement counselling
alcohol and drugs action
Lithium toxicity
vomit and diarrhoea course tremor muscle weakness lethargy confusion seizures slurred speech confusion
Expected side effects of lithium
Fine tremor dry mouth altered taste sensation urinary frequency weight gain
