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Psychiatry > Primary Care Management of Common Mental Health Disorders > Flashcards

Primary Care Management of Common Mental Health Disorders Flashcards

1
Q

How common is mental illness?

A

1 in 4

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2
Q

What majority of GP consultations have a mental health component?

A

40%

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3
Q

What factors predispose a patient to depression?

A

1 - PMH of depression

2 - Significant illnesses causing disability

3 - Other mental health problems, e.g. dementia

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4
Q

What 2 key questions can asked to screen patients for depression?

A

1 - During the last month have you often been bothered by feeling down, depressed or hopeless?

2 - During the last month, have you been bothered by having little interest or pleasure in doing things?

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5
Q

What are the key symptoms of depression and how many of these must be present for a diagnosis of depression to be made?

A
  • Persistent sadness or low mood
  • Loss of ineterest or pleasure
  • Fatigue or low energy

At least 1 of these symptoms must be present

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6
Q

What are the associated symptoms of depression?

A

1 - Disturbed sleep

2 - Poor concentration

3 - Low self-confidence

4 - Poor or increased appetite

5 - Suicidal thoughts or acts

6 - Slowing of movements

7 - Feelings of guilt

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7
Q

How many symptoms define mild depression?

A

4

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8
Q

How many symptoms define moderate depression?

A

5-6

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9
Q

How many symptoms define severe depression?

A

7 or > with or without psychosis

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10
Q

How long should symptoms have been present for in order to be diagnosed as depression?

A

2 weeks

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11
Q

What is the commonly used screening tool for depression in primary care?

A

PHQ-9

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12
Q

How many points must be scored on the PHQ-9 for a diagnosis of mild depression to be made?

A

0-5

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13
Q

How many points must be scored on the PHQ-9 for a diagnosis of moderate depression to be made?

A

6-10

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14
Q

How many points must be scored on the PHQ-9 for a diagnosis of moderately severe depression to be made?

A

11-15

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15
Q

How many points must be scored on the PHQ-9 for a diagnosis of severe depression to be made?

A

16-20

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16
Q

What are the depression guidelines used in primary care?

A

DSM-IV

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17
Q

What are the DSM-IV assessment criteria for diagnosing depression?

A

Depression:

Key symptoms:

1 - Depressed mood

2 - Anhedonia

Additional symptoms:

1 - Sleep difficulties

2 - Fatigue

3 - Reduced concentration

4 - Thoughts of suicide or death

5 - Psychomotor retardation

6 - Feelings of guilt

7 - Changes in appetite

Criteria:

  • Must have at least 1 of the Key symptoms AND a total of 5 out of 9 of the criteria in total
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18
Q

What is the name given to the condition when patients have < 5 of the DSM IV symptoms?

A

Subthreshold depressive symptoms

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19
Q

Using the diagnostic criteria of DSM-IV (5 or > symptoms), how is severity assessed in patients with depression?

A

Mild depression = 5 or > symptoms plus mild functional impairment

Severe depression = 5 or > symptoms plus marked functional impairment

Moderate depression = between mild and severe

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20
Q

What questions must be asked during a suicide risk assessment?

A
  • Have you had suicidal thoughts?
  • Have you had any thoughts or ideas about comitting suicide?
  • Have you made any plans to commit suicide?
  • Have you made any previous attempts to commi suicide?
  • Do you have enough social support?
  • Are you aware of sources of help?
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21
Q

According to the NICE 2018 guidelines, what is STEP ONE in the STEPPED CARE MODEL of depression?

A

Recognition, assessment and initial management

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22
Q

What options might be suggested for initial management of depression?

A

1 - Psycho-education

2 - Lifestyle advice

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23
Q

According to the NICE 2018 guidelines, what is STEP TWO in the STEPPED CARE MODEL of depression?

A

Recognised depression - persistent subthreshold depressive symptoms or mild to moderate depression

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24
Q

In a patient with mild to moderate depression, antidepressants shouldn’t be used unless what criteria are met?

A

1 - They have a past history or moderate or severe depression

OR

2 - They present with subthreshold symptoms that have been present for 2 years or more

OR

3 - They have threshold symptoms for < 2 years but they don’t respond to other interventiosn

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25
Q

According to the NICE 2018 guidelines, what is STEP THREE in the STEPPED CARE MODEL of depression?

A

Persistent subthreshold depressive symptoms with inadequate response to initial interventions

OR

Mild to moderate depression with inadequate response to initial interventions

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26
Q

What are the treatment options for step 2 of the STEPPED CARE MODEL?

A

1 - Offer advice on sleep hygiene

2 - Offer active monitoring

3 - Low-intensity psychological therapy - e.g. CBT

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27
Q

What are the treatment options for step 3 of the STEPPED CARE MODEL?

A

1 - An SSRI

2 - High intenisty psychological intervention (CBT, IPT etc.)

3 - Combined treatments (medication + psychological) for moderate to severe depression

28
Q

What are the follow up guidelines for patients who have been started on treatment for depression?

A

Follow up - 2 weeks after starting then every 2-4 weeks for 3 months

Following remission - Take treatment for at least 6 months after remission and for up to 2 years

29
Q

What options are there for patients who do not respond to initial depression treatment?

A

1 - Switching Antidepressants (initially a different SSRI, if still no response then try TCA or MAOI)

2 - Stopping or reducing antidepressants

30
Q

What should patients be made aware of when stopping antidepressants?

A

Risk of discontinuation symptoms

31
Q

According to the NICE 2018 guidelines, what is STEP FOUR in the STEPPED CARE MODEL of depression?

A

Severe and complex depression

32
Q

What are the treatment options for a patient on Step 4 depression?

A

1 - Inpatient care for those at significant risk of self-harm, have psychotic symptoms or require complex multiprofessional care

33
Q

In what case should patients with bipolar not be started on anti-depressants?

A

If they are in a depressed phase

34
Q

In what cases should bipolar patients stop taking antidepressants?

A

If they become hypomanic

35
Q

What is the suicide risk in bipolar patients compared with that of the general population?

A

20 times

36
Q

What mood stabiliser should be avoided in woman of child-bearing age?

A

Sodium valproate

37
Q

Can sodium valproate be prescribed in primary care?

A

No

38
Q

If woman of child bearing age are started on sodium valproate, what other medication must they be started on?

A

Contraceptive - and sign an agreement between patient and prescriber

39
Q

What are the most commonly encountered anxiety disorders in primary care?

A

GAD

Panic Disorder

Social Anxiety Disorder

40
Q

What are the core features of Generalized Anxiety Disorder (GAD)?

A

1 - Excessive anxiety and worry (occuring more days than not for at least 6 months)

2 - Find it difficult to control worry

3 - Anxiety and worry associated with 3 or more of the following:

  • Restlessness
  • Easily fatigued
  • Difficulty concentrating
  • Irritability
41
Q

What is step 1 in the treatment of GAD?

A

1 - Education about anxiety disorder

2 - Active monitoring of patients function and symptoms

3 - Discourage over the counter treatments

42
Q

What is the assessment system used to score GAD?

A

GAD-7

43
Q

How is the severity of GAD scored?

A

0-5 = mild

6-10 = moderate

11-15 = moderately severe

15-21 = severe anxiety

44
Q

What is step 2 of the treatment for GAD?

A

Low-intensity psychological interventions

45
Q

What is step 3 in the treatment of GAD?

A

High-intensity psychological intervention (CBT etc.)

OR

Drug therapy

46
Q

What is the stepwise approach to pharmacological treatment of GAD?

A

1st - Sertraline/Fluoxetine

2nd - Alternative SSRI or SNRI (venlafaxine/duloxetine)

3rd - Consider pregabalin (beware of abuse potential)

47
Q

What medications should be avoided when treating anxiety in primary care?

A

1 - Benzodiazepines

2 - Antipsychotics

48
Q

How ofte should GAD patients be reviewed once commenced on medication?

A

every 2-4 weeks in first 3 months

49
Q

What is step 4 in the treatment of GAD?

A

Specialist CMHT referral

50
Q

What is the DSM classification of panic disorder?

A
  • Recurring unforeseen panic attacks
  • Followed by at least a month of persistent worry about having another attack OR significant change in behaviour related to the panic attacks
51
Q

What do NICE suggest for treatment of mild-moderate severity of panic attacks?

A

Self-help

52
Q

What do NICE suggest for treatment of moderate-severe panic disorder?

A

Psychological therapy

Medication

53
Q

What are the suggested drugs for treatment of panic disorder?

A

1st: SSRI - Citalopram, Sertraline, Paroxetine, Escitalopram

2nd: Imipramine or Clomipramine

54
Q

What drugs should not be prescribed for panic disorder?

A

Fluoxetine

Benzo’s

Antipsychotics

55
Q

What are the treatment options for social anxiety?

A

1st - CBT

2nd - Setraline or Escitalopram

56
Q

How can grief be differentiated from depression?

A

Grief has the following features:

  • Longing/yearning for the loved one
  • +ve emotions can still be experienced
  • Symptoms worst when thinking about the deceased person
  • People suffering with grief still want to be with others
57
Q

What are the features of prolonged grief disorder?

A

1 - Marked distress and disability

2 - Persistence of this distress and disability more than 6 months after a bereavement

58
Q

What are the treatment options for prolonged grief disorder?

A

1 - Counselling

2 - Antidepressants

3 - CBT

59
Q

How is OCD diagnosed?

A

Obsessions and compulsions that are time consuming (>1hr)

OR

Cause significant distress or functional impairment

60
Q

How is OCD treated?

A

1st - CBT with exposure and response prevention

2nd - SSRI’s (sertraline, citalopram)

3rd - Clomipramine (TCA)

61
Q

What are some of the secondary causes of insomnia?

A

1 - Anxiety/depression

2 - Physical health problems

3 - Obstructive sleep apnoea

62
Q

How is insomnia treated?

A

1 - Sleep hygiene

2 - Sleep diaries

3 - Melatonin or hypnotic Z-drugs (temazepam, zolpidem)

63
Q

Are eating disorders treated in secondary or primary care?

A

Secondary

64
Q

What are some of the adverse affects of antipsychotic medication?

A

1 - Cardiovascular risk factors

2 - QTC prolongation

65
Q

What are some of the risk factors of taking lithium?

A

1 - Disruption of thyroid/kidney function

2 - Lithium toxicity (tremors, dry mouth, altered taste)

Psychiatry (18 decks)

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