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Year 3 > Primary Care Management of Common Mental Health Disorders > Flashcards

Primary Care Management of Common Mental Health Disorders Flashcards

1
Q

what proportion of people suffer from a mental illness?

A

1 in 4

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2
Q

what % of GP consults have a mental health component?

A

40%

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3
Q

how many years earlier do patients with major mental illness die?

A

12 - women

16 -men

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4
Q

be alert to the possibility of depression, especially if?

A

PMHx of depression
significant illnesses causing disability
other mental health problems

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5
Q

what are the 2 key questions to ask when screening for depression?

A

during the last month, have you often been bothered by feeling down, depressed or hopeless?
during the last month, have you been bothered by having little interest or pleasure in doing things?

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6
Q

key symptoms of depression in ICD-10

A

persistent sadness or low mood; and/or
loss of interests or pleasure
fatigue or low energy
at least one of these, most days, most of the time for at least two weeks

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7
Q

in ICD-10, if any of the key symptoms are present what else should you asks about?

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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8
Q

describe the DSM-V diagnosis of depression

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:
  • First 2 criteria (you must have at least one of these):
  • Depressed mood.
  • Loss of interest or pleasure (anhedonia).
  • If both criteria above are met, you need a further 3 criteria from the list below.
  • If only 1 criterion above is met, you need a further 4 criteria from the list below:
  • 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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9
Q

NICE depression guidelines 2009 diagnosis and assessment of depression: what criteria is this based on?

A

DSM-IV

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10
Q

NICE depression guidelines 2009 diagnosis and assessment of depression: for depression what criteria must be met?

A

5/9 criteria including at least 1 of the first 2

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11
Q

NICE depression guidelines 2009 diagnosis and assessment of depression: what is subthreshold depressive symptoms?

A

those having <5 of the criteria

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12
Q

NICE depression guidelines 2009 diagnosis and assessment of depression: what is severity based on>

A

functional impairment

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13
Q

NICE depression guidelines 2009 diagnosis and assessment of depression: mild depression

A

> =5 symptoms but mild functional impairment

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14
Q

NICE depression guidelines 2009 diagnosis and assessment of depression: severe depression

A

> =5 with marked functional impairment

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15
Q

how to perform a suicide risk assessment?

A

ideation
intent
plans - vague, detailed, specific, already in motion
previous attempts
homicidal risk
adequate social support and aware of sources to help
avicse to seek further help if the situation deteriorates

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16
Q

when assessing suicidal risk when must you urgently refer to specialist mental health services?

A

if considerable immediate risk to themselves or others

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17
Q

NICE 2018 treatment guidelines for depression: step one

A

recognition, assessment and initial management

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18
Q

NICE 2018 treatment guidelines for depression: what is involved in step 1?

A

all known and suspected presentations of depression
intervention options: assessment, support, psychoeducation, lifestyle advice, active monitoring and referral for further assessment and inerventions

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19
Q

NICE 2018 treatment guidelines for depression: step 2

A

recognised depression: subthreshold depressive symptoms or mild-moderate depression

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20
Q

NICE 2018 treatment guidelines for depression: what is involved in step 2?

A

offer advice on sleep hygiene
offer active monitoring
low intensity psychological and psychosocial intervenitons
no routine use of antidepressants

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21
Q

what is involved in active monitoring of depression?

A

discuss concerns
provide info
reassess within 2 weeks
contact if they do not attend follow up appointment

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22
Q

what is involved in low-intensity psychological and psychosocial interventions?

A

CBT - individual self help, computerised, group

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23
Q

in step 2 when may you use antidepressants?

A

PMHx of moderate-severe depression
present with subthreshold symptoms that have been present for 2 or more years
they have subthreshold symptoms for <2 years by don’t respond to other interventions

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24
Q

NICE 2018 treatment guidelines for depression: step 3

A

persistent subthreshold depressive symptoms or mild-moderate depression with inadequate response to nitial interventions, and moderate and severe depression

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25
Q

NICE 2018 treatment guidelines for depression: what is involved in step 3?

A

antidepressent - SSRI
high-intensity psychological intervention
combined treatments for moderate to severe

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26
Q

examples of high-intensity psychological intervention

A

individual CBT
interpersonal therapy
behavioural activation
couples therapy if relationship is a contributory factor

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27
Q

follow up of a depressed patient

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

if a response is absent or minimal after 3-4 weeks at therapeutic dose, what can you di?

A

increase level of support and increase dose

switch

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29
Q

switching antidepressants. factors to consider

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

over how long should you stop antidepressants to reduce the disk of discontinuation syndrome?

A

4 weeks

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31
Q

NICE 2018 treatment guidelines for depression: step 4

A

severe and complex depression

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32
Q

NICE 2018 treatment guidelines for depression: what is involved in step 4?

A

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.

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33
Q

what percentage of adults taking antidepressants for depression actually have BPD?

A

10%

34
Q

things to be aware of in BPD

A

• Do not start SSRIs in depressed phase – refer/discuss with 2ry care
• Stop antidepressants if patients become hypomanic
• Suicide risk in bipolar 20 times higher than general population
• Beware sodium valproate in women of child-bearing age
• 2ry care medication only – woman must be on effective contraception
and signed agreement between prescriber and patient

35
Q

DSM IV classification of GAD

A

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).
B. The person finds it difficult to control the worry
C. The anxiety and worry are associated with three or more of the following six symptoms
(with at least some symptoms present for more days than not for the past 6 months).
• 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)

36
Q

NICE GAD 2011: Step 1

A

identification and assessment

37
Q

consider the diagnosis of GAD in what patients?

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.

38
Q

when assessing severity of anxiety, what should you be aware of?

A

level of distress
functional impairment
number, severity and duration of symptoms

39
Q

what other factors may affect the development, course and severity of an 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.
40
Q

NICE GAD 2011: what is involved in step 1?

A

if depression or other anxiety disorder present, treat the 1oy disorder first
for all with GAD offer: education, active monitoring, discourage OTC treatments

41
Q

NICE GAD 2011: step 2

A

for those for whom active monitoring is insufficient

42
Q

NICE GAD 2011: what is involved in step 2?

A

offer low intensity psychological interventions e.g. individual non facilitated self-help, individual guided self-help, psychoeducation groups

43
Q

individual non-facilitated self help in anxiety

A

written based CBT

6 weeks

44
Q

individual guided self-help in anxiety

A

written material with support from a trained practitioner who offers 5-7 weekly/fortnightly face to face/phone sessions lasting 20-30 mins each

45
Q

psychoeducational groups in anxiety

A

usually 6 weekly sessions of 2 hours with a group of patients and a therapist. based on CBT, interactive and including self-help manual

46
Q

NICE GAD 2011: step 3

A

for those with marked functional impairment or those who have not improved with step 2 treatments

47
Q

NICE GAD 2011: what is involved in step 3?

A

offer: high intensity psychological intervention or drug therapy

48
Q

high intensity psychological interventions in step 3 anxiety

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).

49
Q

drugs therapy 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.
• 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

50
Q

NICE GAD 2011: step 4

A

specialist (CMHT) referal

51
Q

when to consider referral to step 4 in GAD?

A

• Severe anxiety disorder with marked functional impairment and:
• Risk of self-harm or suicide.
• Significant comorbidity (substance misuse, personality disorder, complex
physical health problems).
• Self-neglect.
• OR failure to respond to step 3 interventions.
• 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
(although evidence for combination therapy is lacking).

52
Q

DSM classification of 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.

53
Q

Panic attacks are characterized by an abrupt surge of intense fear or physical discomfort, reaching
a peak within a few minutes, in which at least 4 of the following symptoms are present:

A

a peak within a few minutes, in which at least 4 of the following symptoms are present:
• 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.

54
Q

NICE panic disorder 2011: mild-mod

A

self help

55
Q

NICE panic disorder 2011: mod-severe

A

psychological therapy

drug treatment

56
Q

self help in 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)

57
Q

psychological interventions 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.

58
Q

drug treatment in 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
• 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)

59
Q

DSM definition of 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.
• B. Exposure to the feared situation almost invariably provokes anxiety, which may take the
form of a situationally bound or situationally pre-disposed Panic Attack.
• C. The person recognizes that this fear is unreasonable or excessive.
• D. The feared situations are avoided or else are endured with intense anxiety and distress.
• E. The avoidance, anxious anticipation, or distress in the feared social or performance
situation(s) interferes significantly with the person’s normal routine, occupational (academic)
functioning, or social activities or relationships, or there is marked distress about having the
phobia.
• F. The fear, anxiety, or avoidance is persistent, typically lasting 6 or more months.
• G. The fear or avoidance is not due to direct physiological effects of a substance (e.g., drugs,
medications) or a general medical condition not better accounted for by another mental
disorder.

60
Q

people with social anxiety often:

A

view it as a personal failing or flaw rather than a treatable conditions
often avoid contact with health services
often have difficulty taking things in when they are explaned to them

61
Q

screening questions for social anxiety

A

do you find youself avoiding social situations or activities?
are you fearful or embarrassed in social situations?

62
Q

first line treatment of social anxiety

A

CBT

63
Q

2nd line treatment of social anxiety

A

sertraline or escitalopram

continue for 6 months of treatment once has become effective

64
Q

characteristics of acute grief

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.

65
Q

how to differentiate grief from depression

A

• 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.

66
Q

what is prolonged grief disorder?

A

marked stress and disability caused by the grief reaction. and the persistence of this distress and disability more than 6months after a bereavement

67
Q

treatment options for prolonged grief disorder?

A

counselling e.g. Cruse
Antidepressants for comorbid depression
behavioural/cognitive/exposure therapies
refer if significant impairment in functioning

68
Q

screening for 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?

69
Q

diagnosis of OCD

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.

70
Q

1st line treatment of OCD

A

CBT inc exposure and response prevention (asking people to resist their urges/compulsions)

71
Q

2nd line treatment of OCD

A

SSRI - sertraline, citalopram, fluoxetine, paroxetine

often required for up to 12 weeks before response seen

72
Q

3rd line treatment of OCD

A

clomipramine

73
Q

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).

74
Q

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
75
Q

medications for insomnia

A

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

76
Q

how to recognise 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
77
Q

blood tests for antipsychotics

A

CV risk factors for 2nd gen

ECG for QTC prolongation in 1st generation

78
Q

blood tests for lithium

A

thyroid/kidney FTs 6 monthly

lithium levels 3 monthly

79
Q

what drugs should you avoid when taking lithium?

A

nephrotoxic - ACEI, NSAIDs, diuretics

80
Q

expected side-effects of lithium

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

symptoms of lithium toxicity

A 
• Vomiting and diarrhoea
• Coarse tremor (larger movements, especially of hands)
• Muscle weakness
• Lack of coordination including ataxia
• Slurred speech
• Blurred vision
• Lethargy
• Confusion
seizures

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