Primary Care Management of Common Mental Health Disorders Flashcards
How many people suffer from a mental illness?
1 in 4
Where is the majority of mental illness managed exclusively?
In primary care
During a GP consultation what things should make you more alert to the possibility of depression?
PMH of depression
Significant illness causing disability
Other mental health problems, e.g. dementia
NICE recommends the diagnosis of depression be made using what tool?
DSM IV criteria
For depression 5/9 criteria are required (including at least 1 of the first 2 criteria (low mood/anhedonia)
What does NICE say subthreshold depressive symptoms should be defined as?
Having <5 of the DSM IV criteria
What should the severity of depression be based on?
Functional impairment
When someone presents with depression, what risks should you assess for in the GP practice?
Suicide risk (ideation, intent, plans, previous attempts)
Homicidal risk
Social support
If someone is an immediate risk to themselves or others what should you do?
Refer urgently to specialist mental health services
What is the stepped care model used to treat depression?
Least intrusive method used first, if this is ineffective or declined offer next appropriate intervention
What are some initial interventions GPs may advise to help with depression?
Support Psycho-education Lifestyle advice Active monitoring Referral for further assessment/intervention
What may be used to treat mild-moderate depression?
Advice on sleep hygiene
Active monitoring
Low intensity psychological and psychosocial interventions (self help CBT, computerised CBT, group physical activity programme)
DO not routinely used antidepressants
What is involved in active monitoring of depression?
Discuss concerns, provide info on depression
Reassess in 2w
When should you consider using antidepressants in mild-moderate depression?
PPH of moderate-severe depression
Subthreshold symptoms have been present for 2y+
Subthreshold symptoms for <2y but not responding to other interventions
If a person is not responding to initial interventions for depression or has severe depression, what can be offered?
Antidepressants (e.g. SSRI)
High intensity psychological intervention (CBT, IPT, behavioural activation etc.)
What other things should you discuss in your consultation with someone with depression?
Fitness to work
Fitness to drive (significant memory/concentration problems, agitation, behavioural disturbance or suicidal thoughts may impair ability)
When is follow up arranged for people taking antidepressants?
2 weeks after staring
Every 2-3w for 3m
If younger/high risk may see more often
How long do you need to wait before considering changing an antidepressant if it is not working?
3-4 weeks at therapeutic dose if response absent or minimal
If response to an antidepressant is minimal or absent at 3-4w, what must you do?
Increase level of support and increase dose
OR
Switch to another antidepressant (initially a different SSRI, then a different class (e.g. TCA), then can augment (after liaison with psychiatrist only) with another antidepressant (e.g. mitrazapine)/lithium)
What advice should you give on stopping or reducing antidepressants?
Re risk of discontinuation symptoms
Must gradually reduce dose over 4w period
Which patients must you refer for multiprofessional/inpatient care?
Those with severe and complex depression
Risk to life
Severe self neglect
Psychotic symptoms
Should you refer if you suspect bipolar disorder?
Yes
What is generalised anxiety disorder?
Excessive worry about a number of different events
What is panic disorder?
Recurrent panic attacks and persistent worry about further attacks
What is social anxiety disorder?
Persistent fear of one or more social or performance situations that is out of proportion to the actual threat posed by the situation
What is the DSM-4 generalised anxiety disorder classification?
Excessive worry/anxiety on more days than not, for at least 6m about a number of events
Person finds it difficult to control the worry
+ 3+ of:
- Restlessness/feeling on edge
- Fatiguing easily
- Difficulty concentrating/mind going blank
- Irritability
- Muscle tension
- Sleep disturbance
NICE recommends to consider the diagnosis of GAD in which groups of people?
Those presenting with anxiety/significant worry
Frequent attenders with chronic health problems/who seek reassurance about somatic symptoms/who are repeatedly worrying about a wide range of issues
When assessing the severity of anxiety what should you take into account?
Level of distress
Functional impairment
Number, severity and duration of symptoms
What things may affect the development, course and severity of anxiety state?
Other anxiety disorders, e.g. panic disorder Depression Substance misuse Physical health problems Hx of mental health problems Past experience and response to Rxs
How do you manage GAD?
Treat primary disorder first, e.g. depression
Treat co-morbid substance misuse first
Educate about GAD
Active monitoring of function & symptoms
Discourage OTC treatments
If active monitoring insufficient:
- Self-help (guided/non-facilitated)
- Psychoeducational groups (CBT)
If marked functional impairment/not improved with above:
- High intensity CBT, applied relaxation
- Drug therapy
What tool can be used to assess the severity of GAD?
GAD-7 Asks about: - Nervousness/anxiousness/feeling on edge - Control over worries - Excessive worry about different things - Trouble relaxing - Restlessness - Agitation - Being afraid of something bad happening
0-5 mild
6-10 moderate
11-15 moderately severe
15-21 severe anxiety
What drug therapy is recommended for GAD?
SSRI, e.g. sertraline
If ineffective swap to different SSRI/SNRI
If SSRI/SNRI cannot be tolerated give pregabalin
Review 2-4wkly in first 3m, and 3mnthly thereafter
ONLY use benzos for short term crisis
Refer to specialist if severe/marked functional impairment
How long should a patient be kept on their medication for GAD?
For at least 12m after initiation of therapy to reduce risk of relapse
How is severe GAD managed?
Drugs and psychological interventions
May need augmentation of antidepressants
Define panic disorder (via the DSM classification)
Recurring, unforeseen panic attacks, followed by at least 1 month of persistent worry about having another attack and concern about its consequents OR a significant change in behaviour related to the panic attacks
Define panic attack
Abrupt surge of intense fear/physical discomfort, reaching peak in a few minutes with at least 4 of the following:
- Palpitations, pounding heart, tachycardia
- Sweating
- Muscle trembling, shaking
- SoB, sensations of smothering
- Chest pain, discomfort
- Nausea, abdominal distress
- Dizziness, lightheadedness, , instability, feeling faint
- Derealisation, depersonalisation
- Fear of losing control or going crazy
- Fear of dying
- Numbness, tingling sensations
- Chills, hot flushes
How is panic disorder managed?
Mild-moderate: self help
Mod-severe: psychological therapy, drug treatment
What drugs are licensed for panic disorder?
SSRI apart from fluoxetine
Imipramine or clomipramine off label
What is the DSM-5 classification for social phobia?
Persistent fear of 1+ social/performance situations
Fear of embarrassment/humilitation
Exposure to feared situation provoked anxiety
Fear is unreasonable/excessive
Feared situations are avoided/endured with intense anxiety/distress
Avoidance/anxious anticipation interfers with person’s normal routine
Lasting more than 6m and not due to effects of a substance/a medical/psychiatric condition
How is social anxiety treated?
1st line: CBT
2nd line: medication (sertraline/escitalopram) until 6m after treatment has become effective
Name some normal responses to grief
Disbelief/difficulty comprehending loss Bitterness/anger/guilt/lame Impaired functioning Yearning, sadness, emotional and physical pain Forgetfulness/difficulty concentrating Loss of sense of self/purpose in life Feeling disconnected Difficulty engaging in activities/plans for future
How can you differentiate normal grief from depression?
Often want to be with people (depressed people want to be alone)
Yearning/longing for loved one
Positive emotions can still be experienced
Symptoms worst when thinking about decreased person
What is prolonged grief disorder?
Marked distress/disability caused by grief reaction for more than 6m after bereavement
What are the treatment options for prolonged grief disorder?
Counselling
Antidepressants for co-morbid depression
Behavioural/cognitive/exposure therapies
Referral
What is OCD characterised by?
Obsessions/compulsions
What is an obsession?
Unwanted, intrusive thoughts, images or urges
Tend to be repugnant and inconsistent with person’s values
What is a compulsion?
Repetitive behaviours/mental acts the person feels drive to perform
Can be overt/covert
How do you diagnose OCD?
Obsessions and compulsions must be time consuming >1hr, or cause significant distress or functional impairment
How do you treat OCD?
1st line: CBT (exposure and response prevention)
2nd line: medications - SSRIs
3rd line: clomipramine
What are some secondary causes of insomnia?
Anxiety, depression Physical health problems, e.g. pain Obstructive sleep apnoea Excess alcohol/drugs Parasomnias (e.g. restless leg, sleep walking, night terrors, teeth grinding) Circadian rhythm disorder
What are the treatments for insomnia?
Sleep hygiene
Sleep diaries
CBT-I
Medication not routinely advised
What is involved in good sleep hygiene?
Avoid stimulating activities before bed
Avoid caffeine/alcohol/smoking/heavy meals/exercise before bed
Regular day time exercise
Same bedtime every day
Ensure bedroom environment promotes sleep
Relaxation
What drugs can be used to treat insomnia?
Melatonin (>55y for short term insomnia (<13 weeks)
Hypnotic Z drugs only if very severe insomnia
What are the Z-drugs?
Zolpidem, zopiclone, temazepam
What are the issues with the Z-drugs?
Addictive potential
Drowsiness
Only reduce time to fall to sleep by 22 m
What tests must be done for people on lithium?
Thyroid/kidney function 6mnthly
Lithium levels 3 monthly
What are the expected side effects of lithium?
Fine tremor Dry mouth Altered taste sensation Increased thirst Urinary frequency Mild nausea Weight gain
What are the symptoms of lithium toxicity?
Vomiting, diarrhoea Course tremor Muscle weakness Ataxia Slurred speech Blurred vision Lethargy Confusion Seizures
