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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 many people suffer from a mental illness?

A

1 in 4

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2
Q

Where is the majority of mental illness managed exclusively?

A

In primary care

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3
Q

During a GP consultation what things should make you more alert to the possibility of depression?

A

PMH of depression
Significant illness causing disability
Other mental health problems, e.g. dementia

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4
Q

NICE recommends the diagnosis of depression be made using what tool?

A

DSM IV criteria

For depression 5/9 criteria are required (including at least 1 of the first 2 criteria (low mood/anhedonia)

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5
Q

What does NICE say subthreshold depressive symptoms should be defined as?

A

Having <5 of the DSM IV criteria

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6
Q

What should the severity of depression be based on?

A

Functional impairment

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7
Q

When someone presents with depression, what risks should you assess for in the GP practice?

A

Suicide risk (ideation, intent, plans, previous attempts)
Homicidal risk
Social support

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8
Q

If someone is an immediate risk to themselves or others what should you do?

A

Refer urgently to specialist mental health services

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9
Q

What is the stepped care model used to treat depression?

A

Least intrusive method used first, if this is ineffective or declined offer next appropriate intervention

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10
Q

What are some initial interventions GPs may advise to help with depression?

A 
Support
Psycho-education
Lifestyle advice
Active monitoring 
Referral for further assessment/intervention
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11
Q

What may be used to treat mild-moderate depression?

A

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

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12
Q

What is involved in active monitoring of depression?

A

Discuss concerns, provide info on depression

Reassess in 2w

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13
Q

When should you consider using antidepressants in mild-moderate depression?

A

PPH of moderate-severe depression
Subthreshold symptoms have been present for 2y+
Subthreshold symptoms for <2y but not responding to other interventions

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14
Q

If a person is not responding to initial interventions for depression or has severe depression, what can be offered?

A

Antidepressants (e.g. SSRI)

High intensity psychological intervention (CBT, IPT, behavioural activation etc.)

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15
Q

What other things should you discuss in your consultation with someone with depression?

A

Fitness to work
Fitness to drive (significant memory/concentration problems, agitation, behavioural disturbance or suicidal thoughts may impair ability)

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16
Q

When is follow up arranged for people taking antidepressants?

A

2 weeks after staring
Every 2-3w for 3m

If younger/high risk may see more often

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17
Q

How long do you need to wait before considering changing an antidepressant if it is not working?

A

3-4 weeks at therapeutic dose if response absent or minimal

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18
Q

If response to an antidepressant is minimal or absent at 3-4w, what must you do?

A

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)

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19
Q

What advice should you give on stopping or reducing antidepressants?

A

Re risk of discontinuation symptoms

Must gradually reduce dose over 4w period

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20
Q

Which patients must you refer for multiprofessional/inpatient care?

A

Those with severe and complex depression
Risk to life
Severe self neglect
Psychotic symptoms

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21
Q

Should you refer if you suspect bipolar disorder?

A

Yes

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22
Q

What is generalised anxiety disorder?

A

Excessive worry about a number of different events

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23
Q

What is panic disorder?

A

Recurrent panic attacks and persistent worry about further attacks

24
Q

What is social anxiety disorder?

A

Persistent fear of one or more social or performance situations that is out of proportion to the actual threat posed by the situation

25
Q

What is the DSM-4 generalised anxiety disorder classification?

A

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
26
Q

NICE recommends to consider the diagnosis of GAD in which groups of people?

A

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

27
Q

When assessing the severity of anxiety what should you take into account?

A

Level of distress
Functional impairment
Number, severity and duration of symptoms

28
Q

What things may affect the development, course and severity of anxiety state?

A 
Other anxiety disorders, e.g. panic disorder
Depression
Substance misuse
Physical health problems
Hx of mental health problems
Past experience and response to Rxs
29
Q

How do you manage GAD?

A

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
30
Q

What tool can be used to assess the severity of GAD?

A 
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

31
Q

What drug therapy is recommended for GAD?

A

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

32
Q

How long should a patient be kept on their medication for GAD?

A

For at least 12m after initiation of therapy to reduce risk of relapse

33
Q

How is severe GAD managed?

A

Drugs and psychological interventions

May need augmentation of antidepressants

34
Q

Define panic disorder (via the DSM classification)

A

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

35
Q

Define panic attack

A

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
36
Q

How is panic disorder managed?

A

Mild-moderate: self help

Mod-severe: psychological therapy, drug treatment

37
Q

What drugs are licensed for panic disorder?

A

SSRI apart from fluoxetine

Imipramine or clomipramine off label

38
Q

What is the DSM-5 classification for social phobia?

A

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

39
Q

How is social anxiety treated?

A

1st line: CBT

2nd line: medication (sertraline/escitalopram) until 6m after treatment has become effective

40
Q

Name some normal responses to grief

A 
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
41
Q

How can you differentiate normal grief from depression?

A

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

42
Q

What is prolonged grief disorder?

A

Marked distress/disability caused by grief reaction for more than 6m after bereavement

43
Q

What are the treatment options for prolonged grief disorder?

A

Counselling
Antidepressants for co-morbid depression
Behavioural/cognitive/exposure therapies
Referral

44
Q

What is OCD characterised by?

A

Obsessions/compulsions

45
Q

What is an obsession?

A

Unwanted, intrusive thoughts, images or urges

Tend to be repugnant and inconsistent with person’s values

46
Q

What is a compulsion?

A

Repetitive behaviours/mental acts the person feels drive to perform

Can be overt/covert

47
Q

How do you diagnose OCD?

A

Obsessions and compulsions must be time consuming >1hr, or cause significant distress or functional impairment

48
Q

How do you treat OCD?

A

1st line: CBT (exposure and response prevention)
2nd line: medications - SSRIs
3rd line: clomipramine

49
Q

What are some secondary causes of insomnia?

A 
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
50
Q

What are the treatments for insomnia?

A

Sleep hygiene
Sleep diaries
CBT-I
Medication not routinely advised

51
Q

What is involved in good sleep hygiene?

A

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

52
Q

What drugs can be used to treat insomnia?

A

Melatonin (>55y for short term insomnia (<13 weeks)

Hypnotic Z drugs only if very severe insomnia

53
Q

What are the Z-drugs?

A

Zolpidem, zopiclone, temazepam

54
Q

What are the issues with the Z-drugs?

A

Addictive potential
Drowsiness
Only reduce time to fall to sleep by 22 m

55
Q

What tests must be done for people on lithium?

A

Thyroid/kidney function 6mnthly

Lithium levels 3 monthly

56
Q

What are the expected side effects of lithium?

A 
Fine tremor
Dry mouth 
Altered taste sensation 
Increased thirst
Urinary frequency
Mild nausea
Weight gain
57
Q

What are the symptoms of lithium toxicity?

A 
Vomiting, diarrhoea
Course tremor
Muscle weakness
Ataxia
Slurred speech 
Blurred vision 
Lethargy 
Confusion 
Seizures

Psychiatry (26 decks)

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