Primary Care Management of Common Mental Health Problems

Question 1

Which questions can be asked to screen for depression?

Answer 1

• 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?

Question 2

What are the ICD 10 criteria for depression?

Answer 2

D - depressed mood (2 weeks)
E - low energy/fatigue
A - Anhedonia
D - death thoughts
S - disturbed sleep
W - worthlessness
A - appetite changes
M - mentation ( concentration changes or indecisiveness)
P - psychomotor retardation

Question 3

What are the steps in the NICE stepped care model ?

Answer 3

• Step 1: recognition, assessment and initial management (psycho-education, lifestyle advice, active monitoring and referral)
• Step 2: Persistent subthreshold depressive symptoms or mild to moderate depression (advice on sleep hygiene, active monitoring and CBT)
• Step 3: Step 2 + moderate and severe depression (antidepressant, individual CBT, IPT and combined treatments)
• Step 4: severe and complex depression (multiprofessional and possible inpatient care)

Question 4

How can non responders be managed?

Answer 4

• Increase level of support

- Increase dose or switch to another antidepressant

Question 5

What should be included in a suicide risk assessment?

Answer 5

• Suicidal thoughts
• Ideation/intent/plans
• Previous attempts
• Homicidal risk
• Impulsivity/self control
• Access to lethal methods
• Current stressors/ sense of hopelessness
• Protective factors
• Adequate social support, awareness of sources of help
• Arrange help appropriate to risk
• Specialist mental health service if immediate risk
• Advise the person to seek further help if the situation deteriorates

Question 6

What is the DSM IV classification of generalised anxiety disorder?

Answer 6

• Excessive anxiety and worry occurring more days than not for at least six months
• They find it difficult to control their worry
• At least three of the following: restlessness, easily fatigued, difficulty concentrating/ mind going blank, irritability, muscle tension and sleep disturbance

Question 7

How are the different stages of panic disorder managed according to the NICE guidelines?

Answer 7

• Mild to moderate: self help
• Moderate to severe: psychological therapy (CBT) and drug treatment (SSRI - not fluoxetine as first line)
• Avoid BZDs/sedating antihistamines and antipsychotics

Question 8

What are the features of social phobia?

Answer 8

• Persistent fear of social or performance situations
• Exposure to the situation almost invariably causes anxiety
• They recognise the fear is unreasonable or irrational
• The situation is avoided
• It interferes significantly with the person’s normal routines social activities or relationships or work
• The fear, anxiety or avoidance is persistent and typically lasts more than 6 months
• It is not due to the effects of a substance or a general medical condition

Question 9

How can social anxiety disorder be treated?

Answer 9

• 1st line: CBT

- 2nd line: Sertraline or escitalopram

Question 10

How can OCD be treated?

Answer 10

• 1st line: CBT
• 2nd line: SSRIs
• 3rd line: clomipramine
• 4th: Buspirone + SSRI

Question 11

How can insomnia be treated?

Answer 11

• Sleep hygiene
• CBT: sleep diaries
• Hynotics only in severely disabling insomnia