Primary Care Management Of Common Mental Health Disorders Flashcards
In Primary care how to screen for depression
2 key questions:
“Last month have you felt bothered by feeling down, depressed or hopeless?”
“Last month have you been bothered by having little interest or pleasure in doing things?”
DSM IV/V
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:
• Depressed mood.
• Anhedonia •
If both criteria above are met, you need a further 3 criteria from the list below but 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.
How to diagnose depression in primary care?
Should be based on DSM IV criteria
At least 5/9 criteria, with 1 major criteria
PHQ-9
What is subthreshold depression
<5 of the DSM IV criteria
Treatment guidelines of depression in primary care?
Step 1- Recognition, assessment and initial management- psycho-education, lifestyle,e advice, active monitoring and referral for further assessment
Step 2 (for persistent subthreshold or mild-moderate depression)
- advice on sleep hygiene, offer active monitoring
- Psychological and psychosocial interventions
Step 3 (for persistent subthreshold or mild-moderate depression that doesn’t respond to initial interventions)
- Antidepressant (SSRI)
- Psychological intervention
- Combined treatments
Step 4 (Severe and complex depression) Refer
Other things to consider in primary care for depression diagnosis?
Fitness for work ? (Med 3 forms)
Fitness to drive ?
How often should you follow up someone with depression diagnosis?
2 weeks after starting, at intervals of every 2 to 4 weeks for 3 months
If <30 or at greater risk see after 1 week
In primary care how to treat bipolar?
Refer!
Stop antidepressants in manic
Common anxiety disorders seen in primary care?
Generalised anxiety disorder,
Panic disorder (recurrent panic attacks and persistent worry)
Social anxiety disorder
DSM IV classification of generalised anxiety disorder?
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
• 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)
Treatment of Anxiety in primary care
Step 1-Identification (GAD-7) and assessment- education, monitoring, discourage OTC
Step 2- low intensity psychological interventions- individual non-facilitated self-help, individual guided self-help, psychoeducational groups
Step 3- high intensity psychological intervention- CBT, applied relaxation
Drug therapy- SSRI, then SSRI or SNRI, then pregabalin
Review every 2-4 weeks in first 3 months
Step 4- Specialist referral
Panic Disorder DSM classification
Recurring unforeseen panic attacks followed by one month persistent worry about another attack or significant change in behaviour related to attack
Panic attacks s/s?
- 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
Treatment of panic disorder
Mild-moderate: self help
Moderate- severe: psychological therapy or
Drug therapy- SSRI (fluoxetine not licensed for a panic attack)
Social anxiety disorder treatment?
1st line- CBT
2nd line- sertraline or escitalopram
Normal grief presentation
- 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.
- 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.
What is prolonged grief disorder
Marked distress and disability caused by the grief reaction
AND the persistence of this for > 6 months after bereavement
Treatment for prolonged grief disorder
Counselling,
Antidepressant,
Therapies
Refer
Diagnostic criteria for OCD
Obsessions and compulsions must be time consuming >1 hour OR
Cause significant distress OR
Functional impairment
OCD treatment
1st line- CBT with Exposure and Response Prevention
2nd lune- SSRIs
3rd line- Clomipramine
4th line- busipirone + SSRI
Some secondary causes of insomnia
Anxiety/ depression, Physical health problems (eg pain, dyspnoea), Obstructive sleep apnoea, Excess alcohol or illicit drugs, Parasomnias, Circadian rhythm disorder
Insomnia treatment
Sleep hygiene:
- avoid stimulating activities before bed,
- avoid 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
Sleep diaries
Melatonin >55years
Hypnotics (Z drugs)- Zolpidem, zopiclone
management tests done in primary care for people on antipsychotics
Monitoring cardio risk factors for 2nd gen
Monitoring ECG for QTC prolongation
Management tests done for people on lithium in primary care
Thyroid/ kidney function every 6 months
Lithium levels 3 monthly
Avoid nephrotoxic drugs eg ACE i/ NSAIDs/ diuretics
Lithium expected side effects
Fine tremor, Dry mouth, Altered taste sensation, Increased thirst, Urinary frequency, Mild nausea, Weight gain
Lithium signs of toxicity
Vomiting, Diarrhoea, Coarse tremor (NOT FINE) Muscle weakness, Lack of coordination including ataxia, Slurred speech, Blurred vision, Lethargy, Confusion, Seizures,
MEDICAL EMERGENCY
