Primary Care Management Of Common Mental Health Disorders

Question 1

In Primary care how to screen for depression

Answer 1

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?”

Question 2

DSM IV/V

Answer 2

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.

Question 3

How to diagnose depression in primary care?

Answer 3

Should be based on DSM IV criteria
At least 5/9 criteria, with 1 major criteria

PHQ-9

Question 4

What is subthreshold depression

Answer 4

<5 of the DSM IV criteria

Question 5

Treatment guidelines of depression in primary care?

Answer 5

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

Question 6

Other things to consider in primary care for depression diagnosis?

Answer 6

Fitness for work ? (Med 3 forms)

Fitness to drive ?

Question 7

How often should you follow up someone with depression diagnosis?

Answer 7

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

Question 8

In primary care how to treat bipolar?

Answer 8

Refer!

Stop antidepressants in manic

Question 9

Common anxiety disorders seen in primary care?

Answer 9

Generalised anxiety disorder,
Panic disorder (recurrent panic attacks and persistent worry)
Social anxiety disorder

Question 10

DSM IV classification of generalised anxiety disorder?

Answer 10

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)

Question 11

Treatment of Anxiety in primary care

Answer 11

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

Question 12

Panic Disorder DSM classification

Answer 12

Recurring unforeseen panic attacks followed by one month persistent worry about another attack or significant change in behaviour related to attack

Question 13

Panic attacks s/s?

Answer 13

• 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

Question 14

Treatment of panic disorder

Answer 14

Mild-moderate: self help
Moderate- severe: psychological therapy or
Drug therapy- SSRI (fluoxetine not licensed for a panic attack)

Question 15

Social anxiety disorder treatment?

Answer 15

1st line- CBT

2nd line- sertraline or escitalopram

Question 16

Normal grief presentation

Answer 16

• 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.

Question 17

What is prolonged grief disorder

Answer 17

Marked distress and disability caused by the grief reaction

AND the persistence of this for > 6 months after bereavement

Question 18

Treatment for prolonged grief disorder

Answer 18

Counselling,
Antidepressant,
Therapies
Refer

Question 19

Diagnostic criteria for OCD

Answer 19

Obsessions and compulsions must be time consuming >1 hour OR
Cause significant distress OR
Functional impairment

Question 20

OCD treatment

Answer 20

1st line- CBT with Exposure and Response Prevention
2nd lune- SSRIs
3rd line- Clomipramine
4th line- busipirone + SSRI

Question 21

Some secondary causes of insomnia

Answer 21

Anxiety/ depression,
Physical health problems (eg pain, dyspnoea),
Obstructive sleep apnoea,
Excess alcohol or illicit drugs, 
Parasomnias, 
Circadian rhythm disorder

Question 22

Insomnia treatment

Answer 22

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

Question 23

management tests done in primary care for people on antipsychotics

Answer 23

Monitoring cardio risk factors for 2nd gen

Monitoring ECG for QTC prolongation

Question 24

Management tests done for people on lithium in primary care

Answer 24

Thyroid/ kidney function every 6 months
Lithium levels 3 monthly
Avoid nephrotoxic drugs eg ACE i/ NSAIDs/ diuretics

Question 25

Lithium expected side effects

Answer 25

Fine tremor, 
Dry mouth,
Altered taste sensation, 
Increased thirst,
Urinary frequency,
Mild nausea, 
Weight gain

Question 26

Lithium signs of toxicity

Answer 26

Vomiting, 
Diarrhoea, 
Coarse tremor (NOT FINE)
Muscle weakness, 
Lack of coordination including ataxia, 
Slurred speech, 
Blurred vision, 
Lethargy, 
Confusion,
Seizures, 

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