Primary Care Management of Common Mental Disorders

Question 1

What are the main risk factors for depression?

Answer 1

Previous depression
History of other mental illness
History of substance misuse
FH of depression / suicide 
Domestic violence 
Unemployment 
Poor social support network
Recent stressful life event

Question 2

What are the stepwise categories of the NICE treatment of depression?

Answer 2

1. Recognition, assessment and initial management
2. Persistent subthreshold depressive symptoms / mild-moderate depression
3. Unresponsive mild-moderate depression and moderate-severe depression
4. Severe and complex depression

Question 3

What sort of interventions are given to patients with persistent subthreshold depressive symptoms or mild-moderate depression?

Answer 3

• Advice on sleep hygiene
• Offer active monitoring of patients condition (meet in 2 weeks)
• Low intensity psychosocial interventions (CBT)

Don’t usually use antidepressants unless patient has past history of moderate-severe depression, or are not responding to other interventions

Question 4

What sort of interventions are given to patients with intervention resistant mild-moderate depression OR moderate-severe depression?

Answer 4

Antidepressant + CBT

• SSRI are first line due to safeness in overdose

Question 5

If a patient is diagnosed with moderate to severe depression what lifestyle aspects may be affected by this?

Answer 5

Fitness to work

Fitness to drive (if severe concentration, memory, agitation, behavioural disturbance or suicidal thoughts then the patient can’t drive anymore)

Question 6

How often should you follow up with a patient experiencing depression? How long do they stay on meds for?

Answer 6

See people 2 weeks after starting meds, then every 2-4 weeks for 3 months, then longer intervals

If patient is at higher risk of suicide or self harm increase frequency

Patient shpould take meds for 6 months after they feel better, up to 2 years if at high risk of relapse

Question 7

If the patient is a non-responder what should be done?

Answer 7

• If partial response then increase SSRI dose
• If no dose then try different antidepressant
• If very treatment resistant refer to secondary care which may recommend combining antidepressants or augmenting antidepressant qith substance such as lithium

Question 8

What are some signs a patient is suffering from severe-complex depression?

Answer 8

Risk to life (suicidal thoughts)

Severe self neglect (hygiene / diet)

Question 9

What treatment may be used for severe complex depression?

Answer 9

Antidepressant + CBT +/- antipsychotic (depends on presence of psychosis)

ECT - electroconvulsive therapy (used for severe treatment resistant depression)

Question 10

What are the stepwise categories of the NICE treatment of generalized anxiety?

Answer 10

1. Identification and assessment (offer active monitoring)
2. Patients in which active monitoring is insufficient
3. Patients who do not respond to low intensity interventions and those with functional impairment
4. Patients with severe anxiety disorder with marked functional impairment and high risk profile (self neglect / self harm)

Question 11

For patients with generalized anxiety disorders in which active monitoring is insufficient, what treatment should be offered?

Answer 11

Low intensity psychological interventions

Individually done writing and group activities done based on the principles of CBT

Question 12

What interventions are given to patients with generalized anxiety disorders who have functional impairment or who do not respond to low intensity treatments?

Answer 12

CBT or applied relaxation

Can also offer medication:
- Antidepressants: SSRI would be first line

Question 13

What interventions are recommended for Patients with severe anxiety disorder with marked functional impairment and high risk profile (self neglect / self harm)?

Answer 13

Referral to specialist for:

• Combined drug therapies
• Comprehensive care plan including psychsocial interventions

Question 14

For patients with mild panic disorders what interventions are recommended?

Answer 14

Self help

Bibliotherapy based on CBT principles

Support groups

• Education (breathing exercises / importance of exercise)

Question 15

For patients with moderate - severe panic disorders what interventions are recommended?

Answer 15

Psychological therapy - CBT

Possibility of drug treatment depending on treatment resistance / severity (SSRI)

Question 16

What are the treatment options for social anxiety disorder?

Answer 16

1st line - CBT

2nd line - medications (sertraline / escitalopram)

Question 17

What are the treatment options for obsessive compulsive disorder?

Answer 17

1st line - CBT

2nd line - Medication (SSRI’s - usually required at high doses for longer periods)

3rd line - medication: clomipramine

Question 18

What is the first line treatment for insomnia?

Answer 18

Encouragement of good sleep hygiene:

• Avoid stimulating activities before bed
• Avoid exercise / large meals late on
• Regular day time exercise
• Same bed time each day
• Ensure bedroom encourages sleep (no TV / phones)

Question 19

What is an important step for general practitioners when faced with psychotic patients?

Answer 19

Listen to family concerns, can be notoriously difficult to diagnose these patients early on without this