primary care management of common mental health disorders

Question 1

depression risk factors

Answer 1

• prev depression
• hx other mental illness
• hx substance misuse
• FH depression/suicide
• domestic violence
• unemployment
• poor social support network
• recent stressful live event

Question 2

be alert to possibility of depression esp if…

Answer 2

• a PMH depression
• significant illnesses causing disability
• other mental health problems e.g. dementia

Question 3

stepped care model treatment depression

Answer 3

the least intrusive intervention to be provided first

if that intervention is ineffective or declined, offer an approp intervention from next step

Question 4

stepped care model treatment depression: step one

Answer 4

recognition, assessment and initial management

intervention options: assessment, support, psycho-education, lifestyle advice, active monitoring and referral for further assessment//interventions

Question 5

stepped care model treatment depression step 2

Answer 5

recognised depression - persistent subthreshold depressive symptoms or mild-mod depression

advice on sleep hygiene, active monitoring, low-intensity psychological and psychosocial interventions

do not routinely use antidepressants

Question 6

stepped care model treatment depression: step 3

Answer 6

persistent subthreshold depressive symptoms or mild-mod depression with inadequate response to initial intervention and mod-severe depression

antidepressant
high intensity psychological intervention

Question 7

other things to consider with depression

Answer 7

fitness for work
fitness to drive
follow up

Question 8

depression follow-up

Answer 8

2 weeks after starting at intervals every 2-4 weeks for 3mo then longer intervals

under 30 then see after 1wk and as frequent as approp

Question 9

depression non-responders

Answer 9

response absent or minimal after 3-4wks at therapeutic dose, increase level of support and increase dose or switch to another antidepressant

Question 10

stepped care model treatment depression step 4

Answer 10

severe and complex depression

risk to life, severe self-neglect

Question 11

stepped care model treatment depression step 4 intervention options

Answer 11

refer for multiprofessional and possible inpatient care for people with depression who are at risk SH, psychotic symptoms or require multiprofessional care = expert opinion

Question 12

suicide risk factors to assess

Answer 12

prev SH/suicidal behaviour
depression, other MH probs
physicla illness
low socioecomic status
relationship breakdown

Question 13

management bipolar disorder GP

Answer 13

refer if suspected

do not start SSRIs in depressed phase - refer/discuss with 2ry care

Question 14

GAD step 1

Answer 14

identification and assessment

education about GAD, active monitoring of patient’s function and symptoms

Question 15

GAD step 2

Answer 15

from those whom active monitoring in insufficient

offer low intensity psychlogical interventions

• individual non-facilitated self-help
• individual guided self-help
• psychoeducational groups

Question 16

GAD step 3

Answer 16

marked functional impairment or those who have not improved with step 2 rx

high intensity psychological intervention (e.g. CBT) or drug therapy

Question 17

GAD step 4

Answer 17

specialist (CMHT) referall

Question 18

when to consider referral (GAD)

Answer 18

severe anxiety disorder with marked functional impairment and

• risk SH/suicide
• significant co-morbidity e.g. subtance misuse
• self neglect
• failure to response step 3 interventions

Question 19

panic disorder

Answer 19

recurring unforseen panic attacks, followed by at least a month of persistent worry about having another attach and concern over consequences or a significant change in behaviour related to panic attacks

Question 20

presentation of panic attacks

Answer 20

surge of intense fear or physical discomfort, reaching peak in few mins and assoc symptoms
e.g.palpitations, sweating, SOB, chest pain, nausea, dizzy

Question 21

drug treatment of panic disorder

Answer 21

SSRI e.g. sertraline (not fluoxetine)

consider imipramine or clomipramine if unable to use SSRI or no response after 12wks

Question 22

treatment social anxiety disorder

Answer 22

1st line: CBT

2nd line: medication: sertraline or escitalopram

Question 23

differentiating grief from depression

Answer 23

greif incl longing/yearning for loved on
positive emotions can still be experienced
symptoms worse when thinking about deceased person
people want to be with others whereas depressed want to be alone

Question 24

prolonged grief disorder

Answer 24

marked distress and disability caused by grief reaction and persistence of this distress and disability more than 6mo after bereavment

Question 25

prolonged grief disorder: treatment options

Answer 25

counselling antidepressant for comorbid depression behavioural/cognitive/exposure therapies refer if signif impairment in functioning

Question 26

OCD treatment

Answer 26

1st line; CBT 2nd line: medication: SRRI e.g. sertraline 3rd line: medication - clomipramine

Question 27

what 2ry causes are screened for in insomnia

Answer 27

``` anxiety/depression physical probs e.g. pain obstructive sleep apnoea excess alcohol/ilicit drugs parasomnias e.g. sleep terrors circadian rhythm disorder ```

Question 28

insomnia treatment: non-pharmalogical

Answer 28

sleep hygiene sleep diary

Question 29

insomnia treatment: medications

Answer 29

not routinely advised melatonin >55yrs for <13wks use hypnotics - Z-drugs if severe causing marked distress

Question 30

shared care for major mental illnesses

Answer 30

medication monitoring BMI/BP/smoking blood tests: antipsychotics, lithium

Question 31

expected side effects of lithium

Answer 31

``` fine tremor dry mouth altered tast sensation inc thirst urinary frequency mild nausea weight gain ```

Question 32

side effects of lithium toxicity

Answer 32

``` vomiting + diarrhoea coarse tremor muscle weakness lack coordination slurred speech blurred vision lethargy confusion seizures ```