primary care management of common mental health disorders Flashcards
depression risk factors
- prev depression
- hx other mental illness
- hx substance misuse
- FH depression/suicide
- domestic violence
- unemployment
- poor social support network
- recent stressful live event
be alert to possibility of depression esp if…
- a PMH depression
- significant illnesses causing disability
- other mental health problems e.g. dementia
stepped care model treatment depression
the least intrusive intervention to be provided first
if that intervention is ineffective or declined, offer an approp intervention from next step
stepped care model treatment depression: step one
recognition, assessment and initial management
intervention options: assessment, support, psycho-education, lifestyle advice, active monitoring and referral for further assessment//interventions
stepped care model treatment depression step 2
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
stepped care model treatment depression: step 3
persistent subthreshold depressive symptoms or mild-mod depression with inadequate response to initial intervention and mod-severe depression
antidepressant
high intensity psychological intervention
other things to consider with depression
fitness for work
fitness to drive
follow up
depression follow-up
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
depression non-responders
response absent or minimal after 3-4wks at therapeutic dose, increase level of support and increase dose or switch to another antidepressant
stepped care model treatment depression step 4
severe and complex depression
risk to life, severe self-neglect
stepped care model treatment depression step 4 intervention options
refer for multiprofessional and possible inpatient care for people with depression who are at risk SH, psychotic symptoms or require multiprofessional care = expert opinion
suicide risk factors to assess
prev SH/suicidal behaviour depression, other MH probs physicla illness low socioecomic status relationship breakdown
management bipolar disorder GP
refer if suspected
do not start SSRIs in depressed phase - refer/discuss with 2ry care
GAD step 1
identification and assessment
education about GAD, active monitoring of patient’s function and symptoms
GAD step 2
from those whom active monitoring in insufficient
offer low intensity psychlogical interventions
- individual non-facilitated self-help
- individual guided self-help
- psychoeducational groups
GAD step 3
marked functional impairment or those who have not improved with step 2 rx
high intensity psychological intervention (e.g. CBT) or drug therapy
GAD step 4
specialist (CMHT) referall
when to consider referral (GAD)
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
panic disorder
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
presentation of panic attacks
surge of intense fear or physical discomfort, reaching peak in few mins and assoc symptoms
e.g.palpitations, sweating, SOB, chest pain, nausea, dizzy
drug treatment of panic disorder
SSRI e.g. sertraline (not fluoxetine)
consider imipramine or clomipramine if unable to use SSRI or no response after 12wks
treatment social anxiety disorder
1st line: CBT
2nd line: medication: sertraline or escitalopram
differentiating grief from depression
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
prolonged grief disorder
marked distress and disability caused by grief reaction and persistence of this distress and disability more than 6mo after bereavment
prolonged grief disorder: treatment options
counselling
antidepressant for comorbid depression
behavioural/cognitive/exposure therapies
refer if signif impairment in functioning
OCD treatment
1st line; CBT
2nd line: medication: SRRI e.g. sertraline
3rd line: medication - clomipramine
what 2ry causes are screened for in insomnia
anxiety/depression physical probs e.g. pain obstructive sleep apnoea excess alcohol/ilicit drugs parasomnias e.g. sleep terrors circadian rhythm disorder
insomnia treatment: non-pharmalogical
sleep hygiene
sleep diary
insomnia treatment: medications
not routinely advised
melatonin >55yrs for <13wks use
hypnotics - Z-drugs if severe causing marked distress
shared care for major mental illnesses
medication monitoring
BMI/BP/smoking
blood tests: antipsychotics, lithium
expected side effects of lithium
fine tremor dry mouth altered tast sensation inc thirst urinary frequency mild nausea weight gain
side effects of lithium toxicity
vomiting + diarrhoea coarse tremor muscle weakness lack coordination slurred speech blurred vision lethargy confusion seizures
