Primary Care Management of Common Mental Health Disorders Flashcards
What are some risk factors for depression?
Previous depression History of other mental illness History of substance misuse Family history of depression or suicide Domestic violence Unemployment Poor social support network Recent stressful life event
What is the DSM 5 criteria?
For depression:
- 5/9 criteria are required, including at least 1 of the first 2 criteria (low mood/anhedonia).
- Subthreshold depressive symptomsare defined as those having <5 of the DSM IV criteria.
- Severity is based on functional impairment, once the diagnostic criteria have been passed (i.e. once you have 5 or more symptoms, one of which must be from the first two criteria).
- Mild depressionis 5 or more symptoms (one of which must be from the first two criteria) but with mild functional impairment.
- Severe depressionis at least 5 symptoms (one of which must be from the first two criteria), and often most or all will be present) with marked functional impairment.
- Moderate severityfalls between mild and severe.
What are the first 2 DSM 5 criteria?
You must have at least one of these:
- Depressed mood
- Loss of interest or pleasure (anhedonia)
What are the further DSM 5 criteria?
If both criteria above are met, you need a further 3 criteria from the list below.
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
What are the 2018 NICE guidelines on depression diagnosis and assessment?
Diagnosis should be based on DSM IV criteria
What is the PHQ-9?
Patient health questionnaire
Score: 0-5 = mild 6-10 = moderate 11-15 = moderately severe 16-20 = severe depression
What is the PHQ-9?
Patient health questionnaire
Score: 0-5 = mild 6-10 = moderate 11-15 = moderately severe 16-20 = severe depression
What is the stepped care model? (2018 NICE guidelines)
The least intrusive intervention to be provided first. If that intervention is ineffective, or declined, offer an appropriate intervention from the next step.
What is STEP 1 of the stepped care model?
Recognition, assessment & initial management
- All known and suspected presentations of depression
- Intervention options: Assessment, support, psycho-education, lifestyle advice, active monitoring and referral for further assessment and interventions
What is STEP 2 of the stepped care model?
Recognised depression – persistent subthreshold depressive symptoms or mild to moderate depression
- Offer advice on sleep hygiene
- Offer active monitoring(discuss concerns, provide information about depression, reassess within 2w; contact the person if they do not attend follow-up appointment).
- Low-intensity psychological andpsychosocial interventions(e.g. individual self-help based on CBT principles, computerised CBT, group CBT, group physical activity programme).
Donotroutinely use antidepressants (because risk–benefit ratio is poor)
When are antidepressants used in STEP 2 care?
-They have a past history of moderate–severe depression
OR
-They present with subthreshold symptoms that have been present for 2y or more
OR
-They have subthreshold symptoms for <2y but they don’t respond to other interventions
What is STEP 3 of the stepped care model?
Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression
-An antidepressant (normally a selective serotonin reuptake inhibitor [SSRI])
OR
-A high-intensity psychological intervention e.g. individual CBT, interpersonal therapy, behavioural activation, couples therapy where the relationship is a contributory factor
-Combined treatments (medication + high intensity psychological) preferred for moderate to severe depression
What form is used to assess a patents fitness to work?
MED 3
What psychological issues related to depression cause a patient to lose fitness to drive?
Significant memory or concentration problems
Agitation
Behavioural disturbance
Suicidal thoughts
What is the follow-up protocol in treating depression?
- Normally see people 2 weeks after starting, at intervals of every 2 to 4 weeks for 3 months and then at longer intervals if the response is good
- In patients aged under 30, or considered at greater risk, see after one week and as frequently thereafter as appropriate until risk considered no longer clinically important
- Encourage to take for at least 6 months after remission, and for up to 2 years if they are at risk of relapse
What classifies a “non-responder”?
If response absent or minimal after 3 to 4 weeks at therapeutic dose, increase level of support and increase dose OR switch to another antidepressant
How may antidepressants be changed in a non-responder?
- Initially switch to a different SSRI or a better tolerated newer generation antidepressant
- Subsequently to another class that may be less well tolerated e.g. TCA, venlafaxine or MAOI (MAOI specialist initiated only)
- Combining and augmentation: Using combinations should only normally be started in primary care in consultation with a psychiatrist
- Consider combining or augmenting an antidepressant with lithium, an antipsychotic (e.g. quetiapine, aripriprazole etc) or another antidepressant such as mirtazapine
- Stopping or reducing antidepressants: advise re risk of discontinuation symptoms and gradually reduce the dose, normally over a 4 week period
What is STEP 4 of the stepped care model?
Severe and complex depression
- Risk to life
- Severe self-neglect
Intervention options:
-Refer for multiprofessional and possible inpatient care for people with depression who are at significant risk of self-harm, have psychotic symptoms, require complex multiprofessional care or where an expert opinion is needed.
What are the key risk factors to assess in suicide?
- Previous self-harm/suicidal behaviour.
- Depression and other mental health problems.
- Alcohol/drug misuse.
- Physical illness.
- Low socioeconomic status.
- Relationship breakdown.
When do you stop anti-depressants in suspected bipolar disorder?
If they seem to be entering a hypomanic phase
What are 3 types of anxiety disorder?
Generalised Anxiety Disorder
- Excessive worry about a number of different events
- Can exist in isolation or comorbid anxiety/depressive disorders
Panic Disorder
-Recurrent panic attacks and persistent worry about further attacks
Social Anxiety Disorder
-Persistent fear of, or anxiety about, one or more social or performance situations that is out of proportion to the actual threat posed by the situation
How is generalised anxiety disorder classified using DSM-IV?
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 (with at least some symptoms present for more days than not for the past 6 months):
-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)
What is GAD 7 used for?
Assessing anxiety
Score: 0-5 mild 6-10 moderate 11-15 moderately severe anxiety 15-21 severe anxiety
What is the STEP 1 for assessing GED?
Identification and assessment
Consider the diagnosis of generalised anxiety disorder in:
Those presenting with anxiety or significant worry.
Frequent attenders with a chronic health problem.
Frequent attenders without health problems but who are seeking reassurance about somatic symptoms (especially elderly people or those from minority ethnic groups).
Frequent attenders who are repeatedly worrying about a wide range of different issues.
When assessing severity of anxiety, include:
Level of distress.
Functional impairment.
Number, severity and duration of symptoms.
Look out for the following which may affect the development, course and severity of anxiety state:
Other anxiety disorder in addition to generalised anxiety disorder (e.g. panic disorder).
Depression.
Substance misuse.
Physical health problems.
History of mental health problems.
Past experience and response to treatments.
