Primary Care Management of Common Mental Disorders Flashcards
Most mental illness is managed exclusively where?
in primary care
what are the Depression Risk Factors?
- 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 – eg losses, bereavement, losing job
Screening for depression:
Be alert to the possibility of depression, especially if what?
- A PMH of depression.
- Significant illnesses causing disability.
- Other mental health problems, e.g. dementia.
Screening for depression:
what are 2 key questions to ask when screening for depression?
“During the last month, have you often been bothered by feeling down, depressed or hopeless?”
“During the last month, have you been bothered by having little interest or pleasure in doing things?”
There are two classification systems that allow us to diagnose depression – ICD10 and DSM5
what is the ICD -10 Diagnosis of depression?
what is the DSM IV/V diagnosis of depression?
This is what is used in NICE guidelines
Currently no SIGN guidelines on depression
NICE Depression Guidelines NICE 2018, CG90 & 91:
what is required for the diagnosis of depression?
- Diagnosis should be based on DSM IV criteria
- For depression: 5/9 criteria are required, including at least 1 of the first 2 criteria (low mood/anhedonia)
- Subthreshold depressive symptoms are defined as those having <5 of the DSM IV criteria
NICE Depression Guidelines NICE 2018, CG90 & 91:
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)
what is mild moderate and severe dperession?
- Mild depression is 5 or more symptoms (one of which must be from the first two criteria) but with mild functional impairment
- Severe depression is 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 severity falls between mild and severe
what screening tool is used for depression?
NICE 2018 Treatment Guidelines:
STEPPED CARE MODEL - 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 treatment of depression?
STEP ONE: 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 depression treatment?
Step 2: 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 and psychosocial interventions (e.g. individual self-help based on CBT principles, computerised CBT, group CBT, group physical activity programme)
treating depression:
Do not routinely use antidepressants (because risk–benefit ratio is poor), unless what?
- 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 depression treatment?
Step 3: 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 - 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 is behavioural activation?
In depression, people often stop doing the things they used to and become more withdrawn. This, in itself, reinforces low mood. In behavioural activation, patients are asked to look at the impact activities have on mood, and then to schedule activities to help improve mood. They can also look at the cognitive things that inhibit activity, such as rumination. It is easier to train both staff and patients to do behavioural activation, so it is cheaper than CBT.
____ is first line antidepressant in depression
SSRI
in depression what other things should you consider?
fitness for work - med 3 forms
fitness to drive
what follow up is reuqired for dementia treatment?
- 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
Non responders:
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 do you switch antidepressants?
- 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 (mood stabalizer), an antipsychotic (e.g. quetiapine, aripriprazole etc) or another antidepressant such as mirtazapine
Non responders:
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 do you stop or reduce antidepressants?
Advise re risk of discontinuation symptoms and gradually reduce the dose, normally over a 4 week period (minimise the risk of developing discontinuations symptoms.)
Discontinuation symptoms - These include restlessness, irritability, anxiety, insomnia, unsteadiness, sweating, GI upset
what is step 4 of depression treatment? (severe and complex depression)
- Severe and complex depression
- Risk to life
- Severe self-neglect
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
Other treatments, which are only offered in hospital, such as ECT, can be considered, which is a very effective treatment for severe depression.
what is involved in a suicide risk assessment?
The key risk factors to assess are:
Previous self-harm/suicidal behaviour
Depression and other mental health problems
Alcohol/drug misuse
Physical illness (note: those with traumatic brain injuries are at twice the risk of suicide as the general population)
Low socioeconomic status
Relationship breakdown
what is the Screening tool used to grade severity of anxiety?
NICE Generalised Anxiety Disorder 2011, CG113
Step 1: Identification and assessment
what is involved?
If depression or other anxiety disorder present, treat the primary disorder first eg co-morbid depression/anxiety – treat depression first.
Treat co-morbid substance misuse disorder first
•For all identified with generalised anxiety disorder, offer the following treatment: education about anxiety disorder, and active monitoring of patient’s function and symptoms. Discourage over-the-counter treatments (lack of evidence, interactions).
GAD management:
Step 3: For those with marked functional impairment OR for those who have not improved with step 2 treatments
what is done?
High intensity psychological or medication
GAD treatment:
Step 4: Specialist (CMHT) referral. Consider referral to step 4 if what?
Panic attacks are characterized by an abrupt surge of intense fear or physical discomfort, reaching a peak within a few minutes, in which at least 4 of the following symptoms are present:
what is seen in Social Phobia - DSM?
what are the treatments of insomina?
Shared Care for Major Mental illness - what is involved?
- Medication monitoring
- BMI/BP/smoking
- Blood tests:
- Antipsychotics - cardiovascular risk factors
- Lithium (bipolar/adjunct in depression):
- Thyroid / Kidney function tests 6 monthly
- Lithium levels 3 monthly – risk of lithium toxicity
what is the role of 3rd sector organisations?
Involved in supporting our patients in the community
