Primary Care Management of mental health Flashcards
What are the components of the Stepped Care model?
The least intrusive intervention to be provided first/
If that intervention is ineffective, or declined, offer an appropriate intervention for the next step.
Step One of the stepped care model in the context of depression
Recognition, assessment and initial management
- All known and suspected presentations of depression
Intervention options
- assessment
- support
- psychoeducation
- lifestyle advice
- advice monitoring and referral for further assessment and interventions
Step two of the stepped care model in the context of depression
Recognised depression - persistent threshold depressive symptoms or mild to moderate depression
Offer advice on sleep hygiene
Offer advice monitoring
Low intensity psychological and psychosocial interventions
DO NOT routinely use antidepressants
DO NOT routinely use antidepressants in the step two of the stepped care model unless….
Past history of moderate - severe depression
They present with subthreshold symptoms that have been present for 2 years or more
They have subthreshold symptoms for < 2 yrs but they dont respond to other interventions
Examples of advice monitoring
Discuss concerns
provide info about depression
reassess within 2 weeks
contact the person if they do not attend the follow up appointment
Step 3 of the stepped care model in the context of depression
Inadequate response to initial interventions, and moderate to severe depression An antidepressants (SSRI) High intensity psychological intervention - CBT, IPT, behavioural activation, couples therapy Combined treatments of medication and high intensity psychological preferred for moderate to severe depression
Things to consider in primary care management of mental health
Fitness to work
Fitness to drive
In the context of severe depression or anxiety, when is a patient not allowed to drive?
Significant memory or concentration problems
Agitation
Behavioural disturbance
Suicidal thoughts
Follow up after appointment
see people 2 weeks after starting, at intervals of every 2 to 4 weeks for 3 months and then longer intervals if response is good
In patients < 30 or high risk then see after one week and then 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 at risk of relapse
What is done If response is absent or minimal after 3-4 weeks therapeutic dose?
Increase level of support
Increase dose OR switch to another antidepressant
Switching antidepressants
SSRI to
a different SSRI to
another class e.g. TCA, venlafaxine to
combination and augmentation (primary care and psychiatrist) to
- combining with lithium, an antiphyscotic or another antidepressant e.g. mirtazapine
Step 4 of the stepped care model
Severe and complex depression, risk to life, severe self neglect
Intervention options
- refer to multiprofessional and possible inpatient care for people with depression who are at significant risk or have psychotic symptoms
Bipolar disorder and issues with the mediation
2ndry care medication only
women must be on effective contraception and signed agreement between prescriber and patient
What is panic disorder?
Recurrent panic attacks and persistent worry about further attacks
What is 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
Step 1 of the stepped care approach in the context of anxiety
if depression or other anxiety disorder present, treat the primary disorder first e.g. co morbid depression / anxiety - treat the depression first
Treat the co morbid substance misuse disorder first
Step 2 of the stepped care approach in the context of anxiety
For those whome active monitoring is insuffient
Offer; low intensity psychological interventions
- self help
- psychoeducational groups
Step 3 of the stepped care approach in the context of anxiety
For those with marked functional impairment OR for those who have not improved with step 2 treatments
Offer; high intensity psychological therapy or drug therapy
- CBT
- applied relaxation
- SSRI then
- Alternative SSRI or SNRI then
- Pregabalin
See patients every 2-4 weeks in first 3 months then continue therapy for 12 months after initiation to reduce rate of relapse
What SHOULD NOT be offered for anxiety in primary care
Antipsychotics
Step 4 of the stepped care approach in the context of anxiety
Specialist (CMHT) referral
if self harm / suicide risk, significant comorbidity, self neglect or failure to respond to step 3 interventions
Combined therapies
Presentation of panic attacks
Abrupt surge of intense fear or physical discomfort, reaching peak within a few minutes Palpitations/pounding heart tachycardia muscle trembling/shaking sweating SOB sensations of smothering Choking sensations chest pain / discomfort nausea abdo distress dizzy/light headed instability derealisation / depersonalisation fears of losing control or going crazy fear of dying numbness, tingling sensations chills, hot flushes
Treatment of mild - moderate panic disorder
Self help
Treatment of mod - severe panic disorder
Psychological therapy
Drug treatment
- SSRI (NOT FLUOXETINE)
- imipramine or clomipramine
What drugs to avoid in panic disorder
Benzodiazpeines
sedating antihistamines
antipsychotics
Treatment for social anxiety disorder
1st line ; CBT
2nd line ; medication
- sertraline or escitalopram
- continue for 6 months after become effective
Acute grief is characterised by…..
feelings of disbelief and comprehending difficulties
Bitterness/anger/guilt/blame
Impaired functioning
Intense yearning / sadness
emotional and psychical pain
mental fogginess
difficulty concentrating
forgetfulness
loss of sense of self or sense of life purpose
feeling disconnected
difficulty engaging and making plans for future
Grief features that can help differentiate from depression
Longing/yearning from loved one
positive emotions can still be experienced
symptoms worse when thinking about deceased person
people often want to be with others, whereas people with depression tend to want to be alone
Features of prolonged grief disorder
Marked distress and disability caused by the grief reaction
AND
persistence of the distress and disability MORE THAN 6 MONTHS after bereavement
How long is grief for when it turns into prolonged grief disorder?
More than 6 months
Treatment options of prolonged grief disorder
counselling
antidepressants for comorbid depression
behavioural/cognitive/exposure therapies
Refer if significant impairent in functioning
Definition of obsessions
Unwanted intrusive thoughts, images or urges. tend to be repugnant and inconsistent with a persons values
Definition of compulsions
Repetitive behaviours or mental acts the person feels driven to perform
Can be overt (checking theyve locked the door) or convert (mentally repeated a phrase in their head)
To warrant a diagnosis of OCD, what must be present?
Obsessions and compulsions must be time consuming > 1 hr OR cause significant distress OR functional impairment
OCD treatment
1st line; CBT including exposure and response prevention
2nd line; medication
- SSRIs
3rd line; clomipramine
Possible causes of insomnia
Anxiety / depression
Physical health problems (e.g. pain, dyspnoea)
Obstructive sleep apnoea
Excess alcohol or ilicit drugs
Parasomnias (restless legs, sleep walking etc)
Circadian rhythm disorder (especially in shift workers)
Treatment of insomnia
Sleep hygiene Sleep diaries - CBT Medications NOT routinely advised - melatonin > 55 y/o and short term - hypnotics in severe disabling insomnia causing marked distress
Features of sleep hygiene
avoid stimulating activities before bed
avoiding alcohol/caffeine/smoking before bed
Avoiding heavy meals or strenuous activities before bed
regular day time exercise
same bedtime each day
ensure bedroom environment promotes sleep
relaxation
What is a GP’s role in an eating disorder?
Recognise and refer to secondary care
Which medications require tests to monitor their effects?
Antipsychotics
- CV risk factors for 2nd generation
- ECG for QTC prolongation 1st generation
Lithium
- thyroid / kidney function tests 6 monthly
- lithium levels 3 monthly
What does taking lithium put you at risk of?
Lithium toxicity
- fine tremor vs coarse tremor
avoid nephrotoxic drugs
Expected side effects of taking lithium
Fine tremor dry mouth altered taste sensation increased thirst urinary frequency mild nausea weight gain
Symptoms of lithium toxicity
Vomiting diarrhoea coarse tremor (larger movements, especially of hands) muscle weakness lack of coordination including ataxia slurred speech blurred vision lethargy confusion seizures
Suicide Risk assessment
Must always ask about suicidal thoughts
Will not “plant the idea of suicide” in patient
Ideation/Intent/Plans - vague, fleeting / recurring, detailed, specific, already in motion
Previous attempts
Impulsivity/self control
Current stressors / triggers or sense of hopelessness
Protective factors vs risk factors
Assess whether the person has adequate social support and aware of sources of help
Arrange help appropriate to the level of risk
If considerable immediate risk to themselves or others, refer urgently to specialist mental health services
Advise the person to seek further help if the situation deteriorates
