Primary Care Management of mental health

Question 1

What are the components of the Stepped Care model?

Answer 1

The least intrusive intervention to be provided first/

If that intervention is ineffective, or declined, offer an appropriate intervention for the next step.

Question 2

Step One of the stepped care model in the context of depression

Answer 2

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

Question 3

Step two of the stepped care model in the context of depression

Answer 3

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

Question 4

DO NOT routinely use antidepressants in the step two of the stepped care model unless….

Answer 4

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

Question 5

Examples of advice monitoring

Answer 5

Discuss concerns
provide info about depression
reassess within 2 weeks
contact the person if they do not attend the follow up appointment

Question 6

Step 3 of the stepped care model in the context of depression

Answer 6

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

Question 7

Things to consider in primary care management of mental health

Answer 7

Fitness to work

Fitness to drive

Question 8

In the context of severe depression or anxiety, when is a patient not allowed to drive?

Answer 8

Significant memory or concentration problems
Agitation
Behavioural disturbance
Suicidal thoughts

Question 9

Follow up after appointment

Answer 9

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

Question 10

What is done If response is absent or minimal after 3-4 weeks therapeutic dose?

Answer 10

Increase level of support

Increase dose OR switch to another antidepressant

Question 11

Switching antidepressants

Answer 11

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

Question 12

Step 4 of the stepped care model

Answer 12

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

Question 13

Bipolar disorder and issues with the mediation

Answer 13

2ndry care medication only

women must be on effective contraception and signed agreement between prescriber and patient

Question 14

What is panic disorder?

Answer 14

Recurrent panic attacks and persistent worry about further attacks

Question 15

What is social anxiety disorder?

Answer 15

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

Question 16

Step 1 of the stepped care approach in the context of anxiety

Answer 16

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

Question 17

Step 2 of the stepped care approach in the context of anxiety

Answer 17

For those whome active monitoring is insuffient
Offer; low intensity psychological interventions
- self help
- psychoeducational groups

Question 18

Step 3 of the stepped care approach in the context of anxiety

Answer 18

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

Question 19

What SHOULD NOT be offered for anxiety in primary care

Answer 19

Antipsychotics

Question 20

Step 4 of the stepped care approach in the context of anxiety

Answer 20

Specialist (CMHT) referral
if self harm / suicide risk, significant comorbidity, self neglect or failure to respond to step 3 interventions
Combined therapies

Question 21

Presentation of panic attacks

Answer 21

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

Question 22

Treatment of mild - moderate panic disorder

Answer 22

Self help

Question 23

Treatment of mod - severe panic disorder

Answer 23

Psychological therapy
Drug treatment
- SSRI (NOT FLUOXETINE)
- imipramine or clomipramine

Question 24

What drugs to avoid in panic disorder

Answer 24

Benzodiazpeines
sedating antihistamines
antipsychotics

Question 25

Treatment for social anxiety disorder

Answer 25

1st line ; CBT 2nd line ; medication - sertraline or escitalopram - continue for 6 months after become effective

Question 26

Acute grief is characterised by.....

Answer 26

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

Question 27

Grief features that can help differentiate from depression

Answer 27

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

Question 28

Features of prolonged grief disorder

Answer 28

Marked distress and disability caused by the grief reaction AND persistence of the distress and disability MORE THAN 6 MONTHS after bereavement

Question 29

How long is grief for when it turns into prolonged grief disorder?

Answer 29

More than 6 months

Question 30

Treatment options of prolonged grief disorder

Answer 30

counselling antidepressants for comorbid depression behavioural/cognitive/exposure therapies Refer if significant impairent in functioning

Question 31

Definition of obsessions

Answer 31

Unwanted intrusive thoughts, images or urges. tend to be repugnant and inconsistent with a persons values

Question 32

Definition of compulsions

Answer 32

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)

Question 33

To warrant a diagnosis of OCD, what must be present?

Answer 33

Obsessions and compulsions must be time consuming > 1 hr OR cause significant distress OR functional impairment

Question 34

OCD treatment

Answer 34

1st line; CBT including exposure and response prevention 2nd line; medication - SSRIs 3rd line; clomipramine

Question 35

Possible causes of insomnia

Answer 35

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)

Question 36

Treatment of insomnia

Answer 36

``` Sleep hygiene Sleep diaries - CBT Medications NOT routinely advised - melatonin > 55 y/o and short term - hypnotics in severe disabling insomnia causing marked distress ```

Question 37

Features of sleep hygiene

Answer 37

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

Question 38

What is a GP's role in an eating disorder?

Answer 38

Recognise and refer to secondary care

Question 39

Which medications require tests to monitor their effects?

Answer 39

Antipsychotics - CV risk factors for 2nd generation - ECG for QTC prolongation 1st generation Lithium - thyroid / kidney function tests 6 monthly - lithium levels 3 monthly

Question 40

What does taking lithium put you at risk of?

Answer 40

Lithium toxicity - fine tremor vs coarse tremor avoid nephrotoxic drugs

Question 41

Expected side effects of taking lithium

Answer 41

``` Fine tremor dry mouth altered taste sensation increased thirst urinary frequency mild nausea weight gain ```

Question 42

Symptoms of lithium toxicity

Answer 42

``` Vomiting diarrhoea coarse tremor (larger movements, especially of hands) muscle weakness lack of coordination including ataxia slurred speech blurred vision lethargy confusion seizures ```

Question 43

Suicide Risk assessment

Answer 43

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