Primary Care Management Of Mental Health Disorders Flashcards
What are common complaints of people with mental health disorders?
I'm feeling low I've got no energy I'm tired all the time I'm struggling with my motivation I can't stop crying I'm struggling with my sleep I'm not enjoying things like i used to I'm struggling to get to work
Who should you watch out for when suspecting depression
A past medical history of depression
Significant illnesses causing disability
Other mental health disorders e,g, dementia
During the last month have you often felt down, depressed or hopeless?
During the last month have you been bothered by having little interest or pleasure in doing things
What are the three key symptoms you must have to be diagnosed with depression
Persists sadness or low mood
Loss or interests or pleasure
Fatigue or low energy
You must also have some of the 7 screening symptoms of depression
What are the screening symptoms for depression
Disturbed sleep Poor concentration or indecisiveness low self confidence poor or increased appetite suicidal thoughts or acts agitation of movements guilt or self blame
What is a good screening questionnaire for depression
PHQ-9
How do you treat depression in primary care
Recognise depression:
Offer advice on sleep hygiene
Offer active monitoring
Low intensity psychological and psychosocial interventions
Do not routinely use antidepressants unless:
Past history
Subthreshold symptoms for 2 years or more
Don’t respond to other interventions
What high level managements can you use for depression in primary care?
Only if low level interventions don’t work
Antidepressants (SSRI)
High intensity psychological intervention
Combined treatment medication and high intensity psychological interventions, preferred for moderate to severe depression
What else should you consider for people with depression?
Med 3 forms- fit to work form (not legal discretion)
Fitness to drive- very good DVLA document
How do you follow up people with depression
Normally see people after 2 weeks after starting, see them at intervals every 2-4 seeks for 3 months and then at longer intervals if the response is good.
In patients aged under 30, or considered at greater risk, see weekly and as frequently thereafter as appropriate until risk no longer clinically important
Encourage to take for at least 6 months after remission, and for up to 2 tears if they are at risk of relapse
What is the go to drug for depression- lecturer
Sertraline- 50mg, 30mg for elderly. Half the dose to see side effects
How long do you wait until deciding an antidepressant isn’t working and then switching it?
6 weeks
Who do you refer to in patients/ specialist care
Severe and complex depression
Risk to life
Severe self neglect
How do you do a suicide screen?
Ideation/intent/plans- vague, detailed, specific, already in motion
Previous attempts
Homicidal risk
Impulsivity/self control
Access to lethal methods
Current stressors/sense of hopelessness
Protective factors
Assess whether the person has an adequate social support and is aware of sources of help
Arrange help appropriate to the level of risk
What drug can you not give to woman of child bearing age who are bipolar
Sodium valproate
Who prescribes medications for those with bipolar disorders?
Secondary care only!
What are the three main types of anxiety disorder?
Generalised anxiety disorder
Panic disorder
Social anxiety disorder
What is a good questionnaire for anxiety?
GAD-7
How do you treat mild/moderate anxiety
Individual non- facilitated self help- usually 6 week sessions typically written materials based on CBT
Indivudal guided self help- written materials and a trained practitioner
Psychoeducational groups- 6 weekly sessions of 2 hours, based on CBT principles
What can you do for severe anxiety?
CBT
Applied relaxation
Drug therapy- sertraline (SSRI) or fluexoetine
If not SNRI (venlafaxine/duloxetine)
If not pregabalim- can be abused, now controlled drugs
Keep on for 12 months
When should you refer someone with anxiety to secondary care
Risk of self harm/suicide
Significant co-morbidity
Self neglect
Failrue to respond to step 3 treatment
How do you diagnose panic attacks
Surge of fear or physical discomfort reaching a peak in a few minutes
Palpitations Sweating Shaking SOB Chest pain Dizzy Fear of death/loss of control
What drug do you not use for panic disorders?
Fluoxetine!
What’s the best antidepressant
Sertraline
Patients with cardiac, renal and epilepsy can take it
Only has GI side effects that will wear off
What are some useful screening questions for social anxiety disorder?
Useful screening questions:
Do you find yourself avoiding social situations or activities
Are you fearful or embarrassed in social situations
How do you treat social anxiety disorder?
1st line CBT
2nd line- sertraline, citrallopram for 6 months once treatment is working
How do you characterise grief?
Disbelief, diifuckty comprehending Bitterness,anger guilt and blame Impaired functional yearning and sadness Emotional and physical pain Mental fogginess, difficulty concentrating, forgetfulness Loss of purpose Feeling disconnected Difficulty engaging in activities or making plans fro the future
How do you differentiate grief from depression?
Grief includes longing/yearning for loved one
Positive emotions can still be experienced
Symptoms worse when thinking about deceased person
People often want to be with others
How do you treat prolonged grief disorder
Only access 6 months after the loss
Counselling e.g. Cruse
Antidepressants for co-morbid depression
Behavioural/cognitive/exposure therapy
Refer if significant impairment
How do you treat OCD
1st line- CBT, exposure and response prevention
2nd line- SSRI, often required higher dose up to 12 weeks
3rd line- medication, clomipramine (most SSRI or the TCA)
4th line- buspirone and SSRI
What should you screen for when looking at insomnia?
Anxiety/depression Physical health problems-pain, dyspnoea Obstructive sleep apnoea Excess alcohol or illicit drugs Parasomnias Cicadian rhythm disorder
What should you do when checking someone with restless legs
Check their ferritins
What are the rules of sleep hygiene
Avoid stimulations before bed
Avoid alcohol, caffeine, smoking before bed
Avoid heavy meals or strenuous exercise before bed
Regular day time exercise
Same bedtime each day
Ensure bedroom environment promotes sleep
Relaxation
If you can’t sleep after 20 mins get back up and do a relaxing activity (BATH, BOok)
What can you do to treat insomnia?
Sleep diaries
CBT-I (avoiding available in England, sleepspace.ord self funded £95)
Medications not indicated, addictive and don’t work very well
What do you do with eating disorders
Recognise and send to secondary care
What are the symptoms of lithium toxicity
Nausea and vomiting
