Primary care management of mental health Flashcards
What are common psychiatric complaints in primary care?
Feeling low No energy Tired all the time Struggling with motivation Can't stop crying Struggling with sleep Not enjoying things Struggling to get to work
What are risk factors for depression to consider in primary care?
PMH of depression
Significant illnesses causing disability
What questionnaire can be used to assess severity of depression?
PHQ-9
How is depression treated in primary care?
Stepped care model
Step one - recognition and assessment, intervention - psycho-education, lifestyle advice
Step two - Recognised subthreshold symptoms/mild-moderate depression - sleep hygiene, active monitoring, low-intensity psych interventions
Step 3 - unresponsive to initial interventions - Antidepressant or high intensity psych intervention
Step 4 - severe and complex - referral
What is the first line antidepressant used?
SSRI
What needs to be considered about the patient’s life and safety with depression?
Fitness to work
Fitness to drive
What should be done when switching antidepressants?
Initially switch to a different SSRI Subsequently to another class that may be less well tolerated ie tricyclic, MAOI Combining
How should antidepressants be stopped?
Gradually reduce dose over 4 weeks
What are risk factors for suicide?
Suicidal ideation - vague, detailed, specific Previous attempts Impulsivity Access to lethal methods Current stressors Protective factors Assess social support Alcohol/drug misuse Physical illness Relationship breakdown
What is used to assess severity of generalised anxiety disorder?
Level of distress
Functional impairment
Number, severity, and duration of symptoms
What factors can affect development, source, and severity of anxiety state?
Other anxiety disorder in addition Depression Substance misuse Physical health problems History of mental health problems Past experience and response to treatments
What is first line pharmacological treatment for generalised anxiety disorder?
SSRI
When should referral be considered in generalised anxiety disorder?
Risk of self-harm or suicide
Significant comorbidity
Self-neglect
What are features of panic attacks?
Palpitations/tachycardia Sweating Muscle trembling Shortness of breath Choking sensations Chest pain Nausea Dizziness Fear of dying Numbness
What are psychological interventions for panic disorder?
CBT
What pharmacological treatment should be used for panic disorder?
SSRI - citalopram but NOT fluoxetine
What is 1st line treatment for social anxiety disorder?
CBT
How is acute grief characterised?
Feelings of disbelief and difficulty comprehending loss Bitterness/anger/guilt/blame Impaired functioning Intense yearning and sadness Mental fogginess Loss of sense of self Feeling disconnected from other people Difficulty engaging in activities
How does grief differ from depression?
Grief includes longing/yearning for the loved one
Positive emotions can still be experienced
Symptoms worsen when thinking of deceased person
Grief typically wants to be with others, depression wants to be alone
What is prolonged grief disorder?
Marked distress and disability caused by grief reaction
Persistence for more than 6 months after bereavement
How is prolonged grief disorder treated?
Counselling
Antidepressants
Behavioural/cognitive/exposure therapies
Referral if significant impairment in function
What is 1st line treatment for OCD?
CBT
What is 1st line pharmacological treatment for OCD?
SSRIs
What are secondary causes of insomnia?
Anxiety/depression Physical health problems Obstructive sleep apnoea Excess alcohol or illicit drugs Parasomnias Circadian rhythm disorder
How can sleep hygiene be improved?
Avoid stimulating activities 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
What are potential side effects of lithium?
Fine tremor Dry mouth Altered taste sensation Increased thirst Urinary frequency Mild nausea Weight gain
What are symptoms of lithium toxicity?
Vomiting and diarrhoea Coarse tremor Muscle weakness Lack of coordination including ataxia Slurred speech Blurred vision Lethargy Confusion Seizures
