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Psychology & Neuroscience of Affective Disorders > Treating mood disorders in primary care > Flashcards

Treating mood disorders in primary care Flashcards

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1
Q

What are the challenges faced by health practitioners in primary care?

A

In primary care, people will express physical symptoms rather than naming specific mental problems

-> challenge to identify the main issues: diagnosis

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2
Q

What are the key factors of the general practitioner’s role in primary care?

A
  1. Continuity
    - in the treatment and relationship with patients
  2. Pragmatic
  3. Focused
  4. Shared decision making
  5. Careful discussions with the patients
  6. Compassion
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3
Q

What are opportunity costs in primary care?

A

If you do one thing, it’s another you’re not doing

-> ideal treatment to one patient might adversely affect other patients

=> there are opportunity costs for focusing on a disorder

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4
Q

Which disorders are not included as ‘common mental health disorders’ (CMDs)?

A

Psychosis, bipolar or personality disorder

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5
Q

What are the ‘common mental health disorders’ (CMDs) and their prevalence (NHS, 2007)?

A
  • Mixed anxiety-depression: 9%
  • General anxiety disorder (GAD): 4.4%
  • Depression: 2.3%
  • Phobia: 1.4%
  • OCD: 1.1%
  • Panic disorder: 1.1%
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6
Q

What does “managing uncertainty” in primary care refer to?

A

People present themselves with signs of different illnesses, but often things will get better

  • the continuous relationship between GP and patient serves in managing the uncertainty and potentially dealing with worsening symptoms
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6
Q

What does “managing uncertainty” in primary care refer to?

A

People present themselves with signs of different illnesses, but often things will get better

  • the continuous relationship between GP and patient serves in managing the uncertainty and potentially dealing with worsening symptoms
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7
Q

What were general practitioners accused of in the prescription of antidepressants until recently?

A

Over-diagnosing and over-treating

- 50 million prescriptions/year

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8
Q

What did the 2004 NICE depression guidelines advise?

A

Against use of antidepressants for mild depression

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9
Q

What do the currently high antidepressant prescribing rates reflect?

A

Longer term antidepressants (over 2 years)

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10
Q

What do we currently know about the effectiveness of antidepressants?

A
  • Prescribing antidepressants saves life in severe depression
  • Less effective in mild depression
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11
Q

What is the importance of diet in the treatment of affective disorders?

A

Dietetic / nutritional expertise is essential

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12
Q

How is diet related to physical health?

A

Obesity, diabetes, ischaemic heart disease, rheumatoid arthritis

  • involvement of inflammatory cytokines TNFα IL -6
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13
Q

How is diet related to mental health?

A

Mood disorders, schizophrenia, dementia

  • involvement of inflammatory cytokines TNFα IL -6
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14
Q

Which diet increases the risk of depression in postmenopausal women?

A

High glucose diets:

- chips, biscuits, cakes, ice cream, potatoes, processed food, white bread

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15
Q

Which type of diet has evidence for improving depressive symptoms?

A

Mediterranean diet can reduce levels of inflammation

-> its effects would be felt not only in people with diabetes, but also others

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16
Q

Which micronutrient has an important role in mental health and depression?

A

Omega 3 essential fatty acids (Omega 3 EFAs)
- essential for brain function

  • eating fish regularly (3-5 portions/week) might help to reduce depression
    (still debated)
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17
Q

What is coeliac disease?

A

Condition where your immune system attacks your own tissues when you eat gluten
-> damages your gut (small intestine) so you are unable to take in nutrients

-> caused by an adverse reaction to gluten

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18
Q

What is the evidence suggesting that going gluten free helps depression?

A

> People with recent-onset psychosis, multi-episode schizophrenia and bipolar disorder
- may have antibodies to gliadin (part of gluten)

> The state of gastrointestinal wall may affect mental health

> Non-coeliac gluten sensitivity (NCGS) may appear in people who don’t ave coeliac disease

> Many people with coeliac disease who have anxiety or depression will get better by cutting out gluten

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19
Q

What is the nature of the controversy regarding the symptom improvement with dietary exclusion of gluten?

A
  • It is a real effect?
  • Placebo effect?
  • Are there confounders such as FODMAPs?
  • There are no good biomarkers to measure this
  • > potential trial for testing gluten vs. gluten free diets
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20
Q

What are FODMAPs?

A

Short chain, poorly digestible carbohydrates that make the stomach feel bloated
- may cause irritable bowel syndrome (IBS) like symptoms

Fermentescible, Oligosaccharides, Disaccharides, Monosaccharides, and Polyols

21
Q

What are the common extra-intestinal symptoms associated with non-coeliac gluten sensitivity (NCGS)?

A
  • Lack of well-being
  • Tiredness
  • Headache
  • Anxiety
  • Foggy mind
  • Numbness
  • Joint/muscle pain
  • Skin rash / dematitis
22
Q

What is the effect of gluten on people with coeliac disease?

A
  • Guten is split into gliadin and gluten fragments which activate problems with zonulin (protein that protects gastrointestinal wall cells)
  • > causes leakage between cells AND passage of molecules, which may cause inflammation in the regional and systemic immune system

=> Low mood and fatigue in people with coeliac disease

23
Q

What are the dietary key factors for improving mental health?

A

> Favour whole-food Mediterranean diet
- emphasise fish, green vegetables, and nuts

> Consider a month off gluten and then retry

> Avoid trans-fats and fast food

> Reduce/avoid overly sweet and stodgy carbohydrates

> Don’t buy gluten-free foods as they are often quite high in sugar

=> seek expert help of a dietitian

24
Q

Why shouldn’t you buy gluten-free foods?

A

They are often quite high in sugar

25
Q

When should the lack diagnosis of anxiety and depression be deliberate?

A

When patient’s symptoms might be mild, therefore not needing diagnosis

26
Q

What is the criteria for diagnosing depression in primary care (NICE, 2009)?

A

> Key symptoms:
- persistent sadness or low mood
and/or
- marked loss of interest or pleasure

> Associated symptoms

  • disturbed sleep
  • decreased or increased appetite and/or weight
  • fatigue or loss of energy
  • agitation or loos of energy
  • poor concentration or indecisiveness
  • feelings of worthlessness or excessive/inappropriate guilt
  • suicidal thoughts

> Subthreshold depressive symptoms: < 5 symptoms

> Mild depression: +/- > 5 symptoms + minor functional impairment

> Moderate depression: symptoms or functional impairment between mild and severe

> Sever depression: most symptoms + marked interference with function
- with or without psychosis

27
Q

How is the level of depression measured in busy clinical primary care settings?

A

PHQ-9 score

  • score over or = 10 -> MDD
  • score = 5 -> mild depression
  • score = 10 -> moderate
  • score = 15 -> moderately severe
  • score = 20 -> severe depression

BUT controversy on this questionnaire

28
Q

How is anxiety measured in primary care settings?

A

GAD-7 (Generalised anxiety disorder - 7 items):

- cut-off score = 5

29
Q

What are the rate of sensitivity and specificity of the PHQ-9 for measuring major depressive disorder (MDD)?

A
  • Sensitivity 88%

- Specificity 88%

30
Q

What is the sensitivity and specificity of the GAD-7 for measuring generalised anxiety disorder?

A
  • Sensitivity: 89%

- Specificity: 82%

31
Q

What is the sensitivity and specificity of the GAD-7 for measuring panic disorder?

A
  • Sensitivity: 74%

- Specificity: 81%

32
Q

What is the sensitivity and specificity of the GAD-7 for measuring social anxiety disorder?

A
  • Sensitivity: 72%

- Specificity: 80%

33
Q

What is the sensitivity and specificity of the GAD-7 for measuring post-traumatic stress disorder (PTSD)?

A
  • Sensitivity: 66%

- Specificity: 81%

34
Q

How easy or practical are the mental health questionnaires in primary care?

A
  • Doctors will often prioritise helping and taking to their patients rather than filling out the questionnaires
  • Questioning measures of depression within clinical context rather than research led to dropping of PHQ-9
35
Q

How do people with bipolar disorder arrive in primary care settings?

A
  • It’s very unusual to see people who are manic

- Manic patients might end up being taken to hospital or be brought in by the police

36
Q

What paradoxical in the diagnosis of bipolar disorder?

A

To make the diagnosis you need mania or hypomania, but patients will often feel good

37
Q

Why do people with bipolar disorder symptoms seek help?

A

For the depressive symptoms

  • when manic or hypomanic, they will often feel good
38
Q

What characterises bipolar I disorder?

A

Mania (≥ 7 days) with or without major depression

39
Q

What characterises Bipolar II disorder?

A

One or more episodes of hypomania (≥ 4 days)

AND recurrent major depression

40
Q

What is cylcothemia?

A

Mood swings milder than in bipolar disorder

41
Q

What are the NICE guidelines on bipolar disorder diagnosis in primary care?

A

> Ask about hypomania and mania in people who are depressed

> Bipolar disorder should be considered if patient suffered from more than 4 days overactive or disinhibited behaviour

> Mood questionnaires should not be used in primay care

> Formal diagnosis should not be made in primary care, but instead patient should be referred

42
Q

When is bipolar depression more likely than unipolar depression?

A

> Atypical depression:
- sleeping/eating more, psychomotor retardation, fatigue, marked guilt, psychosis

> Lack of response to two or more antidepressants
- patients may be wrongly given antidepressants, which might worsen bipolar disorder symptoms

> Antidepressant-induced hypomania / mania
- occurs in people with bipolar disorder

> Borderline personality disorder

> Family history of bipolar

43
Q

Why were antidepressants previously prescribed for mild depression?

A
  • GPs didn’t have any other alternative

- Lack of therapists to refer patients to

44
Q

What is in place since 2008 regarding access to psychological therapies?

A

Referrals to psychological therapies, in particular CBT, for mild or moderate depression

  • 900,000 treated per year in England
45
Q

What is the minimum time of antidepressant use in a first prescription?

A

At least 6 months

- otherwise symptom recurrence is likely

46
Q

What should be done when prescribing antidepressants for the first time to a patient?

A

Warn patient about side effects and increased suicidal ideation during first few days of pharmacological treatment

  • evidence that small percentage of patients may develop antidepressant-related (feeling highly irritated or restless)
  • may increase suicidal thoughts or action
47
Q

How may antidepressants worsen the symptoms of bipolar disorder patients?

A

By causing
- rapid cycling (faster mood episodes)
or
- mixed effective state (agitated and depressed at the same time), bringing impulsivity which is associated with suicidal actions

48
Q

What is the recommended drug treatment for mild and moderate depression?

A

> No benefits of antidepressants in mild depression

> Antidepressants can be helpful for moderate depression

> They are also beneficial if a sub threshold of depressive symptoms are present for a long time and are not improving with other types of intervention

49
Q

What is the recommended drug treatment for severe depression?

A

Best practice:
- antidepressants (life-saving)
and
- high-intensity psychological intervention: CBT or interpersonal therapy (IPT)

50
Q

What are the British Association for Psychopharmacology guidelines (2015) for antidepressants?

A

> Antidepressants are effective in acute treatment of major depression of moderate and greater severity in adults

  • response rate: 48-50%
  • number needed to treat: 5-7

> Tricyclic antidepressants (TCAs) are no longer recommended
- might be used in low dose in patients with depression and chronic pain

> SSRI’s better tolerated than TCAs overall

Psychology & Neuroscience of Affective Disorders (16 decks)

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