Treating mood disorders in primary care Flashcards
What are the challenges faced by health practitioners in primary care?
In primary care, people will express physical symptoms rather than naming specific mental problems
-> challenge to identify the main issues: diagnosis
What are the key factors of the general practitioner’s role in primary care?
- Continuity
- in the treatment and relationship with patients - Pragmatic
- Focused
- Shared decision making
- Careful discussions with the patients
- Compassion
What are opportunity costs in primary care?
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
Which disorders are not included as ‘common mental health disorders’ (CMDs)?
Psychosis, bipolar or personality disorder
What are the ‘common mental health disorders’ (CMDs) and their prevalence (NHS, 2007)?
- Mixed anxiety-depression: 9%
- General anxiety disorder (GAD): 4.4%
- Depression: 2.3%
- Phobia: 1.4%
- OCD: 1.1%
- Panic disorder: 1.1%
What does “managing uncertainty” in primary care refer to?
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
What does “managing uncertainty” in primary care refer to?
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
What were general practitioners accused of in the prescription of antidepressants until recently?
Over-diagnosing and over-treating
- 50 million prescriptions/year
What did the 2004 NICE depression guidelines advise?
Against use of antidepressants for mild depression
What do the currently high antidepressant prescribing rates reflect?
Longer term antidepressants (over 2 years)
What do we currently know about the effectiveness of antidepressants?
- Prescribing antidepressants saves life in severe depression
- Less effective in mild depression
What is the importance of diet in the treatment of affective disorders?
Dietetic / nutritional expertise is essential
How is diet related to physical health?
Obesity, diabetes, ischaemic heart disease, rheumatoid arthritis
- involvement of inflammatory cytokines TNFα IL -6
How is diet related to mental health?
Mood disorders, schizophrenia, dementia
- involvement of inflammatory cytokines TNFα IL -6
Which diet increases the risk of depression in postmenopausal women?
High glucose diets:
- chips, biscuits, cakes, ice cream, potatoes, processed food, white bread
Which type of diet has evidence for improving depressive symptoms?
Mediterranean diet can reduce levels of inflammation
-> its effects would be felt not only in people with diabetes, but also others
Which micronutrient has an important role in mental health and depression?
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)
What is coeliac disease?
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
What is the evidence suggesting that going gluten free helps depression?
> 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
What is the nature of the controversy regarding the symptom improvement with dietary exclusion of gluten?
- 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
What are FODMAPs?
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
What are the common extra-intestinal symptoms associated with non-coeliac gluten sensitivity (NCGS)?
- Lack of well-being
- Tiredness
- Headache
- Anxiety
- Foggy mind
- Numbness
- Joint/muscle pain
- Skin rash / dematitis
What is the effect of gluten on people with coeliac disease?
- 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
What are the dietary key factors for improving mental health?
> 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
Why shouldn’t you buy gluten-free foods?
They are often quite high in sugar
When should the lack diagnosis of anxiety and depression be deliberate?
When patient’s symptoms might be mild, therefore not needing diagnosis
What is the criteria for diagnosing depression in primary care (NICE, 2009)?
> 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
How is the level of depression measured in busy clinical primary care settings?
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
How is anxiety measured in primary care settings?
GAD-7 (Generalised anxiety disorder - 7 items):
- cut-off score = 5
What are the rate of sensitivity and specificity of the PHQ-9 for measuring major depressive disorder (MDD)?
- Sensitivity 88%
- Specificity 88%
What is the sensitivity and specificity of the GAD-7 for measuring generalised anxiety disorder?
- Sensitivity: 89%
- Specificity: 82%
What is the sensitivity and specificity of the GAD-7 for measuring panic disorder?
- Sensitivity: 74%
- Specificity: 81%
What is the sensitivity and specificity of the GAD-7 for measuring social anxiety disorder?
- Sensitivity: 72%
- Specificity: 80%
What is the sensitivity and specificity of the GAD-7 for measuring post-traumatic stress disorder (PTSD)?
- Sensitivity: 66%
- Specificity: 81%
How easy or practical are the mental health questionnaires in primary care?
- 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
How do people with bipolar disorder arrive in primary care settings?
- 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
What paradoxical in the diagnosis of bipolar disorder?
To make the diagnosis you need mania or hypomania, but patients will often feel good
Why do people with bipolar disorder symptoms seek help?
For the depressive symptoms
- when manic or hypomanic, they will often feel good
What characterises bipolar I disorder?
Mania (≥ 7 days) with or without major depression
What characterises Bipolar II disorder?
One or more episodes of hypomania (≥ 4 days)
AND recurrent major depression
What is cylcothemia?
Mood swings milder than in bipolar disorder
What are the NICE guidelines on bipolar disorder diagnosis in primary care?
> 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
When is bipolar depression more likely than unipolar depression?
> 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
Why were antidepressants previously prescribed for mild depression?
- GPs didn’t have any other alternative
- Lack of therapists to refer patients to
What is in place since 2008 regarding access to psychological therapies?
Referrals to psychological therapies, in particular CBT, for mild or moderate depression
- 900,000 treated per year in England
What is the minimum time of antidepressant use in a first prescription?
At least 6 months
- otherwise symptom recurrence is likely
What should be done when prescribing antidepressants for the first time to a patient?
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
How may antidepressants worsen the symptoms of bipolar disorder patients?
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
What is the recommended drug treatment for mild and moderate depression?
> 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
What is the recommended drug treatment for severe depression?
Best practice:
- antidepressants (life-saving)
and
- high-intensity psychological intervention: CBT or interpersonal therapy (IPT)
What are the British Association for Psychopharmacology guidelines (2015) for antidepressants?
> 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
