Week 7/8 - Mental Health

Question 1

Diagnosis of Depression

Core Symptoms
Associated Symptoms
Severity of Depression
PH-9 Questionnaire
Differential Diagnosis

Answer 1

1. ) Core Symptoms - must have at least one, present most days for at least 2 weeks
   - feeling down, depressed, or hopeless (in last month)
   - little interest or pleasure in doing things
2. ) Associated Symptoms
   - fatigue/low energy, disturbed (↑or↓) sleep
   - change in appetite or weight (↑or↓)
   - ↓concentration, indecisiveness, agitation, slowing of movements
   - feeling worthless, excessive guilt, suicidal thoughts
3. ) Severity of Depression
   - subthreshold: 2-5 symptoms, mild: 5+ symptoms
   - moderate: 5+ w/ mild-severe functional impairment
   - severe: most symptoms, marked functional impairment, can also have psychotic symptoms
4. ) PH-9 Questionnaire - also used to measure severity
   - 27 is max score. 5, 10, 15, 20 represent cut off for mild, moderate, moderately severe, severe depression
5. ) Differential Diagnoses
   - grief reaction: suicidal thoughts, excessive guilt, and psychotic symptoms are rare
   - anxiety disorders, bipolar disorder, premenstrual dysphoric disorder, Parkinson’s, MS, dementia
   - substance misuse, CO poisoning, drug side-effects
   - hypothyroidism, obstructive sleep apnoea syndrome

Question 2

Management of Depression

Psycho-Social Interventions
Anti-Depressants
Assessments
Review Period

Answer 2

1. ) Psycho-Social Interventions
   - low intensity (mild): individual guided self-help, computerised CBT, group-based acitivty programs
   - high intensity (severe): individual CBT, interpersonal therapy, behavioural activation
2. ) Anti-Depressants - moderate-severe depression
   - SSRIs (sertraline, citalopram, fluoxetine, paroxetine)
   - Mirtazapine if also taking NSAIDs, aspirin, heparin, warfarin, triptans
   - symptoms may initially worsen, take time to work
   - should be continued for 6+ months following remission to prevent the risk of relapse
3. ) Assessments - also need managing
   - suicide risk, safeguarding concerns
   - factors affecting development, course and severity (FH, chronic diseases, living conditions, relationships )
   - associated comorbidities (substance misuse, eating disorders, anxiety, psychotic symptoms, dementia)
4. ) Review Period - depends on the risk of suicide
   - initial review within 2 weeks (1 if suicidal)

Question 3

Diagnosis of Generalized Anxiety Disorder (GAD)

Key Symptoms
Risk Factors
GAD-7
Differential Diagnoses

Answer 3

1. ) Key Symptoms - present for at least 6 months
   - chronic excessive worry unrelated to circumstances
   - physiological sx: fatigue, insomnia, restless, irritability, ↓conc, muscle tension, sweating, GI discomfort
2. ) Risk Factors
   - female, FH, substance abuse, other anxiety disorders
   - current/history of physical or emotional trauma
   - side effects: salbutamol, theophylline, beta-blockers, herbal medicines, corticosteroids, anti-depressants
3. ) GAD-7 - questionnaire assesses severity of anxiety
   - frequency of 7 symptoms over last 2 wks
   - 21 is max score. 5, 10, 15 are cut off scores for mild, moderate, and severe anxiety
4. ) Differential Diagnoses
   - situational anxiety, adjustment disorder, depression
   - panic disorder (sudden onset, SOB, palpitations etc)
   - OCD, PTSD, anorexia nervosa, medication-induced

Question 4

Management of Generalised Anxiety Disorder (GAD)

Step 1
Step 2
Step 3
Step 4

Answer 4

1. ) Step 1 - for all people with GAD
   - assess co-morbidities (mental, physical, substances)
   - assess environmental stressors (trauma, work etc.)
   - assess risk of suicide (if severe symptoms)
   - provide info on GAD and treatment options
2. ) Step 2 - people who step 1 not enough but they still do not have marked functional impairment
   - low intensity psychological interventions e.g. self help (individual or guided), psychoeducational groups
3. ) Step 3 - people with marked functional impairment or have not improved with step 2
   - high intensity psychological intervention (e.g. CBT)
   - SSRI (sertraline) or SNRI, pregabalin if contra…
   - review drugs every 2-4wks for first 3 months
   - <30s need review in first week due to ↑suicide risk
4. ) Step 4 - severe anxiety, w/ marked functional impairment OR risk of self-harm, self-neglect, suicide
   - refer for specialist treatment

Question 5

Suicide and Suicide Risk

Assessing Risk
Risk Factors
High Risk Group
Management

Answer 5

1. ) Assessing Risk
   - assessing risk: thoughts about death or suicide? is life worth living? previous attempts? FH of suicide?
   - ask about plans: method? materials? preparations?
   - protective factors: anything make life worth living?
2. ) Risk Factors
   - previous attempts, self-harm, active mental illness
   - FH of mental disorder, suicide or self-harm
   - unemployed, living alone, exposure to suicide
   - physical health issues, substance abuse
3. ) High Risk Groups
   - young/middle-aged men
   - people in contact with the criminal justice system
   - specific occupations e.g. doctors, nurses, veterinary workers, farmers, agricultural workers
4. ) Management
   - need to assess if patient is safe enough to go home
   - high risk: refer to mental health crisis team

Question 6

Self-Harm

Definition
Assessment
Management

Answer 6

1.) Definition - intentional self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act, and is an expression of emotional distress

2. ) Assessment
   - physical risk, psychological state (risk of repeating)
   - mental capacity (if refusing management)
   - safeguarding conerns
3. ) Management
   - info about support, groups, voluntary organizations
   - refferal to ED: if additional risk or self-poisoned
   - referral to crisis or community mental health team
   - referral to CAMHS (children and adolescents)
   - review should be offered within 48 hours

Question 7

MMSE and GPCOG

Answer 7

1. ) MMSE - Mini Mental State Exam
   - used to measure cognitive impairment
   - used for dementia but also suicide risk
2. ) GPCOG - very similar to MMSE
   - however, allows you to ask a family member/friend their experience of any possible cognitive decline
   - used for dementia but also suicide risk

Question 8

Anti-Psychotic Medication

SSRIs
Extrapyramidal Side Effects

Answer 8

1. ) SSRIs - sertraline, citalopram, fluoxetine
   - sertraline most common, fluoxetine preferred in children and adolescents
   - side effects: GI sx, GI bleeding, ↑anxiety/agitation, serotonin syndrome (esp due to DDIs: triptans, MAOi)
   - citalopram contraindicated in prolonged QT interval
   - mirtazapine instead of SSRIs if the patient is on anticoagulation or aspirin
   - when stopping, dose gradually reduced over 4 wk period to ↓discontinuation sx: GI sx, insomnia, mood change, sweating, restlessness, paraesthesia
2. ) Extrapyramidal Side Effects - with anti-psychotics
   - drugs: haloperidol, metoclopramide, SSRIs
   - parkinsonism, akathisia (severe restlessness)
   - acute dystonia (sustained muscle contraction),
   - tardive dyskinesia (involuntary movements)

Question 9

Anorexia Nervosa

Clinical Features
Investigations
Management
Complications

Answer 9

1,) Clinical Features

• BMI <17.5, amenorrhea, depression
• intense fear of gaining weight
• self-induced vomiting, laxative misuse
• distorted perception of body image

2. ) Investigations - FBC, U+Es, CBG, lipid profile
   - hyponatraemia due to excess water intake
   - hypokalemia from vomiting and laxative abuse
   - low blood glucose and low serum cholesterol
3. ) Management
   - general monitoring: e,g, bloods, ECG, weight
   - nutritional support
   - dental hygiene advice due to regular vomiting
   - screen/treat associated mental health problems
   - risk assessment for self-harm and suicide
4. ) Complications
   - infertility due to amenorrhea and anovulation
   - osteoporosis due to chronic oestrogen deficiency
   - arrhythmias, cardiac failure: electrolyte disturbance
   - early death

Question 10

Alcohol Misuse

Normal Limits
Signs of Alcohol Dependence
CAGE Questionnaire
Complications

Answer 10

1. ) Normal Limits
   - less than 14 units a week spread over >3 days
   - 2 units in a pint and glass of wine, 1 unit per shot
2. ) Signs of Alcohol Dependence
   - strong desire to drink every day, drinking alone
   - need a drink to stop trembling (withdrawal)
   - drink early or first thing in the morning
   - neglect other interests/pleasures/responsibilities
3. ) CAGE Questionnaire - 2+ indicates dependence
   - felt the need to Cut down on drinking
   - Annoyed by people criticising drinking habits
   - felt Guilty about drinking
   - Eye-opener: drink first thing in the morning to steady nerves or get rid of a hangover
4. ) Complications
   - liver cirrhosis, portal HTN, oesophageal varices
   - pancreatitis, erectile dysfunction, cardiomyopathy
   - delirium tremens, insomnia, depression, suicide
   - ↓thiamine: Wernicke-Korsakoff, peripheral neuropathy
   - cancer, fetal alcohol syndrome