Week 7: Mental health 1 (depression and anxiety) Flashcards
depression overview
Definition and overview
Refers to both negative affect (low mood) and/or absence of positive affect (loss of interest and pleasure in most activities) and is usually accompanied by a variety of emotional, cognitive, physical and behavioural symptoms
risk factors for depression
- Female (esp postnatal)
- Past history of depression
- Physical illness
- Other mental health problems e.g. dementia or schizophrenia
- Psychosocial problems e.g. divorce, unemployment, poverty
- Risk factors for children
- Family discord
- Bullying
- Abuse
- Drug and alcohol use
- History of parental depression
- Side effect of medication
- Physical illness
presentation of depression
Presentation
- Sad mood that doesn’t go away
- Loss of interest
- Lack of energy
- Loss of confidence
- Poor concentration
- Sleep disturbance
- Change in appetite
- Thoughts of suicide
- Agitation
- Feeling worthless
- Panic
- Apathy
Low mood vs depression
Low mood
- Feeling low from time to time
- Common after distressing event or major life changes, sometime happen for no obvious reasons
- Low mood will often pass after a couple of days or weeks
When does it become depression
- If you are feeling down or no longer get pleasure from things most of each day and this lasts for several weeks
management of depression
- Managing comorbidity i.e. alcohol substance abuse, eating disorder etc
- Managing safeguarding issues
- Assessing and mitigating suicide risk
- CBT
- Counselling
- Social prescribing i.e. physical activity programmes in groups
pharmacological management of depression
Antidepressants are not recommended for initial treatment of mild depression because risk: benefit ratio is poor
moderate to severe depression offer
antidepressants combined with CBT
if suicicdal ideas or plans
make urgent psychiatric referral
- use of mental health act may be necessary
types of antidepressants
SSRIs
SNRIs
SSRIs
- Selective serotonin reuptake inhibitors (SSRIs) are first line (less toxic in overdose and same effectiveness as tricylic)
- Citalopram
- Fluoxetine
- Sertraline
SNRI
- SNRI (serotonin noradrenaline reuptake inhibitors) used as second line
- Duloxetine
electroconvulsive therapy (ECT)
is occasionally used by specialists to gain fast and short term improvement of severe symptoms if other options have failed
screening tool for depression
PHQ9 self assessment
diagnosis of depression
DSM-5
DSM-5 requires….
- Requires at least one of the core symptoms (for >2 weeks)
- Persistent sadness/ low mood
- Loss of interest or pleasure in most activities
- Plus at least ¾ of the following symptoms
- Fatigue
- Worthlessness/ inappropriate guilt
- Recurrent thoughts of death
- Diminished ability to concentrate
- Insomnia
- Changes in appetite/weight loss
monitoring of depression
- See patients who are not considered to be at increased risk of suicide within 2 weeks of starting treatment and review as reg as appropriate
-
See patients with increased risk of suicide who are younger than 30 within one week of starting treatment and review reg
- If pt high risk of suicide- prescribe a limited quantity of antidepressants
- Monitor for signs of akathisia, suicidal ideas and increase anxiety and agitation
treatment duration for depression
- For patients who have benefited from SSRI- continue for at least 6 months after remission tor educe risk of relapse
- When stopping antidepressants reduce dose gradually over a four week period
complications of depression
- For patients who have benefited from SSRI- continue for at least 6 months after remission tor educe risk of relapse
- When stopping antidepressants reduce dose gradually over a four week period
prognosis of depression
- Average length is 6-8 months
- Risk of recurrence is 50-%
- Prognosis worse when psychotic features, anxiety and underlying personality disorder
depression history taking
-
Opening the consultation
- Wash hands
- Introduce name and role
- Confirm pt name and DoB
- Ask pt if happy to talk with you about their current issues
-
PC
- What has brought you to see me today?
- Okay can you tell me more about that
-
HPC
- Screening for depression
- ‘during the past month have you felt…
- Low, depressed or hopeless
- Had little interest in doing things’
- ‘during the past month have you felt…
-
Exploring symptoms of depression
- Ask about sleep
- Ask about mood (persistent sadness most days)
- Appetite change
- Reduced libido
- Reduced concentration
- Negative attitude to the future
- Negative perception of self
- Assess suicide risk
- “When people feel down and depressed, they can feel that life is no longer worth living. Have you ever felt like this?”
-
Screening for other psychiatric disorder inc bipolar, schizophrenia
-
E.g. features of mania suggestive of bipolar
- ‘have you ever experienced periods of feeling particularly high, energetic, euphoric’
-
Features of schizophrenia
- Voices speaking
- Think people are discussing you negatively
- Fear people are out to get you etc
-
E.g. features of mania suggestive of bipolar
- Screening for depression
-
Past psychiatric history
- ‘Have you ever had any other periods of feeling particularly low’
- Past medical history note any conditions e.g. hypothyroidisms that can cause mood disturbance
- Allergies
- Drug history
-
Family history
- “Have any of your parents or siblings had problems with their mental health in the past?”
-
Social history
- General context: accommodation, who they live with, if they can do ADL
- Assess impact of depression on relationships and work
- Smoking
- Alcohol
- Recreational drug use
- Gambling
-
Assess insight
- In severe depression may demonstrate loss of insight into illness
- Ask: ‘what do you think the cause of the problem is’
-
Closing the consultation
- Make sure ICE has been covered
- Thank patient
- Dispose of PPE
generalised anxiety disorder
GAD is a syndrome of ongoing anxiety and worry about many events or thoughts that the patient generally recognises as excessive and inappropriate. The condition can be chronic and debilitating.
risk factors for GAD
- Women > men
- 35-54
- Being divorced
- Living alone or a lone parent
resentation of GAD
- Excessive anxiety and worry for >6 months
- Difficult to control worry
- 3/6 symptoms
- Restlessness
- On edge
- Fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
- Autonomic arousal
- Palpitations
- Sweating
- Shaking
- Dry mouth
- Chest and abdomen
- Nausea or abdominal distress
- Difficulty breathing
- Chest pain
- General symptoms
- Hot flushes or cold chills
- Feeling dizzy
- Fear of dying
Difference between GAD and stress
-
Stress is typically caused by an external trigger
- Trigger can be short term, such as a work deadline or a fight with love one
- Can experience mental and physical symptoms
- Irritability
- Anger
- Fatigue
- Muscle pain
- Difficulty sleeping
-
Anxiety is defined as persistent, excessive worries that don’t go away even in the absence of a stressor
- Can lead to identical set of symptoms as stress
screening tool for anxiety
GAD7
diagnosis of GAD
Diagnosis
- Used the DSM-V criteria or the icd-10
- Clinical judgement based on history can be used
- Physical exam
- Increased HR
- SoB
- Trembling
- Exaggerated startle response
monitoring of anxiety
- Review should be every 4-8 weeks
- For patients on medication, NICE recommends 2-4 weeks for first 3 months
- Medication should be continued for a minimum of one year
- Self-complete questionnaire to monitor outcomes
comolications of anxiety
- Review should be every 4-8 weeks
- For patients on medication, NICE recommends 2-4 weeks for first 3 months
- Medication should be continued for a minimum of one year
- Self-complete questionnaire to monitor outcomes
prognosis of anxiety
chronic disease
management of anxiety
In terms of long-term effectiveness, the best results are from psychotherapy, followed by medication, followed by self-help.
- stepped-care model
The stepped-care model
psycholoigcal therapy for anxiety
CBT
pharmacological treatment for anxiety
- Where rapid response is required
- Benzodiazepines- but only prescribe for up to 4 weeks
- Antidepressants
- Take longer to work than benzodiazepines but they can be continued for longer e.g. SSRI e.g. sitaloprm
self help with anxiety
aerobic exercise training
anxiety history taking
-
Opening the consultation
- Wash hands
- Introduce name and role
- Confirm pt name and DoB
- Ask pt if happy to talk with you about their current issues
-
PC
- What has brought you to see me today?
- Okay can you tell me more about that
-
HPC
- Anxiety and worry on most days
- Generalised- worry about everything
- Long terms
-
Other symptoms inc.
- 3/6 symptoms
- Restlessness
- On edge
- Fatigued
- Difficulty concentrating
- Irritability
- Muscle tension
- Sleep disturbance
- Palpitations
- 3/6 symptoms
-
PMH
- Have you been treated or experienced this before
-
Family history
- “Have any of your parents or siblings had problems with their mental health in the past?”
-
Social history
- General context: accommodation, who they live with, if they can do ADL
- Assess impact of anxiety on relationships and work
- Smoking
- Alcohol
- Recreational drug use
- Gambling
-
Assess insight
- In severe depression may demonstrate loss of insight into illness
- Ask: ‘what do you think the cause of the problem is’
-
Closing the consultation
- Make sure ICE has been covered
- Thank patient
- Dispose of PPE
