15 - Mental Health Flashcards
What is the difference between low mood and depression?
A low mood can happen when you are having some distressing events happening in your life, often lasts for a few days and then lifts
Depression lasts for several weeks and can often be feeling low for no apparent reason
What are the typical presenting features of depression?
Two core symptoms:
- Persistent low mood, feeling down, depressed and hopeless
- Little pleasure or interest in doing things
Other symptoms:
- Disturbed sleep (decreased or increased).
- Decreased or increased appetite and/or weight.
- Fatigue/loss of energy.
- Agitation or slowing of movements.
- Poor concentration or indecisiveness.
- Feelings of worthlessness or excessive/inappropriate guilt.
- Suicidal thoughts or acts
How is depression sorted into a category e.g mild, moderate?
Subthreshold: at least two, but fewer than five symptoms
Mild depression: symptoms in excess of five symptoms and they result in minor functional impairment.
Moderate depression: symptoms or functional impairment are between mild and severe.
Severe depression: most symptoms and they markedly interfere with functioning – with or without psychotic symptoms.
Persistent subthreshold depressive symptoms (dysthymia):
subthreshold symptoms for more days than not for at least 2 years, which is not the consequence of a partially resolved ‘major’ depression
What are some investigations you may do for a patient when diagnosing them with depression?
Rule out other illnesses causing the depression, e.g TFTs, FBCs, dementia, LFTs, U+E’s, ESR, Ca levels
What is the PHQ9 questionnaire and how is the score interpreted?
Score out of 27:
0-4 none
5-9 mild
10-14 moderate
15-19 moderately severe
20-27 severe
5,10,15,20 are all cut off scores
What is the HADS scoring system for depression? (Hospital Anxiety and Depression Scale)
Max score for each subscale is 21
8-10, 11-14, and 15-21 represent cut off points for mild, moderate and severe depression
What is the BDI-II (Beck’s) questionnaire for depression?
21 questions each with a score out of 3
Scores of 14-19, 20-28, and 29-63 can be interpreted as mild, moderate, and severe depression respectively
What are some risk factors for depression?
- Older age
- Recent childbirth
- Stress, or trauma
- Co-existing medical conditions
- Personal or family hx of depression
- Certain medications (e.g., corticosteroids)
- Female
How is the definitive diagnosis of depression made?
- Low mood for most days for two weeks and 4 other symptoms of depression
- FBCs only used to rule out other causes of symptoms like fatigue like thyroid issues, anaemia
How is depression monitored?
- Follow up within the first 2 weeks of prescribing antidepressants to address adverse effects, suicidality, and acceptance of medication taking. Adherence low in depression
- During the 12 week maintenance phase check on patient monthly
- Once symptom remission patients should stay on drug regime for 9-12 months
- Use PHQ9 to monitor symptoms, want a decrease by 50%
What are some complications that can arise when starting a patient on antiepressants?
- SSRIs/SNRIs can cause loss of libido, increased risk of self harm and suicide especially if <25, agitation, unmasking mania if underlying bipolar
- Mirtazapine can cause weight gain
- Antidepressant withdrawal mania
-Antidepressant discontinuation syndrome (when taking for 6 weeks then abruptly stop get symptoms like flu, insomnia, nausea, hyperarousal)
What is the prognosis with depression?
Goals are complete remission. Once remission of symptoms treatment should continue for 9-12 months
.
Third of patients will relapse in a year after stopping treatment and 50% of patients will relapse in a lifetime.
For those who relapse long term antidepressants treatment is advised
How should depression be managed in primary care?
- Manage any suicide risk
- Manage any comorbities and safeguarding concerns e.g psychotic symptoms, eating disorders
- Offer sleep hygiene
- Arrange follow up within 2 weeks
- Subthreshold depression: active monitoring, provide info about the nature and course, follow up in 2 weeks
- Mild to moderate depression/persistent subthreshold: low intensity psychosocial intervention by referral or self referral to IAPT e.g Let’s Talk, group based CBT, avoid routine use of antidepressants unless history of depression or threshold symptoms for at least 2 years
- Moderate or severe: high intensity psychosocial intervention and antidepressants
What is the difference between low intensity and high intensity psychological interventions?
Low intensity: individual guided self help, group based CBT, computerised CBT
High intensity: interpersonal therapy, behavioural activation, couples therapy, individual CBT, counselling and short term psychodynamic psychotherapy
What advice should you give to someone starting antidepressants?
- Explain suicide risk
- Symptoms of anxiety may get worse before they get better
- Explain they need to be used up to 6 months after remission to reduce risk of relapse
- Explain antidepressants can take time to work (6-8 weeks)
- Do not suddenly stop taking them
What antidepressant should you prescribe for someone presenting with depression?
1st Line: SSRI citalopram, fluoxetine, paroxetine, or sertraline. Sertraline has lowest drug interaction and cheapest so first line
2nd Line: different SSRI or Mirtazepine (TCA)
3rd Line: SSRI + Mirtazepine or Venlafaxine (SNRI)
May be offered lithium after lots of other antidepressants tried
What are the side effects for antidepressants?
Side effects should improve in a few weeks
SSRIs and SNRIs: shaky, stomach ache, nausea, loss of appetite, insomnia, headaches, low sex drive, erectile dysfunction, difficulty achieving orgasm, hyponatraemia, suicidal thoughts, risk of diabetes
TCAs: dry mouth, blurred vision, weight gain, constipation, problems passing urine, excessive sweating, palpitations, tachycardia, risk of diabetes
Lithium: dry mouth, metallic taste in mouth, shaking hands, diarrhoea, need to eat salt to prevent lithium toxicity
Which antidepressants should be used/not used when patients are also on the following medications:
- NSAIDs/Aspirin
- Warfarin
- Heparin
- Triptans
- Flecainide
- NSAIDs: do not offer SSRI, offer mirtazapine. If need SSRI give gastroprotection
- Warfarin: do not offer TCA, SSRI, do offer mirtazapine
- Heparin: do not offer SSRI, any alternative will do
- Triptans: do not offer SSRI, offer mirtazapine
- Flecainide: do not offer citalopram as long QT!!! offer sertraline
What is serotonin syndrome?
Often begins a few hours after taking a new drug or increasing the dose of a drug that increases serotonin
Symptoms: confusion, agitation, dilated pupils, nausea, vomiting, see image
If left untreated can lead to seizures, kidney failure, coma and death
What are some places you can signpost patients too with depression?
- IAPT Let’s Talk
- Mind
- Samaritans
- Mental Health Facilitators
- Juniper Lodge (sexual assault)
- Crisis
- Hub of Hope
- Turning point
What are some self help strategies you can advise patients with depression to try?
- Meditation e.g Headspace
- Regular exercise e.g yoga
- Healthy eating
- Self help books and mindfulness
- Sleep hygiene
What should you advise a patient who asks if St John’s Wort will help their depression?
Advise them not to take it as it induces and inhibits CYP450 enzymes so causes lots of other drug interactions
What monitoring needs to be done on antidepressants?
- Suicidal thoughts
- ECG if taking citalopram or escitalopram as may causes long QT and torsades de pointes. Do when palpitations, vertigo, syncope, or seizures develop or before treatment if have cardiac disease
- BP before and whilst taking duloxetine and venlafaxine as can cause HTN
- HypoNa, if at high risk measure every 3 months
What are some symptoms of hyponatraemia and which people are high risk for developing this when taking SSRIs?
- dizziness, drowsiness, confusion, nausea, muscle cramps, or seizures
- need to stop antidepressants if this happens
What are the typical presenting features of generalised anxiety disorder (GAD) in adults?
Chronic, excessive worry for at least 6 months which is not related to particular circumstances/difficult to control, and symptoms of physiological arousal such as restlessness, insomnia, and muscle tension
Some people present with obvious anxiety but some have just somatic symptoms e.g headaches, muscle tension, gastrointestinal symptoms, back pain, and insomnia
What are some diagnostic tools used for GAD?
DSM-5:
- At least 6 months of excessive, difficult to control worry about everyday issues on more days than not
- Worry is not confined to another medical condition/mental disorder e.g substance abuse
- 3 of the following: restlessness/nervousness, being easily fatigued, poor concentration, irritability, muscle tension, or sleep disturbance
ICD-10
- Anxiety which is generalized and persistent, not just in particular situations
- Expression of fears such as that the person or a relative will shortly become ill or have an accident
- Symptoms including persistent nervousness, trembling, muscle tension, sweating, lightheadedness, palpitations, dizziness, and epigastric discomfort
What are some risk factors that increase the likelihood of GAD?
- Female
- FHx
- Current physical or emotional stress.
- History of physical or emotional trauma.
- History of other anxiety disorders such as panic disorder, social phobia, or specific phobias.
- Chronic pain or physical illness (such as arthritis, cancer, COPD)
- History of substance abuse
- Repeated visits with the same physical symptoms which do not respond to treatment
- Medications like salbutamol, theophylline, beta-blockers, herbal medicines (St. John’s wort) and some antidepressants
What are some differential for GAD?
- Other anxiety disroders e.g anorexia nervosa, PTSD, OCD, adjustment disorder
- Medication-induced anxiety
- Hyperthyroidism
- IBS
- Cardiac or Pulmonary disease
- Phaeochromocytoma (anxiety with HTN and/or tachycardia)
- Anaemia
What are some investigations you may do in primary care when a patient that has suspected GAD has somatic symptoms like palpitations, tremors, muscle tension?
- TFTs to rule out hyperthyroidism
- Urine drug screen
- 24-hour urine for vanillylmandelic and metanephrines to rule of phaeochromocytoma
- ECG
- Pulmonary function tests
How should GAD be monitored?
Chronic, fluctuating, remitting and relapsing disorder that generally requires long-term treatment
12 week trial of pharmacotherapy and if effective continue for up to 12 months
What are some complications of GAD and what is the prognosis?
GAD may recur under physical or emotional stress
Depression co-ocurs in 50% of patients with GAD and increases the risk of suicidality
With pharmacotherapy and 6-8 sessions of psychotherapy symptoms can remit for a while
What is the difference between stress and GAD?
Stress often due to an external origin and stops when the stressor is removed
Anxiety is an internal origin and does not stop when a stressor is removed
What is the GAD7 questionnaire and how is the score interpreted?
- Scores of 5, 10, and 15 are taken as cut-off points for mild, moderate, and severe anxiety respectively
- Symptoms in the past 2 weeks
How should you treat a patient with GAD based on their GAD7 score?
What is the ‘stepped approach’ for managing patients with GAD?
Step 1: All GAD patients
- Assess the severity with GAD7
- Enquire about emotional stressors, substance abuse, medical conditions etc
- Provide written info about GAD and treatment options (PILS)
- Active monitoring of symptoms/treatment
Step 2: For people without marked functional impairment who have not improved following step 1
- Individual non-facilitated self-help
- Individual guided self-help (Alice materials and 20 min calls)
- Psychoeducational groups
Step 3: For people with functional impairment or who have not improved since step 2
- High intensity psychological intervention OR
- Drug treatment with first line SSRI reviewing every 2-4 weeks for first 3/12 then every 3/12 e.g sertraline, paroxetine, escitalopram or duloxetine, venlafaxine
In under 30s review in first week and weekly for first month due to risk of suicide
Step 4
- Refer for specialist treatment if at risk of suicide or self harm or self neglect or other treatments haven’t worked
- Do not offer benzos, these are for short term crises
What is the basis of CBT?
Dealing with overwhelming problems in a more positive way by breaking them down into smaller parts
What antidepressants can be used in pregnancy?
Try to only use if benefits outweigh risks e.g birth defects etc
- Duloxetine
- Sertraline (can cause cardiac defects, neonatal withdrawal if used near to term, persistent pulmonary hypertension)
- Citalopram (SSRI pregnancy risk)
How do you perform a mini mental state exam (MMSE) and when would you perform one of these?
Measures cognitive impairment and can be used as an adjunct for dementia
24-30 No cognitive impairment
18-23 Mild cognitive impairment
<18 Severe cognitive impairment
Below 21 increased odds of dementia
What is the GPCOG?
Screening tool for dementia using a patient and an informant questionnaire. Scores on image
If informant questionnaire needed a score of 3/6 or more suggests cognitive impairment
Informant questionnaire asks how patient differs from now and 5-10 years ago e.g using wrong words, memory, recollecting conversations, less able to manage money, unable to manage meds, more assistance needed with transport
What are some factors that increase a person’s risk of committing suicide?
- Really important to assess with depressed patients
- Strongest risk factor is a history of self harm
- Mental illness (particularly depression), male, unemployed, living alone, physical health problems, exposure to suicidal behaviour, substance misuse, F Hx
Precipitating factors: stressful events that can trigger suicide in vulnerable people like divorce, death of a loved one, finacial problems
What are some protective factors that offer protection against a person committing suicide?
- Social support
- Religious belief
- Being responsible for children (especially young)
- Connectedness to other adults
- Easy access to mental health support e.g doctors
- Self esteem and a sense of meaning/purpose to life
How do you conduct a suicide risk assessment?
- Open and careful questions
e. g ‘some people who are very low think about taking their own life, have you ever thought anything like this? - See image for more
What are some warning signs that somebody may be planning to commit suicide?
- Talked about feeling hopeless or trapped
- Acting anxious, agitated or reckless
- Withdrawing from friends and family
- Displaying extreme mood swings
- Talking about wanting to die or looking for a way to kill theirself
What are some groups of people that are at high risk of committing suicide?
After conducting a patient suicide risk assessment, what management should you carry out?
- If actively suicidal keep them in the surgery or with a family member and call the CRISIS team or try voluntary admission or section under MHA
- If risk of suicide but no intent then encourage patient to talk to family/support systems and inform them of support networks like Samaritans.
- Assess any dynamic risk factors e.g substance abuse, mental health disorders. to be treated
- Tell patient to seek help if situation deteriorates
- Review patient frequently, especially after starting pharmacological treatment. Record in notes. Give patient out of hours number.
What is the Doctrine of Double effect?
If doing something morally good has a morally bad side effect it is ethically ok to do this if the bad side effect was not intended. Can foree the bad side effect
e.g morphine for palliative care
What are some helplines for people who:
- Have suicidal ideation
- Experiencing consequences of suicide attempts e.g family member with child who committed suicide
Suicide
- Samaritans
- Shout
- Papryus
- 111
- Calm
- Mind
Suicide consequences
- Help is at Hand
- Healthtalk online: bereavment due to suicide
- SAVE
What is the definition of self harm?
- Intentional act of self-poisoning or self-injury, irrespective of the motivation or apparent purpose of the act, and is an expression of emotional distress.
- Most self poisoning due to OTC drugs, other household substances, or plant material
- Most self injury is cutting
- Can also include suicide attempts
What are some reasons people carry out self harm?
What are some risk factors for self harm?
- Socioeconomic disadvantage
- Social isolation
- Stressful life events, e.g divorce, childhood abuse
- Mental and physical health problems
- Alcohol or drug misuse
People who self harm then increase their risk of committing suicide
How should repeated self harmers be managed in primary care?
- Given advice regarding: self management of superficial injuries (e.g tissue adhesive), harm minimisation techniques, offerred alternative coping strategies, how best to deal with scarring
- Harm minimisation strategies should not be offered if self harming by poisoning
How should a self harm presentation be managed in primary care?
- Refer to A and E and consider patient’s welfare on transportation
- If urgent care not necessary consider referring to secondary mental health services at earliest opportunity following psychological assessment for risk of suicide and other mental health disorders e.g depression
- Prescribe drugs to these patients in small doses and favour low toxicity drugs and also to relatives living with someone at risk of self poisoning
How may self harm present to health care?
- Third party may bring them in as they notices unexplained injuries, inappropriate dressing, depressive symptoms, weight/diet change, substance misuse
- May be found incidentally on examination for another medical problem
How should short term management for self harm in secondary care take place?
- Treat OD (e.g activate charcoal within hour to reduce absorption) or cuts and wounds
- Analgesia/anaesthesia when treatin and sedation if any treatment will evoke distressing memories e.g repairing genital area
- Assess mental capacity and conduct psychosocial assessment alone with patient. If too distressed or difficult due to drug OD then temporary admission and then perform at earliest convienience. Pass to GP and file clearly in notes
- Relatives/cares should be offered emotional support
https://geekymedics.com/wp-content/uploads/2020/08/OSCE-Checklist-Suicide-Risk-Assessment.pdf
How should you manage a self-poisoning in primary care in a rural area with a large distance to the nearest emergency department?
- Consult the TOXBASE app to find initial treatments and consult on the phone with the nearest ED
How is self harm managed long term in primary care?
- Care plan and risk management care plan
- Manage any associated mental health conditions e.g bipolar, depression, drug misuse etc. Take into consideration toxicity (SSRIs low but TCAs high risk of toxicity)
- Refer for any psychological interventions necessary e.g CBT, group therapy
What are some self-help websites you can signpost a patient to when they are self harming?
What are some harm minimisation techniques you can offer to a patient that is self harming?
- Use clean instruments
- Think about wound aftercare
- Avoid major arteries, veins and tendons and go for soft, fleshy parts
- Cut down the depth and the time spent harming
- 5 minute rule to wait to self-harm and think about not wanting the scars or to go to hospital
- Put stickers on areas you want to injure
- Draw slashing lines on paper
- Snap elastic band on wrist
- Use red food colouring to mimic blood
What are the symptoms of an acute stress reaction and how is it treated?
- Occurs after an unexpected life crisis e.g a serious accident or sudden bereavement, sexual assault, domestic violence
- Develop few minutes or hours after event and can last days-weeks. >1 month then assess for PTSD
- Not usually treated as passes on its own but if prolonged can offer CBT, counselling, beta-blockers for physical symptoms, short term diazepam
What is the Kubler Ross model?
Five stages of grief after the death of a loved one
- Denial
- Anger
- Bargaining
- Depression
- Acceptance
How is prolonged grief managed? (more than 6 months)
- Rely on support network of family and friends
- Speak to a grief counsellor e.g Cruse
- Contact support groups e.g Loss Foundation, Child Bereavment UK
What is anorexia nervosa and bulimia nervosa?
Anorexia: low body weight due to restriction of food intake or persistent behaviour which interferes with weight gain and intense fear of gaining weight
Bulimia: recurrent episodes of uncontrolled eating of an abnormally large amount of food over a short time period (binge eating) followed by compensatory behaviour such as self-induced vomiting, laxative abuse or excessive exercise
Use the SCOFF questionnaire to assess and also assess mental health, general obs, muscle tone with squat and sit, risk of refeeding syndrome, BMI, social history e.g bullying, look for electrolyte abnormalities and ECG
What are some causes of loss of libido?
- Relationship problems e.g lack of attraction/trust
- Sexual problems e.g vaginal dryness, vaginismus, ED
- Stress, anxiety, exhaustion
- Depression
- Menopause
- Pregnancy and breastfeeding
- Long term health conditions e.g heart disease, thyroid, diabetes
- Alcohol and drugs
How does OCD present and how is it treated?
Anxiety disorder where intrusive thoughts (obsessions) lead to rituals (compulsions) to neutralise the obsessions
Presentation: obsessions and/or compulsions that cause marked distress, are time consuming (take more than 1 hour per day), or interfere substantially with the person’s normal routine, occupational or academic functioning, or usual social activities or relationships
Treatment (1st Line): CBT with exposure and response prevention, alone or in combination with an SSRI or clomipramine
What are some causes of chronic insomnia (lasting over 4 weeks) and what are some other sleep disorders that are similar to insomnia?
- Stress e.g job, relationship, finances
- Psychiatric comorbidity e.g GAD, depression, PTSD
- Medication e.g antidepressants, steroids, nicotine, caffeine, drug withdrawal, antihypertensives, NSAIDs
- Medical comorbidity e.g BPH, pain, perimenopausal symptoms, Alzheimers
- Poor sleep hygeine and environment
How is insomnia assessed and managed?
Assessment: physical and psychological assessment for underlying cause, sleep diaries, polysomnography
Management: sleep hygeine advice, CBT through IAPT, pharmacological treatment
Pharmacology: short term benzos and Z drugs, short term melatonin, antidepressants, sedating antipsychotics and antihistamines
What are some complications of insomnia?
- Increased risk of depression and anxiety
- Risk of absenteeism, accidents at work and road accidents are increased
- Increased risk of HTN
