Primary Care Management of mental health Flashcards
What are the components of the Stepped Care model?
The least intrusive intervention to be provided first/
If that intervention is ineffective, or declined, offer an appropriate intervention for the next step.
Step One of the stepped care model in the context of depression
Recognition, assessment and initial management
- All known and suspected presentations of depression
Intervention options
- assessment
- support
- psychoeducation
- lifestyle advice
- advice monitoring and referral for further assessment and interventions
Step two of the stepped care model in the context of depression
Recognised depression - persistent threshold depressive symptoms or mild to moderate depression
Offer advice on sleep hygiene
Offer advice monitoring
Low intensity psychological and psychosocial interventions
DO NOT routinely use antidepressants
DO NOT routinely use antidepressants in the step two of the stepped care model unless….
Past history of moderate - severe depression
They present with subthreshold symptoms that have been present for 2 years or more
They have subthreshold symptoms for < 2 yrs but they dont respond to other interventions
Examples of advice monitoring
Discuss concerns
provide info about depression
reassess within 2 weeks
contact the person if they do not attend the follow up appointment
Step 3 of the stepped care model in the context of depression
Inadequate response to initial interventions, and moderate to severe depression An antidepressants (SSRI) High intensity psychological intervention - CBT, IPT, behavioural activation, couples therapy Combined treatments of medication and high intensity psychological preferred for moderate to severe depression
Things to consider in primary care management of mental health
Fitness to work
Fitness to drive
In the context of severe depression or anxiety, when is a patient not allowed to drive?
Significant memory or concentration problems
Agitation
Behavioural disturbance
Suicidal thoughts
Follow up after appointment
see people 2 weeks after starting, at intervals of every 2 to 4 weeks for 3 months and then longer intervals if response is good
In patients < 30 or high risk then see after one week and then as frequently thereafter as appropriate until risk considered no longer clinically important
Encourage to take for at least 6 months after remission and for up to 2 years if at risk of relapse
What is done If response is absent or minimal after 3-4 weeks therapeutic dose?
Increase level of support
Increase dose OR switch to another antidepressant
Switching antidepressants
SSRI to
a different SSRI to
another class e.g. TCA, venlafaxine to
combination and augmentation (primary care and psychiatrist) to
- combining with lithium, an antiphyscotic or another antidepressant e.g. mirtazapine
Step 4 of the stepped care model
Severe and complex depression, risk to life, severe self neglect
Intervention options
- refer to multiprofessional and possible inpatient care for people with depression who are at significant risk or have psychotic symptoms
Bipolar disorder and issues with the mediation
2ndry care medication only
women must be on effective contraception and signed agreement between prescriber and patient
What is panic disorder?
Recurrent panic attacks and persistent worry about further attacks
What is social anxiety disorder?
Persistent fear of, or anxiety about, one or more social or performance situations that is out of proportion to the actual threat posed by the situation
Step 1 of the stepped care approach in the context of anxiety
if depression or other anxiety disorder present, treat the primary disorder first e.g. co morbid depression / anxiety - treat the depression first
Treat the co morbid substance misuse disorder first
