Primary Care Management of Common Mental Health Disorders

Question 1

What are some risk factors for depression?

Answer 1

Previous depression
History of other mental illness
History of substance misuse
Family history of depression or suicide
Domestic violence
Unemployment
Poor social support network
Recent stressful life event

Question 2

What is the DSM 5 criteria?

Answer 2

For depression:

• 5/9 criteria are required, including at least 1 of the first 2 criteria (low mood/anhedonia).
• Subthreshold depressive symptomsare defined as those having <5 of the DSM IV criteria.
• Severity is based on functional impairment, once the diagnostic criteria have been passed (i.e. once you have 5 or more symptoms, one of which must be from the first two criteria).
• Mild depressionis 5 or more symptoms (one of which must be from the first two criteria) but with mild functional impairment.
• Severe depressionis at least 5 symptoms (one of which must be from the first two criteria), and often most or all will be present) with marked functional impairment.
• Moderate severityfalls between mild and severe.

Question 3

What are the first 2 DSM 5 criteria?

Answer 3

You must have at least one of these:

• Depressed mood
• Loss of interest or pleasure (anhedonia)

Question 4

What are the further DSM 5 criteria?

Answer 4

If both criteria above are met, you need a further 3 criteria from the list below.
If only 1 criterion above is met, you need a further 4 criteria from the list below:

• Significant weight loss or gain, or change in appetite
• Sleep difficulties (including hypersomnia)
• Psychomotor agitation or retardation
• Fatigue
• Feelings of worthlessness or inappropriate guilt
• Reduced concentration or indecisiveness
• Recurrent thoughts of death or suicidal thoughts

Question 5

What are the 2018 NICE guidelines on depression diagnosis and assessment?

Answer 5

Diagnosis should be based on DSM IV criteria

Question 6

What is the PHQ-9?

Answer 6

Patient health questionnaire

Score:
0-5 = mild 
6-10 = moderate 
11-15 = moderately severe 
16-20 = severe depression

Question 7

What is the PHQ-9?

Answer 7

Patient health questionnaire

Score:
0-5 = mild 
6-10 = moderate 
11-15 = moderately severe 
16-20 = severe depression

Question 8

What is the stepped care model? (2018 NICE guidelines)

Answer 8

The least intrusive intervention to be provided first. If that intervention is ineffective, or declined, offer an appropriate intervention from the next step.

Question 9

What is STEP 1 of the stepped care model?

Answer 9

Recognition, assessment & initial management

• All known and suspected presentations of depression
• Intervention options: Assessment, support, psycho-education, lifestyle advice, active monitoring and referral for further assessment and interventions

Question 10

What is STEP 2 of the stepped care model?

Answer 10

Recognised depression – persistent subthreshold depressive symptoms or mild to moderate depression

• Offer advice on sleep hygiene
• Offer active monitoring(discuss concerns, provide information about depression, reassess within 2w; contact the person if they do not attend follow-up appointment).
• Low-intensity psychological andpsychosocial interventions(e.g. individual self-help based on CBT principles, computerised CBT, group CBT, group physical activity programme).

Donotroutinely use antidepressants (because risk–benefit ratio is poor)

Question 11

When are antidepressants used in STEP 2 care?

Answer 11

-They have a past history of moderate–severe depression
OR
-They present with subthreshold symptoms that have been present for 2y or more
OR
-They have subthreshold symptoms for <2y but they don’t respond to other interventions

Question 12

What is STEP 3 of the stepped care model?

Answer 12

Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression

-An antidepressant (normally a selective serotonin reuptake inhibitor [SSRI])
OR
-A high-intensity psychological intervention e.g. individual CBT, interpersonal therapy, behavioural activation, couples therapy where the relationship is a contributory factor

-Combined treatments (medication + high intensity psychological) preferred for moderate to severe depression

Question 13

What form is used to assess a patents fitness to work?

Answer 13

MED 3

Question 14

What psychological issues related to depression cause a patient to lose fitness to drive?

Answer 14

Significant memory or concentration problems
Agitation
Behavioural disturbance
Suicidal thoughts

Question 15

What is the follow-up protocol in treating depression?

Answer 15

• Normally see people 2 weeks after starting, at intervals of every 2 to 4 weeks for 3 months and then at longer intervals if the response is good
• In patients aged under 30, or considered at greater risk, see after one week and 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 they are at risk of relapse

Question 16

What classifies a “non-responder”?

Answer 16

If response absent or minimal after 3 to 4 weeks at therapeutic dose, increase level of support and increase dose OR switch to another antidepressant

Question 17

How may antidepressants be changed in a non-responder?

Answer 17

• Initially switch to a different SSRI or a better tolerated newer generation antidepressant
• Subsequently to another class that may be less well tolerated e.g. TCA, venlafaxine or MAOI (MAOI specialist initiated only)
• Combining and augmentation: Using combinations should only normally be started in primary care in consultation with a psychiatrist
• Consider combining or augmenting an antidepressant with lithium, an antipsychotic (e.g. quetiapine, aripriprazole etc) or another antidepressant such as mirtazapine
• Stopping or reducing antidepressants: advise re risk of discontinuation symptoms and gradually reduce the dose, normally over a 4 week period

Question 18

What is STEP 4 of the stepped care model?

Answer 18

Severe and complex depression

• Risk to life
• Severe self-neglect

Intervention options:
-Refer for multiprofessional and possible inpatient care for people with depression who are at significant risk of self-harm, have psychotic symptoms, require complex multiprofessional care or where an expert opinion is needed.

Question 19

What are the key risk factors to assess in suicide?

Answer 19

• Previous self-harm/suicidal behaviour.
• Depression and other mental health problems.
• Alcohol/drug misuse.
• Physical illness.
• Low socioeconomic status.
• Relationship breakdown.

Question 20

When do you stop anti-depressants in suspected bipolar disorder?

Answer 20

If they seem to be entering a hypomanic phase

Question 21

What are 3 types of anxiety disorder?

Answer 21

Generalised Anxiety Disorder

• Excessive worry about a number of different events
• Can exist in isolation or comorbid anxiety/depressive disorders

Panic Disorder
-Recurrent panic attacks and persistent worry about further attacks

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

Question 22

How is generalised anxiety disorder classified using DSM-IV?

Answer 22

A. Excessive anxiety and worry (apprehensive expectation), occurring more days than not for at least 6 months, about a number of events or activities (such as work or school performance).
B. The person finds it difficult to control the worry
C. The anxiety and worry are associated with three or more of the following six symptoms (with at least some symptoms present for more days than not for the past 6 months):
-Restlessness or feeling keyed up or on edge
-Being easily fatigued
-Difficulty concentrating or mind going blank
-Irritability
-Muscle tension
-Sleep disturbance (difficulty falling or staying asleep, or restless unsatisfying sleep)

Question 23

What is GAD 7 used for?

Answer 23

Assessing anxiety

Score:
0-5 mild 
6-10 moderate 
11-15 moderately severe anxiety 
15-21 severe anxiety

Question 24

What is the STEP 1 for assessing GED?

Answer 24

Identification and assessment

Consider the diagnosis of generalised anxiety disorder in:
Those presenting with anxiety or significant worry.
Frequent attenders with a chronic health problem.
Frequent attenders without health problems but who are seeking reassurance about somatic symptoms (especially elderly people or those from minority ethnic groups).
Frequent attenders who are repeatedly worrying about a wide range of different issues.

When assessing severity of anxiety, include:
Level of distress.
Functional impairment.
Number, severity and duration of symptoms.

Look out for the following which may affect the development, course and severity of anxiety state:
Other anxiety disorder in addition to generalised anxiety disorder (e.g. panic disorder).
Depression.
Substance misuse.
Physical health problems.
History of mental health problems.
Past experience and response to treatments.