Depression

Question 1

What are the red flags of headache?

Answer 1

• New severe or unexpected headache.
• progressive or persistent headache or headache that has changed dramatically
• Associated features such as fever, impaired consciousness, seizure, neck stiffness, papillodema, new onset neurological deficit, atypical aura, dizziness, visual disturbances and vomiting.
• contacts with similar symptoms
• precipitating factors such as head trauma, headache triggered by a valsalva manoeuvre, headache that worsens on standing or lying down.
• comorbidities such as immunosuppression and malignancy
• current or recent pregnancy

Question 2

What are the causes of a new severe or unexpected headache?

Answer 2

• Sudden-onset severe headache reaching maximum intensity within 5 minutes may indicate serious causes such as intracranial haemorrhage, venous sinus thrombosis, hypertensive encephalopathy and vertebral artery dissection.
• New onset headache in a person aged over 50 years may indicate a serious cause such as giant cell arteritis or space occupying lesion.

Question 3

What are the causes of progressive or persistent headaches?

Answer 3

Mass lesion

Subdural haematoma

Question 4

Which conditions would cause headaches, fever, Impaired consciousness, seizure, neck pain/stiffness and photophobia?

Answer 4

Meningitis

Encephalitis

Question 5

Which conditions would cause headache and papilloedema?

Answer 5

Space occupying lesions

Cerebral venous sinus thrombosis

Benign intracranial HTN

Question 6

Which conditions causes new-onset neurological deficit and headache?

Answer 6

Cerebrovascular event
Malignancy
SOL
Subacute or chronic subdural haematoma

Question 7

Which conditions would cause atypical aura and headaches ?

Answer 7

Cerebrovascular event

Question 8

Which condition would cause dizziness and headaches?

Answer 8

Ischaemic or haemorrhagic stroke

Question 9

Which conditions cause visual disturbances and headaches?

Answer 9

Migraine
Acute closure glaucoma
Temporal arteritis

Question 10

Which conditions cause vomiting with headaches?

Answer 10

Migraine
Mass lesion
Brain abscess
Carbon monoxide poisoning

Question 11

Why is it important to ask about contacts with similar symptoms when assessing headaches?

Answer 11

Consider serious causes such as carbon monoxide poisoning if household contacts have similar symptoms.

Question 12

What are worrying precipitating factors of headaches?

Answer 12

Preceding recent (usually within the past 3 months) head trauma — consider serious causes such as subacute or chronic subdural hematoma.
• Headache triggered by a Valsalva manoeuvre (such as coughing, sneezing, bending or exertion [physical or sexual]) — consider serious causes such as Chiari 1 malformation or a posterior fossa lesion.
• Headache that worsens on standing — consider a CSF leak.
• Headache that worsens on lying down — consider a space-occupying lesion or cerebral venous sinus thrombosis.

Question 13

What is a worrying condition that causes headaches in pregnancy?

Answer 13

Pre-eclampsia

Question 14

Why is it important to ask about PMH when assessing headaches?

Answer 14

• Compromised immunity (for example due to HIV or immunosuppressive drugs) — consider serious causes such as cerebral infection or malignancy.
• Current or past malignancy — consider serious causes such as cerebral metastases.

Question 15

What is depression?

Answer 15

• Depressive disorders are typically characterised by persistent low mood, loss of interest and enjoyment, neurovegetative disturbance, and reduced energy, causing varying levels of social and occupational dysfunction.

Question 16

What are depression symptoms?

Answer 16

Depressed mood (DSM-5)
Anhedonia (DSM-5)
Functional impairment (DSM-5)
Weight changes 
Libido changes 
Sleep disturbance 
Psychomotor problems 
Low energy 
Excessive guilt 
Poor concentration 
Suicidal ideation 
Medical illness excluded 
Bipolar disorder excluded

Question 17

What is major depressive disorder?

Answer 17

• Major depressive disorder is characterised by the presence of at least five symptoms of depression and can be classified along a spectrum of mild to severe. Severe episodes may include psychotic symptoms such as paranoia, hallucinations, or functional incapacitation.

Question 18

What is minor depression?

Answer 18

• Subthreshold (minor) depression is characterised by the presence of two to four depressive symptoms, including depressed mood or anhedonia, lasting longer than 2 weeks.

Question 19

What is persistent depressive disorder?

Answer 19

• Persistent depressive disorder (dysthymic disorder) is characterised by at least 2 years of three or four dysthymic symptoms for more days than not. Dysthymic symptoms include depressed mood, appetite change, sleep disturbance, low energy, low self-esteem, poor concentration, and hopelessness.

Question 20

What are the key risk factors for depression?

Answer 20

• Older age
• Recent childbirth
• Stress
• Trauma
• Co-existing medical conditions such as diabetes, cancer, stroke, MI and obesity.
• Personal or family hx of depression
• Certain medications such as corticosteroids
• Female sex

Question 21

Investigations for depression

Answer 21

Clinical diagnosis (DSM-5 diagnostic criteria)
FBC- normal (rule out other causes of fatigue)
TFT- rule out hypothyroidism
PhQ-9- positive

Question 22

Differentials for depression

Answer 22

• Adjustment disorder with depressed mood
• Substance/medication
• Bipolar disorder
• Premenstrual dysphoric disorder (PMDD)
• Grief reaction
• Dementia
• Anxiety disorders
• Alcohol abuse
• Anorexia nervosa
• Hypothyroidism
• Obstructive sleep apnoea

Question 23

Management of depression

Answer 23

• Anti-depressant- 1st line usually sertraline or citalopram
• Psychotherapy- 1st line
• Supportive interventions- self-help books
• Computer-based interventions
• SSRIs such as sertraline are recommended as first line by NICE. Although Paroxetine is an SSRI, it would not usually be first choice, due to its short half-life and therefore higher risk of discontinuation symptoms.
• Mirtazapine is a widely prescribed antidepressant but has important side effects of drowsiness and weight gain, which sometimes make it less acceptable to patients. Diazepam is used in acute anxiety as a short course and isn’t a first line option for depression. Gabapentin is a controlled drug and not licensed for first line treatment of depression. St John’s Wort is a herbal remedy- there is some evidence of efficacy but limited data on safety and dosing.

Question 24

How should you assess suicide risk?

Answer 24

1) Directly ask about suicidal thoughts and intent. Do not avoid the word ‘suicide’.

2) Ask:
• Do you ever feel that life is hopeless and not worth living?
• Do you ever think about suicide?
• Have you made any plans for ending your life?
• Do you have the means for doing this available to you?
• What has kept you from acting on these thoughts?

3) Follow up on ‘not really’ answers.
4) Identify risk factors that increase the risk of suicide, particularly previous attempts at suicide or self-harm, or a feeling of hopelessness:
5) Assess adequacy of social support and current personal circumstances.
6) Identify factors that reduce the risk of suicide, including good social support and responsibility for children.

Question 25

Risk factors for suicide

Answer 25

``` • Social characteristics: o Male gender o Young age (< 30 years) o Advanced age o Single or living alone ``` ``` • History: o Prior suicide attempt(s) o FHx of suicide o Hx of substance or alcohol abuse o Recently started on antidepressants ``` ``` • Clinical/diagnostic features: o Hopelessness o Psychosis o Anxiety, agitation, panic attacks o Concurrent physical illness o Severe depression ```

Question 26

What is the HARK questionnaire?

Answer 26

1) One method to elicit possible domestic abuse is the HARK questionnaire. This is widely used in General Practice.

Question 27

What are the HARK questions?

Answer 27

HARK questions – one point is given for every yes answer A good way of making sure that someone is safe to go home is by adding an S to the front of HARK- SHARK H: Humiliation- Within the last year, have you been humiliated or emotionally abused in other ways by your partner or your ex-partner? A: Afraid- Within the last year, have you been afraid of your partner or ex-partner? R: Rape- Within the last year, have you been raped or forced to have any kind of sexual activity by your partner or ex-partner? K: Kick- Within the last year, have you been kicked, hit, slapped or otherwise physically hurt by your partner or ex-partner?

Question 28

What is SENCO and their role?

Answer 28

Special Educational Needs Coordinator (SENCO) The SENCO has a critical role in ensuring that children with disabilities and special educational needs within a school receive the support they need The types of responsibilities that a SENCO has are: • Overseeing the day-to-day operation of the school’s Special Educational Needs (SEN) policy. • Supporting the identification of children with special educational needs. • Co-ordinating provision for children with SEN. • Liaising with parents of children with SEN. • Liaising with other providers, outside agencies, educational psychologists and external agencies. • Ensuring that the school keeps the records of all pupils with SEN up to date.

Question 29

What are the indicators of child abuse?

Answer 29

* Children or adults whose behaviour changes – they may become aggressive, challenging, disruptive, withdrawn or clingy, or they might have difficulty sleeping or start wetting the bed; * Children or adults with clothes which are ill-fitting and/or dirty; * Children or adults with consistently poor hygiene; * Children or adults who make strong efforts to avoid specific family members or friends, without an obvious reason; * Children or adults who don’t want to change clothes in front of others or participate in physical activities; * Children or adults with frequent injuries or unexplained or unusual injuries, bite marks, burns or cuts * Children who are having problems at school, for example, a sudden lack of concentration and learning or they appear to be tired and hungry; * Children who reach developmental milestones, such as learning to speak or walk, late, with no medical reason; * Children who drink alcohol regularly from an early age; * Children who use sexual language or have sexual knowledge that you wouldn’t expect them to have or ask others to behave sexually or play sexual games; * Children with physical sexual health problems, including soreness in the genital and anal areas, sexually transmitted infections or underage pregnancy

Question 30

What are the four key steps used to identify possible abuse?

Answer 30

* Be Alert (know what signs to look for) * Question behaviours (ask if you have any doubts) * Ask for help (you do not have to deal with it alone) * Refer (there are specialists in safeguarding who can help you and should be informed if you have concerns)

Question 31

What should you do if a child is in immediate danger?

Answer 31

It may not always be appropriate to go through all four stages sequentially. If a child is in immediate danger or is at risk of harm, you should refer to children’s social care and/or the police. Before doing so, you should try to establish the basic facts. However, it will be the role of social workers and the police to investigate cases and make a judgement on whether there should be a statutory intervention and/or a criminal investigation.

Question 32

What is ADHD?

Answer 32

* ADHD is a problem of inattention, hyperactivity, and impulsivity according to the American Psychiatric Association. * ADHD is a chronic condition with symptoms that begin in early childhood but often persist into adult life. A key element of the definition is functional impairment across 2 or more domains, most often in school and at home.

Question 33

Which psychiatric disorders are associated with ADHD?

Answer 33

• In addition, patients with ADHD are more likely to have co-existing psychiatric disorders such as oppositional defiant disorder (ODD), conduct disorder, substance abuse, and possibly mood disorders, such as depression and mania.

Question 34

What are the causes of ADHD?

Answer 34

* The aetiology of ADHD is probably multifactorial and composed of genetic and environmental factors. * Genetic predisposition: there is substantial evidence for a genetic contribution to ADHD, with the mean heritability for ADHD shown to be 76% based on twin studies. * ADHD may result from a dysfunction of norepinephrine and dopamine.

Question 35

Types of ADHD

Answer 35

- Hyperactive-impulsive type - Inattentive type - Combined type - Unspecified type

Question 36

Who falls into the hyperactive-impulsive type of ADHD?

Answer 36

o For diagnosis of predominantly hyperactive-impulsive type, the patient must have 6 out of 9 of the following hyperactive-impulsive criteria (older adolescents and adults only need to have 5 of 9 significant issues to meet diagnostic criteria): Often fidgets with hands or feet or squirms in seat Often leaves seat in classroom or in other situations in which remaining seated is expected Often runs about or climbs excessively during inappropriate situations (in adolescents or adults, may be limited to subjective feelings of restlessness) Often has difficulty playing or engaging in leisure activities quietly Is often on the go or often acts as if driven by a motor Often talks excessively Often blurts out answers before questions have been completed Often has difficulty awaiting turn Often interrupts or intrudes on others (e.g., butts into conversations or games).

Question 37

Who falls into the inattentive type of ADHD?

Answer 37

o For diagnosis of predominantly inattentive type, the patient must have 6 out of 9 of the following inattentive criteria (older adolescents and adults only need to have 5 of 9 significant issues to meet diagnostic criteria): Often fails to give close attention to details or makes careless mistakes in schoolwork, work, or other activities Often has difficulty sustaining attention in tasks or play activities Often does not seem to listen when spoken to directly Often does not follow through on instructions and fails to finish schoolwork, chores, or duties in the workplace (not due to oppositional behaviour or failure to understand instructions) Often has difficulty organising tasks and activities Often avoids, dislikes, or is reluctant to engage in tasks that require sustained mental effort (such as schoolwork or homework) Often loses things necessary for tasks or activities (e.g., toys, school assignments, pencils, books, or tools) Is often easily distracted by extraneous stimuli Is often forgetful in daily activities

Question 38

Risk factors of ADHD

Answer 38

- FHx of ADHD - Low birth weight - Maternal smoking during pregnancy - Epilepsy - Male gender

Question 39

How do you diagnose a child with ADHD?

Answer 39

To be diagnosed with ADHD, a child must also have: o been displaying symptoms continuously for at least 6 months o started to show symptoms before the age of 12 o been showing symptoms in at least 2 different settings – for example, at home and at school, to rule out the possibility that the behaviour is just a reaction to certain teachers or to parental control o symptoms that make their lives considerably more difficult on a social, academic or occupational level o symptoms that are not just part of a developmental disorder or difficult phase, and are not better accounted for by another condition

Question 40

Differentials of ADHD

Answer 40

* Learning/language disorder * Oppositional defiant disorder * Depression * Bipolar disorder * Anxiety * Psychosis * Autism spectrum disorder (includes pervasive developmental disorders) * Intellectual disability

Question 41

Management of ADHD

Answer 41

* Stimulant (methylphenidate or amfetamine) + psychoeducation * Behavioural therapy * Non -stimulants (atomoxetine, guanfacine or clonidine)- people with stimulant abuse potential and/or prominent anxiety symptoms.