Mental Health Conditions Flashcards
What is depression
A Mental state characterised by persistent low mood, loss of interest and enjoyment in everyday activities, neurovegetative disturbance, and reduced energy, causing varying levels of social and occupational dysfunction
How common is depression
Affects 5-10% of patients in the primary care setting
Who is affected by depression
Common in people of all ages and may be classified depending on duration, severity and number of symptoms, and the degree of functional impairment
What causes depression
With or without a known genetic component, stressful life events, personality and sex may play role in risk of depression resulting
What are the risk factors for depression
Age >65 Postnatal status PMH or FH of depression or suicide Corticosteroids Interferon Propanolol Oral contraceptives Chronic comorbidities
How does depression present
Persistent low mood Loss of interest and enjoyment Sleep and appetite changes Guilt or self-criticism Poor concentration Reduced energy
What signs may a person with depression show
Weight change Libido change Sleep disturbance Psychomotor problems Low energy Excessive guilt Poor concentration Suicidal ideation
What are the differentials in suspected depression
Adjustment disorder with depressed mood Substance/medication or medical illness associated a Other depressive disorders Bipolar disorder Premenstrual dysphoric disorder Grief reaction Dementia Anxiety disorders Alcohol abuse Anorexia nervosa Hypothyroidism Medicine adverse effects Cushing's disease Vit B12 deficiency Obstructive sleep apnoea
How is suspected depression investigated
1st line: Clinical diagnosis Metabolic panel FBC Thyroid function tests Patient health questionnaires 2 and 9 Edinburgh postnatal depression scale Geriatric depression scale Cornell scale for depression in dementia
Investigations to consider:
24hour free cortisol
Vit B12
Folic acid
What are important discussions to have with patients with depression
Although you may often feel that nothing can help you, effective treatments are available.
Medicines and psychotherapy are the most common treatments
There are many different types of antidepressant meds
They may take several weeks before they become effective and should be taken for many months to prevent recurrent symptoms
Talk therapy allows the patient to explore and change thoughts, attitudes and relationship problems associated with depression
Mild or moderate depression can be treated with therapy alone but sever depression requires both therapy and medication
Warn of problems from abrupt discontinuation of antidepressants
Warn that when initially start taking med, pt may have more energy and therefore may be at greater risk to follow through with suicidal ideations and so must be under regular review especially at beginning of med treatment.
Suicidal risk management is critical
What is suicidal risk management in depressed patients
Suicidal risk management is critical, especially as the risk may increase early in treatment.
Routinely asking patients about suicidal ideation and reducing access to lethal menas can reduce risk of suicide. Close telephone follow up by a trained psychiatrist may help reduce the risk of death by suicide after a previous suicide attempt
How is depression treated
Goal is to eradicate symptoms of depression, improve daily functioning and quality of life, improve workplace functioning, reduce suicidality, minimise treatment adverse effects and prevent relapse.
Treatment options:
- antidepressants
- other pharmacotherapies
- psychotherapies
- supportive interventions
- electroconvulsive therapy (ECT)
Antidepressant options:
- selective serotonin reuptake inhibitors (SSRIs) (citalopram, fluoxetine, sertraline)
- serotonin-noradrenaline reuptake inhibitors (SNRIs) (venlafaxine, desvenlafaxine, duloxetine)
- dopamine reuptake inhibitor (bupropion)
- mirtazapine (a 5-HT2 receptor antagonist)
Therapy options:
- CBT
- Interpersonal psychotherapy (IPT)
- Problem solving therapy (PST)
What are the risks and benefits of treatment for depression
Choice of drug should be based on patient preference, tolerability and past evidence of effectiveness in the patient
Although the net result of antidepressant response is a significant reduction in suicidal ideation, there is evidence of increasedsuicidal behaviour in the first weeks of treatment, particularly in teens and young adults and in those on relatively high starting doses
Follow up pt after 1 to 2 weeks and then monthly for next 12 weeks
Patients are likely to begin to show a response within the first 1 to 2 weeks of treatment, however successful to the point of remission of all symptoms may take 6 to 8 weeks.
Caution required when switching from one antidepressant to another due to the risk of drug interactions, serotonin syndrome, withdrawal symptoms or relapse
What is anxiety
Common condition defined as chronic, excessive worry for at least 6 months that causes distress or impairment.
What is the lifetime prevalence of anxiety
7.8%
Who is most affected by anxiety
More common in high income countries than in lower income countries
Usually starts in adulthood and persists over time
Increased risk during pregnancy and post-natally
Often occurs along with or precedes other mental health disorders.
Patients with chronic physical health conditions, including cardiovascular disease, cancer, respiratory disease, diabetes and PCOS.
What causes anxiety
No single cause but an increase in minor life stressors, the prescence of physical or emotional trauma and genetic factors all seem to contribute
What are the risk factors for anxiety
Family history of anxiety
Physical or emotional stress
History of physical, sexual or emotional trauma
Other anxiety disorders such as panic disorder, social phobia or specific phobias may co-occur
Chronic physical health condition
Female sex
How does anxiety present
At least three key symptoms out of a possible six are required to make a diagnosis:
- restlessness or nervousness
- easily fatigued
- poor concentration
- irritability
- muscle tension
- sleep disturbance
Other diagnostic factors:
- headache
- sweating
- dizziness
- GI symptoms
- Muscle aches
- tachycardia
- SOB
- Trembling
- Exaggerated startle response
- Chest pain (uncommon)
What are the differentials in suspected anxiety
Panic disorder Social phobia OCD PTSD Somatoform disorders Depression Substance or drug induced anxiety disorder CNS depressant withdrawal Situational anxiety (non-pathological) Adjustment disorder Cardiac disease Pulmonary conditions Hyperthyroidism Infections Peptic ulcer disease Crohn's disease IBS
How is suspected anxiety investigated
Clinical diagnosis
Consider:
- thyroid function tests
- urine drug screen
- 24 hour urine for vanillymandelic and metanephrines
- Pulmonary function tests
- ECG
What are important discussions to have with a patient diagnosed with anxiety
Involve the pt and their significant others in choice of treatment.
If accompanied by depression (especially with suicidal thoughts), or if drug or alcohol abuse is present, advise pt that they should seek medical help for symptoms that cause significant distress or impairment in functioning
How is anxiety treated
The main goals are to improve symptoms of anxiety and to reduce or eliminate disability
Pharmacotherapy and psychotherapy are reasonable treatments and are bothe considered first line options or may be used together.
Non-drug therapies:
- Cognitive behavioural therapy (CBT) and cognitive therapy (CT) both help people respond differently to worry habits
- Mindfulness or meditation
- Applied relaxation
- Sleep hygeine counselling
- Exercise interventions
- Self help books
- IPT
Pharmacotherapy:
- SSRI
- SNRI
- other antidepressant (eg mirtazapine, busiprone)
- TCA
- Second generation antipsychoitic
What is alcohol dependence
A common psychoatric disorder that is multifactorial in aetiology, chronic in nature and is associated with a wide variety of medical and psychiatric sequlae.
Features include:
-Increased tolerance
-Withdrawal
-Impaired control of drinking behaviour
-Continued alcohol use despite adverse consequences
Problematic alcohol use is classified in the DSM-5 as alcohol use disorder, with severity specified as mild, moderate or severe, depending on the number of diagnostic criteria that has been met
What is alcohol withdrawal syndrome
Can follow sudden cessation or reduction in alcohol consumption
Combination of physical and emotional symptoms:
- tremors
- anxiety
- nausea
- vomiting
- headache
- an increased heart rate
- sweating
- irritability
- confusion
- insomnia
- nightmares
- high blood pressure
Can be serious so assessed by the Clinical Institute Withdrawal Assessment for Alcohol
How common is alcohol dependence
Alcohol is one of the most widely used psychoactive substances
8 million people currently meet diagnostic criteria for alcohol-use disorders in the US
In primary care settings the prevalence is around 20-36%
Significant global mortality burden (3.2% of global deaths)
More than 24% of English population consume alcohol in a harmful way
Who is mostly affected by alcohol dependence
M>F
Lifetime prevalence:
-males 10%
-females 4%
What causes alcohol dependence
Multifactorial aetiology 50% of the risk of developing alcohol use disorder is gentically determined Association with psychiatric disorders: -Affective disorders -Anxiety disorders -PTSD -Schizophrenia
What is the clinical course for patients with alcohol dependence
Characterised by phases of repeated intoxication, withdrawal and abstinence
Progresses from impulsivity to compulsivity
What are the risk factors for alcohol dependence
Family history of alcoholism
Pre-morbid antisocial behaviour
High trait anxiety level
Lack of facial flushing on exposure to alcohol
Low responsivity to the effects of alcohol
How does alcohol dependence present
Increased tolerance
Denial (be sure to question relatives)
Overwhelming desire for alochol
Out of control drinking
An increasing consumption of alcohol
Social, economic, legal, psychological problems
Nausea, vomiting, abdo pain, haematemesis
Muscle cramps, pain, tendernessm altered sensory perception
Nicotine dependence comorbidity
Withdrawal:
- Increased autonomic activity
- Agitation
- Nervousness
- Generalised seizures
- Delirium
What signs may a patient with alcohol dependence have on examination
Increased/decreased liver size jaundice, ascites Hypertension Tachycardia Impaired nutritional status Alterations in normal dental hygeine Depressions Sweating/ clammy skin Hand tremors Anxiety Insomnia Dilated pupils Irritability Fatigue
Withdrawal:
- tachycardia
- hypotensive
- tremor
- confusion
- fits
- hallucinations
What are the differentials in suspected alcohol dependence
Other substance misuse (especially sedatives)
Psychiatric disorders
How is a patient with suspected alcohol dependence investigated
Diagnosed when, over a 12 month period, the patient’s drinking has caused clinically significant impairment or distress, as determined by the presence of at least 2 or more diagnostic criteria
CAGE Cut down on drinking? Annoyed by being criticised for drinking Guilt over drinking Ever had a drink first thing in morning to steady nerves or get rid of a hangover
Dignosis interview:
-DSM 5 or ICD 10 criteria to make diagnosis
-Alcohol Use Disorders Identification Test
Severity of Alcohol Dependence Questionnaire
Bloods: -Increased YGT -Increased ALT -Increase MCV -AST:ALT>2 -Decreased urea -Decreased platelets Ultasound imaging of fatty liver/ cirrhosis
How is alcohol dependence treated
Detoxification and supportive medical care
-diazepam
-lorazepam
-Oxazepam
-Thiamine
Frequent reassurancem, low-stimulation environment, hydration, vitamin infusion (especially thiamine supplementation or infusion for the prevention/ treatment of Wekicke’s encephalopathy)
Inpatient speciality treatment recommended in the following patients:
-previous episode of significant alcohol withdrawal complications
-concurrent moderate-to-severe medical conditions
-concurrent moderate-to-severe psychiatric conditions
-highly adverse life circumstances
If intensive monitoring not required then outpatient treatment recommended
In mild alcohol dependence:
- physician advise and brief interventions
- Pharmacotherapy to prevent relapse and support abstinence:
- Naltrexone
- Acamprosate
- Disulfiram
- Nalmefene
Prevention:
- family intervention
- internet based interventions
- routine screening in primary care
- Alcoholic Anonymous support groups
What are the potential complications in alcohol dependence
Liver cirrhosis
Mallory-Weiss syndrome
Alcoholic liver disease
Dilated cardiomyopathy- arrythmias, stroke
Oral and oesophageal cancer
Pancreatitis
Vitamin deficiencies (Wernicke-Korsakoff syndrome- vision changes, ataxia, impaired memory)
What is the prognosis in those with alcohol dependence
Relapse is common particularly in first 12 months after treatment initiation
What is self harm
Self-inflicted injury that is not associated with an implicit or explicit intent to die
Self-harm is a broad term which may involve:
- self-injury
- cutting
- burning
- overdose
- ligature
- physical relief of emotional distress by converting emotional suffering to physical
Deliberate self-harm is not an attempt at suicide in the vast majority of cases.
Usually an attempt to maintain control in very stressful situations or emotional pressures (e.g. bullying, abuse, academic pressure or work pressure)
