Primary care management, Flashcards
(31 cards)
How is depression diagnosed?
Symptoms must have been present nearly every day for at least 2w.
At least one of the first 2 criteria, and a total of 5 out of the 9 criteria in total:
First 2 criteria (you must have at least one of these):
- Depressed mood.
- Loss of interest or pleasure (anhedonia).
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.
What is the difference between mild & severe depression?
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.
What is the difference between depression and subthreshold depressive symptoms?
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.
What scoring system can be used for depression?
PHQ-9
0-5 = mild
6-10 = moderate
11-15 = moderately severe
16-20 = severe depression
What is the step one in the stepped care model of depression treatment?
Intervention options: Assessment, support, psycho-education, lifestyle advice, active monitoring and referral for further assessment and interventions
In recognised depression (persistent subthreshold depressive symptoms or mild to moderate depression) what should be done?
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), unless what?
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
Step 3: persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions, and moderate and severe depression: what should be done?
An antidepressant (normally a SSRI) or a high-intensity psychological intervention
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
What are risks of a SSRI?
Can cause GI bleeding particularly in the elderly & can also cause hyponatraemia
When should follow up be done after prescribing an antidepressant?
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
If response absent or minimal after 3 to 4 weeks at therapeutic dose what should be done?
Increase level of support and increase dose OR switch to another antidepressant
What is the advice for managing bipolar in primary care?
Do not start SSRIs in depressed phase – refer/discuss with 2ry care
Stop antidepressants if patients become hypomanic
Require mood stabilisers as treatment
Beware sodium valproate in women of child-bearing age
- 2ry care medication only – woman must be on effective contraception
How is GAD diagnosed?
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).
What scoring system can be used for anxiety?
GAD-7
0-5 mild
6-10 moderate
11-15 moderately severe anxiety
15-21 severe anxiety
When assessing the severity of anxiety what should be included?
Level of distress
Functional impairment
Number, severity and duration of symptoms.
In terms of GAD for those with marked functional impairment or those who have not improved with treatments given already what can be done?
Offer: A high-intensity psychological intervention or drug therapy
- CBT, applied relaxation
- SSRI 1st line (sertraline/fluoxetine)
- 2nd line=switch SSRI or SNRI
(Do not use benzodiazepines except for short term measures during crisis)
Review patients every 2–4w in the first 3m (more frequently in those under 30y, and 3-monthly thereafter.
Continue therapy for at least 12m after initiation to reduce the risk of relapse (high if treatment stopped in first 12m).
What is panic disorder defined as?
Recurring unforeseen panic attacks, followed by at least a month of persistent worry about having another attack and concern about its consequences OR a significant change in behaviour related to the panic attacks.
What is the difference in treatments for mild to moderate compared to mod-severe panic disorder?
Mild- Moderate
- Self-help
- Offer bibliotherapy based on CBT principles
- Offer information on support groups.
- Discuss the benefits of exercise as part of good general health.
- Review progress appropriately based on individual circumstances (often every 4–8w)
Mod-Severe
- Psychological therapy
1- –2 hourly sessions weekly. These should be completed within 4 months. 7–14h is usually optimal. Sometimes, more intense CBT over a shorter timeframe may be appropriate.
Drug treatment
What drug treatment should be used for panic disorders?
Offer an SSRI licensed for panic disorder (citalopram, sertraline, paroxetine, escitalopram but NOT fluoxetine,
If unable to use SSRI or no response after 12w, consider imipramine or clomipramine (off-label indication for both) – beware both are dangerous in overdose.
Avoid benzodiazepines/sedating antihistamines/antipsychotics
If one therapy (CBT, drugs, self-help) fails to give adequate response, try an alternative from this list; if no response, refer for specialist input (CMHT)
What is social phobia?
Persistent fear of one or more social or performance situations in which the person is exposed to unfamiliar people or to possible scrutiny by others. The individual fears that he or she will act in a way (or show anxiety symptoms) that will be embarrassing and humiliating.
The fear, anxiety, or avoidance is persistent, typically lasting 6 or more months
What is the treatment for social anxiety disorder?
1st line: CBT
2nd line: Medication:
- sertraline or escitalopram
- Continue for 6 months of treatment once treatment has become effective.
Marked distress and disability caused by the grief reaction.
AND the persistence of this distress and disability more than 6m after a bereavement.
What is this?
PROLONGED GRIEF DISORDER
- > 6 months after the bereavement
How is prolonged grief disorder treated?
Counselling eg Cruse
Antidepressants for comorbid depression
Behavioural/cognitive/exposure therapies
Refer if significant impairment in functioning
OCD is characterised by obsessions or compulsions (usually both) which must impair function: what is the difference between obsessions and compulsions?
Obsessions: unwanted intrusive thoughts, images or urges. Tend to be repugnant and inconsistent with a person’s values.
Compulsions: repetitive behaviours or mental acts the person feels driven to perform. Can be overt (checking they locked the door) or covert (mentally repeating a phrase in their head).
