Primary care management of common mental health conditions

Question 1

Mental health and primary care stats

Answer 1

40% gp consultations
most handled exclusively by gp
1 in 4 people

Question 2

Major mental illness and death

Answer 2

women - 12 yrs earlier

men - 16 years earlier

Question 3

Be alert to depression especially if…

Answer 3

PMH
significant illness - disability
other mental health problem eg dementia

Question 4

2 key questions for depression

Answer 4

During the last month - feeling down, depressed or hopeless?

During last month - little interest or pleasure?

Question 5

Recognising and diagnosing depression

Answer 5

ICD-10
DSM-5
PHQ-9

Question 6

Suicide risk assessment

Answer 6

suicidal thoughts 
ideation 
intent 
plans 
previous attempts
social support 
level of risk 
immediate risk - refer 
further help
also homicidal risk

Question 7

Stepped care model

Answer 7

Least intrusive intervention provided first
Ineffective/declined
offer appropriate intervention from next step

Question 8

Stepped care model step 1

Answer 8

recognise, assess, initial management

Question 9

step 1 - options

Answer 9

assessment 
support 
psycho-education 
lifestyle advice 
active monitoring

Question 10

Step 2

Answer 10

sleep hygiene
active monitoring
CBT
(medication)

Question 11

step 3

Answer 11

antidepressant - SSRI

CBT, IPT, behavioural activation

Question 12

Follow up

Answer 12

see patients 2 weeks after starting
2-4 weeks interval for 3 months
under 30 at great risk - 1/week
6 months after remission take meds and up to 2 years if relapse risk

Question 13

Do NOT routinely use anti-depressants unless

Answer 13

PMH of mod-severe depression
subthreshold symptoms for 2+years
Subthreshold for <2yrs but not respond to other interventions

Question 14

Fitness for work

Answer 14

Med 3 forms

Question 15

Fitness to drive - must not drive

Answer 15

significant memory or concentration problems, agitation, behaviour or suicidal thoughts

Question 16

Non responders to anti-depressants

Answer 16

absent/minimal after 4 week
increase level of support and dose
OR switch to other

Question 17

Switching anti-depressant

Answer 17

Switch to other SSRI
another class eg TCA
combine and augment
Lithium, antipsychotic or mirtazapine

Question 18

Stopping or reducing anti-depressants

Answer 18

advise risk - discontinuation symptoms and gradually reduce dose over 4 weeks

Question 19

Step 4

Answer 19

severe and complex depression
risk to life
severe self-neglect

Question 20

Step 4 - interventions

Answer 20

multiprofessional - inpatient
self harm
psychotic symptoms

Question 21

Antidepressants in bipolar

Answer 21

do not start SSRI in depressed phase

stop if become hypomanic

Question 22

Panic disorder

Answer 22

Recurrent panic attacks and persistent worry about further attacks

Question 23

Social anxiety disorder

Answer 23

Persistent fear of 1 or more social performance situations out of proportion to actual posed threat

Question 24

GAD - DSM 5

Answer 24

excessive anxiety and worry for atleast 6 months
difficult to control worry
6 symptoms

Question 25

6 part C symptoms in GAD DSM-5

Answer 25

``` restlessness easily fatigued difficult concentrating irritability muscle tension sleep disturbance ```

Question 26

Step 1- GAD

Answer 26

education | active monitoring

Question 27

Step 2 - GAD

Answer 27

CBT guided self help psychoeducational groups

Question 28

Step 3 - GAD

Answer 28

CBT and applied relaxation SSRI eg sertraline SNRI (pregabalin)

Question 29

GAD - BZD

Answer 29

only in short term crisis

Question 30

GBD - pregabalin

Answer 30

beware abuse potential

Question 31

GBD - antipsychotics

Answer 31

do not offer for anxiety disorders

Question 32

Step 4 - GAD

Answer 32

specialist referral self harm, suicide co-morbid eg substance misuse self neglect

Question 33

CMT review

Answer 33

assessment of problem and risks | impact on family and care plan

Question 34

Step 4 - GAD treatment

Answer 34

drug and psychological | augmentation or anti-depressants

Question 35

Symptoms of panic attacks

Answer 35

``` palpitations sweating shaking choking sensation chest pain nausea light headed fear of dying numbness ```

Question 36

Panic disorder (mild-mod)

Answer 36

self help

Question 37

mod-severe panic disorder

Answer 37

psychological therapy | drug treatment

Question 38

Self help

Answer 38

bibliotherapy based on CBT support groups exercise benefits

Question 39

Psychological interventions of panic disorder

Answer 39

CBT self-completed questionnaires alternative therapy if this fails

Question 40

Panic disorder - drug treatment

Answer 40

citalopram, sertraline NOT fluoxetine clomipramine (no response to SSRI after 12wks) avoid BZD, anti-psychotics

Question 41

Screening questions in social anxiety

Answer 41

avoiding social situations? | fearful or embarrassed in social situations?

Question 42

Treating social anxiety disorder

Answer 42

1st line = CBT | 2nd line = sertraline/citalopram

Question 43

Normal grief

Answer 43

``` disbelief anger/guilt/blame impaired functioning yearning and sadness difficult concentrating loss of purpose ```

Question 44

Differentiating grief from depression

Answer 44

Grief - longing/yearning +ve emotions still experienced worst symptoms when thinking of person want to be with others

Question 45

Prolonged grief disorder

Answer 45

distress and disability | persistence - more than 6m

Question 46

Prolonged grief disorder - treatment

Answer 46

counselling anti depressant CBT refer if significant

Question 47

Screening for OCD

Answer 47

do you wash or clean a lot? do you check things a lot? special order? upset by mess? do these problems trouble you?

Question 48

OCD diagnosis

Answer 48

obsessions and compulsions obsession - intrusive thoughts, images Compulsions - repetitive behaviour >1hr or distress or functional impairment

Question 49

overt behaviour - OCD

Answer 49

checking the locked door

Question 50

Covert behaviour - OCD

Answer 50

mentally repeating a phrase in their head

Question 51

OCD treatment

Answer 51

CBT - exposure+response SSRI - up to 12 weeks to see a response clomipramine

Question 52

Insomnia - 2ry causes

Answer 52

anxiety/depression obstructive sleep apnoea excess alcohol/drugs parasomnia eg restless legs, teeth grinding circadian rhythm disorder (shift workers)

Question 53

Insomnia treatments

Answer 53

sleep hygiene sleep diaries - CBT melatonin >55yrs hypnotics if disabling

Question 54

Sleep hygiene

Answer 54

``` avoid stimulating activities avoid alcohol/caffeine before bed avoid heavy meals regular day time exercise relaxation ```

Question 55

Eating disorders - 1 care

Answer 55

recognise and refer

Question 56

Shared care for major mental illness

Answer 56

``` medication monitoring BMI/Bp/smoking blood tests - antipsychotics (ECG) - lithium (thyroid/kidney every 6 months) - lithium levels 3 monthly ```

Question 57

3rd sector

Answer 57

voluntary +community organisations ACIS counselling bereavement counselling alcohol and drugs action

Question 58

Lithium toxicity

Answer 58

``` vomit and diarrhoea course tremor muscle weakness lethargy confusion seizures slurred speech confusion ```

Question 59

Expected side effects of lithium

Answer 59

``` Fine tremor dry mouth altered taste sensation urinary frequency weight gain ```