Primary Care Management Of Mental Health Disorders

Question 1

What are common complaints of people with mental health disorders?

Answer 1

I'm feeling low
I've got no energy
I'm tired all the time
I'm struggling with my motivation
I can't stop crying
I'm struggling with my sleep
I'm not enjoying things like i used to
I'm struggling to get to work

Question 2

Who should you watch out for when suspecting depression

Answer 2

A past medical history of depression
Significant illnesses causing disability
Other mental health disorders e,g, dementia

During the last month have you often felt down, depressed or hopeless?
During the last month have you been bothered by having little interest or pleasure in doing things

Question 3

What are the three key symptoms you must have to be diagnosed with depression

Answer 3

Persists sadness or low mood
Loss or interests or pleasure
Fatigue or low energy

You must also have some of the 7 screening symptoms of depression

Question 4

What are the screening symptoms for depression

Answer 4

Disturbed sleep
Poor concentration or indecisiveness
low self confidence
poor or increased appetite
suicidal thoughts or acts
agitation of movements
guilt or self blame

Question 5

What is a good screening questionnaire for depression

Answer 5

PHQ-9

Question 6

How do you treat depression in primary care

Answer 6

Recognise depression:

Offer advice on sleep hygiene
Offer active monitoring
Low intensity psychological and psychosocial interventions
Do not routinely use antidepressants unless:
Past history
Subthreshold symptoms for 2 years or more
Don’t respond to other interventions

Question 7

What high level managements can you use for depression in primary care?

Answer 7

Only if low level interventions don’t work

Antidepressants (SSRI)
High intensity psychological intervention
Combined treatment medication and high intensity psychological interventions, preferred for moderate to severe depression

Question 8

What else should you consider for people with depression?

Answer 8

Med 3 forms- fit to work form (not legal discretion)

Fitness to drive- very good DVLA document

Question 9

How do you follow up people with depression

Answer 9

Normally see people after 2 weeks after starting, see them at intervals every 2-4 seeks for 3 months and then at longer intervals if the response is good.

In patients aged under 30, or considered at greater risk, see weekly and as frequently thereafter as appropriate until risk no longer clinically important

Encourage to take for at least 6 months after remission, and for up to 2 tears if they are at risk of relapse

Question 10

What is the go to drug for depression- lecturer

Answer 10

Sertraline- 50mg, 30mg for elderly. Half the dose to see side effects

Question 11

How long do you wait until deciding an antidepressant isn’t working and then switching it?

Answer 11

6 weeks

Question 12

Who do you refer to in patients/ specialist care

Answer 12

Severe and complex depression
Risk to life
Severe self neglect

Question 13

How do you do a suicide screen?

Answer 13

Ideation/intent/plans- vague, detailed, specific, already in motion
Previous attempts
Homicidal risk
Impulsivity/self control
Access to lethal methods
Current stressors/sense of hopelessness
Protective factors
Assess whether the person has an adequate social support and is aware of sources of help
Arrange help appropriate to the level of risk

Question 14

What drug can you not give to woman of child bearing age who are bipolar

Answer 14

Sodium valproate

Question 15

Who prescribes medications for those with bipolar disorders?

Answer 15

Secondary care only!

Question 16

What are the three main types of anxiety disorder?

Answer 16

Generalised anxiety disorder

Panic disorder

Social anxiety disorder

Question 17

What is a good questionnaire for anxiety?

Answer 17

GAD-7

Question 18

How do you treat mild/moderate anxiety

Answer 18

Individual non- facilitated self help- usually 6 week sessions typically written materials based on CBT

Indivudal guided self help- written materials and a trained practitioner

Psychoeducational groups- 6 weekly sessions of 2 hours, based on CBT principles

Question 19

What can you do for severe anxiety?

Answer 19

CBT
Applied relaxation

Drug therapy- sertraline (SSRI) or fluexoetine
If not SNRI (venlafaxine/duloxetine)
If not pregabalim- can be abused, now controlled drugs

Keep on for 12 months

Question 20

When should you refer someone with anxiety to secondary care

Answer 20

Risk of self harm/suicide
Significant co-morbidity
Self neglect
Failrue to respond to step 3 treatment

Question 21

How do you diagnose panic attacks

Answer 21

Surge of fear or physical discomfort reaching a peak in a few minutes

Palpitations
Sweating
Shaking
SOB
Chest pain
Dizzy
Fear of death/loss of control

Question 22

What drug do you not use for panic disorders?

Answer 22

Fluoxetine!

Question 23

What’s the best antidepressant

Answer 23

Sertraline

Patients with cardiac, renal and epilepsy can take it

Only has GI side effects that will wear off

Question 24

What are some useful screening questions for social anxiety disorder?

Answer 24

Useful screening questions:

Do you find yourself avoiding social situations or activities
Are you fearful or embarrassed in social situations

Question 25

How do you treat social anxiety disorder?

Answer 25

1st line CBT | 2nd line- sertraline, citrallopram for 6 months once treatment is working

Question 26

How do you characterise grief?

Answer 26

``` Disbelief, diifuckty comprehending Bitterness,anger guilt and blame Impaired functional yearning and sadness Emotional and physical pain Mental fogginess, difficulty concentrating, forgetfulness Loss of purpose Feeling disconnected Difficulty engaging in activities or making plans fro the future ```

Question 27

How do you differentiate grief from depression?

Answer 27

Grief includes longing/yearning for loved one Positive emotions can still be experienced Symptoms worse when thinking about deceased person People often want to be with others

Question 28

How do you treat prolonged grief disorder

Answer 28

Only access 6 months after the loss Counselling e.g. Cruse Antidepressants for co-morbid depression Behavioural/cognitive/exposure therapy Refer if significant impairment

Question 29

How do you treat OCD

Answer 29

1st line- CBT, exposure and response prevention 2nd line- SSRI, often required higher dose up to 12 weeks 3rd line- medication, clomipramine (most SSRI or the TCA) 4th line- buspirone and SSRI

Question 30

What should you screen for when looking at insomnia?

Answer 30

``` Anxiety/depression Physical health problems-pain, dyspnoea Obstructive sleep apnoea Excess alcohol or illicit drugs Parasomnias Cicadian rhythm disorder ```

Question 31

What should you do when checking someone with restless legs

Answer 31

Check their ferritins

Question 32

What are the rules of sleep hygiene

Answer 32

Avoid stimulations before bed Avoid alcohol, caffeine, smoking before bed Avoid heavy meals or strenuous exercise before bed Regular day time exercise Same bedtime each day Ensure bedroom environment promotes sleep Relaxation If you can’t sleep after 20 mins get back up and do a relaxing activity (BATH, BOok)

Question 33

What can you do to treat insomnia?

Answer 33

Sleep diaries CBT-I (avoiding available in England, sleepspace.ord self funded £95) Medications not indicated, addictive and don’t work very well

Question 34

What do you do with eating disorders

Answer 34

Recognise and send to secondary care

Question 35

What are the symptoms of lithium toxicity

Answer 35

Nausea and vomiting