Transcript Mental Health Problems

Care of patients with mental
health problems.
Jo Swallow ST’s- 2012.
Anxiety-An age old problem…
Where is this quote from?
"There is nothing either good or
bad, but thinking makes it so“
……..
Anxiety
Generalised anxiety
3% prevalence in uk.
Excessive worry over
everyday things.
Worry about the
worry!
+ 3 of, restlessness,
easy fatigue,
concentration
difficulty, irritability,
sleep disturbance.
Panic attacks
How many panic
attacks have you had
since I last saw you?
How severe were they
on a scale of 1-5?
Anxiety
T/F – Anxiety is more common than
depression
T/F – Most patients will respond to
treatment
T/F – Most patients will be cured.
T/F – Anxiety is usually a sole morbidity.
T/F – Benzodiazepines are useful drugs in
the treatment of panic disorder.
Name a physical condition which should be
excluded when assessing an anxious
patient…..
Answers
T – anxiety in one form/another is more common
than depression, (it rarely follows pure
generalised/panic forms)
T – improvement is the norm.
F-cure is rare (set pt expectations at outset)
F-usually mixed and often co-exists with other
mental health/physical probs.
F- can worsen panic. And not suitable for ongoing
use, but potentially very useful in a crisis, for 2-4
wks, dependence unlikely in anxiety use.
Thyrotoxicosis. Etoh misuse. Drug s/e (eg
salbutamol/illicit)
Management
Clear explanation re any physical
symptoms. + leaflet
Etoh/caffeine/domestic violence/social
ppt.
Options = CBT, SSRI, Self help
alone/group. (?bblocker for physical syx)
CBT-half improved at 6/12 follow up. 820hrs (1-2hr weekly)
SSRI half improved, NNT=5.
Follow up 2,4,6 wks, 3months, 6 months.
NICE recommends…
Consider and make dx of GAD.
Assess using a scale. Eg. HADS
Self help, signposting. (see last page)
If not aiding, guided self help, groups.
If not aiding, high intensity psychological
intervention (CBT or applied relaxation) or
Drugs for at least 1yr as relapse rate high.
CBT in practice?
Anyone tried this with a patient?
Anyone willing to try?
See DVD clip. – 10minute CBT
Which drugs for GAD?
Fluoxetine ranked first for response
Sertraline ranked first for tolerability
–NICE recommends.
(5 drugs are licensed, duloxetine,
paroxetine, escitalopram,
venlafaxine) (pregabalin- second
line)
Which drugs for panic?
NICE recommends using a licensed
drug for panic.
Citalopram, paroxetine, or
escitalopram
Assess reguarly, full benefit may not
occur before 12 weeks.
If benefits occur continue for 6/12.
Second line in panic are:
imipramine/clomipramine.
SSRI
Start low,
8 wks on any dose,
Minimum total 6/12.
Tail off over 1-2months.
Discontinuation reaction-list syx……
Discontinuation
Dizziness, numbness, tingling,
nausea, headache, sweating,
insomnia, feeling anxious.
Resources for patients
http://www.nice.org.uk/nicemedia/live/13314/54
074/54074.pdf
THIS IS A BRILLIANT RESOURCE (including the
below links, podcasts, diaries, interactive self
help)
http://downloads.bbc.co.uk/health/factsheets/str
uctured.pdf
http://www.moodjuice.scot.nhs.uk/Anxiety.asp
http://www.llttf.com/index.php?section=page&pa
ge_seq=13
Others: Moodkit app for iphone.
http://moodgym.anu.edu.au/welcome
Depression
GP’s fail to diagnose up to half of
their patients with a major
depressive illness.
What subgroups in your community
can you list which have a higher
prevalence of depression?
60% Higher prevalence in africancaribbean, asian, refugee and asylum
seekers than caucasian population.
People with a chronic disease
Family hx
Symptoms of depression.-list
Mystery jets track + others…..
Low mood+diminished pleasure for
2 weeks, nearly every day. + 3/5
Low mood
Loss of interest/pleasure
Weight/apetite change most days
Disturbed sleep
Guilt/low self esteem
Poor concentration
Recurrent suicidal thoughts/acts.
(tiredness, not coping, libido)
Depression scoring.
Cut offs for minor, major.
Why does it matter?
Because – there is no evidence of
benefit for drugs in minor or even
moderate depression
Drugs are only of proven efficacy in
severe depression.
Hx
Triggers
?life events/drugs
?pst hx of manic episodes
Consider delusions/hallucinations. If
present depression not 1st dx.
Physical syx/somatic complaints
(often depression can be missed)
Anxiety syx, most common
comorbidity.
NICE 2009
Assess, quantify with hads/phq9.
Guided self help
Computerised CBT
Group CBT
Interpersonal therapy, behavioural
activation, mindfulness based cbt.
Drugs
Drug treatment for moderate/above
only.
Sertraline may be best choice.
Most effective – mirtazepine,
escitalopram, venlafaxine, sertraline.
Best tolerated – escitalopram,
sertraline, citalopram.
Choice of drug
SSRI and venlafaxine increase gi bleed risk
If risk of GI bleeding, (elderly/on nsaid/aspirin
too)use mirtazepine or trazodone or consider
ppi+SSRI
Pregnancy, STOP paroxetine, consider tricyclics
lower known risks, benefits of other continued
ssri may outweigh risks. Fluoxetine lowest known
risk in preg of ssri but high in breast milk and
manufacturers recommend avoid in b feed.
Breast feeding –sertraline lowest conc in breast
milk. Bnf- present in milk, ‘Not known to be
harmful.’
Risks of drug RX
Self harm and suicide increased risk (in
under 25yrs)
Sexual dysfunction, common.
Hyponatraemia
Fracture risk. – doubling of risk ?inc
falls/red bmd
SSRIs Interact with tamoxifen.(no
parox/fluoxet)
SSRIs Interact with tryptans,
Tricyclics may be safer in elderly pts.
Starting, stopping, swopping.
Rvw after 2 wks (or after 1 wk if <30yrs)
Assess every 2-4wks for 3/12.
If no response after 4 wks consider
compliance, inc dose, or change drug.
Switch to another ssri, or another class
http://mims.co.uk/news/882430/Switchin
g-Antidepressants/
Continue until well for 6/12.
Stopping, withdraw over 4 wks gradually.
Depression Questions?
?etoh, advise abstinence
Exercise, definitely helps, advise
?seasonal component, consider, light
therapy www.sada.org.uk
Co-existing anxiety?
Websites to share
Famous quotes from Hamlet
"To be, or not to be: that is the question". Hamlet quote (Act III, Sc. I).
""This above all: to thine own self be true" Hamlet quote (Act I, Sc. III).
"Though this be madness, yet there is method in 't." Hamlet quote (Act II,
Scene II).
"That it should come to this!". Hamlet quote (Act I, Scene II).
"There is nothing either good or bad, but thinking makes it so" Hamlet quote
(Act II, Sc. II).
"The lady doth protest too much, methinks". Hamlet ( Quote Act III, Sc. II).
"Brevity is the soul of wit". - Hamlet Quote (Act II, Scene II).
"Doubt that the sun doth move, doubt truth to be a liar, but never doubt I
love". Hamlet Quote (Act II, Sc. II).
"Do you think I am easier to be played on than a pipe?" Hamlet Quote (Act
III, Sc. II).
"I will speak daggers to her, but use none". - (Hamlet Quote Act III, Sc. II).