Transcript Mental Health in Primary Care - NHS Scarborough and Ryedale CCG

MENTAL HEALTH UPDATE FOR
PRIMARY CARE
Dr Pratibha Nirodi
Liaison psychiatrist for TEWV
Primary Care Mental Health
• 281 million consultations in Primary Care annually
• 30% of all GP consultations have a Mental Health
component
• 90% Mental Health Problems managed by Primary Care
Intro
• Depression -mild to severe; often with anxiety
• In all cases anxieties can lead to problems with
normal functioning.
• There are several treatments for these conditions both
pharmacological and psychological.
• Huge burden on society in terms of emotional,
social and economic hardship
Comorbid depression and anxiety occur in over half
those who report symptoms
aetiology
• Cause of depression is unclear
• several theories
• biological influences –
genetics, neurotransmitters, endocrine factors
and immune system deficits
• Non biological considerations – early life experiences, life
events, social isolation, gender and socioeconomic factors.
• Generally, a combination of factors
• Anxiety = biological or genetic, cognitive‐ behavioural or that
anxiety is a learned behaviour. (Anxiety is
one of the most common treatable mental disorders)
NICE Depression guidance
• Depression: review of assessment
• Emphasis on psychological interventions
• Pharmacological interventions
new information
efficacy and cost effectiveness
augmenting
• Relapse prevention
• GP key role
Principles for assessment
The guidelines discourage over reliance on the
number of symptoms. Instead:
• Distress
• Duration
• Disability
If the patient’s symptoms have been distressing
and have been present for 2 weeks or more at
a level where they have affected their ability to
function normally then it is likely that they are
significant
Identification and assessment
• Be alert to possible depression
• Particularly in people with a past history of depression
or a chronic physical health problem with associated functional
impairment.
• Consider asking people who may have depression two
questions, specifically:
• During the last month, have you often been bothered by feeling
down, depressed or hopeless?
• During the last month, have you often been bothered by having
little interest or pleasure in doing things?
(PHQ2)
• “Is this something with which you would like help”?
ICD 10
• Individual usually suffers from depressed mood, loss of
interest and enjoyment, reduced energy
• Other common symptoms – • reduced concentration •
reduced self confidence • ideas of guilt/unworthiness •
pessimistic views of future • disturbed sleep •
reduced appetite • ideas/acts of self‐harm or suicide
Role of the General Practitioner
• GPs ideally placed to detect depression
• “Watchful waiting” vs GP involvement in all steps of the model
CG 90 not so explicit about boundaries primary care/ specialist
care
• But: dangers of false diagnosis and medicalisation of
distress
Some evidence of diagnosis and prescription in pts. not actually
depressed
Key points for intervention
• Step 1
Identification
Risk assessment
Active monitoring
• Step 2
Advice on sleep hygiene and activity
Low intensity psychological interventions
• Step 3
High intensity psychological interventions
Referral
• Steps 2, 3, and 4
Antidepressants
The Characteristics of IAPT
• Implements NICE Guidelines
• Not only CBT
• Stepped care- step 1 presence of a care
manager; Step 2 integrated cooperation
between primary care and specialized mental
health care
• Outcome focused-Care is offered not earlier or
more intensely than necessary and not later or
less intensely than needed. Evidence-based
treatment of low intensity as a first step.
Stepped care model
• Model is self-correcting. Self-correcting means that
the results of treatments and decisions about
treatment provisions are monitored systematically
and necessary changes are made ('stepping up') if
current treatments are not achieving significant
health improvement.
• Patient’s choice in the first step between lowintensity treatments, for example: (guided) selfhelp and psycho-education in few group-sessions
or they might even choose to skip the first step.
Stepped care
Problems suitable for IAPT
•
•
•
•
•
•
•
•
•
•
•
•
•
Problems suitable for Talking Therapies
Depression
Generalised anxiety disorder
Psychological problems arising from long term medical conditions
Panic disorder
Social phobia
Specific phobias
OCD Obsessive compulsive disorder
PTSD Post- traumatic stress disorder –moderate/single trauma e.g.
RTA
Health anxiety
Medically Unexplained Physical Symptoms
Post natal depression (mild/moderate)
Employment stress, support required to stay in or obtain work.
Not suitable
• Children
• Psychosis
• Actively suicidal
• Complex problems eg PD, Severe PTSD, Moderate/Severe Eating
disorders
• Drug/Alcohol problems
• Under Secondary Care Services
What is CBT
• To be effective, psychotherapy must be directed at the person’s specific
anxieties/fears and tailored to his or her needs. A typical “side effect” of
psychotherapy is temporary discomfort involved with thinking about
confronting feared situations
• It teaches a person different ways of thinking, behaving, and reacting to
anxiety-producing and fearful situations. CBT can also help people learn and
practice social skills.
• Two specific stand-alone components of CBT are cognitive therapy and
exposure therapy. Cognitive therapy focuses on identifying, challenging, and
then neutralizing unhelpful thoughts underlying anxiety disorders.
Exposure Rx
• Exposure therapy focuses on confronting the fears underlying an anxiety
disorder in order to help people engage in activities they have been avoiding.
Exposure therapy is used along with relaxation exercises and/or imagery.
• One meta-analysis showed found that cognitive therapy was superior to
exposure therapy for treating social anxiety disorder.
Mindfulness based C+T
• It combines mindfulness techniques like meditation, breathing exercises and
stretching, with elements from cognitive therapy to help break the negative
thought patterns that are characteristic of recurrent depression.
• MBCT is recommended by the National Institute for Health and Care
Excellence (NICE) as an effective treatment for people who suffer from
recurrent episodes of depression. Evidence shows that MBCT can, on
average, reduce the risk of relapse of recurrent depression by 43% (Mark et
al, 2014).
• Research also suggests that it’s particularly effective for groups who are more
likely to relapse (Teasdale et al, 2000), as well as being a cost-effective and
accessible treatment for individuals and providers, due to its psycho-social
approach to staying well (Williams & Kuyken, 2012).
MBCT
• MBCT teaches people to pay attention to the present moment, rather than
worrying about the past or the future, and to let go of the negative thoughts
that can tip them over into depression. It also gives people a greater
awareness of their own body, helping them to identify the signs of oncoming
depression and ward off the episode before it starts.
NICE conclusions on antidepressant medication
• When prescribing, should normally be SSRI (Selective Serotonin
Receptor Inhibitors) in generic form
• Avoid using routinely for subthreshold depressive symptoms
• Discuss options, consider side effects, discontinuation, potential
interactions, physical health, previous experience
Starting antidepressant treatment
Obtain patient’s agreement that they have a depressive illness,
then:
• Address patient concerns, views on tablets and
antidepressants, and discuss common myths
Gradual effects and need to persevere
Side effects and drug interactions
Previous experience of efficacy/side effects
Discontinuation symptoms
Not addictive
Ask about St. John’s Wort
• Review after 2 weeks, then at least monthly
• If suicide risk or <30years review after 1 week, then frequently
Mode of action: SSRI (Selective Serotonin Receptor
Inhibitors)
Common Side Effects of SSRIs
• Nausea
• Diarrhoea
• Headache
• Anxiety
• Insomnia/drowsiness- adapt time of taking
• Weight loss/gain
• Sexual difficulties: lack of orgasm
• Care in people at risk of falls
Generic SSRIs: Fluoxetine, Citalopram, Sertraline,
Paroxetine
• Sertraline & Citalopram are safer in patients with Long
term conditions as less interactions with other medication
• Paroxetine more discontinuation symptoms
• Fluoxetine can increase anxiety in approx 10%
• Short term rx (<2 weeks) with a benzodiazepine
Escitalopram
• Isomer of citalopram
• Cochrane report supported it BUT
• Small no’s of patients, short term follow
up, Pharmaceutically sponsored trials
• Not enough information to recommend it
above other treatments as much more
expensive.
SNRIs (Serotonin & Noradrenaline Reuptake
Inhibitors)
• Venlafaxine: can increase blood pressure, more
toxic in overdose.
• Duloxetine: Also used in diabetic neuropathy (&
stress incontinence)
• Side effects similar to SSRI
MIRTAZEPINE-alpha 2 receptor blockade
• Noradrenaline and serotonin would normally bind to these
receptors. By blocking them, mirtazapine prevents
noradrenaline and serotonin from becoming bound.
Mirtazepine
• Works by increasing noradrenaline and
serotonin in unique way (blocking alpha
adrenergic receptors)
• Weight gain
• Sedation- some times useful
• Often used to augment other
antidepressants (combined with SSRI and
venlafaxine)
TCADS (Tricylic Anti Depressants) e.g amitriptyline, clomipramine,
dothiepin
• Work on serotonin and noradrenaline
• Side effects: dry mouth, constipation, blurred vision,
palpitations, urinary retention
• Very toxic in over dose (especially dothiepine)
cardio-toxicity; except lofepramine
Starting Treatment
• Response by 2-4 weeks
• Switch or increase dose if:
• Inadequate response
• Side effects
• Patient prefers
Risks
• Response by 2-4 weeks
• GP’s are used to living in a very risky
• Switch or increase dose if:
world
• We can each expect a suicide every
5 years
• Inadequate response
• Side effects
• Patient prefers
Suicide risk
• Review after 1 week
• Consider other forms of support e.g. More frequent direct or telephone contact
• Consider referral to crisis team
• Advise and monitor potential for increased agitation, anxiety and suicidal
ideation
• Take into account toxicity in overdose
Venlafaxine associated with increased risk
TCAs increased risk (except lofepramine)
Augmenting antidepressants
If person is informed and prepared to accept additional side
effects, consider augmenting with:
• Lithium
• An antipsychotic such as aripiprazole, olanzapine,
quetiapine, risperidone
• Another antidepressant, such as mirtazapine or
venlafaxine
augmentation
• Most robust evidence is available for atypical antipsychotics, particularly
aripiprazole and quetiapine extended-release.
Other options include mirtazapine
Some positive trials on neuromodulation TMS (USA)
The role of topiramate, lamotrigine, pindolol, pramipexole, and sex hormones is
unclear, given the evidence at this time.
Use lithium only after other agents have failed because of associated long-term
risks.
Newer options, such as ketamine-based compounds and tDCS, show promise
for augmentation, but they would benefit from more rigorous trials before
widespread clinical use.
Serotonin syndrome
•
•
•
•
•
•
•
•
•
•
•
:
Agitation or restlessness
Confusion
Rapid heart rate and high blood pressure
Dilated pupils
Loss of muscle coordination or twitching muscles
Muscle rigidity
Heavy sweating
Diarrhoea
Headache
Shivering
Severe serotonin syndrome can be life-threatening. Signs and symptoms include:
• High fever
• Seizures
• Irregular heartbeat
• Unconsciousness
•
Relapse prevention
Need to continue treatment for at least 6/12 from recovery
Continue medication for at least 2 years- (If 2+ recent episodes, other risk
factors, relapse consequences severe e.g occupation)
Psychological interventions: For recurrent depression
Individual CBT (16-20 sessions over 3-4 months) OR
Mindfulness based cognitive therapy
Discontinuation
When stopping antidepressants, gradually reduce dosage
over a 4 week period
• Some people may require longer, esp. With e.g.
paroxetine, venlafaxine
• Exception is fluoxetine
• Warn about discontinuation symptoms – usually settle
within a week
• If symptoms mild: reassure and monitor
• If symptoms severe: reintroduce original dose or another
with longer half life and reduce gradually
Subthreshold and mild depression
• Do not routinely use drugs
• Consider them for:
• Those with a PMH of moderate/severe depression
• H/O 2y + subthreshold symptoms
• Subthreshold / mild depression persisting after other
interventions
Key points on Anti depressants
• The SSRIs are associated with some increased risks in pregnancy, but these are small and
must be balanced on a case by case basis against the benefits of treatment/the harms of not
treating. Sertraline was the antidepressant used by 40% of the women and this was NOT
associated with any problems.
Women who had used paroxetine and fluoxetine at the end of the first
trimester had an
increased risk of congenital anomalies. The absolute risk is still low.
• Maximum recommended doses of citalopram/escitalopram have now been introduced by the
MHRA: make sure you don’t exceed them. ½ dose elderly and those with hepatic damage. Do
not use these drugs in those with known long QT and with other drugs that prolong QT
(methadone, antibiotics, antipsychotics). QT is dose-dependent
• Tamoxifen’s action is inhibited by some other drugs, particularly fluoxetine and
paroxetine. Avoid using these SSRIs in women on tamoxifen. (cytochrome P450)
• In people over 25y, antidepressants protect against suicidal ideation and behaviour, but in
those <25y they may increase the risk.
• Do not offer SSRI for those on aspirin, NSAIDS, Warfarn or heparin and Triptans
• Theophylline, clozapine, methadone or tizamidine- offer Serttraline or citalopram
• In CHD the SSRIs, particularly sertraline, are the drugs of choice.
• Review whether any of your patients are on above maximum recommended
doses of
• citalopram for their age or if they have hepatic disease (poorly defined and
much harder to search for!). Come up with a plan about how you will contact
patients and discuss reducing their dose. This may involve contacting the
CMHT if they are under their care.
• Are any of your patients on tamoxifen and either fluoxetine or paroxetine?
What will you do about this? Is this a safety audit you should do every year?
• Are patients on venlafaxine having a regular BP check? (Regular isn’t defined
but 6m would seem reasonable and with every dose increase.)
venlafxine
• GPs are now able to prescribe venlafaxine once more, but be aware:
• Specialist supervision is required for those who are on doses of 300mg daily or more,
•
•
•
•
•
•
•
or those who are severely depressed, or
are in hospital.
For those using it for anxiety disorders, dose is 75mg daily, and no higher.
Do not use in uncontrolled hypertension, risk of serious cardiac arrhythmias, recent
MI.
Measure blood pressure at initiation and regularly throughout treatments
especially during dose titration – discontinue if
sustained hypertension.
And a massive case–control study (almost 7000 cases, with 30 controls for each
case) has shown that venlafaxine does not
increase the risk of sudden cardiac death or serious arrhythmia (BMJ
2010;340:c249).
What about mirtazapine?
• A Cochrane Review (2011, CD006528) concluded that:
• Mirtazapine is likely to have a faster onset of action than SSRIs.
• It may be that mirtazapine is superior to SSRIs by 6–12w.
• Mirtazapine causes adverse events that lead to a similar frequency of
dropouts as SSRIs and tricyclic antidepressants,
• although the adverse event profile of mirtazapine is different: mirtazapine is
likely to cause weight gain or increased appetite
• and somnolence, but is less likely to cause nausea or vomiting and sexual
dysfunction than SSRIs so may be a useful 2nd
• line option if adverse effects of SSRIs are unacceptable.
Stopping or reducing
• Discontinuation symptoms (such as increased mood swings, restlessness, difficulty
•
•
•
•
•
sleeping, unsteadiness, sweating, abdominal symptoms and altered sensations) can
occur on stopping, missing doses or reducing doses of antidepressants. These
symptoms are usually mild and self-limiting over approximately 1w but can be severe
especially if the drug is stopped abruptly.
Gradually reduce the dose over 4w (although this is not necessary for fluoxetine due
to a long half-life and active metabolites).
Reduce the dose over even longer periods for drugs with a shorter half-life, e.g.
paroxetine, venlafaxine.
If despite this, significant discontinuation symptoms occur and are severe:
Consider reintroducing the original antidepressant at the dose that was effective and
reduce the dose more gradually while monitoring symptoms.
Or restart another antidepressant with a longer half-life from the same class (so
usually fluoxetine for the SSRIs) and reduce slowly once symptoms have settled.
Over 65
• This UK-based cohort study of people aged 65–100y with depression looked at
adverse events by class of antidepressant used (SSRI, tricyclic, other). Follow-up
was over 5y on average. Obviously, because this was an observational cohort trial
there may have been good clinical reasons for selecting one drug over another, which
may affect the outcomes, but nevertheless this study reveals some interesting results
(BMJ 2011;343:d4551):
• SSRIs were associated with the highest risk of falls and hyponatraemia.
• Other antidepressants (non-SSRI, non-tricyclics) were associated with the highest
risk of mortality, self-harm/suicide, stroke/TIA, fracture and epilepsy. However, do
note that these drugs are more likely to be used in those with more severedisease
because they are not first line treatments.
• For all the outcomes, tricyclics never performed as the ‘worst’ drug (when compared
to SSRIs or other antidepressants), but often they were not the ‘best’ either.
Depression and dementia
• Depression is common in dementia, with a prevalence estimated to be greater
than 20%. The US National Institute for Health
• Research has run an RCT of just over 300 patients with dementia to see if
adding an antidepressant might help. Patients with dementia but without
obvious depression were randomised to either placebo, sertraline or
mirtazapine at usual clinical doses. At 13 and 39w follow-up sertraline and
mirtazapine were no better than placebo. More trials like this are needed.
Key points
• GPs should be alert to possible signs of depression in
patients, but should not medicalise distress
• Assessment and management should be carried out
according to the stepped-care model
• Patients should be supported by the GP throughout the
management process
• GPs should use active monitoring for patients as
appropriate
• GPs should have knowledge of:
• low-intensity psychological interventions
• locally available services
• Pharmacological treatment choices should be tailored to
the individual patient
• The use of St John’s wort is not recommended
• High-intensity psychological interventions should be
offered to patients with moderate to severe depression
Anxiety disorders in general practice
Subtypes
• GAD
• Panic disorder
• PTSD
• OCD
• Social phobia
• Specific phobias (e.g. spiders)
• Acute stress disorder
GAD
• GAD (5% of GP patients)
• ICD-10 definition
Anxiety generalised and persistent but not restricted to, or even
strongly predominating in, any particular environmental
circumstances
(i.e. "free-floating")
Generalised anxiety disorder is diagnosed in approximately onethird of patients with the disorder
Low rate of diagnosis can be attributed to several factors:
competing demands and time pressures during consultation
patient description of symptoms
waxing and waning symptoms
co-occurrence with other anxiety and depressive disorders
recognition
Mental disorder recognised
but generalised anxiety
disorder not diagnosed
Mental disorder not recognised
28%
38%
34%
Specific generalised anxiety
disorder diagnosis
Based on a sample of 17,739 patients
5.3% with generalised anxiety disorder (DSM-IV)
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria
Wittchen H-U. J Clin Psychiatry 2002;63(Suppl 8):24–34.
Generalized Anxiety Disorder
• People with generalized anxiety disorder display excessive anxiety or worry
•
•
•
•
•
•
•
•
for months and face several anxiety-related symptoms.
Generalized anxiety disorder symptoms include:
Restlessness or feeling wound-up or on edge
Being easily fatigued
Difficulty concentrating or having their minds go blank
Irritability
Muscle tension
Difficulty controlling the worry
Sleep problems (difficulty falling or staying asleep or restless, unsatisfying
sleep)
Panic disorder
• People with panic disorder have recurrent unexpected panic attacks, which
•
•
•
•
•
are sudden periods of intense fear that may include palpitations, pounding
heart, or accelerated heart rate; sweating; trembling or shaking; sensations of
shortness of breath, smothering, or choking; and feeling of impending doom.
Panic disorder symptoms include:
Sudden and repeated attacks of intense fear
Feelings of being out of control during a panic attack
Intense worries about when the next attack will happen
Fear or avoidance of places where panic attacks have occurred in the past
• Specific phobias and social anxieties
risks
• Shyness, or behavioural inhibition, in childhood
• Being female
• Having few economic resources
• Being divorced or widowed
• Exposure to stressful life events in childhood and adulthood
• Anxiety disorders in close biological relatives
• Parental history of mental disorders
• Elevated afternoon cortisol levels in the saliva (specifically for social anxiety
disorder)
Burden
• Mental health is the single largest cause of disability in the UK
• 22.8% of total burden compared to 15.9% for cancer and 16.2%
for CVD1
• In 2007 £8.94 billion was spent on 2.28 million people with anxiety
disorders2
• By 2026, it is predicted that £14.19 billion will need to be spent on
2.56 million people with anxiety disorders2
• Generalised anxiety disorder negatively impacts patients’ quality of
life. Impairment in patients with generalised anxiety disorder alone
is equivalent to that of major depression
Generalised anxiety disorder is often not recognised in
primary care
Mental disorder recognised
but generalised anxiety
disorder not diagnosed
Mental disorder not recognised
28%
38%
34%
Specific generalised anxiety
disorder diagnosis
Based on a sample of 17,739 patients
5.3% with generalised anxiety disorder (DSM-IV)
DSM-IV, Diagnostic and Statistical Manual of Mental Disorders, 4th ed, criteria
Wittchen H-U. J Clin Psychiatry 2002;63(Suppl 8):24–34.
Frequent users of resources- visits per year and not
always presenting with anxiety (pain, insominia, etc)
20
15
15
14
10
7
5
3
4
2
0
No generalised anxiety
disorder or MDE
(n=16,023)
Pure generalised anxiety
disorder or MDE
(n=666)
Generalised anxiety
disorder and MDE
(n=278)
screening
• Several self-report questionnaires are available to assist doctors in
the detection of generalised anxiety disorder and depression:
• GAD-2 – quick screening tool for generalised anxiety disorder 1
• GAD-7 – screens for generalised anxiety disorder2
• Hospital Anxiety and Depression Scale (HADS) – screens for
anxiety and depression3
However, full diagnosis should be confirmed using DSM-IV or ICD10 diagnostic criteria
GAD-7: screening questionnaire
Over the last 2 weeks, how often have you been
bothered by the following problems?
Not at
all
Several
days
1
Feeling nervous, anxious or on edge
0
1
2
3
2
Not being able to stop or control worrying
0
1
2
3
3
Worrying too much about different things
0
1
2
3
4
Trouble relaxing
0
1
2
3
5
Being so restless that it is hard to sit still
0
1
2
3
6
Becoming easily annoyed or irritable
0
1
2
3
7
Feeling afraid as if something awful might
happen
0
1
2
3
Total score =
=
Add columns
+
More than
half the
days
Nearly
every
day
+
If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along
with other people?
Not difficult at all
Spitzer RL, et al. Arch Intern Med 2006;166:1092–7.
Somewhat difficult
Very difficult
Extremely difficult
Interpreting the GAD-7 results
GAD-7 score
Level of anxiety
Intervention
0–4
Minimal
–
5–9
Mild
–
10–14
Moderate
15–21
Severe
Undertake diagnostic
evaluation
Detects a probable diagnosis of generalised anxiety disorder
A cut-off score of 10 points demonstrates strong sensitivity (89%) and specificity (82%) for
generalised anxiety disorder
Spitzer RL, et al. Arch Intern Med 2006;166:1092–7.
GAD-2: screening questionnaire
Over the last 2 weeks, how often have you been
bothered by the following problems?
Not at
all
Several
days
1
Feeling nervous, anxious or on edge
0
1
2
3
2
Not being able to stop or control worrying
0
1
2
3
Total score =
=
Add columns
+
More than
half the
days
Nearly
every
day
+
A quick and easy to use screening tool for generalised anxiety disorder
A cut-off value of 3 has a sensitivity of 86% and a specificity of 83% for generalised anxiety
disorder
If the total score is ≥3 then refer to other screening and diagnostic tools to make a definitive
diagnosis of GAD
Kroenke K, et al. Ann Intern Med 2007;146:317–25.
Key questions to ask when assessing and diagnosing generalised anxiety disorder
1.
Have you felt stressed or worried lately?
2.
How long have you been feeling stressed or worried?
3.
How often do you feel like this?
4. Is there a particular cause for your worries?
5. What thoughts or worries go through your mind when you feel anxious?
6. Do you feel more tired or more tense than usual?
7. Do you have problems sleeping?
8. How do these problems affect your family/personal life?
9. How do these problems effect your everyday activities?
10.
Why do you think that you feel pain/do not sleep/are fatigued?
11.
Have you felt like this for most of your life?
12.
How do your symptoms affect you physically?
Identification-Step 1: All known and suspected
presentations of GAD
• Identify and communicate the diagnosis of GAD as early as possible to help
•
•
•
•
people understand the disorder and start effective treatment promptly. [new
2011]
Consider the diagnosis of GAD in people presenting with anxiety or significant
worry, and in people who attend primary care frequently who:
have a chronic physical health problem or
do not have a physical health problem but are seeking reassurance about
somatic symptoms (particularly older people and people from minority ethnic
groups) or
are repeatedly worrying about a wide range of different issues. [new 2011)
Stepped care for GAD
• Step 1 – identification and assessment, education and active monitoring
• Step 2 – individual pure self help, individual guided self help or psycho-
educational groups.
Books: ‘Living with fear’ by Marks IM,
‘Mastery of your anxiety and panic’ by Barlow DH
‘Overcoming anxiety’ by Kennerley H.
• Step 3 – high-intensity psychological interventions (CBT or applied
relaxation)
OR
drug treatment (Sertraline).
See them within 1 week of starting rx
• Full anxiolytic effect takes 2 weeks or more.
• Important to continue Rx after remission to prevent relapse (at least 1
year).
• Step 4 – consider referral to secondary care
SSRI/SNRI at step 3
• Sertraline 1st line
• If ineffective/ not tolerated then another SSRI or SNRI
• Consider: withdrawal syndrome/ side effect profile/ risk of
suicide/self harm-toxicity in OD/previous experience of drug Rx
Benzodiazepines
• Do not offer BDZs for Rx of GAD apart from short-term measures
during a crisis. Advice in BNF - not be used as sole rx for chronic
anxiety.
• Avoid driving- even the next morning
• Can become habit forming after 2 weeks
• In long term can cause rebound insomnia and anxiety
Beta blockers
• B blockers help with palpitations and tremor NOT
psychological symptoms/muscle tension
• Side effects: cold extremities, tiredness
• NOT with asthma
Anti psychotics
• Do not use antipsychotics for rx of GAD in primary
care e.g chlorpromazine, haloperidol, risperidone,
aripiprazole
• Risks out weigh benefits
• Weight gain, increased risk of Diabetes, Cardio
vascular disease including stroke
Principles of care in GAD
• Provide contact numbers and info about what to do
and who to contact in a crisis
• Comorbid anxiety or physical disorder? Treat the
primary disorder first (the one that is more severe)
• Non-harmful alcohol misuse not a contraindication to
rx of GAD. However with harmful and dependent
alcohol misuse , rx this first as alone it may lead to a
significant improvement in GAD
SMI
• bipolar disorder and schizophrenia managed by primary care health
•
•
•
•
professionals
essential to know how these conditions may present and the current
treatments
Bipolar disorder often under‐diagnosed in primary Care.
People with schizophrenia are often monitored by primary care
A holistic recovery focused approach to care is recommended.
Bipolar disorder• Although 90% will have experienced a major
depressive episode this does not have to be present to warrant
diagnosis to be made
• 15-24 years
• Substance misuse common
• higher risk of physical health problems and of suicide
Types BAD
• Type I is characterised
one or more manic episodes (lasting at least a week). Although
having depressive episode is not required for the diagnosis
• The majority of people will experience both depressive and mania
• Misdiagnosis due to
individuals are likely to present with a depressive episode; often
more than one episode depression before mania
• Type 2- one episode hypomania and one depression
ICD 10
• Emotional
• Physical
Mood swings such as euphoria/elation to
anger/irritability
Immediate gratification of wishes
Cognitive Racing thoughts, pressure of speech Distracti
ble Flight of ideas
Impaired judgement
Behavioural Intrusive/demanding/
aggressive Impulsive
Sexually disinhibited, increased libido
Increased energy/always on the go
Decreased need for sleep
Appetite changes
Lack of attention to personal hygiene/gene
ral health
Psychotic symptoms in mania
Delusions generally mood congruent.
Grandiose in nature –
beliefs about being royalty or
having special powers but can be
persecutory
Hallucinations –
most commonly auditory, don’t tend to be u
npleasant
Rx BAD
• Acute- antipsychotics, mood stabiliser; short term benzoz
• Maintenance- lithium, Olanzepine or quetiapine; anticonvulsants, self
management- Early warning signs, lifestyle changes; psychological- CBT,IPT
and psychoeducation
• Liaison with and referral to secondary care
Schizophrenia
• Positive symptoms
Schizophrenic thinking withdrawal insertion broadcast
Delusions
Hallucinations- auditory primarily
third person
• Negative
Lower mood
Loss of interest ; lack motivation
Social withdrawal
Schizophrenia facts
Genetic loading or environmental factors such as childhood
trauma, are more likely to develop symptoms.
About 1% of the population develop
schizophrenia .
It affects males and females equally
It often first appears in early adulthood.
Substance misuse
Rx Schizophrenia
• NICE recommends that oral antipsychotic. Decrease the positive sym
•
•
•
•
•
ptoms.
Side effects
weight gain, cardiovascular problems and, with clozapine in particular, a
granulocytosis
Clozapine should be offered to people who have not successfully been
treated with at least two other antipsychotic medications. Any serious s
ide effects may affect compliance with the medication.
Depot- non compliance
Psychoeducation, CBT for psychosis, support groups Carer support
Work in a recovery focused manner, conveying hope and optimism
Rx contd.
• Yearly physical health checks to monitor cardio‐vascular disease in
particular
• A Family Intervention Programme should be offered
• Art therapy for negative symptoms
• CBT for distressing symptoms
• CMHT
CMHTs
• Ultimately we rely on secondary care to Rx SMI
• more integrated cooperation between primary care
and specialized mental health care
• THANK YOU and QUESTIONS