Care of patients with mental health problems.

1. Care of patients with mental health problems. Jo Swallow ST’s- 2012.

2. Anxiety-An age old problem… • Where is this quote from? • "There is nothing either good or bad, but thinking makes it so“ ……..

3. 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

4. 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…..

5. 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)

6. 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. 8-20hrs (1-2hr weekly) • SSRI half improved, NNT=5. • Follow up 2,4,6 wks, 3months, 6 months.

7. 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.

8. CBT in practice? • Anyone tried this with a patient? • Anyone willing to try? • See DVD clip. – 10minute CBT

9. 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)

10. 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.

11. SSRI • Start low, • 8 wks on any dose, • Minimum total 6/12. • Tail off over 1-2months. • Discontinuation reaction-list syx……

12. Discontinuation • Dizziness, numbness, tingling, nausea, headache, sweating, insomnia, feeling anxious.

13. Resources for patients • http://www.nice.org.uk/nicemedia/live/13314/54074/54074.pdf • THIS IS A BRILLIANT RESOURCE (including the below links, podcasts, diaries, interactive self help) • http://downloads.bbc.co.uk/health/factsheets/structured.pdf • http://www.moodjuice.scot.nhs.uk/Anxiety.asp • http://www.llttf.com/index.php?section=page&page_seq=13 • Others: Moodkit app for iphone. • http://moodgym.anu.edu.au/welcome

14. 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?

15. 60% Higher prevalence in african-caribbean, asian, refugee and asylum seekers than caucasian population. • People with a chronic disease • Family hx

16. Symptoms of depression.-list • Mystery jets track + others…..

17. 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)

18. 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.

19. 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.

20. NICE 2009 • Assess, quantify with hads/phq9. • Guided self help • Computerised CBT • Group CBT • Interpersonal therapy, behavioural activation, mindfulness based cbt. • Drugs

21. Drug treatment for moderate/above only. • Sertraline may be best choice. • Most effective – mirtazepine, escitalopram, venlafaxine, sertraline. • Best tolerated – escitalopram, sertraline, citalopram.

22. 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.’

23. 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.

24. 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/Switching-Antidepressants/ • Continue until well for 6/12. • Stopping, withdraw over 4 wks gradually.

25. Depression Questions? • ?etoh, advise abstinence • Exercise, definitely helps, advise • ?seasonal component, consider, light therapy www.sada.org.uk • Co-existing anxiety?

26. Websites to share

27. 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).