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ALL OU NEED TO KNOW ABOUT LOW MOOD Faaduma Aden Here’s what we do: ■ Weekly tutorials open to all! ■ Focussed on core presentations and teaching diagnostic technique If you’re new here… ■ Bstudentsl students, for medical ■ Reviewed by doctors to ensure W elcome to accuracy T eaching ■ We’ll keep you updated about our Things! upcoming events via email and groupchats!Session will be covering Depression Suicide risk Anxiety OCD CPP - MHA, MCA, DOLsDepressionMental Health hxMental Health hx Main structure ■ PC ■ HPC ■ Systems review including risk ■ past psychiatric hx ■ PMH, DH, FH, SH ■ Personal hx ■ Criminal hx ■ Premorbid hx ■ Collateral hxMental Health hx Main structure Formulation ■ PC ● This takes into ■ HPC ■ Systems review account the including risk Bio,Psycho,Social ■ past psychiatric hx factors that are ■ PMH, DH, FH, SH ■ Personal hx contributing to their mental condition. ■ Criminal hx ● Specifically, the ■ Premorbid hx predisposing, ■ Collateral hx precipitating, perpetuating and protective factorsMental Health hx Main structure Formulation ■ PC ● This takes into ■ HPC ■ Systems review account the including risk Bio,Psycho,Social ■ past psychiatric hx factors that are ■ PMH, DH, FH, SH ■ Personal hx contributing to their mental condition. ■ Criminal hx ● Specifically, the ■ Premorbid hx predisposing, ■ Collateral hx precipitating, perpetuating and protective factors Key Points for Hx taking ● Difficult to maintain rigid structure, Mental health Hx is like a conversation, and questions are asked opportunistically ● Signposting ● Normalising Mental Health hx SR From Y5 OSCE pack Mental Health hx SR From Y5 OSCE pack Mental Health hx SR From Y5 OSCE packMental Health hx From Y5 OSCE packMental Health hx From Y5 OSCE packMental Health hx From Y5 OSCE packMental Health hx From Y5 OSCE packCondition specific questions Depression Anxiety PsychosisCondition specific questions Depression Anxiety Psychosis Core: Persistently low mood, Decreased energy ie fatigue, anhedonia, Bio: weight change, sleep change, cognitive issues ie reduced concentration, memory problems, reduced libido activity change ie psychomotor retardation or agitation, Negative mood change: guilt, feelings of worthlessness, reduced motivaiton, hoplessnesss, suicidal ideation Psychotic depression - delusions - nihilistic, cortads, hallucinationsCondition specific questions Depression Anxiety Psychosis Core: Nervousness, On-edge Persistently low mood, Decreased energy ie fatigue, Difficulty concentrating anhedonia, Fatigue Muscular tension or motor Bio: restlessness weight change, sleep change, Sympathetic autonomic cognitive issues ie reduced overactivity concentration, memory GI upset, dry mouth, problems, reduced libido activity change Irritability/mood ie psychomotor retardation or disturbance Sleep disturbance. agitation, Somatic symptoms Negative mood change: palpitations, guilt, feelings of worthlessness, sweating, trembling, reduced motivaiton, dyspnoea, chest pain, hoplessnesss, suicidal ideation Psychotic depression - dizziness, chills, hot delusions - nihilistic, cortads, flushes) hallucinationsCondition specific questions Depression Anxiety Psychosis +ve: Core: Nervousness, On-edge auditory hallucinations: Persistently low mood, Difficulty concentrating number of voices, 3rd Decreased energy ie fatigue, Fatigue anhedonia, person -[talking about the Bio: Muscular tension or motor patient] outside the head, restlessness commanding? Asked to weight change, sleep change, Sympathetic autonomic harm self or others? cognitive issues ie reduced overactivity Delusions: concentration, memory persecutory, reference, problems, reduced libido GI upset, dry mouth, activity change Irritability/mood grandeur, nihilistic - disturbance everything is ie psychomotor retardation or Sleep disturbance. mood congruent/incongruent, agitation, Somatic symptoms thought disorder Negative mood change: -ve: guilt, feelings of worthlessness, palpitations, apathy, anhedonia, blunted sweating, trembling, reduced motivaiton, dyspnoea, chest pain, affect, poverty of speech and hoplessnesss, suicidal ideation dizziness, chills, hot thought, lack of motivation, Psychotic depression - flushes) passivity phenomena delusions - nihilistic, cortads, Organic causes: hallucinations dementia, delirium - can happen in old or youngMSE - Mental State Exam ASEPTIC From Y5 OSCE packMSE - Mental State Exam ASEPTIC From Y5 OSCE packMSE - Mental State Exam ASEPTIC From Y5 OSCE packMSE - Mental State Exam ASEPTIC From Y5 OSCE packMSE - Mental State Exam ASEPTIC From Y5 OSCE packMSE - Mental State Exam ASEPTIC From Y5 OSCE packMSE - Mental State Exam ASEPTIC From Y5 OSCE packFrom Y5 OSCE packCase 1 You are an F2 working in Gp 24 year old Johnny presents, with feeling tired all the time How would you assess this patient? What would you do next? How would you manage this patient Depression Hx Markscheme From Y5 OSCE pack Depression MSE Markscheme From Y5 OSCE packDepression DSM V Criteria Risk factors ● 1 of the symptoms below + present most ● Female sex. days for > 2 weeks ● Older age. ● Past Hx / Family Hx of depression. ○ Low mood ● Personal, social, or environmental ○ Anhedonia factors ○ Low energy a. EG relationship issues or ● 5 of 9 symptoms breakdown, bereavement, ○ Low mood stress, poverty, unemployment, ○ Anhedonia homelessness, social isolation, ○ Unintentional weight loss / change in or Adverse childhood appetite experiences ● Postpartum period. ○ sleep disturbance (insomnia or ● History of other mental health hypersomnia) ○ psychomotor changes (agitation or conditions and/or substance misuse retardation) ● Other chronic physical health conditions associated with ○ tiredness, fatigue, or low energy, or functional impairment decreased efficiency ○ a sense of worthlessness or Investigations excessive, inappropriate guilt ○ Reduced concentration ● PHQ9 ○ suicidal ideation, or suicide attempts. ○ Less severe = PHQ9<16 ○ More Severe = PHQ9>16 Management Step 1: ■ Active monitoring ■ Psychoeducation Step 2: ■ Medication ■ Low intensity therapy – Guided self help, group physical activity, group CBT Step 3 ■ Medication ■ High intensity psychological therapies – CBT, interpersonal therapy, behavioural activation Step 4 ■ Medication + high intensity psychotherapy +/- ECT ■ involve specialist, – consider inpatient care – crisis servicesManagement - Antidepressants Key points 1. Avoid TCAs and venlafaxine - risk of death from overdose 2. TCAs lower seizure threshold 3. Sertraline, citalopram if on other medical conditions - have least drug interaction profile 4. Fluoxetine for <30 year olds 5. Mirtazapine → if ↑ risk of bleeding eg on warfarin, heparin or NSAIDs 6. Paroxetine / sertraline if pregnant Serotonin syndrome ■ PC: – neuromuscular excitation, autonomic effects, and altered mental status. – Symptoms include: clonus, hyperreflexia,tremor, muscle rigidity, confusion ■ Due to excess serotonin ■ Toxicity ranges from mild to severe - hence syndrome ■ Invgx - – clinical diagnosis, use Hunter Serotonin Toxicity Criteria (HSTC) to aide diagnosis, ■ Mgx – Mild severity - ■ stop drug, reduce dose – Moderate severity - ■ stop drug + observation, ■ consider offering benzodiazepine or cyproheptadine – Severe - ■ stop drug, emergency supportive care, ■ consider activated charcoal, chlorpromazine / cyproheptadine, stopping the drugCase 2 You are an F1 in AE, Robert has been brought to the hospital after an overdose. He has been assessed and is deemed medically fit and is awaiting a psychiatric review. Please take a History from him Overdose Hx From Y5 OSCE pack Overdose Hx Risk factors for Suicide - Male sex - Hx deliberate self harm - Drug/alcohol misuse - Hx mental illness - Hx chronic disease - Advancing age - Unemployment or social isolation - Being unmarried, divorced or widowed From Y5 OSCE packAnxietyCase 3 You are an F1 in GP Debbie has come in to discuss concerns about chest pain Please take a History Anxiety Hx Markscheme From Y5 OSCE pack Anxiety Hx Markscheme From Y5 OSCE packAnxiety disorders Acute stress reaction PTSD Duration >3 days AND ≤ 4 weeks after event > 4 weeks Criteria Occurs immediately after a direct or indirect traumatic event eg Anxiety Due to exposure to trauma mugging, accident, cardiac arrest etc Results in emotional distress Key Key Key symptoms ● Reflection, intrusive thoughts ● Flash backs, nightmares ● Negative mood change ● Avoidance ● Dissociation ● Negative mood change: self blame, negative ● Avoidance or triggers beliefs, ● Hypervigilance, concentration difficulty, sleep Other clinical features problems ● Rapid onset Other clinical features ● Heightened arousal ● Palpitations, chest discomfort/pain, SOB, ● Overwhelming anxiety, sense of unreality hypervigilance ● Palpitations, chest discomfort/pain, SOB, hypervigilance Mgx 1st line: Trauma focussed CBT Depends on severity Occasionally use medication for symptomatic relief Mild: Trauma focussed CBT or EMDR Moderate / not responding to psychotherapy: antidepressants eg sertraline Severe: referral to secondary psychiatric care GAD Panic Attacks Adjustment disorder Duration ≥ 6 months Recurrent Episodic short lasting attacks ≤6 months Criteria ● Persistent, Excessive worry Recurrent Episodes of sudden onset ● Temporary maladaptive response to major ● Generalised over various domains unexpected anxiety attacks life change / life stressor eg relocation, ● Free floating - Worried most days appear to be random with no specific trigger, bereavement, new job ● Difficult to control worry Last 10 - 60 mins ● Lasts <6 months after the stressor ends ● Causes significant impairment in Fear of having another attack ● Emotional or behavioural symptoms due to functioning stressor ● Not due to substance misuse or ● Symptoms are excessive compared to another medical condition or mental severity of stressor, causing distress disorder ● Impairment in life eg social, work, school Key Associated with ≥ 3 of symptoms below Key features Key features symptoms ● Restlessness / on edge, easily Intense fear, feel like they will die, or lose ● Mood disturbance: depression or anxiety fatigued, difficulty concentrating, control / go crazy ● Avoidance irritability, muscle tension, sleep Other clinical features disturbance Other Clinical features ● insomnia, headache, abdominal pain, chest Other clinical features Palpitations, Sweating, Trembling/shaking, SOB, pain and palpitations. ● Sympathetic / autonomic overactivity: choking sensation, Chest pain/discomfort, nervousness, trembling/shaking, GI Nausea, Dizzy/lightheaded, Derealization upset, palpitations, sweating, dry depersonalization, Paresthesias, Chills/hot mouth flushes. Mgx Psychoeducation, self guided psychotherapy psychotherapy - CBT psychotherapy - CBT, group therapy, family therapy Low intensity CBT Self care - stress management, physical activity Self care - stress management, physical activity, High intensity CBT/applied relaxation or Medication for symptomatic relief support network medication Referral to secondary care if severe Sertraline 1st line Referral to secondary careAnxiety disorder - How I Differentiate Between them Acute stress disorer PTSD GAD Panick Attacks Adjustment disorder >3 days AND ≤ 4 ≥ 4 weeks ≥ 6 months Episodes of <6 months weeks from event Traumatic Persistent anxiety, no Within 3 months of Rapid Onset Event Excessive pattern to major life stressor/ Traumatic event worry, focus trigger change changes Normally fine Maladaptive aside from response to stress episodes Traumatic eventAnxiety Management Step 1 - Mild / Initial management Active monitoring, psycho education, social intervention Step 2 - Mild Low intensity psych intervention - self help, psychoeducational groups Step 3 - Moderate / Treatment resistant Mild Medication OR high intensity psychological therapies CBT/applied relaxation therapy - Moderate Step 4 - Severe / at risk of self harm Medication +/- high intensity psychological therapies CBT/applied relaxation. Involve specialist, consider inpatient care Conservative Self Care Advice: Physical exercise, social supportCase 4 You’re an F2 working in GP. Sarah Smith has come in to discuss some concerns regarding her mental health. Please take a History and examine her OCD Hx Markscheme Extra things ● SR ○ Depression ○ Mania, ○ Psychosis ● Past Psychiatric Hx Insight Severity - impact on functioning Severity - risk From Y5 OSCE packOCD Core features DSM V criteria Obsession or compulsion, and causes significant functional ● Acknowledge originating from impairment / distress own mind ● Repetitive + unpleasant, ● Don’t need both for diagnosis ● Obsession acknowledged as ○ recurrent unwanted, intrusive thoughts or images unreasonable ● Tries to resist it but causing distress / anxiety / disgust ○ eg someone being horribly injured, unsuccessful ● Compulsions: ● Experience is not pleasurable ○ repetitive behavioural or mental actions patient is compelled to do, aimed at reducing the anxiety or Main categories prevent a situation ● Checking ○ Can be overt or mental eg saying a certain phrase ● Contamination / Mental Contamination a number of times, or doing a certain action ● Symmetry and ordering Significant time investment and interference with daily life. ● Ruminations / Intrusive Thoughts Severity assessed via Y-BCOS scale Not attributable to other physical or mental health condition ● HoardingY -BOCs Scales 8-15 = Mild OCD 16-23 = Moderate OCD 32-40 = Extreme OCD Initial Active monitoring Management Psychoeducation Guided self help Mild Low intensity CBT including ERP Moderate Choose one of High intensity CBT + ERP Medication: ■ Sertraline 1st line, ■ clomipramine 2nd line If SSRI effective, continue for at least 12 months, Severe Refer to secondary care MH team for assessment Offer SSRI + High Intensity CBT [including ERP]CPPMCA vs MHA vs DOLs MHA ■ for treating MH condition, based on treatability, necessity / risk, objective judgement ■ Can't treat physical health under MHA MCA ■ assess capacity - 4 criteria: understand, retain, judge, communicate ■ Time and decision dependent DOLs ■ Comes under the MCA ■ restrict ability to leave if patient lack capacity and clear clinical reason why cant leave If in doubt - think why is patient in hospital ■ Mental health - MHA ■ Physical health - MCAT ypes of sections 2 compulsory admission to hospital for assessment, valid for 28 days, can be upgraded to a section 3 once in hospital if confirmed mental illness + needs to be admitted against their will 3 6 month treatment order – pt with established psychiatric diagnosis, AHMP and 2 docs who have seen the patient within 24h 4 emergency treatment order, when S2 would be too slow, can be changed to section 2 on hospital arrival, 72h 5(2) 72h doctor’s holding power – hospital inpatient who is trying to leave and must have suspected psychiatric disorder 5(4) 6h nurse’s holding power 135 warrant to ENTER PROPERTY and take person to place of safety in 72h e.g. police station, A&E etc – magistrate approval 136 Police power to take person from public place to place of safety if suspected mental disorder conferring immediate risk in 24hSBA1.1 A 34 year old man is admitted to the emergency room after a fall. On examination there is an open fracture wound at the right proximal humerus. A right shoulder X-ray confirms a fractured proximal humerus and distal clavicle. is currently managing well in the community and adherent to medication. He ise also refusing to be operated on.. What is the next best management? A. Restrict him B. Assess Capacity C. Put him under a DOLs D. Assess him under the MHASBA 1.1 A 34 year old man is admitted to the emergency room after a fall. On examination there is an open fracture wound at the right proximal humerus. A right shoulder X-ray confirms a fractured proximal humerus and distal clavicle. is currently managing well in the community and adherent to medication. He ise also refusing to be operated on. What is the next best management? A. Restrict him B. Assess Capacity C. Put him under a DOLs D. Assess him under the MHASBA1.2 During the capacity assessment the patient states they do not want treatment because the pain has gone down therefore there is no problem. They also state they are more concerned about going home as the hospital is suspicious and plotting against them. You have explained the risks to them but they deny that there is a risk. Assume all possible reasonable adjustments have been made. What is the next best management? A. Restrict him B. Place him under a section 5(2) C. Put him under a DOLs D. Assess him under the MHASBA1.2 During the capacity assessment the patient states they do not want treatment because the pain has gone down therefore there is no problem. They also state they are more concerned about going home as the hospital is suspicious and plotting against them. You have explained the risks to them but they deny that there is a risk. Assume all possible reasonable adjustments have been made. What is the next best management? A. Restrict him B. Place him under a section 5(2) C. Put him under a DOLs D. Assess him under the MHA THANKS FOR WATCHING! Please fill out the feedback form on Medall and see you next week!