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Mental Health Joanna McSwiggan Q1. Mental Health A 28-year-old woman attends General Practice with a 3-month history of worsening low mood. She has experienced loss of concentration and is only able to sleep for 4 hours each night. Her family have noticed her clothes look looser on her and she has lost interest in several of her hobbies. She denies any thoughts of self-harm or of life not worth living. According to the DSM-5, what are the requirements for a diagnosis of depression to be made? a) ≥5 symptoms, experienced almost daily for at least 4 weeks b) ≥5 symptoms, experienced almost daily for at least 2 weeks c) ≥5 symptoms, experienced almost daily for at least 3 months d) ≥4 symptoms, experienced almost daily for at least 2 weeks e) ≥4 symptoms, experienced almost daily for at least 3 months Q1. Depression Answer: b) ≥5 symptoms, experienced almost daily for at least 2 weeks In DSM-5, depression is defined as the presence of at least 5 out of the following 9 symptoms present almost everyday for at least 2 weeks. At least one of which must be low mood or anhedonia 1. Depressed mood 2. Anhedonia - Loss of interest or pleasure in almost all activities 3. Significant changes in appetite or weight 4. Sleep disturbances - Insomnia or hypersomnia 5. Fatigue, low energy, reduced efficiency at completing tasks 6. Excessive worries or thoughts of guilt or worthlessness 7. Psychomotor agitation or retardation which is observable by others 8. Difficulty concentrating or making decisions 9. Recurrent thoughts of death, suicidal ideation (with no plan) or suicide plan/attempt Q2. Depression 6 months later this patient returns to the GP. She has been taking Sertraline daily. Recently she has noticed great improvement in her mood and has had no depressive symptoms. She would like to know if she can now stop taking the Sertraline, what is the most appropriate advice to give her? a) Trial stopping Sertraline for 2 weeks and review b) Continue for a further 3 months and review c) Continue for a further 12 months and review d) She can stop taking Sertraline today e) Continue for a further 6 months and review Q2. Depression Answer: e) Continue for a further 6 months and review • To greatly reduce the risk of relapse it is recommended that anti-depressants be continued for at least 6 months after remission. • The SSRI dose is then tapered down over a 4-week period • History of recurrent depression, having a chronic health condition, unhealthy coping mechanisms and personal/social/environmental factors (which contributed to depression) still being present all increase the likelihood of relapse. Discontinuation symptoms • Stopping or reducing the dose of anti-depressant can put some patients at risk of discontinuation/withdrawal symptoms. • Start within 1-4 days • Symptoms can range from mild to severe: sensory symptoms (paraesthesia, electric shock sensations), GI symptoms, sleep disturbances, disequilibrium, irritability, somatic symptoms (headache, tremor, sweating, flu-like symptoms) Q3. Mental Health A 19-year-old attends the GP due to his father being concerned about recent changes in his behaviour. Over the past 4 days he has been sleeping very little and has stayed up at night spending money on online shopping and cleaning the house. On examination he is friendly, has pressured speech and is easily distracted by his surroundings. He denies any hallucinations. He has a history of depression for which he takes citalopram. What is the most likely diagnosis? a) Bipolar Disorder Type I b) Bipolar Disorder Type II c) Obsessive Compulsive Disorder d) Schizoaffective Disorder e) Generalised Anxiety Disorder Q3. BPAD Answer: b) Bipolar Disorder Type II Bipolar disorder Type I 🡪 Depression + Mania Bipolar disorder Type II 🡪 Depression + Hypomania • Bipolar Affective Disorder (BPAD) is a mood disorder characterised by periods of depression and mania/hypomania Symptoms • Elevated mood or irritability • Increased energy, overactivity, decreased need for sleep • Inflated self-esteem and confidence • Insomnia, loss of inhibitions, impulsivity, increased appetite • Flight of ideas, pressured speech, poor attention © Geekymedics • Mania – symptoms are more severe, lasting at least 7 days, significant functional impact on daily activities, may require hospitalisation, psychotic symptoms (auditory hallucinations, delusions of grandeur) • Hypomania – symptoms last at least 4 days, less severe, no significant impairment Q4. BPAD A 33-year-old man attends a psychiatry clinic to discuss starting lithium for the management of his bipolar disorder. Which of the following should be monitored when starting lithium? a) Echocardiogram b) LFTs and U&E c) Coagulation screen d) U&E and TFTs e) LFTs and TFTs Q4. BPAD Answer: d) U&E and TFTs Lithium is a mood stabiliser used in the management of BPAD, it requires close monitoring • Narrow therapeutic range 0.4-1.0mmol/L, check levels 12 hours post-dose • Lithium levels measured weekly until stable then every 3 months for the first year then every 6 months Monitoring • TFTs –hypothyroidism • U&E, eGFR – nephrotoxicity, nephrogenic diabetes insipidus • Calcium – hyperparathyroidism 🡪 hypecalcaemia • ECG – T-wave inversion/flattening • BMI – Weight gain Other AE: GI upset, polyuria, hand tremors, intracranial hypertension Q5. Mental Health A 21-year-old woman attends her GP due to feeling constantly ‘on the edge’ and wakens most nights worrying about the future. She mentions that sometimes she feels her heart racing in her chest and often feels lightheaded but has never fainted. She first noticed her symptoms start 6 months ago when she moved house and started a new-high stress job. On examination she appears restless in the chair and has sweaty palms. What is the most likely diagnosis? a) Generalised anxiety disorder b) Panic disorder c) Acute stress disorder d) Bipolar Affective Disorder e) Avoidant personality disorder Q5. Generalised anxiety disorder (GAD) Answer: a) Generalised anxiety disorder • This patient describes persistent symptoms of anxiety e.g. feeling on the edge, wakening at night, worrying about the future and autonomic over-activity (light-headedness, sweating) • “Central feature is excessive worry about a number of different events associated with heightened tension” (NICE) • Commonly occurs with depression and other anxiety disorders (OCD, PTSD, social phobia) • Symptoms of depersonalisation and derealisation also occur with depression, schizophrenia, substance misuse and epilepsy Differentials : • Hyperthyroidism • Cardiac disease • Drug-induced anxiety: salbutamol, theophylline, antidepressants, corticosteroids, caffeine Q6. Generalised anxiety disorder (GAD) A year later this patient returns to her GP for a review. She has recently been promoted at work but finds it difficult to work under pressure and give presentations as she experiences nausea, sweating and hand tremors. She would like to know if there is anything the GP can prescribe to help these symptoms. Which of the following medications can be used to treat the somatic symptoms of GAD? a) Sertraline b) Nifedipine c) Propranolol d) Bisoprolol e) Salbutamol Q6. Generalised anxiety disorder (GAD) Answer: c) Propranolol Can be used to manage somatic symptoms (sweating, tachycardia, abdominal spasms, dizziness, etc) but consider risk of overdose. Management • Education and self-help • CBT • Sertraline/SSRI 🡪 Alternative SSRI or SNRI (e.g. duloxetine) ❌ Sertraline – SSRI used in the management of GAD but does not target somatic symptoms ❌ Nifedipine – Dihydropyridine Calcium Channel Blocker ❌ Bisoprolol- Cardio-selective beta blocker ❌ Salbutamol – Short-acting β₂ adrenergic receptor agonist, can cause hand tremors Q7. Mental Health Adam, a 33-year-old man has recently been admitted to a psychiatric ward. He tells you that for the last year MI5 has been following him through an implant in his brain. He confides in you that they can put thoughts in and out of his head and are able to change his mood. Adam can also hear voices in his head talking to each other and criticising him. He regularly takes cannabis and drinks 12 units of alcohol a week. A collateral history is taken from his siblings who are concerned that he has become increasingly withdrawn, refusing to go out and lacks motivation to carry out daily chores. What is the most likely diagnosis? a) Schizoaffective disorder b) Bipolar Disorder c) Schizotypal disorder d) Schizophrenia e) Autoimmune encephalitis Q7. Schizophrenia Answer: d) Schizophrenia • Relapsing/remitting form of psychosis with positive and negative symptoms which affect multiple areas of a person’s life • Risk factors: family history, childhood trauma, cannabis use, unemployment, isolation, urban living, history of mental illness or self-harm Schneider's first rank Negative symptoms Other symptoms • Thought disorders - • Anhedonia • Lack of insight withdrawal, insertion, • Alogia (poverty of speech) • Neologisms broadcasting • Auditory hallucinations – • Avolition (poor motivation) • Mood-related symptoms thought echo, third-person • Affective flattening • Cognition issues – memory • Disinterest in ADL and learning • Delusional perceptions • Passivity phenomena • Disorganised speech and behaviours Q8. Mental Health 6 months later Adam attends a review appointment in a psychiatric outpatient clinic. He is currently prescribed Olanzapine and has previously tried Aripiprazole but has had little improvement with these medications. The doctor believes Adam would benefit from stopping the Olanzapine and starting another anti-psychotic, Clozapine. Which adverse effect is associated with Clozapine? a) Tardive dyskinesia b) Acute dystonia c) Agranulocytosis d) Hyposalivation e) Diarrhoea Q8. Schizophrenia Answer: c) Agranulocytosis Clozapine is used in the management of • Atypical anti-psychotics 🡪 Metabolic side schizophrenia if 2 anti-psychotics (at least one is 2nd effects more common gen/atypical) were trialled consecutively for 6-8 weeks each st • 1 gen/Typical anti-psychotics 🡪 Extrapyramidal side-effects Adverse effects: (parkinsonism, acute dystonia, tardive dyskinesia, akathisia) more common • Agranulocytosis, neutropenia – monitor FBC • Myocarditis • Both increase risk of stroke and VTE in elderly patients. • Reduced seizure threshold • Weight gain Anti-psychotic monitoring: • FBC, U&E, LFTs • Hypersalivation • Lipids, weight • Prolactin • Constipation – risk of bowel obstruction • Fasting blood glucose • Blood pressure • Baseline ECG • Annual CVD risk assessment Depression BPAD GAD Schizophrenia o Self-guided help o Mood stabiliser – o Education and o CBT sodium valproate, self-help o Counselling o Family intervention o CBT lithium o CBT o Assess CVD risk o Behavioural o Mx depression – o Sertraline/SSRI 🡪 o Atypical activation fluoxetine Alternative SSRI or anti-psychotic – o Mx mania – SNRI (e.g. o Pharmacological risperidone, mx olanzapine, duloxetine) olanzapine, o SSRI haloperidol aripiprazole o Stop o Treatment o SNRI anti-depressant resistant: Clozapine o Mirtazipinr o MAOI o Assess CVD risk o Mx acute o <18 years: episode/risk of harm – Fluoxetine de-escalation, o Refractory lorazepam, depression - ECT promethazine, or haloperidol THANKS! 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