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DEPRESSION, AXNIETY, OCD MCA/MHA Year 4 M&M Teaching Psychiatry PPALS Caitlin and LucreziaTODAY'S TOPICS TO COVER TEACHING • Depression • Drug counselling: sertraline • Anxiety disorders (GAD and differential diagnoses) • The Mental Health Act • The Mental Capacity Act • SBAQsDEPRESSION WHAT IS IT? A PERIOD OF LOW MOOD THAT PERSISTS FOR A NUMBER OF WEEKS/MONTHS AND INTERFERES WITH EVERYDAY LIFE CLINICAL FEATURES Core symptoms: Low mood, anhedonia and anergia Biological symptoms: change to appetite, sleep disturbance (early morning waking), poor concentration and low libido Cognitive symptoms: Feeling worthless, negative cognition about self/world/future For at least 2 weeks!! Depression Hx tip: always screen for other psychiatric conditions eg bipolar disorder and schizophrenia!! Source: Geeky Medics website Diagnosis 1. Questionnaires for assessing symptom severity (PHQ-9- over the last 2 weeks, how often have you been bothered by...) 2. ICD-10 or DSM-V to classify as mild, moderate or severe. 3. ICD-10 criteria are more clear-cut but NICE guidelines refer to DSM- V MANAGEMENT 1.Lifestyle change 2.Risk assessment, safeguarding and address co-morbidities if present 3.Mild to moderate: offer low intensity psychosocial intervention (referral or self-referral to IAPT) 4.Moderate to severe: offer high intensity psychosocial intervention and antidepressant medication 5.Pharmacological: SSRI first-line (usually sertraline in adults and fluoxetine in children)SSRI Choice of Sertraline, fluoxetine, citalopram Antidepressant of choice, 1st line antidepressant SNRI Venlafaxine, duloxetine 2nd line TCA Amitriptyline, imipramine Toxicity in overdose so avoid in patients at risk of attempted suicide. DRUG COUNSELLING SERTRALINE Action: increases levels of serotonin in brain Timeline: tablet taken once a day (take during morning if trouble sleeping) How to take: taken as a tablet Length of treat: once resolution of symptoms achieved continue for 6 months (longer if at risk of relapse) Effects (time before): 4-6 weeks to feel full benefits Tests: n/a Important side effects: increased risk of suicidal ideation (rare), sexual dysfunction, serotonin syndrome, discontinuation syndrome... Caution: increased risk of bleeding (with concurrent NSAID use), avoid St John's wort/triptans Supplementary information: avoid grapefruit juice, elderly THE MENTAL HEALTH ACT 1983 a mental health disorder.eatment and rights of a person with Sectioning under the MHA Section 2: assessment, up to 28 days and non-renewable. Section 3: treatment, up to 6 months and renewable. Section 135: gives police permission to break into somebody's property and remove the person to a place of safety. Tip for memorising Section 136: gives police permission to remove the person from a public 135, on the drive space to a place of safety 136, out in the sticksAT LEAST 2 4-6 WEEKS WEEKS Depression How long it takes to see full How long symptoms must benefits of antidepressant The have been present medication Important Numbers 6 MONTHS WITHIN 1 WEEK How long antidepressants When patients under 30 should be continued should be reviewed after following resolution of starting antidepressant symptoms medication.Generalised anxiety disorder and differential diagnoses ANY ANXIETY HX Key things to ask: When does it happen? (constant/intermittent) What triggers it? (fear of crowded spaces/obsessive thoughts and checking behaviours/specific phobia) Associated physical symptoms (SOB/palpitations/sweats/dizzy) and what di they think with these symptoms (i'm going to die) Impact on life (ICE ICE ICE)- copy mechanism RISK ASSESSMENT GENERALISED ANXIETY DISORDER Persists for >6 Free floating Physical symptoms months (GAD-7 anxiety, not related not explained by questionnaire) to a specific events organic causes/EPIDEMIOLOGY DIFFERENTIAL -ACE DIAGNOSIS -Female 2:1 -Other anxiety disorders -Other MH Hx PTSD Depressive disorders -Organic: Hyperthyroidism, ACSGAD-7 QUESTIONNAIRE Mild anxiety=5 Severe anxiety= 1510f LIFESTYLE o physical activity.uce caffeine and increase t e D PSYCHOLOGICAL e A CBT g G Exposure therapy a n PHARMACOLOGICAL a SSRI- sertraline, escitalopram M SNRI- duloxetine, venlafaxine Atypical antidepressants- mirtazapinePost Traumatic Stress Disorder (PTSD) Traumatic= think trauma Mnemonic: HARD Hyper-arousal Avoidance of situations/activities/memories of the event Re-experiencing the event: strong fear, horror, nightmares Distress: strong, overwhelming fear Key diagnostic criteria: 1.Exposure to an event/situation 2.following the traumatic event, developing characteristic syndrome features ^^ 3.Symptoms present for >4 weeks Dx Acute stress reaction Complex post traumatic stress disorder OBSESSIVE COMPULSIVE DISORDER (OCD) WHAT? KEY DIAGNOSTIC MANAGEMENT CRITERIA Obsessions are unwanted, intrusive, 1.Biopsychosocial model distressing thoughts/images. 1. Persistent thoughts 2.Trauma-focused CBT/EMDR Compulsions are repetitive 2. Obsessions/compulsions take >1 behaviours/mental acts that a hour of the day 3.SSRIs person feels driven to perform to 3. Symptoms not due to other relieve anxiety. medical condition/drugs. Mental Capacity Act 2005 1.Does the patient have impairment/ disturbance of brain function? 2. If yes, does this mean they are unable to make a decision? Determine if the patient can: •Understand information relevant to the decision (e.g. consequences, risks, benefits, alternatives) •Retain the information (for long enough to make a decision) •Weigh up the information to make a decision (pros and cons) •Communicate the decision (by any means) ALWAYS RISK ASSESS ICE EARLY S MAKE SURE YOU READ THE STATION I T BIOPSYCHOSOCIAL COMPONENTS INTO (MENTION QUESTIONNAIRES) E C DON'T BE AFRAID TO USE WORDS SUCH AS 'SUICIDAL' AND 'DEPRESSED', BUT S INCLUDE WARNING SHOTS O USE NHS WEBSITE AND ROYAL COLLEGE OF PSYCHIATRISTS PATIENT LEAFLETS FOR EXPLANATION STATIONSTHANK YOU FOR LISTENING!