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OK, I think I'm gonna give it a start now and hopefully some more people will join later. So today we're gonna be talking about low mood. So conditions to do with that. Um Hi, Edema, by the way. Um So this is a teaching things um session. So usually what teaching things does is that they provide weekly tutorials open to anyone and they focus on core presentations and teaching and diagnostic techniques and being able to differentiate between conditions it's um taught to you by medical students and um it's reviewed by doctors to ensure accuracy and if you want to stay update with future sessions as what's coming in the co in the coming weeks, um just check the events here on me or via email or group chats. OK. So the focus of today's session will be mostly on depression, suicide, anxiety, O CD and some um clinical professional practice um criteria which is to do with the Mental Health Act and the Mental Capacity Act. Um OK, so first of all depression, so to do to um diagnose depression or any other of these conditions, you need to know the mental health history um have any of you guys done this before? And if so, do you know any of the conditions? Um any of the sections of the mental health history, um aside from like the presenting complaint, history, presenting complaint, past medical history, social history, drug history, anything that's specific to the mental health history, it would be great to have lots of comments and on the chat, this is a very um interactive um feature of lots of case studies. No, that's ok. Um So the structure again, like any other history has got the presenting complaint, history of presenting complaint and assistance review to rule out any other conditions that it could be. Um the key thing here in a mental health history is that you've got the past psychiatric history. So um we'll go into this more in more detail later. That's the key thing. Um ok. Um Yeah, the session will be um on demand on me. Um the past medical history, drug history, family history and social history is the same as any other history. We've got the personal history. So learning about the person themselves and the factors that could be influencing their mental health, their criminal history. So have they had a run in with the law and their premorbid history? So what were they like before they had the mental health condition? And a collateral history is very useful because sometimes the patient may not be able to give you all the details themselves or have a different perspective and having information from other family members can be really help, helpful. Yes. Previous history of depression anxiety. Yeah, that'll be part of the past psychiatric history. Um All right, another thing that we do in mental health is that we create formulations. So this is where we think about the biopsychosocial um factors that influence people's mental health. And that will um we will um categorize all the different factors that could be influencing into predisposing. So they've had this from the beginning like genetics or um where they grew up. Um and that predisposes them to the mental health condition, but doesn't necessarily mean they'll get it precipitating factors. So things that triggered or led up to this mental health condition. So for example, losing a job or um a separation um and then perpetuating factors. So things that there are still here now that are push and continuing that are causing the mental health um situation to continue. So, for example, um poor finances or social isolation and there's also protective factors, things that stop you from getting the mental health condition or protect you from it. For example, having friends and family who can support you. Um The key thing about mental health history is that when it comes to talking to patients, not so much with actors in oy, but um it requires a, a delicate touch to it. So it's not always going to be structured like going from the top to the bottom. Um, it can go back and forth. You might have to be a bit opportunistic about what factors you talk about. Um, especially since the person is in a vulnerable situation may not want to talk about certain things. Um, so some key things I like to do is time posting. So just saying I'm going to be asking about your previous mental health, um, history just to get an idea of what could be causing this. If there's any other factors that could be causing this or I'd like to know what medications you've had before, just to give them an idea of what I'm going into and that can help ease them into it. Another thing is normalizing. So a lot of the things we ask about is very sensitive. So for example, suicide risk and it can be quite difficult asking. That's the one thing I find very useful is to just normalize it. So sometimes people who feel low in mood or um have, oh, feel very, feel low in energy or have these feelings of guilt can also feel that their life might not be worth living or they feel so low that they don't want to exist anymore. Have you ever had thoughts like this? So, just easing into it and normalizing, it can make it easier to approach these topics. But those are a couple of things that I use to take the mental health history. Um Next, I'm just gonna go into a little bit more detail about each section and then we'll do some case studies. Um So yeah, the first thing is just an introduction just to get to know what's um bothering the patient. Um After that is the history of presenting complaint. Can you guys give me any like questions you'd like to ask in the history of presenting complaint section? Anything at all? Yeah, it does take some time to type. So I'll in the interest of time, I'll just continue a bit. Um So some factors in the history of presenting complaint is just finding out about the events leading up to this. So what caused you to have these symptoms? Um um the nature of the problem, some like what symptoms specifically do they have. And this could be a good chance to ask about other symptoms that might be related to the condition you have in mind. So if you think they might have depression, asking about other symptoms related to depression, um Also asking about the impact on their life because with mental health conditions, the main thing is what is the severity of it is decided by how it's impacting your life, your function. Are you able to socialize, go to work and your relationships? Um Yes, those are usually the questions and I like a nice way. I like to do it is using the Socrates, but instead of Socrates, I shorten it to oats. So o for onset. So when did this start? Um, a for associate factors of other symptoms, they might, that they might have t for tank. So, um, how was it like in the beginning? And how did it progress? Did it get worse? Did it get better? Um, is it there all the time or does it come and go, um, exacerbating relieving factors? So what makes it better or worse and severity? Which is the impact on their life? Um, I'll come back to systems review later. The next session section is the past medical history. And in this mark scheme, they've also included the past psychiatric history. So the past psychiatric history is very useful because it tells you about if they've had um, previous inpatient experiences. So that can tell you about the severity of their mental health condition, um, if they've had any previous treatments. So that can tell you what works, what doesn't work. Maybe they're not complying with the medication or the management. Um, and also certain medications they might be on could have, um, side effects that might be causing their presenting complaint. So it's good, all good information to have. Um, yes, and the other medical conditions can tell you if they have like a chronic health condition can perpetuate having other mood disorders, like having low mood or depression. The next section is the drug history which is just asking about medications they're on. Um, and family history. This is important because um in mental health, certain um conditions can be linked genetically or they have a higher, you have a higher risk if you have a family history of a certain mental health condition. So that is useful. Um That's mostly it. Um and also just the relationship with the family can also impact their mental health. Um The next is the personal history. So this is quite um extensive. You won't have a chance to do this normally in like a ay scenario. But um, in the real world, you usually do go through this. Um, and this is just looking into their childhood, their education, um, if they've had it like their relationships and um, yeah, I think that's mostly it. Um, yes and then re can't be that. So one second. Um, yeah, employment as well. So being sacked from the job can have an impact on someone as well. Um, the next section is the past medical history. Very similar to what we went before to what we went through before this can help impact the medications they go through. Um, so certain medications may not be compatible with certain health conditions. Um, and again, substance misuse is very much linked to mental health conditions. It could be that the substance misuse could be used for coping or it could be a precipitating factor to them getting the mental health condition. Um, and lastly the social history. So, and criminal history. So if they've had any arrests or um imprisonments and the social history. Again, looking at alcohol and drug use, but also their social circumstances. So housing finances, these can be important stressors that can um precipitate a mental health crisis. Um and also just their relationship in home settings, things that could be helped out in the community setting, for example, sending them to um group therapies or activities, for example, and we've spoken about the premorbid personalities just how they were before they got the mental health condition. So another question. Um So there's specific que um questions you ask for different conditions. So, depression, anxiety and psychosis. Um is there any specific symptoms you would expect to see in someone with depression? There are usually two core symptoms or three core symptoms for diagnosing depression. Yes, lots of enjoyment things. Yeah. And hid Donia. Yeah. No mood. Um Yeah. So having a persistent low mood and decreased energy and fatigue are the core symptoms for depression? Um Can you think of any other um symptoms like biological or psy uh psychological symptoms that they might have? Suicidal ideation is one of them? Yep, weight loss or gain, correct? And that can be due to appetite change, disturbed sleep. Yeah. Yeah, that's really great. So yeah, the core symptoms, as I said is persistent low mood and decreased energy. Um and I had on you um but they can have other symptoms like we've spoken about weight change, cognitive issues and not being able to concentrate memory changes. This is more apparent in elderly people. So they might have symptoms of dementia, but they could just be that they have no mood um or depression, um reduced libido, um psychomotor retardation or agitation. So, having slow mo movements or faster movements, um and negative feelings like guilt, feelings of worthlessness, um reduced motivation, hopelessness. Um And sometimes in some instances, you can have some psychotic elements to as well. So, delusions. Um So for example, ages is where you think um your body is rotting or that you're already dead. Um and also hallucinations. So hearing voices, these can be negative um voices saying negative things. Um Yeah. And then for anxiety, what symptoms would you expect to see? It can be quite similar to depression but just some other things that you might see in anxiety, oftentimes anxiety might be mistaken for another condition. Yeah. Feeling dread. That's right. Yeah, feeling dread or feeling on edge. Heart palpitations, sweating. Yeah, excessive worrying. Correct. So, yeah, oftentimes um negative thinking schemes. Yeah. So with anxiety, it can often be um mistaken for like a physical condition. So like a heart condition, cardiac condition or breathlessness, asthma maybe. But in in fact, it's anxiety. So yeah, they have the key thing is the nervousness and the consistent worrying and that can cause things like difficulty concentrating, fatigue um and sympathetic symptoms also. So gi upset, dry mouth, um they can also have sleep disturbances and somatic symptoms, like the palpitations or sweating. That's all the fight or flight symptoms that you'd get. Um, and lastly it's psychosis. Um, there's some key things with psychosis. You've got your positive symptoms and your negative symptoms. Can anyone give you some examples? Hallucination? Yep. That's a positive symptom. Yeah. So, the thing with hallucinations and psychosis is that, um, there are specific ones, for example, auditory hallucinations, they can hear voices in the third person. So someone's speaking about them. So um s Tom is like this or Tom is doing this and sometimes they can hear outside their head and that's symptoms that you could um see in um schizophrenia. Anything else? Yeah. Not move on. Yeah. So you've got your positive symptoms, which is usually hallucinations and delusions. Um and these can be of different kinds like of persecution. So someone's out to get them of reference. So anything on TV is referencing them grandeur that they're doing something great or um like leg God or something. Um Nihilism and it can be mood congruent or incongruent. So if they're depressed, they can have nihilistic delusions or if um otherwise they could ha be depressed or low in mood but still have deletions of grandeur. So it depends and negative symptoms. So this is where they are losing something. So they have apathy and hid, blunted affect, um poverty of speech. So reduced speech, um lack of motivation and the passivity phenomena. So things are just happening to them. Um And they don't have any control. Um Yeah, and there might be organic causes for some of the symptoms seen in psychosis, for example, the hallucinations and um um the weird behavior could be due to delirium or dementia. And this can, um well, with delirium, it can happen in the old or young. So that's a good thing to keep in mind as a differential. Ok. We'll just quickly go through the mental state exam. I think it'd be better to just apply it than to go through it. But the slides will be available. Um But just quickly, what does aseptic stand for or anything else you use to remember the mental state exam or the different aspects? Yeah, your parents. Yeah. All right. In the intern of plan, I'm just gonna quickly move on. So yeah, it stands for appearance and um behavior for a um and then s is for speech, E is for emotion, which is mood and affect and then P is for perception and that's why you hear your hallucinations, auditory, visual tactile. So they might feel something under their skin. Um T is for thought and that comes into two sections. You've got your thought form and you thought content, content and the way I think of it thought form is the logic of their thinking. So, is it logical? Just one thought after the follow the next? So just like how I'm speaking now, it's all logical. Everything links. Um Sometimes it might not link, they might jump between things or they might go round in circles until they come back to the point. So yeah, that's thought form and then thought content what they're thinking about. So these could be delusions which aren't um which aren't realistic. Um They can have phobias, they can have obsessions, compulsions. Um Yeah, and with mood um the, so you have the subject of an objective. So the subject if is the mood, how does the patient describe them? They can say they're very happy or very low in mood but then you have your affect, which is how you see them in the moment. Well, when you're taking the history and they could be saying they're very elated but their face could be very blunt or flat and then that would be the affect um and also how they react throughout the consultation. So it could be that they're um very low in mood at first and then they start crying and then they start laughing and you would say that's label. So it's moving up and down. And so affect is what you see objectively and the mood is just how they are, how they feel that they are. Um Yeah, speech is just how they're speaking. Main things is just the volume, the tone and the rate um and appearance in general is it like, is there any signs of neglect um weight loss, et cetera? Um and also like the clothes they're wearing, it might show certain things like dark clothes could be like the low mood, very bright colorful clothes could be that the slightly go the elevated mood or like going through a mania or et cetera. Um Yeah, risk assessment is always key, making sure that you assess for self harm or you have suicidal ideation, cognition. So it could be that they're just um delirious, so they're not able to answer the questions properly and you can test that very quickly by just seeing if they're orientated to time place and person. Um It could also be that just very groggy from any substances they've used. So asking them to if they're unable to answer those questions and they seem very groggy just asking them to count down from 20 to 1. And if they're not able to do that just coming back another time and lastly insight. So are they aware that they have a illness? And do they feel that they need help? And um yeah, I think that's mostly it and the way I like to remember it is the three eyes. Um Yeah, I think the last one was, yeah, impact. So how's it affecting them? And then you summarize. So here I think the slide deck will be available after this. So I'll skip over this, but this is just what you would see normally on the left and then on the right, there's like what you would see in mainly in psychosis and it's slightly different with different mental health conditions. Um All right. The first case, it's gonna be a bit difficult cause you can't talk but just ask some questions and I'll answer or I can just give you the case as is um and just have a thought in your mind like what questions you might be asking? So you enough to um working GP 24 year old Johnny presents. He's feeling very tired all the time. How would you assess this patient? What would you do next? And how would you manage this patient? So I'll give you the presenting complaint. So he's feeling very tired. It's been going on for a month now and he just doesn't understand what's going on. He's just tired all the time. What questions would you ask about? If not, what I can do is just go through the case and then, so what events have been happening recently? Ok. So I, he recently moved into university. Um, he's been struggling a bit with his grades. It's just difficult keeping up with the new environment and all the heart load of work. He feels like it could be just all the hard work that he's doing on the late nights that might be causing him to feel tired. Yeah. So, yeah, he hasn't been able to do the things he enjoys, so he hasn't been able to go to a football club. Um, he, he used to like it, but now just doesn't feel up to it. Um He's lacking motivation. He hasn't been sleeping well and the thing with sleep issues is good to ask specific questions. So, um he has been sleeping late at night. He's trying to sleep, but just can't and then waking up very early in the morning and unable to go back to sleep. Um Weight changes, his appetite is fine, is slightly reduced actually. Um But he hasn't lost any weight. He's just struggles to find the time to eat. Um No one's noticed he's felt this way. He's very far from his family and he doesn't want to bother them. He feels a bit guilty that he's doing this like he's got this opportunity to go to university and he's just feeling sad all the time or low all the time. He hasn't had any psychiatric conditions in the past, any other questions, medications, he's not on any. Um he doesn't have any support. So he lives in halls. So he is surrounded by people, but he just doesn't feel close to open up to anyone. Um And he hasn't gone to like any of the people in university to talk about this. He feels like it. He, he just feels like he's low in energy and there's nothing else going on. Um Any other questions, maybe like a systematic uh systems review. Yes. Suicide risk is always important. Um especially for a mental health history. So he's been having, um, he hasn't harmed himself before. Um, but he has been feeling quite low about the future. He feels it's a bit hopeless and there's no point in anything he knows this is temporary, but just starts feeling this way and some days he just wants to sleep and for it to all to end. Um, but he would never harm himself. Um So his mother used to have um depression and anxiety in the past. This is really great guys, by the way, many plans. No, he hasn't made any plans. He's just thinking about it and that's really important protective factors. Um Not really. Um So he calls home sometimes but there isn't anything he enjoys or wants to do. He's just always tired. Yeah, that's very important. So it could be that the low and um feeling tired all the time could be due to anemia or thyroid. Um Yeah, he's not having any palpitations or um any others symptoms of anemia. Well, thy right. So that's a good question. Um He feels like it's just the workload and the new environment that's worsening. It cos his condition he feels like if he has a break, it might be able to help him to reset. All right. So in the interest of time, we'll stop it there. Um So this is the Depression His History mo scheme. Um We'll go through it quickly. Um Yeah, so the main thing is just the presenting complaint the history of presenting complaint is sort of like an oats of the symptoms. So, um when did it start? How has it progressed? Is there anything worsening or improving it? Um things with low energy asking about symptoms that could other symptoms that they might have? So lack of sleep, um appetite and also um conditions that might cause this. So for example, depression. So asking about low mood, um and other, I think those are the most main things um concentration effect on his life. So school is a big thing but also um other things like his relationships with people, has he been withdrawing himself? Um Yes. And I think that's mostly it, the other thing is to just do a review of symptoms. So make sure that it's nothing else. So asking about symptoms of psychosis, even though it's not, it's very obvious that he might not have it. It's just good to ask these questions because I've seen it in hospitals where the person seems very fine and very normal. Then he asks about one specific thing he's like, yeah, actually I've been hearing these voices and they've been telling me these things and telling me I'm a terrible person. So it's always good to ask about hallucinations, um delusions. Um Yeah, and risk factor, very important. This helps assess the severity of his condition what you're gonna do next. So if he's having active plans of suicide, then you're going to want to have an assessment with, with, um, another doctor and possibly consider either referring him to the crisis team or, um, in patient referral because he is in severe risk. Um, family history, drug history. You guys? Oh, no, no. Yeah, you did drug history, um, social history. So, just who is he living with? Um, how's he coping, um, alcohol and smoking and recreation. Drugs is really important. So oftentimes people can use, um, medications and drugs to alcohol and drugs to cope with the symptoms and their use might increase during this time. So with Johnny, he's been drinking a bit more, but that's just because he wants to fit in. Um, ice is also really important. So what is the patient thinking? Do they think that they have a mental health condition or what are they concerned about? So, for him, he was just worried about um what's causing this and like how it's impacting his studies, he just wants to get better and he's willing to do anything to do that. Um, and just insight. So what do you think might be causing this just to see if and then if they don't say a mental health illness, do you think that it could be depression or et cetera? Just to see the where to, just to see their insight into their condition? Do they think there's anything wrong? But since he came into the GP, he definitely thinks there's something wrong. Um Yeah, I think that's it mostly. Um, yeah, and an important thing someone mentioned is other conditions. So, screening for anemia, hyperthyroid, um, he said that he's not, he's low in energy. So maybe he's having some sleeping problems. So, um, maybe sleep apnea might be affecting that. So, like does he have daytime sleepiness? That's another thing. Um, just other clinical stuff that might be causing this. I think that's it. So, what investigations would you do after having this history? So, you might do some, um, bloods. Yes, FB CST FT S an iron study just in case there might be anemia or hyperthyroid causing these symptoms. Um, yeah, that's right. And is there a specific test you can do for depression or it's not really a test but screening and that's it. Yep. The P HQ nine questionnaire. Um, that's the one I found, but there's other questionnaires as well. Oh, no, I was supposed to do an M SE. Well, if you were to do an Embassy, one of the things you would be looking for is just, um, let and neglect. So, do they have matted hair? Do they seem like they haven't washed for a while? Is there like a foul odor coming from them? Um, is their clothes baggy? Does that mean that they've lost weight? Possibly? Um, their behaviors are like, are they n, um, not making eye contact, are they fidgeting a lot or just not, um, having reduced movement? Um, their speech. So it could be low in volume, um very slow. Um And their mood, they'll say it's low and during the consultation, they might be tearful. Um Yeah. Um and yeah, perception. So they, they might have hallucinations. Um F form usually is normal. Um and they might have some other like in terms of content, it could be that they're having some delusions. Um They might have some symptoms of like guilt or hopelessness. A not a common thing with depression and anxiety is having ruminations so constantly thinking about certain things. Um Yeah, and the combination would usually be normal and insight. So, are they aware that um things are not um well, at the moment and would they be willing to get some medication or some help? Um All right. So with depression, um so the nice criteria says that it's just one of these two motion low mood or, and Hedonia. Um and in the DSM five, it's low mood and heon your low energy and it's persistent. So having it most days for more than two weeks and with the DS and five, it also includes some other symptoms that you can have. So five of the nine symptoms below which you can read low mood, anhedonia, unintentional weight loss. Um And that would be a quite in the um diagnosis of depression. Um some risk factors for depression could be um being female, older age and that could be linked to just isolation and having the sense of identity, um and person, personal factors. So like relationship breakdowns, poverty, homelessness, adverse childhood experiences, um the postpartum period. So there's something called postpartum depression. Um and your history of mental health and chronic conditions can also cause low mood and you're right investigations. So, uh nice guidelines have changed recently in June. So they've now changed it to just less severe or more severe before it was um, subthreshold, mild, moderate and severe. Um But yeah, a score of less than 16 is less severe and a score of more than 16 is more severe. Um So the management for depression is it, it comes in stages. So if they're less severe, you would start off with active monitoring. So just having follow up appointments with them, making sure that they're doing well, give them psycho education. So self guided um um materials that they can go through themselves. Um if that doesn't work and they would like some management, you can give them either medication, although that's not recommended unless the person prefers it and it would be better to give them some low intensity therapy. So like guided self help group, physical activity, group, CBT. Um this is like a nice guidance cycle of all the low intensity therapies you can give before um turning to medication. Um And then for step three, that's for m um more severe or for less severe c um depression which has not been rea um managed with the step two management and that could be medication or high intensity therapy, which is CBT or interpersonal therapy. Um And stage four is mainly for very severe um depression where you're concerned about the risk of self harm or harm to others. And this is where you would give medication, high intensity psychotherapy, maybe ect um and involve a specialist. So consider inpatient care or crisis services. So for example, if they're plan, if they have active plans of suicide. Um Yeah, another thing. So the main management for depression is antidepressants. Um So oftentimes you go full sertraline. Um So I haven't done much on here. I just wrote down the key points for SBA all questions. So avoiding TCA S or tricyclic antidepressants and then the vaccine, they have a risk of overdose um or death by overdose. Um and TCA S lower the seizure threshold. So they might be preferred for someone who has epilepsy um compared to sertraline and other SSRI S or S MRI s. Um sertraline and citalopram um are good if they are on any other medications cause they have a low interaction profile. Um FLUoxetine is usually given for people under 30 n tazepam if they have a high risk of bleeding or if they have low weight or so due to reduced appetite and sleeping problems, it can help with that as well. Um And paroxetine or Celine if you're pregnant. Um and the key thing um to warn about with antidepressants is to just warn the patient if they have any symptoms of confusion of um rigidity, muscle rigidity and hyper reflexes to come back because it could be serotonin syndrome. Um And this is where they just have an overdose of um the SSRI s or too much serotonin in their, in their, in their system. And that can cause toxicity range with a range of symptoms which is seen on this grid. Um And the management can depend on the toxicity level. So it could just be stopping the drug and reducing the dose or um other medications like benzodiazepine or Cipro heptadine to reduce um Tarax the muscles and reduce the hyperreflexia and clonus. What's some key things you advise the person on if you start someone on sexually or any SSRI we just noticed the time. So I might quickly go pie this. Um Yeah, normally you would advise them on. Um So in the first couple of weeks of the med, in the first week of the medication, they might feel lower or low in mood and then yeah, they have to stick to it not to stop suddenly. Um So yeah, in the first week, they might feel low in mood and then after a while around 4 to 6 weeks, they might feel start to feel better. They might also have an increase in the suicidal ideation or s um So in the first week, you always give them a follow up appointment just to see how they're doing. Um And even if they do get feel better at 4 to 6 weeks, they have to continue it for at least six months for them to see an um, a continuing effect and not to stop it suddenly. Um Yeah, so case two, we'll go through this a bit quicker. Um, so Robert's been brought to the hospital after an overdose, he's been assessed and is deemed medically fit and is awaiting psychiatric review. Um Please take a history from them. So any questions you'd like to ask, this is a bit different from like a depression history. Ok. So he overdosed on 32 tablets of paracetamol. Ok. So before the overdose, he just put his kids to sleep. Um and he was just having some time to himself, he was having a little bit of wine and started to get this headache and he thought he could um reduce the headache with the paracetamol. But before he knew it, he started taking more um tablets until he finished two packs. Um Yeah. Did he regret it? He regretted it after he did it. Yes. Um He realized that he was leaving his two Children behind and he felt really bad about it. So, um so he knew he was dangerous. He uh he knew it was dangerous and felt bad for doing it. But at the same time, he was feeling extremely low and um wanted a way out. So he took the paracetamol past medical history. So he hasn't got any significant past medical history. So he wrote down, he wrote a note, he didn't plan to do this. It was all of a sudden, um, and he wrote a note apologizing to his family for, um, let um for failing them. Um So he didn't tell anyone. So after he did it, he wrote a note um, apologizing to everyone and then he was found, um it turns out that his mother in law came round in the evening just to drop off some shopping and she noticed that he was there very unwell and he was sent to the hospital. So at the, at the time, he felt like a failure for not being able to kill himself properly. Um And the child, he felt his kids would have been better with another family member or because he was letting them down. Um He doesn't have any thoughts of harming anyone else. He has two kids, but now that he's thinking about his family and his kids, um he's thinking he won't, he won't try to kill himself again. He'll, so currently the mother-in-law is taking care of the kids. Um He would be grateful for some ideas as to how to cope with things. Um He's scared and realized that um he wants to be around for his kids and his mother said that she'll move in to help with the kids. So he wants help with whatever he can get, like, any medications or counseling. Yeah. Um, no relevant family history. So, um, so he drinks beer most evenings and he doesn't use any substances. Um, he used to work but he was recently left. Um, he's been off work for 11 months due to a bereavement. So he lost his wife 11 months ago when she gave birth to his youngest son. And so he's been off work trying to take care of him. No history of psychiatric conditions. Um and he was recently been told by his workplace that he might be let go if he stays off work for longer than a year. Ok. So in the interest of time, we'll stop it now. Um So with an overdose history, it's a bit different to a normal uh mental health history. You want to establish the facts of what's been going on before, during and after the overdose. So before the overdose, what the events leading up to it. Um Was he feeling low at the time? Um What was he think? What were his thoughts as he was going through it? Um And also was it planned or impulsive? That's an important factor and things like gathering um materials to commit the suicide, writing a note making sure he's not found. Um Yeah. Um and then during the overdose what they did. So like what method they used? If it's a medication, what medication, how many tablets? Um and if they did it with alcohol as well cause that can affect the management also if it was staggered or all at once cause again, that affects the management. Um Yeah. And did they take any steps to not be found? So locking the door, making sure no one can come in. Um And then after the overdose, how were they found, did they contact anyone? Um Did they want any help? Um Did they vomit as well? Because that can help with the management of the overdose? Um Yeah, and how did they feel after they were found? Did they have regret? Were they upset that they were found? Um, yeah, and did they think that the self harm or the um the medication that they took would kill them at the time? Um And then after, um did they have any regret? Um And yeah, how, yeah, I said how they felt when the help arrived and then after this, you establish if they have any risk. So if a any social factors that might be affecting them, so, and how and social history can help with that also checking for any protective factors. So, is there anything that makes them stop wanting to carry out the suicide? Is there anything that was to make them keep living? Um, what will they do when they go home? This is a very important question because if they say that they want to harm themselves again, then you can't let them go home. Um And previous self harm or suicide will let you know if there's a risk of them doing it again. Um Also asking them how they feel now that can give you an idea of where they're at. Um Yeah, so those are usually the questions you go through and also just general questions about um the social history. So like who's at home? Um Any recent bereavement or h how are they, are they working currently? Do they have any financial issue? Um, yes, any recent stressor, um, and drug and alcohol use as well. So that's usually what you ask them about and then also asking if they have a support network that's very important as well. Um, yes, and then the family history of psychiatric conditions as well. Um, in terms of management, it's very similar to the depression management. So you discuss with the senior and then you see if they're safe for discharge. So if they've mentioned anything, like having any plans when they, uh, of suicide, when they go home, then you're not going to let them go. Um, we can give them the crisis line. Um, if they ever feel these symptoms again or these feelings again and also consider the safety of the kids. So safeguarding will probably have to be involved. Um, yeah, and giving them any like co um, counseling or sending them to counseling or um, like CBT or medications as well. Um, so an important thing for the overdose history, but also just suicide risk in general is a suicide risk assessment. So um there's this really nice new want it called Sad Persons, which um gives you a list of things that put you at higher risk of committing suicide or attempting it. Um So like being male aged, so you're, when you're younger, you're more impulsive and also like there's a high risk of bullying and social media presence when you're older, risk of isolation. Um Previous suicide attempts means that they are high risk of doing a day again. Um alcohol and substance use, so it could be that it's used to cope and oftentimes that can make you more impulsive, um rational thinking loss. So sometimes delusions and hallucinations can cause this. So if they have pretty severe delusions and hallucinations that is impacting their quality of life, they might do this as well. Ok. Anxiety. So you've got another case, you've got two more cases. Hopefully we'll get through this quickly. Um So yeah, Debbie has come to discuss concerns about chest pain. What questions would you ask? We'll limit this to like four minutes. Maybe I can tell you the history of presenting of things. So she's been having this chest pain for a while. Socrates is very important. So you want to distinguish if the chest pain is medical or psychiatric. So it's an achy pain, essentially. Sometimes she feels like a pressure, it's not radiating anywhere. Um she also has like, um, it's random. It happens any time of the day it lasts a few minutes and then goes away. Um, and she says it's like a five out of 10. It's not terrible, but it's terrifying and it started about three weeks ago. Um, yeah, so no tearing pain. He is fever. Any red flags. There's no red flags past medical history. So she has asthma and it's well controlled. She uses the blue inhaler sometimes if she has an attack. Any other questions in mind. So drug history, she's just on asthma. I mean, um blue inhaler and salbutamol. No family. His oh no. Her father died from a sudden cardiac arrest at 45 years old. Um She's worried that since his health, she had this, he had this sudden health condition. She's what it could be. Ha she's worried she's inherited something and it could be happening to her. Now, recent stressor. So three weeks ago, um she was involved in a bus accident and she had minor injuries, but they resolved very quickly, but she still terrified of the event and has me like thoughts of it, thoughts of it every day and nightmares and she doesn't drink or do any substances. Any other questions in mind, ice. So, um she's concerned she may have a heart condition, especially as her father died of a sudden cardiac arrest. We'd like some tests done to rule this out. Um Any other symptoms of chest pain. So she's had some palpitations, some shortness of breath. Um, and she's finding it slightly more difficult to breathe when she gets the palpitations. No sweating, tingling. Um, she does have a sense of dread in the morning. Yeah. So in the interest of time, uh, one last one, is this the first time? So, yeah, this is the first time she's ever felt like this. It started three weeks ago. Sleeping habit. So she's been sleeping less, having trouble sleeping. She's having flashbacks of the event night um as nightmares and just ruminations during the day. All right. So I'm gonna move on. Um So this was an anxiety history. Um And usually with anxiety, they don't usually present with, I have anxiety, they present with other symptoms like um chest pain, shortness of breath, palpitations, anything else like uh somatic symptoms more so than having anxiety. Um So, a good thing to ask is just the Socrates just to make sure that it's nothing serious or um organic or clinical. Um And then ask them how they're feeling generally. So their mood, are they feeling any dread or nervousness? Um Is there anything in particular they worry about? So if there's something in particular that can give you an idea of what's causing this, um If they feel like something bad is going to happen, that's more to do with general anxiety or O CD. Um And then the somatic symptoms that you guys were asking which was great. So like palpitations up it gi upset, sweatiness, tingling, dizziness. Um and also just ruling out condi um symptoms of other conditions like um hyperthyroid or anemia. But a good thing to do is just do an investigation for that as well. Um A good thing. Uh One thing that someone asked was um if there was anything that happened and that's great the trigger. So it was an accident but also asking about if there's a pattern to the symptom symptoms. So, is it a specific time of day? So the patient might say it's random but just asking, does it happen more often in the day? Does it happen more often during the work week? Does it happen less on the weekends? It can give you an idea of when it's happening? Um Yes. Um and yeah, ask them if they feel like there's anything that could have caused this um and ask them if they have like fears of specific things like going outside. Um a good thing to ask is just the impact on their life in general. So with this patient, she's been going out less because she's constantly terrified. Um And thinks it could be the sound of the traffic that might be causing this. Um She just always gets these palpitations. Um So she's been avoiding going outside and it's been affecting her work. So, again, impact on their life is very important with any mental health condition just to see how we can manage it. Um Yes, this is more to do with O CD um which we'll be doing next. Um So repeated unpleasant images, et cetera and depersonalization, utilization. That's something you can see with PTSD or with um acute stress disorder. Um Yes. And then all the other cons um parts of the mental health history. So, does anyone have any ideas of what this could be a specific person? What condition does she have? The was any ideas? Anything is all right? If not, I'll continue on. So, anxiety disorders, I've split it into two things. So we've got um acute stress reaction and PTSD, which is the first thing and these are due to traumatic events. So something out of the ordinary, like seeing an accident, seeing a cardiac arrest, you can be involved in this situation or just seeing it, which is indirect. Um And that can cause intense emotions of fear and um heightened arrival and anxiety. Um It ha with acute stress reaction that happens immediately after the situation up to hearing the definition say more than three days and less than four weeks after the event. Um And usually it resolves a less than four weeks before the event, uh less a less than four weeks after the event, it usually resolves. Um if not, then it becomes PTSD. And yeah, the symptoms are, you can have somatic symptoms like palpitations, chest pain, um dissociation, avoiding triggers. So, if it's to do with an accident, they might avoid going outside. Um, and the management for this is to just have trauma focused CBT. Um, and occasionally medications for symptomatic relief, for example, the palpitations or the shortness of breath. Um, yes. And then PTSD is what acute stress reaction in my mind becomes after, um, more than four weeks. So again, it's due to trauma or traumatic experience and you have similar symptoms. I think here there, flashbacks, nightmares, um more negative mood changes as this has been going on for much longer. So, self blame, negative beliefs and being hypervigilant. Um And here, the management depends on the severity. So if it's mild, then we can give traumas to focus CBD or eye movement desensitization. Um If it's moderate or not responding to psychotherapy, then you can give antidepressants and if it's very severe and they have um thoughts of self harm or um h hurting others, um then you would refer to psychiatry. The other um three anxiety disorders is generalized anxiety disorder, um panic attacks and adjustment disorder. So with generalized anxiety disorder, again, I like to differentiate, differentiate these by timing. So this has been going on for more than six months. And the key thing here is that it's persistent and excessive worry. So you're constantly feeling worried and it's more worried than it's warranted for the situation and it's generalized. So it could be for one day about work another day is about your family another day could be about health and it's free floating. So you always have this general sense of worry. Um And it's difficult to control. Um and it's causing significant impairment functioning and it's not caused by anything else like any mental health conditions, any other physical conditions or substances being misused. And that's the criteria. Um Some key symptoms is like restlessness, feeling on edge, being fatigued as well and difficulty concentrating and some sympathetic and um somatic symptoms. Um The management here is psychoeducation and so that could be self guided therapy, some low intensity CBT if that doesn't work high intensity CBT and applied relaxation techniques, if that doesn't work some medications as well. Um And referral secondary care, panic attacks is quite different. It's sudden episodes of um intense fear that they feel and it's short lasting lasts around 10 to 15 minutes. Um And the key thing here is that the, it's not triggered by anything specific, it could be anything and it's the fear of having another attack that's very persistent. Um So yeah, and when they do have the attack, they have this intense fear, either they're going to die or they're going crazy. Um And they have all the symptoms like the somatic symptoms, like dizziness, palpitations and paraestesia. So like the tingling and the dizziness. Um And then the management here is again, psychotherapy and self care. So just stress management, physical activity and that goes for all the other conditions as well, just teaching them stress management, physical activity and any other social issues that might be helped and medications for symptomatic relief. But they avoid, and they mention to avoid benzodiazepines um and referral to secondary care if he gets severe and then adjustment disorder is a bit different. It's usually less than six months after the stressor. So this is a temporary maladaptive response. So to a life stressor, this is different to the other two conditions you're talking about um acute stress reaction and PTSD because um it's a normal stressor. So for example, moving homes a bereavement, um a stressful job, um things that you would expect in real life um and it usually lasts less than six months after the stress has happened or it ends. Um and it can be like emotional behavioral symptoms. So feeling low in mood or avoidance or it could also be insomnia, headaches, abdominal pain. And the key thing here is that the symptoms they feel is excessive to the stressor that they have. Um And again, the management would be psychotherapy self care. Um maybe family therapy if there's like a family element to the stressor. Yeah. And here's just a little grid that you can look at later, just how I differentiate between the anxiety disorders. I find that these two are quite similar acute stress disorder and PTSD. And the main difference is just timing. Has it been more than four weeks? And has it been a traumatic event? And with these, again, the timing helps G ad is persistent with adjustment disorder. It's like a normal stressor specific thing that happened. And then after that, they've had these mil adaptive responses and panic attacks is just a fear of fear. Um, and these episodes of intense fear that they have and it's not triggered by anything specific. All right. And the management, we've gone over it a couple of times and it's also quite similar to um depression is just active monitoring and psychoeducation initially. If they're mild and then load, it increases the low intensity cle interventions. And then if it's moderate, you start off with medication or high intensity psychological therapies and if it's severe and this is there's a risk of self harm or harm to others, then you would do medication, high intensity psychological therapies and also involving a specialist. And another thing is just to always give conservative selfcare advice. It always helps to just physical ex exercise, social support, any like group activities, they can join like a football club. Um and any like um So for example, in GP, that's a social prescribe, prescriber to help with any um any is social issues like if they're having trouble getting a job. Um Yes. So final case, sorry, this took so long, but it'll be quicker. And so, yeah, Sarah Smith, she has concerns regarding her mental health. Um Her presenting complaint is she's just feeling really anxious any questions you have in mind how long? So this has been going on for as this started about four months ago. Um So it's usually when she goes out she has um these horrible images of hurting people. Um Yeah, event there wasn't anything specific that started it, it just started around four months ago. Um You know, she would never act on it. She would never do something to harm anyone, but she feels like an evil person for even having these thoughts. Um She doesn't hear any voices, family history, um No family history of any mental dis mental health disorders or other conditions. Um doesn't use any recreational drugs. Um She has felt this way before she's had this intense anxiety before about driving. Um She felt like she would hit people if she were to get behind the wheel. Um Ever since she stopped um driving and takes an Uber everywhere. So in the interest of time, I think we'll stop it better. Another question I would have asked is just like, does she have any, does she do anything to help the thoughts go away? In that case, I would have said that she washes her ha, washes her hands um and just cleaning her hands, helps her reduce the thought, it helps reduce the thoughts and the images. Um and she's aware that it's irrational and that she would never do this, but the thoughts to themselves are causing fear and Yeah, you, you would also ask about low mood. Um Yeah. So d so the questions you would normally ask about is just what's going through your mind. Um Do you have any repeated unpleasant images? Um And how do you feel when you get these thoughts? And would you ever act on them as a very good question to ask? Just to see that it's the thoughts that are causing the fear and that they wouldn't, they, they have insight, they're aware that it's abnormal but they're unable to control it. Um And do they have to do certain things to help the thoughts go away or is there anything that helps the thoughts go away? Is a less, it is a more generic question. Um And if not, you can not specifically, do they need to check things? Do they need to clean things? Um And can they resist your thought? So can they resist the thought and the urge to respond to it? Um And that can tell you the severity of the symptoms. Um And how long it's going on. Um And yeah, the key thing with mental health um histories is to always check the dysfunction. So how is it affecting her life? Um In this one, she's having difficulty with work. So she's avoiding to go outside. Um She has, she's been seeing her friends less, she's struggling to attend work, um has had multiple sick days and is concerned her boss might, her boss might fire her. So again, just seeing how it's affecting her life, um any psychiatric complications. So it could be that OCD is comorbid with other mental health conditions like depression. Um Any psychosis or anxiety, any other anxiety conditions. So asking about a general systems review just to see what's causing this and risking risk accessing. So is she going to cause any harm to others? Any harm to herself? Any thoughts of suicide? Um OK. Is there anything else I would have written? No. Um Yeah. So with OCD, um the DSM five criteria is that there's either an obsession or a compulsion, you don't have to have both for the diagnosis. Um And an obsession is an unwanted intrusive thought or images causing distress, um anxiety or disgust easy, for example, someone being injured or someone having a terrible illness. Um or it could be also like socially inappropriate thoughts as well. Um And all of these cause distress to the person because they would never do that or they don't want to do that, but they have these images coming up in their mind. Um Then compulsions, these are repetitive behaviors or mental acts that they do to, that they're compelled to do to reduce the anxiety or prevent the situation from happening. And this could be an action sort of washing your hand or it could be a mental thing like counting numbers or saying certain phrases in their head. Um And the key thing here is just the amount of time investment that's needed for this um for this condition. That is the way they assess severity. So the core features here is that they, they acknowledge that it's originating from their own mind, it's repetitive and unpleasant. Um And they try to resist it but they can't and it's not something that they enjoy. Some categories of like um compulsions that they might have is checking things. So like checking the ovens off, checking the doors been locked. Um And that could be because they have this fear of the house um burning down or that someone's going to vote them contamination. So, washing the hands. Um symmetry having things in order rumination and hoarding. Um Yeah. So this is the YB O CS scale. Um and it helps determine the severity of the CD symptoms and these are the scores and in terms of categorizing them and it's mainly about um how often they have thoughts and what and how much time it takes out of their day to do the compulsions or um yeah, I think that's mostly it. So management. So the initial management again, if it's mild is just active monitoring, psychoeducation like with other um conditions and if that doesn't work, they can do low intensity CBT um or E RP. So um gradual exposure to this is gradual exposure to the trigger in a safe environment. Um And then if that doesn't work or if the condition is moderate. You can do high intensity CBT and E RP with medications like sertraline, which is usually first line or, um, clomiPRAMINE, um, that second line unless they've had it before and it's more effective. Um, and with OC D you usually give the medications for a bit longer. So, usually 12 months at least, and then it would usually go on for longer than that to have successful management of the, um, symptoms. So tell them to not stop the drug even if they feel better for at least 12 months. Um And yeah, if it's very severe, they have thoughts of harming themselves or harming others. Um again, refer to secondary care. Um I think that's the final side. Oh, no, CPP. Um So yeah, quickly this is we have the Mental Capacity Act, the Mental Health Act and the d um deprivation of liberties. So the Mental Health Act is for um treating a mental health condition. It's usually if they've had um it's like they're usually detained under the mental health pack if they've got a mental disorder, if they're at risk to um to their health or safety or the safety of others. Um and that they must have treatment and that will improve them. Um And they need to be detained. Um And you can't use the ma to treat physical conditions. Um And then the Mental Capacity Act is used to assess capacities anyone over the age of 16. Um It is assumed to have capacity and it's decision and time specific. Um And we, the four criteria used to assess is understanding, retaining, judging, being able to judge things and communicate um your ideas. Um And if you're judged to not have capacity, um then they, you're allowed to restrict or restrain the person, but they need to be safeguarded to make sure that this isn't rest restricting their liberty. So, um you need to make sure that you have the patient's best interest in mind and that's when you would put in adults deprivation of liberty safeguards. Um And that's just to make sure that the, the, um, restrictions that you're using is um in accord, er, is appropriate and um in the patient's best interest and there isn't any adverse effects that might be coming out of this, that's um, more, less benefit that is more harmful than the benefit from restricting them. Um, it's usually an FDA, they usually ask if a person comes with these symptoms, would you restrict them over the uh under the MCA or the MH A? And the main thing I remember is that if it's a mental health condition used MHA A, if it's a physical health condition, then you would use the Mental Capacity Act. Ok. And these are the types of sections in the interest of time, I'll just skip over them. But the main thing is section two, which is to detain them for 28 days you just assess them or give some medication. Um And a 52 is used by doctors and for three days is to hold them, hold a patient, an inpatient um to if they suspect them of psychiatric disorder to have them assessed. And a 54 is the equivalent for nurses by six hours. And a one through six is used by police to detain a person in a public space and bring them to a place of safety and they're held for 24 hours and then released unless they've been deemed to have a mental health disorder that needs detaining and they'll be taken in as an inpatient. Um Those are the key ones I usually go through but these are popular SBA questions. Um Yeah, so S PA S, I've got two S PA S and then they'll be over, sorry, it run on for so long. I think we have a pole. Um Yeah, so uh 34 I'll just give you some time to read this and think about it maybe 30 seconds. Ok. So if you have an answer in mind, uh you can see the question on here as well, which is good. Yeah. Assess capacity, correct. Um Yeah. And the main reason you would assess capacity is because um you can't assume that um he doesn't have capacity. You always have to assume they have capacity even if they have a mental health um condition. So if they're making decisions that seem unwise. Um You would assess capacity. Um And also there's no indication that his mental health condition is worsened or causing any risk to himself. Um And additionally, you can't restrict him at all until you've put him under. Uh if, until you've assessed his capacity and found out that he lacks a capacity and you can hold him or else if they do have capacity, then they're able to leave because again, patient has autonomy. Um Next question. So you've got one response, one more. OK, we've got three responses. That's good. Um So um with this person, I would assess him on the, put him on the dose. Um Yeah. So um you've explained to him the condition and the risk that it takes. So if you were to go home, this could be um lethal life threatening. And instead of saying that he understands this, but he still wants to go home, he says that um there is no risk as he doesn't feel any pain and he is more concerned about some um other things and suspicious that you're plotting against him. So, and all reasonable adjustments have been made for him to understand. So if he's having difficulty understanding, you've um like hired an interpreter or you've explained it in multiple ways more than once and they still have the same thoughts. So under the based on your capacity assessment, he now lacks capacity because he's unable to um understand the risks. And weigh up the um pros and cons. Um In that case, you can say that he lacks capacity and in that case, you would put him on the doors so that you can um tell him that he can't leave the premises and he needs to stay, to be assessed. Um You put them on the doors because you want to respect their rights and make sure that you're not restricting them more than necessary. But this usually happens in with inpatients. So for example, if they're very, if you have a delirious patient and he's run, he wants to leave the hospital, you would put them on the doors to make sure, make sure they stay. If they're very delirious and trying to pull out the cannula, you might put some gloves on them again, that's restricting them because they're not being able to use their hands and this is against their will. Um But you have to do this so that they would um comply and have, um, you can treat them well. So usually the doors is if they're not complying, but if they are, they lack capacity, but they're consenting, then that's fine. Um Yeah, and the dose is just to make sure that you're maintaining the patient's rights. All right. So I guess that's everything. Um Sorry, it took so long and if you could um do the feedback that's been set on the chat, that would be really helpful. Thanks. There's any questions. No, in that case. Um If that's all. Well, thanks for staying for so long. Uh Edema. A Yeah, the size will be up on metal. No problem. Um, ok, so if there's no questions, I think I'll end it there then. Yeah. Bye everyone.