THE PERSON WITH MOOD OR ANXIETY SYMPTOMS
Depression GAD Bipolar Disorder
5 or more symptoms in same 2-week period with At least one (1) Group of disorders “mania and melancholy”
Ø Low mood (pervasive sadness) OR anhedonia (GAD, panic disorder, social anxiety, separation “difficult to dx as need manic episode”
PLUS (diurnal pattern of – e.g. worse AM/better PM) anxiety, specific phobia, PTSD, agorophobia) Mania = feeling amazing!! NO sleep needed!
Ø Suicidal ideation
Uncontrolled XS worry/anxiety on most days
Define Ø
Ø
Interest loss
XS Guilt / worthlessness
for 6/12 months with ≥ 3 out of 6 symptoms
Bipolar I = Major depression + mania
Criteria for mania
/Sx Ø Energy loss
BELOW causing significant impairments to
ADLs, social and occupational life Ø > 1 week of elevated mood plus 3 Sx
Ø Poor concentration Ø > 1 week of irritable plus 4 Sx
Ø Loss of appetite + >5% wt loss D istractability
I rritability
Ø Psychomotor retardation I ndiscretion / impulsive / irritable –, XS spend, sex,
C oncentration impaired – circumstantial
Ø Sleep disturbance (insomnia, hypersomnia) thoughts substance (impaired function)
Function impaired during episode BUT not b/w episodes G randiosity – ?special powers or talents, ?new
A nxiety, nervousness, worry on most days
hobbies, interest, hobbies
(1) Unipolar depression (NO mania or hypomania) N o control over worry
F light of ideas (distractibility) – pressured speech
• Melancholic depression (early AM waking, psychomotor T ime > 6/12 (rapid speech), clanging, word salad, alogia
agitation, diurnal mood variation) R estlesness
A ctivity increased energy (goal-directed)
• Atypical depression (sleep a lot and eat a lot) E nergy decrease S leep deficit – no sleep
• Depression due to general medical condition or substance S leep impaired
T alkativeness (racing thoughts)
Types. misuse (CS, cannabis, Roaccutane, SSRI) T ension in muscles
• Dysthmia = (> 2 years) persistent depressive disorder (longer-
lasting, less depressive symptoms with minimal fxn impairment) Bipolar II = milder hypomania
AND
• Catatonic depression è ECT needed Ø Depressed mood for 2 weeks
• NOT due to drugs or substance absue Ø Hypomania Sx (elation) > at least 4 days
• Normal bereavement è low mood <6/12 post trauma event
• NOT due to other mental health illness
(2) Bipolar depression Ø NO impaired function
Ø mania and/or hypomania Sx present in life Ø Lower Lows – higher suicide risk
Biological cause Biological cause 1% of population
• Early childhood (pre-term, dev. trauma, TBI) • NO specific biological markers • FHx
• CO-morbidities (e.g. low Vit D, CVD, hypothyroidism, chronic • HPA axis abnormalities [CRH release • Childhood traumatic events
pain, inflammation) è higher relapse risk increased by amygdala] • Acquired brain injury (3x more likely to
• Meds (steroids, chemotherapy, anti-psychotics) • Anxiety inherited (possible epigenetic, develop)
Cause. Psychological cause intergeneration effects) • Hypermania causes = steroids (anabolic, CS,
• Recent childhood (stressors, loss job) • Biology of arousal –resting tachycardia, isoniazid)
• Past trauma and losses (previous abuse) hyperventilation
Social cause • Personality (?OCPD, OCD)
• Poverty , homelessness and rural vs urban
• Adjustment disorder (specific traumatic event with no physical • Performance anxiety • Substance induced bipolar (e.g. stimulant,
& emotional symptoms of clinical depression) • Trauma (PTSD) steroids, anti-depressant)
• anxiety, substance use disorder • Panic disorder (cannot leave house) - • Schizophrenia & its subtypes
• PTSD DISABLING IRRATIONAL FEAR • Personality disorder (e.g. cluster B types ®
DDx. • Personality disorder (e.g. borderline) • Panic attack è Abnormal intense fear of borderline, histrionic)
• negative affect of schizoaffective disorder losing control, losing your mind or dying • Organic causes (thyroid storm, pheo)
• Bereavement/grief = abnormal if after 4/12 post-event • Agoraphobia (fear of the market place,
• Organic causes (hypothyroid, T2DM, PD, post-stroke/MI) going out) ® avoid many situations
• Social phobia è Fear of criticism
• DASS21 (anxiety, stress, depression cause of low mood) Exclude ddx: • MSE, thyroid, CV, Resp exam
• Edinburgh Post-natal depression Ø FBC, EUC, CMP, CRP, Fe, B12, folate, TFT, • FBC, EUC, LFT, CRP, TFT, BSL
Ix Exclude ddx:
Ø
vitamin D
ECG:
• Urine drug screen and B-HCG
Ø FBC, EUC, CMP, CRP, Fe, B12, folate, TFT, vitamin D • Li concentration
Ø ECG ® CT/MRI brain • CT or MRI brain +/- EEG
Lifestyle (1st line = mild) Non-pharm Acute episodes
1. Involuntary Ax (scheduled under MH act 2007)
• Better diet, regular exercise • Cognitive behavioural therapy (e.g.
® call on-call psych reg for mania
graded exposure + minimise avoidance
• Improve sleep hygiene 2. Once-off Anti-psychotics (haloperidol,
behaviour)
• Avoid smoking, drugs, alcohol olanzapine or risperidone)
• Muscle relaxation (mindfulness, clench 3. Add Mood stabiliser (Li, Na val or lamotrigine)
• Address social issues – work, finances, housing and relax from bottom to top) acutely + prophylactically
• Address co-morbidities (DM, RA, OA, Chronic pain, cancer) • Abdominal breathing (box breathing) 4. Check blood/urine for illicit drugs
• AVOID
GPMP needed + safety planning (when to go to ED) • Breath counting
Ø Anti-depressant = may trigger mania
Ø BZDs – falls, sedation in elderly
Refer to: (2nd line = mod) Pharm Beware of Li Toxicity (esp. long-term use)
Mx • CBT or psychodynamic psychotherapy 1. SSRI – fluoxetine, paroxetine • Acute = fine tremor, urinary freq., polydipsia (DI),
ankle oedema, GI (N/D) è seizures
• Case worker, significant other, NGOs (black dog, lifeline) 2. SNRI - venlafaxine
• Long = CKD, hypo/hyperthyroidism, HPTH
3. MAOi / mirtazapine
• Cause = due to changing Na levels ®
Medication Acute agitation / risk of suicide dehydration, low salt diet, Addison’s
• SSRI (fluoxetine (child), sertraline (adult)) • BZD (GABA agonists) potent anxiolytics, Monitoring:
® beware of tolerance / Dependence • Check Li levels EUC/CMP, TFT weekly for 3/12
• SNRI > mirtazapine (if poor appetite), TCAs
• Avoid ACEi/ARB, NSAID, diuretics, SSRI,
metronidazole (increase Li toxicity)
If unresponsive / refractory CI for Li use: AKI ® Change to:
Invasive (If psychosis present)
• ?ECT (less effective than for MDD) • Lamotrigine (BD tablet) è inconvenient, SJS
• If Rx resistant è ECT, TMS
• Valproate (OD tablet) è check LFT.
1) Stigma
2) Lack of resources (E.G. remote communities)
Assessing suicide risk
Barriers 3) Lack of trained clinician’s • All patients are “high risk”, as suicide risk
fluctuates
4) Incorrect or missed diagnosis (incorrectly prescribed)
• We are NOT independent observers of
suicide risk (it is interaction between pt and
dr)
• Suicide risk assessment (is BAD) = can
never be a basis for clinical decisions,
because the base rate is too low + known
risk factors are too common, to identify a
person at risk of suicide
• Game theory (b/w dr and pt)=
Aim to provide a good standard of
patient-specific care NOT to predict what
will happen
• Address modifiable RF (untreated mental
illness, substance use etc)
• Mobilise support networks ® instill hope
• Avoid behaviour or service responses that
might trigger suicide
, MAJOR DEPRESSIVE DISORDER
• Major depression – clinical diagnosis
• Major depressive disorder – One of more episodes of major depression
Examples Investigations
Endocrine Hypo/hyperthyroid, Addison’s, Cushing’s, DM Ø MMSE, DASS21, MAS, GAD-7, PC-PTSD-5
Ø Bloods = FBC, EUC, LFT, BSL, Fe studies,
Chronic disease Cancer, CCF, COPD, chronic pain, post-partum, hearing loss
B12, folate
Medical Metabolic Hypercalcemia, anaemia Ø Hormone screen = LH/FSH, ACTH, TSH,
causes GH, PrL
Neuro • Parkinson’s, MS, TBI, dementia
Ø Viral serology (extended panel)
• CVA (STROKE), complex partial seizure
Ø Imaging = CT abdo, brain (CVA)
Viral Hepatitis, EBV, HIV Ø Deficiency – Fe, B12, Folate, B1, B3
Meds • Corticosteroids, oral COCP/POP, Ø Urine Tox screen
• Anti-HTN, statins, anti-psychotics,
• PD meds , maxolon
Iatrogenic
causes Euphoria Cannabis, opioids, stimulants, inhalants
Irritable/ Agitation Caffeine, cannabis, tobacco withdrawal
Environment Job loss, relationship breakdown, social isolation
Management options for mild, moderate and major depressive disorder
Mild Mod Severe
Alternatives:
Signs 2 core or main plus at 2 core or main plus at least 3/9 cognitive two core or main plus at least 4/9
(ICD-10 least 2/9 cognitive symptoms (> 2 wks) cognitive cognitive symptoms (> 2 wks) • Increasing dosage
symptoms(> 2 wks) More likely social and work affected
criteria) of anti-depressant
Somatic Sx Marked appetite loss, weight loss, loss of libido, diurnal variation of mood, psychomotor agitation
*Avoid TCA – risk of OD
• Psychoeducation about family commitments, chronic disease Mx and depression ® Relapse prevention plan
Education
• Risk outcomes assessment +assess social support • Adding 2nd line
• Lifestyle (Diet / exercise / sleep / reduce smoking and alcohol or medications that affect mood agent
Non-pharm • Psych Intervention e.g. CBT, family focused therapy, mindfulness • Switch to other
• Manage co-morbidities – hearing, vision, pain, constipation agent OR
None MUST TAKE FOR AT LEAST 3/12 for effect (LAG TIME) psychologist
*suggest SSRI if Check Na+ levels before commencing • ECT – needs patient
Pharm counselling ineffective • 1st line = SSRI ® sertraline/Zoloft, fluoxetine/Prozac, escitalopram (lexipro) consent
• 2nd line = SNRI (venlafaxine, duloxetine) ® more effective but more A/E
• 3rd line = mirtazapine (will cause wt gain, sedation)
• Primary care Mx • Specialist service referral . • ADMIT - (+++ self-harm, suicidal
• ECT (if meds fail) – risk of retrograde • Outreach or crisis team (e.g. Local
Referral amnesia MH support line -1800 011 511)
Ind. • CI = UA and CVA • Suicide ideation
• Ineffective meds
• Psychotic/manic episode
Major complications of depression:
1. Suicide: the risk of suicide in patients with depression is four times higher than in patients without depression
2. PMHx of substance abuse = BIGGEST RF for suicidal attempts
3. Chronic disease (e.g. DM, HIV, HD, CF) ® prolongs depression
4. Reduced QoL: patients may struggle with employment and relationships
5. Beware of psych referral mismatch
6. Antidepressant A/E: ↓sexual dysfunction, risk of self-harm, weight gain, hyponatraemia + agitation, insomnia
Rationale of creating a GP mental health treatment plan (GPMHP) inc. financial benefits for patient
• GP identifies what type of health care you will require to
improve/manage mental health condition
Purpose of GPMHP
• Details what you and your doctor have agreed you are
aiming to achieve. Identify RF for Protective factors
• claim up to 10 sessions each calendar year with a Medicare
registered mental health professional suicide for suicide
Rationale • (i.e. psychologist, psychiatrist, social worker or occupational • Access to • Married
therapist) for an initial 6 sessions, with the possibility of 4 weapons • Dependents
more after a review
Requirements GP appointment + Medicare card + ID (handguns) • Fear of social
Cost Free • Chronic disease disapproval
Savings
Medicare rebate may provide more then 50% off compared to • Substance abuse • Coping skills
out-of-pocket
Referral Patient’s choice
• Male • Fear of
• Mental Health Care Plan gives twenty sessions partially • Low SES suicide
Length of GPMHP
covered by Medicare until 30 June 2022. • FHx of suicide
• MHCP referral covers up to six mental health sessions at a
time – need to revisit GP for another referral
• Stigma (social and cultural)
Barriers to Rx
• Financial + logistical (seek counselling and paying for meds)
depression
• Misconception about psych meds (i.e. A/E, addiction)
