MANAGEMENT OF MENTAL HEALTH PROBLEMS

1. MANAGEMENT OF MENTAL HEALTH PROBLEMS RUTH BANNISTER

2. OVERVIEW • SIGNPOSTING • DUMMIES GUIDE TO PSYCH MEDS • OVERVIEW OF MENTAL HEALTH SERVICES • MANAGEMENT OF COMMON MENTAL HEALTH PROBLEMS: • ANXIETY & DEPRESSION (brief) • OCD • PERSONALITY DISORDER • BIPOLAR DISORDER • PSYCHOSES • EATING DISORDERS

3. Standard CPA Majority May only be seen in OPD review No CCO No CMHT involvement other than at triage/referral Mild to moderate illness Mood disorders Majority bipolar Transient psychosis Stable psychosis with good insight Enhanced CPA Minority Complex care needs Multiple individuals involved Formal care plan CCO Psychiatrist Chronic psychoses Bipolar Complex PDs Poor compliance/ limited insight Those on depot meds Care Plan Approach

4. MH MANAGEMENT • How would this patient present? • What would initial management be? • What is your role as a GP? • When would you refer?

5. DEPRESSION • Mild and moderate depression is domain of primary care – specialist services not needed • NICE (2009) – very good prescribing advice • Support services as appropriate • Medication – titrate doses/allow time to work • REVIEW after trial of Tx, then try alternative • Refer if: • High suicide risk (U) • Psychotic depression (U) • History of bipolar disorder (R/S) • Failure or partial response following 2 OR MORE attempts to treat (R)

6. ANXIETY • Primary Care Management • Panic disorder Vs Generalised anxiety disorder • NICE (2007) • Benzos (no role in panic disorder, max 2-4/52 in GAD) • CBT, psychotherapy, anxiety Mx groups • SSRIs (SNRIs 2nd line), B blockers • Bibliotherapy / self help • Refer if no improvement after 1st line and 2nd line treatments tried (R)

7. OCD • Closely related to anxiety disorders • Presence of either, or both: • Obsessions – unwanted intrusive thought, image or urge which repeatedly enters the person’s mind • Compulsions – repetitive behaviours or mental acts that the person feels driven to perform – overt Vs covert • Significant functional impairment and/or distress • Consider other MH comorbidities • Consider in dermatology presentations

8. OCD cont • Can be managed in primary care, refer only if trials of tx not effective • NICE (2005) • Assess risk (death related thoughts vs suicidal intent) • CBT • SSRIs (esp sertraline) add in if ‘moderate’ • 2nd line clomipramine (no SNRIs, TCAs)

9. OCD cont • Refer if no response to: • Full trial of at least 1 SSRI alone • Full trial of combined SSRI + CBT • Full trial of clomipramine alone

10. PERSONALITY DISORDER • Pervasive and maladapted patterns of behaviour, thinking and control of emotions • Must be enduring, not limited to episodes of mental illness • Significant distress / disturbance in social function • Schizoid – paranoid ideas, difficulty mixing • Histrionic – impulsive, unstable, borderline • Dependent – anxious, obsessive

11. PD cont • Presentations • Impulsive acts/ behaviour • Antisocial behaviour • Poor coping skills • Trivial triggers • Unstable mood • Anger / temper difficulties / aggression / violence • Self harm (objective suicidal intent) • ‘I think I’m bipolar’

12. PD cont • Borderline personality disorder (EUPD) • Instability of interpersonal relationships, self image and mood • Impulsive behaviour • Rapid fluctuations from periods of confidence to despair • Fear of abandonment and rejection • Strong tendency to self harm and suicidal thoughts • May present with brief psychotic phenomena (pseudohallucinations) • Substantial impairment of social and occupational functioning, and quality of life

13. BPD • NICE (2009) • “CMHT responsible for assessment, diagnosis, treatment and management of BPD” • Primary care: • recognition and referral for assessment • Crisis presentation • Refer if: • Diagnostic clarification • If co-morbid MH problems • Increasing levels of distress or risk to self or others • For specialist treatment • Pt requests it

14. PD cont • Very common, variable support needs • Often most challenging patients for CMHT • Often present in primary care when in crisis so need some confidence in area (see later) • Complaints regarding other secondary services • Clear professional boundaries and avoid conflict • Involve family/ carers with care plans • Good professional housekeeping

15. PD cont • Pharmacology (initiated by secondary care) • SSRIs – never TCAs!!!!!! • Mood stabilisers • Low dose antipsychotics • DBT (secondary care referral) • Anger Mx etc (primary care)

16. SELF HARM/ RISK ASSESSMENT Not only Crisis team – GPs can apply principles Case examples

17. SELF HARM/ RISK ASSESSMENT Not only Crisis team – GPs can apply principles • Details of act • Where, when, how, why? • Impulsive or planned? • Did they tell anyone, A&E, 999? • Measures to avoid being discovered, planning (storing meds), note, will, ‘sorting out affairs’ • Even if no true intent – may be ‘accidentally successful’ • If in doubt – Crisis team for assessment

18. BIPOLAR DISORDER • NICE (2006) • Management led by secondary care • Role of primary care: • Monitoring of physical health in established cases • Recognition / referral for diagnosis in new presentations • Liason with secondary care if signs of relapse/deterioration • Monitoring of bloods according to medication

19. BAD cont… • ‘annual physical health review’ • Lipid levels / cholesterol if >40 • Glucose • Weight • Smoking status • BP • According to medication • TFTs, LFTs, U&Es, FBC, ‘levels’

20. BAD cont… • New or suspected presentations: • People with mania or severe depression who are a danger to themselves or other people (U) • For assessment and development of a care plan: (R) • periods of overactive, disinhibited behaviour lasting at least 4 days, with or without periods of depression, • Or.. 3 or more depressive episodes of depression and a history of overactive/ disinhibitied behaviour

21. BAD cont…. • Patients with existing bipolar disorder • Consider referring if new patient registers with practice / new to area • Refer urgently if managed solely in primary care and if: • Acute exacerbation of symptoms (mania or severe depression) • Increase in degree or change in nature of risk to self or others • Consider secondary care review if: • Functioning declines significantly, or response to treatment is poor • Treatment adherance is a problem • Suspected alcohol or drug misuse • Pt considering stopping prophylactic medication

22. PSYCHOSES • ACUTE vs CHRONIC • Schizophrenia • Schizoaffective disorder • Depression with psychosis • Drug induced psychosis • Medical cause – delerium – not only elderly!!!!

23. Psychosis cont… • NICE (Schizophrenia) • Secondary care led (often CCO) • Role of primary care: • Recognition of new presentations (not PC) • Recognition of relapses (might not self present) • Ongoing monitoring – physical and mental health • ‘annual health check’ • Monitoring associated with medication • Compliance / non compliance • Physical sequelae

24. Psychosis cont… • Annual health review: • Focus on cardiovascular disease/ diabetes • Send copy of any results to CCO or psych • Weight • BM • Lipids • BP • Lifestyle factors

25. Psychosis cont… • Consider re-referral if: • Poor treatment response • Poor compliance with meds • Intolerable side effects • Comorbid substance abuse • Risk to patient or others • Consult care plan or consider referral to CCO if: • Suspected relapse • Presents in crisis

26. EATING DISORDERS • Presentations • Weight loss • Menstrual problems / infertility • GI symptoms • Abdominal pain/ bloating • Altered bowel habit • Epigastric pain • Dizziness / fainting episodes

27. Affects every body system CVS - Arrythmias - structural Renal - Electrolytes - Renal failure GI Endocrine - Inc osteoporosis Resp GU - Infertility CNS - seizures - structural changes - proximal myopathy Signs BMI – may be normal!!!! Dental problems Lanugo hair Russel sign Hypotension Bradycardia Hypothermia ED cont

28. ED cont… • INVESTIGATIONS • Bloods • U&Es!!!! Urea & Creatinine Potassium & Sodium • Electrolytes - Ca, Mg, Phosphate, Bicarb, Chloride • FBC – Hb, Plts, Wcc • Cortisol – high!! • Cholesterol - High!! • BM – hypoglycaemia • Hormones – GH, FSH, LH, thyroid function • ECG • QT prolongation • Potassium related changes • Ischaemic chnages

29. ED cont… • NICE (2007) • Shared care between primary and secondary services • Secondary services: • Community / outpatient based • Psychological & nutritional interventions / treatment Grimsby based ED service • Specialist inpatient units (BMI <14) (out of area)

30. ED cont… Role of GP • High level of suspicion / recognition of possible ED diagnosis • Rule out differential diagnosis (eg thyroid ) • Initial Assessment • Medical admission in emergency • Ongoing monitoring of physical health • Long term sequelae (eg DEXA scans)

31. ED cont… • Initial assessment • History may be difficult AN vs BN Periods, purging behaviours • Examination • BMI (if agreeable!!) • Pulse, BP, temp, random BM • CVS • Abd exam • General – hands, mouth, skin, muscle wasting • Bloods (minimum FBC, U&E) • ECG

32. ED cont… • Management • BN – role for SSRIs (esp fluoxetine) • AN – no recommended drugs • Refer for community OPD treatment (ED service not psych) • Admit urgently if…. (NICE) • BMI <13 (or rapid ongoing weight loss) • BP < 80/50 • HR < 40 • Clinically ‘shut down’ or dehydration • Temp < 34.5’ • K <2.5, Na <130, PO< 0.5 • ECG rate <40 or prolonged QT

33. ADHD • Presentations: • Known since childhood, end of paediatric care • Core symptoms: • Inattention • Hyperactivity • Impulsivity • Variable severity – only those with degree of social, psychological, educational or occupational impairment should be diagnosed • Substance misuse, often overlap with other MH diagnoses (PD, LD)

34. ADHD (adults) • NICE • Medication doses recommended are higher than in BNF • Diagnosis/assessment / initiation of treatment is role of secondary care • Paediatrics • Mental health / psychiatry • Specialist adult ADHD service (not in Grimsby)

35. ADHD cont.. • Refer • Adults with suspected ADHD • Adults previously diagnosed with ADHD in childhood and with persisting symptoms • Pre-drug assessment • Hx of exercise syncope, undue breathlessness and other CVS symptoms • Substance misuse • HR & BP • Weight • FHx of CVS problems (sudden death esp) • ECG