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mood anxiety disorders in primary care a review

Mood & Anxiety Disorders in Primary Care: A Review

Arun V. Ravindran, MB, MSc, PhD, FRCPC, FRCPsych

Professor and Director, Global Mental Health and Office of Fellowship Training, Department of Psychiatry; Graduate Faculty, Department of Psychology and Institute of Medical Sciences; University of Toronto

Chief, Division of Mood and Anxiety Disorders, Centre for Addiction and Mental Health

Toronto, Ontario, Canada


What is Anxiety?

  • Diffuse, unpleasant, vague sense of apprehension often accompanied by autonomic symptoms

When do you treat Anxiety?

  • “Anxiety symptoms exist on a continuum and milder forms of recent onset often remit without treatment.”
  • Need for treatment determined by:
    • Severity and persistence of symptoms
    • Presence of co-morbidity
    • Disability + Impaired function
    • Impact on social function
the spectrum of anxiety disorders


stress disorder


anxiety disorder


Panic disorder

Obsessive-compulsive disorder

Generalized anxiety disorder

The Spectrum of Anxiety Disorders
anxiety disorders dsm iv fear vs distress disorders
Anxiety Disorders – DSM-IV – Fear vs. Distress Disorders

Panic Disorder


Specific Phobia

Social Phobia





key fears in anxiety disorders
Key Fears in Anxiety Disorders
  • PD/A – Dying, going crazy or losing control
  • SP – Harm from an external object or situation
  • SAD – Humiliation or embarrassment
  • GAD – Future events involving real life concerns
  • PTSD – Re-experiencing trauma in memories/dreams
  • OCD – Harm, uncertainty, uncontrollable actions
epidemiology of anxiety disorders
Epidemiology of Anxiety Disorders

Disorder Life Time Prevalence

Panic Disorder 2 – 5%

Specific Phobias 1 – 19%

Agoraphobia 0.2 – 5%

Social Phobia 5 – 12%

General Anxiety Disorder 1 – 6%

Post Traumatic Stress Disorder 2 – 8%

Obsessive-Compulsive Disorder 2 – 3%

As a group 20-30%

psychophysiology of anxiety disorders
Psychophysiology of Anxiety Disorders

Triple Vulnerability Model

Genetic contribution to temperament

Generalized Psychological


Generalized Biological



Sense of diminished control

Early Learning

Experiences and Familial/Social


key decision points in the management of anxiety disorders
Key Decision Points in the Management of Anxiety Disorders

A. Identify anxiety symptoms

Determine if anxiety causing distress or functional impairment

Assess suicidality

  • B. Differential diagnosis
  • Is anxiety due to other medical or psychiatric condition?
  • Is anxiety comorbid with other medical or psychiatric condition?
  • Is anxiety medication-induced or drug-related?
  • Perform physical exam & baseline laboratory assessment

C. Identify specific anxiety disorder

Panic, specific, SAD, OCD, GAD, PTSD

  • Co-morbid mental disorders
  • If substance abuse: avoid BZDs
  • If another anxiety disorder: consider therapies that are 1st-line for both disorders
  • If mood disorder: consider therapies that are effective for both disorders, also refer to depression or bipolar disorder guidelines

Comorbid medical conditions

If medical: assess benefits and risks of medication for the anxiety disorder, but consider impact of untreated anxiety

  • D. Consider psychological and pharmacological treatment
  • Patient preference and motivation extremely important when choosing treatment modality
  • If formal psychological treatment not applied, all patients should receive education and support to encourage them to face their fears

BZD=benzodiazepine, SSRI=selective serotonin reuptake inhibitors, SNRIs=serotonin norepinephrine reuptake inhibitorsMAOIs=monoamine oxidase inhibitors

treatment of anxiety disorders in primary care general principles
Treatment of Anxiety Disorders in Primary Care: General Principles
  • Screening
    • Beck Anxiety Inventory (BAI; 21 items)
  • Interventions
    • Pharmacotherapy (mild to moderate)
    • CBT (mild to moderate)
    • Antidepressants + CBT (moderate to severe)
  • Maintain antidepressants + CBT boosters – 1-2 years
the cbt package the proven intervention
The “CBT Package” – The Proven Intervention
  • Psychoeducation
  • Monitoring/early cue detection
  • Applied relaxation
  • Imaginal and in vivo exposure
  • Coping skills rehearsal
  • Cognitive restructuring
case history
Case History

Jenny, 56-year-old accountant, married with three grown children

  • Describes herself as a ‘worrier’
  • Has worried more “for the past 1 year” about her children’s health, finances, marital relationship, the future

Jenny is likely suffering from:

  • Clinical Depression
  • Generalized Anxiety Disorder
  • Adjustment Disorder
  • Alcohol dependence

What further information is useful in her diagnosis?

generalized anxiety disorder gad the facts
Generalized Anxiety Disorder (GAD): The Facts

“Inappropriate and/or extreme worry with multiple somatic anxiety”

- Restlessness

- Poor concentration

- Fatigue

- Irritability

- Sleep difficulties

- Tension

  • 5% of the general population
  • Onset in adolescence, disability and chronic course
  • Comorbidity and vulnerability to MDD
treatment of gad
Treatment of GAD
  • Pharmacotherapy
    • Antidepressants
    • Beta blockers
    • Benzodiazepines
    • Anticonvulsants
    • Buspirone
  • Psychotherapy
    • CBT
  • Recent advances
    • Focus on “worries”
    • Mindfulness and acceptance
case history1
Case History

Sam, 24-year-old computer programmer, single and living on his own

  • 1 year history of physical symptoms
  • Has seen several physicians – multiple investigations
  • Convinced that he has heart disease and believes that it is being missed

Which of the following is most likely?

  • Hypothyroidism
  • Panic Disorder
  • Schizophrenia
  • Incompetent Physicians
panic disorder and panic disorder with agoraphobia pd a
Panic Disorder and Panic Disorder with Agoraphobia (PD/A)

“Characterized by panic attacks and avoidance behaviour”

  • Prevalence
    • Lifetime 3-5%
    • Specialty clinics 10-60%
  • Impaired function
  • High rates of utilization
  • Early evidence of anxiety
  • Common medical/psychiatric co-morbidity
pd a diagnosis dsm iv
PD/A Diagnosis (DSM-IV)

Diagnostic criteria: recurrent panic attacks


4 or more of the following:

  • Dyspnea or the sensation of being smothered
  • Depersonalization or derealization
  • Fear of going crazy or of losing self-control
  • Fear of dying
  • Palpitations or tachycardia
  • Sweating
  • Trembling or shaking
  • Feeling of choking
  • Chest pain or discomfort
  • Nausea or abdominal upset
  • Dizziness, feeling of unsteadiness or faintness
  • Numbness or tingling sensation
  • Flushes or chills

Physical symptoms

treatment of pd a
Treatment of PD/A
  • Pharmacotherapy
    • Antidepressants
    • Benzodiazepines
  • Psychotherapy
    • CBT plus
      • Breathing retraining
      • Relaxation exercises
  • Recent advances
    • Mindfulness based CBT (MBCT)/Mindfulness based stress reduction (MBSR)
    • Sensation focused intensive treatment (SFIT)
    • Virtual reality exposure therapy
pd a treatment outcomes
PD/A: Treatment Outcomes
  • CBT vs. pharmacotherapy vs. combination
    • Similar benefit short-term
    • CBT better on long term
    • CBT useful
    • Sequential PT + CBT – new trend
  • In General
    • Low remission rate – 20-50%
    • High rates of relapse – 25-85% on discontinuation

Good initial response – less probability of relapse

case history2
Case History

Brian, 30-year-old graduate student, engaged to be married in 6 months

  • Is very anxious and apprehensive about the event
  • “I don’t like being looked at”, “I think people will laugh at how I look or what I say”
  • History of shyness, being ‘quiet’

What further information would be useful for diagnosis?

What is the likely diagnoses?

social phobia social anxiety disorder sad
Social Phobia/Social Anxiety Disorder (SAD)

Carly Simon

Barbra Streisand

Donny Osmond

sad signs and symptoms
SAD: Signs and Symptoms


  • Fear of scrutiny, humiliation and embarrassment,
  • Exposure promotes anxiety


  • Blushing, sweating, tremor


  • Avoidance and anticipatory anxiety in social/performance situations
  • Good Insight
treatment of sad
Treatment of SAD

Pharmacotherapy vs. CBT vs. combination


  • Improve cognitive and physical symptoms
  • Reduce anticipatory anxiety and avoidance
  • Treat comorbid conditions
  • Improve functioning


  • Psychoeducation
  • CBT plus
    • Social skills training
    • Exposure therapy
performance specific anxiety
Performance-Specific Anxiety
  • SAD vs. shyness vs. performance anxiety
  • Proposed overlap with non-generalized SAD
  • Evidence for benefit with propranolol (RCTs)
    • Surgical patients and surgeons
    • Dental patients
    • Medical students
  • Benzodiazepines – decrease anticipatory anxiety but may impair performance
specific phobias
Specific Phobias

Specific phobia is excessive or irrational fear of object or situation, and is usually associated with avoidance of feared object

  • Lifetime prevalence: 12.5%
  • Median age of onset: 7 years

Common Phobias: animal and blood-injection, claustrophobia, heights


  • Pharmacotherapy: Difficult to use and unproven
  • Psychotherapy: In vivo and virtual exposure
case history3
Case History

Sonya – 33 year old housewife brought against her wishes by her husband

  • Vague complaints – 3-4 years
  • “I don’t understand what is wrong with her” – husband
  • Superstitious about leaving the house without knocking on the door posts. “It’s bad luck if I don’t.”
  • Spends half an hour each night checking and double-checking that the doors and windows are locked and all kitchen appliances are turned off
  • Not able to cope with housework because she spends too much time on one task. “I’m a perfectionist.”

What would your diagnosis be?

obsessive compulsive disorder ocd
Obsessive Compulsive Disorder (OCD)
  • Obsessions and/or compulsions
    • Recurrent, persistent ideas, thoughts, impulses or images
    • Repetitive, purposeful and intentional behaviours that are performed in response to an obsession
  • Repetitive, unpleasant and ego dystonic + resisted
  • Excessive/unreasonable
  • Marked distress and impact on functioning
  • Affects 2-3 % of the population, with onset in teens
ocd common obsessions and compulsions
OCD: Common Obsessions and Compulsions
  • Obsessions
    • Repetitive thoughts about contamination
    • Repetitive doubts
    • Intense need for orderliness and symmetry
    • Aggressive impulses
    • Repeated sexual imagery
  • Compulsions
    • Behaviours
      • Hand washing
      • Ordering
      • Checking
      • Demanding reassurance
      • Repeating actions
    • Mental Acts
      • Counting
      • Repeating words silently
treatment of ocd
Treatment of OCD
  • Pharmacotherapy
    • Serotonergic agents
    • AAPs
    • Combination
  • Psychotherapy
    • CBT with focus on
      • Exposure and response prevention
      • Cognitive interventions
  • Poorer outcomes in
    • Males
    • Early onset
    • Delayed treatment
case history4
Case History

Goran, a 47-year-old parking attendant

  • Complains of feeling tired and ‘down’ for the past 5-6 months, since being robbed and beaten up at work last year
  • Has difficulty sleeping due to nightmares, is ‘jumpy’ and irritable
  • Feels distant from family and friends
  • Constant sense of inner and physical tension

Do you think Goran is suffering from:

  • Fibromyalgia
  • Fatigue
  • Post traumatic stress
  • Overwork
ptsd key features
PTSD: Key Features
  • Exposure to threat to life or physical integrity


  • Emotional reaction of fear, helplessness or horror
  • Persistent intrusive reexperience of the event
  • Avoidance of trauma-associated stimuli and

numbing – emotional and behaviouralwithdrawal

  • Persistent symptoms of increased arousal
  • Duration 1 month to years
  • Prevalence 3-4 %
  • High risk of suicide


ptsd treatment
PTSD - Treatment

Both Pharmacotherapy and Psychotherapy are useful


  • Antidepressants and atypical antipsychotics


  • Trauma focused therapies best results
  • CBT, exposure therapy beneficial
  • Less effective - IPT, psychodynamic therapy, supportive therapy
  • Different types of trauma may respond to different psychotherapies, benefit across subtypes
acute stress disorder
Acute Stress Disorder

Follows within 1 month acute exposure to threat and lasts few days to 4 weeks

Intervention: Brief and immediate

Focus on high risk population


  • Information Education
  • Psychological support
  • Crisis intervention
  • “Emotional first aid”

Does immediate intervention prevent PTSD?

anxiety disorders primary care perspectives
Anxiety Disorders: Primary Care Perspectives
  • Often present with somatic symptoms or complaints related to co-morbid conditions
  • High utilizers of primary care
  • May need to treat multiple anxiety disorders
  • Education and CBT-based brief interventions useful
  • Deal with barriers to care
a case history
A Case History

Maria, a 47-year-old married lady, reports feeling ‘not her usual self’ for the past 6-8 months

  • She reports feeling both sad and anxious
  • She has difficulty sleeping and is always tired
  • Her appetite has decreased and she has lost 15 lbs. in the past 6 months
  • Her brother died in a car accident about 1 year ago. She feels guilty about an argument they had just before, and thinks about it a lot.

What is your diagnosis?

mood affective disorders
Mood/Affective Disorders

Definition: Mental illnesses presenting with altered mood/affect as the primary symptom

  • Affect: External expression of an internal state (i.e. mood)
  • Affect is more transient, mood is more sustained
  • Two broad syndromes of mood disorders
    • Depression
    • Mania
how common are mood disorders and what is their disease burden
How Common Are Mood Disorders and What is Their Disease Burden?
  • Life time prevalence
    • Unipolar depression 8-20%
    • Bipolar disorder 1%
  • WHO: Depression is the leading cause of disability
  • Impact on:
    • Quality of life
    • Impaired function (occupational, social)
    • Suicide
    • Physical health
what causes mood disorders
What Causes Mood Disorders?
  • Genetic vulnerability
  • Social and environmental factors
    • Life stressors
    • Early childhood experiences
    • Social determinants
  • Neurobiological factors
    • Neurotransmitter/neurohormonal challenges
    • Neural circuitry

Usually a multi-factorial etiology

defining a depressive disorder dsm
Defining a Depressive Disorder (DSM)
  • Clinically significant behavioural or psychological syndrome, associated with
    • Distress/disability
    • Increased risk of death/pain
  • Not simply
    • Lowered mood
    • Response to loss
    • Maladaptive reaction to stress
  • Two key forms
    • Major depressive disorder (MDD)
    • Dysthymic disorder (DD)/Persistent depressive disorder (DSM5)
depression is complex multidimensional
Depression is Complex, Multidimensional

Emotional Symptoms

  • Feelings of guilt
  • Suicidal
  • Lack of interest
  • Sadness

Associated Symptoms

  • Brooding
  • Obsessive rumination
  • Irritability
  • Excessive worry over physical health
  • Pain
  • Tearfulness
  • Anxiety or phobias

Physical Symptoms

  • Lack of energy
  • Decreased concentration
  • Change in appetite
  • Change in sleep
  • Change in psychomotor skills

APA. DSM-IV-TR; 2000:352,356.

what are the important subtypes of mdd and dd
What Are the Important Subtypes of MDD and DD?
  • Chronic depression
  • Melancholic depression
  • Atypical depression
  • Psychotic depression
  • Postpartum depression
  • Seasonal affective disorder
how do patients with depression present in primary care
How Do Patients with Depression Present in Primary Care?
  • Less than 20% seek help from family physicians
  • Only 50% are recognized as depressed
  • 2/3 present in practice with somatic symptoms only
  • Common screening tools for primary care
    • Brief Hamilton Depression Rating Scale (HDRS; 7 items)
    • Beck Depression Inventory (BDI-II; 21 items)
    • Patient Health Questionnaire (depression only) (PHQ-9; 9 items)
  • Screening tools are specially useful in high risk populations
high risk groups and symptomatic presentation of mdd
High Risk Groups and Symptomatic Presentation of MDD

Patten et al., 2009; J Affect Disord.

managing depression in primary care
Managing Depression in Primary Care
  • Assessment
    • Suicide risk
    • Physical health
    • Psychosocial issues
    • Psychiatric morbidity
  • Management: “Stepped care approach”
    • Watchful waiting
    • Guided self-management
    • Brief psychological/pharmacological interventions
    • Referral to specialists
  • Determine diagnosis and point in continuum of care
what are the phases of treatment for depression and their goals
What Are the Phases of Treatment for Depression and Their Goals?
  • Acute
    • Target goals
      • Remission
      • Restoration of function
    • Outcome measures
  • Maintenance
    • Resolve residual symptoms
    • Treat co-morbidities
    • Prevent recurrence

Use chronic disease management model

what are the effective interventions for depression
What Are the Effective Interventions for Depression?
  • Pharmacotherapy
    • Antidepressant agents
      • Older agents – TCAs, MAOIs
      • Newer agents – SSRIs, SNRIs, atypical antipsychotics, novel agents
  • Psychological therapies
    • Cognitive Behaviour Therapy (CBT)
    • Interpersonal Therapy (IPT)
    • Other modalities, supportive therapy
  • Combination: Medication + psychotherapy
  • Psychosocial interventions
  • Neurostimulation
    • Electroconvulsive Therapy (ECT)
    • Rapid transcranial magnetic therapy (rTMS)
    • Investigational modalities
  • Chronic disease management model
psychotherapy best modalities
Psychotherapy: Best Modalities
  • Cognitive behaviour therapy (CBT)
    • Basis: Thoughts, emotions and behaviours are inter-related
    • Focus on dispelling cognitive misperceptions of self, others and surroundings and modifying maladaptive emotional and behavioural responses
  • Interpersonal therapy (IPT)
    • Basis: Problematic interpersonal relationships may contribute to depressive onset and maintenance
    • Focus on at least 1 key area: Role transitions, Interpersonal role disputes, Grief, Interpersonal deficits
  • Pick the most appropriate form based on the need
  • Both forms effective in acute and maintenance treatment
how does depression affect physical health
How does Depression Affect Physical Health?
  • Increase the effect of risk factors
    • Obesity
    • Smoking
    • Cardiovascular
    • Immune
  • Increase the risk of chronicity
  • Worsen pain disorders
  • Reduce treatment adherence
  • Reduce participation in prevention
what is the long term outcome of depressive disorders
What is the Long-term Outcome of Depressive Disorders?
  • MDD
    • Variable duration
    • Spontaneous recovery in many
    • Longer illness  poor outcome
    • Often recurrent
    • 20% non-recovery and chronic course
  • Dysthymia/Persistent depressive disorder
    • Chronic fluctuating course
    • Superimposed MDD  double depression
    • Poor function
case history5
Case History

Susan, a 20-year-old university student, presents with symptom of 2 months’ duration (worsening in last 2 weeks)

  • Has started many projects, but is easily distracted and does not complete them – has affected her grades
  • Is sleeping less (but does not feel tired)
  • Has been buying unneeded things impulsively from the internet
  • Her friends say her mood is unpredictable, and that she gets overly excited or angry about even little things.

What is your assessment of this patient?

symptom overlap the complexity of mood disorders
Symptom Overlap: The Complexity of Mood Disorders


Bipolar Depression

Bipolar Mania

Mixed State

Agitated Depression

Treatment Resistant Depression

Unipolar Depression

*All have potential for psychotic presentation/escalation

bipolar disorder and bipolar spectrum disorders
Bipolar Disorder and Bipolar Spectrum Disorders
  • BP I: Mania with/without depression
  • BP II: Depression with hypomania - Recurrent MDE with clear-cut hypomanic episodes (lasting at least 4 days)
  • BP Spectrum/ Complex Subtypes
    • Mixed states: Mania and depression
    • Rapid cycling, Ultra-rapid cycling, Ultradian
    • Cyclothymia
    • Substance/Antidepressant-induced hypomania
  • Prevalence:
    • Bipolar I Disorder: 1.2-1.6%
    • Bipolar II Disorder: 2-6%
    • Bipolar Spectrum Disorders: 6.4%
bipolar disorder burden of disease
Bipolar Disorder:Burden of Disease
  • High degree of psychiatric/physical co-morbidity and psychosocial consequences:
    • Suicidality
    • Substance abuse
    • Medical illnesses
    • Employment and family problems
  • Increased mortality than those without bipolar disorder:
    • 2.5 times more likely to die in 12 months, if untreated
  • One of the world’s 10 most disabling conditions
  • DALYs highest in 14-44 year olds
diagnosing mania
Diagnosing Mania

Mood: Abnormally and persistently elevated, expansive or irritable

Duration: At least one week or requiring admission


Three (four if irritable mood) or more of the following:

  • Grandiosity
  • More talkative
  • Flight of ideas
  • Distractibility
  • Less need for sleep
  • More goal-directed activity
  • Excessive involvement in pleasurable activities
hypomania presentation
Hypomania: Presentation

A distinct period of persistently elevated, expansive or irritable mood, lasting at least 4 days


Three (four if irritable mood) or more of the following:

  • Grandiosity
  • More talkative
  • Flight of ideas
  • Distractibility
  • Less need for sleep
  • More goal-directed activity
  • Excessive involvement in pleasurable activities

More commonly seen in primary care than mania

the complex bipolar patient
Mixed episodes

Both manic and depressive symptoms

 comorbid substance use disorders

risk of suicide and psychosis

Rapid cycling

4 or more cycles/year with > 8 weeks of well periods

Occurs in Bipolar I and II

The Complex Bipolar Patient
the complex bipolar patient co morbidities complications
The Complex Bipolar Patient: Co-morbidities/Complications
  • Anxiety disorders
    • High co-morbidity (up to 92%)
    • Risk factor for bipolar disorder
    • May elevate risk of suicide
  • Substance abuse
    • High rates of co-morbidity vs. the general population
    • Higher prevalence of complex subtypes
  • ADHD
    • Bi-directional relationship
    • Overlap of symptoms
    • ADHD as a prodrome
  • Personality disorders (cluster B)
  • Medical conditions
    • Obesity
    • Cardiovascular
    • Endocrine
    • Cerebral pathology
  • Suicide
    • 15% suicide rate
    • 25-50% attempt suicide in lifetime
bipolar disorders management
Bipolar Disorders: Management

Chronic disease management model: Long term, interdisciplinary, education focused and integrated

  • Bipolar I Disorder
    • Emergency management
    • Acute care/short-term
    • Mixed/rapid cycling states
    • Bipolar mania
    • Bipolar depression
  • Bipolar II Disorder
    • Mainly depression
  • Maintenance treatment and prophylaxis
issues specific to primary care
Issues Specific to Primary Care
  • Diagnostic difficulties – screening tools
    • Patient Health Questionnaire (depression only) (PHQ-9; 9 items)
    • Mood Disorder Questionnaire (mania only; 17 items)
  • Check for “destabilization”/non response to antidepressants
  • Use antidepressants with caution
  • Referral for consultation/shared care
  • Treatment adherence
  • Risk of suicide /financial difficulties
  • Medical issues, e.g. obesity, cardiovascular disease
  • Psychoeducation and support through life transition for patient and family
  • Relapse prevention
what interventions are useful for bipolar disorders
What Interventions are Useful for Bipolar Disorders?
  • Pharmacotherapy
    • Antipsychotics
    • Mood stabilizers
      • Lithium carbonate
      • Anticonvulsants
  • Psychotherapy
    • Psychoeducation
    • CBT, IPT
    • Family interventions
    • Benefits: Improve adherence and function, early identification of relapse and suicidal ideation, prevent suicide
  • Neurostimulation
    • ECT
bipolar patients baseline investigations and monitoring
Bipolar Patients: Baseline Investigations and Monitoring
  • CBC electrolytes
  • Fasting lipids and glucose
  • Liver function levels
  • TSH + ECG
  • Urine analysis

Regular monitoring:

  • The above +
  • Weight, smoking status and alcohol use
  • Medication serum levels
  • Cognitive function