MANAGEMENT OF MANAGEMENT OF MENTAL HEALTH MENTAL HEALTH

PROBLEMSPROBLEMS

RUTH BANNISTERRUTH BANNISTER

OVERVIEWOVERVIEW SIGNPOSTINGSIGNPOSTING DUMMIES GUIDE TO PSYCH MEDSDUMMIES GUIDE TO PSYCH MEDS OVERVIEW OF MENTAL HEALTH OVERVIEW OF MENTAL HEALTH

SERVICESSERVICES MANAGEMENT OF COMMON MENTAL MANAGEMENT OF COMMON MENTAL

HEALTH PROBLEMS:HEALTH PROBLEMS: ANXIETY & DEPRESSION (brief)ANXIETY & DEPRESSION (brief) OCDOCD PERSONALITY DISORDERPERSONALITY DISORDER BIPOLAR DISORDERBIPOLAR DISORDER PSYCHOSESPSYCHOSES EATING DISORDERSEATING DISORDERS

Care Plan ApproachCare Plan Approach

Standard CPAStandard CPA MajorityMajority May only be seen in May only be seen in

OPD reviewOPD review No CCONo CCO No CMHT involvement No CMHT involvement

other than at other than at triage/referraltriage/referral Mild to moderate illnessMild to moderate illness Mood disordersMood disorders Majority bipolarMajority bipolar Transient psychosisTransient psychosis Stable psychosis with Stable psychosis with

good insightgood insight

Enhanced CPAEnhanced CPA MinorityMinority Complex care needsComplex care needs Multiple individuals Multiple individuals

involvedinvolved Formal care planFormal care plan CCOCCO PsychiatristPsychiatrist

Chronic psychosesChronic psychoses BipolarBipolar Complex PDsComplex PDs Poor compliance/ limited Poor compliance/ limited

insightinsight Those on depot medsThose on depot meds

MH MANAGEMENTMH MANAGEMENT

How would this patient present?How would this patient present? What would initial management be?What would initial management be? What is your role as a GP?What is your role as a GP? When would you refer?When would you refer?

DEPRESSIONDEPRESSION Mild and moderate depression is domain of Mild and moderate depression is domain of

primary care – specialist services not neededprimary care – specialist services not needed NICE (2009) – very good prescribing adviceNICE (2009) – very good prescribing advice Support services as appropriateSupport services as appropriate Medication – titrate doses/allow time to workMedication – titrate doses/allow time to work REVIEWREVIEW after trial of Tx, then try alternative after trial of Tx, then try alternative Refer if:Refer if:

High suicide risk (U)High suicide risk (U) Psychotic depression (U)Psychotic depression (U) History of bipolar disorder (R/S)History of bipolar disorder (R/S) Failure or partial response following Failure or partial response following 2 OR MORE2 OR MORE

attempts to treat (R)attempts to treat (R)

ANXIETYANXIETY Primary Care ManagementPrimary Care Management Panic disorder Vs Generalised anxiety Panic disorder Vs Generalised anxiety

disorderdisorder NICE (2007)NICE (2007) Benzos (no role in panic disorder, max Benzos (no role in panic disorder, max

2-4/52 in GAD)2-4/52 in GAD) CBT, psychotherapy, anxiety Mx groupsCBT, psychotherapy, anxiety Mx groups SSRIs (SNRIs 2SSRIs (SNRIs 2ndnd line), B blockers line), B blockers Bibliotherapy / self helpBibliotherapy / self help Refer if no improvement after 1Refer if no improvement after 1stst line line

and 2and 2ndnd line treatments tried (R) line treatments tried (R)

OCDOCD Closely related to anxiety disordersClosely related to anxiety disorders Presence of either, or both:Presence of either, or both:

Obsessions – unwanted intrusive thought, Obsessions – unwanted intrusive thought, image or urge which repeatedly enters the image or urge which repeatedly enters the person’s mindperson’s mind

Compulsions – repetitive behaviours or Compulsions – repetitive behaviours or mental acts that the person feels driven to mental acts that the person feels driven to perform – overt Vs covertperform – overt Vs covert

Significant functional impairment Significant functional impairment and/or distressand/or distress

Consider other MH comorbiditiesConsider other MH comorbidities Consider in dermatology presentationsConsider in dermatology presentations

OCD contOCD cont

Can be managed in primary care, refer Can be managed in primary care, refer only if trials of tx not effectiveonly if trials of tx not effective

NICE (2005)NICE (2005) Assess risk (death related thoughts vs Assess risk (death related thoughts vs

suicidal intent)suicidal intent) CBT CBT SSRIs (esp sertraline) add in if SSRIs (esp sertraline) add in if

‘moderate’‘moderate’ 22ndnd line clomipramine (no SNRIs, TCAs) line clomipramine (no SNRIs, TCAs)

OCD contOCD cont

Refer if no response to:Refer if no response to: Full trial of at least 1 SSRI aloneFull trial of at least 1 SSRI alone Full trial of combined SSRI + CBTFull trial of combined SSRI + CBT Full trial of clomipramine aloneFull trial of clomipramine alone

PERSONALITY PERSONALITY DISORDERDISORDER

Pervasive and maladapted patterns of Pervasive and maladapted patterns of behaviour, thinking and control of emotionsbehaviour, thinking and control of emotions Must be enduring, not limited to episodes of Must be enduring, not limited to episodes of

mental illnessmental illness Significant distress / disturbance in social Significant distress / disturbance in social

functionfunction Schizoid – paranoid ideas, difficulty mixingSchizoid – paranoid ideas, difficulty mixing Histrionic – impulsive, unstable, borderlineHistrionic – impulsive, unstable, borderline Dependent – anxious, obsessiveDependent – anxious, obsessive

PD contPD cont

PresentationsPresentations Impulsive acts/ behaviourImpulsive acts/ behaviour Antisocial behaviourAntisocial behaviour Poor coping skillsPoor coping skills Trivial triggersTrivial triggers Unstable moodUnstable mood Anger / temper difficulties / aggression / Anger / temper difficulties / aggression /

violenceviolence Self harm (objective suicidal intent)Self harm (objective suicidal intent) ‘‘I think I’m bipolar’I think I’m bipolar’

PD contPD cont Borderline personality disorder (EUPD)Borderline personality disorder (EUPD)

Instability of interpersonal relationships, Instability of interpersonal relationships, self image and moodself image and mood

Impulsive behaviourImpulsive behaviour Rapid fluctuations from periods of Rapid fluctuations from periods of

confidence to despairconfidence to despair Fear of abandonment and rejectionFear of abandonment and rejection Strong tendency to self harm and suicidal Strong tendency to self harm and suicidal

thoughtsthoughts May present with brief psychotic May present with brief psychotic

phenomena (pseudohallucinations)phenomena (pseudohallucinations) Substantial impairment of social and Substantial impairment of social and

occupational functioning, and quality of occupational functioning, and quality of lifelife

BPDBPD NICE (2009)NICE (2009) ““CMHT responsible for assessment, CMHT responsible for assessment,

diagnosis, treatment and management of diagnosis, treatment and management of BPD”BPD”

Primary care:Primary care: recognition and referral for assessmentrecognition and referral for assessment Crisis presentationCrisis presentation

Refer if:Refer if: Diagnostic clarificationDiagnostic clarification If co-morbid MH problemsIf co-morbid MH problems Increasing levels of distress or risk to self or Increasing levels of distress or risk to self or

othersothers For specialist treatmentFor specialist treatment Pt requests itPt requests it

PD contPD cont

Very common, variable support needsVery common, variable support needs Often most challenging patients for CMHTOften most challenging patients for CMHT Often present in primary care when in crisis Often present in primary care when in crisis

so need some confidence in area (see later)so need some confidence in area (see later) Complaints regarding other secondary Complaints regarding other secondary

servicesservices Clear professional boundaries and avoid conflictClear professional boundaries and avoid conflict Involve family/ carers with care plansInvolve family/ carers with care plans Good professional housekeepingGood professional housekeeping

PD contPD cont

Pharmacology (initiated by Pharmacology (initiated by secondary care)secondary care) SSRIs – never TCAs!!!!!!SSRIs – never TCAs!!!!!! Mood stabilisersMood stabilisers Low dose antipsychoticsLow dose antipsychotics

DBT (secondary care referral)DBT (secondary care referral) Anger Mx etc (primary care)Anger Mx etc (primary care)

SELF HARM/ RISK SELF HARM/ RISK ASSESSMENTASSESSMENT

Not only Crisis team – GPs can apply Not only Crisis team – GPs can apply principlesprinciples

Case examplesCase examples

SELF HARM/ RISK SELF HARM/ RISK ASSESSMENTASSESSMENT

Not only Crisis team – GPs can apply Not only Crisis team – GPs can apply principlesprinciples

Details of actDetails of act Where, when, how, why?Where, when, how, why? Impulsive or planned?Impulsive or planned? Did they tell anyone, A&E, 999?Did they tell anyone, A&E, 999? Measures to avoid being discovered, planning Measures to avoid being discovered, planning

(storing meds), note, will, ‘sorting out affairs’(storing meds), note, will, ‘sorting out affairs’ Even if no true intent – may be Even if no true intent – may be

‘accidentally successful’‘accidentally successful’ If in doubt – Crisis team for assessmentIf in doubt – Crisis team for assessment

BIPOLAR DISORDERBIPOLAR DISORDER

NICE (2006)NICE (2006) Management led by secondary careManagement led by secondary care Role of primary care:Role of primary care:

Monitoring of physical health in established Monitoring of physical health in established casescases

Recognition / referral for diagnosis in new Recognition / referral for diagnosis in new presentationspresentations

Liason with secondary care if signs of Liason with secondary care if signs of relapse/deteriorationrelapse/deterioration

Monitoring of bloods according to Monitoring of bloods according to medicationmedication

BAD cont…BAD cont…

‘‘annual physical health review’ annual physical health review’ Lipid levels / cholesterol if >40Lipid levels / cholesterol if >40 GlucoseGlucose Weight Weight Smoking statusSmoking status BPBP

According to medicationAccording to medication TFTs, LFTs, U&Es, FBC, ‘levels’TFTs, LFTs, U&Es, FBC, ‘levels’

BAD cont…BAD cont…

New or suspected presentations:New or suspected presentations: People with mania or severe depression who People with mania or severe depression who

are a danger to themselves or other people are a danger to themselves or other people (U)(U)

For assessment and development of a care For assessment and development of a care plan: (R)plan: (R) periods of overactive, disinhibited behaviour periods of overactive, disinhibited behaviour

lasting at least lasting at least 4 days, 4 days, with or without periods of with or without periods of depression, depression,

Or.. 3 or more depressive episodes of depression Or.. 3 or more depressive episodes of depression and a history of overactive/ disinhibitied and a history of overactive/ disinhibitied behaviourbehaviour

BAD cont….BAD cont…. Patients with existing bipolar disorderPatients with existing bipolar disorder

Consider referring if new patient registers with Consider referring if new patient registers with practice / new to areapractice / new to area

Refer urgently if managed solely in primary care and Refer urgently if managed solely in primary care and if:if:

Acute exacerbation of symptoms (mania or severe depression)Acute exacerbation of symptoms (mania or severe depression) Increase in degree or change in nature of risk to self or othersIncrease in degree or change in nature of risk to self or others

Consider secondary care review if:Consider secondary care review if: Functioning declines significantly, or response to treatment is Functioning declines significantly, or response to treatment is

poorpoor Treatment adherance is a problemTreatment adherance is a problem Suspected alcohol or drug misuseSuspected alcohol or drug misuse Pt considering stopping prophylactic medicationPt considering stopping prophylactic medication

PSYCHOSESPSYCHOSES

ACUTE vs CHRONICACUTE vs CHRONIC SchizophreniaSchizophrenia Schizoaffective disorderSchizoaffective disorder Depression with psychosisDepression with psychosis Drug induced psychosisDrug induced psychosis Medical cause – delerium – not only Medical cause – delerium – not only

elderly!!!!elderly!!!!

Psychosis cont…Psychosis cont…

NICE (Schizophrenia)NICE (Schizophrenia) Secondary care led (often CCO)Secondary care led (often CCO) Role of primary care:Role of primary care:

Recognition of new presentations (not PC)Recognition of new presentations (not PC) Recognition of relapses (might not self Recognition of relapses (might not self

present)present) Ongoing monitoring – physical and mental Ongoing monitoring – physical and mental

healthhealth ‘‘annual health check’annual health check’ Monitoring associated with medicationMonitoring associated with medication

Compliance / non complianceCompliance / non compliance Physical sequelaePhysical sequelae

Psychosis cont…Psychosis cont…

Annual health review:Annual health review: Focus on cardiovascular disease/ Focus on cardiovascular disease/

diabetesdiabetes Send copy of any results to CCO or Send copy of any results to CCO or

psychpsych WeightWeight BMBM LipidsLipids BPBP Lifestyle factorsLifestyle factors

Psychosis cont…Psychosis cont…

Consider re-referral if:Consider re-referral if: Poor treatment responsePoor treatment response Poor compliance with medsPoor compliance with meds Intolerable side effectsIntolerable side effects Comorbid substance abuseComorbid substance abuse Risk to patient or othersRisk to patient or others

Consult care plan or consider referral Consult care plan or consider referral to CCO if:to CCO if: Suspected relapseSuspected relapse Presents in crisisPresents in crisis

EATING DISORDERSEATING DISORDERS

PresentationsPresentations Weight lossWeight loss Menstrual problems / infertilityMenstrual problems / infertility GI symptomsGI symptoms

Abdominal pain/ bloatingAbdominal pain/ bloating Altered bowel habitAltered bowel habit Epigastric painEpigastric pain

Dizziness / fainting episodesDizziness / fainting episodes

ED contED cont Affects every body Affects every body

systemsystem CVS - Arrythmias CVS - Arrythmias

- - structuralstructural

Renal - ElectrolytesRenal - Electrolytes - Renal failure- Renal failure

GIGI Endocrine - Inc Endocrine - Inc

osteoporosisosteoporosis RespResp GU - InfertilityGU - Infertility CNS - seizuresCNS - seizures

- structural - structural changeschanges

- proximal - proximal myopathymyopathy

SignsSigns BMI – BMI – may be may be

normal!!!!normal!!!! Dental problemsDental problems Lanugo hairLanugo hair Russel signRussel sign HypotensionHypotension BradycardiaBradycardia HypothermiaHypothermia

ED cont…ED cont… INVESTIGATIONSINVESTIGATIONS

Bloods Bloods U&Es!!!! U&Es!!!! Urea & CreatinineUrea & Creatinine

Potassium & SodiumPotassium & Sodium Electrolytes - Ca, Mg, Phosphate, Bicarb, ChlorideElectrolytes - Ca, Mg, Phosphate, Bicarb, Chloride FBC – Hb, Plts, WccFBC – Hb, Plts, Wcc Cortisol – high!!Cortisol – high!! Cholesterol - High!!Cholesterol - High!! BM – hypoglycaemiaBM – hypoglycaemia Hormones – GH, FSH, LH, thyroid functionHormones – GH, FSH, LH, thyroid function

ECGECG QT prolongationQT prolongation Potassium related changesPotassium related changes Ischaemic chnagesIschaemic chnages

ED cont…ED cont…

NICE (2007)NICE (2007) Shared care between primary and Shared care between primary and

secondary servicessecondary services Secondary services:Secondary services:

Community / outpatient basedCommunity / outpatient based Psychological & nutritional interventions / Psychological & nutritional interventions /

treatmenttreatment

Grimsby based ED serviceGrimsby based ED service Specialist inpatient units (BMI <14)Specialist inpatient units (BMI <14)

(out of area)(out of area)

ED cont…ED cont…

Role of GPRole of GP High level of suspicion / recognition High level of suspicion / recognition

of possible ED diagnosisof possible ED diagnosis Rule out differential diagnosis (eg Rule out differential diagnosis (eg

thyroid )thyroid ) Initial AssessmentInitial Assessment Medical admission in emergencyMedical admission in emergency Ongoing monitoring of physical health Ongoing monitoring of physical health Long term sequelae (eg DEXA scans)Long term sequelae (eg DEXA scans)

ED cont…ED cont… Initial assessmentInitial assessment History History may be difficultmay be difficult

AN vs BNAN vs BNPeriods, purging behavioursPeriods, purging behaviours

ExaminationExamination BMI (if agreeable!!)BMI (if agreeable!!) Pulse, BP, temp, random BMPulse, BP, temp, random BM CVSCVS Abd examAbd exam General – hands, mouth, skin, muscle wastingGeneral – hands, mouth, skin, muscle wasting Bloods (minimum FBC, U&E)Bloods (minimum FBC, U&E) ECGECG

ED cont…ED cont… ManagementManagement

BN – role for SSRIs (esp fluoxetine)BN – role for SSRIs (esp fluoxetine) AN – no recommended drugsAN – no recommended drugs Refer for community OPD treatment Refer for community OPD treatment

(ED service not psych)(ED service not psych) Admit urgently if…. (NICE)Admit urgently if…. (NICE)

BMI <13 (or rapid ongoing weight loss)BMI <13 (or rapid ongoing weight loss) BP < 80/50BP < 80/50 HR < 40HR < 40 Clinically ‘shut down’ or dehydrationClinically ‘shut down’ or dehydration Temp < 34.5’Temp < 34.5’ K <2.5, Na <130, PO< 0.5K <2.5, Na <130, PO< 0.5 ECG rate <40 or prolonged QTECG rate <40 or prolonged QT

ADHDADHD

Presentations:Presentations: Known since childhood, end of paediatric Known since childhood, end of paediatric

carecare Core symptoms:Core symptoms:

InattentionInattention HyperactivityHyperactivity ImpulsivityImpulsivity Variable severity – only those with degree of Variable severity – only those with degree of

social, psychological, educational or social, psychological, educational or occupational impairment should be diagnosedoccupational impairment should be diagnosed

Substance misuse, often overlap with other Substance misuse, often overlap with other MH diagnoses (PD, LD)MH diagnoses (PD, LD)

ADHD (adults)ADHD (adults)

NICENICE Medication doses recommended are Medication doses recommended are

higher than in BNFhigher than in BNF Diagnosis/assessment / initiation of Diagnosis/assessment / initiation of

treatment is role of secondary caretreatment is role of secondary care PaediatricsPaediatrics Mental health / psychiatryMental health / psychiatry Specialist adult ADHD service (not in Specialist adult ADHD service (not in

Grimsby)Grimsby)

ADHD cont..ADHD cont.. ReferRefer

Adults with suspected ADHDAdults with suspected ADHD Adults previously diagnosed with ADHD in Adults previously diagnosed with ADHD in

childhood and with persisting symptomschildhood and with persisting symptoms Pre-drug assessmentPre-drug assessment

Hx of exercise syncope, undue breathlessness Hx of exercise syncope, undue breathlessness and other CVS symptomsand other CVS symptoms

Substance misuseSubstance misuse HR & BPHR & BP WeightWeight FHx of CVS problems (sudden death esp)FHx of CVS problems (sudden death esp) ECGECG