Dr.

Hanan Abbas Associate professor of family medicine

A 40 year old man comes to see you because he feels down. He is not sleeping well and feels guilty at times that he doesn't feel as well as he should. You ask him some further questions and decide that he has mild depression. You discuss treatment options with him but he doesn't want any form of therapy at present. Which one of the following statements is correct? You should advise him to start a selective serotonin reuptake inhibitor (SSRI) You should advise him to start a tricyclic antidepressant It would be reasonable to advise watchful waiting with review in two weeks You should refer him to a psychiatrist for a second opinion

At a practice meeting one of your colleagues discusses what policies you should put in place regarding screening for depression. Your practice already has policies for screening for breast cancer and cervical cancer. In which one of the following groups is screening for depression LEAST likely to be worthwhile? Patients with a past history of depression Patients with dementia Patients with physical illnesses that cause disability Patients with short lived physical illnesses

A 50 year old woman had depression 18 months ago and now wants to stop taking her SSRI. She has made a full recovery and you see no reason for her to continue her treatment. You decide to stop the treatment. What should you advise her? She can stop treatment immediately She should gradually reduce the dose over two weeks She should gradually reduce the dose over four weeks She should gradually reduce the dose over eight weeks

A 60 year old man comes to see you because he has a headache. His blood pressure is 200/100 mm Hg. He is not one of your usual patients. He says he is taking an antidepressant but is unsure of its name. He is also taking a decongestant for a cold. Which one of the following antidepressants is he likely to be taking? Paroxetine Imipramine Phenelzine Citalopram

You start a 45 year old man with moderate depression on an SSRI. How soon after starting the antidepressant should he be reviewed by a member of the primary care team? One week Two weeks Four weeks Six weeks Eight weeks

A 40 year old woman has chronic depression. Her psychiatrist started her on phenelzine, but this did not work so he advised her to stop taking it. She comes to see you a week later and says she feels low and needs something else. Which one of the following statements is correct? You should start her on an SSRI immediately She should not start another antidepressant for at least two weeks after stopping a monoamine oxidase inhibitor

A 30 year old woman comes to see you because she has panic attacks. She works as a nurse. On examination she has a tachycardia and you notice that both her eyes look strange. What is the most likely diagnosis? Panic disorder Graves' disease Factitious self administration of thyroxin Hashimoto's disease Retro-orbital tumour

You feel that a 50 year old woman with generalised anxiety disorder needs medium to long term drug treatment. Which one of the following should you advise? A selective noradrenaline reuptake inhibitor A tricyclic antidepressant A benzodiazepine An SSRI Buspirone

You start a 40 year old man on paroxetine for anxiety. He gradually improves after 12 weeks of treatment and asks whether he can stop taking the drug. How should you advise him? He can stop the treatment He should stay on treatment for at least six months after he has improved He should stay on treatment for at least 12 months after he has improved

A 50 year old man comes to see you because he feels sad all the time. He is waking early in the morning and has no energy. He has little interest in his usual activities. He has also lost his appetite. He has had these symptoms for two months. You feel he has moderate depression but he is reluctant to start antidepressants. You could offer reading materials based on the principles of cognitive behavioural therapy

Abraham Lincoln- depression Isaac Newton- depression Ernest Hemingway - depression John Nash (A Beautiful Mind) schizophrenia

 Depression Major depression a combination of symptoms (see symptom list) that interfere with the ability to work, study, sleep, eat, and enjoy once pleasurable activities. Dysthymia long-term, chronic symptoms that do not disable, but keep one from functioning well or from feeling good. Bipolar disorder cycling mood changes: severe highs (mania) and lows (depression)

Persistent sad, anxious, or "empty" mood Feelings of hopelessness Feelings of guilt, worthlessness, helplessness Loss of interest or pleasure in hobbies and activities that were once enjoyed, including sex Decreased energy, fatigue, being "slowed down" Difficulty concentrating, remembering, making decisions Insomnia, early-morning awakening, or oversleeping Appetite and/or weight loss or overeating and weight gain Thoughts of death or suicide; suicide attempts Restlessness, irritability Persistent physical symptoms that do not respond to treatment, such as headaches, digestive disorders, and chronic pain

 Genetics Change in brain structure or function Low self esteem Unable to deal with stress Physical changes Stroke Heart Attack Cancer Parkinsons Hormonal disorders/changes Environment Work Home Life events Loss Relationships ending Financial problems Onset Genetic predisposition + Environment + Physiological stress Drug abuse can cause or make worse

Twice as often in women than men hormonal factors menstrual cycle changes pregnancy miscarriage postpartum period pre-menopause menopause Other stresses responsibilities both at work and home single parenthood caring for children and for aging parents.

 6 million men in the United States Less likely to admit to depression less likely to be diagnosed Often masked by alcohol or drugs, or by working excessively long hours. Depression typically shows up as being irritable, angry, and discouraged The rate of suicide in men is 4X that of women, though more women attempt it. Higher rate of heart disease deaths associated with depression

Psychiatry is a branch of medicine that deals with disorders in which mental ( emotional or cognitive) or behavioral features are prominent. The bulk of mild mental disorder has always been managed by family doctors.

Globally, major depression ranks fourth in terms of disability-adjusted life years and may soon be the second leading cause of disability worldwide. It is estimated that 6 percent to 10 % of patients in primary practice have major depression. In other studies the frequency of mental disorders in general practice varies from 11 % to 36 %.

The World Health Organizations study of mental disorder in general health care screened over 25000 people in 14 countries worldwide and assessed 5500 in detail. The most common disorders were depression(10 %),and generalized anxiety disorder (8 %).

The 1993 world development report of the World Bank estimated that mental health problems produce 8 % of the global burden of disease, a toll greater than exacted by tuberculosis, cancer, or heart disease. Much of the burden falls on women and young adults. It is estimated that major depression in the United States is associated with 20,000 suicides and $47 billion in health care costs annually.

Mental health problems have a significant impact on physical health. Research indicates that among elderly patients with high mean depressive scores, the risk of coronary heart disease increased 40 % while the risk of death increased 60 % compared with elderly patients with the lowest mean depressive scores.

The general reluctance of patients to seek care for mental health problems complicates the diagnosis of mental illness. Survey results show that 40 % of patients with major depression do not want or perceive the need for treatment. Patients consistently underreport emotional issues to their physicians. One study demonstrated that only 20 % to 30 percent of patients with emotional /psychological issues reported these to their primary care physicians. Many patients somatize their psychological issues.

Poor outcome is associated with delayed or insufficient initial treatment, more severe illness, older age at onset, co-morbid physical illness, and continuing problems with family, marriage, or employment.

A clear account of current problems, including social circumstances and an estimate of concurrent physical illness (substance abuse) that might influence the presentation. Topics covered : prior psychiatric and medical problems & their treatment, and illicit drugs, level of functioning at home and at work, initial suspicion of risk to the pt or others should be clarified gently but thoroughly.

Substance abuse and/or domestic violence Social factors related to psychological symptoms:
Loss: personal due to death or desertion Conflict: interpersonal within family, work Change: adolescence, menopause, senescence Maladjustment: home, work Stress: unexpected event or chronic problem

It is a myth that asking about suicidal ideas may lead pts to consider suicide for the first time. Fleeting thoughts of suicide are common in pts with mental health problems. Screening for suicide risk and access to lethal means, even in apparently asymptomatic patients, is a critically important part of the family physician's role in reducing mortality and morbidity from mental illness.

Do: * Let the pt tell his story, take the pt seriously, Allow time for emotions to calm, inquire about thoughts of suicide or violence, offer reassurance where possible, start to forge a trusting relationship, remember that listening is something.

Use closed questions too soon. pay more attention to the case notes than to the pt. be too rigid or disorganized, exert flexible control. avoid sensitive topics (such as ideas of self harm, or embarrassing ones such as sexual history). take a face value technical words the pt might use such as depressed .

Appearance: cleanliness, posture, gait.

Behavior: facial expression, cooperation or aggression activity, agitation. Speech: form and pattern, volume and rate, it is coherent, logical, and congruent with questioning. Thought: particular preoccupations, ideas and beliefs, are they rational, fixed or delusional. Mood: apathetic, irritable, labile, optimistic or pessimistic: thoughts of suicide.

Perception: abnormalities including hallucinations ( auditory, visual, smell, touch, taste). Intellect: brief note of intellectual functions (is pt oriented in time, place, and person? Is the pt able to function intellectually at level expected from his history? Insight: how the pt explain or attribute his or her symptoms?

Pts with mental disorders often suffer stigma, the experience of being discriminated against and rejected by others, and a consequent feeling of shame and disgrace. Mortality rates: psychiatric disorders are associated with increased risk of death from all causes.

Mortality rates are higher among schizophrenics, men, and younger pts. Fitness to drive: a driver with mental disorder has a slightly increased risk of being involved in road traffic accidents, with personality disorders, and side effects of drug treatment. Mental disorder may restrict a pts voting rights, under the Mental Health Act.

Among many Americans there is still a pervasive reluctance to seek care for mental health problems, just as there is still a public refusal to acknowledge the clinical basis of these problems and to ascribe mental health problems to a "moral deficiency."

The recent Surgeon General's report has even documented an increased tendency to associate mental health problems with the potential for violence, even though there is no evidence to support this association.

There is no evidence, however, that an improved level of diagnosis without a concomitant improvement in therapy is beneficial. One study estimates that less than 10 % of patients diagnosed with major depression receive demonstrably beneficial therapy.

Among family physicians, 35 % were very confident and 48 % were mostly confident about their overall ability to manage depression. However, although primary care physicians prescribe 41 % of antidepressants, the requisite followup visits are not always scheduled.

Studies demonstrate that patients treated with antidepressant medication have a visit frequency far below that recommended in the guidelines issued by the Agency for Healthcare Research and Quality.

Many mood problems are reactions to distressing circumstances such as bereavement and resolve spontaneously, such pts benefit from reassurance and time.

Presenting problems: Inappropriate requests for urgent attention, appointments, home visits. Increased frequency for consultation or requests for tests. Unexpected or disproportionate outbursts during consultation( tear, anger). Excessive anxiety about another family member ( child, elder).

Pt factors: nature of presentation. Severity of disorder. Relatively high frequency of recent consultations.

Positive attitude to mental disorder and psychiatric pts. Interest and knowledge of mental disorder. Bias in assessment.

Interview skills- doctors who are better at detection: 1. Make early eye contact. 2. Clarify presenting problems. 3. Avoid checklist questioning. 4. Ask more open and clarifying questions. 5. Spend less time talking and interrupt less. 6. Seem less rushed. 7. Show empathy. 8. Are sensitive to emotional, verbal and non verbal cues.

Benzodiazepine dependence has been highlighted as a particular problem in general practice. There has been a steady decline in prescribing benzodiazepines over the past decade, due to better practices within primary care.

Previous suicidal thoughts or behavior. Marked depressive symptoms. Painful or disabling physical illness. Previous impulsive behavior, including self harm. Family, personal, or social disruption such as bereavement, marital breakdown.

Male sex. Younger age. Severe disorder. Experience of separation in early life. Associated misuse of drugs. Social problems. Inappropriate responses to medical attention.

Most moderate anxiety and depressive disorders are managed successfully in primary care. Brief structured counseling by general practitioners is as effective as anxiolytic drugs.

Teaching relaxation techniques. Supporting use of self help techniques.

What impact does mental illness have on society? Do mental illnesses fit within the definition of public health?

Why is mental illness difficult to treat? Discuss some public health interventions that could lessen the impact of mental illness on individuals and society.