Transcript Clinical Guidelines for primary care
Slide 1
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 2
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 3
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 4
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 5
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 6
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 7
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 8
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 9
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 10
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 11
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 12
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 13
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 14
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 15
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 16
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
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F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
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Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 2
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 3
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 4
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
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F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 5
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 6
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 7
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
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F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 8
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 9
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 10
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
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F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
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Slide 11
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
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Slide 12
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 13
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
Back to
contents
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 14
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
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Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
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Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
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F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
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Slide 15
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
Back to
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
Back to
contents
PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
Back to
contents
PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
Back to
contents
F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
Back to
contents
Slide 16
Primary Care Guidelines for Common Mental Illness
These primary care mental health guidelines are designed to help primary care practitioners assess and plan care for adults who are presenting with a range of mental health problems.
They have been designed and written by the primary care LIT committee and Haringey LES team with input from experts in the field throughout Haringey using Haringey's previous and
C&I’s existing guidelines as a foundation. They were written in line with 2007 national guidelines – check for updates from this date.
These guidelines are designed to be used directly fromyour computer, although can be printed off as a paper version. They are intended to help you make clinical decisions rather than
direct your actions. When viewing on the web, when any underlined item is clicked on you will be connected to that page or relevant external web site (although HTPCT and BEHMHT
cannot be responsible for the content or accuracy of any external web site).
If you have any questions or need to contact someone about these guidelines please contact one of the LES team in the first instance.
The LES team. July 2007: Dorian Cole (Clinical Specialist – 020 8442 6870) Dr Martin Lindsay (GP MH lead North East PBC – 020 8493 9100) Dr Belinda Agoe (GP MH lead central
PBC – 020 8888 3227) Dr Muhammed Akunjee (GP MH lead South East PBC – 020 8881 9606) Dr Robert Mayer (GP MH lead West PBC – 020 8340 6628)
Contents (click on heading to go to page):
Depression – Identification and assessment
Depression – Management
Antidepressants – drug choice guidance
Anxiety – Identification and management
Anxiety drug treatment guidance
Eating disorders
Where you see
this sign, click
on it to be
directed to the
latest NICE
guidelines for
that condition
Psychosis and schizophrenia – identification, assessment and referral
Psychosis and schizophrenia – management following discharge from complex care team
Psychosis and schizophrenia – managing physical health
Assessing and managing risk to self
Assessing and managing risk to others
1st edition – September 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines.
NICE
Primary Care Guidelines for Common Mental Illness
Depression - Identification & Assessment
First Questions to ask …
Core Clinical Symptoms
• Have you been bothered by feeling down, depressed or hopeless? How bad is
this?
• depressed mood, and/or
• Have you lost interest in things? Do you get less pleasure from things you used
to enjoy?
• loss of energy & fatigue
• Are you more tired than usual?
• poor concentration
If “yes” to the above, prompt further about individual symptoms (see core
symptom box)
• loss of interest, and/or
Additional Symptoms
Mild Depression:
At least 2 core symptoms plus
at least 2 additional. Person
has some difficulty continuing
with ordinary activities but
does not cease to function.
• reduced self-esteem & selfconfidence
• disturbed sleep
Dysthymia:
Ante and Post Natal Care:
• change in appetite or weight
Mild depression >2yrs
• 1st contact – enquire about past/current mental health history
• feelings of guilt or worthlessness
• If high risk or actual symptoms/diagnosis, GP to communicate with midwife, HV
and hospital services
• pessimism/ hopelessness
• suicidal thoughts or acts
• Agree and write care plan
• See woman every month ante and post natal
• Observe specific pharmacological guidance
Higher Risk Groups
•
•
•
•
•
•
•
•
•
•
• agitation/slowing
Past history of depression
Family history of depression
Women who are pregnant and up to 6 months post- childbirth
Socially isolated
Those with ongoing difficult relationships
Concurrent physical illness
Multiple adverse events eg. loss, bereavement, childhood separation or abuse
Drug & alcohol misusers
Carers
Those in residential care
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Most of the day for at least 2 weeks
Other clinical signs
• “Tired all the time”
Moderate Depression:
At least 2 core symptoms plus
at least 3/4 additional. Person
usually has considerable
difficulty in continuing with
normal social & work activity.
• Irritability
• Loss of libido
• Medically unexplained physical
symptoms
• Depression associated with physical
illness
• Frequent attendance
• Self-neglect
• Diurnal variation
If further systematic assessment
needed, consider use of PHQ9,
HADS or EPNDS
Severe Depression:
All 3 typical symptoms plus at
least 4 additional, some of
which are severe. Person
shows considerable distress
& agitation (or retardation) &
unlikely to be able to continue
with normal activity.
Back to
contents
Primary Care Guidelines for Common Mental Illness
Depression - Management
Primary Care and psychological Management
Mild Depression
• Listen & Support • Inform & Educate •Patient leaflet • Problem-Solve • Increase Activity & Exercise • Increase social
support • Consider other family members
•Book prescription Guided Self-help, Computerised CBT and other brief talking therapy useful – consider referral to
Graduate Mental Health Workers (Health in Mind) . Also consider social care input – Harts, 60+
Primary Care Management
• Listen & Support • Inform & Educate • Problem-Solve • Self-help and book prescription • Increase Activity & Exercise •
• Increase social support • Consider other family members •Also consider social care input – Harts, 60+
Dysthymia
Moderate Depression
Pharmacological Management
Consider prescribing antidepressants – first line choice Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Consider referral for a specific talking therapy – Graduate Mental Health Workers (Health in Mind) , Primary Care PTS or
other (ie Derman, Mind, NAFSAT, ACLC)
ASSESS RISK
Severe Depression
Actively suicidal & urgent risk to
self or others
POOR RESPONSE to adequate
treatments/ complex management
issues
under 18 – CAMHS on 020
8442 6467
18 to 65 yrs – call START on
020 8442 6714
Over 65 – call 020 8442 6702
Patient choice
Pharmacological Management
Currently no evidence to suggest that antidepressant medication is effective in mild depression. Prescribe only if clinically
indicated.
BEHMHT will
consider crisis
and/or inpatient
needs
Primary Care Management
• Assess, Identify risks/stressors and protectors – see guidelines on assessing risk. Consider other family members for
support and issues of risk (ie impact on children). Negotiate and write a clear plan of care. Give information to patient and carer
of out of hour support.
Pharmacological Management
Prescribed antidepressants- first line choice= Fluoxetine or Citalopram. Second line choice = venlaflaxine
Psychological Management
Refer to START for consideration for talking therapy such as CBT, IPT, CAT
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Choice Guidance
Key Facts
• When an antidepressant is to be prescribed in routine care it should be an SSRI (as effective and less severe side effects than tricyclics)
• Prescriptions when possible should be generic. PCT recommend 1 st line – Fluoxetine or Citalopram.
• If SSRI is not effective, different type of medication should then be offered. PCT recommend 2 nd line - Venlafaxine
• Patients seem to have better outcomes if given GOOD, CLEAR INFORMATION about anti-depressants – explain drugs plus give a Patient Information Leaflet
Questions to consider when choosing antidepressants
• Is the patient at risk of suicide?
YES – SSRI’s (Fluoxetine or Citalopram). consider issues of toxicity in overdose
• Is sedation needed?
YES – Mirtazapine or ‘Older’ tricyclics
• Will anticholinergic effects be particularly problematic ? YES – SSRI’s, Venlafaxine
• Does the patient have significant other illness?
YES – avoid tricyclics, check BNF for individual drugs eg. CV/hepatic/renal imparirment
• Is the patient taking OTC or prescribed medications?
YES – check BNF for significant interactions
• Does the patient have symptoms of anxiety?
YES - see anxiety guidelines
• Is the patient pregnant or breastfeeding?
YES – avoid drugs in 1st trimester if possible. Only use if benefits of treatment outweigh possible risks to foetus/baby & of not
treating the mother. Discuss with psychiatrist or psychiatric pharmacist. For complex cases: National Centre for Drugs in Pregnancy 0191 232 1525
Drug
SSRI's
Fluoxetine
Citalopram
Paroxetine
Sertraline
Tricyclics (TCA)
Amitriptyline
Clomipramine
Dothiepin
Imipramine
Lofepramine
Others
Venlafaxine
Mirtazapine
Reboxetine
Trazodone
Oral Start
Dose
mg/d
Toxicity in
overdose
CV efects
Sedation
Anticholiner Nausea
gic effects
W eight gain
20mg
20mg
20mg
50mg
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
++
++
++
++
Tendency for
£2
initial weight loss £3
then regain
£6
£3
125mg
125mg
125mg
125mg
140mg
+++
+
+++
+++
0
+++
++
++
++
0
+++
++
+++
+
+
+++
+++
++
++
++
++
++
0
++
+
Weight gain well £5
documented
£13
£4
£9
£31
75mg
30mg
8mg
150-300mg
?
0
0
+
++
0
+
+
+
++
0
++
0
0
+
+
++
0
+
+++
Wt. Loss
Wt. Gain
No reports of
weight changes
Adapted from Bazire, S. Psychotropic Drug Directory, 2005 Prices from Drug Tariff July 2007
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Cost (28
days)
£24
£11
£19
£19 to £39
Back to
contents
Primary Care Guidelines for Common Mental Illness
Antidepressants - Drug Treatment Guidance
Initiating medication
Treatment Regime
• Choose drug in line with drug choice guidelines
overleaf
• Aim for the minimum effective dose
• Agree follow-up plan – Review every 1-2 weeks at
start of treatment. Monitoring of suicide risk essential
if high risk. If low risk, every two to four weeks
• Provide good, clear drug counselling plus a patient
information leaflet
• Give selected antidepressant
RESPONSE
• Titrate to therapeutic dose
• Assess response over 4-6wks (longer in
elderly)
• Increase dose after 2 & 4 weeks if appropriate
To stop
treatment, taper
dose and/or
frequency over
a min. of 4wks
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
• Give an antidepressant from a different class
Drug Counselling
Advise the patient:
• That it may take 2-4wks to start noticing the positive
effects (4-8wks in older people)
No response or poorly tolerated
• Of the common side effects they are likely to
(CHECK COMPLIANCE FIRST)
experience
• That they need to keep taking the medication even
when they feel better
• That antidepressants are NOT addictive – but must not
stop suddenly
• Of dosing& titration regime where appropriate
• To come back and see you in 1-4wkswhether or not
they have been taking medication
• That they should consult you before stopping taking
the tolerated
medication
Poorly
• Titrate to therapeutic dose
RESPONSE
• Assess response over 4-6wks (longer in
elderly)
Continue for 4-6 months
at same dosage once
well (12mths in the
elderly)
RESPONSE
Taper dose over
6mths for those
on longer-term
maintenance
treatment
For patients with
3+ episodes in
the last 5yrs, or
a total of 5+
episodes,
consider
maintenance
treatment for 5
years
• Increase dose after 2 & 4 weeks if appropriate
No response or poorly tolerated
(CHECK COMPLIANCE FIRST)
RESPONSE
• Give an antidepressant
from a different class
(or from within class – see BNF for washout
periods)
• Titrate to therapeutic dose
NO RESPONSE
• Assess response over 4-6wks
(longer in
elderly)
(CHECK COMPLIANCE FIRST)
• Increase dose after 2 & 4 weeks if appropriate
Link to United Kingdom psychiatric pharmacy group web site
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
contents
Primary Care Guidelines for Common Mental Illness
Anxiety - Identification & Management
Predisposing factors
• Life events/ stressors
• Anxious personality
Assessment
• Screening questions:
“How are you feeling in yourself?”
“Have you found yourself worrying a lot?”
• Consider other causes of symptoms e.g.
thyrotoxicosis, stimulant drug use
• Consider comorbidity inc depression
• Look out for drug/alcohol use
• Consider somatic problems, eg pain
• Determine:
- duration of symptoms
- severity of impairment
- degree of avoidance
- degree of accompanying depression
• Assess risk
Core Symptoms
• Mental symptoms: eg. feeling ‘on edge’,
apprehension, worry about future, fear of
something bad happening, difficulty
concentrating, depressive symptoms
• Physical tension & arousal: eg.
restlessness, muscle tension, inability to
relax, sweating, stomach or chest pains,
dizziness, overbreathing NB. May
present as physical complaint
Primary care management
Common Anxiety Disorders in Primary Care
(co-existence should be considered)
• Educate about anxiety
• Provide self-help information & support
Mixed Anxiety & Depression (MAD)
• Low or sad mood & loss of interest or pleasure
• Prominent anxiety or worry
• Multiple depressive or anxiety symptoms
Generalised Anxiety Disorder (GAD)
• Excessive anxiety & worry about several events or activities
• Book prescription
• Encourage relaxation techniques, regular
exercise and sleep & stress management
Mild
• Avoid over-investigation of physical
symptoms and help patient make links
between anxiety & presenting physical
symptoms
• Trouble controlling these feelings
• Manage comorbidity & substance use
• Symptoms present at least half the days in last 6 mths
• Watchful waiting
Panic Disorder
• Recurrent panic attacks
• Worry about the cause or consequences
• Attempt to avoid situations that trigger attacks
• May be associated with agoraphobia
Primary care psychological management
Moderate
• CBT, as second line treatment if
symptoms are causing significant distress
or impairment of functioning
Other Anxiety Disorders
Pharmacological management
Phobic Disorders
• Agoraphobia
• Social phobia
• Specific phobia
• Medication should be a third line treatment
in the management of anxiety
• Drugs may be indicated if:
Obsessive-compulsive (OCD)
• Recurrent thoughts or impulses
• Attempts to suppress or “neutralise” these
• Repetitive physical or mental behaviours
Post Traumatic Stress Disorder (PTSD)
• Lasting response (at least 2 weeks) to a traumatic event that
impairs functioning
• Intrusive memories: flashbacks/ nightmares
• Behaviour change: eg. avoidance of
• Avoidance behaviour
feared situations
• Numbness, detachment
• hyperarousal, anxiety, irritability
• Treatment only indicated following several months of symptoms
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Consider referral for talking therapies, in
particular guided self help (Health in Mind)
- significant depressive symptoms
(esp. in Mixed Anxiety Depression)
- persistent or very disabling anxiety
symptoms
-Short term only
Severe
Discuss with START (020 8442 6714) if:
• Chronic, severe, disabling symptoms
• Poor response to other treatments
• Risk of suicide or self-harm
Back to
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Primary Care Guidelines for Common Mental Illness
Anxiety - Drug Treatment Guidance
NB. Self-management strategies & talking therapies should be the first line treatments for anxiety disorders. Medication may be
considered for acute distress, for persistent or disabling anxiety symptoms, or where there are significant depressive symptoms
Anxiety Disorder
Licensed Drug
Acute Stress Disorder
• Benzodiazepines ( avoid short acting such as Lorazapam)
• Up to 7 days. With caution.
Mixed Anxiety & Depression (MAD)
Generalised Anxiety Disorder (GAD)
Panic Disorder (and agoraphobia)
Obsessive-Compulsive Disorder (OCD)
Post-Traumatic Stress Disorder (PTSD)
Social Phobia (Generalised)
Social Phobia (Non-Generalised)
Specific Phobias
No specific drug licensed. Follow antidepressant prescribing
guidelines. Consider drug anxiolytic properties.
•
•
•
•
•
1 - Paroxetine
2 - Venlafaxine
3 - Buspirone
1 - Citalopram
2 - Paroxetine
Preferred
options
•
•
•
•
1 - Fluoxetine
2 - Paroxetine
3 - Sertraline
4 - Clomipramine
Haringey
TPCT
pharmacy
team
as advised
by the
• Paroxetine
Only consider pharmacotherapy for symptomatic management in
one-off/ short-term circumstances e.g. beta-blockers/
benzodiazapines for air travel
Treatment Regime
• When using antidepressant medication to treat anxiety disorders, start therapy at ¼-½ of normal recommended dose for depression to minimise risk of exacerbating the
anxiety (“activation syndrome”) and increase compliance. Use syrup if necessary.
Key message:
“Start Low, Go Slow”
• Titrate to therapeutic dose If symptoms show improvement after 12wks of treatment, continue for a minimum of one year. Withdraw drug slowly.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Back to
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Primary Care Guidelines for Common Mental Illness
Eating Disorders- Identification & Management
Monitor for 8 weeks
Core Clinical Symptoms
Assessment
• Height and
Weight, BMI
(weight kg /height
m squared)
ANOREXIA NERVOSA
• Body weight maintained 15% below expected for
age and height/ BMI < 17.5kg/m2
•Restricting intake
•Self induced vomiting and/or purging
• Other causes of
weight loss, inc
thyroid disease,
stimulant use
•Excessive exercise
• Other difficulties
associated with
binging and
purging ie Tooth
decay
• Symptoms of
depression
(difficult to treat
until nutritional
state is
successfully being
treated)
BMI >17kg/m2
No additional co morbidity
• Weight loss self-induced by
Consider
• Investigations Full
blood count, blood
chemistry, pulse,
blood pressure
Mild Anorexia:
Mild and moderate
Bulimia
• Morbid dread of fatness
• Self set low weight threshold
Moderate Anorexia:
• Disturbance of endocrine system
•BMI 15 – 17kg/m2
• Anorexia Nervosa has the highest death rate of any
psychological disorder
•No evidence of system
failure
BULIMIA NERVOSA
• Attempts to counteract excess calorie intake by
•Self induced vomiting
Book prescription
Use of self help
books
Food diary
Explore extent of
problem
Consider
involvement of
family
•Use of drugs
• Bingeing, with preoccupation with food and craving
Give information
Severe Bulimia
Daily purging
Electrolyte imbalance
Co-morbidity
Consider referral if
failure to respond
under 18 –
CAMHS on 020
8442 6467
18 to 65 yrs –
call START on
020 8442 6714
•Self induced purging
•Alternating periods of starvation and
bingeing
•Use of drugs and/or neglect of insulin use
in diabetes
• Morbid dread of fatness
• Self set low weight threshold
• Possible history of anorexia
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Severe Anorexia
BMI <15kg/m2
Rapid weight loss
Evidence of system
failure
The Phoenix
Wing, St Ann's
Hospital, St
Ann's Road,
London
N15 3TH
Telephone
Number: 020
8442 6387
Fax Number:
020 8442 6192
Urgent referral
and admission to
acute medical
hospital if lifethreatening
Back to
contents
Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Assessment & referral
Assessment (PSQ Bebbington and Nayani, 1995)
Hypomania: Over the past year, have there been times when you felt very happy indeed
without a break for days on end?
If yes - Was there an obvious reason for this? Did your relatives or friends think it was
strange or complain about it?
Thought insertion: Over the past year, have you ever felt that your thoughts were directly
interfered with or controlled by some outside force or person?
If yes - Did this come about in a way that many people would find hard to believe, for
instance, through telepathy?
Paranoia: Over the past year, have there been times when you felt that people were against
you?
If yes - Have there been times when you felt that people were deliberately acting to harm you
or your interests?
·
Have there been times when you felt that a group of people were plotting to cause you
serious harm or injury?
Strange experiences: Over the past year, have there been times when you felt that
something strange was going on?
If yes - Did you feel it was so strange that other people would find it very hard to believe?
Hallucinations: Over the past year, have there been times when you heard or saw things
that other people couldn't?
If yes- Did you at any time hear voices saying quite a few words or sentences when there
was no-one around that might account for it?
Prodromal Period
• Early signs of deterioration in
personal functioning
• Changes in affect, cognition,
thought content, motivation
and behaviour
• 50% do not develop frank
psychosis
• active follow up in primary care
In all cases consider starting antipsychotic
medication Risperidone is first line treatment
Acutely disturbed
Significant impact
on dependant
children?
Family history of psychoses
Past history of psychoses
Drug misusers
Onset most commonly in 2nd or 3rd decade –
but can occur at any age
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Urgent referral to Children Services on
020 8489 5402
Ante and Post Natal Care:
• 1st contact – enquire about past/current MI history
• If high risk or actual symptoms/diagnosis, GP to communicate
with midwife, HV and hospital services
• Refer to START - agree and write care plan Also consider
social care input – Harts,
• See woman every month ante and post natal
New diagnosis of
psychosis – first
presentation
Patient new to
the area - with
previously
diagnosed
psychosis
Higher Risk Groups
•
•
•
•
Urgent /Emergency Referral to START 020 8442 6714
Known patient
(sole
management in
Primary Care)
Referral to START 020 8442 6714
(NB: START will refer patients to Early Intervention
Service when established)
Discussion with Link worker/psychiatrist – refer to
START with patient’s agreement.
Consider referral to START depending on:
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance misuse
• Level of risk
Discussion with Link worker/psychiatrist
• Manage in primary Care with SMI care plan
• Anti psychotic prescribing, with pt leaflet
• Monitor repeat prescribing
• Consider wider social and support issues
• Refer to exercise and work/education
opportunities
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia – Management following discharge from CMHT
(inc Support and Recovery Teams)
Concordance and repeat prescriptions
Work with patient to help
Monitor repeat prescription picked up
Check for side effects
Use pt leaflet
Patients
needs stable
Depot medication
Specialist input no
longer required
Discharge Planning
and Care Plan
Sole Primary
Care
Management
Agree plan
Competent practice nurse
Appointments opportunity to assess
Physical Health
Proactive plan – utilise health action plan
Assess and review at least once a year
Target smoking, eating and exercise behaviour
Pt identified
Plan agreed
Dates agreed
SMI Register
Crisis and
Contingency Plan in
place (CPA)
Shared Care
In agreement with
psychiatrist,
explicitly agrees
who is doing what,
when, how, why
and with whom.
On list
Care plan in place
Reviewed at least once a year
Carers
Cares assessment and needs
Support and counselling for carers (Health in
Mind)
Regular review of carers needs
Is there a child carer? – assess needs and refer
to children services
Relapse Indicators
Why, When, Who, How
To refer back to START
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
improve general well-being and
feelings of worth
Access to employment and education –
‘Tomorrow's People, Richmond
Fellowship, New deal, Job centre Plus.
Consider referral/signposting to
therapeutic network, and or day
services
Book prescription for stress and esteem
issues
Stress management and relaxation skills
Structure and activity planning and
Problem solving
Debt management
Also consider social care input – Harts, 60+
and Services for All
If acute relapse – instigate crisis
and contingency plan
Discussion with Link worker or
psychiatrist –
refer to START with patient’s knowledge.
• Patients views
• Previous history
• Problems with medication
• Concerns about comorbid substance
misuse
• Level of risk
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Primary Care Guidelines for Common Mental Illness
Psychosis and Schizophrenia - Physical Health Care
Provide routine physical
health checks at least 1x
every year. Record on SMI
register
Monitor increased risk of
cardiovascular disease
Promote healthy lifestyle
Monitor drug side effects
To be provided usually in primary care
If no contact with primary care
Secondary care should monitor physical health
Consider:
• Primary prevention (use standard scoring systems)
• Secondary prevention in those with established heart disease
• Specific monitoring in relation to certain antipsychotic drugs (see BNF)
For example, good diet and exercise
Actively encourage smoking cessation
EPS/akathisia
Weight gain/diabetes
Sexual dysfunction
Promote wider well being activity: Goal setting, problem
solving, access to education and employment.
Stress management – referral to Therapeutic Network and
Day services
Lethargy
Effects on eyes
Focus on
Neurological
Consider:
• Extrapyramidal side effects
• Tardive dyskinesia
Metabolic and endocrine
Consider:
• Routine urine/blood screen for diabetes
• Selective screen for other endocrine
disorders (high prolactin), eg
amenorroea, glalactorrhoea
Weight
Consider routine weight monitoring
Other side effects of medication
Photosensitivity and chlorpromazine
Cover key areas on regular basis; agree frequency with service user and document in notes
Regular monitoring
Primary and secondary care services identify/allocate and document responsibilities for monitoring physical health
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
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Suicide risk factors:
• History of prior
attempts
• Current severity of
depressive or other
mental illness
Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk to Self– Suicide/Self-Harm
• The suicide rate in Haringey is 11.7/100 000 compared with the nation rate of 8.5/100 000 (based on 2006/7 GP registered population)
• Asking about suicide does not put the idea into someone’s head or increase the risk - patients are often relieved to have the chance to talk about
their fears
• Alcohol & drug misuse
ASSESSMENT
• Social isolation
• Low self esteem and
perception of being a
burden
Ideation
“Are you feeling like life is not worth living”
or
“Have you had thoughts about harming or killing yourself?”
• Rejected by loved ones
• Life-threatening/
chronic physical illness
Intention
• Being an single young
man
• Significant
anniversaries
Consider risk of harm
due to:
Yes
•Sexual vulnerability
• Child abuse
No
• Check medication for toxicity & limit quantity
No
• Make shared action plan with patient about
what they would do if felt more suicidal: eg.
social support, contact GP, Samaritans, go
to A&E etc.
• Active sharing of issues with carer
• Discuss with START if patient requires more
intensive assessment
• Identify protective factors
Unlikely/No
Likely/Yes
• Adult and elder abuse
Remember: Any previous suicide attempts are the biggest indicator of future risk
•Risk from partner
Thoughts of self-harm related to psychotic symptoms may increase risk.
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
Moderate Risk
• Monitor regularly – every one to four weeks
Risk
“How likely is it that you might act on these plans?”
and
“Have you ever tried to harm yourself or end your life before?”
Or (if psychotic)
“Have you heard voices telling you to harm yourself?”
•Enquire
about
riskrisk
again
as appropriate
• Enquire
about
again
as appropriate
•Identify
protective
factors
• Identify
protective
factors
Planning
• Suicides in the family
•Domestic violence
•Review
• Reviewroutinely
routinely
No
Yes
“Have you made any plans or preparations about how you would
do this?”
Prompt: method, suicide note etc.
•Self-neglect
Lower Risk
Yes
“Have you felt like acting on these thoughts”
or
“Have you considered actually ending your life?
• Impulsivity
• Recent discharge from
psychiatric hospital
MANAGEMENT
Higher Risk
• Discuss directly with START or out of
hours service 020 8442 6714
• If children in family – also consider referral
to children services
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Primary Care Guidelines for Common Mental Illness
Assessing & Managing Risk - Harm to others
Difficulty of
assessing risk
Harm to others - risk
factors:
• Prior history of violent
behaviour
• Diagnosis of
schizophrenia,
paranoid psychosis,
personality disorder,
severe depression
• Alcohol & drug misuse
• Unstable living
arrangements
• Low educational
attainment
• There is no exact formula which can be used to assess the risk of harm to others – the following outlines some important factors to consider
• Clinical judgement is a key factor - concerns may sometimes be difficult to define . If unsure about what action to take, seek advice from ICS,
your link worker or psychiatrist
Ideation/ Mental
State
ASSESSMENT
MANAGEMENT
“Have you had thoughts about harming other people?”
Hostile/ suspicious/ angry presentation.
Evidence of paranoid/ persecutory delusions, command
hallucinations.
Worries that someone trying to hurt you? Felt need to protect self?
Lower Risk
Intention
• Unstable employment
• Being a younger man
“How you would do this?” Prompt: method, access to means
• History of suffering
chronic violence
Risk
No
No
Draft 1 – july 2007. Written by Haringey PC LIT. Developed from Haringey and C&I guidelines
• Discuss with/ refer toSTART if patient
requires more intensive risk monitoring or
further assessment
Higher Risk
Unlikely/No
Remember: Previous history of violent behaviour is the biggest indicator of future risk.
Violent thoughts related to acute psychotic symptoms may increase risk.
• Monitor regularly
• Make shared action plan with patient/ carers
about what they would do if felt risk had
increased: eg. social support, contact GP,
go to A&E, contact police etc.
Yes
“How likely is it that you might act on these plans?”
What has stopped these plans being carried out so far?
Previous history of harm to others
“Have you heard voices telling you to harm others?”
riskrisk
again
as appropriate
••Enquire
Enquireabout
about
again
as appropriate
Moderate Risk
Yes
“Have you made any plans or preparations about harming
someone?” (risk to partner/family?)
••Review
Reviewroutinely
•Identify protective
•Identify
protectivefactors
factors
Yes
“Are you afraid you might act on these thoughts”
Or Overt threats made to others
Have these been acted on?
Planning
No
Likely/Yes
• Urgent telephone referral to START
• If immediate risk call police on 999
Risk to children under 18years
• Risk of harm to children direct or indirect?
• See LSCB protocol
• If in doubt, contact PCT child protection team
on 020 8442 6987
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PRO BLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
A n xie ty
K e n n e rle y, H e le n
1997
S o c ia l
A n x ie ty/
S o c ia l P h o b ia
O ve rc om in g S o c ia l A n xie ty B u tle r, G illia n
a n d S h yn e ss
O ve rc om in g
A n xie ty: A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2003
S tre s s
T h e R e la xa tio n a n d S tres s
R e d u c tio n W o rk s h o p
D a vis , R o b b ins ,
2000
E s h e lm a n & M cK a y
H e a lth
A n x ie ty
S to p W o rryin g
About Your
H e a lth!
Z g o u rid e s , G e o rg e
2002
M a n a g in g S tre ss : T e a c h
Y o u rs e lf
L o o k e r, T e rry a n d
G re g s o n , O lg a
2003
O b s e s s io n s
&
C o m p u ls io n s
U n d e rs ta n d in g
O b s e ss io ns
and
C o m p u ls io ns
T a llis, F ra n k
1992
W o rry
H o w to S to p W o rryin g
T a llis, F ra n k
1990
P a n ic
O ve rc om in g
P a n ic
S ilo ve , D e rric k
1997
C h ild S e x u a l
Abuse
(A d u lt
S u rv iv o rs )
T h e C o u ra g e to H e a l
B a ss , E lle n a n d
D a vie s , L a u ra
2002
P a n ic A ttac ks
In g h am , C h ris tin e
2000
P T S D /T ra u m a
O ve rc om in g T ra um atic
S tre ss
H e rb e rt, C la u d ia &
W etm o re , A n n
1999
A n x ie ty
B O O K T IT L E
A U T H O R (S ) Y E A R
1999
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PROBLEM
IS S U E
BOOK
T IT L E
PROBLEM
IS S U E
A U T H O R (S )
YE AR
O ve rc om in g
D e p re s s io n
G ilb e rt, P a u l
2000
B e re a v e m e n t
L ivin g w ith L o s s
M in d O ve r
M ood
G re e n b e rg e r,
D e n n is a n d
P a d e sk y, C h ris tin e
1995
A n o re x ia
N e rv o s a
B re a k in g fre e from
T re a s u re , J a n e t
A n o re xia N e rv o s a : A
S u rviva l G u id e fo r F am ilie s,
F rie n d s a n d S u ffe re rs
1997
O ve rc om in g
D e p re s s io n : A
F ive A re a s
A p p ro a c h
W illiam s , C h ris
2001
O ve rc om in g A n o re xia
N e rvo s a
F re e m a n,
C h ris to p h e r &
C o o p e r, P e te r
2002
S e lf-E s te e m
O ve rc om in g
L o w S e lfE ste em
F e n n e ll, M e la n ie
1999
O ve rc om in g B in g e E a tin g
F a irb u rn , C h ris
1995
M a n ic
D e p re s s io n
O ve rc om in g
M o o d S w in g s
S c ott, J a n
2001
G e ttin g B e tte r B it(e ) b y
B it(e )
S c hm id t, U lrik e a n d 1 9 9 3
T re a s u re , J a n e t
D e p re s s io n
B in g e -E a tin g
D is o rd e r a n d
B u lim ia
N e rv o s a
B O O K T IT L E
A U T H O R (S ) Y E A R
M c N e ill T a ylo r, L iz
2000
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F rom 1 st O ctober 2007
A ll referrals to H aringe y A dult M ental
H ealth S ervices should be m ade to:
STAR T
(S h ort term assessm en t an d recovery team )
S t A nn’s H ospital, S t A nn’s
R oad, N 15 3T H
020 8442 6714 or 6706
Fax 020 8442 6705
START
is the new sing le p oint of e ntry for m e nta l he a lth, rep la c ing E R C a nd du ty tea m s. T he te am is a M D T inc lud ing
ps yc hia try, nurs ing, soc ia l w ork a nd ps yc holog y.
S T A R T provides a 24 hour 7 d a y a w e e k servic e
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