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Overview: Common Mental Disorders

• What are they ?• Why are they important ?• How do they affect sufferers ?• What should you look out for ?• What are the risks?• When should you refer to secondary care?

Common Mental Disorders• Depression• Anxiety Disorders

– Generalized Anxiety Disorder– Panic Disorder– Phobic Anxiety Disorder– Social Anxiety Disorder– Obsessive Compulsive Disorder– Post Traumatic Stress Disorder

Common Mental Disorders: and these too!

• Mixed Anxiety and Depression• Adjustment Disorders

• Mixed anxiety & depressive reaction• Brief or prolonged depressive reaction• Disturbance of emotions, conduct or both

• Dysthymia • sub threshold depression

• Remember they occur with other disorders e.g., PD

Proportion of people aged 16-64 meeting the criteria for at least one common mental disorder

in England

14

14.5

15

15.5

16

16.5

17

17.5

18

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How common are they? One week and lifetime prevalence rates

Common Mental Disorder

1-week prevalence(England 2007)

Life-time prevalence (USA – 2005)

Mixed Anxiety & Depression

9% -

Generalized Anxiety Disorder

4.4% 5.7%

PTSD 3% 6.8%Depression 2.3% 16.6%Phobias 1.4% 12.5%Panic Disorder 1.1% 4.7%

Why are they important ?• On the increase• 1:6 people affected with co-morbidity• Many sufferers do not seek help

– 38% of people in ONS 2007 sought help

• Many are undiagnosed by their GP– 32% of anxiety and depression undetected for 3 years– 14% had disabling illness

• Many are untreated– 24% in ONS 2007 receiving treatment (14% medication)

Why are they important?

• Depression will become most significant burden than COPD, IHD, Diabetes in 2030 (WHO)

• They complicate other illnesses and increase morbidity e.g., depression and stroke or IHD

• Increase risk of suicide

How do they affect sufferers? Depression

• Mood/Cognitive– low mood– low self esteem– guilt & hopelessness– poor attention– poor concentration– ruminations

• Behaviour/Physical– Tearfulness– irritability– disturbed sleep– loss of libido– fatigue– headaches– aches and pains

• Mild relatively few core symptoms, a limited duration and little impact on day-to-day functioning

• Moderate all core symptoms of the disorder plus other related symptoms, duration beyond that required by minimum diagnostic criteria, and a clear impact on functioning

• Severe most or all symptoms of the disorder, often of long duration and with very marked impact on functioning

• Persistent sub-threshold symptoms and associated functional impairment that do not meet full diagnostic criteria but have a substantial impact on a person’s life, and which are present for a significant period of time

Severity of common mental health disorders

Syndrome of depression Core features Low mood Decreased sense of pleasure Fatiguability and poor concentration Self-reproach Mild episode Moderate episode Severe episode Anxiety symptoms Anhedonia Exaggeration of all features of a Tearfulness Reduced concentration of a moderate episode Mood responsive to events Reduced self-esteem and confidence Negative memories and attitudes In psychotic cases: Suicidal thoughts Delusions of guilt Psychomotor retardation Auditory hallucinations Mood worse in morning Lack of insight Disturbed sleep (early waking) Depressive stupor Loss of appetite and weight Loss of libido Constipation, Amenorrhoea

What should you look out for?• Family history of depression• Past history of depression• Somatic symptoms• Chronic physical health problem• Interpersonal relations, living conditions & life events• During the last month have often been bothered by:

– Feeling down, depressed, or hopeless– Having little interest or pleasure in doing things?

• Consider administering PHQ-9

Anxiety Disorder• Common • Symptoms:

• Mental tension –excessive worry, feeling tense or nervous, poor concentration

• Physical tension –restlessness, headaches, tremors, inability to relax

• Physiological arousal –sweating, dizziness, pounding heart, dry mouth

• Often occurs in those with chronic tendency to worry

• Triggered by stressful events

• Lasting over 6 months• Check physical health

e.g., thyrotoxicosis• Check for comorbidity

Other Anxiety Disorders

Panic Disorder• Intermittent apprehension• Panic attacks• May be related to specific

situations or spontaneous• Avoidance of situations• Panic disorder with or

without agoraphobia

Specific Phobias• Extreme and persistent

disproportionate fear of object or situation

• Immediate anxiety or panic attack

• Avoidance• May interfere with day to

day life

Other Anxiety DisordersSocial Anxiety Disorder

• Social phobia• Intense fear of social

situations• Fear of being judged,

embarrassed or humiliated• Avoidance of situations• Impacts on attainment at

school or work• Alcohol use and depression

• Follows one or more traumatic events

• Usually up to a month• Common in survivors of life

threatening events• Re-experiencing of trauma

with flashbacks, nightmares and intrusive memories

• Excessive anxiety with hyper vigilance, avoidance, numbness

PTSD

Other Anxiety DisordersObsessive Compulsive Disorders

• Presence of obsessions, ruminations or both

• Intrusive repetitive thought, image or urge

• Usually seen as unusual or excessive

• Compulsions – repetitive mental acts or behaviour

• Considerable anxiety

• Past history• Symptoms of an

anxiety disorder• Recent traumatic

event. • Ask about feelings of

anxiety and ability to stop or control worry

• Consider using the GAD-2 scale.

Identification of anxiety

Identification of anxiety

The GAD-7 tool was developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke and colleagues, with an educational grant from Pfizer Inc.

Generalised Anxiety Disorder Scale -2 (GAD-2) is the first two questions of the GAD-7 scale

Over the last two weeks, how often have you been bothered by the following problems?• Feeling nervous, anxious or on edge • Not being able to stop or control worrying

Consider asking:

•

Also ask:

For significant communication difficulties, consider using the Distress Thermometer and/or asking a family member or carer about the person’s symptoms

Identification: anxiety 3

Do you find yourself avoiding places or activities and does this cause you problems?

CMHDs presentation and severity Recommended interventions

Step 1All disorders – known and suspected presentations

All disorders: Identification, assessment, psycho-education, active monitoring; referral for further assessment and interventions

Step 2Persistent sub-threshold depressive symptoms or mild to moderate depression; GAD; mild to moderate panic disorder; mild to moderate OCD; PTSD (including mild to moderate)

DepressionGAD and panic disorderOCDPTSDAll disorders – Support groups, educational and employment support services; referral for further assessment and interventions

Step 3Persistent sub-threshold depressive symptoms; mild to moderate depression not responded to a low-intensity intervention; moderate or severe depression; GAD with functional impairment or has not responded to low-intensity intervention; moderate to severe panic disorder; OCD with moderate or severe functional impairment; PTSD

DepressionGADPanic disorderOCD PTSDAll disorders – Support groups, educational and employment support services; referral for further assessment and interventions

Treatment of DepressionNICE Guidelines (2007)

• Step 1: Recognition in primary care and general hospital settings

• Step 2: Treatment of mild depression in primary care

• Step 3: Treatment of moderate to severe depression in primary care

• Step 4: Treatment of depression by mental health specialists

• Step 5: Inpatient treatment for depression

Step 4: Treatment of depression by mental health specialists

• Key issues are:– Compliance/dosage– Suicide risk– Previous history– Psychosocial stressors– Relationships – Personality factors

• Clarify diagnosis & risks• Provide information• Consider medication

change• Consider CBT • Consider augmentation• Consider antipsychotic

Outcome• Poor outcome often associated with early onset• Relapse is higher with early and late onset

disorders• Treatment response

– 50% develop a 2nd episode– 70% develop a 3rd episode– 90% develop a 4th episode

Stepped care for people with GAD

• Step 1 Identification and assessment; education about GAD and treatment options; active monitoring

• Step 2 Low-intensity psychological interventions: individual non-facilitated self-help, individual guided self-help and psycho-educational groups

• Step 3 Choice of a high-intensity psychological intervention (cognitive behavioural therapy/applied relaxation) or a drug treatment

• Step 4 Highly specialist treatment, such as complex drug and/or psychological treatment regimens; input from multi-agency teams, crisis services, day hospitals or inpatient care

Referral to secondary care

• Severe anxiety with– Marked functional impairment – Poor response– Comorbidity– Risk

• risk of self-harm • Suicide • self-neglect

Specialist treatment

• Multiprofessional collaboration• Combinations of treatment:

• psychological and drug treatments or• combinations of antidepressants or • augmentation of antidepressants with other drugs.

• Increased risk of side effects and limited evidence for efficacy

Course and Outcome

• Frequent attendance (GP, cardiologist and gastroenterologists)

• Chronic condition (60% still ill over 12years)

• Comorbidity is common and associated with worse outcome

Summary• Anxiety and depression affect 1:6 adults • The commonest presentation is mixed anxiety &

depression• Many cases are undiagnosed and untreated for years

thus impairing ability to work and function• Simple two-question screening tools can be useful• Assessments should consider functional impairment &

associated social and interpersonal difficulties• Poor response or risks should prompt referral to

secondary care