Management of mental health in primary care

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Management of mental health in Primary Care Prepared by: NG WEI WEI 3 Sept 2015 KKBP

Transcript of Management of mental health in primary care

Page 1: Management of mental health in primary care

Management of mental health in

Primary Care

Prepared by: NG WEI WEI 3 Sept 2015KKBP

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Mental disorders affect hundreds of millions of people and if left untreated create an enormous suffering , disability and economic loss.

Intergrating mental health services into primary care is the most viable way to close the treatment gap and ensuring people get mental health they need.

Introduction

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Source: NHMS 2011

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1. Reduce stigma for people with mental disorder with their families

2. Improve assess of care3. Improve prevention and detection of

mental disorder4. Better physical asssessbility 5. Better financial assessbility ( nearer to

house, transport etc)6. Better acceptbility

Rationale intergrating mental health into primary health care

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The burden of mental disorders is great Mental and physical health problems are interwoven The treatment gap for mental disorders is enormous Primary care for mental health enhances assess Primary care for mental health promotes respect of

human rights Primary care for mental health affordable and cost

effective Primary care for mental health generates good

health outcomes

Reasons for intergrating mental health into primary care

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First level care within the formal health system

Essential services Early identification of mental disorders treatment of common mental disorders Management of stable psychiatric patient Refer to general hospital if required Attention to the mental health needs of

people with physical health problems Mental health promotion and prevention

Primary care service for mental health

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Objective Enable stable psychiatry patient to receive

optimal treatment at primary care and prevent relapse

Specific1. To identify psychiatry patient that suitable to

receive treatment at primary care 2. To carry out assessment to psychiatric patient

that will receive treatment in primary care3. To plan and carry out intervention to

psychiatry patient and their families.

Integration of mental health in primary care KKM

Source: Garis panduan pelaksanaan perkhidmatan rawatan kesihatan mental di Klinik Kesihatan 2009, KKM

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1. Assessment of patient -using threshld assessment grid (TAG) –

penilaian keterukan masalah kesihatan mental

-to perform during first visit and each following visits.

-to refer to psychiatry specialist if the condition moderate and above

Principle of management of mental patient in primary care

Source: Garis panduan pelaksanaan perkhidmatan rawatan kesihatan mental di Klinik Kesihatan 2009, KKM

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2. Assessment on medication takan and side effect of each medications

-to assess during every visit -to asses and educate patient regarding the

types of medications taking and its side effect

3. Physical examination -vital signs , weight ( every visits) - Blood investigations (yearly)-RBS, FBC, LFT, RP, ECG (patient age more

than 40)

Source: Garis panduan pelaksanaan perkhidmatan rawatan kesihatan mental di Klinik Kesihatan 2009, KKM

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Every visit

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Every visit

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Yearly/PRN

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1. Depression2. Schizophrenia3. Dementia diseases4. Anxiety5. Social anxiety disorders

Common mental disorders

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Lifetime occurrence is between 8 to 10 percent

4th most disbabling diseases in the world

Depression

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DASS-Depression anxiety stress scale

Screening tools

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Depressed mood or loss of interest or plesure in daily activities for more than 2 weeks

Mood represent a change from person’s baseline

Impaired function-social, occupational , educational

Diagnosis criteria

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Depressed mood or irritable Decreased interest or plesure Significant weight change (5%) or change in appetite Change in sleep (insomnia or hypersomnia) Change in activity (psychomotor agitation or

retardation) Fatigue or loss of energy Guilt/ worthlessness Concentration Suicidality ( presences of al least 5 of these 9, present nearly every

day)

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Appearance Behavior Speech Mood Perception Thought form Thought content Cognition Insight

Mental state examination

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Serious risk of suicide Serious risk of harm to others Significant self neglect Severe depressive disorders Severe psychotic disorders Lack or breakdown of social supports Initiation of ECT Treatment resistant depression A need to address comorbid conditions

Criteria for referral for hospital admission

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1 Pharmalogical

2 Non pharmalogical- Cognitive behavioral therapy - ECT

Principle of Management

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Usually monitored in primary care with specific advice about continuation of medication with lowest effective dose and what to do if symptoms recur.

Maintenance therapy

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NO DRUGS TRADE NAME

MAX DOSE (mg/day)

DOSE AVAILABLE(mg/tab)

LIST

Tricyclic tertiary amines (TCA)1 Amitryptyline Apo-

amtryiline300 25mg B

2. Clomipramine Apo-clomipramine

250 25mg, 100mg A

3. Dothiepin Prothiaden 300 25mg, 75mg A4. Imipramine Imipress 300 25mg B

SSRI1. Ecitalopram Lexapro 20 10mg A2. Fluoxetine Prozac 60 20mg A3. Fluvoxamine LUVOX 300 100mg B4. Sertaline ZOLOFT 200 50mg B

Anti depressant list 2014

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NO

DRUGS TRADE NAME

MAX DOSE

DOSES AVAILABLE (MG/TAB)

LIST

SNRI1 Duloxetine Cymbalta 120 30mg,60mg A2 Velanfaxine Effexor 375 75mg ANassa (Noradrenergic and specific seretonergic antidepressants1 Mirtazapine Remeron 45mg 15mg, 30mg ARIMA( Reversible inhibitor of MAO-a)1 Moclobemide Aurorix 600 150mg A

Others1 Agomelatine Valdoxan 50mg 25mg A

Anti depressant list 2014

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No DRUGS TRADE NAME

MAX DOSE

DOSE AVAILABLE (MG/TAB)

LIST

1 Lamotrigine Lamictal 200 100mg A2 Sodium Valproate Epilin 2000 200mg B3 Lithium

CarbonateLithium 1800 300mg A

Mood Stabilizer

NO DRUGS TRADE NAME

MAX DOSE

DOSE AVAILABLE (MG/TAB)

LIST

1 Benzhexol Artane 2mg

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No DRUGS TRADE NAME MAX DOSE

DOSES AVAILABLE (MG/TAB)

LIST

1. Alprazolam Xanax 4mg 0.25mg,0.5mg, 1mg

A/KK

2 Bromazepam

Lexotan 60mg

3 Clonazepam Rivotril/Klonopin

20 2mg B

4 Diazepam tab

Valium 5mg B

5 Diazepam rectal

5mg C

6 Lorazepam Ativan 10 1mg A/KK

7 Midazolam (IM)

Dormicum 10 A/KK

8 Zolpidem Stilnox 10 10mg A

Benzodiazepines

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Diagnosis a) Characteristic of symptoms : 2 or more of following each present for one

month period -Delusions-Hallucinations-Disorganized speech-Grossly disorganized or catatonic behavior-Negative symptoms( affective flattening ,

alogia or avolition)

Schizophrenia

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Auditory hallucinations -third person -in the forms of commentary Delusions of thought-thought withdrawal -thought insertion-thought broadcasting Passivity experience Somatic hallucinations Feeling or actions experienced as made or influence by

external agents Delusional perception

Schneider’s First Rank symptoms

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Mood Affect Attention Concentration Cognitive function

Mental state examination

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Blood test-RP, LFT, calcium, FBC, glucose, FLP, FBS Radiological-CT/MRI (to look for presence of neurological

abnormalitty ) Urine -urine toxicology Others: 24 hours cortisol/ 24 hours

cathecholamines

Investigation

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Management

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High risk suicide or homicide Others illness related behavior that endanger relationship,

reputations or assets Severe psychotic , depression or catatonic symptoms Lack of capacity to cooperate with treatment Lack of loss of appropriate psychosocial support Failure of outpatient treatment Non- compliance with treatment plan (eg depot medication) Significant changes in medication for patient high risk of

relapse Need to address comorbid conditions ( eg inpatient

toxification, physical problems , serious medication side effects

Hospital referral for admission

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NO DRUGS TRADE NAME

MAX DOSE

STRENGTH AVAILABLE (MG/TAB)

LIST

1 CHLORPROMAZINE

LARGACTIL

1000 25MG/100MG B

2 HALOLPERIDOL HALDOL 30 1.5MG, 5MG B3 PERPHENAZINE TRILAFON 24 4MG B4 SULPIRIDE DOGMATI

L2400 200MG B

5 TRIFLUOPERAZINE

STELAZINE

30 5MG B

6 FLUPENTHIXOL DECANOATE INJ

FLUANXOL

20MG/ML B

7 FLUPHENAZINE MODECATE

25MG/ML B

8 ZUCLOPENTHIXOL DECANOATE INJ

CLOPIXOL

9 ZUCLOPENTHIXOL ACETATE INJ

CLOPIXOLACUPHASE

10 ZUCLOPENTHIXOL ORAL DROPS

CLOPIXOL DROPS

20MG/ML (20ML/BOTTLE)

A

Anti psychotic list 2014

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NO DRUGS TRADE NAME

MAX DOSE

STRENGTH AVAILABLE

LIST

1 CLOZAPINE CLOZARIL 900 25MG, 100MG A2 RISPERIDONE RISPERDA

L16 1MG,2MG B

3 AMISULPIRIDE SOLIAN1200

1200mg 400mg A

4 ARIPIPRAZOLE ARIP MT 30 10MG, 15MG A5 OLANZAPINE ZYPREXA 20 5MG,10MG A6 PALIPERIDONE INVEGA 30 3MG,6MG A7 QUETIAPINE SEROQUE

L XR800 50MG,200MG,4

00MGA

8 PALIPERIDONE INJ

SUSTENNA

75MG/ML, 150MG/ML

A

9 RISPERIDONE ORAL SOLUTION

RISPEDAL DROPS

1MG/ML A

Atypical second generation antipsychotic

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Anxiety disorder

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Recurrent panic attack which are not secondary to substance misuse, medical conditions or other psychiatric disorder .

Panic attack- Periods of intense fear characterized by a

constellation of symptoms that develop rapidly , reach a peak of intesity in about 10 minutes, and generally do not last longer than 30 minutes

Panic disorder

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Palpitations, pounding heart Sweating Trembling or shaking Sense of shortness of breath Feeling of choking or difficulties swallowing Chest pain Nausea or abdominal discomfort Feeling dizzy, unsteady, light headed, or faint Derealization or depersonalization ( feeling detach from oneself

or one’s surrounding Fear of losing control or going crazy Fear of dying Numbness or tingling sensations Chills or hot flashes

History

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Emergency treatment of an acute panic attack• Maintain a reassuring and calm attitude • If symptoms are severe and distressing

consider use of benzodiazepine • Exclude medical causes if first presentation

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SSRI SNRI Benzodiazepine

Pharmalogical treatment

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Cognitive behavioural therapy (CBT) - To treat avoidance by exposure- relaxation technique- Control of hyperventilation

Psychological

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Anxiety and panic symptoms associated with places or situations where escape maybe difficult or embrassing eg crowds, public places, travelling alone or away from home , leading to avoidance

Managementa)pharmalogicalb)Psychological -behavioural methold- exposure techinque,

relaxation training and anxiety management

Agoraphobia

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Symptoms of incapacitating anxiety (psychological and or autonomic ) are not secondary to delusional or obscessive thoughts and are restricted to particular social situations leading to a desire for excape or avoidance

Managementa) Psychological- Cognitive behavioural therapy( CBT)b) Pharmalogical -SSRI and SNRI , Benzodiazepine

Social phobia

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Recurring excessive and unreasonble psycological or autonomic symptoms of anxiety in the presence of speicific feared object or situation leading to avoidance

5 subtypes- animals, aspect of natural environment,

blood/injection/injury, situational and others

Simple or specific phobias

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a) Psychological -behavioural therapy- Wolpe’s systemic

desensitization with relaxation and graded exposure

-cognitive method- education/anxiety management, coping skills and strategies

b) Pharmacology-generally not used

Management

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Excessive worry and feeling of apprehension about everyday events/ problems , with symptoms of muscle and psychic tension, causing significant distress/ functional impairment

Generalized anxiety disorders

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Obscessive compulsive disorders Acute stress reaction Post traumatic stress disorder Prolong grief disorder Depersonalization syndrome

Others anxiety disorders

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Dementia

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Syndrome characterize by progressive , usually irrervible global cognitive deficits

Causes -Alzheimer’s disease-vascular dementia -lewy body dementia-frontal temporal dementia

overview

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Clinical features

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Detailed history MSE Cognitive testing-MMSE Physical examination Radioimaging-ct -MRI

Approach to patient

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Score Degree of impairment25-30 Normal 20-25 Mild 10-20 Moderate 0-10 Severe

Interpretation of MMSE

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Screening for elderly who is >60 yearls old Patient that is less than 60 years old who at

risk of dementia To refer to FMS or psychiatry specialist if

score less than 5

Elderly Cognitive Assessment Questionaire (ECAQ)

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A) Assessment -diagnostic, functional and socialB) Cognitive enhancement- Acetylcholinesterase inhibitors (tacrine, donepezil,

rivastagmine) , antioxidants ( selegilne, vitamin E) c) Treat psychosis/agitationd) Treat depression / insomniae) Treat underlying medical illnessf) Psychological support- to both patient and care giversg)Funtional management -maximize mobility, encourage independence with self care,

toilet and feeding assist with communication h) Social management -acommodation , activities , financial matter

Principle of management

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NO DRUGS TRADE NAME

MAX DOSE

DOSES AVAILABLE

LIST

1 DONEPEZIL ARICEPT/TORPEZIL

10 5MG,10MG A

2 RIVASTIGMINE TAB

EXELON 12 1.5MG,3MG A

3 RIVASTIGMINE PATCH

EXELON PATCH

13.3 4.6MG/24HR9.5MG/24HR

A

4 MEMANTINE HCL

EBIXA 20 5MG,10MG

LIST MEDICATION 2014

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Appendix

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Prevention?

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1.Intergrating Mental Health into primary care – Global perspective – WHO 2006

2. Oxford of handbook of psychiatry 3rd edition

3. NICE guidelines- pathway of common mental disorders in primary care

4. Garis Panduan Pelaksanaan Perkhidmatan Rawatan Kesihatan Mental Di Klinik Kesihatan, 2009 (second edition)

5. Garis Panduan Pemeriksaan Kesihatan Jemaah Haji (Edisi 6) 2014

References

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