Mental Health/Primary Care Integration: Lessons from Five Counties
Management of mental health in primary care
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Transcript of Management of mental health in primary care
Management of mental health in
Primary Care
Prepared by: NG WEI WEI 3 Sept 2015KKBP
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
Source: NHMS 2011
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
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
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
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
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
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
Every visit
Every visit
Yearly/PRN
1. Depression2. Schizophrenia3. Dementia diseases4. Anxiety5. Social anxiety disorders
Common mental disorders
Lifetime occurrence is between 8 to 10 percent
4th most disbabling diseases in the world
Depression
DASS-Depression anxiety stress scale
Screening tools
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
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)
Appearance Behavior Speech Mood Perception Thought form Thought content Cognition Insight
Mental state examination
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
1 Pharmalogical
2 Non pharmalogical- Cognitive behavioral therapy - ECT
Principle of Management
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
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
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
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
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
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
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
Mood Affect Attention Concentration Cognitive function
Mental state examination
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
Management
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
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
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
Anxiety disorder
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
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
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
SSRI SNRI Benzodiazepine
Pharmalogical treatment
Cognitive behavioural therapy (CBT) - To treat avoidance by exposure- relaxation technique- Control of hyperventilation
Psychological
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
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
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
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
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
Obscessive compulsive disorders Acute stress reaction Post traumatic stress disorder Prolong grief disorder Depersonalization syndrome
Others anxiety disorders
Dementia
Syndrome characterize by progressive , usually irrervible global cognitive deficits
Causes -Alzheimer’s disease-vascular dementia -lewy body dementia-frontal temporal dementia
overview
Clinical features
Detailed history MSE Cognitive testing-MMSE Physical examination Radioimaging-ct -MRI
Approach to patient
Score Degree of impairment25-30 Normal 20-25 Mild 10-20 Moderate 0-10 Severe
Interpretation of MMSE
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)
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
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
Appendix
Prevention?
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
Thanks you