* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download 01 PPT Anxiety_Depression_Insomnia 2016
Survey
Document related concepts
Asperger syndrome wikipedia , lookup
Deinstitutionalisation wikipedia , lookup
Moral treatment wikipedia , lookup
Psychiatric survivors movement wikipedia , lookup
Mental disorder wikipedia , lookup
Mental status examination wikipedia , lookup
Lifetrack Therapy wikipedia , lookup
Major depressive disorder wikipedia , lookup
History of psychiatric institutions wikipedia , lookup
Causes of mental disorders wikipedia , lookup
Externalizing disorders wikipedia , lookup
Emergency psychiatry wikipedia , lookup
Abnormal psychology wikipedia , lookup
Transcript
Management of Anxiety, Depression and Insomnia in Primary Care Settings NURS 870 Spring 2016 Anxiety, Depression and Insomnia in Primary Care Objectives: Role of mental health treatment in primary care 2. Review of key neurotransmitters 3. Approach to patient with anxiety 4. Approach to the patient with depression 5. Review of Psychotropic Pharmacology 6. Approach to the patient with insomnia 1. 1. Role of mental health treatment in primary care From 2011 AAFP Position Paper Prevalence and Cost Psychiatric problems are a major health issue. In the United States, neuropsychiatric disorders have now surpassed other disorders such as cardiovascular diseases and malignant neoplasms as the number one cause of disability as expressed as disability-adjusted life years.19 According to the most recent data available, mental health expenditures in the United States, expressed as a percentage of total health care expenditures, were more than 6%. For the year, that amounted to a cost approaching $100 billion.20 Analysis of the sources of payment for those expenditures for the same year revealed that 10% of Medicaid funding and more than 20% of state and local funding was spent on mental health care. Suicide remains a significant cause of death and lost productive lives, with the most recent U.S. data (from 2007) showing that almost 35,000 people died that year from all forms of suicide.21 Top 10 Causes of Death United States - 1916 Prevalence and Cost Among adults, depression ranks as a significant cause of disease and disability, with a lifetime prevalence of over 16%. When analyzed by sex, the 12 month prevalence of depression averages about 8% to 9% for women and 4% to 5% for men.20 When depression is broken down into various degrees of severity, more than 30% of U.S. adult cases identified in 2007 are listed as being in a “severe” category.21 Approximately 52% of those adults received some form of treatment, with 38% receiving what was considered adequate treatment.22 Similarly, anxiety disorder represents a significant cause of disease and disability among adults, with a 12 month prevalence of 18% in 2004. Twenty three percent of those affected patients were classified as having “severe” disorder.12 Approximately 37% of adults with anxiety disorder receive treatment in any 12 month period, with only 34% of those patients receiving adequate treatment.12 Prevalence and Cost Depressive disorders of all types are found to have a lifetime prevalence of 11% of 13- to 18-year-olds, with 3% of those affected having “severe” disorder.23 The prevalence of depressive disorders at any one time is thought to be approximately 8%.23 As in adults, the prevalence of depression in girls age 13 to 17 is nearly 3 times as great as that in boys for the same age group. Anxiety disorders of all types occur with a lifetime prevalence of 25% of 13- to 18-year-olds, with approximately 5% to 6% of those affected classified as having “severe” disorder.23 Again, statistics for anxiety disorder in this age category show a significant female predominance.23 Prevalence and Cost Two subgroup of adults have a higher-than-average prevalence of mental health disorder and deserve special mention. A higher-than-average number of U.S. military veterans of Operation Enduring Freedom (Afghanistan) and Operation Iraqi Freedom (Iraq) reported mental health problems, (11.3% and 19.1% respectively) compared with the entire population of post-deployment U.S. military veterans in the survey period.24 Thirty-five percent of Iraq veterans were reported to have accessed mental health services during the year after returning home.25 The suicide rate in this population was not appreciably higher than in the general population of post-deployment veterans, although certain subgroups (those veterans with selected mental health diagnoses) were observed to have a higher than normal rate.25 The other subgroup of U.S. adults with higher than average occurrence of mental health disorder is the U.S. inmate population. In data from surveys of inmates in state, federal and local jails, the 12 month occurrence of all mental health disorders was found to be 56%, 45% and 64% respectively.26,27 Fewer than 50% of the affected inmates ever received any treatment for their disorder.26,27 NP Role in Dx & Rx Another important distinction between psychiatric practices and family medicine practices is that while patients who present for psychiatric treatment usually have severe symptoms that leave little doubt about the diagnosis, patients in the family physician's office typically present with vague somatic complaints such as “fatigue,” “feeling nervous,” etc., without an established psychiatric diagnosis. Unlike the psychiatric professional whose patients accept the diagnosis and the need for treatment, the family physician has to identify mental health problems that are frequently obscured by patient reluctance to acknowledge the problem or by physical symptoms that mask the underlying problem. NP Role in Dx & Rx The general reluctance of patients to seek care for mental health problems complicates the diagnosis of mental illness. Survey results show that 40% of patients with major depression do not want or perceive the need for treatment.11,32 Patients consistently underreport emotional issues to their physicians. One study found that only 20% to 30% of patients with emotional/psychologic issues reported these to their primary care physicians.4 Many patients somatize their psychologic issues. One in three patients who go to the emergency department with acute chest pain is suffering from either panic disorder or depression.13 Eighty percent of patients with depression present initially with physical symptoms such as pain or fatigue or worsening symptoms of a chronic medical illness.35 Payment Payment for office visits with a mental health diagnosis code has traditionally been discounted by Medicare for primary care. Many managed care plans do not pay family physicians for the provision of psychiatric care, even though family physicians are frequently in the position to diagnose and provide the care. While lack of payment is not the only reason for the documented failures in mental illness detection, the absence of payment has an impact on the lack of screening in primary care practices. This policy is also contradictory to the public's stated preference for care. A survey conducted for the NMHA indicated that 72% of diagnosed patients and 61% of symptomatic but undiagnosed people want greater involvement of their primary care physician in their treatment.29 This not only reflects the level of rapport between patients and family physicians, but it is also indicative of the level of apprehension caused by the potential stigma attached to mental illness and to accessing the formal mental health system. 2. Neurotransmitter Review Neurotransmission Review Neurotransmission Like a key inserted into a lock, chemicals fit precisely into specific receptor cells (made of protein) in axons, dendrites Receptor cells open or close doors (ion channels) into cell; allow interchange of chemicals, ions, e.g., sodium (Na+), potassium (K+), calcium (Ca+) Depolarization changes cell’s electrical charge Neurotransmitter Roles Absence or excess can play major role in brain disease, behavioral disorders Single neurotransmitter can affect other brain chemicals and several different subtypes of receptor cells in different brain regions Neurotransmitters can have different effects in different brain parts Types of Neurotransmitters Amines Monoamines (norepinephrine, dopamine, serotonin, melatonin) Acetylcholine Amino acids (glutamate, GABA [gammaaminobutyric acid]) Peptides (endorphins, enkephalins, substance P) may affect pain transmission Norepinephrine (NE) Can be excitatory or inhibitory Levels fluctuate with sleep and wakefulness Plays a role in changes in levels of attention and vigilance Involved in attributing a rewarding value to a stimulus Part of the regulation of mood Antidepressants block the reuptake of NE into the presynaptic cell or inhibit monoamine oxidase from metabolizing it Dopamine (DA) Generally excitatory Involved in the control of complex movements, motivation, & cognition and in regulation emotional responses Many drugs of abuse (e.g. cocaine, amphetamines) cause DA release, suggest a role in whatever makes things pleasurable Involved in movement disorders e.g. PD and in many deficits seen in schizophrenia Antipsychotic drugs block DA receptors in the postsynaptic cell Serotonin (5-HT) Mostly Inhibitory Levels fluctuate with sleep and wakefulness, suggesting a role in arousal and modulation of general activity levels of the CNS esp. the onset of sleep Plays a role in mood and probably in the delusions, hallucinations, and withdrawal of schizophrenia Involved in temperature regulations and pain control system Plays a role in affective and anxiety disorders Antidepressants block its reuptake into the presynaptic cell The Synapse 3. Approach to Anxiety Anxiety Disorders Anxiety is a normal human emotion that everyone experiences occasionally during times of stress Pathologic “anxiety is the distressing experience of dread, foreboding, or panic accompanied by a variety of autonomic—primarily sympathetic—bodily symptoms. The distress, therefore, is both psychic and physical.” (Goroll p.1461) 29% estimated life-time prevalence in the general population Anxious patients often present to the primary care office convinced something is very wrong with their body and need an explanation for how badly they feel Undiagnosed and untreated anxiety add to the cost of medical care (2nd opinion for benign CP in ED…) Anxiety Disorders Panic Disorder: People with this condition have feelings of terror that strike suddenly and repeatedly with no warning. Other symptoms of a panic attack include sweating, chest pain, palpitations (irregular heartbeats), and a feeling of choking, which may make the person feel like he or she is having a heart attack or "going crazy." Obsessive Compulsive Disorder (OCD): People with OCD are plagued by constant thoughts or fears that cause them to perform certain rituals or routines. The disturbing thoughts are called obsessions, and the rituals are called compulsions. An example is a person with an unreasonable fear of germs who constantly washes his or her hands. Post-Traumatic Stress Disorder (PTSD): is a condition that can develop following a traumatic and/or terrifying event, such as a sexual or physical assault, the unexpected death of a loved one, or a natural disaster. People with PTSD often have lasting and frightening thoughts and memories of the event, and tend to be emotionally numb. Social anxiety disorder: Also called social phobia, social anxiety disorder involves overwhelming worry and self-consciousness about everyday social situations. The worry often centers on a fear of being judged by others, or behaving in a way that might cause embarrassment or lead to ridicule. Specific Phobias: A specific phobia is an intense fear of a specific object or situation, such as snakes, heights, or flying. The level of fear usually is inappropriate to the situation and may cause the person to avoid common, everyday situations. Generalized Anxiety Disorder: This disorder involves excessive, unrealistic worry and tension, even if there is little or nothing to provoke the anxiety. Anxiety Symptoms Feelings of panic, fear, and uneasiness Shortness of breath Palpitations An inability to be still and calm Uncontrollable, obsessive thoughts Repeated thoughts or flashbacks of traumatic experiences Dry mouth Numbness or tingling in the hands or feet Nightmares Nausea Ritualistic behaviors, such as repeated hand washing Muscle tension Dizziness Problems sleeping Cold or sweaty hands and/or feet Symptom Dimension of Anxiety Anxiety disorders are co-morbid with: Other anxiety disorders Depression Substance abuse ADHD Bipolar Disorder Pain Disorders Sleep Disorders Panic Attack ► Usually last 5 to 30 minutes ► Varying degrees of intensity ► Depression is a common co-morbid ► Average age of onset is age 22-23 ► An intense discrete episode of anxiety Predisposing Factors to Panic & GAD Biological Aspects Serotonin ► Some individuals have hypersensitive 5HT receptors ► SSRI’s are effective Predisposing Factors to Panic & GAD Medical Conditions Thyroid Disorders Acute MI Substance Abuse Hypoglycemia Caffeine Intoxication Mitral Valve Prolapse Complex Partial Seizures Phobias--Background Assessment Social Phobias May be well defined e.g. fear of eating in public or May involve general social situations Onset begins in late childhood or early adolescence Chronic, often lifelong course Interferes with social & occupational functioning OCD-Background Assessment ► Obsessions: the unwanted, intrusive, persistent ideas, thoughts, impulses, or images that cause marked anxiety or distress ► Compulsions: unwanted repetitive behavior patterns or mental acts OCD-Background Assessment ► Equally common among men & women ► May begin in childhood, usually adolescence or early adulthood ► Usually chronic ► Often complicated by depression or substance Behaviors of OCD Rituals Aggressive urges Shouting obscenities Kleptomania Binge shopping Repetitive sexual behaviors PT Stress Disorder Background Assessment Symptoms Reexperiencing the traumatic event Sustained high level of anxiety or arousal A general numbing of responsiveness Intrusive recollections or nightmares Depression PT Stress Disorder Background Assessment ► Development of characteristic symptoms following exposure to an extreme traumatic stressor involving a personal threat to physical integrity or to physical integrity of others PT Stress Disorder Background Assessment ► Symptoms must be present for more than 1 month ► Symptoms must cause significant interference with social, occupational, & other areas of functioning ► If the symptoms have not been present for more than 1 month the diagnosis assigned is acute stress disorder How does the Primary care NP diagnose Anxiety? Anxiety: Beck Anxiety Inventory 0 – 21 indicates very low anxiety 22 – 35 indicates moderate anxiety > 36 is a potential cause for concern 4. Approach to Depression Depression Common symptoms of depression: Fatigue or loss of energy almost every day Feelings of worthlessness or guilt almost every day Impaired concentration, indecisiveness Insomnia or hypersomnia (excessive sleeping) almost every day Markedly diminished interest or pleasure in almost all activities nearly every day (called anhedonia, this symptom can be indicated by reports from significant others.) Psychomotor agitation or retardation (restlessness or being slowed down) Recurring thoughts of death or suicide (not just fearing death) Significant weight loss or gain (a change of more than 5% of body weight in a month) Symptoms must be present every day or nearly every day for at least two weeks. Who is at risk for major depression? Major depression affects about 6.7% of the U.S. population over age 18, according to the National Institute of Mental Health. Overall, between 20% and 25% may suffer an episode of major depression at some point during their lifetime. Differences Anxiety Depression Psychomotor hyperactivity ► Slowed speech & thought process Tremors & palpitations ► Loss of interest in usual activities Rapid pulse, breathing disturbances, dizziness ► Inability to experience pleasure ► Thoughts of death/suicide Differences Anxiety ► Does not regard defects or mistakes as irrevocable ► ► Depression ► Regards mistakes as beyond redemption Uncertain in negative evaluations ► Absolute in negative evaluations Predicts that only certain events may go badly ► Global view that nothing will turn out right Differences Anxiety ► Predominately fear or apprehension ► DFA ► Phobia ► Depersonalizations ► Derealizations Depression ► Predominately sad or hopeless with feelings of despair ► Diurnal variation (feels worse in the morning) How does the Primary care NP diagnose depression? Depression: Beck Depression Inventory http://www.apa.org/pi/about/publications/caregivers/pra ctice-settings/assessment/tools/beck-depression.aspx Interpretation Score <15: Mild Depression Score 15-30: Moderate Depression Score >30: Severe Depression Always ask depressed patients something like, Has it ever gotten so bad that…. You thought the world would be better off without you? Delineate extent of suicidal ideation When did you begin to have suicidal thoughts? Did any event (stressor) precipitate the suicidal thoughts? How often do you think about suicide? Do you feel as if you're a burden? Or that life isn't worth living? What makes you feel better (e.g., contact with family, use of substances)? What makes you feel worse (e.g., being alone)? Do you have a plan to end your life? How much control of your suicidal ideas do you have? Can you suppress them or call someone for help? What stops you from killing yourself (e.g., family, religious beliefs)? Ascertain plans for furtherance and lethality Do you own a gun or have access to firearms? Do you have access to potentially harmful medications? Have you imagined your funeral and how people will react to your death? Have you “practiced” your suicide? (e.g., put the gun to your head or held the medications in your hand)? Have you changed your will or life insurance policy or given away your possessions? AFP - 1999 Risk factors associated with completed suicide Epidemiologic factors Male, white, age greater than 65 years Widowed or divorced Living alone; no children under the age of 18 in the household Presence of stressful life events Access to firearms Psychiatric disorders Major depression Substance abuse (particularly alcohol) Schizophrenia Panic disorder Borderline personality disorder Additionally, in adolescents: impulsive, aggressive and antisocial behavior; presence of family violence and disruption Past history History of previous suicide attempt Family history of suicide attempt Symptoms associated with suicide Hopelessness Anhedonia Insomnia AFP - 1999 Suicidal Ideation Contract for safety Sample: I, Jane Doe, promise not to harm myself in any way. If I have such thoughts I pledge to first call my primary care provider [insert your name and emergency on-call or contact number] or Crisis intervention. Signed: __________________ (patient signs here) Witnessed: _______________ (you sign here) Crisis Intervention for your county: Cumberland: 717-763-2222 Dauphin : 717-232-7511 AFP - 1999 When is patient confidentiality gone? 1. Suicidal intent 2. Homicidal intent Psychotherapy Patients with anxiety, depression benefit greatly from talk therapy such as CBT (cognitive behavioral therapy). For patients with mild-moderate symptoms, try psychotherapy first! 5. Psychopharmacology Depression/Anxiety Meds: SSRIs Selective serotonin reuptake inhibitors (SSRIs) approved to treat depression and anxiety: Citalopram (Celexa) Escitalopram (Lexapro) Fluoxetine (Prozac, Prozac Weekly, Sarafem) Paroxetine (Paxil, Paxil CR, Pexeva) Sertraline (Zoloft) SSRIs: Common side-effects All SSRIs work in a similar way and generally cause similar side effects. However, each SSRI has a different chemical makeup, so one may affect you a little differently from another. Nausea Dry mouth Headache Diarrhea Nervousness, agitation or restlessness Reduced sexual desire or difficulty reaching orgasm Inability to maintain an erection (erectile dysfunction) Rash Increased sweating Weight gain Drowsiness Insomnia 2nd Line Depression Meds: SNRIs Serotonin and norepinephrine reuptake inhibitors approved to treat depression Duloxetine (Cymbalta) Venlafaxine (Effexor, Effexor XR) Desvenlafaxine (Pristiq) 2nd Line Depression Meds: SNRIs Other antidepressants: Wellbutrin (bupropion) – no sexual dysfunction Remeron (mirtazipine) – good for sleep/appetitie Oleptro (trazodone) – good for sleep Elavil (amitriptyline) – good for sleep/pain Others for anxiety: Others for depression: Starting Dose Bupropion: Mirtazpine: Trazodone: Amitryline: Usual Daily Dose Extreme “Psychiatrist” Range no sexual dysfunction BUT lowers seizure threshold good for sleep and poor appetite; + weight gain good for sleep; + constipation good for sleep & pain; + weight gain FDA Suicidality “Black Box” warning for all antidepressants: Anyone who starts being treated with antidepressant medicines, particularly those being treated for depression, should be watched closely for worsening of depression and for increased suicidal thinking or behavior. Close observation of adults may be especially important when antidepressant medications are started for the first time or when doses for their antidepressant medications have been changed. Adults whose symptoms worsen while being treated with antidepressants, including an increase in suicidal thinking or behavior, should be evaluated by their health care professional. Benzodiazepines Treatment should be brief and for specific symptoms Target Symptoms for Benzodiazepines Psychological Irritability Uneasiness Worry Fear Insomnia Benzodiazepines Benzodiazepines No clinical advantage over each other BUT Clients with persistent anxiety should take one with a long half-life; with fluctuating anxiety a shorter half life Lipid solubility determines the rapidity of onset and the intensity of effect e.g. Diazepam (Valium) is more lipid than Lorazepam (Ativan) thus moves more readily into and then out of CNS and is more extensively distributed to peripheral sites particularly to fat cells Benzodiazepines Elderly Clients More vulnerable to side effects Aging brain Dose from one half to one third of the usual daily dose used for adults Select BZ with no active metabolites since they are less affected by liver disease, the age of the patient or drug interactions e.g. Klonopin, Ativan, Serax Avoid use in the elderly – often makes them worse. Consider Haldol – then geriatric psychiatry consult Nonbenzodiazepine Antianxiety Agents BuSpar (Buspirone) No addictive potential Does not exhibit muscle –relaxant or anticonvulsant activity, interaction with CNS depressants, or sedative-hypnotic properties Not effective in management of drug or alcohol withdrawal or panic disorder Generally takes several weeks to take effect Nonbenzodiazepine Antianxiety Agents Inderal (Propranolol) (beta-blocker) Catapress (Clonidine) (an alpha 2 receptor agonist) Both used for off-label treatment of anxiety Act by blocking peripheral or central noradrenergic (norepinephrine) activity and many of the manifestations of anxiety (e.g. tremor, palpitations, tachycardia, sweating) Nonbenzodiazepine Antianxiety Agents Propranolol-Used in treatment of performance anxiety Clonidine-also used to block physiological symptoms of opioid symptoms of opioid withdrawal and the tachycardia and excessive salivation seen with atypical antipsychotic clozapine Prescribing Pearls Start with an SSRI; plan to treat for 6-12 months If first SSRI not effective due to intolerable side effects, or no benefit after ~4-6 weeks at max dose, try a second SSRI. If 2nd SSRI not effective, try a second line agent (i.e. Bupropion or Duloxetine) Once you fine a med that is effective, but patient still has symptoms, choose add-on therapy to address those remaining symptoms. Anxiety – Clonidine, Guanfacine or Klonopin Sleep – Trazodone, Mirtazapine Pain – amitriptyline, gabapentin Prescribing Pearls Always counsel about the black box warning, and instruct patients to call if they have new or worsening thoughts about self-harm. Monitor for symptoms of mania/hypomania incase patient has undiagnosed bipolar disorder. Counsel patients to expect side effects the first week as neurotransmitter levels are rising. Side effects become markedly improved after the first week. Follow patients monthly until symptoms improve Cognitive Behavior Therapy is highly beneficial when patients have access. 6. Insomnia Insomnia Insomnia is a sleep disorder that is characterized by difficulty falling and/or staying asleep. People with insomnia have one or more of the following symptoms: Difficulty falling asleep Waking up often during the night and having trouble going back to sleep Waking up too early in the morning Feeling tired upon waking Insomnia causes & symptoms Causes of acute insomnia can include: Causes of chronic insomnia include: Significant life stress (job loss or change, death of a loved one, divorce, moving). Depression and/or anxiety. Chronic stress. Illness. Pain or discomfort at night. Emotional or physical discomfort. Symptoms of Insomnia: Environmental factors like noise, light, or extreme temperatures (hot or cold) that interfere with sleep. Sleepiness during the day. General tiredness. Irritability. Problems with concentration or memory. Some medications (for example those used to treat colds, allergies, depression, high blood pressure and asthma) may interfere with sleep. Interferences in normal sleep schedule (jet lag or switching from a day to night shift, for example). Sleep Hygiene Avoid napping during the day. It can disturb the normal pattern of sleep and wakefulness. Avoid stimulants such as caffeine, nicotine, and alcohol too close to bedtime. While alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half as the body begins to metabolize the alcohol, causing arousal. Exercise can promote good sleep. Vigorous exercise should be taken in the morning or late afternoon. A relaxing exercise, like yoga, can be done before bed to help initiate a restful night's sleep. Food can be disruptive right before sleep. Stay away from large meals close to bedtime. Also dietary changes can cause sleep problems, if someone is struggling with a sleep problem, it's not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine. Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently as children and adults. Light exposure helps maintain a healthy sleep-wake cycle. Establish a regular relaxing bedtime routine. Try to avoid emotionally upsetting conversations and activities before trying to go to sleep. Don't dwell on, or bring your problems to bed. Associate your bed with sleep. It's not a good idea to use your bed to watch TV, listen to the radio, or read. Make sure that the sleep environment is pleasant and relaxing. The bed should be comfortable, the room should not be too hot or cold, or too bright. Retrieved April 7, 2015 http://sleepfoundation.org/ask-the-expert/sleep-hygiene?page=0%2C0 Sleep Hygiene regularize sleep and wake times, avoid caffeine, create dark and quiet sleep environment, and limit napping; effective for 40% of patients with chronic insomnia Feb 2015 Audio Digest Family Practice Stimulus control avoid looking at clock at night, do not remain in bed when awake and not drowsy, avoid screen time (eg, television, computer), and read, do craft, or do crossword puzzle until drowsy, then return to bed; associated with highest level of evidence for effectiveness Feb 2015 Audio Digest Family Practice Meds used to treat Insomnia: 1. 2. Consider treating underlying depression/anxiety first Sleep Meds: Hypnotics Ambien Lunesta Sonata Antihistamines diphenhydramine Melatonin Rozerem Tricyclics Trazodone amitriptyline Benzos Restoril Concerns with treatment of insomnia: 1. Any medication, including over-the-counter meds, used to treat insomnia are potentially habit-forming and addicting. 2. Prescription sleep aids are controlled substances. 3. Should be taken when the patient has a full 8-hours to sleep. Ambien Zombie Nation http://video.foxnews.com/v/1843051633001/whats-allthe-commotion-about-ambien/?#sp=show-clips https://www.youtube.com/watch?v=amAjJ_tgcsQ Online Resources NIH – Mental Health https://www.nimh.nih.gov/health/index.shtml DSM 5 Manual – Free on Google Docs! https://docs.google.com/file/d/0BwDYtZFWfxMbWs2UC1WdWJzZTQ/edit?pli=1