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Common Complex Mental Health Presentations in Primary Care (Or what the PPS Psychiatrists get to see a lot of…) ADHD in Adults Atypical Depression Bipolar II Disorder Treatment Non-responsive Depression Severe Anxiety Disorders Adult ADHD ADHD – Category vs Dimension Number of People “Not a disorder but a normally distributed human trait!” Attention/Concentration Adult ADD/ADHD MUST have had clear childhood ADD/ADHD symptoms to diagnose – past diagnosis parental report/history of ADHD symptoms school reports (disruptive, would do better if concentrated on work more, etc) Said to be common (5-10% of Adults) but most often misdiagnosed and/or missed Co-morbidity is the RULE Adult ADD/ADHD Common co-morbid conditions: A+D – often polysubstance (NB response to Amphetamines helpful in diagnosing) Anxiety Depression/BPAD Antisocial Learning disorders Tend to respond poorly to treatment for these conditions alone Adult ADHD - Barriers to Diagnosis No DSM criteria specifically for adult ADHD Doctors are not aware and trained in diagnosing adult ADHD General disbelief of ADHD as a clinical entity Patient embarrassment/stigma etc Reluctance to treat with controlled substance High incidence of substance abuse in ADHD patients Cross-over symptoms with co-morbid disorders Adult ADHD - Diagnosis Pervasive symptoms of ADD/ADHD all life Attention/concentration problems Inattention to boring tasks even if important Inattention in social situations Easily distracted Hyperactivity uncommon/not necessary At least 3 of: Low stress tolerance Impulsivity Disorganisation Easily irritated/angered Mood swings/reactivity Can’t complete tasks Low self esteem Adult ADHD - Diagnosis High index of suspicion esp in patients who have “never made a go of life” and present with multiple MH symptoms Screening using ASRS (Adult ADHD Self Rating Scale) Childhood symptoms of ADHD Consensus criteria for diagnosis as in last slide Response to amphetamines if ever exposed (paradoxical) Adult ADHD - Treatment Rx is mainstay of treatment – Methylphenidate 20-80 mg/day – SA reqd Dexamphetamine 5-20 mg/day – SA reqd Atomoxetine (SNRA) – unfunded Education/self management – recommend “Driven to Distraction” Once Rx, Psychological Intervention may help – strategies to live with ADHD, improve self-esteem, manage stress, etc. Adult ADHD -Treatment Treatment of Comorbidities: Contract re NO A+D abuse, if necessary random urines Monitor progress, MAY see reduction in symptoms OR may need to progress to treatment of these in own right ADD plus Anxiety – may tolerate stimulants poorly – Atomoxetine best BUT unfunded Atypical Depression Atypical Depression Depression that differs from “typical” depression by virtue of: Increased sleep (even if broken) Increased eating and/or weight Increased interpersonal sensitivity “Weighed down” heavy feeling of tiredness Importance of recognition: Non- or partial-response to most antidepressants – poor outcome Atypical Depression Effective treatments: Self-management strategies esp exercise Medications: Paroxetine (NNT – 6) – first line Rx Venlafaxine (anecdotal evidence only) Phenelzine (NNT – 3) Cognitive Behaviour Therapy – most effective treatment Bipolar II Disorder Bipolar II Disorder Common – 15% of people with depression Depression - commonly atypical profile Only present when depressed – hypomania seldom brings people to attention Tend to do poorly with treatment with antidepressants alone – Incomplete treatment response for depressive episodes Risk of triggering hypomania, OR of triggering or worsening rapid cycling (NB – rapid cycling common) Bipolar II Disorder - Diagnosis Depressive episodes PLUS at least one period of significant hypomania Elevated/irritable mood state, PLUS Increased confidence, feel “bullet proof” Increased energy, overactivity Increased rate of thinking and talk Reduced need for sleep Impulsivity Impaired judgement – spending, sexual behaviour, interpersonal behaviour Bipolar II Disorder - Treatment Mainstay of treatment is Mood Stabilising Medication: Rapid cycling – Na Valproate (600-800 mg nocte) Slow cycling (less than 3 cycles per year) – Lithium Carbonate (500-750 mg nocte) Blood monitoring required for both – aim for low therapeutic level Hypomania goes rapidly, depression slowly (may take a number of months to resolve) Bipolar II Disorder - Treatment May require treatment with Antidepressant once stabilised on lithium/valproate Self-management important – education, exercise, stress, etc. Psychological intervention helpful – address vulnerability factors, improve stress management – improves outcome/reduced relapse risk Poorly Treatment Responsive Depression Poorly Treatment Responsive Depression Defined as non- or partial-response to an adequate dose of medication, for an adequate duration, with good adherence Effectively means 20-40 mg SSRI for 4-6 weeks (NB if no response at 20 mg after 2-3 weeks, trial increase to 40 mg) Should be seen as a trigger for further assessment re cause of poor response Poorly Treatment Responsive Depression Review diagnosis/presentation – ?adherence (common…) – ?why - address ?psychosocial issues/trigger – need CBT ?bipolar depression – need mood stabiliser ?atypical depression – need effective ADs/CBT ?comorbid A+D – need A+D Intervention ?other comorbidity - anxiety disorder, ADHD, etc Intervention for these as appropriate Poorly Treatment Responsive Depression If above factors excluded, evidencebased treatment options for treatment non-responsive depression are: Substitute option 1 – Alternate SSRI* Substitute option 2 - Venlafaxine or TCA Augment option – Lithium, T3 Addition option – CBT Continued non-response OR unsure Indication for Psychiatric Consultation *Note that non-response to 1 SSRI is NOT highly predictive of non-response to a second, so first-line strategy should be trial of a second SSRI. Severe Anxiety Disorders Severe Anxiety Disorders Severe anxiety disorders tend to follow relapsing/remitting chronic course Cause very high levels of suffering/distress and disability – “heart-sink” patients Somatisation/physical symptoms ++ Co-morbidity is the rule rather than exception: Other anxiety disorders Depression A+D abuse/dependence Treating Severe Anxiety Disorders Treatment of choice (greatest efficacy) for mild to moderate anxiety disorders is CBT HOWEVER optimal treatment of severe anxiety disorders is combined Rx and CBT (patients often struggle to make progress overcoming symptoms with CBT alone) THUS… key to improving outcome for severe anxiety is optimal Rx PLUS CBT/Psychological Intervention, plus assertive management of co-morbidities Treating Severe Anxiety Disorders NB – CBT ineffective in patients who are also prescribed BZP for treatment of anxiety Avoid BZP for all but brief use for severe acute anxiety (e.g., severe panic disorder – use PRN Lorazepam as backup to behav. anxiety management techniques) Mainstay of drug treatment is the non-BZP medications effective in anxiety disorders Treating Severe Anxiety Disorders Effective medications (start low go slow): OCD: SSRI (higher dose), Clomipramine Panic D/O: Paroxetine, Imipramine GAD: Imipramine, Paroxetine, Buspirone PTSD: SSRI, Venlafaxine, TCA esp. Imipramine Social Anxiety: Paroxetine, Phenelzine Other medications: Venlafaxine/TCA: Helpful in mixed anxiety/depression Quetiapine: Low-dose (25-75 mg) helpful for sleep/anxiety, instead of BZP Questions and Cases