dynamic factors - agitation vs slowing, restlessness
honest feedback to supports
initiate treatment - small DZP
there is time to wait for Dx
if fail to return
child abuse and safety
at practice or at home
effectiveness: equality effective amongst SSRItolerability: better tolerated than SNRI, TCA and MAOI. general activating - avoid night dosing.
short acting SSRI and other antidepressants (TCA, mirtazapine, mianserin) need 2-4 days washout period when switchingmoclobemide require - 1-2 days washoutlong acting - fluoxetine - require 1 w washout period when switching to another antidepressant (2 w for TCA)- MAOI require 2 w when switching to another antidepressant
effectiveness: similar to SSRI and mirtazapinetolerability: less than SSRI but better than TCA. taper slowly risk of discontinuation symptoms. use cautiously in people with CVD due to CVS SE
effectiveness: all are effective, role in severe or melancholic depressiontolerability: less well tolerated, anticholinergic SE, orthostatic hypotension, sedation, can prolong Qt
eMH can be used as:
provide brief info, guide to find info
assessment, give info about eMH, follow-up, try something else or something more
assessment and follow-up, show how to use the eMH resources, provide emotional and technical support, encourage and remind to use resources between app.
role of primary therapist - designing and delivering the therapy combining eMH and other FPS, set assignments
Cyclothymic disorder is often described as a milder form of bipolar
disorder. The person experiences chronic fluctuating moods over at least
two years, involving periods of hypomania (a mild to moderate level of
mania) and periods of depressive symptoms, with very short periods (no
more than two months) of normality between. The duration of the symptoms
are shorter, less severe and not as regular, and therefore don't fit
the criteria of bipolar disorder or major depression.
The symptoms of dysthymia are similar to those of major depression but
are less severe. However, in the case of dysthymia, symptoms last
longer. A person has to have this milder depression for more than two
years to be diagnosed with dysthymia.
SAD is a mood disorder
that has a seasonal pattern. The cause of the disorder is unclear, but
it's thought to be related to the variation in light exposure in
different seasons. It's characterised by mood disturbances (either
periods of depression or mania) that begin and end in a particular
season. Depression which starts in winter and subsides when the season
ends is the most common. It's usually diagnosed after the person has had
the same symptoms during winter for a couple of years. People with SAD
depression are more likely to experience a lack of energy, sleep too
much, overeat, gain weight and crave for carbohydrates. SAD is very rare
in Australia and more likely to be found in countries with shorter days
and longer periods of darkness, such as in the cold climate areas of
the Northern Hemisphere.
slow motor functionchanges in
appetite or weight depressed mooddifficulty concentrating
guilt insomnia or
sleeping too much a lack of
interest or pleasure in most activities low energy
levels thoughts of
death or suicide
The SPI model involves identifying actions within each of the steps below, which are reflected in the BeyondNow app:
the etendency to swing bw the two contrasting poles of elevated mood and depression with a return to largely normal functioning bw these episodes
BPD I 18+, BPD II >mid 20s1/4 of all suicidesreduced life expectancy by 9 yearsrelationship breakdown, employment disruption, legal consequencescomorbidities eg drugsBPD I 13 low days/ 1 highBPD II 38 low days/1 high:- frequent and lengthier depression1/3 attempt suicideprolonged cognition impairment20% transition directly into another mood state without recoveryclues:early age of depression <25 yosevere depressionmelancholic featuresatypical features - hyperphagia, hypersomniaFHx of BPDmultiple episodes ofd epressionsevere PNDpsychotic features of depression
defines a hypomanic episode as including, over the course of at least
four days, elevated mood plus three of the following symptoms OR
irritable mood plus four of the following symptoms:
the episode is associated with an unequivocal change in functioning that is uncharacteritic for the person when not symptomatic
disturbance in mood and the change in functioning is observable by others
episode is not severe enough to cause marked impairment in social or occupational functional or to necessitate hospitalisation
episode not attributable to physiological effect of a substance
hypomania with:severe enough to cause impairment in social or occupational functional or to necessitate hospitalisationpsychotic features (hallucination, delusions) by definition is maniaprolonged >7 days
40-50% of BPD pt have comorbid anxiety
40-50% have substance use disorder
self harm is more than suicide and homocide:
monotherapy where possibleonce dau=ily where possiblemx efficacy for min SE
best if in mania frequentlygold standardprotective against suicidetrough leveles 0.6-0.8, range treatment rangedose adjustment frequent due to water intake, salt intake, medications, illness (dehydration), renal function, Ca levels, TSH, BSL and weightlevel can be lower if mainly depression, more if usually in mania but no more than 1.0
FBE, CUE, LFT, TSH, Ca/Po4, glucoseweight
slow release 450 mgnoctelower dose elderly, impaired renal function
trough leveles 0.6-0.8, range treatment rangedose adjustment
frequent due to water intake, salt intake, medications, illness
(dehydration), renal function, Ca levels, TSH, BSL and weightlevel can be lower if mainly depression, more if usually in mania but no more than 1.0day 5 after initiationtrough at 12 h after doseweekly until stable3-6 monthlycheck for renal Fn, T=thyroid function, Ca (hyper Ca), weight gain
check for renal Fn, T=thyroid function, Ca (hyper Ca), weight gain
fine tremordry mouthaltered taste sensationincreased thirstincreased frequency of urinationmild nauseaweight gainteratogenicity
not commonsecond linecan use with Li or alonestart 250 mg bdincrease dose weekly until 500 mg bdtitrate dose to resposnse, max 2 g/d
check trough levels 12 after dose once on established doselevels every 6 moaim for 300-600 umol/lmonitor LFT, FBE, wt gain
sedationwt gaintremorhair thinningmenstrual irregularityteratogenicityGI irritation
if in depression frequentlybetter at preventing depressionSE SJS severe 1/10,000 to 1/1000; ask pt to look for rashmost rashes are benign hypersentivity rashesstart 25 mg nocteincrease dose by 25 mg per week or fortnightly, up to 200 mg
wt, BSL, lipidstremor - extrapyramidal SE
headachesnauseadiarrhoearash (handout from BDI
quetiapine*resperidoneolanzapine*aripirazole*prevent mania and depression
6 monthlywtBSL, lipidsEPSEraised PRL and sexual SEcholinergic SE eg constipation
never alone with BPDIrare to push into mania with BPDIIefficacy - evidence lacking
2 y stabilizing periodwean anti-psychotic firstwean otherswean slowly
useful in acute mania and severe depression, melancholiaSE mememory loss80% success ratecourse u t 20in hospital
loss of healthy partnerloss life plansdealing with stigmaincreased responsibility in being a carer
at its core a recovery approach encourages people to take control of their lives and nurtures hope that they can achieve their goals despite the presence of mental illness
Explain to your patient that for safety reasons you
would like to discuss their use of certain medicines. Ask the patient
about their medicines and provide them with an opportunity to explain
This medicine you are taking can pose risks if it is overused or
combined with other high-risk medicines. Can you please tell me about
There are some details I will need to clarify with you about ...
Can you tell me how this situation arose? (eg, how you came to
obtain prescriptions from a number of different providers/pharmacies)...
This includes over-the-counter medicines, prescribed medicines and
illicit drugs. Ask about the dose, duration of treatment, formulations,
adverse effects and routes of administration, and determine whether
there is a history of substance use disorder.
All these factors can signal an increased risk of prolonged or problematic use:
signs of intoxication, withdrawal or intravenous drug use (IVDU) (common
IV injection sites are antecubital fossa, groin, neck), or other
substance use that is not IVDU.
Consider further investigations (eg, urine drug screening or screening
for blood-borne diseases, and assessing physical complications)
Explore with the patient their presenting problem, current concerns and most recent diagnosis/es.
developing a written management plan to document patient and prescriber
responsibilities, goals and expectations and desired outcomes in
Discuss with the patient that you plan to link in with other providers
to gather more information so you can formulate a comprehensive
management plan. Request permission from the patient to communicate with
Although it may be confronting and distressing to encounter a patient
showing signs of dependence and/or drug-seeking behaviours, it is
important to remember:1
For patients taking opioids, morphine equivalent doses (MED) of
> 50 mg are associated with an increased risk of harm, and titrating
to high doses of > 100 mg MED or more per day should be undertaken
only with specialist involvement.
Compared with patients receiving > 20 mg MED per day of
opioids, patients receiving 100 mg MED per day or more have an 8.9-fold
increase in overdose risk.
When making this decision, keep in mind:
When prescribing, there is no obligation to prescribe the maximum PBS
quantity, or usual pack size, of the medicine, or any repeats.
Prescribing in smaller quantities is an option to address the
patient's immediate need for the medicine, while minimising potential
Staged supply arrangements
(dispensing at intervals of one or more days rather than dispensing the
whole prescribed amount) can be particularly helpful for patients with
drug dependency, those with a mental illness or patients who are
otherwise unable to manage their medicines safely
This may be appropriate if you require further information or advice
before making a decision with the patient about their management plan,
or for short-term management while waiting for the first specialist
Patients on a high daily dose of prescription opioids (eg, > 50 MED),
those with a history of injecting drugs or other substance use
disorder, those taking multiple concurrent sedative medications or
alcohol (eg, opioids and benzodiazepines),
those with high-risk medicine use, and those with a history of opioid
overdose may require take-home naloxone to treat opioid overdose, which
is available on the PBS for this indication.
When treatment is no longer appropriate, or the benefits of treatment no
longer outweigh the harms, it may be appropriate to taper the dose or
deprescribe the medicine. This depends on factors such as the duration of treatment and the dose of medicine the patient is currently taking
If the patient reports withdrawal symptoms (or if a previous attempt at
tapering was unsuccessful), the rate of taper can be slowed – for
example, by reducing the size of dose reduction each month, and/or
extending the time spent at each dose level before stepping down.
Offer non-pharmacological approaches and, when necessary, other pharmacological options to help manage symptoms
Medication-assisted treatment for opioid dependence (MATOD) may be a more suitable option for some patients.
it can be challenging to explain your decision to the patient. It is
important not to dismiss the patient and their health condition merely
because they have an issue with dependence.
If the patient requests a medicine by name or brand, focus the
conversation on their reasons for the request and their underlying
Explain that you would like to make your own clinical assessment, as it
would not be appropriate to just repeat another medical practitioner's
Following the assessment, explain to the patient that you would like to
help them to manage their condition, but you do not feel it is safe or
appropriate to prescribe the medicine.
regularly for at least 20 minutes, preferably more than 4–5 hours prior to bedtime
Opioids have a very limited role in the management of chronic non-malignant pain (CNCP) due to the methodological weakness of chronic pain studies
in adequately informing the long-term effects. All other treatment
options including non-pharmacological options and non-opioid options
should be considered as the primary interventions of care.
Opioid treatment may be appropriate for only a small proportion
of patients with moderate or severe pain that significantly affects
function or quality of life and has not responded to other treatments. An assessment of risk in individual patients, and management of this risk, is essential.
monotherapy for short-term treatment of primary insomnia characterised by poor-quality sleep in patients aged 55 years or over