Treatment for Non-Responsive Depression

When a patient fails to respond to fluoxetine, which is a selective serotonin reuptake inhibitor (SSRI), it is recommended to switch to another SSRI first. If this doesn’t work, the NICE update on depression (2010) suggests trying a newer generation antidepressant that is better tolerated. It is important to find the right medication for each individual patient, as depression can have a significant impact on their quality of life. Therefore, healthcare professionals should closely monitor patients and adjust their treatment plan accordingly.

For generalised anxiety disorder, pregabalin is suggested as a third line treatment option. If the patient is unable to tolerate SSRIs and SNRIs, pregabalin can be considered as an alternative. However, amitriptyline is not recommended for this condition.

Dealing with anxiety and depression is a common issue, and initial treatments may not always be effective. It is important for healthcare professionals to be knowledgeable about second and third line treatments, which may be initiated by some GPs or prescribed after specialist advice. The GP is responsible for ongoing monitoring and safety, including being aware of potential drug interactions.

Anxiety is a common disorder that can manifest in various ways. According to NICE, the primary feature is excessive worry about multiple events associated with heightened tension. It is crucial to consider potential physical causes when diagnosing psychiatric disorders such as anxiety. Hyperthyroidism, cardiac disease, and medication-induced anxiety are important alternative causes. Medications that may trigger anxiety include salbutamol, theophylline, corticosteroids, antidepressants, and caffeine.

NICE recommends a stepwise approach for managing generalised anxiety disorder (GAD). The first step is education about GAD and active monitoring. The second step involves low-intensity psychological interventions such as individual non-facilitated self-help, individual guided self-help, or psychoeducational groups. The third step includes high-intensity psychological interventions such as cognitive behavioural therapy or applied relaxation, or drug treatment. Sertraline is the first-line SSRI recommended by NICE. If sertraline is ineffective, an alternative SSRI or a serotonin–noradrenaline reuptake inhibitor (SNRI) such as duloxetine or venlafaxine may be offered. If the person cannot tolerate SSRIs or SNRIs, pregabalin may be considered. For patients under the age of 30 years, NICE recommends warning them of the increased risk of suicidal thinking and self-harm and weekly follow-up for the first month.

The management of panic disorder also follows a stepwise approach. The first step is recognition and diagnosis, followed by treatment in primary care. NICE recommends either cognitive behavioural therapy or drug treatment. SSRIs are the first-line treatment. If contraindicated or no response after 12 weeks, imipramine or clomipramine should be offered. The third step involves reviewing and considering alternative treatments, followed by review and referral to specialist mental health services in the fourth and fifth steps, respectively.

Balint Groups: A Patient-Centred Approach to Healthcare

Michael Balint, a Hungarian psychoanalyst and psychiatrist, played a significant role in shaping modern views on patient-centred healthcare. He believed that many presenting complaints had underlying psychological and emotional problems that needed to be explored to understand patients better. Balint coined the phrase ‘the doctor as a drug’, emphasizing the importance of the doctor-patient relationship in the healing process.

During the 1950s, Balint established small groups called ‘Balint Groups’ that allowed GPs to discuss their patients on an informal basis. These groups were similar to discussions held amongst GP Registrars during their half-day release. Balint’s ideas were published in the book ‘The doctor, his patient and the illness’.

Balint Groups provide a safe space for GPs to discuss their patients’ emotional and psychological needs, which can often be overlooked in a busy clinical setting. By exploring these areas, GPs can gain a deeper understanding of their patients and provide more effective care. Balint’s patient-centred approach to healthcare has had a significant impact on modern medicine and continues to be used today.

Urinary retention may be caused by tricyclic antidepressants, particularly Amitriptyline, due to its anticholinergic effects. This can result in symptoms such as tachycardia, dry mouth, mydriasis, and urinary retention. However, SSRIs like fluoxetine and SNRIs like venlafaxine are not typically associated with these side effects, with dry mouth and urinary retention being rare occurrences. Unlike Amitriptyline, Diazepam, a benzodiazepine, doesn’t have anticholinergic effects.

Tricyclic antidepressants (TCAs) are not commonly used for depression anymore due to their side-effects and potential for toxicity in overdose. However, they are still widely used for the treatment of neuropathic pain, where smaller doses are typically required. The common side-effects of TCAs include drowsiness, dry mouth, blurred vision, constipation, urinary retention, and lengthening of QT interval. When choosing a TCA, low-dose amitriptyline is commonly used for the management of neuropathic pain and the prevention of headaches. Lofepramine is preferred due to its lower incidence of toxicity in overdose, while amitriptyline and dosulepin are considered the most dangerous in overdose. The sedative effects of TCAs vary, with amitriptyline, clomipramine, dosulepin, and trazodone being more sedative, while imipramine and nortriptyline are less sedative. Trazodone is technically a ‘tricyclic-related antidepressant’.

Relationship Issues vs. Depression: Understanding the Difference

There is no clear indication of depression in this patient’s history. Despite experiencing disharmony in her relationship, she is still able to lead a normal life and enjoy most of it. Therefore, there is no need to prescribe antidepressants or refer her to a psychiatrist. Instead, offering support and guidance towards relationship counseling is the best course of action. It is important to understand the difference between relationship issues and depression, as they require different approaches to treatment. By addressing the root cause of the problem, the patient can work towards resolving her relationship issues and improving her overall well-being.

Understanding the Mental Health Condition of a Redundant Middle-Aged Man

This man is likely experiencing depression due to being made redundant in mid-life. His fear of bowel cancer is a manifestation of hypochondriasis, which is a somatoform disorder. However, it is distinct from somatisation, although there can be overlap. Additionally, he is exhibiting heavy alcohol consumption as a symptom of his condition.

Given his expressed suicidal thoughts, tricyclics should be avoided. Instead, citalopram is recommended due to its more benign toxicity profile. While cognitive therapy may be helpful, it is unlikely to lead to complete resolution of his condition given the nature of his symptoms. It is important to understand the complexity of his mental health condition and provide appropriate support and treatment.

Patients who are taking a SSRI should not use triptans.

Selective serotonin reuptake inhibitors (SSRIs) are the first-line treatment for depression, with citalopram and fluoxetine being the preferred options. They should be used with caution in children and adolescents, and patients should be monitored for increased anxiety and agitation. Gastrointestinal symptoms are the most common side-effect, and there is an increased risk of gastrointestinal bleeding. Citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in certain patients. SSRIs have a higher propensity for drug interactions, and patients should be reviewed after 2 weeks of treatment. When stopping a SSRI, the dose should be gradually reduced over a 4 week period. Use of SSRIs during pregnancy should be weighed against the risks and benefits.

Erectile dysfunction (ED) is the inability to achieve and maintain an erection sufficient for satisfactory sexual performance. It can be caused by organic, psychogenic, or mixed factors, as well as certain medications.

Symptoms that suggest a psychogenic cause of ED include a sudden onset, early loss of erection, self-stimulated or morning erections, premature ejaculation or inability to ejaculate, relationship problems or changes, major life events, and psychological issues.

Symptoms that suggest an organic cause of ED include a gradual onset, normal ejaculation, normal libido (except in hypogonadal men), a history of medical risk factors (such as cardiovascular, endocrine, or neurological conditions), pelvic or scrotal trauma, radiotherapy or surgery, current use of medications known to cause ED, smoking, high alcohol consumption, or use of recreational or bodybuilding drugs.

Erectile dysfunction (ED) is a condition where a man is unable to achieve or maintain an erection that is sufficient for sexual performance. It is not a disease but a symptom that can be caused by organic, psychogenic, or mixed factors. It is important to differentiate between the causes of ED, with factors such as a gradual onset of symptoms and lack of tumescence favoring an organic cause, while sudden onset of symptoms and decreased libido favoring a psychogenic cause. Risk factors for ED include cardiovascular disease, alcohol use, and certain medications.

To assess for ED, it is recommended to measure lipid and fasting glucose serum levels to calculate cardiovascular risk. Free testosterone should also be measured in the morning, and if low or borderline, further assessment may be needed. PDE-5 inhibitors, such as sildenafil, are the first-line treatment for ED and should be prescribed to all patients regardless of the cause. Vacuum erection devices can be used as an alternative for those who cannot or will not take PDE-5 inhibitors. Referral to urology may be appropriate for young men who have always had difficulty achieving an erection, and those who cycle for more than three hours per week should be advised to stop.

Understanding Obsessive-Compulsive Disorder (OCD)

Obsessive-compulsive disorder (OCD) is a mental health condition that affects 1 to 3% of the population. It is characterized by the presence of obsessions, which are unwanted intrusive thoughts, images, or urges, and compulsions, which are repetitive behaviors or mental acts that a person feels driven to perform. These symptoms can cause significant functional impairment and distress.

Risk factors for OCD include a family history of the condition, age (with peak onset between 10-20 years), pregnancy/postnatal period, and a history of abuse, bullying, or neglect.

The management of OCD involves classifying the level of impairment as mild, moderate, or severe using the Y-BOCS scale. For mild impairment, low-intensity psychological treatments such as cognitive behavioral therapy (CBT) including exposure and response prevention (ERP) are recommended. If this is insufficient, a course of an SSRI or more intensive CBT (including ERP) can be offered. For moderate impairment, a choice of either an SSRI or more intensive CBT (including ERP) is recommended, with clomipramine as an alternative first-line drug treatment to an SSRI if necessary. For severe impairment, referral to the secondary care mental health team for assessment is necessary, with combined treatment of an SSRI and CBT (including ERP) or clomipramine as an alternative while awaiting assessment.

ERP is a psychological method that involves exposing a patient to an anxiety-provoking situation and stopping them from engaging in their usual safety behavior. This helps them confront their anxiety, leading to the eventual extinction of the response. Treatment with an SSRI should continue for at least 12 months to prevent relapse and allow time for improvement. Compared to depression, the SSRI usually requires a higher dose and a longer duration of treatment (at least 12 weeks) for an initial response.

Erotomania, also known as De Clérambault’s syndrome, is a type of delusion where the patient firmly believes that another person is deeply in love with them.

Understanding Othello’s Syndrome

Othello’s syndrome is a condition characterized by extreme jealousy and suspicion that one’s partner is being unfaithful, even in the absence of any concrete evidence. This type of pathological jealousy can lead to socially unacceptable behavior, such as stalking, accusations, and even violence. People with Othello’s syndrome may become obsessed with their partner’s every move, constantly checking their phone, email, and social media accounts for signs of infidelity. They may also isolate themselves from friends and family, becoming increasingly paranoid and controlling.