Ch14: Mental Health Flashcards
SIGECAPS mnemonic for major depressive disorder symptoms
S - sleep I - interest G - guilt E - energy C - concentration A - appetite P - psychomotor S - suicidality
MDD diagnostic criteria
5 or more symptoms present in the same 2 week period, one of which must be (1) depressed mood and/or (2) loss of interest or pleasure in usual activities
- insomnia or hypersomnia, staying asleep is problematic
- feelings of worthlessness
- fatigue or loss of energy
- diminished ability to think clearly or make decisions
- loss of food enjoyment, increase or decrease in appetite
- psychomotor retardation or agitation
- recurrent thoughts of death, passive without a plan, or active suicidality
diagnostic criteria of GAD
3 or more of the following symptoms reported as occurring on most days for 6 or more months
- worry that is disproportionate to daily concerns, continued to worry even when the concerning event resolved
- anxiety with mental and physical hypervigilance
- muscular tension, GI upset
- reports of mind racing, difficulty with concentration
- hyperarousal - irritability is common
- energy loss, fatigue, chronically feeling tired despite adequate opportunity to rest
- restlessness, constantly feeling physically “keyed up”
- classically difficult to initiate sleep
WATCHERS mnemonic for GAD symptoms
W - worry A - anxiety T - tension in body C - concentration difficulty H - hyperarousal E - energy loss R - restlessness S - sleep disturbance
remission of symptoms in GAD/MDD typically takes how long with medication? how long should someone be on these?
- time to remission typically takes 4-8 weeks (~6 weeks to feel effect of that dose)
- if they have a second episode, consider longer-term maintenance therapy
- when tapering off medication, taper over >6 weeks to avoid discontinuation syndrome and monitor carefully for mood disorder relapse
in someone with a mood disorder with vegetative symptoms, avoid prescribing an SSRI that is….
sedating
in someone with a mood disorder with energy/anxiety/restlessness, avoid prescribing an SSRI that is…
activating
most activating of the SSRIs
fluoxetine (Prozac)
most sedating of the SSRIs
paroxetine (Paxil)
middle of the road SSRIs in terms of sedating vs. activating (3)
- sertraline (Zoloft)
- citalopram (Celexa)
- escitalopram (Lexapro)
medication class with the best effect (first line) on lifting and smoothing mood
SSRIs
SNRIs have similar effects to SSRIs but additionally help with….
increasing focus
medication class: venlafaxine (Effexor)
SNRI
medication class: duloxetine (Cymbalta)
SNRI
medication class: desvenlafaxine (Pristiq)
SNRI
the SNRIs as a class tend to be more [sedating vs. activating], but not terribly
activating
medication class: fluoxetine (Prozac)
SSRI
medication class: sertraline (Zoloft)
SSRI
medication class: citalopram (Celexa)
SSRI
medication class: escitalopram (Lexapro)
SSRI
medication class: bupropion (Wellbutrin)
SDRI (selective dopamine reuptake inhibitor)
the SDRI bupropion as a class tend to be more [sedating vs. activating], but not terribly
activating
helpful add-on agent when someone with MDD has an incomplete response with an SSRI
bupropion (Wellbutrin) - SDRI
appropriate use and indication for buspirone (Buspar)
anxiolytic, helpful in alleviating hypervigilance associated with anxiety, not as useful for worry
buspirone is not rapid-acting like the benzos, this needs to be used regularly for many weeks before feeling an effect (common misconception that can be taken PRN with providers)
what is the single most common adverse effect with SSRIs, SNRIs, and SDRI?
sexual dysfunction = 20-40%
anorgasmia, erectile dysfunction, altered libido
FDA BBW on SSRIs
increased the risk of suicidal thinking and behavior in children, adolescents, and young adults <24yo in short-term studies, this has not been noted in adults >24yo
in adults 65yo or older, the use of antidepressants reduces suicidality risk
SSRI with a remarkably long half-life
fluoxetine (Prozac) - half life of 84 hrs, metabolite 7-15 days
which SSRI is not a CYP450 isoenzyme inhibitor at all :)
escitalopram (Lexapro)
which SSRIs (2) are the least inhibiting of CYP450 isoenzymes
- escitalopram (Lexapro)
- citalopram (Celexa)
which SSRI is the most inhibiting of CYP450 isoenzymes?
fluoxetine (Prozac)
which SSRI has a dose limitation due to potential QT prolongation?
citalopram (Celexa)
the SSRI with the longest half life, _____, is thus a poor choice for which patient population?
fluoxetine (Prozac)
poor choice in elderly adults (reduced clearance of medications)
antidepressant withdrawal syndrome symptoms (serotonin withdrawal)
- nausea
- headache
- flu-like symptoms
- anxiety/ hyperarousal
- insomnia
- imbalance (dizziness, difficulty with coordination)
- sensory disturbances (nightmares are common)
treatment for antidepressant withdrawal syndrome
- restart old dose of SSRI
- leave on regular dose x1 week
- start a 6 week taper
FINISH mnemonic for symptoms of serotonin withdrawal (antidepressant withdrawal syndrome)
F - flu like symptoms I - insomnia N - nausea I - imbalance S - sensory disturbances H - hyperarousal
is SSRI withdrawal life threatening?
no, bothersome but not dangerous
tends to go away by 7 days
when you see a psychoactive medication that has a side effective weight gain, very often that is because it causes ________ which should be monitored by this lab
insulin resistance
monitor blood sugar and lipid profile (triglycerides, most commonly)
medication class: olanzapine (Zyprexa)
2nd generation antipsychotic
is becoming standard of care for someone being started on a ____ [med class] to also start metformin, even if they don’t yet have diabetes
2nd generation antipsychotic
major type of side effect with the 2nd generation antipsychotics
metabolic effects
which (3) 2nd generation antipsychotics cause the least weight gain and thus least risk for DM and HLD
- ziprasidone (Geodon)
- aripiprazole (Abilify)
- paliperidone (Invega)
medication class: olanzapine (Zyprexa)
2nd gen antipsychotic
medication class: clozapine (Clozaril)
2nd gen antipsychotic
medication class: risperidone (Risperdal)
2nd gen antipsychotic
medication class: quetiapine (Seroquel)
2nd gen antipsychotic
medication class: ziprasidone (Geodon)
2nd gen antipsychotic
medication class: aripiprazole (Abilify)
2nd gen antipsychotic
medication class: paliperidone (Invega)
2nd gen antipsychotic
medication class: asenapine (Saphris)
2nd gen antipsychotic
medication class: iloperidone (Fanapt)
2nd gen antipsychotic
CAGE questionnaire
C - cut down
A - annoyed
G - guilty
E - eye opener
- have you ever felt you ought to cut down on drinking?
- have people annoyed you by criticizing your drinking?
- have you ever felt bad or guilty about your drinking?
- have you ever had a drink first thing in the morning to steady your nerves or get rid of a hang over?
expected AST/ALT elevation in alcohol abuse
modest
1-3x upper limit of normal
higher AST = S for substance
expected macrocytosis in alcohol abuse
modest
between 100-106
expected triglycerides in alcohol abuse
modest
elevated but <500
elevated CAGE score
2 or higher responses are positive
diagnostic criteria for substance use disorder
a problematic pattern of substance use that leads to clinically significant impairment or distress
2 or more of the following symptoms within the last 12 months:
- substance use in larger amounts over longer period that intended
- desires to cut down and/or has tried unsuccessfully in the past
- excessive time spent obtaining substance, using substance, or recovering from its effects
- craving or a strong desire to use
- inability to maintain major role obligations
- continued substance use despite recurrent social or interpersonal problems related to use
- substance use in potentially hazardous positions
- continued use despite recurrent social or interpersonal problems related to use
- important social, occupational, or recreational activities are given up or reduced s/t use
- tolerance (needing more to get same effect, diminished effect with same amount)
- withdrawal (set of characteristic withdrawal symptoms, same or other substances are used to avoid withdrawal)
what is codependence in the context of substance abuse
behavior patterns of family members and friends that are strongly affected by the person’s substance use. Includes enabling behaviors with the short-term goal of conflict avoidance, including:
- making excuses for the substance abuser’s behavior (e.g., call in sick to work for them) in order to protect their loved one
- provide funds, drugs, and/or alcohol to the abuser with the end result of the substance abuser being protected from taking responsibility for their actions
enablers often have strong feelings of guilt, anger, or depression because their efforts are not helpful in curing the substance abuse, and are often accompanied by refusal to accept the substance abuse as an illness
BBW: do not combine benzodiazepines with….
other CNS depressants including alcohol and opioids
opioid antagonist for overdose
naloxone (Narcan)
s/s alcohol withdrawal
occurs within several hours to several days after cessation of heavy and prolonged use
- tachycardia
- BP elevation
- diaphoresis
- hand tremor
- insomnia
- GI upset
- short-lived hallucinations (visual, tactile, auditory)
- psychomotor agitation
- anxiety
- grand mal seizure
medical marijuana evidence-based indications include….
- anxiety
- depression
- GI disorders
- nausea s/t chemotherapy
- MS
- chronic pain
- AIDs
- epilepsy
- glaucoma
stimulants are all based around the original drug….
amphetamine
(2) OTC medications with the possibility of being abused like a stimulant d/t amphetamine-like effects
ephedrine, pseudoephedrine
stimulants/amphetamine street name & route
meth, crystal, speed
inhaled, smoked, injected
overdose on meth/stimulants/amphetamines OR cocaine symptoms
- tachycardia or bradycardia
- high or low BP
- chills, sweating, nausea, vomiting
- psychomotor agitation or retardation
- muscle weakness
- dilated pupils
- arrhythmias
- coma
- confusion/AMS
- seizure
- death
withdrawal symptoms from meth/stimulants/amphetamines OR cocaine
- depressed mood
- fatigue
- vivid and disturbing dreams
- sleep disturbance
- increased appetite
- psychomotor agitation or retardation
not fatal
street name and route for cocaine
coke, snow, flake, blow, crack
inhaled, smoked, injected
withdrawal symptoms from hallucinogens
none
can have psychological dependence but does not cause physical dependence or withdrawal
hallucinogenic drugs
- psilocybin (mushrooms)
- mescaline (peyote cactus)
- LSD
- ketamine (Special K)
- phencyclidine (PCP)
- dextromethorphan at high doses (robotripping)
opioids, morphine, oxycodone street version of the drug
heroin
overdose on heroin/opioids symptoms
- respiratory depression
- constricted pupils
- constipation
- respiratory arrest
- unresponsiveness/coma
- hypothermia
- hypotension
- bradycardia
- death
symptoms of opioid/heroin withdrawal
- cravings
- muscle cramps and myalgias
- diarrhea and abdominal cramps
- rhinorrhea
- lacrimation
- goose bumps
- fever
- papillary dilation
- hypertension
- tachycardia
- yawning
- temperature dysregulation
medication class: diazepam (Valium)
benzodiazepine
medication class: chlordiazepoxide (Librium)
benzodiazepine
medication class: clonazepam (Klonopin)
benzodiazepine
medication class: lorazepam (Ativan)
benzodiazepine
medication class: alprazolam (Xanax)
benzodiazepine
(2) examples of barbiturates
- secobarbital
- pentobarbital
symptoms of benzodiazepine or barbiturate withdrawal
- anxiety
- dysphoria
- phonophobia, photophobia
- nausea
- muscle twitching
- seizures
benzodiazepine receptor antagonist that can be used to reverse benzo overdose
flumazenil (Anexate)
