Depression, Anxiety, Bipolar Disorder Flashcards
what is the leading cause of disability worldwide, and is a major contributor to the global burden of disease?
depression
what is the purpose of the DSM?
- Original purpose was to collect statistics on mentally ill
- Used for billing
- Communication between providers (“common language”)
7 limitations of the DSM5
- Very long, tedious (~947 pages!)
- Discrete criteria for diagnosing individual disorders when people are more complex
- Pathologizes normal experiences (ex: homosexuality)
- Sx missing from criteria
- Good resource but no replacement for clinical judgment
- A patient does NOT need to perfectly fit DSM criteria in order to receive treatment
- a controversial, ever-changing guide
what sx are missing from the DSM5 criteria for depression?
- Physical symptoms (loss of sex drive, HA, GI problems)
- Motivation
- Tearfulness/emotionality
- Irritability/Anger (seen mostly in men)
how do you respond to a patient when asked “isn’t this normal”
- All DSM disorders are on a spectrum
- “Normal” may need treatment while “abnormal” may not– depends if it is effecting their lives
- Ask open-ended question(s) at beginning of encounter.
- Use SIGECAPS and other questions to gather specific information.
- Use targeted psychosocial questions to determine etiology of mood issues (ex. Fhx, substance abuse?)
- Come up with initial management plan
what is correlated with a high chance of mood disorder?
number of physical symptoms
goals of psychosocial history when assessing for depression?
- Genetics
- Social Hx
- Current circumstances
- Physical stressors
what 3 things in Fhx are strongly associated w/ genetic depression?
- depression
- anxiety
- alcohol abuse
what to ask about to determine if their depression is related to genetics
- Fhx of depression, anxiety, ETOH abuse, bipolar, substance abuse, sucide
- Pts past psych hx
- Determine their BASELINE
Strong genetic component of depression is often tx how?
often a reason for pharmacologic management as a component of treatment
what to ask about to determine if their depression is related to their social history
- family origin- marital status of parents, # siblings, overall experience in family
- Place of birth and subsequent moves
- Issues with friendships or relationships
- Work/education history
- Criminal/legal issues
- Trauma
- Substance Use
how to treat depression with a strong social component
- Multiple stressors can take physical toll (pharmacology) or guide a referral to therapy/support
- Multiple stressors in the past likely need therapy eventually
how to treat medical Issues that mimic or exacerbate psych disorders
tx independently (ex. thyroid, anemia, injury)
what to ask about to determine if their depression is related to a current circumstance
- what brings patient in today for treatment?
- What are the current stressors in his or her life (if any)?
- What support does the patient have?
how to tx depression related to a current circumstance
- Significant stress/issues is indication for psychotherapy (and possibly meds)
- Encourage to get support around specific stressor
DSM5 criteria for treating Persistent depressive disorder (dysthymia)
- Remember rule of 2’s!
1. Depressed mood for most of the day, most days for at least 2 years
2. 2 or more of the following symptoms: appetite issues, sleep issues, low energy/fatigue, low self-esteem, trouble concentrating/making decisions, hopelessness
3. During 2 year period has not been symptom-free for 2 months or more - Can co-occur with Major Depressive Episodes
- *It is a milder depression that lasts most of the time, but it can “dip” down into major depression episodes at times
DSM5 criteria for treating Major depressive disorder
- 5 or more symptoms present for at least 2 weeks:
SIGECAPS + depressed mood or anhedonia - Symptoms cause significant distress or impairment in social, occupational, or other important areas of functioning
- Episode is not due to physiological effects of a substance or another medical condition
- Occurrence is not better explained by other psychiatric disorder (ex. Bipolar)
- There has never been a manic or hypomanic episode
what does SIGECAPS stand for?
- sleep (hypersomnia or insomnia)
- interest (anhedonia)
- guilt (worthlessness, hopelessness, helplessness)
- Energy (high or low/fatigued)
- Concentration (difficulty focusing or making decisions)
- Appetite (changes/weight changes)
- Psychomotor (retardation or agitation)
- Suicidality (thoughts of death or wishing to be dead)
what is considered full remission
2+ months w/o symptoms
initial management plan for a pt with depression
- treat physical sx
- reassurance and education
- therapy or lifestyle modifications
- Meds
- Combo of above
if the patient has a underlying medical condition that has not been treated at all or adequately (and is linked to mood issues), which do you treat first?
the underlying medical issue
what is the connection btwn physical and mental sx?
- there are seratonin receptors else where in the body that can be affected by depression–> can affect the whole body
- education is important!
what is the connection btwn depression and the immune system?
you can feel more depressed when your immune system is ramped up
**depression can precede diagnosis!!
what medical conditions are associated w/ depression
autoimmune disease, cancer, heart disease, diabetes, hepatitis C, stroke, Parkinsons, Alzheimers, MS
If the patient’s symptoms seem expected given his circumstances and likely to resolve on their own, how should you tx
- oftentimes you can educate him about them “negotiate a plan” for next steps
- *F/U is key!!!
*best option for those w/ little or no mental health issues in their hx
examples of circumstances that will likely resole on their own
- baby blues
- grief/loss
- major life changes (even if good)
when is therapy or lifestyle modification not a good option for depression?
- If patient’s mood or cognitive symptoms make it hard to participate (Ie. confused or delusional)
- If sx resolve completely with medication or other treatments
what are lifestyle modifications that can help w/ depression
exercise
sleep
diet
alternative therapies
when is therapy or lifestyle modification an ideal option for depression?
- ideal by itself if sx are mild to moderate and largely due to situation (ex: divorce) AND PMH not significant
- w/ meds if sx are severe, and patient has significant current/past stressors and significant PMH
what is important to consider when you are going to prescribe meds for depression?
- can be used short term for acute situations (sleep meds for grief)
- use different meds for more severe depressions
- pt education/choice is VERY important
what are sx of low serotonin
- emotional aspects
- physical ailments ( GI complaints or migraines)
- anxiety
*more serotonin receptors in GI tract than brain
what is anhedonia
lack of interests
what are sx of low NE
- flat aspects of depression (stunted mood/energy/”blah”)
2. chronic pain
what are sx of low dopamine
- anhedonia (w/o hyperemotional features)
- low energy
- low motivation
- possibly addictive behaviors (porn, gambling, shopping)
*similar to NE
what is the mechanism of action for most anti-depressants
reuptake inhibitors
- don’t increase amount of NT but block the reuptake so more gets taken up by the other neuron
- use the NTs you have more effectively
types of SSRIs by activation level
Highest to lowest
Paxil, Celexa, Lexapro, Zoloft, Prozac
characteristics of prozac (fluoxetine)
- MOST activating souse in pts who are fatigued w/ other SSRIs-be careful w/ anxiety
- LONGEST half-life so takes the longest to start working and longest to get out of system as well
what is the dose regimen for prozac (fluoxetine)
- start w/ 10mg WITH FOOD in AM
- increase by 10mg every 1-2 weeks
- Final dose (20-80mg)
*To stop: taper by 10mg per week
what is the dose regimen for zoloft (sertraline)
- start w/ 25mg
- increase by 25mg a week up to 100mg
- final dose: 100-200mg (25-300mg)
*to stop: taper by 25-50mg every 2-3 weeks (slow is always best)
characteristics of zoloft (sertraline)
- slightly more likely to cause cause GI upset*
- nice dosing flexibility as tablets come in low dose and are easy to split
characteristics of celexa (citalopram)
- Good alternative to zoloft and lexapro
- very INEXPENSIVE
- max dose is 40mg due to possible QT prolongation
when should you instruct a patient to take celexa (citalopram)
am or pm WITH FOOD
characteristics of lexapro (escitalopram)
- stereoisomer of Celexa so dosing is HALF celexa
- tends to have FEWEST side effects (Biggest is sedation)
- good flexibility w/ dosing although pills are hard to split
what SSRIs need to be taken with food?
- Celexa (citalopram)
- Lexapro (escitalopram)
- Prozac (fluoxetine)
- Paxil (paroxetine)
characteristics of Paxil (paroxetine)
- most sedation, weigh gain, sexual side effects
- STRONG association w/ Discontinuation Syndrome
common side effects with SSRIs
GI: nausea/constipation/diarrhea
Sedation
HA/dizziness
Dry mouth
- most SE go away
- SE for most psych meds (except Wellbutrin- no sedation)
Long term side effects of SSRIs
- sexual- lower libido, decreased ability to have an orgasm
- Cognitive- feeling spacey, loss of words/focus
- Feeling Flat- dull, unemotional, failure to react appropriately to an emotional event
how to help manage sexual SE on SSRIs
- adding Wellbutrin may help (if you can get by with lowering SSRI dose as well)
- ED meds
*work w/ patient based on level of tolerability
how to help manage cognitive SE on SSRIs
- Wellbutrin may help
2. educate patient
how to help manage “feeling flat” SE on SSRIs
- Downregulation of NE- DA a possibility so adding Wellbutrin may help
- lower SSRI
- Therapy
Symptoms of discontinuation syndrome
- Sensory sx (electrical shock, numbness)
- Disequilibrium (LH, dizzy, vertigo)
- General Somatic Sx (lethargy, HA, tremor, sweating, anorexia)
- Affective sx (irritability, anxiety, tearfulness)
- GI (N/V, diarrhea)
- Sleep disturbance (nightmares, insomnia, excessive dreaming)
Addiction vs Discontinuation Syndrome
Addiction:
- development of tolerance (need to increase dose)
- associated w/ feeling high or “altered mental state”
- person still has cravings after W/D period
Discontinuation:
- No tolerance
- used to feel “normal”
- After D/C syndrome resolves, NO cravings
what are SNRIs
- Effexor XR (venlafaxine)
- Pristiq (desvenlafaxine)
- Cymbalta (duloxetine)
- Remeron (mirtazapine)
Characteristics of Effexor XR (venlafaxine)
- low doses have more SE effects. More NE as dose increases
- high risk of D/C syndrome- may need to use SSRI tablet w/ pts experiencing trouble
- good 2nd option if pt fails SSRIs or needs help w/ energy/concentration/pain
*not sedative!
how should effexor XR (venlafaxine) be taken?
AM with food (not sedative)
*taper up and dwon
characteristics of Pristiq (desvenlafaxine)
- active metabolite of Effexor (less d-d interactions bc not metabolized in liver)
- well-tolerated given high starting dose
- $$ than Effexor
- not a lot of dosing flexibility
- can have D/C syndrome
what is the best SNRI with fewest side effects
pristiq (desvenlafaxine)
what med has equal SE and NE effects at all doses
Cymbalta (duloxetine)
*SNRI
Cymbalta (duloxetine) characteristics
- worth trying in pts struggling with pain along w/ depression
- may need to add an SSRI to help if it is is helping w/ pain component
- biggest SE is being TOO activating or increasing anxiety
- nausea is common
what is unique about remeron (mirtazapine)
- no sexual or GI side effects but strong association w/ sedation and weight gain
- fantastic for pts who can’t eat/sleep
how should one take remeron (mirtazapine)
-in PM bc its sedative
how does remeron (mirtazapine) work
SNRI
-stimulates certain SE receptors like SSRI’s but blocks other that cause SE’s
considerations for SNRIs
- higher incidence of SE (nausea, insomina, HA)
- too much NE is similar to having too much caffeine (HR, sweatiness, teeth clenching, dry mouth, dizzy)
- increase BP
what class is wellbutrin (buproprion)
NDRI
*only AD that boost NE and DA
characteristics of wellbutrin (buproprion)
- most activating so take in AM
- can be too activating (crawling out of skin)
- not great for anxiety
- NO sexual or weight gain SE (bc no serotonin)
what are the contraindications for Wellbutrin (buproprion)?
- Seizure disorder
- Bulimia (risk for seizures bc their electrolytes are already off)
special considerations before starting an AD
- beware of bipolar disorder
2. pt should stay on meds for minimum of 6 months after remission to avoid relapse
How to manage Nausea associated with AD
- take at end of meal
- move to PM
How to manage sedation associated with AD
- switch to SNRI
- more to PM
How to manage weight gain associated with AD
- if on Paxil, switch to different SSRI or to SNRI
- add wellbutrin
How to manage sexual side effects associated with AD
- lower dose
- add Wellbutrin
- change to SNRI
- augment w/ ED tx
when is someone most at risk for D/C Syndrome
-any pt discontinuing an AD that boost serotonin (Biggest offenders are Paxil and Effexor- but all have potential)
how can you manage D/C syndrome
-use low dose Celexa, Zoloft or Lexapro to wean them off more slowly
what are the main types of anxiety disorders
- Generalized anxiety disorder (GAD)
- Panic disorder
- Agoraphobia
- Social anxiety disorder (social phobia)
- Specific phobia
what is anxiety
-Normal human emotion related to apprehension about a potentially harmful event – affects cognition, physicality and behavior
how can anxiety be beneficial
- can be beneficial in keeping person out of harm
- Can increase attention and improve performance
anxiety is maladaptive if:
- intensity out of proportion to the threat
- persists once threat is gone
- becomes generalized to multiple situations
- having a negative effect on the person’s life and functioning
A 30 year old women complains of increased muscle tension. It has become worse over the past 7 months, despite her attempts to control it. She worries about her 2 year old daughter getting sick, Ebola coming to the United States, the decline in the economy, whether or not her husband is going to get laid off and if her parents are coming to visit for the holidays. Oftentimes, she is restless and unable to sleep at night. She is tired during the day and irritable with her family.
Dx?
GAD
DSM 5 criteria for generalized anxiety disorder
- Excessive anxiety and worry for 6+ months about a VAIRETY of issues
- Worry is difficult to control
- 3 of 6 key symptoms-
- restless/keyed up
- easily fatigued
- difficulty concentrating or “going blank”
- irritability
- muscle tension
- sleep disturbance - Cause impairment
- Not attributable to other cause/disorder
what is GAD associated w/
Depression
- Should be part of depression evaluation
- 50% of those with GAD will convert to major depression (their etiology is strongly linked)
things to ask about w/ GAD
- Constant worry – if yes, about what?
- “What if’s…” or catastrophizing
- Trouble sleeping because worrying
- Physical tenseness, GI symptoms, headaches etc.
- Troubles concentrating, reading, thinking clearly
how do you treat GAD
- therapy if possible
- serotonin agens (SSRI, SNRI)- explain to patients that depression and anxiety are linked and these meds treat both
- Judicious use of benzodiazepines (“-pams”)
- Buspar (buspirone)
how do benzos work
- They act by enhancing the effects of GABA (a substance that slows neuronal transmission and is therefore calming)
- used to tx anxiety, seizures and muscle relaxants
Pluses of benzos
- Can be very effective in treating anxiety, agitation, insomnia, racing thoughts
- Work immediately (no need to wait for SSRI to kick in)
- Can be used prn (unlike SSRI’s)
Negatives of benzos
- . Side effects: sedation, decreased reflexes
- Significant interaction with alcohol (more than additive)
- Possible development of tolerance then addiction
- Increased risk of falls, cognitive decline in elderly
examples of benzos
klonopin (clonazepam)
ativan (lorazepam)
-Start with 0.5 mg, max is 2 mg total a day
characteristics of klonopin (clonazepam)
- Longest half-life so used to cover long period of time (often qd, bid or qhs for sleep)
- Start with 0.5 mg (or even half that), max dose for me is 2mg total a day
characteristics of ativan (lorazepam)
- Short half-life so good for situational anxiety and for shorter periods of time (panic attacks, flying etc.)
- Start with 0.5 mg, max is 2 mg total a day
considerations w/ benzo use
- Possibility for tolerance/addiction (less likely with lower doses and prn use)
- MUST avoid alcohol while benzo in system (compounding effect)
- Caution when first using due to sedation – tell pts to try at home
- Rarely used as monotherapy (exception: flying or very specific situations)
- Avoid Xanax (alprazolam) if possible due to higher risk for addiction
*Education of patient is important to understand safety – some patients are afraid to take and others may start increasing usage
when is buspar (buspirone) commonly used
- tx GAD
- Posited to increase serotonin (by different action than SSRI’s)
- Often used as augmentation for SSRI’s or try if other meds not helpful
*No addictive properties
how do you prescribe buspar (buspirone)
start w/ low dose and increase as tolerated to max 60/day
what are panic attacks
abrupt surge of intense fear or discomfort that reaches a peak within minutes, and during which time four+ symptoms occur:
- palpitations, increased HR
- sensation of SOB or smothering
- sweating
- CP, LH, nausea
- shaking
- fear of dying/losing control/going crazy
- paresthesia
Symptoms of panic attacks
- palpitations, increased HR
- sensation of SOB or smothering
- sweating
- CP, LH, nausea
what is panic disorder
- panic attacks w/ 4+ sx occur
- At least 1 month or more of one or both
- Worry about having another panic attack
- Maladaptive behaviors related to avoiding an attack or its consequences - no trigger– often w/ underlying anxiety or depression
tx of panic disorder
- SSRI’s
- Benzos prn (at first sign of impending attack or, if there are triggers, before the trigger) – best is Ativan 0.5-1 mg
- Rule out other medical conditions (frequently diagnosed in ER for first time)
- Therapy (cognitive behavioral, biofeedback, mindfulness) can help with triggers, relaxation techniques, biofeedback
what is the DSM 5 agoraphobia
A. Marked fear or anxiety for 6+ months (out of proportion to any threat) about 2+:
- Using public transportation
- Being in open spaces (parking lots etc.)
- Being in enclosed places (theaters etc.)
- Being in a crowd/standing in line
B-I: The patient worries about these situations, avoids these situations and (if forced) is extremely fearful and anxious in them. Often, patients avoid leaving their homes.
It was thought that panic disorder often led to __
agoraphobia
agoraphobia treatment
- SSRI’s
- Benzos or beta blockers prn (especially prior to stressful exposure
- Therapy
what is social anxiety disorder
- Fear about social situations in which person is exposed to possible scrutiny (public speaking is most common example)
- Fear of being embarrassed, humiliated or rejected
- Either avoids situations or endures with intense anxiety
- 6+ months
- Out of proportion to the circumstances
social anxiety disorder treatment
- Therapy: relaxation techniques
- Prn Benzodiazepines
- Prn beta-blockers
how can PRN beta-blockers help with social anxiety disorder
- BP meds that block the actions of epinephrine on the heart (decreased sympathetic activity)
- 20-40 mg of inderal (propranolol) about an hour before event (can take more frequently)
- Watch for dizziness, hypotensive symptoms
- Plus is no addiction potential!
characteristics of introvers
- Gain their energy from being alone (become drained from group situations) – need time to recharge
- Form a few deep attachments
- Dislike small talk, cocktail parties
- Think carefully before speaking
- Get agitated and irritated without enough time alone or undisturbed
what effects do phobias have
- Persistent, irrational, exaggerated and pathological fear of a specific situation or stimulus that results in conscious avoidance of the dreaded circumstances
- Active avoidance of trigger or high anxiety related to it
most common single mental disorder
phobia
examples: animals, blood, needles, heights
Obsessive Compulsive and Related Disorders
- Obsessive Compulsive Disorder *
- Body Dysmorphic Disorder *
- Hoarding Disorder
- Trichotillomania
- Excoriation Disorder
*Also have due to substance abuse, medical disorder, other
diagnosis of OCD
Obsessions:
- Recurrent, intrusive thoughts, urges or images that cause marked anxiety or distress
- The person attempts to ignore them or lesson them (often by compulsions)
Compulsions:
- Repetitive behaviors that the person feels driven to perform
- Behaviors are aimed at reducing anxiety or preventing a dreaded situation
common themes of OCD
checking, germs, intrusive worries/thoughts
- Typically the patients knows that what they’re doing seems “crazy” and doesn’t make any sense, but they can’t stop.
- The compulsions may lessen anxiety for a short period of time, but the obsession continues which leads to more compulsions – a vicious cycle. Can completely consume a person’s life
OCD treatment
- Exposure therapy, Cognitive Behavioral Therapy etc.
- SSRI’s (often need much higher doses)
- Atypical antipsychotics
- Be careful with benzos due to risk of overuse
what is body dysmorphic disorder
Preoccupation with perceived defects or flaws in physical appearance
- Often feel deformed by imagined or tiny flaw
- Most common are skin, hair, nose
signs of body dysmorphic disorder
- Performs repetitive behaviors (mirror checking, reassurance seeking etc.) or mental acts (comparing self to others) in response to appearance concerns
- Patients often believe people are looking at them and laughing
- Compulsions common (applying makeup, checking mirrors, reassurance seeking)
w/ BBD, __% seek cosmetic treatment
80%
*NO improvement seen in anxiety
what is BDD associated w/
HIGH rate of suicidality
*Unlike OCD, insight is very poor (they are convinced of reality of defect)
BDD treatment
- Education about diagnosis (often a relief). Avoid reassurances and focus on improving quality of life
- Therapy - CBT designed for BDD
- SSRI’s
- Augmentation with atypical anti-psychotics
- Buspar may be worth trying as augmentation to SSRI
what is a hoarding disorder
- Persistent difficulty parting with items regardless of value
- Perceived need to save items
- Distress when thinking of getting rid of items
- Cluttered, blocked living spaces
- New addition to DSM
tx of hoarding disorder
similar to OCD
- Exposure therapy, Cognitive Behavioral Therapy etc.
- SSRI’s (often need much higher doses)
- Atypical antipsychotics
- Be careful with benzos due to risk of overuse
what is trichotillomania
- Recurrent hair pulling
- Recurrent attempts to stop
- Often starts with eyelashes, brows
- Can be associated with eating hair
tx of trichotillomania
similar to OCD
- Exposure therapy, Cognitive Behavioral Therapy etc.
- SSRI’s (often need much higher doses)
- Atypical antipsychotics
- Be careful with benzos due to risk of overuse
what is excoriation
- recurrent skin picking
- recurrent attempts to stop
*new to DSM5
what is the approximate incidence and demographics of patients with bipolar disorder
- Incidence: about 3% (hard to determine because it occurs on a spectrum)
- Equal in gender and race
- Onset typically in late teens/early twenties (characteristic age of onset)
Risk factors for BPD
- Commonly first onset of episode, will go off to college and then will onset due to stress
- teens-early twenties
- Strong genetic component- concordance in monozygotic twins is 65-80%
- Biggest factor is family history (someone in family history with manic depressive disorder or bipolar)
- you will hear some sort of history that supports maybe a family history of bipolar disorder
Hx/ROS questions to help determine in someone has BPD
- *Key thing is to look for it
1. Anger or depression is the most common presentation
2. hx of depression? (txing but not getting better?)
3. periods of depression + episodes of mania or hypomania (more common)
one disorder that is missed for years and years before caught
BPD
A person can be diagnosed with BPD after how many manic episodes?
after 1 episode (and no depression)
Key questions to ask to patients with depression
- Have you ever had a time where you didn’t need to sleep and didn’t miss it?
- Have you ever had time where you felt really good (“too good”)?
- Do you ever have times where you have extreme irritability or anger?
- If patients answer no to these questions, treat for depression
- If patients answer yes to ANY of these questions, can dive further into other symptoms (ASK ABOUT FAMILY HISTORY)
How do you dx BPD II?
hypomania (DIGFAST)
Distractibility- racing thoughts
Indiscretion/impulse- spending lots of money, sex, high risk activities
Grandiosity- inflated self-esteem
Flight of ideas- topic jumping
Fun-
Sleep-decreased need or ability to
talkativeness-pressure speech (loud, fast)
Irritability- road rage, physically fight
BPD is also associated w/
- ADHD
- high rates of comorbidity
- substance abuse
- anxiety
- depression
how can you differentiate between ADHD and BPD?
- look for the up and down of the bipolar
- If you treat for ADHD when they truly have BPD, their mania will get worse
- If they have both, treat mood disorder first (BPD) then ADHD
how do you dx BPD I?
Mania– more severe
- also DIGFAST but more severe (ex. severe flight of ideas)
- Other psychotic features
- Hallucinations: sensations that seem real, but are not (auditory most common)
- Delusions: false beliefs (ex. Person believes government has listening devices implanted in his dental fillings) - Thinking and speech may become disorganized
*often require hospitalization bc they are not functioning (not suicidal)
what are hallucinations?
-Sensations that seem real, but are not (auditory most common)
- Anything with the senses (most common is hearing voices, patient is actually hearing the voice like if someone were talking to them)
- Can be seeing things that aren’t there
- Can have sensation of smell
- Can have sensation of touch
what are delusions?
-false beliefs (ex. Person believes government has listening devices implanted in his dental fillings)
- Ex. Person on TV directly talking to me
- Ex. Someone is reading my thoughts
Additional qualifiers for both BPD1 and BPD2
- Rapid cycling: distinct periods of mania/depression occurring at least 4 times a year
- Mixed features: a “confusing mixture of mood, thought and behavioral symptoms that appear to be out of synch with one another”
what do you do if you think BPD is unlikely but possible?
tx for depression (w/ SSRI) and warn about hypomania sx
how do you tx BPD?
- mood stabilizer
ex. lithium, Depakote, Lamictal, carbamazepine, Atypical antipsychotics - Refer
other tx considerations for BPD
- Adequate sleep is essential in treating BPD and preventing relapse
- Regular routine (sleep, meals, exercise) etc. are important. -Often patients with BPD are very sensitive to changes in routine
- Extremely rare to use only 1 medication to treat BPD
- Typical 1-2 mood stabilizers, possibly an antidepressant, benzo and/or sleep medication
- Ideally, change 1 medication at a time to see the effect (doesn’t include sleep medication)
- Involving family members can be helpful to get a sense of the patient’s behavior, mood swings, etc.
why is BPD often treated w/ multiple meds?
- Typical 1-2 mood stabilizers, possibly an antidepressant, benzo and/or sleep medication
- Medications are limited in what they can do, so will use multiple drugs to get better results and cover more of the symptoms
- Pretty typical to see patient with BPD on like 5 medications
- Ideally, change 1 medication at a time to see the effect (doesn’t include sleep medication)
why is sleep so crucial for BPD
Disruption in sleep can cause manic episode, so having enough sleep is very important (ex. Flying/traveling, black Friday)
Starting dosage of Lithium and when the patient should take it
- 300mg every PM w/ FOOD
- increase 300mg every week up to 900mg a day
Starting dosage of Depakote and when the patient should take it
250mg every PM
- increase by 250mg up to weight x 10, usual dose 250-1000mg)
- won’t work at higher doses if it doesn’t work at 1000mg
common risks and SE of Lithium
- side effects: nausea, increased thirst, mild tremor
- Can effect thyroid, kidneys (so monitoring needed every 6-12 months or if symptoms occur)
- Caution in patients with renal disease
- Caution if patient is taking diuretics, NSAIDs, or anything that increases risk of dehydration (illness, physical activity, spending time in the sun, etc)
- narrow TI– requires blood monitoring in doses
benefits of Lithium
- neuroprotective
- protective against suicide in BP patients
- CHEAP
controvesry/stigma around Lithium
- traditionally used in higher doses= more SE
2. its been around for a while and used to tx everything (schizophrenia and dementia)
Common risks and side effects of Depakote
- Increased depression, PCOS, hair loss, weight gain
- preg. Category X so not a first choice in young women, would need to be on BC medication)
- Use in caution with hepatic disease –monitor LFT’s annually or if symptoms occur)
Depakote is also used to tx
- seizures (anti-convulsant)
- migraine prophylaxis
common risks associated with using carbamazepine
- Slight increase in aplastic anemia
- Slight risk of Stevens-Johnson syndrome *MUCH higher in Asians so genetic screen needed before treatment)
- Numerous drug-drug interactions
- CAN’T BE USED IN PREGNANCY
why does Lamotrigine/lamictal need to be tirated up VERY slowly?
- Need to follow strict rules in prescribing and follow-up due to risk of Stevens-Johnson syndrome (approx. 1 in 1000)
- can be very effective med
lamotrigine/lamictal is used to treat what
depression in BPD primarily
*would not work for someone who is manic
what is stevens-johnson syndrome
- Can occur with ANY medication
- First sign is often rash or blisters involving mucous membranes
- May also have systemic symptoms like fever, swollen lymph nodes
- Can develop into severe skin reaction which requires hospitalization and treatment in burn unit
*often seen w/ lamotigine/lamictal
what should you tell a pt starting lamotigine/lamictal regarding stevens johnson syndrome
- About 10% of people get a faint red rash with Lamictal. That is okay and tends to go away. Don’t increase dose until it’s gone.
- Any progressive rash, involvement of mucous membranes or systemic symptoms, stop medication and seek treatment immediately
side effects of lamotigine/lamictol
- no weight gain or sexual SE
- occasional HA
- GI upset
- stevens johnson syndrome
atypical antipsychotics are most commonly used for
- schzophrenia (high doses)
- BPD (medium doses)
- depression, anxiety, OCD (low doses)
- Can be very effective for mood and anxiety disorders, so don’t be afraid to use, but try AD’s first
- Act on numerous receptors in brain, which have effects on all 3 main NTs, GABA, histamine, etc.
what is the most and least sedating atypical antipsychotics?
most: Zyprexa
least: Abilify
SE of atypical antipsychotics
- All can potentially cause metabolic issues (weight, glucose, cholesterol)
- akathisia (inner restlessness, need to move)–esp. Abilify
- slight risk of tardive dyskinesia (involuntary, repetitive movements, often of mouth, jaw, etc)
- RARE Others: parkinsonism, dystonia, neuroleptic malignant syndrome (flu-like presentation)
do atypical antipsychotics or “typical” antipsychotics have more SE?
typical
when would you use Zyprexa (Olanzapine)
- very fast and effective with mania depression, anxiety, insomnia
- excellent for acute tx but not feasible long term w/ most patients
SE of Zyprexa (Olanzapine)
sedation
metabolic (weight gain)
when would you use Abilify (Ariprprazole)
- Often works well for depression, BPD etc.
2. Fewer metabolic side effects so can be good for long term use
SE of Abilify (Ariprprazole)
-SE: akathisia; can be too “activating” or increase anxiety; can take time to titrate to effective dose
what is the incidence and common characteristics of people who develop schizophrenia
- 1% of population
- M=F, but males have eariler onset
- partial genetic component
- associated w/ advance PATERNAL age
risk factors for schizophrenia
- genetics
- advanced paternal age
- birth Dec.-May (in N. hemisphere)—possible viral link
- possible stress trigger (w/ genetic component)
- Often begins in late adolescent/early adulthood; may have “prodromal syndrome” which begins earlier (childhood schizo is rare)
- “dopamine hypothesis”– either too much or too little in parts of brain
what are the 3 categories of sx in schizo.
- positive- hallucinations and delusions
- negative- blunting
- disorganized
describe hallucinations that can occur w/ schizo.
- Most common are auditory (voices, sounds, things)
- Hallucinations can be good or bad
- Visual, tactile, olfactory, gustatory are often indicative of medical issues or substance-related psychosis
- If tactile or olfactory, want to look too see if there is an underlying cause
describe delusions that can occur w/ schizo.
- False ideas based on incorrect perceptions of reality; not culturally accepted
- Common types are reference, persecution, grandeur, mind-reading, thought broadcasting, thought control
- Big concern is a delusion combined with “command hallucination” – where voice(s) are instructing the person to do something. Biggest risk of harm to others
- Telling someone to do something bad with a delusion
-Psychotic and command hallucination to tell me to hurt my children, that would cause a lot of conflict in me, but I know I am the type of person and mother to not do that HOWEVER, if I have a delusion WITH the command hallucination that the devil has taken over my children and the only way to set them free is to kill them, would believe this and do it
describe negative sx that occur w/ schizo
- Blunting of emotions: appear unemotional even while talking about emotionally charged issues
- Flat affect: blank expression, “robotic”- Not seeming engaged
- Lack of initiative, apathetic- Sitting in their parents house, doesn’t want to leave, do anything
- Often does not get better with medication
- A lot of these patients end up losing their social support because of these negative symptoms
described the disorganized sx seen w/ schizo.
- Loose associations
- Word salad- Someone is talking and using real words, but doesn’t make sense
- Neologisms (made up words)
- Thought blocking (getting stuck)
- Catatonia (strange postures- Get into weird positions like sculptures and hold that position
- Echolalia- Repeating back what people say to them
- Bizarre behavior often related to delusions/hallucinations (Stereotype- ex. Homeless, out on the street yelling, carrying on)
- Hard to follow what these patients are talking about
tx options for schizo
- antipsychotic (higher doses)
- referral to community mental health center (which has prescribers, therapists, groups, help with jobs/functioning etc.)
- support groups for pt. and/or caregivers
describe the prognosis of shizo.
- Prognosis is typically poor compared to other mental health conditions
- Unusual that someone gets back to baseline level of functioning
- Tends to be very debilitating disease
why is there such a high suicide rate w/ schizo?
- Especially when person is first diagnosed
- Going along fine, and then whole life changes
- Those that start of high functioning, higher risk because it is a higher shift for them
describe psychotic depression
- Depression with psychotic features with it
- Often auditory hallucinations
- When you treat this, hallucinations get better
describe Schizophreniform disorder
- Duration 1-6 months and my be able to still function
2. Like a precursor to schizophrenia
describe Schizoaffective disorder
- The presence of a mood disorder and schizophrenia (look for psychotic symptoms when mood issues NOT present to differentiate from mania or psychotic depression)
- Schizophrenia + Depression for ex.
- Sometimes hard to differentiate mania vs schizophrenia:
- Psychotic symptoms with schizophrenia, doesn’t have that up and down like it does in just BPD
- Since we treat everything similarly, sometimes hard to differentiate this
describe delusional disorder
- A delusion of a least 1 month; absence of other schizophrenia symptoms
- Ex. Delusion that there is a chip in my brain and listening to my thoughts, but everything else in my life is normal (no other symptoms) - Most people can function better as just delusional disorder vs. schizophrenia
describe brief psychotic disorder
- Symptoms last 1-30 days but then person returns to complete normal functioning (usually in the context of a severe stressor)
- Has psychotic episode and then revert back to normal
Ex. Someone came to the door and told them their father died- patient developed psychotic symptoms (patient may not even remember it)
what is substance/medication-induced psychotic disorder
-Typically it is when they are on the medication or substance and are fine when they are off of it
