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Applied Behavioral Medicine > Insomina, Sucide, and Ped Anxiety and Depression > Flashcards

Insomina, Sucide, and Ped Anxiety and Depression Flashcards

1
Q

What are the hypnotic drugs and their MOA

A

Ambien, Luensta, Sonata,

MOA: selective GABA stimulator

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2
Q

What are the Benzodiazepines that treat insomnia and their MOA

A

Restoril, Klonopin (long acting), Ativan (short acting)

MOA: Stimulate GABA receptor
*not as selective for sleep

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3
Q

What category of drug and MOA is Trazadone

A

Antidepressant

MOA: SSRI

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4
Q

What category of drug and MOA is Remeron

A

Antidepressant

MOA: SNRI

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5
Q

What category of drug and MOA is Seroquel

A

Atypical antipsychotic

antihistaminergic

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6
Q

What is the MOA of Rozerem

A

Melatonin receptor agonist– stimulates the release of melatonin
-Involved in circadian rhythm

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7
Q

What is the MOA of Belsomra

A

Orexin receptor antagonist – blocks orexin which promotes “wakefulness”

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8
Q

what insomina meds come in tablets that can easily be split?

A

Ambien, Lunesta, Trazaone,

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9
Q

What is the best use for Ambien and Ambien CR

A

Ambien: falling asleep (and often adequate for staying asleep 6-8 hrs)

  • Be able to get 8ish hrs of sleep or still in the system
    2. Works quickly (take when you are about to get in bed bc if you stay up if might experience side effects)

Ambien CR: Falling AND staying asleep longer (2nd burst after about 4 hrs)
-best if pt wakes too early w/ regular ambien

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10
Q

What is the best use for Lunesta

A

Falling AND staying asleep

*similar to Ambien

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11
Q

What is the best use for Sonata

A
  1. Falling asleep (very short half-life so NO help w/ STAYING asleep)
  2. good for PRN use (if person wakes during night some of the time)
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12
Q

What is the best use for Restoril

A
  1. STAYING asleep

2. Can be good if anxiety is a significant component

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13
Q

What is the best use for Klonopin and Ativan

A
  1. Insomina related to anxiety

2. High anxiety upon wakening–> Klonapin

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14
Q

What is the best use for Trazadone

A
  1. Alternative to hypnotics and benzos
  2. Can help SOME pts w/ sleep
  3. Good alternative for someone w/ hx of addiction bc there is NO risk of tolerance/dependence
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15
Q

What is the best use for Remeron

A
  1. Alternative to hypnotics and benzos

2. Good alternative for someone w/ hx of addiction bc there is NO risk of tolerance/dependence

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16
Q

What is the best use for Seroquel

A
  1. Very good for sleep at LOW doses (not mood stabilizing dose)
  2. Often works when other don’t
  3. Good alternative for someone w/ hx of addiction bc there is NO risk of tolerance/dependence
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17
Q

What is the best use for Rozerem

A

Effects very different from other sleep meds. Often not effective

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18
Q

What is the best use for Belsomra

A

-haven’t seen much clinical benefit despite heavy marketing

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19
Q

Negatives of Ambien and Ambien CR

A
  1. Can be in your system for 8 hrs
  2. Memory loss
  3. Slight risk of bizarre behavior (driving, sleeping walking, sleep eating)
  4. habit forming??

Ambien CR: TOO long acting and above SE

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20
Q

Negatives of Lunesta

A
  1. bad taste in mouth- metallicy

2. habit forming??

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21
Q

Negatives of Sonata

A
  1. habit forming?
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22
Q

Negatives of Restoril

A
  1. NOT as good for FALLING asleep
  2. Must avoid ETOH
  3. Watch for morning sedation**
  4. Potential for tolerance/addiction
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23
Q

Negatives of Klonopin, Ativan

A
  1. NOT as effective for sleep as the hypnotics
  2. Must avoid ETOH
  3. Potential for tolerance/addiction
  4. Any of the usual benzo side effects
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24
Q

Negatives of Trazadone

A
  1. Not as efficacious
  2. Can cause daytime sedation
  3. Priapism a rare but serious side effect (erection that won’t go away)*
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25
Q

Negatives of Remeron

A
  1. Sedation

2. weight gain**

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26
Q

Negatives of Seroquel

A
  1. Weight gain

2. metabolic issues

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27
Q

Negatives of Rozerem

A
  1. Not a controlled substance

2. Often not effective

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28
Q

Negatives of Belsomra

A
  1. Next day sedation**
  2. VERY expensive $10/pill
  3. Clinically haven’t seen much benefit– be careful of overmarketing of the newest thing
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29
Q

What insomnia meds can cause weight gain

A
  1. Remeron

2. Seroquel

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30
Q

What meds are best for FALLING asleep ONLY

A
  1. Sonata
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31
Q

What meds are best for falling AND staying alseep

A
  1. Ambien and Ambien CR

2. Lunesta

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32
Q

What is a longterm strategy for addressing insomnia

A

Educate on good sleep hygiene

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33
Q

describe the rate of depression in kids

A
  • 2% in young kids (ages 5-12)
  • 20% “lifetime” in teens

-4-8% point prevalence (similar to asthma – which is #1 chronic condition pediatricians see)

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34
Q

how do you diagnose depression in pediatrics

A
  1. 50% sad or anhedonic x 2 weeks +
  2. SIGECAPS
  3. Often G(uilt) is manifested as low self-worth/self-esteem
  4. E(nergy): lower motivation and lower physical energy
  5. Appetite – adolescents usually eat more, severe depression can cause decreased appetite
  6. P(sychomotor Retardation): “checked out”
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35
Q

What are major complaints in peds for depression?

A

**in kids, the chief complaint is NOT sadness, anhedonia.
Usually parents complain about irritability, mood swings

Somatic complaints very common, often midline (head, stomach etc.)

36
Q

How does depression in peds effect development

A
  1. Decreased school performance (grades, ability to go to college etc.)
  2. School; socialization interrupted (lack of friends which is important in peds/adolescence)*
    Isolation
  3. Eroded family relationships (parents have trouble liking their kid)
  4. Increased physical medical costs (50%)
37
Q

Causes of pediatric depression

A
  1. loss
  2. family strife
  3. friend strife
  4. bullying
  5. genetics

Heritability: identical twins study
Depression = 45% (similar to hypertension, cholesterol); more heritable than Type 2 Diabetes
**helpful to tell patients this (genetics versus moral failing!)

38
Q

what is the treatment for pediatric depresssion

A
  1. CBT- ideal
  2. SSRI (use Cymbalta over Effexor due to d/c syndrome)

Alternatives (smaller effect size)

  1. Omega 3
  2. SAME-e, can induce mania
  3. Light therapy (good data) – as good as meds, 30 mins every morning; problem is compliance, but good alternative if don’t want meds
  4. Exercise
  5. 80% use religion/spirituality to help get better
39
Q

describe CBT for pediatric depression

A
  1. Works on fixing cognitive distortion and associated behaviors
  2. High functioning people do it automatically (ex: using cortex to calm self about being stressed on exam)
  3. “Cognitive Distortion” – a lie you tell yourself; don’t treat it by reassurance – train person how to cope with it
  4. Short term 12-16 weeks is ideal – heavily supported by the data; “should be treated just like a drug” – change if they’re not getting better
  5. Not just “friend” therapy

**Behavior actually seems to be more important than the cognitive (perhaps because anxiety is more associated with midbrain)

40
Q

___ controls thinking/reasoning

___ learns through experience (behavioral changes)

A

Cortex

Midbrain:

41
Q

describe the use of SSRIs for depression in peds

A

-Effect size = 0.6
-60% of patients will get better by 50% on first SSRI
Black box Warning: 1-2% increase in SI in kids

*use Cymbalta over Effexor due to d/c syndrome (Dr. Morley feels it is very hard to get off of); has approval down to age 7 (unlike Pristiq)

42
Q

According to the TADS study what did they conclude is the best tx of adolescent depression?

A

combo therapy (CBT + Prozac) more effective all the way through (age 12-17)

43
Q

what is the Black Box Warning for SSRI in Peds

A 
Warns of increased suicidality with SSRI’s
2200 kids
SI was 4% versus 2% in placebo
NO suicides
**used Paxil

Post Black Box:
22% fewer RX’s for SSRI’s
14% rise in deaths = 147 deaths

44
Q

*cutting is ____, not ___ behavior

A

emotional regulation

NOT suicidal behavior

45
Q

describe the tx algorithm for peds depression

A
  1. Start Prozac, Zoloft or Lexapro (best data) and/or CBT
  2. No response – try change to 2nd SSRI (50% respond)
  3. Use Cymbalta
  4. No response – add lithium low dose (sensitizes brain to serotonin)
  5. No response – add atypical (Abilify)
  • *underdosing = huge PCP mistake
  • *if insomnia, efficacy of Prozac drops from 66% to 39%
46
Q

what is the biggest problem PCPs make what treating peds depression and anxiety

A

underdosing

47
Q

what is the prevalence of pediatric anxiety

A

10-20% (more common in little kids than depression)

48
Q

Negative consequences of ped. anxiety

A
  1. Isolation
  2. Poor school performance or avoidance
  3. Poor self-image
  4. 75% of his pts would trade for toothache
49
Q

core sx of ped. anxiety

A
  1. ***Irritability, anger (symptom of many disorders in kids)
  2. *Worry
  3. Separation symptoms (when young) – clingy to parent
  4. Isolation
  5. Procrastination (perfectionism) – may lead to poor school performance
  6. School refusal
  7. Somatic (“always in the middle” – headache, chest pain, GI)
50
Q

what does OCD look like in peds

A
  1. Kids have rituals (usually without an obsession) – irresistible urge but don’t necessarily have a reason why – “Because I have to”
  2. Evening out (ex: tapping equally on both sides); counting; rituals
  3. **key is whether or not it’s affecting their life
  4. Intrusive Thoughts
51
Q

describe intrusive thoughts in ped OCD

A
  1. often whatever is most tortuous to them – ex: molesting kids – “ego-dystonic”, shaming, beat self up about it – patient is VERY disturbed by having these thoughts
  2. Common are killing someone, going to do something inappropriate sexually
  3. If OCD, totally safe (they won’t do it), but VERY scary
  4. unrealistic
52
Q

describe panic in peds

A
  • sense of impending doom (may help differentiate from other physical issues)
  • Real damage is when it starts to limit their world due to avoidance
53
Q

what is panic homeostasis

A

: PA’s self-limiting because Parasympathetic Nervous System kicks in
Exposure and response prevention helps with this

54
Q

The CAMS study concluded the best way to tx childhood anxiety is

A

Combo of CBT and Zoloft is best (drugs better than therapy)

age 12-17

55
Q

describe the tx algorithm for pediatric anxiety

A

*Need to ask about depression due to overlap, may be more socially acceptable to complain of being stressed versus sad
**need higher doses for anxiety, esp. OCD
Big mistake of PCP’s is underdosing (risks happen at low doses anyway so might as well be therapeutic)

  1. SSRI – Prozac, Zoloft, Lexapro and/or CBT (80% with dep have comorbid anxiety)
  2. If no response, try 2nd SSRI
  3. If no response, add low dose lithium (increases sensitivity to SE)
  4. If no response, add atypical
  5. Consider Cymbalta over 13

Others (rare): Strattera, Intuniva, Wellbutrin

56
Q

why are Benzos not used in kids for anxiety

A

possible disinhibition and/or dependency

57
Q

How long do you treat for pediatric anxiety

A
  1. 9 mos after remission

2. Take kids off to see how they do because they may not need it anymore (risk of 2nd depression is 50%)

58
Q

How does the presentation of pediatric OCD differ from adult OCD

A
  1. Kids may not always realise that their thoughts, worries or behaviours are excessive. For example, while an OCD affected adult may recognize that stopping a superstitious ritual is desirable, an OCD-affected child may view the ritual as a literally protective act (e.g., a child who doesn’t want to stop being afraid of germs or to stop repetitively washing, compared with an adult who desperately wants to be able to stop and to lose the worries)
  2. Religious and somatic (body or health-related) symptoms appear to be more common in child versus adolescent or adult groups and ordering and hoarding symptoms more common in child/adolescent versus adult groups
59
Q

How does the presentation of pediatric depression and anxiety differ from adults?

A
  1. Somatic complaints (often midline: headache, stomach)
  2. CC is mood swings or irritability NOT sadness or anhedonia
  3. Kids more more likely to attempt suicide and FAIL and adults are more likely to succeed at sucide
60
Q

Does the law expect practitioners to predict and prevent suicides?

A

NO– practitioners are expected to perform competent assessments, including identifying risk factors and protective factors, and take reasonable precautions if needed

61
Q

describe the progression of suicide

A

*Some steps may be skipped

  1. Ideation: 8 million people annually
  2. Plan: 2.5 million
  3. Rehearsal
  4. Attempt: 1 million
  5. Successful Suicides: 33,000
62
Q

How should you make asking about suicide part of depression assessment

A
  1. Normalize Questions
  2. Assess Ideation
  3. Assess Plan
  4. Assess for Lethality
  5. Assess for other Risk Factors
  6. Assess for Protective Factors
63
Q

how can you normalize asking about suicide?

A
  1. Create rapport (esp if new patient)

“Sometimes when people are depressed, they have thoughts of killing themselves so I ask all my depressed patients these questions.”

64
Q

how do you assess for ideation of suicide

A
  1. Do you ever wish you were dead? (this can get around religious issues)
  2. Have you ever had thoughts about killing yourself?
  3. When did you last have thoughts about killing yourself?
65
Q

how do you assess for a plan for suicide

A
  1. Have you thought about how you would do it?
  2. How close have you come to doing it?
  3. Are you planning to kill yourself?
  4. How are you planning to kill yourself?
  5. What OTHER plans do you have?
66
Q

How can you assess for lethality

A
  1. Do you have firearms or other weapons in your home?
  2. Do you have access to them elsewhere?
    - Also ask about pills, other weapons

*If yes, this must be addressed prior to the patient returning home and verified independently (by family member for instance)

67
Q

Risk factors for Suicide

A
  1. ***Previous attempt is biggest risk factor (39 times more likely to die if there was a previous attempt)
  2. **Access to firearms
  3. Depression plus anxiety/agitation, panic attacks, insomnia, substance abuse
  4. Personality disorders (in particular borderline, antisocial) – “Angry impulsivity”
  5. Physical illness (ex: chronic pain, terminal illness)
  6. 1st degree relatives who have suicided
  7. Recent loss: relationship, job
68
Q

Someone with a previous attempt of suicide is ___ times more likely to die if there was a previous attempt

A

39

69
Q

Identify a patient’s protective factors related to suicide

A
  1. # 1 is having children under 18 living in the same home
  2. Religion
  3. Family support or other support structures
  4. Therapeutic relationship
70
Q

describe what YOUR plan of action would be if someone is suicidal

A
  1. Hospitalize if necessary
  2. Remove threats (guns, pills etc.)
  3. Involve family, friends to help with removing threats, monitoring patients, ensuring they receive care (balance with confidentiality)
  4. Change/start medications
  5. Engage current therapist or get patient set up with therapist
  6. Close follow-up
71
Q

__ of inpatients who killed themselves denied suicidal ideation

A

2/3

1/3 had a contract

72
Q

Explain the inherent conflict in a provider-patient relationship if a patient is suicidal and strategies to manage it

A
  1. 2/3 of inpatients who killed themselves denied suicidal ideation– 1/3 had a contract
    “If a patient is willing to lose everything why should they give a damn about you after only meeting you an hour ago!”
    What can a provider do if the patient is not going to be honest?
73
Q

Suicidal ideation is very common in __ patients and needs to be explored but doesn’t mean they will act on it

A

depressed

74
Q

Does asking about suicide increase the likelihood of an attempt?

A

NO

*Asking someone directly about suicidal intent lowers anxiety, opens up communication
and lowers the risk of an impulsive act

75
Q

additional tips for suicide assessment

A
  1. Therapeutic alliance important
  2. Involving family and friends may be necessary (balance with confidentiality).
  3. Often getting family or friends to monitor patient until medications start to work is effective
  4. Hospitalization is an option (patient should not drive themselves)
76
Q

What can a provider do if the patient is not going to be honest about suicide

A
  1. Look at their behavior (ie. agitation)
  2. Look at other risk factors
  3. Are they withdrawing from friends?
  4. In room 20 hrs a day?
  5. Ask for feedback from family or support group
  6. Look at OBJECTIVE data!
77
Q

why should we talk about suicide

A

bc talking about it can prevent it

78
Q

who is most at risk for sucide?

A
  1. Rate for men is 4x the rate for women
  2. Women make twice as many suicide attempts than men
  3. Most suicides are COMPLETED by men aged 24-65
  4. Highest rate is men over age 70
  5. LGBT have higher rates of attempts and deaths
  6. American Indian/Whites have the highest rates
  7. Hispanic, Black and Asian rates are lowest
79
Q

Direct verbal clues for suicide

A
  1. “I’ve decided to kill myself ”
  2. “I wish I were dead”
  3. “I’m going to commit suicide”
  4. “I’m going to end it all”
  5. If (such and such) doesn’t happen, I’ll kill myself ”
80
Q

Indirect verbal clues for suicde

A
  1. “I’m tired of life, I just can’t go on”
  2. “My family would be better off without me”
  3. “Who cares if I’m dead anyway”
  4. “I just want out”
  5. “I won’t be around much longer”
  6. Pretty soon you won’t have to worry about me”
81
Q

behavorial clues for suicide

A
  1. Any previous suicide attempt
  2. Acquiring a gun or stockpiling pills
  3. Co-occurring depression, moodiness, hopelessness
  4. Putting personal affairs in order
  5. Giving away prized possessions
  6. Sudden interest or disinterest in religion
  7. Drug or alcohol abuse, or relapse
  8. Unexplained anger aggression and irritability
82
Q

Situational clues for suicide

A
  1. Being fired or being expelled from school
  2. A recent unwanted move
  3. Loss of any major relationship
  4. Death of a spouse, child, or best friend, especially if by suicide
  5. Diagnosis of a serious or terminal illness
  6. Sudden unexpected loss of freedom/fear of punishment
  7. Anticipated loss of financial security
  8. Loss of a cherished therapist, counselor or teacher
  9. Fear of becoming a burden to others
83
Q

Less direct approach when asking about suicide

A

“Have you been unhappy lately?
Have you been very unhappy lately?
Have you been so very unhappy lately that you’ve been thinking about ending your life?”
• “Do you ever wish you could go to sleep and never wake up?”

84
Q

direct approach when asking about suicide

A

“You know, when people are as upset as you seem
to be, they sometimes wish they were dead. I’m wondering if you’re feeling that way, too?”
• “You look pretty miserable, I wonder if you’re thinking about suicide?”
• “Are you thinking about killing yourself?”

85
Q

Tips for asking the suicide question

A
  • If in doubt, don’t wait, ask the question
    • If the person is reluctant, be persistent
    • Talk to the person alone in a private setting
    • Allow the person to talk freely
  • give yourself plenty of times
    -have resources handy: QPR card, phone numbers, counselors/therapist names, other info
86
Q

How to persuade someone to stay alive

A

Listen to the problem and give them your full attention
• Remember, suicide is not the problem, only the solution to a perceived insoluble problem
• Do not rush to judgment
• Offer hope in any form

Then..
Offer to help

*your willingness to listen and to help can rekindle hope, and make all the difference

87
Q

Suicidal people often believe they cannot be helped, so you may have to do more than just refer someone

A
  1. Take the person directly to someone who can help
  2. Get a commitment from them to accept help, then make arrangements to that help
  3. Give referral information and try to get a good faith commitment not to complete or attempt suicide

*Any willingness to accept help at some time, even if in the future, is a good outcome

Applied Behavioral Medicine (6 decks)

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