Mental Health Flashcards by katie gazda

Antipsychotic meds-how to screen for and manage side effects, complications, and sequela

Meds for Anxiety: continue for 6-12mos after resolution of sx. May take 6 weeks w/ titration for effect

Typical and Atypical antipsychotics-Tardive dyskinesia- AIMS tool to screen

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Sense of risk or harm, disturbing thoughts and images
RF: Strong familial and genetic pattern, Subgroup will have tourettes
Repetitive behaviors high level of discomfort if unable to complete behavior

OCD

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Tx for OCD in kids

CBT first line, Pharm SSRI-safest

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Screen by identifying TRAUMA symptoms:
Trauma-know traumatic experience
Re-experience- includes flashbacks and nightmares
Avoidance- avoid stimuli associated with the event
Unable to function
Month or longer
Arousal-hypervigilant, sleep disturbances, concentration difficulties, or exaggerated startle response

PTSD

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TX for PTSD

Psychotherapy is core for PTSD w/trauma-focused CBT, EDMR. B-blocker-propranolol could be used for somatic symptoms-not well studied in children.
BPD

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What potential concerns to screen for with anti psych meds?

ESP/ TD, sedation . blurred vision, dizziness, urinary retention, confusion, hallucinations, tachycardia, dry mouth, prolonged QT, gynecomastia, galactorrhea, increased or decreased prolactin level

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What potential concerns to screen for with SSRI meds?

can exacerbate depression, suicidality, dry mouth, sexual dysfunction, headache, night sweats, fatigue, weight gain

Lexapro, zoloft, prozac. BBW in kids (SI)

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What potential concerns to screen for with Benzos?

controlled medication- risk for addiction, tolerance/ dependence, withdrawal if abruptly d/c, short term- use as needed (sparingly), CSA, PMP review, resp depression

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How to screen for tardive dyskinesia ( facial tics like lip-smacking, tongue thrusting and rapid blinking)

AIMES scale - usually caused as side effect of antipsychotic med (ex. Olanzapine)

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What to do if AIMS screening is positive?

notify the pts mental health specialist and discuss/ send copy of AIMS evaluation

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not recommended for bipolar disorder; avoid in OSA

Benzos

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Extreme irritability- aggressive outbursts

Violent behavior

Borderline personality disorder

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Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms and rules are violated
Onset Toddlerhood… diagnosed from 4 to 6 years old, and a formal diagnosis is typically made when the child is 7 years old or older.
frequently associated with a history of harsh discipline, abuse, or neglect.
Most commonly, referrals for clinical treatment are for aggressive behavior patterns

Conduct Disorder

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pattern of problems with rules and authority figures. ODD symptoms emerge during the preschool years and persist for a minimum of 6 months
Usually dx at school age
Most commonly, referrals for clinical treatment are for aggressive behavior patterns

Oppositional Defiant Disorder

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diagnosed >4yo, inattention, hyperactivity, impulsivity inappropriate for developmental age should exist in at least 2 settings, ADD: attention issues more common adulthood (less hyperactive), poor work performance, failed relationships, frequent MVC,

ADHD

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Dx and screenings for ADHD

Diagnostics: BP, EKG not necessary
Screening: Vanderbilt ADHD Scales, ADHD rating scale, obtain from two domains (home/school)

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Tx for ADHD

Behavior management alone if <6yo; over age 6 combine behavioral therapy with meds
Amphetamines: ex. Vyvanse 70mg/day; others 0.3-1.0 mg/kg/day
Methylphenidate (ritalin): less emotional lability
Alpha agonist: clonidine
Strattera
School accommodations may be needed (Section 504 service plan)- requires 60-day evaluation in most states

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difficulty with social communication and restricted, repetitive patterns of behavior, interest, or activities.

Persistent deficits in social communication and social interaction across multiple contexts
restricted , repetitive patterns of behavior, interests, or activities
Intellectual disability or global developmental delay
School age-inability to build friendships, difficulty transitioning, isolation
Adolescence- rote learning

ASD

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Screenings for ASD

MCHAT-under 2,
CAST -over age of 3

validated screening tool at 18 and 24 months of age for early identification
Routine developmental screening is suggested at nine-, 18-, and 24- or 30-month well-child visits

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Dx for ASD

Comprehensive assessment by interdisciplinary team or child psychologist, developmental pediatrician
Dx confirm with DSM-5 for ASD

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Tx for ASD

Early intensive behavioral intervention- 25 hours per week recommended for preschool to early school aged children with ASD
Cognitive behavior therapy- decreases anxiety symptoms in older children with ASD who has average to above average ASD

Aripiprazole (Abilify) and risperidone (Risperdal)- approved for ASD-associated irritability, explosive outburst, aggression, and self injury
aripiprazole - children 6-17 yrs
risperidone - children 5-16 years
s/e: weight gain, tremor, sedation, and extrapyramidal symptoms
Melatonin- insomnia
Ritalin- ADHD

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mood instability irritable, chronic sleep problems, risky behaviors, racing thoughts, talk fast, psychotic symptoms, Hallmark: don’t feel like they need to sleep and feel rested after 1-2 hours

Bipolar Type 1

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hypomania (depression followed by periods of feeling well and emotionally healthy) and major depression

Bipolar Type 2

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Dx for Bipolar

CBC, CMP, Lipid panel, TFT, urine drug screen, mood disorder questionnaire (MDQ), patient health questionnaire PHQ, Columbia suicide severity rating scale

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Tx for Bipolar

Lithium carbonate, valproate (depakote), carbamazepine/oxcarbazepine, lamotrigine, Atypical antipsychotic ex. Abilify, zyprexa, risperdal, seroquel, geodon SE: hyperlipidemia, wt gain, EPS, nipple discharge Psychotherapy Partial hospitalization program/intensive outpatient program ECT Abstaining from caffeine, alcohol, and illicit drugs 12-step programs as appropriate Encourage structure Exercise, social interaction Stable living environment Refer to psychologist for maximized tx

restriction of food intake resulting in low body weight, intense fear of gaining weight or becoming fat, and disturbance of body image Restrictive type Binge eating/purging type Define: loss of control and the feelings of guilt, shame, and embarrassment Overweight or obese Highest mortality rate of any mental health disorder

Anorexia

uncontrolled eating of an abnormally large amount of food in a short period, followed by compensatory behaviors such as self induced vomiting, laxative abuse, or excessive exercise

Bulimia

Dx criteria for anorexia

- Refusal to maintain bodyweight at or above minimally normal weight for height/age (less than 85th percentile). Or failure to gain weight during growth periods so that weight drops below 85% - intense fear of "being fat" - body dysmorphia - binge eating/ purging subtype

Dx criteria for bulimia

- consuming large quantities of food in a short period of time (w/in 2 hours) - loss of control during binge episodes - engaging in repeated behavior to lose weight, including purging, excessive exercise or fasting - binging or purging behaviors that occur at least once a week for at least 3 min

what should eval include for eating disorder

thorough H&P | Assess cormobidities

Dx for eating disorder

TSH, CBC, CMP, FBS, FSH (amenorrhea), U/A, ECG, possible bone density

eating disorder differentials

IBS, PUD< hyperthyroidism, CNS lesions, hormonal and metabolic diseases, immune disorders, OCD, SUD, Major depression

How to do refeeding plan for pts with an eating disorder

1.1 pounds (0.5 kg) per week goal

the primary role of PCP in eating disorder

Screening and early ID- EAT 26

Sequelae and co-morbids for eating disorder

``` death= arrhythmias, hypokalemia alcohol/ drug addictions osteoporosis - get DEXA scan GI disturbances Gynecological/ fertility probs ```

Pharm tx for OCD

SSRI and SNRI first line

1st line RX for PTSD

SSRI or SNRI Long term SE: weight gain and sexual dysfunction Benzos shortest length of time possible; caution in elderly. CI current or previous substance abuse Can cause rebound insomnia

Onset 16-30 years old; men earlier than women. Rare in children RF: genetics and environment Born during winter, advanced paternal age, parental stressors, OB complications, severe childhood abuse, cannabis use

schizophrenia

50-day prodromal period during which pt may experience changes in grades, sleep, mood, reduced concentration, attention, drive, and motivation\

schizophrenia

(sx added)- auditory hallucinations (voices, whispers; can be profane, critical, and derogatory or command); Visual hallucinations, tactile hallucinations; delusions

+ schizophrenia sx

(decrease or loss of normal functions): strong predictor of long term disability; deficit syndrome (disorganized behavior, progression of negative sx, and sx less responsive to meds and tx)

- schizophrenia sx

problems focusing, monitoring and evaluating performance, problem solving, setting and maintaining goals, serial learning, immparied verbal fluency.

cognitive sx

tests for appearance, attitude, speech, behavior, mood/affect, perceptions, thought process, sensorium, insight, judgment

Mental Status Exam (MSE):

Dx for schizophrenia

Labs and CT or MRI to r/o structural or traumatic conditions | Min 1 mo of positive sx and 6 mos of social disruption

TX of schizophrenia

assertive community treatment programs; skills training, CBT (individual or group for 4-9 mos) antipsychotics:

(sometimes irreversible: chewing, tongue protrusion, facial grimacing, jerking extremities), extrapyramidal sx; hyperprolactinemia affecting BMD and sexual performance. Muscarinic and cholinergic (dry mouth, blurred vision, constipations, drowsiness, weight gain), and alpha-1 (orthostatic hypotension)

Tardive dyskinesia- SE of antipsychotics:

TX of tardive dyskinesia or EPS

Tx tardive dyskinesia w/ clozapine Tx EPS sx w/ benztropine 2mg IM or diphenhydramine 50mg

also improve negative sx w/ lower risk of EPSs→ increased CV risk (weight gain, dyslipidemia, DM, accelerated cardiovascular disease) and premature death. Med trials should last 2-6 weeks. Continue tx for 1 yr after relief is obtained

Second-generation/atypical antipsychotics

most often caused by an adverse reaction to neuroleptic or antipsychotic drugs Medical emergency → elevated core body temp and modest-severe muscle rigidity + 2 or more: Diaphoresis, tachycardia, elevated or labile BP, dysphagia, incontinence, tremor, changes in LOC, mutism, leukocytosis, lab evidence of muscle injury and hepatic enzyme elevations

Neuroleptic malignant syndrome (NMS)

Pt preoccupied with bodily sx and feel they have a serious illness; highly anxious (HAs, sure they have a brian tumor) Somatic symptom disorder and illness anxiety disorder are two different diagnoses that replaced hypochondriac Screening: Somatic symptom scale-8;

Somatic Symptom Disorder

Tx of Somatic Symptom Disorder

Tx: schedule short frequent visits (2-4 weeks) treat underlying anxiety/depression w/ ssri or snri. Try to get into mental health tx, often resistant; empathy, stress coping; limit diagnostic testing CBT

Substance Use disorders | Screening:

Adults: AUDIT (14 +; alcohol only) Kids: CRAFFT (car, relax, alone, forget, friends, trouble), s2bibi Drugs: DAST-10

5-100mg; up to 300mg daily. Metabolized by liver w/ long half-life (caution liver)- for Alcohol withdrawal

Chlordiazepoxide (Libirum)

1-4mg q2-4hrs; less concern for liver injury- Alcohol withdrawal

Lorazepam (Ativan)

long half-life; ease of tapering | - Alcohol withdrawal

Diazepam (Valium)

opioid antagonist. once daily PO (50mg) or once monthly IM (380mg). CI: cirrhosis, patients needing opioids. SE: GI, HA, dizziness, lightheadedness, weakness. More common early in tx 50mg po once daily OR IM 380 mg monthly. Avoid w/ opioids or if used in last week. CI Cirrhosis SE: lightheaded, dizzy, weak, GI sx; usually resolve after early tx. Alcohol can be consumed - for alcohol cravings

Naltrexone (Revia or Vivitrol)

FDA approved; Do not have to stop drinking alcohol. Helps reduce amount consumed. ``` 2 tabs 3x/day If pts weigh <132 lbs reduce to bid. SE: minor GI Better for a patient who may want to continue drinking and slowly decrease consumption Renally cleared; CI GFR <30 Teratogenic ```

Acamprosate (Campral)

alcohol deterrent; abstinence only- no OTC meds with alcohol Can remain in body for 2 wks - for alcohol cravings

Disulfiram (Antabuse)

Vitamin Replacement for Alcohol

Thiamine 100-200 mg daily B12 IM 1000 mg monthly or 100 mg daily Multivitamin with folic acid

who should be screened for alcohol and substance abuse?

screen everyone age 18 or older in primary care incl. pregnant women - AUDIT, CRAFFT, CAGE

DX for substance abuse?

drug screen, LFTs, renal fx, STD, hepatitis, HCG, TSH, other nutrients

management plan for alcohol use disorder

trusting relationship | refer to support groups, psychotherapy/ CBT, rehab, pain mgmt specialist when indicated

Tx for opioid use dosrder titrated for opioid withdrawal by specialist Full opioid agonist Eventually will need maintenance therapy, watch for QT prolonging drugs and drugs that accelerate/slow methadone metabolism

Methadone

Wait to give until withdrawal symptoms present Partial opioid agonist which can precipitate withdrawal symptoms but utilized inpatient when clinical opiate withdrawal score is high 8 to 10 or greater then tapered over minimum of 5 days Tx for opioid use dosrder

Buprenorphine/ naloxone (Suboxone)

Suppresses hyperactivity- Tx for opioid use dosrder

Clonidine

Augmenting agents:Tx for opioid use dosrder

NSAIDS/tylenol, muscle relaxers,n/v meds, anti diarrhea meds

Nicotine replacement therapy (NRT)

gum, lozenge, nasal spray, dermal patches. Careful during pregnancy takes 14-30 days

antidepressant approved for smoking cessation in a person who smokes 10 more cigarettes/day. Can be used in conjunction with NRT Taper up dose, Start 1 week before quit date, continue for 7-12 weeks

Bupropion (Wellbutrin or Zyban)

start tx 1 week before quitting nicotine. Minimum 12 week tx. Not recommended to use with NRT SE: nausea

Varenicline tartrate (Chantix)

Substance use disorder: | At least 2 of the following in a 12 month period

Substance taken in larger amounts over longer period of time than intended Persistent desire or unsuccessful effort to cut down or control use Great amount of time spent to obtain substance craving/ strong desire/urge Recurrent use resulting in failure to fulfill major role obligations at work, school home Continued use despite social interpersonal problems caused by substance affects Social occupational or recreational activities are given up or reduced due to use Recurrent use in situations in which it is physically hazardous Use continued despite knowledge of having a physical or psychological problems due to substance Tolerance or withdrawal

“Chronic relapsing brain disease characterized by compulsive drug seeking and use despite harmful consequences”

addiction

patient exhibits drug seeking behavior and appears aggressive but they in fact have untreated actual pain

Pseudoaddiction

TX for ADD/ ADHD tx

Amphetamines, methylphenidate, psychostimulants. strattera is non stimulant and will not provoke anxiety Stimulants increase risk for PVD or Raynauds

age group PTSD sx- infants

feeding problems, failure to thrive, sleep probs, irritability

age group PTSD sx- preschool

sleep probs, nightmares, developmental regression, aggression, extreme tamper tantrums, anxiety sx, sudden worsening fears, irritability, avoidance of sx

age group PTSD sx- school age

sleep probs, nightmares, developmental regression, repetitive themes in play and social withdrawal, may have partial amnesia of events, new onset anxiety or fears, panic attacks, impaired concentration ,impaired school performance, avoidance sx or hypervigilance, somatic complaints `

age group PTSD sx- adolescents

acting out , sleep probs/ nightmares, extreme startling, social withdrawal, fears, anxiety, panic attacks, depression, anger or rage, internalizing, suicidal ideation, impaired concentration, impaired school performance, hypervigilance

evaulation of trauma sx

careful direct clinical interview including child avoid prompting leading questions invasion of privacy, how trauma occurred, sx pattern Trauma, re-experience, avoidance, unable to fx, month or longer, arousal

factors influencing the severity of PTSD response

severity of the trauma exposure parental distress related to the trauma temporal proximity to the event

management for PTSD

referral to behavioral health, CBT, report social services, medication mgmt