Mental Health Flashcards
Unipolar Depression
Presentation: Five or more of the following for at least two consecutive weeks and at least one symptom must be either depressed mood or loss of interest/pleasure.
- A depressed mood most of the day
- Loss of pleasure in activities (Anhedonia)
- Insomnia
- Psychomotor retardation
- Fatigue
- Decreased ability in concentrating
- Feelings of worthlessness
- Sleep disturbances
- 5% weight change in <1 month or decrease in appetite
- Recurrent thoughts of death and/or suicide
Screenings:
- PHQ-2
- PHQ-9 (Required by Medicare for nursing homes)
Diagnosis:
- A history of one or more major depressive episodes, without history of mania.
- Consider lab work if this is the patient’s first episode of depression, depression without any precipitant, or if they are elderly
- CBC, B12, Folate, CMP, UA, TSH, HCG, UDS, Glucose
Unipolar Depression Treatment
Pharmacotherapy and psychotherapy
- Selective serotonin reuptake inhibitors are first line
- Examples: Fluoxetine (Prozac), Paroxetine (Paxil), Sertraline (Zoloft), citalopram (Celexa), Escitalopram (Lexapro)
- Side effects: GI Discomfort (diarrhea), sexual dysfunction, weight gain
Important points:
- Start at sub therapeutic dose and titrate up
- Screen the patient for bipolar disorder before beginning SSRI
- If SSRI is stopped, taper is slowly.
OTHER treatment options:
- Second generation antipsychotics
- Aripiprazole, brexpiprazole, quetiapine, risperidone
- Serotonin and norepinephrine reuptake inhibitors
- Venlafaxine, duloxetine
- Lithium
- Norepinephrine and dopamine reuptake inhibitors (Atypical antidepressants)
- Buproprion (Contraindicated with seizure disorder)
- Typical antipsychotics
- Haloperidol, chlorpromazine (Black box warning: Elderly at risk for death with antipsychotics)
- Monoamine oxidase inhibitors
- Phenelzine, tranylcypromine (Do not combine with SSRIs or TCAs)
- Tricyclic antidepressants
- Amitriptyline, nortriptyline
Acute Serotonin Syndrome
Potential life threatening syndrome related to serotonin toxicity
Presentation:
- Agitation, diaphoresis, tachycardia, hyperthermia, tremor, hyperreflexia, clonus
Diagnosis:
- Hunter toxicity criterial decision rules
- Serotonergic (Overdose, drug-drug interaction, or initiation increase of dose) agent plus at least 1 of the following
- Spontaneous cloud
- Inducible clonus + agitation or diaphoresis
- Ocular clonus + agitation or diaphoresis
- Tremor + hyperreflexia
- Hypertonia + temperature > 100.4 + ocular clonus or inducible clonus
Treatment:
- Refer to emergency room
- Supportive therapies and benzodiazepines
Malignant Neuroleptic Syndrome
Rare, life threatening complication associated with the use of antipsychotics
Presentation:
- Sudden onset of high fevers, muscular rigidity, mental status changes, dysautonomia and urinary incontinence
Diagnosis:
- Clinical diagnosis
Treatment:
- Refer to the emergency room
Generalized Anxiety Disorder
Diagnosis:
- Patient presents with persistent worry more days than not for at least 6 months
- The worrying is difficult to manage and associated with 3 or more of the following:
- Restlessness
- Sleep disturbances
- Muscle tension
- Fatigue
- Difficult with concentration
- Irritability
- The symptoms are not due to another medical condition including MI, arrhythmia anemia, hyperthyroidism, hypoglycemia
Treatment:
- Cognitive behavioral therapy (CBT)
- Selective Serotonin Reuptake Inhibitors (SSRIs)
GAD-7 Screening Tool
Over the last 2 weeks have you been bothered by:
1. Feeling nervous, anxious or on edge?
2. Not being able to stop or control worrying
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless it’s hard to sit still
6. Become easily annoyed or irritable
7. Feeling afraid as if something awful might happen
0-4 points = minimal or no anxiety
5-9 points = Mild anxiety
10-14 points = Moderate anxiety
15-21 points = Severe anxiety
Bipolar Disorder
Presentation:
- Depressed mood, insomnia, sleep disturbances, abrupt mood changes, anxiety, irritability, impulsivity, substance abuse, relationship complications, delusions
Diagnosis:
- Bipolar 1: Experience major depression, hypomania and mania
- DSM-5 Mania: Severe enough to cause significant impairment in social or occupational functioning, or requires hospitalization to prevent harm to self or others, or psychotic features lasting at least 7 consecutive days.
- Bipolar 2: At least 1 major depressive episode and 1 hypomaniac episode WITHOUT manic episodes.
- DSM-5 Hypomania: Abnormal and persistent elevated mood/energy lasting a minimum of 4 consecutive days and occurs for most of the day.
Screening tool:
- Mood disorder questionnaire is the most wildly used to screen for bipolar.
Treatment:
- Co-manage with Psychiatry
- Maintenance treatment usually consisted of daily use of the medication that was effective in treating the acute symptoms
- Valproate, Lithium, Quetiapine
Lithium
Narrow therapeutic range
Half life is approximately 24 hours
Presentation:
- Nausea, vomiting and diarrhea
- Neurological symptoms seen later
Target Serum Level:
- 0.8 - 1.2 mEq/L
Mild Toxicity:
- 1.5 - 2.4 mEq/L
Medical Emergency:
- Levels >2.5 mEq/L
Alcohol Abuse
Alcohol related deaths per year in the US: > 85,000
Approximately 3 in 10 adults in the US use alcohol in an unhealthy way
Risk Factors:
- Male Gender
- Ages 18 to 20
- Native American and white ethnicity
- Significant disability
- Other substance use disorder
- Mood disorder
- Personality disorder
Single item alcohol screening question:
- How many times in the past year have you had (5 for a man, 4 for a woman) drinks in a day?
CAGE questions
- Have you ever felt you should cut down on your drinking?
- Have people annoyed you by criticizing your drinking?
- Have you ever felt bad or guilty about your drinking?
- Have you ever take a drink first thing in the morning (eye opener) to stead your nerves or get rid of a hangover?
**Answering “year” to 2 or more questions is a positive indicator for potentially severe alcohol use disorder
**77% sensitivity and 70% specificity
REMEMBER: Alcoholism puts you in a CAGE
Presentation of alcohol withdrawal
Minor withdrawal symptoms:
- Insomnia, tremor, mild anxiety, gastrointestinal symptoms, headache, diaphoresis, palpitations
Delirium tremors
- Characterized by agitation, disorientation, hallucinations, and autonomic instability
- Manage inpatient, use CIWA to guide treatment with benzodiazepines
Treatment:
- Psychosocial interventions
- Counseling, support groups
- Disulfiram: Aversive agent
-Medication of choice if patient wants to completely abstain
- Patient becomes ill if they drink alcohol while taking this
- Naltrexone
- Medication of choice if patient wants to reduce drinking
- Contraindicated in concurrent opiate use
Attention deficit hyperactivity disorder (ADHD)
Presentation: Inattention, hyperactivity and impulsivity
- Hyperactivity: Generally presents by 4 years of age and peaks by year 7 or 8.
- Impulsivity: Generally presents by 4 years of age and is a lifelong complication.
- Inattention: Generally presents by 8 or 9 years of age and is a lifelong complication.
Diagnosis:
- Evaluation for ADHD begins at 4 years old and must impair functioning in school, social skills and/or occupational activities.
DSM-5 TR Diagnostic criteria for ADHD:
- Children <17 years: >6 symptoms of hyperactivity and impulsivity or >6 symptoms of inattention
- Individuals >17 years: >5 symptoms of hyperactivity and impulsivity or >5 symptoms of inattention.
- Several symptoms were present before 12 years old
- Several symptoms are present in 2+ settings
- Symptoms interfere with functioning/life
- Symptoms not due to another mental disorder
Hyperactivity & Impulsivity symptoms
- Excessive fidgeting
- Difficulty remaining seated
- Restlessness
- Difficulty playing quietly
- Difficult to keep up with
- Excessive talking
- Difficulty taking turns
- Blurting out
- Interrupting others
Inattention symptoms
- Failure to pay attention to detail
- Difficulty maintaining attention
- Difficulty listening (even if directly addressed)
- Fails to follow through/complete tasks
- Difficulty with organization
- Avoids tasks that require prolonged mental effort
- Loses objects
- Easily distracted
- Forgetful
ADHD Other helpful tools & Treatment
- Conners comprehensive behavior rating scales
- ADHD rating scale-5
Treatment:
- Children 4 & 5 years: Parent or caregiver training in behavior management (PTBM) alone. Add on medication if this is successful.
- Children and adolescents >6: Medication preferred rather than behavioral therapy alone.
- Stimulants are generally first line
- Short acting: Methylphenidate, dexmethylphenidate, amphetamine and dextroamphetamine
- Long acting: Methylphenidate, amphetamines, and the SNRIs (Atomoxetine and Violoxazine)
- Selective norepinephrine reuptake inhibitors (SNRIs) are an alternative option
- Atomoxetine and Violoxazine
Before Medication Criteria
- Confirmed diagnosis using DSM, child is >6 years, caregiver is accepting, school is on board with monitoring and administering medication, without significant anxiety and substance abuse is not a concern.
- If child is <6 years, has history of seizure, Tourette syndrome, or significant developmental delay, patient should be co-managed.
Autism Spectrum Disorder (ASD)
Neurodevelopment disorder that has spectrum of symptoms and presentations but is characterized by deficits in social communications and the presence of specific interest and repetitive behaviors.
DSM-5 TR diagnostics criteria for ASD:
- Persistent deficits in social communications and interactions
- Difficulty with social-emotional reciprocity (Lack of sharing of interests with others or the ability to understand other’s feelings)
- Lack of non-verbal communication (Does not make eye contact or lacks facial expressions)
- Difficulty developing and maintains relationships with others
- Restricted, repetitive patterns of behaviors, interests, or activities; demonstrated by >2 of the following
- Repetitive movements, use of objects or speech (Hand flapping)
- Insistence on sameness and routine
- Restricted, fixated interests
- Increased or decreased response to sensory input
- Symptoms must impair functioning and present early in development
- Symptoms are not better explained by another diagnosis
Tools to make visits easier: Have practice visits, use visuals, allow patient to touch and examine instruments, keep visit and instructions simple.
Treatment: Behavior and educational interventions.
