Mental Health 2 Flashcards by Lauren Arruda

What screening tool can be used for major depressive episode?

Patient Health Questionnaire (PHQ-9) or Quick Inventory of Depressive Symptomalogy-Self-Report (QIDS-SR16)

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What screening tool can be used to rate severity & remission of depression

7-Item Hamilton Depression Rating Scale (HAMD-7)

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What does the Mood Disorder Questionnaire (MDQ) assess?

Screening instrument for manic or hypomanic symptoms

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What is the first line drug used for peds with depression?

Fluoxetine. Started at LOW doses.
And initiate psychological treatments if not already initiated

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T/F Antidepressants are approved by Health Canada for unipolar depression in pts <18 years?

False- consider meds when: psychological treatments are unavaialble or unsuccessful, pt prefers to use meds, &/or pt has co-morbid anxiety disorders

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How often should follow up be for Peads started on anti-depressants?

Weekly x4wks after initiation, then q2wks, then q4wks ongoing

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When should you start to see improvements with antidepressants?

May need 6 weeks to see full effect but may see improvement in 1-2wks

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What is the 1st line treatment for teens with mild/mod depression?

Active monitoring - visits virtual/in person for 1-2weeks, prescribe self-care (exercise, peer support groups), set boundaries with social media use and try all strategies for 6-8 weeks before moving on to psychological treatments as 2nd line and pharmacotherapy as 3rd line

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When should you refer to a specialist for depression?

After 2 failed SSRIs and 1 course of CBT/IPT
or 3 treatment failures in general or psychotic symptoms

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What are some contributing factors of depression?

Drugs: benzos, opioids, steroids, clonidine. methyldopa, phenobarbital
Substances: alcohol, cannabis, stimulants
Conditions: sleep apnea, autoimmune, hypothyroid, anemia, DM, CVD, stroke, pain
Situations: social stressors, peri-partum, menopause

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What are some considerations for prescribing older adults on antidepressants?

Start at low doses and monitor carefully *inc risk for AEs, falls risk.
May take longer to see effects 12+ weeks

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What antidepressants are preferred for the older adult?

es/citalopram, sertraline, bupropion (if no insomnia, or dec appetite) and duloxetine

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What are some of the most common AE with antidepressants?

H - headache (or dizziness)
A - anxiety/agitation, restless (typically only in first 2wks)
N - nausea
D - diarrhea (or other GI upset)
S - sleep disturbances, inc suicidality (for those <24yrs)

Others: sexual dysfunction, wt gain, emotional detachment/personality changes, osteoporotic #’s (esp >70yrs), bleeding (esp older adult, or on NSAIDs), hyponatremia, seizures, serotonin syndrome, QT prolongation (for es/citalopram - consider pre ECG)

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What is safe to prescribe for depression in pregnancy?

1st line for mild - psychotherapy

1st line mod/severe: SSRIs: sertraline, escitalopram, citalopram using lowest effective dose

*Avoid SNRIs, bupropion, mirtazapine, vilazodone due to less safety data available

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What is the expected duration of treatment for antidepressants?

If First episode- 12 months
Second episode - 2 years
2 or more episodes - do not stop medication

Continue on meds for 6-12m after cessation of symptoms as there is an inc risk of relapse with shorter treatment durations

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What is the 1st line treatment for mild depression in adults?

CBT, behavioural activation (BA), & interpersonal therapy (IPT), with CBT showing to be most effective

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What is the 1st line treatment for MDD with seasonal pattern?

Light therapy - 30mins exposure/day with effects seen in 1-3 wks

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When to refer someone with depression to ED?

Active suicidal ideation

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How often can antidepressants be titrated up?

Every 2 weeks by 5-10mg to max doses

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What is the recommendation for tapering down antidepressants?

Average 25% decrease/wk while monitoring for side effects
Start with taper of drug 1 every 4-7 days, then stop
Then next day slowly titre up drug 2

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When should the minimum therapeutic dose be achieved for antidepressants?

Within the first 2weeks (no changes here) and then can be increased if necessary over the next 4–6 weeks.

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Which populations should the SSRI Paroxetine not be used or avoided?

Older adults, pregnancy

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What are the withdrawal symptoms common with antidepressant discontinuation?

F - flu-like
I - insomnia
N - nausea
I - imbalance
S - sensory disturbances
H - hyperactivity

Usually lasts for 1-2wks but can be longer for some
*highest risk with venlafaxine and paroxetine

How to taper for discontinuation of antidepressant?

Short Taper (for low doses, short duration<6wks or rapid taper needed for AE) - dec dose by 25-50% q2-4wks

Long Taper - Benzos (high doses/duration, high risk of relapse or hx withdrawal sx) - dec dose by 25-50% of previous dose over months. As dose lowers make smaller reductions and longer intervals. When at lowest dose available dose every other day or switch to suspension if available

T/F: A washout period is indicated for all antidepressant switches

F - A washout period usually is not necessary when switching between most antidepressants (except to and from MAOIs)

When to refer to psychiatry?

Fail to achieve remission Experience symptoms of psychosis Fail to eat or drink Have other comorbid psychiatric illness Child or adolescent - often complex Score 7 or greater on SADPERSONS Support for people with newly diagnosed severe depression, anxiety disorders, bipolar disorders and psychosis is usually done in consultation with psychiatrists as well as mental health counsellors. However, NPs in primary health care settings often provide on going care and monitoring for people with these conditions once they are stabilized.

What if you need to place your patient on a form 1?

Requires a physician consult. NPs are not able to form patients

What is the SADPERSONS scale used for and what does it stand for?

Assesses suicide risk in adults based on ten criteria considered as risk factors. The 10 risk factors from the scale are: S: Male sex A: Age (<19 or >45 years) D: Depression P: Previous attempt E: Excess alcohol or substance use R: Rational thinking loss S: Social supports lacking O: Organized plan N: No spouse S: Sickness SAD PERSONS score range from 0 to 10, where the higher the score, the higher the suicide risk: 0-4: Low risk; 5-6: Medium risk; 7-10: High risk. *Several studies have found that the scales sensitivity is low so its clinical value may be put under serious question

How do you interpret the results of the PHQ-9?

Score Severity Recommendations 0 - 4 None No specific recommendations 5 - 9 Mild Monitoring symptoms 10 - 19 Moderate Referring for treatment 20 - 27 Severe Starting treatment and monitoring

When is St.Johns Wort used?

Non-pharm- There is evidence to show that St. John’s wort is effective and a potential first-line monotherapy option for patients with MDD of mild to moderate severity Caution: can decrease the bioavailability of many drugs. When combined with other serotonergic medications, there is an increased risk of serotonin syndrome

what is the 1st line treatment for insomnia?

Non Pharm: - sleep hygiene - exercise in am, nothing vigorous 3hrs prior to sleep - avoid daytime naps - keep scheduled sleep/wake times - relaxation strategies - prevent light disturbing circadian rhythm - acupuncture with CBT - I (improvements seen within 3-4 sessions (3-4wks))

As part of insomnia investigations a sleep diary is generally recommended for how long?

1-2 weeks

What is the 1st line pharmacotherapy recommended for insomnia?

Sedative Analectic Hypnotics aka benzodiazepines and Z-drugs. Benzo: Temazepam Z-drugs: - Try initially 1-4wks - lowest dose, and only PRN - should see improvement within first few days of use - if insomnia persists for >1m refer to specialist

When to D/C insomnia meds?

low stress time period with an extremely slow taper

What is the role of benzos in anxiety?

For short term use at start of treatment to provide rapid relief while waiting for longer acting meds to kick in

Among the following, what is the first-line agent in post-traumatic stress disorder (PTSD)? fluvoxamine mirtazapine paroxetine moclobemide

paroxetine

True or False Psychotherapy and pharmacotherapy (including benzodiazapines) are not usually required during the first four weeks following a traumatic event since most people who experience trauma do not develop PTSD.

True - most will not develop PTSD - may impeded natural recovery

True or False Second-generation antipsychotics (risperidone, olanzapine, quetiapine, aripiprazole or ziprasidone) are effective initially to control agitation in mania.

True

Which of the following options is considered a first-line treatment for obsessive-compulsive disorder (OCD)? Clomipramide SSRI SNRI Benzodiazepines

SSRI SNRIs are second line Benzo's are not indicated

Which of the following options are non-pharmacological measures used in the treatment of anxiety disorders? Select all that apply. Cognitive Behavior Therapy (CBT) Reduction in caffeine or other stimulants Smoking cessation Aerobic exercises several times a week

Everything but smoking - I guess coping mechanism?

Which one of the following is the first line pharmacological approach for the management of panic disorder? Benzodiazepines Tricyclic Antidepressants (TCA) Serotonin Reuptake Inhibitors (SSRI) Hypnotics

SSRIs

Which one of the following options has been shown to be of superior efficacy in the treatment of depression based on systematic reviews? escitalopram quetiapine trazadone bupropion

escitalopram

Bi polar T/F if pt is taking an antidepressant it should be d/c'ed?

True

Bi polar First line for mania?

Lithium Quetiapine Divalproex Also lamotrigine, aripiprazole

Bi polar Treatment for mod-severe mania?

Send to ED - will likely need multiple agents Manage mild mania symtoms in office

Bi polar What drugs require therapeutic levels?

Lithium, valproate (anticonvulsant), carbamazepine (anticonvulsant) *can take level 9-13h post dose and adjust as needed and can also take anytime there is suspicion of non adherence/toxicity

Bi polar What is the best treatment for depression in bipolar?

Quetiapine Avoid antidepressants* & ariprazole

Bi polar 1st lines for mono therapy maintenance?

Lithium, quetiapine also divalproex, lamotrigine, aripiprazole

Bi polar 1st line combo for maintenance?

Quetiapine + lithium/divalproex Aripiprazole + lithium/divalproex

Bi polar How long is med treatment typically?

Lifelong min 1yr

Bi polar What are the recommendations for pregnancy?

Use monotherapy Most have teratogenic effects but safer to treat than not for mom Pregnancy contract: 1pg document with symptoms and patients preferences on how to treat shared with team

Bi polar What are we monitoring with the use of lithium and how often?

serum Cr, lytes, CBC, Ca, TSH, ECG 5 days post start lithium level 9-13hr post dose then q3-6m once stable

What are the general guidelines regarding meds that require tapering down?

- Most accepted approach: decrease dose by 25%, reducing every 1-2wks or longer intervals if needed ie benzos require a 1-2yr taper - Taper 1 drug at a time - If withdrawal symptoms present – restart med - General rule: if drug required taper up, it will likely require taper down

what is the first line treatment for OCD?

CBT + SSRI

What are the side effects of SSRIs?

GI upset, anorexia, HA, dry mouth, agitation, tremors, somnolence, insomnia, dizziness, diaphoresis Contraindicated with MAOIs Risk for serotonin syndrome - assess other drugs affecting serotinin Risk for QTc prolongation

Best first line pharm recommended for mild-mod depression?

sertraline, escitalopram, citalopram, bupropion