Mental Health Flashcards
Name the SSRIs.
Fluoxetine Sertraline Citalopram Escitalopram Fluvoxamine Paroxetine
Are SSRIs approved for Canada for use in kids and teens?
no
What is the mechanism of action of SSRIs?
- inhibit serotonin transporters, block reuptake and so increasing the concentration of the neurotransmitter serotonin within the synapse
- Speciifc SSRIs ma alos influence other neurotransmitter systems (e.g. dopamine, norepienphrine)
How are SSRIs metabolized?
the liver
- are rapidly absorbed
- absorption largely unaffected by ingestion of food
What is the halflife of fluoxetine?
96 hours (long-acting drug) Paroxetine is 21 h
What are the guidelines for initiating therapy with SSRIs?
- goal to achieve the minimum effective dose
- start low, often similar or slightly lower than for adults and titrate up
- do not need labs before starting
- usually do not interact with a lot of other meds
- weekly monitoring for the first 4 weeks
- then every 2 weeks
- then at 12 weeks and then as clinically indicated
- assess for SI, and adverse effects
-once achieve response should continue the med for at least 12 months to decrease chance of relapse
What is the reported effective of SSRIs for tens with depression?
40-70%
-most evidence is for fluoxetine
Can you use SSRIs for anxiety? Which one?
Yes they are effective. Can be considered early in the course if anxiety is severe or causing significant impairment.
No specific SSRI is superior to others for anxiety.
What are the side effects of SSRIS?
GI symptoms, sleep changes (either insomnia or somnolence or vivid dreams), restlessness, headache, appetite changes, sexual dysfunction
- may see agitation or impulsivity (make sure to RO bipolar)
- SE are dose dependent and decrease over time
-Risk of suicide is greater with untreated depression than that associated with appropriate SSRI use
Rare s/e: coagulopathy, SIADH, serotonin syndrome, QT prolongatino (esp with citalopram)
What is serotonin syndrome?
mental status change, myoclonus, ataxia, diaphoresis, fever, autonomic dysregulation
What is the concern with QT prolongation and SSRIs?
Most specific to citalopram at doses >40mg OD.
Do not exceed this dose.
Do not use citalopram in kids with congenital long QT.
Patients with underlying congenital heart disease or hepatic impairment (affecting citalpram metabolism) should be treated with caution if receiving citalopram and monitored closely for cardiac adverse effects, including torsades de pointes
How do you discontinue SSRI?
slow taper during a stress free time (e.g. the summer)
What are the emotions experienced by kids related to divorce?
- adjustment occurs in stages
- may experience loss, sadness, confusion, fear of abandonment, anger, guilt, grief, conflicts related to loyalty and misconceptions
- most feel worry about what the future holds
- overwhelming majority do not experience serious outcomes
What are some negative impacts that divorce can have for kids?
- score lower on measures of academic achievement, conduct, psychologic adjustment, self-concept and social relationships
- this can extend into adulthood with early marriage, divorce, risky sexual behaviour, etc
What are the 3 most significant factors that impact a child’s well-being during a divorce?
- quality of parenting
- quality of parent-child relationship
- degree, frequency, intensity and duration of hostile conflict
True or false. Most kids do not experience short and long term negative outcomes due to divorce.
True.
What are some family risk factors for difficulties with divorce?
ongoing conflict btwn parents (esp if abusive or focused on the kids) diminished capacity to parent/poor parenting lack of monitoring children' activities multiple family transitions parent mental health problems chaotic, unstable household impaired child-parer relationship economic decline
What are some family protective factors related to divorce?
- protection from conflict btwn parents
- cooperative parenting (except in cases of domestic violence)
- healthy relationship btwn child and parents
- parents’ psychological well-being
- quality, authoritative parenting
- household structure and stability
- supportive sibling relationships and extended family relationships
- economic stability
What is effective parenting?
- communicate well and frequently
- express love and devotion
- discipline with clear guidelines, limits and developmentally appropriate expectations
- -allow kids to feel a wide variety of emotions surrounding the divorce
What are characteristics of a positive parent-child relationship?
- warmth, supportiveness, effective problem-solving, positive communication
- low levels of conflict and negativity
- parents need to listen without judgment and be empathetic
What is the one of the most damaging aspects of divorce?
- ongoing parental conflict
- mediation is an effective way to resolve conflict
Which type of arrangement after divorce is the best for kids?
kids who parents have joint-custody are better adjusted
What are some considerations related to divorce for kids
- do better with routine and frequent access to both parents to develop memory of the other in their absence
- risk of losing attachment with one parent if they don’t see them often enough
What are some considerations related to divorce for kids 4-5 years old?
- often blame themselves, are clingy
- may take sides
- need to prevent this by involving both parents in day to day activities (e.g. parent-teacher interviews)
- keep conflict out of view of children
What are some considerations related to divorce for teens?
- peers become their reference group
- need access to both parents
What are the negative outcomes associated with ADHD in teens?
-higher risk for school failure, poor social relationships, MVCs, delinquency, poor vocational outcomes, more likely to experiment with substances
True or False. Children with repaired CHD are at increased risk for ADHD.
True.
True or False. Children with arrhythmic heart disease (long QT, Brugada, WPW, etc) are at increased risk for ADHD.
Unknown.
Which structural CHD are associated with a risk of sudden death?
ToF
d-transposition of the great arteries (esp after Mustard or Senning procedures)
Is the risk of sudden death increased in kids with ADHD on stimulants increased compared to the general population?
no, they don’t think so
Which of the following on hx or px would prompt you to get an evaluation by a cardiologist before starting a patient on ADHD meds?
- SOB with exercise or poor expressive tolerance
- fainting or sz with exercise or startle
- palpitations with exercise
- FHx sudden death
- personal or family history of non-ischemic heart disease
- long QT or other familial arrhythmias
- WPW
- cardiomyopathy
- heart transplant
- pHTN
- defibrillator
- HTN
- organic murmur
- sternotomy incision
- other abnormal cardiac findings
What cardiac work up do you need to do in kids before starting ADHD meds?
-none including no ECG unless there is an abnormal hx or px
For patients with known CHD or arrhythmias what should be the approach to starting ADHD meds?
- discuss with the cardiologist before starting to ensure there is a consensus
- these kids should benefit from these meds too
What is the postpartum blues?
- emotional disturbance with crying, confusion, mood lability, anxiety and depressed mood
- appear during the first week postpartum, last for a few hours to a few days and have few negative sequelae
What is postpartum psychosis?
-severe disorder beginning within 4 weeks postpartum with delusions, hallucinations and gross impairment of functioning
What is postpartum depression?
- begins or extends into the postpartum period,
- dysphoric mood, fatigue, anorexia, sleep disturbances, anxiety, excessive guild, suicidal thoughts
- symptoms need to be present for at least a month and impair functioning
- can last several months
-RF include hx of mood disorders, depression symptoms during pregnancy and FHx of psych d/o
What are the consequences of maternal depression while pregnant?
- inadequate prenatal care
- poor nutrition
- higher preterm birth
- low birth weight
- pre-eclampsia
- spontaneous abortions
What are the consequences of maternal depression for an infant?
- infant can develop anger and protective style of coping, passivity, withdrawal, self-regulatory behaviour, dysregulated attention and arousal
- lower cognitive performance
- negative affect
What are the consequences of maternal depression for a toddler?
- passive noncompliance
- less mature expression of autonomy
- internalizing and externalizing problems
- lower interaction (in physical and creative play)
- lower cognitive performance
What are the consequences of maternal depression for a school aged child?
- impaired adaptive funcitoning
- internalizing and externalizing problems
- affectie d/o
- anxiety d/o
- conduct d/o
- ADHD
- lower IQ scores
What are the consequences of maternal depression for a teen?
- affective d/o (eg depression)
- anxiety d/o
- phobias
- panic d/o
- conduct d/o
- substance abuse
- alcohol dependence
- ADHD
- learning d/o
What are some risk factors or contextual factors that might influence or exacerbate parental depression?
- marital conflict
- stressful life events
- limited social support
- poverty
- lower social class
- lower maternal education
What are the recommendations of SSRIs for pregnant or breastfeeding mums?
- need to discuss the benefits and the risks
- low risk of toxic effects with SSRIs
- no neurological or developmental abnormalities have been demonstrated in infants who are exposed to SSRIs via breastmilk
- no risk of fetal anomalies specific to SSRIs
What are the recommendations regarding St John’s Wart for depression in pregnant and breast feeding moms?
- does have an effect for mild to moderate depression
- not enough evidence to say it is safe during pregnancy or breastfeeding so it should be avoided
- it also has ++interactions with other drugs
What are some interventions besides medication that can be recommended to families of mum’s with depression?
- social support and home visiting interventions
- family therapy for school-age kids to focus on communication around the illness
- psychotherapy
What is the role of the MD in maternal depression?
- heightened awareness of it
- collaborate with the mum’s MD
- discuss how the mum’s mood might affect parenting and contribute to the child’s problems
- regular developmental surveillance
- anticipatory guidance
What is the role of elimination diets or elimination of food allergens for the treatment of ADHD?
- there may be a role of elimination of food allergens in a small subset of kids with atopic histories, FHx migraine, FHx of food reactivity
- for most kids there is no role
What is the role of sugar and aspartame in ADHD?
-it is a myth that sugar causes hyperactive behaviour
What is the role of vitamin supplementation in the treatment of ADHD?
- should be reserved for kids who have a deficiency in the specific vitamin including iron
- there are some toxicities associated with megavitamin therapy
- b/c kids can have appetite suppression related to meds they may benefit from a multivitamin
What is the role of nootropics in ADHD?
nootropics are substances reported to enhance mental competence (e.g. piracetam)
-no specific studies of these for ADHD
What is the role of herbal teas in kids with ADHD?
- herbal tas with chamomile, spearmint, lemon grass and other herbs and flowers are considered a safe and effective way to help a child relax
- many of the other herbal remedies have been studied in adults but none have been studied specifically in ADHD and may have some side effects
What is the risk associated with ginkgo bilboa?
-avoid in pts on anticoagulants, anti platelet agents and pts with bleeding disorders
What is the role of melatonin in ADHD?
- successful in treating sleep problems in ADHD
- side effects include reduced daytime alertness, increased fatigue, sleepiness, headache, irritability (with high doses)
What is the role of vision therapy and oculovestibular treatment in ADHD?
none. no evidence to support it
What is the role of sound training in ADHD?
no evidence to support it
What is an alternative to stimulants that may have some evidence behind it?
- biofeedback
- goal is to facilitate the patients physiological and psychological self-regulation
- involves a substantial commitment from the child and family
What is the role of hypnotherapy in ADHD?
-can be helpful in th multimodal treatment context for controlling secondary symptoms
What is autism?
neurobehavioural disorder characterized by impairment in social relatedness, delayed and disordered communication and restricted, perseverative and stereotypic behaviour patterns
What are the pros and cons of intervention for autism?
PROS:
-improve skills (e.g. eye contact, symbolic play, peer interactions)
CONS::
- intensive
- costly
- require significant parental commitment
What is early intensive behavioural intervention (IBI) for autism?
- theory is to positively reinforce desired behaviours and ignore/punish negative behaviours (e.g. aggression, self-stimulatory)
- intensive therapy provided by caregiver for 2-3 yrs for 40 h/week
- the earlier the better
What is the optimal age to start therapy for autism?
- unknown
- most studies start when kids is
What are alternative approaches to autism other than IBI?
- discrete training: highly structured sessions with child/teacher sitting next to each other, teacher consistently present stimulus to child until desired response is obtained
- normalized teaching: loosely structured sessions that occur during the child’ play and are paced by the child
- LEAP: classroom program, 3h/day, focused on social development
- Flor time: home based, 20-30 min/day x8, follow child’s play
TEACCH: focused on achieving optimal functioning in society as adult, provides lifelong continuum of services
What is the CPS recommendation regarding interventions for autism?
- minimum 15 h/wk of structured, individualized treatment
- family should be involved with ongoing evaluation and adjustments
What are the stats around suicide for males and females?
-males more likely to complete
-females more likely to attempt (3-4x more likely)
-
What are risk factors for suicide in teens?
- history of mental illness
- previous suicide attempt
- impulsivity
- precipitating factor/recent stressor
- trigger for past physical or sexual abuse
- exposure to suicide via the media
- family history of suicide
- family conflict
- parental mental illness
- lack of connection to social support
- hopelessness
Which mental illnesses have been particularly associated with suicide?
- depression
- substance use
- conduct d/o
- bipolar d/o
- psychotic d/o
What are some common precipitating factors for adolescent suicide?
- break-up
- conflict with family or peers
- recent or impending academic disappointment
- bullying
- disclosure of homosexual orientation
- legal involvement or impending court proceedings
