Mental Health Assessment Flashcards

1
Q

DSM-5 Means

A

Diagnostic and Statistical Manual of Mental Disorder

“Bible of neuropsychiatry

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2
Q

DSM provides what information?

A
Age of onset of illness
Clinical course of disease
Complication
Predisposing factors
Prevalence
Differential Diagnoses
Diagnostic criteria
Number of symptoms/time course required
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3
Q

MSE is what?

A

Mental Status Examination

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4
Q

MSE includes:

A
Appearance
Attitude
Psychomotor Activity (over or underactive)
Speech/Language/Eye Contact
Mood 
Affect (reactive, limited/excessive facial expression)
Thought content/process
Insight/judgment
Neuropsychiatric evaluation
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5
Q

Depression has been associated with:

A

increased risk of morbidity and mortality in pts with chronic medical conditions such as CVD

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6
Q

Medical Conditions that can cause Depression

A
Hypothyroidism
Alzheimer's disease
Decreased Vit B12/folate
PK disease
Severe anemia
Cancer
Infxn
Autoimmune
Post-stroke
Menopause
HF
Electrolyte imbalance
CAD
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7
Q

Substance disorders that can cause depression

A
Alcoholism
Marijuana
Nicotine
Opiate
Stimulant
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8
Q

Medications that can cause depression

A
BB
Benzo
Opioids
Clonidine
Barbiturates
Anticonvulsants
Interferon
Oral Contraceptive
Isotretinoin
Glucocorticoids
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9
Q

Define Dysthymia

A

Persisttent Depressive Disorder

  1. Chronic disturbance of mood involving depressed mood combined with at least 2 other symptoms
  2. Experienced a depressive mood more days than not for at least 2 years
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10
Q

Other symptoms include

A
Appetite disturbance
Low energy
Sleep disturbance
Feelings of hopelessness
Low self-esteem
Poor concentration or indecisiveness
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11
Q

Define Major Depressive Disorder

A
  1. Five or more of the following symptoms with at least 1 being the first two
    - Depressed mood
    - Decreased interest or pleasure
    - Decreased energy
    - Feeling worthlessness/guilt
    - Changes in body weight
    - Poor concentration
    - Sleep disturbances
    - Recurrent thoughts of death
    - Psychomotor agitation or retardation
  2. Experience 5+ symptoms nearly every day for at least 2 week and they’ve caused a change in daily function
  3. Symptoms are not due to substance or medical condition
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12
Q

Assessing Symptoms of Depression

A
SIGE CAPS
S: sleep
I: Interested
G: Guilt
E: Energy
C: Concentration
A: Appetite
P: Psychomotor (agitated or motivation problems)
S: Suicide
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13
Q

What increases a patient’s risk for suicide

A
Widowed/unmarried/living alone
Male
Feelings of hopelessness
Prior suicide attempts/plans
FH
Serious medical conditions
Lack of social support
Substance abuse
History of psych admission
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14
Q

Black box warning for antidepressants?

A

High risk of suicidal behavior was found during the first 30 days

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15
Q

Why treat depression?

A

Increase QofL
Decreased suicide risk
Decreased morbidity/mortality of other disease states

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16
Q

Psychotherapy options

A

Cognitive Behavioral Therapy
Interpersonal therapy
Group Therapy

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17
Q

Electroconvulsive Therapy Used for

A

Only for severe depression, resistant depression, depression + psyotic/catatonic feature, or severe suicidal ideation

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18
Q

How does electroconvulsive therapy work?

A

Electrical charge is applied to stimulate the brain and produce a seizure which last about 1 minute
- 6 to 12 treatments then continued antidepressant therapy

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19
Q

Bright Light Therapy

A

For seasonal affective disorder
Exposed to 30 of artificial light upon rising
1-2 weeks long

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20
Q

Vagal Nerve Stimulation Uses

A

Adjunctive to long-term, chronic or recurrent depression (>2 years), no responding to at least 4 trials of drugs

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21
Q

Vagal Nerve Stimulations works how?

A

Surgical implantation under the skin on the chest causes electrical connection to vagal nerve
When activated mild pulses are sent to nerve and travel to brainstem which results in improved mood and depressive symptoms
Take 10 weeks to see a response

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22
Q

Decreased Positive Affect =

A
Anhedonia
Lack of Motivation
Decreased Energy
Apathy
Decreased executive function
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23
Q

Treatment of decrease positive affect

A

Drugs that increase NE and DA

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24
Q

Increased Negative Affect =

A
Worry
Worthlessness
Suicidal ideation
Anxious
Guilt
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25
Q

Treatment of increased negative affects

A

Drugs that increase 5HT

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26
Q

Treatment Guidelines Overview

A
  1. Perform full history/physical, lab evaluation, mental health assessment
  2. Initial Therapy
  3. Partial Response
  4. No response
  5. TCA no recommend but can be used for partial or no response
  6. MAOI should be last line therapy
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27
Q

Initial Therapy Options

A
SSRI
SNRI
Bupropion
Mirtazapine
- Titrate to therapeutic dose and assess for efficacy in 4-6 weeks
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28
Q

Partial Response Options

A
  1. Increase dose if not at max

2. Add psychotherapy if agrees AND/OR add augmentation agent

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29
Q

Augmentation agent options

A

Non-MAOI with different MOA
Lithium
THyroid hormone
2nd gen antipsychotic

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30
Q

No Response Options

A

D/c initial drug and try another

May switch to drug in the same class

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31
Q

Acute Phase Treatment

A

Usual 6-12 weeks

Goal: reach remission of symptoms

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32
Q

Continuation Phase Treatment

A

Continue effective drug for 4-9 months after remission is achieved
Goal: prevent relapse

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33
Q

Maintenance Phase Treatment

A

Continued treatment for 12 months and longer after remission

Goal: prevent recurrences

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34
Q

After 1 episode of depression,

A

pt has a 50% chance of recurrence

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35
Q

After 2 episodes of depression,

A

pt has a 70% chance of recurrence

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36
Q

After 3 episodes of depression,

A

pt has a 90% chance of recurrence, so lifetime antidepressants therapy is recommended

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37
Q

Elderly dosing

A

1/2 normal dose for a week and then increase to therapeutic dose if side effects are not seen

38
Q

Stopping antidepressants

A

Dose should be taper

NEVER stop abruptly

39
Q

STAR-D stands for

A

Sequenced Treatment Alternative to Relieve Depression

40
Q

Conclusions reached by STAR-D?

A
  • Approximately 30% of pts reach remission after 14 weeks of treatment
  • Remission rates increased with each level of the study
  • Higher relapse rates were seen with more treatment levels
  • Achieving remission vs just getting a response showed less likelihood to relapse and had better daily function
41
Q

Drug Specific Conlusions from STAR-D

A
  • Remission rate was slightly higher for venlafaxine XR groups
  • Bupropion was better tolerated
  • Remission rates between mirtazapine and nortriptyline were not significant
  • Remission rates between T3 and lithium were not significant but T3 was better tolerated
  • Venlafaxine + Mirtazapine was better tolerated
42
Q

SSRI Drugs

A
Fluoxetine
Paroxetine
Sertraline
Citalopram
Escitalopram
43
Q

SSRI Side Effects

A

Serotonin AE: GI, sleep, agitation, anorexia, sexual dysfunction
Hyponatremia, GI bleeds

44
Q

Citalopram specific SE

A

Prolong QT interval

45
Q

Fluoxetine Drug interaction

A

2D6 and 3A4 inhibitor

46
Q

Paroxetine Drug interaction

A

2D6 inhibitor

47
Q

SSRI PD

A

Caution with NSAID, antiplatelets, anticoags (risk of bleed)
CI with MAOI
Risk of SS with other serotonergic meds

48
Q

Peds + SSRI

A

Fluoxetine
Sertraline
Escitalopram

49
Q

SSRI Dosing/Counseling

A

QD in AM

With food if problems with nausea

50
Q

SSRI use

A

CVD
Elderly
Decrease negative affect
Comorbid anxiety disorders

51
Q

SSRI avoid use in

A

Hyponatremia pt
Serotonergic agnet
NSAID/antiplatelets
Sexual dysfunction

52
Q

Things that inhibit serotonin metabolism

A
Phenelzine
Tranylcypromine
Selegiline
Linezolid
St. John's Wort
53
Q

Things that increase release of serotonin:

A
Meperidine
Dextromethorphan
Cocaine
LSD
Ecstasy
54
Q

Things that are serotonin receptor agonist

A

Buspirone

Lithium

55
Q

Things that cause Inhibition of Serotonin reuptake

A
SSRI
TCA
Venlafaxine
Duloxetine
Tramadol
Dextromethorphan
Meperidine
56
Q

SNRI Drugs

A

Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran

57
Q

SNRI AE

A

NE AE: tachycardi, elevated BP, insomnia, tremor, sweating, pseudo-antichol
Serotonine SE

58
Q

Duloxetine Specific SE

A

Elevated LFT

59
Q

Venlafaxine Specific SE

A

Prolonged QT interval

60
Q

Duloxetine Drug Interaction

A

2D6 inhibitor

61
Q

Levomilnacipran Drug Interaction

A

3A4 substrate

62
Q

SNRI PD

A
CI with MAOI
Caution with NSAIDs, antiplatelets, anticoag
Caution with other serotonergic
Caution with meds that increase NE
Can decrease HTN meds
63
Q

SNRI Dosing/Counseling

A

AM

With food for GI upset

64
Q

SNRI good choice for:

A

Pts with apathy, low motivation
Hypersomnia
Obese
Pts with pain

65
Q

SNRI Avoid in

A

HTN pts

CVD pts

66
Q

Buproprion AE

A

Decrease seizure threshold
NE AE
DE AE: psychotic symptoms, bad dreams

67
Q

Bupropion DI

A

Inhibitor of 2D6

68
Q

Bupropion PD

A

CI with MAOI
Caution with meds that augment DA
Caution with meds that increase NE
Caution in meds that also decrease seizure threshold

69
Q

Bupropion Dosing/Counseling

A
Extended Release (XL): QD AM
Sustained release (SR): BID, not at bedtime, doses separate by 8 hours and no more than 200 mg per dose
70
Q

Bupropion good choice in

A

No sexual dysfunction
Smokers
Low motivation/energy
Obese

71
Q

Bupropion avoid is:

A

Predispose to seizures
Anorexia
CVD

72
Q

Tertiary TCAs

A

Amitriptyline
Imipramine
Doxepin
Clomipramine

73
Q

Secondary amine TCAs

A

Nortriptyline

Desipramine

74
Q

TCA SE

A
NE
5HT
Anticholinergic (M1)
Sedation and weight gain (H1)
Orthostatic hypoTN (alpha-1)
Arrhythmias (Na/K block)
Decreased seizure threshold
75
Q

TCA Interaction

A

2D6 substrate (narrow therapeutic window so if you have a 2D6 inhibitor could cause toxic SE)

76
Q

TCA PD

A
CI with MAOI
Anticholinergics
Sedating medcations
Caution with meds that increase NE
Caution with serotenergic meds
Decreases effect of clonidine
77
Q

Peds + TCA

A

Amitriptyline, nortriptyline, doxepine >12

Imipramine and desipramine >6

78
Q

TCA Dosing

A

Start low and go slow

Take at bedtime (sedation)

79
Q

TCA Good choice for:

A

Neuropathic pain
Migraine headaches
Insomnia
Decreased appetite

80
Q

TCA Avoid in:

A
History of arrhythmias
CVD
Predisposed to seizures
Elderly
Suicidal
81
Q

Mirtazapine AE

A

Sedation (H1)
Weight gain (H1)
Increased cholesterol
Rare agranulocytosis and increased liver transaminases

82
Q

Mirtazapine Drug Interactions

A
CI with MAOI
Sedating medication
Caution with meds that increase NE
Caution with serotonergic agents
Decrease clonidine effect
83
Q

Mirtazapine Dosing/Counseling

A

Take at bedtime

84
Q

Mirtazapine good choice in:

A

Less sexual dysfunction
Loss of appetite
Insomnia

85
Q

Mirtazapine avoid in:

A

Obese
Hypersomnia
Elevated cholesterol and LFT

86
Q

Vilazodone AE

A

GI upset

87
Q

Vilazodone drug interactions

A

3A4 substrate
CI with MAOI
Caution with NSAIDs, antipaltelets, anticoags

88
Q

Vilazodone Dosing/Counseling

A

QD AM with food

Food increases absorption

89
Q

MAOI Drugs

A

Isocarboxazid
Phenelzine
Tranylcypromine
Selegiline patch

90
Q

MAOI SE

A

NE
5HT
Orthostatic hypotension

91
Q

MAOI Drug/Food Interactions

A

Tyramine foods
CI with other antidepressants
CI with serotonergic meds
CI with NE and DA increasing meds

92
Q

MAOI Limitations

A

No longer first line agent

CI in pts who can’t understand or have trouble remembering med instructions