Mental Health I Flashcards
1
Q
Anorexia Nonpharm
A
Family interventions and treatment
Stepwise nutrition goals
Ensure boost to achieve weight gain
Trained meal support
Exercise limited (yoga ok)
Warming
Monitoring binge/purge behaviors
Once body fat normalized >20%
Psychotherapy can start
2
Q
Pharm pro kinetic anorexia
A
1 domperidone
Can use metoclopramide if nausea
Helps with decrease feeling full in early stages of feeding
3
Q
If domperidone or metoclopramide not effective for nausea what can you add ?
A
Erythromycin / azithro ??
4
Q
Constipation for anorexia
A
Prucalopride
- help normalize colonic function
-especially if chronic laxative use
5
Q
Should zinc be added to anorexia
A
Yes - increases rate of weight gain
Zinc gluconate 100mg with meals for 2 months
6
Q
What can be added for anorexia patients with coexisting depression or anxiety ?
A
SSRI- fluoxetine
7
Q
What vitamin should be added to all anorexia patient
A
Thiamine 100mg daily IM x 5 days at start of refeeding
- beginning of feeding to prevent wernake-korsakoff syndrome
And
zinc gluconate x2 months
8
Q
Can give olanzapine 3-4 mo until no longer requires , cyproheptadine (helps with weight gain)
Both have modest weight gain and hypnotic effect
A
9
Q
Can give clonazepam for severe anxiety also SGA seroquel to decrease dependence (if having meal anxiety)
A
10
Q
What are you cautious of with anorexia ?
A
Refeeding syndrome
-serious lytes abnormalities
Hallmark: hypophosphatemia
KPMg
11
Q
First diagnosis of anorexia ? What do you do?
A
Counsel re regarding diagnosis
Increase food intake for weight gain and normalize eating
Weekly follow up
Thiamine x 5 days
Oral zinc x 2 months
Others:
Domperidone or metoclopramide
Olanzapine or cyproheptadine
Clonazepam or seroquel for anxiety
12
Q
If no improvement of anorexia within 1-2 months after everything implemented AND medically unstable or suicidal
A
Urgent referral to psych or medical
If some improvement, continue the course and do non urgent referral
13
Q
Bulimia pharm
A
Could trial SSRI
Fluoxetine
Can also use (venlafaxine, trazodone)
14
Q
Bulimia Nonpharm
A
Assess si/sh/ depression
CBT helpful in addressing cognitive and emotional issues
Psychoed groups
Self help approach offers accessible early interventions for both adolescents and adults
15
Q
Weight gain targets ?
A
0.2-0.5 kg per week for outpatient until normal BMI > 18.5 is reached
16
Q
Additional therapeutic targets
A
> 20% body fat
Continued linear growth in those whose epiphyses have not closed
Menstruation (but this may resume due to stress)
Ovulation
Decreased fear of weight gain
Normalization of strength
Normalization or cognitive function
17
Q
What is first line for insomnia?
A
CBT-insomnia #1
Can also do stimulus control therapy to eliminate maladaptive behaviors
Sleep hygiene education
Relaxation techniques
Sleep restriction
Paradoxical
Multi component therapy
18
Q
What are pharm options for insomnia?
A
Mainstay - nonprescription first (dimenhydramine, melatonin)
Should use only for < 4 days
Diphenhydramine (Benadryl) -> use with caution / associated with cognitive impairment, increase risk for falls, work related injuries
-intermittent use only <4x/ week
-if >7 days , need to be R/a
FIRST LINE for >55 and kids:
Melatonin **
If still having difficulty sleeping after 1 week could try prescription:
Benzos
Non benzos agonist (zolpidem, zoplicone)
Trazodone actually not well supported
19
Q
If duration of symptoms of insomnia <3 days what do you suggest:
A
Usually self limiting upon resolution of acute stressor
Recommend: good hygiene practices. If insomnia occurs in a predictable pattern, consider short term drug therapy (2-3 nights only)
20
Q
If duration of insomnia 3days - 3 weeks (short term) or chronic (>3 weeks) what dk you suggest ?
A
Assess sleep hygiene and recommend CBT-i#1
If nonprescription drug therapy (melatonin) used and ineffective after 3 nights or required >7 days consecutive consider prescription
21
Q
Treatment option for mild to moderate depression
A
Mild - moderate = psychotherapy are AS effective as medication for depression
22
Q
Treatment options for severe depression
A
Pharmacotherapy preferred
23
Q
What is first line for depression Nonpharm
A
CBT, behavioral activation and interpersonal therapy #1
Other Nonpharm
- exercise and yoga
-dietary outcome decrease refined/ processed food and increase fruits/ vegetables/ lean protein
- light therapy (if seasonal pattern)
-novel neurostimulation therapies (adjunct strategies)
24
Q
PTSD do you treat within first 4 weeks of disturbed event?
A
No, allow natural resilience and usual emotional supports
25
If those with a traumatic event have impaired functioning and overwhelmed feelings within 4 weeks following traumatic event ? What is your treatment plan
Psychotherapy or pharm are both considered #1 and should be tailored to patient preference
26
If there is a comorbid mood
Disorder in ptsd, treat the mood disorder as primary condition
Also important to manage chronic pain and sleep disturbances as well as
27
If there is a substance use disorder and ptsd ? What is your treatment plan
Refer
28
What is #1 Nonpharm approach for ptsd
#1 Trauma focused psychotherapy
Other approaches:
CBT
Prolonged exposure
Cognitive processing therapy
Eye movement desensitization and reprocessing therapy
Supportive therapy
29
Regardless of psychotherapy treatment modality what is critical to have ?
Behavioural stabilization
Initiation trauma focused psychotherapy prior to stabilization may exacerbate pre existing comorbid symptoms of depression
In those who do not need stabilization and are unable or delayed in accessing in person psychotherapy -> internet CBT can be considered
30
What is #1 pharm for ptsd
FPSV
“Very scared forever PTSD”
VSFP
Fluoxetine
Paroxetine
Sertraline
Venlafaxine
31
What are SE of SSRI
BAD SSRI
B- body weight increase
A- anxiety
D- dizziness
S- serotonin syndrome
S-stimulated
R- reproductive (sex) dysfunction
I- insomnia
32
What meds can be used for nightmares in ptsd and for sleep
Disturbances ?
Nightmares -> prazosin
Sleep disturbances-> if not responding to sleep hygiene or CBT - I // can try trazodone
33
DI with SSRI
Concurrent use with MAOI, linezolid, methylene blue = CI due to risk of serotonin syndrome
Increase risk of GI bleed with NSAIDS and anti platelet drugs
Avoid with drugs that prolong QTc
34
What are adjuncts/ can you augment for PTsd treatment ?
SGA
“ASO”
Ability
Seroquel
Olanzapine
35
cannabis and ptsd ?
Not recommended / not enough evidence
36
What do you watch for when you augment with SGA
Metabolic adverse events such as weight gain, glucose abnormalities, dyslipidemia
37
Are benzos recommended in ptsd
NO- not even as adjuncts
38
PTSD and pregnancy treatment
PTSD can worsen or relapse ptsd during pregnancy
Screen pre conception , throughout preg and pp
Treatment:
CBT
If severe -> refer to psychiatrist
SSRI
CES
Citalopram
Escitalopram
Sertraline
Same management if breastfeeding
39
Nonpharm for first episode/ acute episode schizophrenia
Determine appropriate treatment setting
Ensure safety, decrease environmental stressors,
If acutely agitated , risk of harm to self or others -> hospitalize
40
Nonpharm for stable phase schizophrenia
Usually occurs over 6 months but may take longer and may be incomplete
Focus should be on:
Med adherence
Stress management
S/s of post psychotic depression and suicidality
Substance use
Education about early relapse
***psychosocial interventions are essential in all parts of illness***
CBT
Motivational interviewing, social and vocational skills , employment support programs, peer support groups
Counseling regarding health diets exercise (taichi)
Substance use teaching
41
Pharm approaches for acute episode schizophrenia
Haldol IM
Haldol IM + Ativan = better effect
First line tho:
SGA (can use FGA but SGA better)
Ability
Lurasidone
Olanzapine
Paliperidone
Seroquel
Risperidone
Ziprasidone
**start low and titrate slow over 1-2 weeks**
IF FGA - use intermittent potency
Loxapine, perphenazine
Benzos can be used for anxiety/ agitation while titrating the dose
42
Pharm approach for acute phase in general
Antipsychotics continued for 2 weeks
If lack of response / assess adherence and substance use
If partial response @ 4 weeks ; re-assess at 8 weeks to determine if a switch to a different medication is indicated
DURATION OF ADEQUATE TRIAL: 4-8wks
43
Stabilizing phase pharm
Avoid changes to meds unless intolerable side effects
You want to continue maintenance pharm for 1-2 years ( for first episode who are in remission)
Longer treatment 2-5 years may be required for individuals with long duration of untreated psychosis, slower response, substance use, hx
If >2 episodes -> pharm until stable and relapse free for 5 years
Many will need forever meds // lack of adherence , relapse takes longer, recovery not as great resulting in persistent residual symptoms and functional disability
44
Treatment for treatment resistant schizophrenia
Clozapine
ONLY MED to shown effective
AE// agranulocytosis / need for regular blood work monitoring
45
Treatment for comorbid conditions in schizophrenia such as
Depression
SGA effective for depressive symptoms in acute phase
Calgary depression scale for schizophrenia can differentiate MDD or negative schizophrenia symptoms
Antidepressant could be useful in major depression in stabilization phases
CBT also
Useful **
46
Substance use and schizophrenia
Smoking - bupropion, venlafaxine
cannabis - poor adherence and greater severity and chronicity of symptoms
- harm reduction approach incorporates motivational interviewing for those with comorbid substance use /- also referral
47
Pregnancy and schizophrenia
First onset in preg// what next ?
Emergency - referral to psychiatrist and OBGYN
Safe meds for pregnancy :
Olanzapine
48
PP and schizophrenia and breastfeeding
PP- restart meds asap / high risk of relapse ; If babe exposed to clozapine need to watch neutrophil count
BF- olanzapine only
Some recommend not to BF
49
Consider use of long acting injectable SGA for treatment if no adherence/ comorbid substance use
50
Antipsychotic induced side effects
Orthostatic hypotension (
low potency FGA and clozapine and SGA)
DRESS (
rash with several SGA)
Dyslipidemia
(clozapine/ olanzapine)
Hyperprolactinemia
(high potency FGA, risperidone, paliperidone)
Sexual dysfunction (all)
EPS
(more prominent with FGA then SGA)
Glucose abnormalities
(Both FGA/ SGA)
Neuroleptic malignant syndrome
(Rare but can occur with all)
- medical emergency
Sedation and cognitive effects
-all
Weight gain
-low potency FGA but also many SGA
51
Monitoring for orthostatic hypotension with schizophrenia
VS at 12 weeks then annually
52
Monitoring dyslipidemia with schizophrenia
Fasting lipid at 12 week after initiation then annually; if increase weight the q6mo
53
Hyperprolactin monitoring
Monitoring for 3 months after initiating then yearly
54
EPS monitoring
Baseline assessment, monitor weekly for 2-4 weeks until resolves
In stable pt, Monitor TD at every clinical encounter and q6mo
Symptoms of TD include uncontrollable movements of the face and body such as:
Facial grimacing (commonly involving lower facial muscles)
Finger movement (piano playing movements)
Rocking or thrusting of the pelvis (duck-like gait)
Jaw swinging.
Repetitive chewing.
Rapid eye blinking.
Tongue thrusting.
Restlessness.
55
Monitoring glucose
At 12 weeks after initiation and yearly
56
Monitoring weight gain
Weight =6 letters = 6 months
Monthly for 6 months then Q3months when on stable dosing
Waist circumference yearly
57
what to watch for with olanzapine
Dyslipidemia
Weight gain
Glucose abnormalities
Orthostatic hypotension
58
OCD first line treatments
Specialized CBT + SSRI
Citalopram
Escitalopram
Sertraline
Fluoxetine
Fluvoxamine
Paroxetine
Consider CBT as first line treatment for most patients, since pharmacotherapy is associated with high risk of relapse when treatment is discontinued
BUT since accessing a therapist with expertise in OCD is limited, starting an antidepressant until CBT can be obtained is a reasonable approach
59
When do OCD treatment see benefits ?
6 weeks may take up to 12 weeks for max improvement
60
What happens if there is not much improvement at 6 weeks for ocd
Assess adherence and consider escalation to max recommended tolerate dose before switching agents
Can augment with :
Abilify 10-15mg
Risperidone 0.5-3 mg
(Higher doses than MDD)
IF not tolerated, augment with
Lamtrogine
Memantine
Topiramate amantadine
61
Are benzos helpful in treating OCD
NO
62
OCD in pregnancy/ BF? Treatment
Specialized CBT #1
If severe and ++ impairment = SSRI
63
Nonpharm for bipolar
Psycho education
-consisting of information about illness as well as training in coping skills
**structured group psychoed=good**
-evidence also supports CBT, family therapy
64
Pharm for mania
Mod-severe = hospital
Mild:
#1 : lithium (caution: renal disease)
Others: quitiapine, divalproex
“Little deep Q”
65
Severe mania episodes pharm
Can do 2 drugs
Lithium or divalproex + SGA like
seroquel
Or
Lithium or divalproex + abilify or respiridone
** trial at least 2 weeks before assessing efficacy **
66
Depressive episodes of bipolar disease first line treatment
LLLSC
If unmedicated start first line treatment:
Lithium
Lamotrigine
Lurasidone
Seroquel
Cariprazine
67
If depression is severe in bipolar what is the treatment
Lithium or divalproex + Lurasidone
Lithium + seroquel
68
Adequate response for bipolar
2-4 weeks to assess efficacy
69
Maintenance bipolar therapy pharm / what is considered remission?
If doing well for 2 months = remission
To prevent relapse, interventions include psychosocial strategies, such as psychoed, CBT, family therapy, interpersonal and social treatment
First line:
Lithium
Seroquel
Divalproex
Lamotrigine
Abilify
Arsenapine
Cariprazine= ineffective for maintenance phase only effective for mania and depressive phase
70
Bipolar in children (mania and depressive)
Mania:
Lithium
risperidone
Abilify
Asenapine
Seroquel
Depression:
#1 Lurasidone
Need to refer children to child psychiatrist for treatment ****
71
Bipolar for elderly first line
Mania - lithium, divalproex
Depression- lurasidone, seroquel
SGA= increase stroke risk and mortality in elderly
72
Bipolar and pregnancy
Consult with OBGYN and psychiatrist
73
Lithium levels
0.5-1.0
74
Lithium adverse event
NVD
Polyuria
Polydipsia
Fine tremor
Renal effects
LMNOP
L-lithium
M-movement (tremor)
N-nephrology and nephrogenic diabetes insipidus (polyuria/polydipsia)
O-hypothyroidism (increases risk)
P-pregnancy (teratogen)
75
Monitoring for lithium
When starting:
Lytes, 24h urine for ClCr
Check serum 5days after starting/ changes then Q3-6 mo once stable
Q6mo
SCr, lytes, CBC, TSH, serum levels
76
Lithium drug interactions
NSAIDS
ACEI
ARB
Thiazide diuretic
** Avoid large changes in salt and coffee intake , fluid intake **
Coffee can reduce lithium levels so important not to change your normal consumption
77
What meds should you not prescribe for anorexia nervosa ?
TCA, MAOI and bupropion
Bupropion has been associated with an increase risk of seizures in patients with eating disorders
MAOI and TCA ( toxicity and poor adherence)
78
First line pharm for depression
SSRI (due to tolerability)
Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline
Side effects mainly GI tract, CNS and sexual function
SSRI increase risk of GI bleeding
79
Minimum therapeutic dose should be achieved in ___for depression
2 weeks
If side effects are severe, persist >2 weeks and are intolerable. Consider either decreasing the dose or switching agents
80
Duration of treatment for depression?
Typically 9 months
2 years if severe / recurrence
81
First line choice for depression in pregnancy for mild to moderate depressive episode
Psychotherapy (interpersonal therapy, CBT)
82
Treatment for moderate to severe depression in pregnancy
Antidepressant
escitalopram
Citalopram
Sertraline
** are the best for pregnancy and BF
83
Older aldults and depression
Start at a lower dose and carefully monitor side effects , increase risk for falls) may also take longer to respond 12+ weeks
Possibly preferred es/citalopram, sertraline, duloxetine
84
What are adjuncts to depression?
Ability
Brexiprazole ??
d=b to remember
85
When do you augment depression meds?
Moderate to severe depression or refractory depression
-> When there is more than 3 previous depressive episodes
Or when there is a partial response to antidepressant
** it is not recommended for long term use // watch for metabolic effects , weight gain, dyslipidemia, glucose irregularities
86
Treatment for treatment resistance depression?
First, antidepressants can be switched either within a medication class or to a different class. Most physicians switch out of the class.
Augment for partial response// for severe depression or refractory, augmentation is strongly advised
SSRI or SNRI + intranasal esketamine has been approved
ECT an option
87
antidepressant exposure in utero
May be associated with persistent pulmonary hypertension
NAS
88
Postpartum blues treatment
Supportive care / self limiting
Requiring only monitoring
89
PPD treatment first line
#1 psychotherapy (IPT/ CBT)
If more severe antidepressants + psychotherapy
CES #1
90
N/v/c/D with SSRI - what do you do
Usually diminishes after 1-2 weeks
Nausea - take with food
Constipation- increase fiber, fluids, laxatives
Diarrhea - probiotics, limit caffeine, alcohol, fluid replacement
91
Activation / anxiety, nervousness, agitation
Usually diminishes after 1-2 weeks
Consider short term benzo for extreme anxiety
Severe agitation could indicate intolerance to SSRI - avoid use
92
Somnolence
Usually diminishes 1-2 weeks of therapy
Consider bedtime dosing
93
Insomnia and SSRI
Usually diminishes after 1-2 weeks of therapy
Daytime dosing
Consider short term hypnotic (benzo/ z drugs) only for severe cases
Counsel on sleep hygiene
94
Weight gain
Counsel on healthy diet, exercise routines
Monitor metabolic parameters (BP, lipid, glucose)
Consider switching to bupropion which causes weight loss
95
Sex dysfunction
Usually improvement is achieved with remission of depression
Consider starting a PDE5 inhibitor in males
Consider switching to antidepressant with least associated sex dysfunction (bupropion, mirtaZapine, vortioxetine, vilazodone)
96
Serotonin syndrome
(Dilated pupils, hyperreflexia, sweating, fever, agitation, nystagmus, chloride, delirium)
Stop the drug immediately / refer to hospital
97
anxiety disorders starts where for treatment
Nonpharm (its the basis and should include psycho education)
CBT, exposure therapy and mindfulness based therapy
Specific CBT is the preferred psychotherapy if available
Exercise also helpful
Caffeine and other stimulants should be reduced
Alcohol used at minimum
Balanced lifestyle and healthy sleep hygiene
98
Pharm for panic disorder
SSRI
( best when SSRI + CBT is paired)
99
Treatment for agoraphobia
CBT *** pharm not effective
100
Social anxiety pharm
SSRI/ SNRI + CBT
* fluoxetine less effective**
101
First line for specific phobia
Exposure therapy #1
Pharm therapy rarely needed but prn benzo prior to exposure maybe helpful
102
First line GAD
First is CBT ***
First line pharm is:
SSRI and SNRI
103
How do you titrate anxiety meds
Start low dose, titrate every 1-2 weeks
Optimal clinical response = 12 weeks
Most need to stay on meds for 12-24 months to achieve remission
104
Benzos for anxiety
Can be used in the beginning of treatment while waiting for antidepressants to take effect (6-8 weeks)
Also for panic attacks
Or to reduce anxiety and agitation related to SSRI
105
When there is a partial response to meds for anxiety what is next
Augment with another agent with SGA
106
Adjuncts to panic disorder
SGA- Abilify, olanzapine, risperidone,
107
Adjuncts for GAD
Pregabalin
Or
Olanzapine, seroquel, abilify OSA
108
What med can be taken before an anxiety provoking event in social anxiety
Propanolol low dose or atenolol taken 30-60 min before an anxiety provoking event
109
First like for anxiety and pregnancy
CBT and interpersonal therapy
110
If ++ impairment in pregnancy with anxiety what to do next
SSRI
CES
111
What can you augment for OCD treatment
Can augment with :
Abilify 10-15mg
Risperidone 0.5-3 mg
(Higher doses than MDD)
IF not tolerated, augment with
Lamtrogine
Memantine
Topiramate amantadine
112
How long should antipsychotics meds be continued for first episode ?
Minimum 2 weeks unless there are significantly tolerability issues
113
What is an adequate trial for antipsychotics
4-6 weeks at a dose within the therapeutic range
If there is a partial response at 4 weeks, reassess as 8 weeks in order to determine if a switch to a different antipsychotic med is indicated
Patients who fail to demonstrate even a minimum response by that time are unlikely to benefit from a longer trial, consider switching to a different antipsychotic and consulting with a psychiatrist
114
Stabilization phase how long do you continue pharmacotherapy for first episode ?
1-2 years
115
When is longer treatment required for antipsychotics / 2-5 years ?
Long duration of untreated psychosis
More severe illness
Slower response
Substance abuse
History or suicidal or aggressive behaviour
116
For a patient that has has >2 episodes of acute schizophrenia, how long do you continue maintenance ?
Until the patient is stable and relapse free for at least 5 years
117
How to taper antipsychotics
Gradually reduce by <20% every 2-4 weeks
Reduce over a period of 6-12 months for first episode
And 6-24 months for those who have had more than 2 episodes
Monitor closely, early signs of relapse, restabilize on previous effective dose asap
118
Which Med has shown superior efficacy in the treatment of depression based on systematic reviews ?
Escitalopram
