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Thera II > Mental Health I > Flashcards

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

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2
Q

Pharm pro kinetic anorexia

A

1 domperidone

Can use metoclopramide if nausea

Helps with decrease feeling full in early stages of feeding

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3
Q

If domperidone or metoclopramide not effective for nausea what can you add ?

A

Erythromycin / azithro ??

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4
Q

Constipation for anorexia

A

Prucalopride

  • help normalize colonic function
    -especially if chronic laxative use
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5
Q

Should zinc be added to anorexia

A

Yes - increases rate of weight gain

Zinc gluconate 100mg with meals for 2 months

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6
Q

What can be added for anorexia patients with coexisting depression or anxiety ?

A

SSRI- fluoxetine

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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

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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
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9
Q

Can give clonazepam for severe anxiety also SGA seroquel to decrease dependence (if having meal anxiety)

A
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10
Q

What are you cautious of with anorexia ?

A

Refeeding syndrome

-serious lytes abnormalities
Hallmark: hypophosphatemia

KPMg

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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

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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

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13
Q

Bulimia pharm

A

Could trial SSRI
Fluoxetine
Can also use (venlafaxine, trazodone)

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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

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15
Q

Weight gain targets ?

A

0.2-0.5 kg per week for outpatient until normal BMI > 18.5 is reached

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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

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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

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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

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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)

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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

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21
Q

Treatment option for mild to moderate depression

A

Mild - moderate = psychotherapy are AS effective as medication for depression

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22
Q

Treatment options for severe depression

A

Pharmacotherapy preferred

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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)

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24
Q

PTSD do you treat within first 4 weeks of disturbed event?

A

No, allow natural resilience and usual emotional supports

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25
Q

If those with a traumatic event have impaired functioning and overwhelmed feelings within 4 weeks following traumatic event ? What is your treatment plan

A

Psychotherapy or pharm are both considered #1 and should be tailored to patient preference

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26
Q

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

A
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27
Q

If there is a substance use disorder and ptsd ? What is your treatment plan

A

Refer

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28
Q

What is #1 Nonpharm approach for ptsd

A

1 Trauma focused psychotherapy

Other approaches:
CBT
Prolonged exposure
Cognitive processing therapy
Eye movement desensitization and reprocessing therapy
Supportive therapy

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29
Q

Regardless of psychotherapy treatment modality what is critical to have ?

A

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

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30
Q

What is #1 pharm for ptsd

A

FPSV

“Very scared forever PTSD”
VSFP

Fluoxetine
Paroxetine
Sertraline
Venlafaxine

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31
Q

What are SE of SSRI

A

BAD SSRI

B- body weight increase
A- anxiety
D- dizziness
S- serotonin syndrome
S-stimulated
R- reproductive (sex) dysfunction
I- insomnia

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32
Q

What meds can be used for nightmares in ptsd and for sleep
Disturbances ?

A

Nightmares -> prazosin

Sleep disturbances-> if not responding to sleep hygiene or CBT - I // can try trazodone

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33
Q

DI with SSRI

A

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

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34
Q

What are adjuncts/ can you augment for PTsd treatment ?

A

SGA

“ASO”

Ability
Seroquel
Olanzapine

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35
Q

cannabis and ptsd ?

A

Not recommended / not enough evidence

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36
Q

What do you watch for when you augment with SGA

A

Metabolic adverse events such as weight gain, glucose abnormalities, dyslipidemia

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37
Q

Are benzos recommended in ptsd

A

NO- not even as adjuncts

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38
Q

PTSD and pregnancy treatment

A

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

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39
Q

Nonpharm for first episode/ acute episode schizophrenia

A

Determine appropriate treatment setting
Ensure safety, decrease environmental stressors,

If acutely agitated , risk of harm to self or others -> hospitalize

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40
Q

Nonpharm for stable phase schizophrenia

A

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

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41
Q

Pharm approaches for acute episode schizophrenia

A

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

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42
Q

Pharm approach for acute phase in general

A

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

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43
Q

Stabilizing phase pharm

A

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

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44
Q

Treatment for treatment resistant schizophrenia

A

Clozapine
ONLY MED to shown effective

AE// agranulocytosis / need for regular blood work monitoring

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45
Q

Treatment for comorbid conditions in schizophrenia such as
Depression

A

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 **

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46
Q

Substance use and schizophrenia

A

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

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47
Q

Pregnancy and schizophrenia
First onset in preg// what next ?

A

Emergency - referral to psychiatrist and OBGYN

Safe meds for pregnancy :
Olanzapine

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48
Q

PP and schizophrenia and breastfeeding

A

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
Q

Consider use of long acting injectable SGA for treatment if no adherence/ comorbid substance use

A
50
Q

Antipsychotic induced side effects

A

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
Q

Monitoring for orthostatic hypotension with schizophrenia

A

VS at 12 weeks then annually

52
Q

Monitoring dyslipidemia with schizophrenia

A

Fasting lipid at 12 week after initiation then annually; if increase weight the q6mo

53
Q

Hyperprolactin monitoring

A

Monitoring for 3 months after initiating then yearly

54
Q

EPS monitoring

A

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
Q

Monitoring glucose

A

At 12 weeks after initiation and yearly

56
Q

Monitoring weight gain

A

Weight =6 letters = 6 months

Monthly for 6 months then Q3months when on stable dosing

Waist circumference yearly

57
Q

what to watch for with olanzapine

A

Dyslipidemia

Weight gain

Glucose abnormalities

Orthostatic hypotension

58
Q

OCD first line treatments

A

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
Q

When do OCD treatment see benefits ?

A

6 weeks may take up to 12 weeks for max improvement

60
Q

What happens if there is not much improvement at 6 weeks for ocd

A

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
Q

Are benzos helpful in treating OCD

A

NO

62
Q

OCD in pregnancy/ BF? Treatment

A

Specialized CBT #1

If severe and ++ impairment = SSRI

63
Q

Nonpharm for bipolar

A

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
Q

Pharm for mania

A

Mod-severe = hospital

Mild:
#1 : lithium (caution: renal disease)
Others: quitiapine, divalproex

“Little deep Q”

65
Q

Severe mania episodes pharm

A

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
Q

Depressive episodes of bipolar disease first line treatment

A

LLLSC

If unmedicated start first line treatment:
Lithium
Lamotrigine
Lurasidone
Seroquel
Cariprazine

67
Q

If depression is severe in bipolar what is the treatment

A

Lithium or divalproex + Lurasidone

Lithium + seroquel

68
Q

Adequate response for bipolar

A

2-4 weeks to assess efficacy

69
Q

Maintenance bipolar therapy pharm / what is considered remission?

A

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
Q

Bipolar in children (mania and depressive)

A

Mania:

Lithium
risperidone
Abilify
Asenapine
Seroquel

Depression:
#1 Lurasidone

Need to refer children to child psychiatrist for treatment **

71
Q

Bipolar for elderly first line

A

Mania - lithium, divalproex

Depression- lurasidone, seroquel

SGA= increase stroke risk and mortality in elderly

72
Q

Bipolar and pregnancy

A

Consult with OBGYN and psychiatrist

73
Q

Lithium levels

A

0.5-1.0

74
Q

Lithium adverse event

A

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
Q

Monitoring for lithium

A

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
Q

Lithium drug interactions

A

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
Q

What meds should you not prescribe for anorexia nervosa ?

A

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
Q

First line pharm for depression

A

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
Q

Minimum therapeutic dose should be achieved in ___for depression

A

2 weeks

If side effects are severe, persist >2 weeks and are intolerable. Consider either decreasing the dose or switching agents

80
Q

Duration of treatment for depression?

A

Typically 9 months
2 years if severe / recurrence

81
Q

First line choice for depression in pregnancy for mild to moderate depressive episode

A

Psychotherapy (interpersonal therapy, CBT)

82
Q

Treatment for moderate to severe depression in pregnancy

A

Antidepressant

escitalopram
Citalopram
Sertraline

** are the best for pregnancy and BF

83
Q

Older aldults and depression

A

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
Q

What are adjuncts to depression?

A

Ability
Brexiprazole ??

d=b to remember

85
Q

When do you augment depression meds?

A

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
Q

Treatment for treatment resistance depression?

A

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
Q

antidepressant exposure in utero

A

May be associated with persistent pulmonary hypertension

NAS

88
Q

Postpartum blues treatment

A

Supportive care / self limiting
Requiring only monitoring

89
Q

PPD treatment first line

A

1 psychotherapy (IPT/ CBT)

If more severe antidepressants + psychotherapy
CES #1

90
Q

N/v/c/D with SSRI - what do you do

A

Usually diminishes after 1-2 weeks

Nausea - take with food

Constipation- increase fiber, fluids, laxatives

Diarrhea - probiotics, limit caffeine, alcohol, fluid replacement

91
Q

Activation / anxiety, nervousness, agitation

A

Usually diminishes after 1-2 weeks

Consider short term benzo for extreme anxiety

Severe agitation could indicate intolerance to SSRI - avoid use

92
Q

Somnolence

A

Usually diminishes 1-2 weeks of therapy

Consider bedtime dosing

93
Q

Insomnia and SSRI

A

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
Q

Weight gain

A

Counsel on healthy diet, exercise routines

Monitor metabolic parameters (BP, lipid, glucose)

Consider switching to bupropion which causes weight loss

95
Q

Sex dysfunction

A

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
Q

Serotonin syndrome
(Dilated pupils, hyperreflexia, sweating, fever, agitation, nystagmus, chloride, delirium)

A

Stop the drug immediately / refer to hospital

97
Q

anxiety disorders starts where for treatment

A

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
Q

Pharm for panic disorder

A

SSRI

( best when SSRI + CBT is paired)

99
Q

Treatment for agoraphobia

A

CBT *** pharm not effective

100
Q

Social anxiety pharm

A

SSRI/ SNRI + CBT

  • fluoxetine less effective**
101
Q

First line for specific phobia

A

Exposure therapy #1

Pharm therapy rarely needed but prn benzo prior to exposure maybe helpful

102
Q

First line GAD

A

First is CBT ***

First line pharm is:

SSRI and SNRI

103
Q

How do you titrate anxiety meds

A

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
Q

Benzos for anxiety

A

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
Q

When there is a partial response to meds for anxiety what is next

A

Augment with another agent with SGA

106
Q

Adjuncts to panic disorder

A

SGA- Abilify, olanzapine, risperidone,

107
Q

Adjuncts for GAD

A

Pregabalin

Or

Olanzapine, seroquel, abilify OSA

108
Q

What med can be taken before an anxiety provoking event in social anxiety

A

Propanolol low dose or atenolol taken 30-60 min before an anxiety provoking event

109
Q

First like for anxiety and pregnancy

A

CBT and interpersonal therapy

110
Q

If ++ impairment in pregnancy with anxiety what to do next

A

SSRI
CES

111
Q

What can you augment for OCD treatment

A

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
Q

How long should antipsychotics meds be continued for first episode ?

A

Minimum 2 weeks unless there are significantly tolerability issues

113
Q

What is an adequate trial for antipsychotics

A

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
Q

Stabilization phase how long do you continue pharmacotherapy for first episode ?

A

1-2 years

115
Q

When is longer treatment required for antipsychotics / 2-5 years ?

A

Long duration of untreated psychosis

More severe illness

Slower response

Substance abuse

History or suicidal or aggressive behaviour

116
Q

For a patient that has has >2 episodes of acute schizophrenia, how long do you continue maintenance ?

A

Until the patient is stable and relapse free for at least 5 years

117
Q

How to taper antipsychotics

A

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
Q

Which Med has shown superior efficacy in the treatment of depression based on systematic reviews ?

A

Escitalopram

Thera II (12 decks)

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