Mental Health in Adults Flashcards
What is the most common class of mental disorders?
Anxiety disorders
- Phobias are the leading cause
What two conditions are often associated with GAD?
- Mixed headache
- IBS
Common complaints patients present with if you suspect anxiety
Worry, anxiety, fear
Anxiety physical complaints
- Fatigue
- Irritability
- Cognitive changes
- Sleep disturbances
- Other psychiatric illnesses (depression, SUD)
What is the definition of GAD?
Excessive anxiety and worry about a number of events or activities
Diagnostic considerations for anxiety
Must meet criteria in DSM-5 with symptoms being at a moderate to severe level impacting hygiene, relationships, employment, education
Screening tools that can be used for anxiety
- GAD-7
- PC-PTSD
- SPIN
- PHQ-SADS
- PHQ-15
Diagnostic tests and labs for anxiety
- Complete physical exam
- Thorough ROS
- CBC, CMP, TSH, vitamin B12, electrolytes
- Toxicology screen
- ECG (if necessary)
When is a mental health referral indicated for patients with anxiety? To the ED?
- Mental health referral if not responding to first line medications
- ED referral if at risk for harming themselves or others
Pharmacotherapy management for anxiety
- Antidepressants (SSRIs, SNRIs)
- Benzodiazepines (acute anxiety)
- Buspirone (for GAD only)
- Atypical antipsychotics
- Monitor for metabolic disorder
When prescribing medications for anxiety, how long should therapy continue?
Medications should be continued for at least 6-12 months after symptoms have resolved
- To avoid relapse
Benzodiazepines should not be prescribed for what disorder?
Insomnia
- Can cause rebound insomnia when benzodiazepine is discontinued
What classification of medication is contraindicated for patients with a history of risk for suicide?
TCAs
Common clinical presentation of unipolar depression
- Disinterest
- Persistent sadness
- Helplessness
- Pessimism
- Worthlessness
- Guilt
- Tiredness
- Confusion
- Irritability
- Decreased concentration
- Diminished hygiene
- Increased alcohol intake
- Unexplained weight loss or weight gain
- Thoughts of death
Common clinical presentation of bipolar disorder
- Bipolar I
- Mania
- Hypomania
- Severe depression
Common clinical presentation of bipolar disorder
- Bipolar II
- History of hypomania and major depression
- NO manic episodes
Common clinical presentation of bipolar disorder (general)
- Profound depression
- Several days of reduced or no sleep without fatigue
- Mood swings
- Racing thoughts
- Irritability and irrationality
Clinical presentation of seasonal affective disorder (SAD)
Symptoms associated with bipolar I and II but related to changes in season (especially during fall and winter)
- Hypomania
- Mania
- Depression
- Carbohydrate craving
If a patient is taking medications for seasonal affective disorder (SAD), when should they wean off their medications?
Can wean off during warmer months
What is normally the first sign of depression in children/adolescents/adults and older adults?
Children, adolescents, adults → irritability
Older adults → cognitive dysfunction
Non pharmacologic management of depression and bipolar disorder
- Psychotherapy
- CBT
- Family therapy
- Substance use counseling
- Promote healthy lifestyle changes
- SAD → bright light therapy
- Bipolar → ECT
Medications for depression therapy
- SSRIs
- SNRIs
- Atypical antidepressants
- TCAs
- MAOIs
What patient education should be mentioned with MAOI therapy?
Avoid foods high in tyramine
- Aged cheese, sauerkraut, cured meats, draft beer, fermented soy products
Indications for immediate referral for patients with substance use disorder
- Withdrawal seizures (from benzodiazepines or alcohol withdrawal)
- Delirium tremens
- Overdose
- Suicidality/homicidality/psychosis
- Ready for treatment
What is tolerance?
A person no longer responds to a drug in the way they did at first, so it takes a higher dose of the drug to achieve the same effect as when the person first used it
What is dependence and withdrawal?
Dependence means that when a person stops using a drug, their body goes through “withdrawal”
- A group of physical and mental symptoms that can range from mild to life-threatening
What substances are considered CNS sedatives?
- Alcohol
- Barbiturates
- Benzodiazepines
- Opioids
What substances are considered CNS stimulants?
- Cocaine
- Amphetamines
What substances are considered psychotomimetic and hallucinogens?
- PCP
- LSD
- Inhalants
- Anabolic steroids
- Injection drug use
If a patient presents with acute pain, can the provider prescribe opioids?
Yes - start with immediate release opioids
- Prescribe only for <3 days or 7 days maximum
- Reevaluate every 3 months
How would patients with substance use disorder (SUD) initially present?
Behavioral problems appear first
- Early manifestations of addiction are rarely apparent with routine examination
Clinical presentation of CNS sedatives
- Tranquilization
- Fine lateral or coarse nystagmus
- Decreased alertness (intoxication)
- Ataxia
- Slurred speech
- Sedation (moderate intoxication)
- Somnolence
- Staggering
- Dysarthria
- Coma
- Respiratory depression and death
Clinical presentation of opioid addiction
- Euphoria
- Calmness
- Sedation
- Constricted pupils
- Decreased RR and bowel motility
- Mildly decreased BP and HR
- N/V
- Generalized itchiness
Clinical presentation of stimulant use
- Enhanced state of alertness
- High energy
- Euphoria
- Appetite suppression
- Decreased need for sleep
Clinical presentation of hallucinogen use
- Extreme euphoria to severe depression/paranoia/panic or transient psychosis
- Pupil dilation
- Tachycardia or HTN
- Hyperthermic crisis → dry skin, agitation, muscle hypertonicity, seizures
Clinical presentation of cannabis use
- Euphoria
- Relaxation
- Altered sensory perception
Alcohol withdrawal begins __ hours after the patient’s last drink, and can last 1-2 days
6-24 hours
How soon does delirium tremens occur after alcohol consumption?
Occurs within 72-96 hours after last alcohol consumption
Signs and symptoms of delirium tremens
- Severe tachycardia
- Tremor
- Confusion
- Hallucinations
- Agitation
- Diaphoresis
- Fever
- Seizures
Screening tools for substance use disorder (SUD)
AUDIT and CRAFFT for alcohol
DAST-10 for SUD
Lab tests that can be ordered for patients with substance use disorder (SUD)
- CBC, CMP, BUN, creatinine, LFT, glucose, electrolytes
- Hepatitis panel
- HIV screening
- HCG test
- Thyroid test
- Drug screening
Alcohol abuse lab findings
- AST to ALT ratio of 2:1 → alcohol related liver disease
- Elevated GGT (most sensitive marker of excessive alcohol use)
- Elevated MCV
- Elevated CDT
Gold standard medication for alcohol withdrawal
Benzodiazepines (based on CIWA score)
Medication for opioid overdose
Naloxone
SSRI and SNRI side effects
- Sexual dysfunction
- Nausea, diarrhea, constipation
- Dry mouth
- Headache
- Dizziness
- Insomnia
TCA side effects
- Drowsiness, fatigue, sedation
- Dry mouth
- Weight gain
