Mental Health (MDD, MMD, Anxiety, PTSD) Flashcards
Presentation of Psychiatric Symptoms
- Usually non-specific; vague; uneasiness
- Incumbent on practitioner to identify clusters and patterns
- Many symptoms of common psychiatric disorders have a
somatic component - Important to have knowledge regarding common psychiatric
disorders but when in doubt—refer
Chronic Medical Conditions (co- occurring)
Chronic pain
- Chronic illnesses i.e. RA, COPD, CA, DM, OA, Cardiac disease, Lupus,
Fibromyalgia
- Orthopedic problems which limit function i.e. chronic back pain, joint
disease
- Obesity/anorexia/chronic weight problems
Mood Disorders
Most Common psychiatric disorder (along with anxiety
disorders) to be treated in primary care settings
- Often poorly identified and difficult to treat in primary
settings
- Symptoms reduce capacity for relationships, work and
functionality
- Leading cause of sick days and low productivity
- Includes: dysthymia, depression, mania, mixed state bipolar
Depression
Common emotional state
- 2/3 of people who are clinically depressed go undiagnosed and untreated in the U.S.
- Exists on a continuum—bereavement, acute situational
depression, dysthymia, major depressive disorder
- Age and cultural differences affect behavioral manifestations
Incidence & demographics
Depression has lifetime prevalence of 24% for women and
15% for men
- 15 million adults in U.S. each year
- Estimated between 5%-13% of all adults in primary care
settings have major depressive disorder (MDD)
- MDD assoc with high mortality; 15% will commit suicide
- Leading cause of disability; associated with morbidity and
mortality
Depressive Disorders
PCP is often the gatekeeper for persons with depression
- Becomes pathological if……
- It is disproportionate to events and sustained over a significant
time period
- It significantly impairs normal social functioning
- It significantly impairs normal somatic functioning i.e. vegetative
symptoms such as appetite, sleep, interest, motivation,
relationships
- It is seemingly unrelated to any identifiable precipitant
Major Depressive Disorder (MDD)
Complex brain-based illness with a primary characteristic of
a persistent disturbance in mood
###Excessive or distorted degree of sadness; manifests with
behavioral, affective, cognitive and somatic symptoms
- Etiology—multiple theories range from psychological to
neuro-biological
- Endrocrine dysfunction (HPA)
- Neurotransmitter dysfunction (5HT, NE)
- Genetic
- early attachment, trauma, etc.
- Psycho-social stressors, level of resilience, etc.
MDD Risk and Screening
Disease course is variable; often chronic in nature
- Risk factors include: family hx, prior episode of MDD, female (>50), postpartum, chronic illness co-morbidity, single, significant environmental stressors, childhood trauma, high utilizer of medical care, chronic pain
- Major depression is 2-3 more times as prevalent in primary
care settings than in general pubic
- American College of Preventive Medicine (ACPM) recommends
screening and appropriate treatment for depression at the primary
care level
- Screen by asking 2 questions:
- Over the past month, have you felt down, depressed or hopeless?
- Over the past month, have you felt little interest or pleasure in
doing things?
Symptoms & Presentation MDD
- Get detailed hx; social, medical, family
- Characteristic low energy is common; mood described as
blah, empty, discouraged, blue, down in the dumps - Sleep disturbance is almost always present;
hyper/hyposomnia; early morning awakenings; frequent
awakenings - Women often report symptoms prior to menses
- Weight change can be either up or down
DSM Criteria–SIGECAPS
Constellation of symptoms that last for 2+ weeks, not a normal part of the patient’s behavior and include 5 of the following:
Depressed mood and/or anhedonia MUST be present
- S—changes in SLEEP; insomnia or hypersomnia
- I— loss or INTEREST in usual activities (ANHEDONIA)
- G—feelings of GUILT, hopelessness
- E—decreased ENERGY
- C—poor CONCENTRATION
- A—changes in APPETITE; increased or decreased
- P—PSYCHOMOTOR slowing or agitation
- S—SUICIDAL ideation, plans, or attempts
Mental Status Exam
Appearance: unkempt, tired, disheveled
- Speech: underproductive, slow, monotone
- Affect: constricted, blunted, sad, anxious, irritable
- Mood: sad, depressed, hopeless, guilty, worried, anxious,
irritable
- Thought process and content: slowing, distractible,
ruminative, morbid preoccupation, suicidal ideation,
thoughts of being better off dead or not waking up
- Cognition, concentration, memory: may be impaired
Differentials
- Hypothyroidism and apathetic hypothyroidism in elderly
- Alcohol, substance abuse
- Dementia, delirium
- Hypercalcemia
- Parkinson’s disease
- Stroke, seizure disorder
- Medications: H2 blockers, beta blockers, CNS antihypertensives, steroids
- Major medical illness
Labs, Imaging, Other
- No diagnostic test to determine depression
- Consider CBC, TSH or TFTs, B-12, HIV test, BAL or Tox screen if indicated, LFTs, Antinuclear antibody (ANA),
Dexamethasone suppression test (Cushing), lyme titer - MRI or CT scan if neuro abnormality is suspected
Susan is 48 years old, married, and a mother of 2 teenaged children, ages 13 and 16. She presents to her PCP with complaints of fatigue, muscle aches and pain, insomnia, irritability, loss of appetite, and feelings of “hopelessness.” Upon questioning, she determines that she has had these complaints for at least the past few months – if not longer. Her husband is now employed after
being laid off for 6 months – in a similar job, but with slightly lower pay. She continues to work part-time at the local library, but has recently been finding it increasingly difficult to focus on her work. Symptoms of depression can mimic all but which of the following?
a. Folate and vitamin B12 deficiency
b. Anemia
c. Hypothyroidism
d. Crohn’s disease
c
After lab work, Susan is diagnosed with hypothyroidism and prescribed thyroid hormone. After 6 weeks she returns to her PCP for routine follow-up. Although her thyroid function tests are now within normal range, her depressive symptoms persist; specifically, her energy level has somewhat improved but she continues to complain of fatigue, pain, insomnia, loss of appetite,
and feeling “hopeless”. How might you alter your treatment approach?
a. Make no changes
b. Send her for additional testing including brain CT scan and
HIV serology
c. Increase the dose of her thyroid hormone
d. Maintain thyroid hormone at this level and add an
antidepressant agent
c
Typical Scenario
- 30 y/o female
30 y/o female presented to her PCP/NP with symptoms of frequent h.a., insomnia, feeling overwhelmed, and low
energy. Exam was unremarkable and blood workup
supported mild iron def. anemia. She returned after one
month with improvement in anemia but worsening of prior
symptoms. Pt revealed she’d been feeling sad and had little interest in prior activities she’d once enjoyed. She had some passive suicidal thoughts and poor concentration. Overall she reported feeling like a failure. There were no
recognizable losses. Stated she’d had an episode like this
prior, but without such intensity. No complaints of over productivity or euphoria. Her PCP prescribed antidepressants and referred her to psychiatry.
Clinical Management
Ensure patient safety; assess self-destructive/suicidal
behavior
- Anti-depressant Management
- Inform pt that therapeutic effect may take 4-6 weeks
- Psycho-ed re: side effects
- Continue for at least 8-12 months
- Identify clear measurements and engage patient to use therapy as
adjunct—the two work hand in hand
- May trigger a manic episode for those patients who are bipolar
- Refer if in doubt
Self-destructive and suicidal behavior
- Self-destructive behaviors are maladaptive measures used to restore balance when individual is overwhelmed
Self-destructive behaviors are maladaptive measures used to restore balance when individual is overwhelmed - Nail biting - Cutting; burning - Smoking - Overeating - Hair pulling - Reckless behaviors - Sexual indiscretions - Alcohol/drugs - suicide
Suicide Factoids
3rd leading cause of death between 15-24 yrs old
- 7th leading cause of male deaths; 16th cause for females
- For every 2 murders there are 3 suicides
- More men than women die by suicide 4:1 but women attempt 3 times more often
- Risk for elderly is under appreciated; especially in males
Lethality assessment
Low
no hx of attempts; supports in place; no drugs; no
recent loss; wants help
Lethality assessment
Moderate
has considered lethal method but no plan; hx of
less lethal attempts, uses substances; weighs out life/death
pros and cons
Lethality assessment
High
current lethal plan w/obtainable means; hx of
previous attempts; poor communication; no supports; uses
substances often to excess; depressed; wants to die; may
have impending serious loss (divorce, job loss, court, jail,
etc)
Protective Factors
- Children in the home
- Sense of responsibility to the family
- Pregnancy
- Spiritual or religious belief system
- Reality testing intact
- Coping/problem solving ability
- Social supports
- Employment or meaningful work
- Meaningful relationships
Levels of threat
- Chronic
- Suicidal ideation
- Suicide threat
- Suicidal gesture
- Suicide attempt
- Successful suicide
Direct Questioning
- Have you ever thought of taking your own life?
- Have you ever been so sad that you wanted to end it all?
- How long have you been feeling this way?
- How are you thinking of hurting/harming/killing yourself?
- Never agree to keep clinical information a secret—get help
- Don’t accept denial at face value—probe
- Ask what are your reasons for living
- Ask what has changed to improve your outlook
Pharmacological Agents–SSRI
- Selective serotonin reuptake inhibitors (SSRI)—act primarily to serotonin in CNS
- Celexa (citalopram)-20-40mg (no longer FDA approved for
60mg) - Lexapro (escitalopram)-10-20mg
- Prozac (fluoxetine)-20-60mg-energizing, long half life (CPY 450) *only FDA approved anti-depressant for children
- Paxil (paroxetine)-20-60mg-also targets anxiety & panic;
significant discontinuation syndrome - Zoloft (sertraline)-25-200mg—also anxiety and mild OCD; GI upset, headache common
Common side effects of SSRI
GI upset, sexual dysfunction,
nervousness, headache, dry mouth, sleepiness, weight gain
Which of the following agents is likely not an
appropriate antidepressant for a patient with
cardiovascular disease?
a. TCAs
b. SSRIs
c. SNRIs
d. Atypical antidepressants, such as bupropion
a
Pharmacological Agents–Other
SNRIs-
- SNRIs-
- Venlafaxine (Effexor)—75-375mg, energizing, significant discontinuation syndrome
- Duloxetine (Cymbalta)—30-120mg; sig discontinuation syndrome, pain syndromes
NDRIs
- Wellbutrin (bupropion)—nervousness, HA, insomnia, smoking, ADHD, sz threshold; 150-450mg
