Psych Flashcards
Psychiatric Treatment in Primary Care
Objectives
- Identify and assess patients presenting with d_____ and a______
- Understand common medical conditions that can mi____ psychiatric symptoms
- Initiate and manage psycho________ treatment for depression and anxiety
- C______ psychotropic medications and understand mon______ protocols for common psychiatric medications
- Refer patients to appropriate settings for treatment
- Assess risk for s_______and h_____ behavior
- Identify and assess patients presenting with depression and anxiety
- Understand common medical conditions that can mimic psychiatric symptoms
- Initiate and manage psychopharmacological treatment for depression and anxiety
- Continue psychotropic medications and understand monitoring protocols for common psychiatric medications
- Refer patients to appropriate settings for treatment
- Assess risk for suicidal and homicidal behavior
Why don’t I just refer to psychiatry?
- Time between onset and diagnosis can be __-__ years
- Barriers to treatment include:
- Cost and limited _____ coverage
- Limited options and ____ wait times
- Lack of aw______
- Social st_____
Primary care providers have a unique opportunity to identify and treat mental health conditions…don’t be ____!
- Time between onset and diagnosis can be 3-4 years
- Barriers to treatment include:
- Cost and limited insurance coverage
- Limited options and long wait times
- Lack of awareness
- Social stigma
Primary care providers have a unique opportunity to identify and treat mental health conditions…don’t be afraid!
- bulk of mental health care done at primary care level, and many general practitioners are subscribing these medications/chart is old and numbers are rising*
- You are first line*
Clinical Presentations of Depression and Anxiety
- “I’m so t____all the time”
- “My st_____is always in a knot”
- “My hands feel n____”
- “My heart keeps r_____”
- “I can’t sl_____”
- “I constantly have loose _____”
- “I’m so tired all the time”
- “My stomach is always in a knot”
- “My hands feel numb”
- “My heart keeps racing”
- “I can’t sleep”
- “I constantly have loose stools”
Clinical Presentations
- Often patients present with s_____ manifestations of depression and anxiety
- Neuro_____ symptoms (fatigue, poor sleep, decreased concentration/memory)
- P____
- N____ness/ti____
- N_______
- Head_____
- Palp________
- Work up their complaint from a medical perspective including appropriate l____
- Often patients present with somatic manifestations of depression and anxiety
- Neurovegetative symptoms (fatigue, poor sleep, decreased concentration/memory)
- Pain
- Numbness/tingling
- Nausea
- Headache
- Palpitations
- Work up their complaint from a medical perspective including appropriate labs
don’t automatically think anxiety, workup medical issues first, diabetic neuropathy etc., trouble breathing -> CHF/COPD
Common diagnoses that mimic symptoms of mood disorders
- Endocrine/metabolic d/o
- Hyper/hypo_______ (fatigue, weight changes, palpitations, muscle aches)
- D_______ (fatigue, irritability, weight changes)
- El______ imbalance (Mg, Ca, K, Na)
- Cardiopulmonary
- C_ _ , CO_ _
- (1) process
- Mononucleosis, viral hepatitis, HIV, acute bacterial infection, tuberculosis
- Endocrine/metabolic d/o
- Hyper/hypothyroidism (fatigue, weight changes, palpitations, muscle aches)
- Diabetes (fatigue, irritability, weight changes)
- Electrolyte imbalance (Mg, Ca, K, Na) •
- Cardiopulmonary
- CHF, COPD
- Infectious disease process
- Mononucleosis, viral hepatitis, HIV, acute bacterial infection, tuberculosis
Common diagnoses that mimic symptoms of mood disorders
- Vitamin __/___ deficiency (low energy, poor concentration)
- An____ (fatigue)
- Rh_______ d/o
- Fibromyalgia, systemic lupus erythematosus, Lyme disease
- Medication (1)
- Corticosteroids, stimulants, benzodiazepines, muscle relaxants
- ____ use – order utox
- Withdrawal and use (cocaine, EToH, tobacco, K, heroin…)
Co______ depression/anxiety can also occur alongside any medical condition
- Vitamin D/B12 deficiency (low energy, poor concentration)
- Anemia (fatigue)
- Rheumatologic d/o
- Fibromyalgia, systemic lupus erythematosus, Lyme disease
- Medication side effects
- Corticosteroids, stimulants, benzodiazepines, muscle relaxants
- Drug use – order utox
- Withdrawal and use (cocaine, EToH, tobacco, K, heroin…)
Comorbid depression/anxiety can also occur alongside any medical condition
DSM-5 Persistent Depressive Disorder
At least __ of the following symptoms have to have been present during the same __-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood)
- Depressed or irritable _____
- Diminished in_____ or loss of pl_____ in almost all activities (anhedonia)
- Significant w______ change or appetite disturbance
- _____ disturbance (insomnia or hypersomnia)
- ________ agitation or retardation
- F______ or loss of energy
- Feelings of _____lessness
- Diminished ability to think or con_______; indecisiveness
- Recurrent thoughts of d_____, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide
At least 5 of the following symptoms have to have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood)
- Depressed mood or irritable mood
- Diminished interest or loss of pleasure in almost all activities (anhedonia)
- Significant weight change or appetite disturbance
- Sleep disturbance (insomnia or hypersomnia)
- Psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness
- Diminished ability to think or concentrate; indecisiveness
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide
DSM 5- Generalized Anxiety Disorder
The presence of excessive anxiety and _____ about a variety of topics, events, or activities. Worry occurs more often than not for at least ___ months and is clearly excessive.
The worry is experienced as very challenging to control. The worry in both adults and children may easily _____ from one topic to another.
The presence of excessive anxiety and worry about a variety of topics, events, or activities. Worry occurs more often than not for at least six months and is clearly excessive.
The worry is experienced as very challenging to control. The worry in both adults and children may easily shift from one topic to another.
DSM-5 Generalized Anxiety Disorder
The anxiety and worry are accompanied by at least __ of the following physical or cognitive symptoms:
- Edginess or r_____lessness
- Tiring easily; more f_____ than usual
- Impaired con_____ or feeling as though the mind goes blank
- Irr____ (which may or may not be observable to others)
- Increased muscle ____ or soreness
- Difficulty sl_____ (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)
The anxiety and worry are accompanied by at least three of the following physical or cognitive symptoms:
- Edginess or restlessness
- Tiring easily; more fatigued than usual
- Impaired concentration or feeling as though the mind goes blank
- Irritability (which may or may not be observable to others)
- Increased muscle aches or soreness
- Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)
Depression Clinical Assessment
(1) initial screening
What are the questions?
- Clinical scales are a quick and reliable way to screen for depression and anxiety
- ____ a diagnostic tool (use DSM criteria for diagnosis)
- Depression
- PHQ-2 should be completed how frequently? score of __ or greater are considered positive
- Positive score prompts further assessment with (1)
PHQ-2
- Clinical scales are a quick and reliable way to screen for depression and anxiety
- NOT a diagnostic tool (use DSM criteria for diagnosis)
- Depression
- PHQ-2 should be completed annually, score of 3 or greater are considered positive
- Positive score prompts further assessment with PHQ-9
PHQ-9
PHQ9- Scoring
- 0-4
- Provisional diagnosis =
- Treatment recommendation =
- 5-9
- Provisional diagnosis =
- Treatment recommendation =
- 10-14
- Provisional diagnosis (3)
- Treatment recommendation (3)
- 0-4
- Provisional diagnosis = None/minimal
- Treatment recommendation = None
- 5-9
- Provisional diagnosis = Minimal symptoms
- Treatment recommendation = Support, educate to call if worse, return in 1 month
- 10-14
- Provisional diagnosis = Minor depression, Dysthmia, Mild major depression
- Treatment recommendation = Support, watchful waiting, antidepressants and psychotherapy, antidepressants and psychotherapy
PHQ9- Scoring
- 15-19
- Provisional diagnosis =
- Treatment recommendation =
- >20
- Provisional diagnosis =
- Treatment recommendation =
- 15-19
- Provisional diagnosis = Moderately severe major depression
- Treatment recommendation = Antidepressant or psychotherapy
- >20
- Provisional diagnosis = Severe major depression
- Treatment recommendation = Antidepressant AND Psychotherapy (especially if not improved on monotherapy)
PHQ-A
Ages ___-___
Uses ____ scoring guide as PHQ-9
Modified PHQ-9 for adolescents
Age 11-17
Uses same scoring guide as PHQ-9
Physical Warning Signs that a Teen Needs Help
- ____ on arms or legs or other physical signs of self-____
- Rapid or major ____ loss or gain
- Physical injuries without good _______
- Many stomach, head, and/or back _____
- Worsening of a _____ condition
- Cuts on arms or legs or other physical signs of self-harm
- Rapid or major weight loss or gain
- Physical injuries without good explanation
- Many stomach, head, and/or back aches
- Worsening of a chronic condition
Behavioral or Emotional Warning Signs that a Teen Needs Help
- Major change in e____ and/or sl_____ habits
- Signs of frustration, stress, or anger
- Re_______ difficulties with family, friends, classmates, or teachers
- Sk______ school, not participating in class, and/or drop in grades
- Changes or problems with en____ level or con_____
- Sudden mood _____
- Feeling down, hopeless, worthless, guilty
- Major change in eating and/or sleeping habits
- Signs of frustration, stress, or anger
- Relationship difficulties with family, friends, classmates, or teachers
- Skipping school, not participating in class, and/or drop in grades
- Changes or problems with energy level or concentration
- Sudden mood swings
- Feeling down, hopeless, worthless, guilty
Behavioral or Emotional Warning Signs that a Teen Needs Help
- Aggressive or v_____ behavior
- Sudden loss of self con____ or sense of security
- Risky behaviors, breaking l___, st____, hurting people
- Signs of al____ or dr___ use
- Losing _____ in things that were once enjoyed
- Constant concern about _____ appearance or decrease in personal hy____
- Is_____ from others and often spends time alone
- Se_____ about activities and whereabouts
- Aggressive or violent behavior
- Sudden loss of self confidence or sense of security
- Risky behaviors, breaking laws, stealing, hurting people
- Signs of alcohol or drug use
- Losing interest in things that were once enjoyed
- Constant concern about physical appearance or decrease in personal hygiene
- Isolation from others and often spends time alone
- Secretive about activities and whereabouts
(1)
Tool for postpartum depression
- Can be used in the ___natal period as well
- Takes into account ____day experience of pregnancy
Edinburgh Postnatal Depression Scale
- Can be used in the prenatal period as well
- Takes into account everyday experience of pregnancy
(1)
Screening tool for Anxiety
What populations used for?
Over the last (1), how often have you been bothered by the following problems?
(7) Questions
GAD-7
Can be used in adolescents and perinatal patients as well
Over the last 2 weeks, how often have you been bothered by the following problems?
- Feeling nervous, anxious, or edge?
- Not being able to stop or control worrying?
- Worrying too much about different things
- Trouble relaxing
- Being so restless that it is hard to sit still
- Becoming easily annoyed or irritable
- Feeling afraid, as if something awful might happen
GAD-7 Scoring
- Minimal Anxiety =
- Mild Anxiety =
- Moderate Anxiety =
- Severe Anxiety =
- Minimal Anxiety = 0-4
- Mild Anxiety = 5-9
- Moderate Anxiety = 10-14
- Severe Anxiety = 15-21
Psychotherapy: Cognitive Behavioral Therapy (CBT)
- Should be considered in what patients? Exceptions include (2)?
- (1) + (1) often produces best outcomes
- Psychotherapy alone may be a good first line treatment for what type of cases?
- Can be particularly beneficial for those waiting to avoid _____ and those with significant psychosocial/inter_____l conflicts
Other forms of therapy include psychodynamic, psychoanalytical, play, dialectic behavioral therapy
- Should be considered in (nearly) every patient, exceptions are personality disorders, intellectual delay… But they can still get some benefit
- Combination of psychotherapy + medication management often produce the best outcomes
- Psychotherapy alone may be a good first-line treatment for mild-moderate cases (Some patients add-on medications during psychotherapy treatment)
- Can be particularly beneficial for those waiting to avoid medications and those with significant psychosocial/interpersonal conflicts
Other forms of therapy include psychodynamic, psychoanalytical, play, dialectic behavioral therapy
- not really for people with personality disorder*
- Good first line treatment for depression/mild anxiety*
- Medications may not help interpersonal conflicts - like an estranged parent that just comes into your life*
***BEFORE PSYCHOPHARMACOLOGICAL TREATMENT**
**RULE OUT (1)**
What questions do you ask?
**RULE OUT MANIA**
Period of 4-5 days with no need to sleep, excess energy, risky behavior, impulsivitiy?
no way to rule out that a patient won’t become manic on a medication - all these meds are activating but try to screen bipolar (any period of 4-5 days where you do not sleep and are have alot of energy)
(1)
First Line Pharm Treatment for Anxiety and Depression
Drug Class (1)
(2) Rx preferred
dosing, frequency, increase by how much how often?
SSRIs – first line treatment
- Sertraline (Zoloft)
- Start with 50 mg q daily, increase by increments of 25-50 mg q 4 weeks (ish) if necessary
- Escitalopram (Lexapro)
- Start with 10 mg q daily, increase by 5 mg q 4 weeks (ish) if necessary
There is a 25mg tablet but i have not seen any therapeutic benefit with it (zoloft)
Medication Naive Patients
What should you do to the starting dose for a med naive patient?
Why?
(1) is KEY
Can _____ dose to help with _________
For med naïve patients, start with half tab for 1-2 weeks because…
Common side effects: Nausea, headache (usually occur in within the first 1-2 weeks)
Psychoeducation is KEY here
Can reduce dose to help with tolerability
- you are going to feel nausea for the first week - try to tolerate it for at least 1-2 weeks - all about tolerability*
- lots of GI side effects bc we have serotonin receptors in our GI tract*
Symptom Improvement with Pharm Therapy
When should you start to see symptom improvement?
When should you start to see maximum response?
Follow up should occur when?
Advise and educate to reach out if they start experience what type of symptoms?
Black Box Warning =
Symptom improvement begins 3-4 weeks after treatment
Maximum response seen in 6-8 weeks
Follow up should occur within 4-6 weeks
Advise patients to reach out if manic symptoms occur (sudden increase in energy, unusual idea, impulsivity)
BB Warning for suicidality
SSRIs
Examples
- Sertraline (Zoloft)
- Escitalopram (Lexapro)
- Fluoxetine (Prozac)
- Citalopram (Celexa)
- Fluvoxamine (Luvox)
- Paroxetine (Paxil)
- can prolong QT*
- paxil has an ER formulation now bc half life is so short can precipitate withdrawal (I don’t like paxil)*
SNRIs
Examples
- Venlafaxine XR (Effexor XR)
- desvenlafaxine (Pristq)
- duloxetine (Cymbalta)
SNRI’s
Important to monitor what? why?
W______ side effects possible
When should we use SNRIs?
Monitor BP after initiation and throughout treatment, because they have a norepi component can effect BP/HR
Withdrawal side effects possible
- If patient fails 2 SSRI’s can try SNRI*
- but bc they have norepi component can impact BP and heart rate and higher likelihood of withdrawal (dizzy, more depressed)*
- Does not exclude patients with cardiac history but monitor (research shows zoloft more favorable for cardiac)*
Atypical Agents
(2)
- Bupropion (Welbutrin, Welbutrin SR, Welbutrin XL)
- Mirtazapine (Remeron)
Bupropion
(Welbutrin, Welbutrin SR, Welbutrin XL)
- Improves con_____, av_____
- Does it work for anxiety?
- Third line agent for ______
- Little to no _____ side effects
- Great for ______ cessation and can be used in combo with gum/patch
- Improves concentration, avoltion
- Does not impact anxiety (no direct serotonin action) and can INCREASE anxiety
- Third line agent for ADHD
- Little to no sexual side effects
- Great for smoking cessation and can be used in combo with gum/patch
Bupropion
(Welbutrin, Welbutrin SR, Welbutrin XL)
- Improves con_____, av_____
- Does it work for anxiety?
- Third line agent for ______
- Little to no _____ side effects
- Great for ______ cessation and can be used in combo with gum/patch
- Improves concentration, avoltion
- Does not impact anxiety (no direct serotonin action) and can INCREASE anxiety
- Third line agent for ADHD
- Little to no sexual side effects
- Great for smoking cessation and can be used in combo with gum/patch
would not use wellbutrin as first line because does not act on serotonin
Mirtazapine
- Very se______ – can be used for sl____ and mood
- Great for ____ patients (bc it can increase app______, increases w_____)
- Very sedating – can be used for sleep and mood
- Great for geri patients (bc it can increase appetite, increases weight)
Tricyclic Antidepressants (TCAs)
Clinical use?
Off label uses (3)
Not commonly used in clinical practice today
Off-label uses for pain management, sleep, migraine prophylaxis
Tricyclic Antidepressants (TCAs)
- Monitor ___ (orthostats), ____ rate, ___ changes (increased PR interval usually)
- EKG changes usually ____ dependent but want to have a baseline and monitor annually once patient is stabilized
- Extreme _____ in those with pre-existing _____ issues
- Monitor BP (orthostats), heart rate, EKG changes (increased PR interval usually)
- EKG changes usually dosed dependent but want to have a baseline and monitor annually once patient is stabilized
- Extreme caution in those with pre-existing cardiovascular issues
you will not be initiating any of these but if patients are on these meds - monitor
Monamine Oxidase Inhibitors (MAOIs)
Clinical use?
Strict diet of?
Rarely used today
Patients must adhere to strict low-tyramine diet (no aged cheeses, wine, soy sauce, sausages, fermented products such as kimchi)
you will not be initiating any of these but if patients are on these meds - monitor
How do you rule out bipolar disorder?
(1)
Mood Disorder Questionnaire
Antidepressant Dosing Chart
Antidepressant Dosing Chart
Depression Pharm Therapy for Adolescents
Psychotherapy
- Should be used in ______ with medication
- Many psycho______ factors impact mood
Psychopharmacology
- (1) considered first line (FDA approved for 8 and up)
- (1) (FDA approved for 12 and up)
- Do you start at regular doses?
- BLACK BOX WARNING =
- Maintain ____ follow up
- Coordinate with _______
- Create _____ plans
Psychotherapy
- Should be used in conjunction with medication
- Many psychosocial factors impact mood
Psychopharmacology
- Fluoxetine considered first line (FDA approved for 8 and up)
- Escitalopram (FDA approved for 12 and up)
- Start at half doses and closely monitor (include parents)
- BLACK BOX WARNING - become impulsive and suicidal quickly
- Maintain close follow up
- Coordinate with schools
- Create safety plans
Anxiety Pharm Treatment
(4)
Buspirone
Gabapentin
Hydroxyzine
Benzodiazepines
Buspirone
Drug class
Is it a controlled substance?
MOA
Dose, Frequency
How long does it take to be effective?
Anxiolytic
not controlled
Works only on serotonin anxiety receptors, less serotonin-based side effects
Dosing BID or TID, 10-20 mg
Takes a few weeks to become effective
Gabapentin
____-label use
Is it a controlled substance?
Dosing, Frequency?
Efficacy?
Off-label use
Controlled substance in some states (can have street value)
100-300 mg TID for anxiety
Mixed efficacy
Hydroxyzine
Drug Class
Dosing, Frequency
Can be helpful for _____
Antihistamine
25-50mg PRN Q6-8 hours
Can be helpful for sleep (sedating effect)
Benzodiazepines
- _____ term (4-6 weeks), ____ use only
- Use longer acting agents (clonazepam, diazepam) to minimize ______ anxiety
- Side effects of long term use included decreased c______ functioning, de_____? Dizziness
- Short term (4-6 weeks), PRN use only
- Use longer acting agents (clonazepam, diazepam) to minimize rebound anxiety
- Side effects of long term use included decreased cognitive functioning, dementia? Dizziness
Benzodiazepine Medication Chart
Should you continue psychotropics for these patients?
- “I just moved to town”
- My psychiatric provider retired”
- “My new insurance is out of network with my current psychiatrist”
- “I can’t afford my behavioral health copay”
YES
CONTINUE PSYCHOTROPICS
- “I just moved to town”
- My psychiatric provider retired”
- “My new insurance is out of network with my current psychiatrist”
- “I can’t afford my behavioral health copay”
Depression Care Model
Good example of a collaborative care model - where Primary care mainly manages patient with anxiety/depression with curbside counseling by psychiatrist
ADHD
ADHD in Primary Care
- Are we expected to initiate ADHD medication in primary care? If so, what needs to be done first?
- When do ADHD symptoms usually present? Is rare in?
- Be cautious in the time of COVID
- Would not expect primary care to initiate medication for ADHD without neuropsychiatric testing.
- Symptoms should have presented themselves in childhood; adult onset rare
- Be cautious in the time of COVID
- Symptoms should have presented themselves in childhood; adult onset rare
Continuation of Stimulants
Obtain d______ documentation from a _______ provider
Check (1) before prescribing refills or bridge medications
- EKG testing not recommended but it is policy in some locations, why?
- Assess for patient’s own history of _____ disease
- Assess for family history of sudden cardiac _____, conduction issues
- Perform _____ drug screen (may want to do it randomly)
- ______ level
- Monitor _____cardia, ang_____, palp______
Obtain diagnostic documentation from a psychiatric provider
Check PMP before prescribing refills or bridge medications
- EKG testing not recommended but it is policy in some locations (prolonged QT)
- Assess for patient’s own history of cardiac disease
- Assess for family history of sudden cardiac death, conduction issues
- Perform urine drug screen (may want to do it randomly)
- TSH level
- Monitor tachycardia, angina, palpitations
Mood Stabilizers
(4)
Lithium
Depakote
Lamotrigine (Lamictal)
Carbamazepine (Tegretol)
Lithium
Comes in standard (BID/TID) or extended release (usually qd or BID)
Narrow therapeutic index (____-____ mEq/L)
- Lab must be ordered at peak level, which occurs ___ hours after last dose
- Run __-__ days after initiation or change in dose
- Lithium levels change with ______ status… consider summer
Narrow therapeutic index (0.8-1.2 mEq/L)
- Lab must be ordered at peak level, which occurs 12 hours after last dose
- Run 5-7 days after initiation or change in dose
- Lithium levels change with hydration status… consider summer
therapeutic levels every 6 months and 5-7 days after dose change
Signs of Lithium Toxicity
- GI =
- Neuro: ataxia, con_____ , agitation, monoclonic jerks, s______ (if severe)
- Cardiac =
- Some patients may need _____ to excrete severe toxicity
- Will need monitoring – send to ___
- GI: N/V/D
- Neuro: ataxia, confusion, agitation, monoclonic jerks, seizures (if severe)
- Cardiac: Prolonged qTC
- Some patients may need dialysis to excrete severe toxicity
- Will need monitoring – send to ER
Lithium
- Monitor (1) hormone, (1) function and lithium level q __ months
- Congenital malformations (1) in pregnancy; make sure female patients are taking (1)
- Monitor TSH, renal function and lithium level q 6 months
- Congenital malformations (neural tube defects) in pregnancy; make sure female patients are taking BC
Depakote
Comes in standard (BID) or extended release (usually qd or BID)
Narrow therapeutic index (__-___mg/L)
- Lab must be ordered at ____ level, which occurs __ hours after last dose
- Run __-__ days after initiation or change in dose
Narrow therapeutic index (50-100 mg/L)
- Lab must be ordered at peak level, which occurs 12 hours after last dose
- Run 5-7 days after initiation or change in dose
Signs of Depakote Toxicity
- GI =
- Neuro: ag_____, ______ jerks
- Cardiac: ____cardia, ____tension
- Pulm: Respiratory _______
- Will need monitoring - send to ___
- GI: N/V/D,
- Neuro: agitation, monoclonic jerks
- Cardiac: tachycardia, hypotension
- Pulm: Respiratory depression
- Will need monitoring - send to ER
Depakote Monitoring
- Monitor (1) (bc metabolized by liver) and Depakote level q__ months if stable; increase monitoring in patients with renal disease
- Congenital malformations(_____ anomaly) in pregnancy; make sure female patients are taking ___
- Monitor LFTS (bc metabolized by liver) and Depakote level q 6 months if stable; increase monitoring in patients with renal disease
- Congenital malformations(Epstein’s anomaly) in pregnancy; make sure female patients are taking BC
Lamotrigine (Lamictal)
Typically doses used for (1) (50-200 mg) are ____ than those for (1) (up to 500mg)
- Interactions:
- Depakote (in____ lamotrigine metabolism)
- Tegretol (in_____ lamotrigine metabolism)
- Oral contraceptives (___duce lamotrigine metabolism)
- Early concerns that lamotrigine may make contraception ineffective are unfounded
- Used often because of low (1) profile
Typically doses used for bipolar disorder (50-200 mg) are lower than those for seizures (up to 500mg)
- Interactions:
- Depakote (inhibits lamotrigine metabolism)
- Tegretol (induces lamotrigine metabolism)
- Oral contraceptives (induce lamotrigine metabolism)
- Early concerns that lamotrigine may make contraception ineffective are unfounded
- Used often because of low side-effect profile
Lamotrigine (Lamictal)
BE WARY OF _____ upon initiation and after each dose increase (still lifetime risk while on drug)
- Bl_____, painful, itchy; usually begins in m___cutaneous areas (mouth, eyes) and then spreads
- Accompanied by f____, j_____ and muscle pain
- Re_____ if patient has stopped for more than 5 days.
BE WARY OF RASH upon initiation and after each dose increase (still lifetime risk while on drug)
- Blistering, painful, itchy; usually begins in mucocutaneous areas (mouth, eyes) and then spreads
- Accompanied by fever, joint and muscle pain
- Retitrate if patient has stopped for more than 5 days.
Carbamazepine (Tegretol)
Clinical Use today?
- Need carbamazepine levels after initiation and _______ after stabilization
- __ to __mcg/mL
- Dizziness, drowsiness, arrhythmia, hypotension, seizures, coma
- __ to __mcg/mL
Not a great mood stabilizer but still used in some patients today
- Need carbamazepine levels after initiation and annually after stabilization
- 4 to 12 mcg/mL
- Dizziness, drowsiness, arrhythmia, hypotension à seizures, coma
- 4 to 12 mcg/mL
Carbamazepine (Tegretol)
Important to monitor for what? (1)*
- Taper and D/C treatment if ANC is less than ____ mm3 .
Significant interactions with many common drugs: statins, antipsychotics, glucocorticoids, oral anticoagulants
CBC for agranulocytosis (or use Absolute Neutrophil Count ANC)
- Taper and D/C treatment if ANC is less than ____ mm3 .
Significant interactions with many common drugs: st____, anti______, gluco_______, oral antic________
Antipsychotics
- Can be used to treat both ______-spectrum disorders and/or _____ disorder
- More recently have been used as adjunctive treatment for ________
- Can be used to treat both psychotic-spectrum disorders and/or bipolar disorder
- More recently have been used as adjunctive treatment for depression
(1)
haldol, thorazine, fluphenazine
- Higher risk of EPS
- Higher risk of prolonged qTC (annual EKG recommended)
- Occyulogyric crisis may occur
AVOID these old school meds
First generation Antipsychotics
Second generation Antipsychotics
aripirazole, risperidone, quetiapine, clozapine, olanzapine, cariprazine, lurasidone
- _____ risk of EPS but still possible (especially aripiprazole)
- Higher risk of ______ disorders; monitor A1c, lipids, weight
- Risperidone and lurasidone: can increase prolactin, disrupt m_____, cause gyn______
- Clozapine requires monthly _____ and input into REMS system
- Can cause paralytic _____… check for frequency of BMs
- Lower risk of EPS but still possible (especially aripiprazole)
- Higher risk of metabolic disorders; monitor A1c, lipids, weight
- Risperidone and lurasidone: can increase prolactin, disrupt menses, cause gynecomastia
- Clozapine requires monthly ANC and input into REMS system
- Can cause paralytic ileus… check for frequency of BMs
Continuation of Care
When is this appropriate?
- Patients can be highly functional on stable antipsychotic/mood stabilizer regimens.
- However would likely benefit from connection to psychiatry/therapy in the long term
- Ideally, should have some comfort in providing br_____ medications if patient is in between care
- Can call _______ to confirm past meds
- Most psychiatric providers do not have quick lab access and you should work together to monitor ____ and S/__ of medications
- Patients can be highly functional on stable antipsychotic/mood stabilizer regimens.
- However would likely benefit from connection to psychiatry/therapy in the long term
- Ideally, should have some comfort in providing bridge medications if patient is in between care
- Can call pharmacy to confirm past meds
- Most psychiatric providers do not have quick lab access and you should work together to monitor levels and S/E of medications
When to Refer
- “I keep having ____attacks”
- “I feel ____less all the time”
- “Sometimes I think I’m getting secret _____ through TikTok”
- “Every night I have night_____ of something that happened when I was seven”
- “The only way to help with withdrawal is to _____to use… I can’t _____”
- “I keep having panic attacks”
- “I feel hopeless all the time”
- “Sometimes I think I’m getting secret messages through TikTok”
- “Every night I have nightmares of something that happened when I was seven”
- “The only way to help with withdrawal is to continue to use… I can’t stop”
So when should I refer to psychiatry?
- W______ outcomes with treatment of SSRIs/SNRIs in patients with mild-severe mood disorders
- Mood disorders complicated by other diagnoses (p______ disorders, disordered ea____, ps_____)
- History of multiple _______ or emergency room visits
- Bi_____ disorder/sch________ spectrum disorders
- Stable patients on complex _______ regimens (adjunctive treatments such as lithium, aripiprazole)
It is your responsibility to check with your state’s _____ to understand your scope of practice
- Worsening outcomes with treatment of SSRIs/SNRIs in patients with mild-severe mood disorders
- Mood disorders complicated by other diagnoses (personality disorders, disordered eating, psychosis)
- History of multiple hospitalizations or emergency room visits
- Bipolar disorder/schizophrenia spectrum disorders
- Stable patients on complex medication regimens (adjunctive treatments such as lithium, aripiprazole)
It is your responsibility to check with your state’s BON to understand your scope of practice
Addictions
- ______ use disorder within your ___ (Chantix, patches, lozenges, gum, Buproprion)
- Can offer mot______ interviewing and harm-_____ strategies
- Patients with active addictions should receive c_____ and M_ _
- Can be trained and waivered in sub_____ (but patient should also be in some sort of counseling/program) -
- N______ effective for AUD, but patient should be in counseling or a program
- Any other drug (K, LSD, heroin, rx drug abuse, etc) should be treated in an ______ setting
- Generally, addictions (aside from tobacco and sometimes EtOH) should receive treatment in a sp_____ clinic or pr______
- Tobacco use disorder within your scope (Chantix, patches, lozenges, gum, Buproprion)
- Can offer motivational interviewing and harm-reduction strategies
- Patients with active addictions should receive counseling and MAT
- Can be trained and waivered in suboxone (but patient should also be in some sort of counseling/program) -
- Naltrexone effective for AUD, but patient should be in counseling or a program
- Any other drug (K, LSD, heroin, rx drug abuse, etc) should be treated in an addiction setting
- Generally, addictions (aside from tobacco and sometimes EtOH) should receive treatment in a specialty clinic or program
Crisis Management
- “I keep having thoughts of wanting to ____ myself”
- “What’s the point of _____”
- “People would be _____ off without me”
- “Next time I see her, I’m going to ch___ her”
- “I’ve been _____ a lot of my things recently…”
- “I keep having thoughts of wanting to hurt myself”
- “What’s the point of living”
- “People would be better off without me”
- “Next time I see her, I’m going to choke her”
- “I’ve been selling a lot of my things recently…”
Suicide and Risk Management
NEVER leave patient alone (or end the call) if patient is?
NEVER leave patient alone (or end the call) if patient is actively suicidal
High Risk Groups
- Age
- A_____ and young adults
- O____ patients
- Gender
- _____ are more likely to complete suicide (3x)
- Race
- American In_____ and Al_____ Natives have highest risk, followed by non-Hispanic whites, Asian and Pacific Islanders, African Americans and Hispanics
- Geographic
- Higher rates of suicide in r____ communities; gap is widening
- In urban areas, ______ Americans have a higher suicide rate than in rural areas
- May be due to access to firearms
- Age
- Adolescents and young adults
- Older patients
- Gender
- Males are more likely to complete suicide (3x)
- Race
- American Indian and Alaska Natives have highest risk, followed by non-Hispanic whites, Asian and Pacific Islanders, African Americans and Hispanics
- Geographic
- Higher rates of suicide in rural communities; gap is widening
- In urban areas, African Americans have a higher suicide rate than in rural areas
- May be due to access to firearms
Suicide and Risk Management
- My patient is suicidal… what do I do!?
- Take a breath and do not panic.
- Assess for id_____ and in____
- Is this imminent? What sort of supports does the patient have? Can they name friends or family members that care about them/ that they can call?
- Have clinic s______ worker assess patient (if available)
- Can the patient go to the ER by themselves?
- Follow clinic-specific policies and protocols
- Confirm patient _______ if this is a telehealth visit
- My patient is suicidal… what do I do!?
- Take a breath and do not panic.
- Assess for ideation and intent
- Is this imminent? What sort of supports does the patient have? Can they name friends or family members that care about them/ that they can call?
- Have clinic social worker assess patient (if available)
- DO NOT let patient go to ER by themselves; call EMS from the clinic
- Follow clinic-specific policies and protocols
- Confirm patient location if this is a telehealth visit
Suicide and Risk Management
- If a patient has ______ suicidality
- Confirm there are no firearms or possible weapons in the home
- Connect patient to BH services
- Create a safety plan
- When in doubt, call ____
- If patient is not in the clinic or on a call and leaves a threatening message, call patient’s (1)
- This does not violate _____ due to nature of situation
Patient Safety Plan Template
Fill out with patient, give them a copy and a keep a copy in the cart
What is included in the patient safety plan?
Fill out with patient, give them a copy and a keep a copy in the cart
Suicide and Risk Management
(1)
- Mental Hygiene Law 9.46
- Requirement regardless of clinical practice setting -
- When patient is “likely to engage in conduct that could seriously harm the patient themselves or others.”
- Does not have to specify that plan is to use firearms
- Do not have to establish that patient had a firearm
- (or google “SAFE Act Reporting)
NY SAFE ACT
- Mental Hygiene Law 9.46
- Requirement regardless of clinical practice setting -
- When patient is “likely to engage in conduct that could seriously harm the patient themselves or others.”
- Does not have to specify that plan is to use firearms
- Do not have to establish that patient had a firearm
- (or google “SAFE Act Reporting)
Referrals to the ____
- Bizarre/nonsensical behavior
- Sudden deviation from normal behavior
- Manic episodes
- Think: acute disturbance of thought - are patients based in reality?
- Agitation/aggression
- Intoxication/withdrawal
- Are they a danger to themselves or others?
- Are they psychiatrically impaired and can not care for themselves?
- Are they at risk of becoming the above?
Referrals to the ER
- Bizarre/nonsensical behavior
- Sudden deviation from normal behavior
- Manic episodes
- Think: acute disturbance of thought - are patients based in reality?
- Agitation/aggression
- Intoxication/withdrawal
- Are they a danger to themselves or others?
- Are they psychiatrically impaired and can not care for themselves?
- Are they at risk of becoming the above?
New York City Resources
- “Do you know where I can get help?”
- “How do I find a therapist?”
- “I want to see someone today.”
- “Who can I call late at night?”
- “I’m really concerned about my friend…they are acting strange.”
Resources
- Where can I get help?
- 1888-NYC Well
- Text: “WELL” to 65173
- Chat online (https://nycwell.cityofnewyork.us/en/)
- Can look up agencies in NYC that offer psychiatry and psychotherapy services
- Same day/next day services:
- Mindful Care (https://mindful.care/)
- Search tools:
- ZocDoc, Headway.co, insurance website
- Walk in Clinics (for non-emergencies)
- Bellevue
- Zucker Hillside
- Mobile Crisis
- Non suicidal/homicidal emergencies
- Use NYC Well number
