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
How do you rule out bipolar disorder?
(1)
Mood Disorder Questionnaire
Antidepressant Dosing Chart
Antidepressant Dosing Chart
Benzodiazepine Medication Chart
Depression Care Model
Good example of a collaborative care model - where Primary care mainly manages patient with anxiety/depression with curbside counseling by psychiatrist
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
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
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)
