Psych

Question 1

Major Depression

Answer 1

persistent depression that lasts at least 2 wk and includes ≥5 of the following symptoms, with one symptom being either the first or second one:

1. Depressed mood most of the day nearly qd
2. Loss of interest or pleasure in usual activities (anhedonia)

Titrate antidepressants until patient answers “yes” to the following questions: Are you 100% better? Are you again doing activities and hobbies that you enjoy (i.e., enjoying life again)?
b) If the patient is no better on the top dose of medication, change to a different medication—consider change to a different class

Question 2

Dysthymic disorder

Answer 2

depressed mood on most days for at least 2 yr; during the depression period, also has at least 2 of the following:

1. Poor appetite or overeating
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration/difficulty making decisions
6. Feelings of hopelessness

May have symptom-free periods, but not >2 mo at a time

Treatment

1. Often has an early and insidious onset and is a chronic disorder; may have concomitant medical disorders
2. Antidepressants have been effective in a majority of patients (Table 18.1)
3. Counseling has been found to be beneficial for some patients

Question 3

General Anxiety Disorder

Answer 3

First line: SSRI or SNRI, consider trying different first line before trying second line
Second line: TCA or benzodiazepine or buspirone. If using buspirone, increase dose q2wk until maximum (safer than benzodiazepines)
Consider propranolol 10 mg or hydroxyzine (Atarax) 10 mg before anxiety-producing events
Bedtime agent may help with insomnia

Question 4

Panic Attack

Answer 4

CBD treatment
SSRI or SNRI - usually paroxetine or venlafaxine
Atarax at start of attack may stop it
Consider a low dose benzo until SSRI/SNRI takes effect

Question 5

PTSD

Answer 5

refer to a psychiatrist or psychiatric NP because of the difficulty in diagnosis and complexity in management

SSRI or venlafaxine can be started until patient can see specialist; also consider prazosin 1 mg hs and titrate to 3-15 mg as tolerated (do not stop cold turkey)

Do not give benzodiazepines; there is no evidence they help PTSD and they may worsen recovery

Avoid atypical antipsychotics (not much evidence they help)