Psychopharmacology 1 Flashcards
1
Q
Psych Assessment (10)
A
- Make sure there is a clear way of triaging children in primary care that belong in the ED
- Assess severity of all symptoms—functional impairment is key
- Emphasize the child’s functioning –if severe belongs with a mental health professional
- Assess sleeping pattern
- Identify what are the environmental factors that may have precipitated any change – The Safe Environment for Every Kid (SEEK questionnaire)
- Screen for substance abuse
- Differentiate new versus exacerbation of a old or chronic problems
- Are there any prior evaluations and prior and current treatment
- Overview of common disorders
- Determine if medication is appropriate treatment
2
Q
Questions to ask in deciding to prescribe medication (5)
A
- Are there sufficient symptoms?
- Have symptoms been present for sufficient period?
- Does the child have sufficient impairment, distress or both from the symptoms in ways that negatively affect life and emotional well-being?
- Is the disorder sufficiently different from normal levels of activity and impulsivity (in contrast with ADHD), worry and concern (in contrast with anxiety disorder) or demoralization or grief (in contrast with episode of depression)?
- Have behavioral management programs (for ADHD), cognitive behavioral therapy for anxiety been sufficient in duration and quality if they are available?
3
Q
Psychoeducation Prior to Prescribing (6)
A
PARENTS NEED TO:
- Understand that mental health problems are common and not their fault
- If you are planning to offer medication, let the parent understand that treatment of mental health disorders are like treating any health problem (normalization)
- If there is a family member that has the same diagnosis and responded well to treatment, review their experience and offer hope
- If there is a family member who has the same but not responded well treatment, there may be difference
- Common disorders are common—ADHD, anxiety and depression is common
- When there are several options available, presenting a menu of options can allow for individualization
4
Q
Plan Before the initiation of any pharmacological agents (11)
A
- Identify the treatment goals
- Discuss of adverse medication effects
- Risks, benefits, and alternatives to proposed treatment – Changing side effect profiles
- Prolonged QT with citalopram
- Review pre‐existing medication regime and make sure no interactions are present
- Limit the total numbers of medication
- Give treatments a chance to work
- Use of standardized tool to monitor pharmacological effects
- Use of standard tool to monitor for suicidal risk in SSRI and in antiepileptic drugs
- Waiting for more severe symptoms to appear is not a good option
- Metabolic screening is indicated for patients on antipsychotic drugs
5
Q
Basic Principles of Psychotherapeutic Interventions and Techniques (15)
A
- Psychiatric medications should be one part of the treatment plan.
- The medication approaches to mental illness needs to address the chronic nature of some mental health problems and therefore cannot be used alone.
- The side effects and efficacy of each class of drugs in pediatric and adolescent drugs need to be considered.
- In general, children may need higher doses due to the faster metabolism, the kidney clearance and increased liver size in relationship to the body surface area.
- Problem solving strategies, behavioral strategies, psychoeducation, and support are part of the treatment
- When prescribing, treat a primary diagnosis first or the one that is causing the most functional impairment.
- Symptoms need to be evaluated at baseline and during treatment via a rating scale.
- Scale should be indicated for the problem
- Pick medications that are approved for the child’s age and problem if possible—Go slow and start low,
- Use the medication for an adequate trial before changing or adding any medication.
- For PNP’s in primary care if you start to need to add another medication, the child needs to be seen by child mental health specialist.
- Multiple medications mean multiple side effects and can be problematic.
- Use environmental or behavioral strategies rather than adding the medication
- Develop an alliance with the family and child. Encourage their participation in drug choice. How do they respond to the word “Medication”.
- Make sure they understand the side effects of the drugs. These need to be reinforced with handout if possible.
6
Q
Three C’s of pharmacotherapy
A
- Communication (return phone calls and emails promptly)
- Conscientiousness (of standard of practice and sociocultural needs)
- Collaboration (therapists, other care providers, and families)
7
Q
Psychotropic Polypharmacy (5)
A
- ↑ in % of child visits with psychotropics prescribed from 1996 – 2007
- Mul class psychotropic treatment ↑from 14.3% (1996 – 1999) to 20.2% (2004 – 2007).
- ↑ use of ADHD, an depressants, antipsychotics
- ↑co‐prescribing ADHD and antipsychotic meds
8
Q
Safe Prescribing of Pyschotropic Medications (9)
A
- Medication need to efficacious, safe, and have a reasonably predictable, readily detected and well managed ADE profile
- Follow guidelines that are readily established; always include vital signs, height, weight
- Know how to diagnose the disorder and know the differentials
- Know the psychosocial treatments including CBT and parent behavioral management training
- Know the medication prescribed in terms of route, duration of action, dosage, and side effects
- Know the follow up procedure and keep up with the procedure
- Must have an outside expert consult if you have a problem that is outside your scope
- Get adequate payment of services
- Minimal regulatory and administrative barriers
9
Q
Principles of Pharmacological Treatment for Psychiatric Illness (5)
A
- Identify target symptoms
- Maximize dosages of medication before discontinuing or adding another
- Change and adjust one drug at time
- Monitor side effect
- Discontinue the drug that is of the least benefit
10
Q
Informed Consent Prior to Starting Treatment: Needs (6)
A
- Document discussion about medication and need for follow up – Document clear parameters for seeking ED treatment (rash on lithium; suicidal plan on SSRI)
- Educate regarding mild, moderate, or severe side effects
- Document that you informed patient of potential long term adverse effects
- Cost needs to be discussed. Make sure insurance will cover medication
- If you will need to monitor labs, explain this in the chart
- If there is a risk of drug to drug interaction (especially in CYP 450 isoenzymes), make sure family knows not to add a medication without checking with you
11
Q
FDA Boxed Warnings (3)
A
- SSRIs and Suicidality
- Initially stated that child should be seen weekly for first 4 weeks, every 2 weeks for next 4 weeks, at 12 weeks and at discretion of provider after this
- Now focuses on parent knowing the risks of suicidal ideation and what to watch for
12
Q
Stimulants and Cardiac Concerns (3)
A
- Boxed Warning: Misuse of amphetamines can cause sudden death and serious CV adverse effects
- Warning but not boxed for Methylphenidate
- Bottom line: Take a personal and family cardiac history with an emphasis on sudden death, structural defects, syncope, arrhythmias, sudden unexplained death and long QT before writing for stimulants
13
Q
Stimulants: Concerns about abuse and dependence (2)
A
- High potential for abuse
2. May divert stimulants for money
14
Q
Choosing a Stimulant: MPH or AMP – Duration (3)
A
- Consider Immediate release (3‐4 hours)
- Intermediate release (6‐8 hours)
- Extended release (10‐12 hours)
15
Q
Choosing a Stimulant: MPH or AMP – Ability to swallow pills (2)
A
- No: Liquid, chewable, beaded, dermal, oral disintegration
2. Yes all options are available
