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533 > Week 12: Adult Mental Health > Flashcards

Week 12: Adult Mental Health Flashcards

1
Q

Depression screening in adults

A
  • screen ALL adults every visit, including pregnant and postpartum women
  • PHQ-2
    • PHQ-9 (older adults, cog impaired adults, nursing home residents)
      • used as f/u after phq2
        • higher S&S
        • diagnostic & can give severity of depression
  • geriatric depression scale
  • Beck Depression inventory
  • Edinburgh postnatal depression scale
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2
Q

Depression labs

A
  • get TSH
  • CBC
  • UA (drug screening)
  • fasting blood glucose
  • B12
  • folate
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3
Q

MDD assessment

A
  • get baseline PHQ9 Hx, PE
  • mental status exam
  • suicide risk (thoughts of hurting, SI, plan?)
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4
Q

MDD management

A
  • #1: Safety! Assess ALL for suicidal ideation
  • r/o other conditions that can cause depression
  • mild depression → psychosocial and psychotherapy (no meds)
    • CBT
    • interpersonal therapy (IPT)
    • problem solving therapy (PST)
  • moderate/severe → meds + therapy
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5
Q

MDD pharm management

A
  • moderate-severe depression:
    • 1st line: SSRI (sertraline), SNRI, bupropion, mirtazapine
  • start low dose for 1-2 wks before dose increase. monitor for suicidal ideation, efficacy and ADE
  • educate it takes few weeks for meds to work
    • need to continue meds for 6-9months+
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6
Q

SSRI antidepressants list

A
  • SSRI [energizing to least energizing]
    • fluoxetine (Prozac)
    • sertraline (Zoloft)
    • citalopram (Celexa)
    • escitalopram (Lexapro)
      • causes QT prolongation
    • paroxetine (Paxil)
      • causes weight gain
      • most sedating
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7
Q

SNRI antidepressants and side effects

A
  • increases norepinephrine and serotonin to improve motivation/focus AND mood
  • venlafaxine (Effexor)
  • desvenlafaxine (Prestiq)
  • duloxetine (Cymbalta)
  • atomoxetine (Straterra)
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8
Q

bupropion (Wellbutrin)

A
  • good choice antidepressant if don’t have anxiety and have nicotine addiction
  • lower risk of decreased libido
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9
Q

antidepressants may induce

A
  • mania in susceptible pts
  • black box warning of increased risk of suicidal thoughts/behavior in young people
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10
Q

which antidepressant for pt with anxiety?

A
  • want less energizing
    • venlafaxine or duloxetine
  • NO bupropion (Wellbutrin)
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11
Q

which antidepressants to avoid with pt’s with cardiac conditions?

A
  • TCA’s (-triptyline) [high risk of cardiac arrhythmia, no in older adults)
  • citalopram (Celexa) & escitalopram (Lexapro) [QT prolongation]
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12
Q

pt has depression and ADHD, give what med?

A

bupropion or venlafaxine

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13
Q

avoid which antidepressant for severe renal/GI issues and seizure?

A

NO bupropion (lowers seizure threshold)

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14
Q

antidepressant treatment duration

A
  • initial improvement in 1-2 wks, max in 4-12 weeks
    • If no response in 4-8 weeks, switch to different antidepressant w/in diff or same class
  • after remission of sx’s, continue for 4-9 months
  • if 1-2 episodes, can titrate off but if 2 eps, give 1 yr to titrate off. if 3 eps, need continuous maintenance therapy
  • OLDER adults takes 12-16 weeks for relief of sx’s (slower process)
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15
Q

fluoxetine pearls

A
  • least likely to gain weight
  • most activating
  • long half life
  • for adolescents and non compliance
  • don’t take at night
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16
Q

paroxetine pearls

A
  • interacts with a lot of other meds
  • bad withdrawal
  • weight gain
  • sedating, good for insomnia pts
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17
Q

citalopram pearls

A
  • black box warning QTc prolongation
  • NO with CVD dz
  • (max dose 40mg QD, 20 mg QD if > 60 yrs old)
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18
Q

escitalopram pearls

A

weight neutral

neither sedating or activating

qt prolongation

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19
Q

venlafaxine (Effexor) and desvenlafaxine (Pristiq), want to monitor?

A

monitor HR and BP

induces hypertensive crisis

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20
Q

mirtazapine pearls

A
  • low doses = sedation/drowsiness (15mg, 0.5 tab at half strength) = improves sleep
  • if higher dose, sedative factor diminishes
  • improves appetite, for pts who are not eating and causes weight gain
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21
Q

when to refer pts with depression?

A
  • EMERGENT/inpatient if:
    • immediate risk of self or others
    • profound impaired/acutely suffering
    • sx’s serotonin syndrome or withdrawal, neuroleptic malignant syndrome or lithium toxicity
  • urgent psych w/in 1 week if
    • high suicide risk but currently safe
    • psych comorbidities
    • indications for ECT
  • f/u psych w/in 1 month if…
    • recurrent sx’s not responding
    • complication with med management that requires frequent f/u
    • a/s with dementia
    • psychotherapy, fam education or group support
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22
Q

depression presents with what

A

headache, back pain, chronic pain, “tired all the time”

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23
Q

MDD dx in adults

A
  • SIGECAPS: 5 or more sx’s (1 must be depressed mood or lost of interest/pleasure) for 2 weeks:
  • sleep (insomnia)
  • interest loss
  • guilt (worthlessness)
  • energy low/fatigue
  • concentration (diminished ability)
  • appetite (weight gain or anorexia)
  • psychomotor agitation/irritation
  • suicidal/death thoughts

can’t be due to drug or medical condition (hypothyroidism)

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24
Q

which antidepressant good for sleep aid?

A

paroxetine, trazodone (Desryl), TCAs

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25
Q

obsessive compulsive disorder symptoms usually occur before what age?

A

15 year old

Inflexible, no spontaneity

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26
Q

delusions

A
  • false, fixed beliefs
  • Grandiose, jealousy, persecutory, somatic, mixed
  • “I AM GOD!”
  • a/s with acute illness or schizophrenia
  • r/o organic causes (delirium), looking at psychosis
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27
Q

Hallucinations

A

false sensory experience with NO objects

ie: hearing voices

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28
Q

illusions

A

misinterpretation of reality

ie: sees tree branches as goblins

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29
Q

Magical thinking

A

the patient feels thoughts or wishes can CONTROL OTHERS

the belief that one’s ideas, thoughts, actions, words, or use of symbols can influence the course of events in the material world

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30
Q

what complaints would someone with GAD have?

A

GENERAL complaints; normal PE/VS

Restlessness, fatigue, difficulty concentrating in relation to many events or activities

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31
Q

DSM 5 for GAD:

A
  • 3 or more x 6+ months:
    • restlessness or feeling on edge
    • easy fatiguability
    • difficulty concentrating
    • irritability
    • muscle tension
    • sleep disturbance
32
Q

panic attak

A

abrupt surge of intense fear or intense discomfort that reaches a peak within minutes

33
Q

GAD physical examination

A
  • important to ask for psychosocial stressors or hx or evidence of trauma or abuse (increase risk for anxiety disorders)
    • ask trauma history & refer if necessary
  • complete physical exam
  • ask about headaches and bowel habits → IBS
34
Q

GAD diagnostics

A
  • must r/o other medical causes
  • urine toxicology
  • older adults: infection, anemia, e- imbalance, liver/kidney dysfunction, thyroid, hyperparathyroidism, glucose intolerance
  • caffeine
  • ECG for panic attacks
  • GAD -7 screening tool
  • med SE’s
35
Q

GAD management non pharm

A
  • psychotherapy/CBT first line mono therapy or w/ meds
  • exercise as adjunct
36
Q

GAD management pharm & education

A
  • # 1: SSRI & SNRI first line
    • paroxetine, venlafaxine
      • continue 6-12 months after sx has resolved. if pt doesn’t respond, add med or switch med, AND refer
      • educate:
        • takes 6 wks for effect
        • discontinuation syndrome if missed or stop med abruptly,
        • serotonin syndrome
  • Benzodiazepines - Lorazepam
    • increase GABA activity in a few minutes onset
    • risk of falls, confusion, memory problems
    • rebound insomnia if stop
    • NO in previous substance abuse
  • buspirone“anxious to take the bus”
    • non sedating
    • non addictive alt to benzos
    • not 1st line..takes 1-3 wks for effect and short ½ life (2-3x/day)
    • no effect on depression
  • Quetiapine (antipsychotic) can be used WITH SSRI/SNRI
37
Q

bipolar disorder diagnostics

A
  • if no previous dx, get drug urine test
  • CBC
  • TSH
  • liver
  • renal profile
38
Q

important to differentiate bipolar and depression by

A

asking about past dx of bipolar or hx of mania or hypomania, age of onset, features of illness, course of illness, hx of tx and family history

bc if treat for depression, it can make their mania worse

39
Q

screening tools for bipolar

A
  • Mood Disorder Questionnaire (MDQ)
  • Composite International Diagnostic Interview (CIDI)
  • also ask: hx/current eps of mania and/or depression, SI?, impact of sx’s on pt’s daily life, family hx
40
Q

for acute mania, what meds?

A
  • lithium (careful monitoring of thyroid, parathyroid, renal, and cardiac)
  • divalproex (Valproate)
  • carbamazepine (Tegretol)
  • SGA - asenapine (Saphris), apriprazole (Ambilify), olanzapine (Zyprexa), ziprasidone (Geodon)
  • ECT
41
Q

GAD follow up

A
  • weekly/biweekly to titrate meds
  • assess SI
  • assess comorbidities (depression)
42
Q

PTSD pharm tx

A
  • Either witnessing a trauma or experiencing a trauma
  • paroxetine, sertraline
  • NO BENZOs
43
Q

positive vs negative sx’s of schizophrenia

A
  • Positive sx:
    • hallucinations,
    • disorganized behavior
    • mania
    • suspiciousness
  • Negative sx:
    • Deprssion sx
    • Apathy
    • Abstract thinking problems
    • Anhedonia
    • Attention deficits
44
Q

schizophrenia physical exam findings

A
  • Abnormal smooth pursuit eye movement
  • Poor eye hand movement /clumsy
  • Soft signs: asterognosis, twitches, tics, rapid eye blinking
  • Impaired rapid alternating movements
  • Impairment in fine motor, left right confusion, see neurological hard signs like weakness, decreased reflexes
45
Q

schizophrenia management

A

acute phase → hospitalize

antidepressants, anxiolytics, anticonvulsants

mini mental status exam (disorganized thinking, tangential loose speech, blunt affect, bland mood, hallucinations/delusions)

46
Q

schizophrenia 1st gen vs 2nd gen antipsychotics

A
  • typical antipsychotics (1st gen)
    • same effectiveness
    • mostly on positive sx’s but DON’T impact negative sx’s
    • haloperidol, fluphenazine, chlorpromazine
  • atypical antipsychotics (2nd gen)
    • clozapine
    • olanzapine
    • risperidone
47
Q

neuroleptic malignant syndrome sx’s and common in what meds?

A
  • mostly from 1st gen antipsychotics
  • life-threatening
  • sx’s: F.E.V.E.R.
    • fever/hyperthermia
    • encephalopathy
    • vitals unstable (hypotension)
    • elevated CPK levels
    • rigidity of muscles
  • hyperreflexia
48
Q

neuroleptic malignant syndrome diagnotics

A

CPK, WBC, LFTs

49
Q

NMS treatment

A
  • STOP antipsychotics
  • same day ER
  • administer tantrum (dantrolene) or parlodel (bromocriptine)
  • antipyretic and cooling blanket
  • IV hydration
  • benzos for muscle rigidity (catatonic sx’s)
50
Q

depression and neuropathic pain, what antidepressant?

which antidepressant for diabetic neuropathy ?

A

TCA’s or venlafaxine

diabetic neuropathy pain: duloxetine (Cymbalta)

51
Q

TCA’s side effects

A
  • sedating
  • anticholinergic effects
  • contraindicated with pts with arrhythmias / cardiac dz
52
Q

SSRI side effects

A
  • irritability
  • insomina
  • agitation
  • sexual dysfunction
  • GI distress
  • warn all pts increased risk of suicidde when starting med.
  • if < 25 yrs old or severely depressed pts, need weekly f/u x 1 month, then bi weekly x 1 month, then monthly
53
Q

when to refer for depression?

A
  • not sure about diagnostic
  • manic or psychotic sx present
  • tx failure or severe sx’s
  • substance abuse
  • risk for suicide
54
Q

questionnaire to assess alcohol consumption

A

CAGE

  • CUT down?
  • ANNOYED someone judging u?
  • GUILTY feelings about drinking?
  • EYE opener (another drink) to get rid of hangover next day?
  • yes to 2 or more is 77% / 80% specific but may be biased to gender, ehtnicity, age

AUDIT and AUDIT-C test online

  • more sensitive, not gender/eth biased but time consuming
55
Q

pts with substance use disorder should be screened for

A

comorbidities (anxiety disorder, depression, PTSD, sleep disturbances) & to treat it bc higher rates of relapse.

56
Q

which meds treat opioid dependence?

A

methadone, naltrexone, buprenorphine

57
Q

PTSD DSM 5 dx

A
  • Exposure to actual or threatened death, injury, or sexual violence
  • > 50% have mood, anxiety, or SUD with PTSD
  • 1 or more of:
    • Recurrent, involuntary, or intrusive memories of the traumatic event
    • Recurrent distressing dreams related to the traumatic event
    • Dissociative reactions (flashbacks) where it feels as if the traumatic event is recurring (children may reenact traumatic events during play)
    • Intense distress to cues that remind patient of the event
  • Avoidance of stimuli associated with the traumatic event
  • Negative alterations in cognition associated with traumatic event (2 or more of the following):
    • Inability to remember important aspects
    • Persistent and exaggerated negative beliefs about oneself and/or the role one played in the traumatic event
    • Diminished interest/participation in significant events
    • Feelings of detachment from others
    • Persistent inability to experience positive emotions
  • Marked alterations in arousal and reactivity as evidenced by:
    • Irritable behavior
    • Reckless or self-destructive behavior
    • Hypervigilance
    • Exaggerated startle response
    • Sleep disturbance
  • Symptoms last > 1 month and are not attributable to another medical or mental condition

*Note: Acute stress disorder meets criteria for PTSD, but symptoms are self-limited and last for a minimum of 2 days and a maximum of 4 weeks.

58
Q

tools for PTSD

A
  • PTSD checklist - 17 reported sx’s of PTSD if bothered w/in the past month
  • PCL-M (military)
  • PCL -C (civilian)
  • PCL-S (specific stressful experience)
59
Q

PTSD treatment

A
  • if no psych comorbidities, SI, prior trauma, sx’s of refractory top rio rtf, can treat primary care setting with referral to psychotherapist
  • CBT, exposure therapy
  • SSRI’s for positive sx’s (nightmares, flashbacks) /SNRI
    • 1st line: paroxetine, sertraline, fluvoxamine, fluoxetine, citalopram
    • slow dose titration up
    • counsel suicide risk of med
  • NO anxiolytics (abuse) or benzos
60
Q

PTSD long term prognosis

A
  • chronic condition
  • 1 yr f/u ⅔ still have sx’s
  • at 10 yr f/u, ⅓ continue have sx’s
  • early tx can decrease chronicity of illness → consider tx of sx present > 4 wks
61
Q

first break psychosis

A

focus on safety of patient and those around him

if pt at risk of harming himself or others or unable to care for himself, ADMIT TO PSYCH!

62
Q

which medication is a/s with DECREASED suicide attempts?

A

clozapine

reduces suicide attempts in schizophrenia/schizoaffective disorder

63
Q

which substance abuse drug most likely cause psychotic episodes?

A

nicotine

smoking - induces cytochrome P450, which lowers clozapine serum concentrations = emergence of psychotic sx’s

get accurate smoking hx and stop smoking

64
Q

schizophrenia treatment

A

clozapine gold standard

  • can add ECT if sx’s come back. they have synergetic effects and can try if don’t respond to clozapine alone
65
Q

Bipolar 1 disorder DSM 5

A
  • at least 1 mania episode:
    • distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week
  • must have at least 3 concurrently:
    • inflated self esteem / grandiosity
    • decreased need for sleep
    • more talkative than usual
    • flight of ideas or racing thoughts
    • distractibility
    • increased goal directed activity or psychomotor agitation
    • excessive involvement in pleasurable activities with high risk for neg consequences (gambling, spending spree, risky sexual behavior)
  • must impair job / social
  • can’t be substance induced
66
Q

Bipolar II disorder DSM

A

at least 1 episode of depression or 1 episode of hypOmania

  • persistently elevated, expansive, or irritable mood x at least 4 days which is diff from non depressed mood
  • during hypomanic episode, need at least 3 of manic sx’s present, although episode is not sever enough to cause impairment tin job/social, hospitalize
67
Q

if bipolar is left untreated,

A
  • 20% will commit suicide
  • risk is highest in depressed state or mixed states (mania + depression)
  • onset can be any stage of life
    • can be later in life
  • ½ are misdx with depression
  • affects men and women equally
68
Q

bipolar mania med treatment

A
  • Lithium for mania + depression
    • has anti-suicide effect 8-9x reduction
    • taken night time or twice daily
    • narrow TI
    • lots of drug-drug intxn
  • lamotrigine (Lamictal) NOT for acute mania but approved mood stabilizer for bipolar tx
  • carbamazepine (Tegretol) 2nd line
  • olanzapine (Zyprexa), risperidone (Risperdal) ziprasidone (Abilify), quetiapine (Seroquel) = acute mania
    • SE: EPS, sedation, weight gain
69
Q

lithium monitoring

A
  • TSH monitoring! (causes hypothyroidism)
  • affect renal function and electrolyte levels
  • monitor thyroid, parathyroid, renal, and cardiac changes
  • narrow TI, measured 12 hrs after last dose
  • goal: 0.6-1
70
Q

which drugs affect lithium levels?

A

since it’s renally excreted, any change in renal function can affect lithium levels

NSAIDs, diuretics ACE inhibitors, ARBs

71
Q

if pt has acute bipolar depressive sx’s,

A
  • goal is safety and improved mood!
  • anticonvulsants, antidepressants, SGA, lithium
  • don’t use antidepressants alone! use olanzapine and fluoxetine combo
  • lithium or valproate can be used in combo with SGA for bipolar depression
72
Q

schizophrenia diagnostics

A
  • Aim—R/O organic cause
  • complete neuro exam and psych assessment/mental status exam!
  • Blood chemistries
  • Hepatic and renal studies
  • Thyroid studies
  • CBC
  • Syphilis
  • HIV infection screen
  • Alcohol and drug testing
  • CT, MRI
73
Q

important to ask depressed pt about

A

drug use, alcohol use

74
Q

serotonin syndrome sx’s

A

SHIVERS

  • shivering
  • hyperreflexia
  • increasing temperatures
  • vital sign instability (HR/BP/RR)
  • encephalopathy (alter LOC)
  • restlessness
  • sweating
75
Q

delirium tremens

A
  • severe alcohol withdrawal symptoms occurring 72-96 hrs after last consumption
  • severe tachycardia, tremor, confusion, hallucinations, agitation, diaphoresis, fever, seizures
76
Q

immediate referral indicated for substance use disorders:

A
  • withdrawal seizures
  • delirium tremens
  • overdose of any substance that causes unstable VS –> ED!
    • opioid OD: pinpoint pupils, respiratory depression = give naloxone
  • suicidal/homicidal/psychosis
  • ready for treatment for moderate - severe SUD should be referred to facility that can provide it
77
Q
A

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