Week 12: Adult Mental Health Flashcards
Depression screening in adults
- 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
- used as f/u after phq2
- PHQ-9 (older adults, cog impaired adults, nursing home residents)
- geriatric depression scale
- Beck Depression inventory
- Edinburgh postnatal depression scale
Depression labs
- get TSH
- CBC
- UA (drug screening)
- fasting blood glucose
- B12
- folate
MDD assessment
- get baseline PHQ9 Hx, PE
- mental status exam
- suicide risk (thoughts of hurting, SI, plan?)
MDD management
- #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
MDD pharm management
- 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+
SSRI antidepressants list
- SSRI [energizing to least energizing]
- fluoxetine (Prozac)
- sertraline (Zoloft)
- citalopram (Celexa)
- escitalopram (Lexapro)
- causes QT prolongation
- paroxetine (Paxil)
- causes weight gain
- most sedating
SNRI antidepressants and side effects
- increases norepinephrine and serotonin to improve motivation/focus AND mood
- venlafaxine (Effexor)
- desvenlafaxine (Prestiq)
- duloxetine (Cymbalta)
- atomoxetine (Straterra)
bupropion (Wellbutrin)
- good choice antidepressant if don’t have anxiety and have nicotine addiction
- lower risk of decreased libido
antidepressants may induce
- mania in susceptible pts
- black box warning of increased risk of suicidal thoughts/behavior in young people
which antidepressant for pt with anxiety?
- want less energizing
- venlafaxine or duloxetine
- NO bupropion (Wellbutrin)
which antidepressants to avoid with pt’s with cardiac conditions?
- TCA’s (-triptyline) [high risk of cardiac arrhythmia, no in older adults)
- citalopram (Celexa) & escitalopram (Lexapro) [QT prolongation]
pt has depression and ADHD, give what med?
bupropion or venlafaxine
avoid which antidepressant for severe renal/GI issues and seizure?
NO bupropion (lowers seizure threshold)
antidepressant treatment duration
- 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)
fluoxetine pearls
- least likely to gain weight
- most activating
- long half life
- for adolescents and non compliance
- don’t take at night
paroxetine pearls
- interacts with a lot of other meds
- bad withdrawal
- weight gain
- sedating, good for insomnia pts
citalopram pearls
- black box warning QTc prolongation
- NO with CVD dz
- (max dose 40mg QD, 20 mg QD if > 60 yrs old)
escitalopram pearls
weight neutral
neither sedating or activating
qt prolongation
venlafaxine (Effexor) and desvenlafaxine (Pristiq), want to monitor?
monitor HR and BP
induces hypertensive crisis
mirtazapine pearls
- 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
when to refer pts with depression?
- 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
depression presents with what
headache, back pain, chronic pain, “tired all the time”
MDD dx in adults
- 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)
which antidepressant good for sleep aid?
paroxetine, trazodone (Desryl), TCAs
obsessive compulsive disorder symptoms usually occur before what age?
15 year old
Inflexible, no spontaneity
delusions
- 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
Hallucinations
false sensory experience with NO objects
ie: hearing voices
illusions
misinterpretation of reality
ie: sees tree branches as goblins
Magical thinking
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
what complaints would someone with GAD have?
GENERAL complaints; normal PE/VS
Restlessness, fatigue, difficulty concentrating in relation to many events or activities
DSM 5 for GAD:
- 3 or more x 6+ months:
- restlessness or feeling on edge
- easy fatiguability
- difficulty concentrating
- irritability
- muscle tension
- sleep disturbance
panic attak
abrupt surge of intense fear or intense discomfort that reaches a peak within minutes
GAD physical examination
-
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
GAD diagnostics
- 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
GAD management non pharm
- psychotherapy/CBT first line mono therapy or w/ meds
- exercise as adjunct
GAD management pharm & education
- # 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
-
paroxetine, venlafaxine
- 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
bipolar disorder diagnostics
- if no previous dx, get drug urine test
- CBC
- TSH
- liver
- renal profile
important to differentiate bipolar and depression by
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
screening tools for bipolar
- 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
for acute mania, what meds?
- lithium (careful monitoring of thyroid, parathyroid, renal, and cardiac)
- divalproex (Valproate)
- carbamazepine (Tegretol)
- SGA - asenapine (Saphris), apriprazole (Ambilify), olanzapine (Zyprexa), ziprasidone (Geodon)
- ECT
GAD follow up
- weekly/biweekly to titrate meds
- assess SI
- assess comorbidities (depression)
PTSD pharm tx
- Either witnessing a trauma or experiencing a trauma
- paroxetine, sertraline
- NO BENZOs
positive vs negative sx’s of schizophrenia
- Positive sx:
- hallucinations,
- disorganized behavior
- mania
- suspiciousness
- Negative sx:
- Deprssion sx
- Apathy
- Abstract thinking problems
- Anhedonia
- Attention deficits
schizophrenia physical exam findings
- 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
schizophrenia management
acute phase → hospitalize
antidepressants, anxiolytics, anticonvulsants
mini mental status exam (disorganized thinking, tangential loose speech, blunt affect, bland mood, hallucinations/delusions)
schizophrenia 1st gen vs 2nd gen antipsychotics
- 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
neuroleptic malignant syndrome sx’s and common in what meds?
- 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
neuroleptic malignant syndrome diagnotics
CPK, WBC, LFTs
NMS treatment
- STOP antipsychotics
- same day ER
- administer tantrum (dantrolene) or parlodel (bromocriptine)
- antipyretic and cooling blanket
- IV hydration
- benzos for muscle rigidity (catatonic sx’s)
depression and neuropathic pain, what antidepressant?
which antidepressant for diabetic neuropathy ?
TCA’s or venlafaxine
diabetic neuropathy pain: duloxetine (Cymbalta)
TCA’s side effects
- sedating
- anticholinergic effects
- contraindicated with pts with arrhythmias / cardiac dz
SSRI side effects
- 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
when to refer for depression?
- not sure about diagnostic
- manic or psychotic sx present
- tx failure or severe sx’s
- substance abuse
- risk for suicide
questionnaire to assess alcohol consumption
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
pts with substance use disorder should be screened for
comorbidities (anxiety disorder, depression, PTSD, sleep disturbances) & to treat it bc higher rates of relapse.
which meds treat opioid dependence?
methadone, naltrexone, buprenorphine
PTSD DSM 5 dx
- 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.
tools for PTSD
- 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)
PTSD treatment
- 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
PTSD long term prognosis
- 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
first break psychosis
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!
which medication is a/s with DECREASED suicide attempts?
clozapine
reduces suicide attempts in schizophrenia/schizoaffective disorder
which substance abuse drug most likely cause psychotic episodes?
nicotine
smoking - induces cytochrome P450, which lowers clozapine serum concentrations = emergence of psychotic sx’s
get accurate smoking hx and stop smoking
schizophrenia treatment
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
Bipolar 1 disorder DSM 5
- 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
Bipolar II disorder DSM
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
if bipolar is left untreated,
- 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
bipolar mania med treatment
-
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
lithium monitoring
- 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
which drugs affect lithium levels?
since it’s renally excreted, any change in renal function can affect lithium levels
NSAIDs, diuretics ACE inhibitors, ARBs
if pt has acute bipolar depressive sx’s,
- 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
schizophrenia diagnostics
- 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
important to ask depressed pt about
drug use, alcohol use
serotonin syndrome sx’s
SHIVERS
- shivering
- hyperreflexia
- increasing temperatures
- vital sign instability (HR/BP/RR)
- encephalopathy (alter LOC)
- restlessness
- sweating
delirium tremens
- severe alcohol withdrawal symptoms occurring 72-96 hrs after last consumption
- severe tachycardia, tremor, confusion, hallucinations, agitation, diaphoresis, fever, seizures
immediate referral indicated for substance use disorders:
- 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
