Mental Health Assessment Flashcards
(92 cards)
1
Q
DSM-5 Means
A
Diagnostic and Statistical Manual of Mental Disorder
“Bible of neuropsychiatry
2
Q
DSM provides what information?
A
Age of onset of illness Clinical course of disease Complication Predisposing factors Prevalence Differential Diagnoses Diagnostic criteria Number of symptoms/time course required
3
Q
MSE is what?
A
Mental Status Examination
4
Q
MSE includes:
A
Appearance Attitude Psychomotor Activity (over or underactive) Speech/Language/Eye Contact Mood Affect (reactive, limited/excessive facial expression) Thought content/process Insight/judgment Neuropsychiatric evaluation
5
Q
Depression has been associated with:
A
increased risk of morbidity and mortality in pts with chronic medical conditions such as CVD
6
Q
Medical Conditions that can cause Depression
A
Hypothyroidism Alzheimer's disease Decreased Vit B12/folate PK disease Severe anemia Cancer Infxn Autoimmune Post-stroke Menopause HF Electrolyte imbalance CAD
7
Q
Substance disorders that can cause depression
A
Alcoholism Marijuana Nicotine Opiate Stimulant
8
Q
Medications that can cause depression
A
BB Benzo Opioids Clonidine Barbiturates Anticonvulsants Interferon Oral Contraceptive Isotretinoin Glucocorticoids
9
Q
Define Dysthymia
A
Persisttent Depressive Disorder
- Chronic disturbance of mood involving depressed mood combined with at least 2 other symptoms
- Experienced a depressive mood more days than not for at least 2 years
10
Q
Other symptoms include
A
Appetite disturbance Low energy Sleep disturbance Feelings of hopelessness Low self-esteem Poor concentration or indecisiveness
11
Q
Define Major Depressive Disorder
A
- Five or more of the following symptoms with at least 1 being the first two
- Depressed mood
- Decreased interest or pleasure
- Decreased energy
- Feeling worthlessness/guilt
- Changes in body weight
- Poor concentration
- Sleep disturbances
- Recurrent thoughts of death
- Psychomotor agitation or retardation - Experience 5+ symptoms nearly every day for at least 2 week and they’ve caused a change in daily function
- Symptoms are not due to substance or medical condition
12
Q
Assessing Symptoms of Depression
A
SIGE CAPS S: sleep I: Interested G: Guilt E: Energy C: Concentration A: Appetite P: Psychomotor (agitated or motivation problems) S: Suicide
13
Q
What increases a patient’s risk for suicide
A
Widowed/unmarried/living alone Male Feelings of hopelessness Prior suicide attempts/plans FH Serious medical conditions Lack of social support Substance abuse History of psych admission
14
Q
Black box warning for antidepressants?
A
High risk of suicidal behavior was found during the first 30 days
15
Q
Why treat depression?
A
Increase QofL
Decreased suicide risk
Decreased morbidity/mortality of other disease states
16
Q
Psychotherapy options
A
Cognitive Behavioral Therapy
Interpersonal therapy
Group Therapy
17
Q
Electroconvulsive Therapy Used for
A
Only for severe depression, resistant depression, depression + psyotic/catatonic feature, or severe suicidal ideation
18
Q
How does electroconvulsive therapy work?
A
Electrical charge is applied to stimulate the brain and produce a seizure which last about 1 minute
- 6 to 12 treatments then continued antidepressant therapy
19
Q
Bright Light Therapy
A
For seasonal affective disorder
Exposed to 30 of artificial light upon rising
1-2 weeks long
20
Q
Vagal Nerve Stimulation Uses
A
Adjunctive to long-term, chronic or recurrent depression (>2 years), no responding to at least 4 trials of drugs
21
Q
Vagal Nerve Stimulations works how?
A
Surgical implantation under the skin on the chest causes electrical connection to vagal nerve
When activated mild pulses are sent to nerve and travel to brainstem which results in improved mood and depressive symptoms
Take 10 weeks to see a response
22
Q
Decreased Positive Affect =
A
Anhedonia Lack of Motivation Decreased Energy Apathy Decreased executive function
23
Q
Treatment of decrease positive affect
A
Drugs that increase NE and DA
24
Q
Increased Negative Affect =
A
Worry Worthlessness Suicidal ideation Anxious Guilt
25
Treatment of increased negative affects
Drugs that increase 5HT
26
Treatment Guidelines Overview
1. Perform full history/physical, lab evaluation, mental health assessment
2. Initial Therapy
3. Partial Response
4. No response
5. TCA no recommend but can be used for partial or no response
6. MAOI should be last line therapy
27
Initial Therapy Options
```
SSRI
SNRI
Bupropion
Mirtazapine
- Titrate to therapeutic dose and assess for efficacy in 4-6 weeks
```
28
Partial Response Options
1. Increase dose if not at max
| 2. Add psychotherapy if agrees AND/OR add augmentation agent
29
Augmentation agent options
Non-MAOI with different MOA
Lithium
THyroid hormone
2nd gen antipsychotic
30
No Response Options
D/c initial drug and try another
| May switch to drug in the same class
31
Acute Phase Treatment
Usual 6-12 weeks
| Goal: reach remission of symptoms
32
Continuation Phase Treatment
Continue effective drug for 4-9 months after remission is achieved
Goal: prevent relapse
33
Maintenance Phase Treatment
Continued treatment for 12 months and longer after remission
| Goal: prevent recurrences
34
After 1 episode of depression,
pt has a 50% chance of recurrence
35
After 2 episodes of depression,
pt has a 70% chance of recurrence
36
After 3 episodes of depression,
pt has a 90% chance of recurrence, so lifetime antidepressants therapy is recommended
37
Elderly dosing
1/2 normal dose for a week and then increase to therapeutic dose if side effects are not seen
38
Stopping antidepressants
Dose should be taper
| NEVER stop abruptly
39
STAR-D stands for
Sequenced Treatment Alternative to Relieve Depression
40
Conclusions reached by STAR-D?
- Approximately 30% of pts reach remission after 14 weeks of treatment
- Remission rates increased with each level of the study
- Higher relapse rates were seen with more treatment levels
- Achieving remission vs just getting a response showed less likelihood to relapse and had better daily function
41
Drug Specific Conlusions from STAR-D
- Remission rate was slightly higher for venlafaxine XR groups
- Bupropion was better tolerated
- Remission rates between mirtazapine and nortriptyline were not significant
- Remission rates between T3 and lithium were not significant but T3 was better tolerated
- Venlafaxine + Mirtazapine was better tolerated
42
SSRI Drugs
```
Fluoxetine
Paroxetine
Sertraline
Citalopram
Escitalopram
```
43
SSRI Side Effects
Serotonin AE: GI, sleep, agitation, anorexia, sexual dysfunction
Hyponatremia, GI bleeds
44
Citalopram specific SE
Prolong QT interval
45
Fluoxetine Drug interaction
2D6 and 3A4 inhibitor
46
Paroxetine Drug interaction
2D6 inhibitor
47
SSRI PD
Caution with NSAID, antiplatelets, anticoags (risk of bleed)
CI with MAOI
Risk of SS with other serotonergic meds
48
Peds + SSRI
Fluoxetine
Sertraline
Escitalopram
49
SSRI Dosing/Counseling
QD in AM
| With food if problems with nausea
50
SSRI use
CVD
Elderly
Decrease negative affect
Comorbid anxiety disorders
51
SSRI avoid use in
Hyponatremia pt
Serotonergic agnet
NSAID/antiplatelets
Sexual dysfunction
52
Things that inhibit serotonin metabolism
```
Phenelzine
Tranylcypromine
Selegiline
Linezolid
St. John's Wort
```
53
Things that increase release of serotonin:
```
Meperidine
Dextromethorphan
Cocaine
LSD
Ecstasy
```
54
Things that are serotonin receptor agonist
Buspirone
| Lithium
55
Things that cause Inhibition of Serotonin reuptake
```
SSRI
TCA
Venlafaxine
Duloxetine
Tramadol
Dextromethorphan
Meperidine
```
56
SNRI Drugs
Venlafaxine
Desvenlafaxine
Duloxetine
Levomilnacipran
57
SNRI AE
NE AE: tachycardi, elevated BP, insomnia, tremor, sweating, pseudo-antichol
Serotonine SE
58
Duloxetine Specific SE
Elevated LFT
59
Venlafaxine Specific SE
Prolonged QT interval
60
Duloxetine Drug Interaction
2D6 inhibitor
61
Levomilnacipran Drug Interaction
3A4 substrate
62
SNRI PD
```
CI with MAOI
Caution with NSAIDs, antiplatelets, anticoag
Caution with other serotonergic
Caution with meds that increase NE
Can decrease HTN meds
```
63
SNRI Dosing/Counseling
AM
| With food for GI upset
64
SNRI good choice for:
Pts with apathy, low motivation
Hypersomnia
Obese
Pts with pain
65
SNRI Avoid in
HTN pts
| CVD pts
66
Buproprion AE
Decrease seizure threshold
NE AE
DE AE: psychotic symptoms, bad dreams
67
Bupropion DI
Inhibitor of 2D6
68
Bupropion PD
CI with MAOI
Caution with meds that augment DA
Caution with meds that increase NE
Caution in meds that also decrease seizure threshold
69
Bupropion Dosing/Counseling
```
Extended Release (XL): QD AM
Sustained release (SR): BID, not at bedtime, doses separate by 8 hours and no more than 200 mg per dose
```
70
Bupropion good choice in
No sexual dysfunction
Smokers
Low motivation/energy
Obese
71
Bupropion avoid is:
Predispose to seizures
Anorexia
CVD
72
Tertiary TCAs
Amitriptyline
Imipramine
Doxepin
Clomipramine
73
Secondary amine TCAs
Nortriptyline
| Desipramine
74
TCA SE
```
NE
5HT
Anticholinergic (M1)
Sedation and weight gain (H1)
Orthostatic hypoTN (alpha-1)
Arrhythmias (Na/K block)
Decreased seizure threshold
```
75
TCA Interaction
2D6 substrate (narrow therapeutic window so if you have a 2D6 inhibitor could cause toxic SE)
76
TCA PD
```
CI with MAOI
Anticholinergics
Sedating medcations
Caution with meds that increase NE
Caution with serotenergic meds
Decreases effect of clonidine
```
77
Peds + TCA
Amitriptyline, nortriptyline, doxepine >12
| Imipramine and desipramine >6
78
TCA Dosing
Start low and go slow
| Take at bedtime (sedation)
79
TCA Good choice for:
Neuropathic pain
Migraine headaches
Insomnia
Decreased appetite
80
TCA Avoid in:
```
History of arrhythmias
CVD
Predisposed to seizures
Elderly
Suicidal
```
81
Mirtazapine AE
Sedation (H1)
Weight gain (H1)
Increased cholesterol
Rare agranulocytosis and increased liver transaminases
82
Mirtazapine Drug Interactions
```
CI with MAOI
Sedating medication
Caution with meds that increase NE
Caution with serotonergic agents
Decrease clonidine effect
```
83
Mirtazapine Dosing/Counseling
Take at bedtime
84
Mirtazapine good choice in:
Less sexual dysfunction
Loss of appetite
Insomnia
85
Mirtazapine avoid in:
Obese
Hypersomnia
Elevated cholesterol and LFT
86
Vilazodone AE
GI upset
87
Vilazodone drug interactions
3A4 substrate
CI with MAOI
Caution with NSAIDs, antipaltelets, anticoags
88
Vilazodone Dosing/Counseling
QD AM with food
| Food increases absorption
89
MAOI Drugs
Isocarboxazid
Phenelzine
Tranylcypromine
Selegiline patch
90
MAOI SE
NE
5HT
Orthostatic hypotension
91
MAOI Drug/Food Interactions
Tyramine foods
CI with other antidepressants
CI with serotonergic meds
CI with NE and DA increasing meds
92
MAOI Limitations
No longer first line agent
| CI in pts who can't understand or have trouble remembering med instructions
