Psych

Question 1

Psychiatric Treatment in Primary Care

Objectives

1. Identify and assess patients presenting with d_____ and a______
2. Understand common medical conditions that can mi____ psychiatric symptoms
3. Initiate and manage psycho________ treatment for depression and anxiety
4. C______ psychotropic medications and understand mon______ protocols for common psychiatric medications
5. Refer patients to appropriate settings for treatment
6. Assess risk for s_______and h_____ behavior

Answer 1

1. Identify and assess patients presenting with depression and anxiety
2. Understand common medical conditions that can mimic psychiatric symptoms
3. Initiate and manage psychopharmacological treatment for depression and anxiety
4. Continue psychotropic medications and understand monitoring protocols for common psychiatric medications
5. Refer patients to appropriate settings for treatment
6. Assess risk for suicidal and homicidal behavior

Question 2

Why don’t I just refer to psychiatry?

• Time between onset and diagnosis can be __-__ years
• Barriers to treatment include:
  
  • Cost and limited _____ coverage
  • Limited options and ____ wait times
  • Lack of aw______
  • Social st_____

Primary care providers have a unique opportunity to identify and treat mental health conditions…don’t be ____!

Answer 2

• Time between onset and diagnosis can be 3-4 years
• Barriers to treatment include:
  
  • Cost and limited insurance coverage
  • Limited options and long wait times
  • Lack of awareness
  • Social stigma

Primary care providers have a unique opportunity to identify and treat mental health conditions…don’t be afraid!

• bulk of mental health care done at primary care level, and many general practitioners are subscribing these medications/chart is old and numbers are rising*
• You are first line*

Question 3

Clinical Presentations of Depression and Anxiety

• “I’m so t____all the time”
• “My st_____is always in a knot”
• “My hands feel n____”
• “My heart keeps r_____”
• “I can’t sl_____”
• “I constantly have loose _____”

Answer 3

• “I’m so tired all the time”
• “My stomach is always in a knot”
• “My hands feel numb”
• “My heart keeps racing”
• “I can’t sleep”
• “I constantly have loose stools”

Question 4

Clinical Presentations

• Often patients present with s_____ manifestations of depression and anxiety
  
  • Neuro_____ symptoms (fatigue, poor sleep, decreased concentration/memory)
  • P____
  • N____ness/ti____
  • N_______
  • Head_____
  • Palp________
• Work up their complaint from a medical perspective including appropriate l____

Answer 4

• Often patients present with somatic manifestations of depression and anxiety
  
  • Neurovegetative symptoms (fatigue, poor sleep, decreased concentration/memory)
  • Pain
  • Numbness/tingling
  • Nausea
  • Headache
  • Palpitations
• Work up their complaint from a medical perspective including appropriate labs

don’t automatically think anxiety, workup medical issues first, diabetic neuropathy etc., trouble breathing -> CHF/COPD

Question 5

Common diagnoses that mimic symptoms of mood disorders

• Endocrine/metabolic d/o
  
  • Hyper/hypo_______ (fatigue, weight changes, palpitations, muscle aches)
  • D_______ (fatigue, irritability, weight changes)
  • El______ imbalance (Mg, Ca, K, Na)
• Cardiopulmonary
  
  • C_ _ , CO_ _
• (1) process
  
  • Mononucleosis, viral hepatitis, HIV, acute bacterial infection, tuberculosis

Answer 5

• Endocrine/metabolic d/o
  
  • Hyper/hypothyroidism (fatigue, weight changes, palpitations, muscle aches)
  • Diabetes (fatigue, irritability, weight changes)
  • Electrolyte imbalance (Mg, Ca, K, Na) •
• Cardiopulmonary
  
  • CHF, COPD
• Infectious disease process
  
  • Mononucleosis, viral hepatitis, HIV, acute bacterial infection, tuberculosis

Question 6

Common diagnoses that mimic symptoms of mood disorders

• Vitamin __/___ deficiency (low energy, poor concentration)
• An____ (fatigue)
• Rh_______ d/o
  
  • Fibromyalgia, systemic lupus erythematosus, Lyme disease
• Medication (1)
  
  • Corticosteroids, stimulants, benzodiazepines, muscle relaxants
• ____ use – order utox
  
  • Withdrawal and use (cocaine, EToH, tobacco, K, heroin…)

Co______ depression/anxiety can also occur alongside any medical condition

Answer 6

• Vitamin D/B12 deficiency (low energy, poor concentration)
• Anemia (fatigue)
• Rheumatologic d/o
  
  • Fibromyalgia, systemic lupus erythematosus, Lyme disease
• Medication side effects
  
  • Corticosteroids, stimulants, benzodiazepines, muscle relaxants
• Drug use – order utox
  
  • Withdrawal and use (cocaine, EToH, tobacco, K, heroin…)

Comorbid depression/anxiety can also occur alongside any medical condition

Question 7

DSM-5 Persistent Depressive Disorder

At least __ of the following symptoms have to have been present during the same __-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood)

• Depressed or irritable _____
• Diminished in_____ or loss of pl_____ in almost all activities (anhedonia)
• Significant w______ change or appetite disturbance
• _____ disturbance (insomnia or hypersomnia)
• ________ agitation or retardation
• F______ or loss of energy
• Feelings of _____lessness
• Diminished ability to think or con_______; indecisiveness
• Recurrent thoughts of d_____, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide

Answer 7

At least 5 of the following symptoms have to have been present during the same 2-week period (and at least 1 of the symptoms must be diminished interest/pleasure or depressed mood)

• Depressed mood or irritable mood
• Diminished interest or loss of pleasure in almost all activities (anhedonia)
• Significant weight change or appetite disturbance
• Sleep disturbance (insomnia or hypersomnia)
• Psychomotor agitation or retardation
• Fatigue or loss of energy
• Feelings of worthlessness
• Diminished ability to think or concentrate; indecisiveness
• Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or specific plan for committing suicide

Question 8

DSM 5- Generalized Anxiety Disorder

The presence of excessive anxiety and _____ about a variety of topics, events, or activities. Worry occurs more often than not for at least ___ months and is clearly excessive.

The worry is experienced as very challenging to control. The worry in both adults and children may easily _____ from one topic to another.

Answer 8

The presence of excessive anxiety and worry about a variety of topics, events, or activities. Worry occurs more often than not for at least six months and is clearly excessive.

The worry is experienced as very challenging to control. The worry in both adults and children may easily shift from one topic to another.

Question 9

DSM-5 Generalized Anxiety Disorder

The anxiety and worry are accompanied by at least __ of the following physical or cognitive symptoms:

• Edginess or r_____lessness
• Tiring easily; more f_____ than usual
• Impaired con_____ or feeling as though the mind goes blank
• Irr____ (which may or may not be observable to others)
• Increased muscle ____ or soreness
• Difficulty sl_____ (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)

Answer 9

The anxiety and worry are accompanied by at least three of the following physical or cognitive symptoms:

• Edginess or restlessness
• Tiring easily; more fatigued than usual
• Impaired concentration or feeling as though the mind goes blank
• Irritability (which may or may not be observable to others)
• Increased muscle aches or soreness
• Difficulty sleeping (due to trouble falling asleep or staying asleep, restlessness at night, or unsatisfying sleep)

Question 10

Depression Clinical Assessment

(1) initial screening

What are the questions?

• Clinical scales are a quick and reliable way to screen for depression and anxiety
  
  • ____ a diagnostic tool (use DSM criteria for diagnosis)
• Depression
  
  • PHQ-2 should be completed how frequently? score of __ or greater are considered positive
• Positive score prompts further assessment with (1)

Answer 10

PHQ-2

• Clinical scales are a quick and reliable way to screen for depression and anxiety
  
  • NOT a diagnostic tool (use DSM criteria for diagnosis)
• Depression
  
  • PHQ-2 should be completed annually, score of 3 or greater are considered positive
• Positive score prompts further assessment with PHQ-9

Question 11

PHQ-9

Answer 11

Question 12

PHQ9- Scoring

1. 0-4
   
   1. Provisional diagnosis =
   2. Treatment recommendation =
2. 5-9
   
   1. Provisional diagnosis =
   2. Treatment recommendation =
3. 10-14
   
   1. Provisional diagnosis (3)
   2. Treatment recommendation (3)

Answer 12

1. 0-4
   
   1. Provisional diagnosis = None/minimal
   2. Treatment recommendation = None
2. 5-9
   
   1. Provisional diagnosis = Minimal symptoms
   2. Treatment recommendation = Support, educate to call if worse, return in 1 month
3. 10-14
   
   1. Provisional diagnosis = Minor depression, Dysthmia, Mild major depression
   2. Treatment recommendation = Support, watchful waiting, antidepressants and psychotherapy, antidepressants and psychotherapy

Question 13

PHQ9- Scoring

1. 15-19
   
   1. Provisional diagnosis =
   2. Treatment recommendation =
2. >20
   
   1. Provisional diagnosis =
   2. Treatment recommendation =

Answer 13

1. 15-19
   
   1. Provisional diagnosis = Moderately severe major depression
   2. Treatment recommendation = Antidepressant or psychotherapy
2. >20
   
   1. Provisional diagnosis = Severe major depression
   2. Treatment recommendation = Antidepressant AND Psychotherapy (especially if not improved on monotherapy)

Question 14

PHQ-A

Ages ___-___

Uses ____ scoring guide as PHQ-9

Answer 14

Modified PHQ-9 for adolescents

Age 11-17

Uses same scoring guide as PHQ-9

Question 15

Physical Warning Signs that a Teen Needs Help

1. ____ on arms or legs or other physical signs of self-____
2. Rapid or major ____ loss or gain
3. Physical injuries without good _______
4. Many stomach, head, and/or back _____
5. Worsening of a _____ condition

Answer 15

1. Cuts on arms or legs or other physical signs of self-harm
2. Rapid or major weight loss or gain
3. Physical injuries without good explanation
4. Many stomach, head, and/or back aches
5. Worsening of a chronic condition

Question 16

Behavioral or Emotional Warning Signs that a Teen Needs Help

1. Major change in e____ and/or sl_____ habits
2. Signs of frustration, stress, or anger
3. Re_______ difficulties with family, friends, classmates, or teachers
4. Sk______ school, not participating in class, and/or drop in grades
5. Changes or problems with en____ level or con_____
6. Sudden mood _____
7. Feeling down, hopeless, worthless, guilty

Answer 16

1. Major change in eating and/or sleeping habits
2. Signs of frustration, stress, or anger
3. Relationship difficulties with family, friends, classmates, or teachers
4. Skipping school, not participating in class, and/or drop in grades
5. Changes or problems with energy level or concentration
6. Sudden mood swings
7. Feeling down, hopeless, worthless, guilty

Question 17

Behavioral or Emotional Warning Signs that a Teen Needs Help

1. Aggressive or v_____ behavior
2. Sudden loss of self con____ or sense of security
3. Risky behaviors, breaking l___, st____, hurting people
4. Signs of al____ or dr___ use
5. Losing _____ in things that were once enjoyed
6. Constant concern about _____ appearance or decrease in personal hy____
7. Is_____ from others and often spends time alone
8. Se_____ about activities and whereabouts

Answer 17

1. Aggressive or violent behavior
2. Sudden loss of self confidence or sense of security
3. Risky behaviors, breaking laws, stealing, hurting people
4. Signs of alcohol or drug use
5. Losing interest in things that were once enjoyed
6. Constant concern about physical appearance or decrease in personal hygiene
7. Isolation from others and often spends time alone
8. Secretive about activities and whereabouts

Question 18

(1)

Tool for postpartum depression

• Can be used in the ___natal period as well
• Takes into account ____day experience of pregnancy

Answer 18

Edinburgh Postnatal Depression Scale

• Can be used in the prenatal period as well
• Takes into account everyday experience of pregnancy

Question 19

(1)

Screening tool for Anxiety

What populations used for?

Over the last (1), how often have you been bothered by the following problems?

(7) Questions

Answer 19

GAD-7

Can be used in adolescents and perinatal patients as well

Over the last 2 weeks, how often have you been bothered by the following problems?

1. Feeling nervous, anxious, or edge?
2. Not being able to stop or control worrying?
3. Worrying too much about different things
4. Trouble relaxing
5. Being so restless that it is hard to sit still
6. Becoming easily annoyed or irritable
7. Feeling afraid, as if something awful might happen

Question 20

GAD-7 Scoring

1. Minimal Anxiety =
2. Mild Anxiety =
3. Moderate Anxiety =
4. Severe Anxiety =

Answer 20

1. Minimal Anxiety = 0-4
2. Mild Anxiety = 5-9
3. Moderate Anxiety = 10-14
4. Severe Anxiety = 15-21

Question 21

Psychotherapy: Cognitive Behavioral Therapy (CBT)

• Should be considered in what patients? Exceptions include (2)?
• (1) + (1) often produces best outcomes
• Psychotherapy alone may be a good first line treatment for what type of cases?
• Can be particularly beneficial for those waiting to avoid _____ and those with significant psychosocial/inter_____l conflicts

Other forms of therapy include psychodynamic, psychoanalytical, play, dialectic behavioral therapy

Answer 21

• Should be considered in (nearly) every patient, exceptions are personality disorders, intellectual delay… But they can still get some benefit
• Combination of psychotherapy + medication management often produce the best outcomes
• Psychotherapy alone may be a good first-line treatment for mild-moderate cases (Some patients add-on medications during psychotherapy treatment)
• Can be particularly beneficial for those waiting to avoid medications and those with significant psychosocial/interpersonal conflicts

Other forms of therapy include psychodynamic, psychoanalytical, play, dialectic behavioral therapy

• not really for people with personality disorder*
• Good first line treatment for depression/mild anxiety*
• Medications may not help interpersonal conflicts - like an estranged parent that just comes into your life*

Question 22

***BEFORE PSYCHOPHARMACOLOGICAL TREATMENT**

**RULE OUT (1)**

What questions do you ask?

Answer 22

**RULE OUT MANIA**

Period of 4-5 days with no need to sleep, excess energy, risky behavior, impulsivitiy?

no way to rule out that a patient won’t become manic on a medication - all these meds are activating but try to screen bipolar (any period of 4-5 days where you do not sleep and are have alot of energy)

Question 23

(1)

First Line Pharm Treatment for Anxiety and Depression

Drug Class (1)

(2) Rx preferred

dosing, frequency, increase by how much how often?

Answer 23

SSRIs – first line treatment

• Sertraline (Zoloft)
  
  • Start with 50 mg q daily, increase by increments of 25-50 mg q 4 weeks (ish) if necessary
• Escitalopram (Lexapro)
  
  • Start with 10 mg q daily, increase by 5 mg q 4 weeks (ish) if necessary

There is a 25mg tablet but i have not seen any therapeutic benefit with it (zoloft)

Question 24

Medication Naive Patients

What should you do to the starting dose for a med naive patient?

Why?

(1) is KEY

Can _____ dose to help with _________

Answer 24

For med naïve patients, start with half tab for 1-2 weeks because…

Common side effects: Nausea, headache (usually occur in within the first 1-2 weeks)

Psychoeducation is KEY here

Can reduce dose to help with tolerability

• you are going to feel nausea for the first week - try to tolerate it for at least 1-2 weeks - all about tolerability*
• lots of GI side effects bc we have serotonin receptors in our GI tract*

Question 25

Symptom Improvement with Pharm Therapy When should you start to see symptom improvement? When should you start to see maximum response? Follow up should occur when? Advise and educate to reach out if they start experience what type of symptoms? **Black Box Warning =**

Answer 25

Symptom improvement begins **3-4 weeks** after treatment Maximum response seen in **6-8 weeks** Follow up should occur within **4-6 weeks** Advise patients to reach out if **manic symptoms** occur (sudden increase in energy, unusual idea, impulsivity) **BB Warning for suicidality**

Question 26

SSRIs Examples

Answer 26

* Sertraline (Zoloft) * Escitalopram (Lexapro) * Fluoxetine (Prozac) * Citalopram (Celexa) * Fluvoxamine (Luvox) * Paroxetine (Paxil) * can prolong QT* * paxil has an ER formulation now bc half life is so short can precipitate withdrawal (I don't like paxil)*

Question 27

SNRIs Examples

Answer 27

* Venlafaxine XR (Effexor XR) * desvenlafaxine (Pristq) * duloxetine (Cymbalta)

Question 28

SNRI's Important to monitor what? why? W\_\_\_\_\_\_ side effects possible When should we use SNRIs?

Answer 28

Monitor BP after initiation and throughout treatment, because they have a norepi component can effect BP/HR Withdrawal side effects possible * If patient fails 2 SSRI's can try SNRI* * but bc they have norepi component can impact BP and heart rate and higher likelihood of withdrawal (dizzy, more depressed)* * Does not exclude patients with cardiac history but monitor (research shows zoloft more favorable for cardiac)*

Question 29

Atypical Agents (2)

Answer 29

* Bupropion (Welbutrin, Welbutrin SR, Welbutrin XL) * Mirtazapine (Remeron)

Question 30

Bupropion (Welbutrin, Welbutrin SR, Welbutrin XL) * Improves con\_\_\_\_\_, av\_\_\_\_\_ * Does it work for anxiety? * Third line agent for \_\_\_\_\_\_ * Little to no _____ side effects * Great for ______ cessation and can be used in combo with gum/patch

Answer 30

* Improves concentration, avoltion * Does not impact anxiety (no direct serotonin action) and can INCREASE anxiety * Third line agent for ADHD * Little to no sexual side effects * Great for smoking cessation and can be used in combo with gum/patch

Question 31

Bupropion (Welbutrin, Welbutrin SR, Welbutrin XL) * Improves con\_\_\_\_\_, av\_\_\_\_\_ * Does it work for anxiety? * Third line agent for \_\_\_\_\_\_ * Little to no _____ side effects * Great for ______ cessation and can be used in combo with gum/patch

Answer 31

* Improves concentration, avoltion * **Does not impact anxiety (no direct serotonin action) and can INCREASE anxiety** * Third line agent for ADHD * Little to no sexual side effects * Great for smoking cessation and can be used in combo with gum/patch *would not use wellbutrin as first line because does not act on serotonin*

Question 32

Mirtazapine * Very se\_\_\_\_\_\_ – can be used for sl\_\_\_\_ and mood * Great for ____ patients (bc it can increase app\_\_\_\_\_\_, increases w\_\_\_\_\_)

Answer 32

* Very sedating – can be used for sleep and mood * Great for geri patients (bc it can increase appetite, increases weight)

Question 33

Tricyclic Antidepressants (TCAs) Clinical use? Off label uses (3)

Answer 33

**Not commonly used in clinical practice today** Off-label uses for pain management, sleep, migraine prophylaxis

Question 34

Tricyclic Antidepressants (TCAs) * Monitor ___ (orthostats), ____ rate, ___ changes (increased PR interval usually) * EKG changes usually ____ dependent but want to have a baseline and monitor annually once patient is stabilized * Extreme _____ in those with pre-existing _____ issues

Answer 34

* Monitor BP (orthostats), heart rate, EKG changes (increased PR interval usually) * EKG changes usually dosed dependent but want to have a baseline and monitor annually once patient is stabilized * Extreme caution in those with pre-existing cardiovascular issues *you will not be initiating any of these but if patients are on these meds - monitor*

Question 35

Monamine Oxidase Inhibitors (MAOIs) Clinical use? Strict diet of?

Answer 35

Rarely used today Patients must adhere to strict low-tyramine diet (no aged cheeses, wine, soy sauce, sausages, fermented products such as kimchi) *you will not be initiating any of these but if patients are on these meds - monitor*

Question 36

How do you rule out bipolar disorder? (1)

Answer 36

Mood Disorder Questionnaire

Question 37

Antidepressant Dosing Chart

Answer 37

Question 38

Antidepressant Dosing Chart

Answer 38

Question 39

Depression Pharm Therapy for Adolescents **Psychotherapy** * Should be used in ______ with medication * Many psycho\_\_\_\_\_\_ factors impact mood **Psychopharmacology** * **(1)** considered first line (FDA approved for 8 and up) * **(1)** (FDA approved for 12 and up) * Do you start at regular doses? * BLACK BOX WARNING = * Maintain ____ follow up * Coordinate with \_\_\_\_\_\_\_ * Create _____ plans

Answer 39

**Psychotherapy** * Should be used in conjunction with medication * Many psychosocial factors impact mood **Psychopharmacology** * **Fluoxetine** considered first line (FDA approved for 8 and up) * **Escitalopram** (FDA approved for 12 and up) * Start at half doses and closely monitor *(include parents)* * BLACK BOX WARNING *- become impulsive and suicidal quickly* * Maintain close follow up * Coordinate with schools * Create safety plans

Question 40

Anxiety Pharm Treatment (4)

Answer 40

Buspirone Gabapentin Hydroxyzine Benzodiazepines

Question 41

Buspirone **Drug class** Is it a controlled substance? MOA Dose, Frequency How long does it take to be effective?

Answer 41

**Anxiolytic** not controlled Works only on serotonin anxiety receptors, less serotonin-based side effects Dosing BID or TID, 10-20 mg Takes a few weeks to become effective

Question 42

Gabapentin \_\_\_\_-label use Is it a controlled substance? Dosing, Frequency? Efficacy?

Answer 42

Off-label use Controlled substance in some states (can have street value) 100-300 mg TID for anxiety Mixed efficacy

Question 43

Hydroxyzine Drug Class Dosing, Frequency Can be helpful for \_\_\_\_\_

Answer 43

**Antihistamine** 25-50mg PRN Q6-8 hours Can be helpful for sleep (sedating effect)

Question 44

Benzodiazepines * **\_\_\_\_\_ term (4-6 weeks), ____ use only** * **Use longer acting agents (clonazepam, diazepam) to minimize ______ anxiety** * Side effects of long term use included decreased c\_\_\_\_\_\_ functioning, de\_\_\_\_\_? Dizziness

Answer 44

* **Short term (4-6 weeks), PRN use only** * **Use longer acting agents (clonazepam, diazepam) to minimize rebound anxiety** * Side effects of long term use included decreased cognitive functioning, dementia? Dizziness

Question 45

Benzodiazepine Medication Chart

Answer 45

Question 46

Should you continue psychotropics for these patients? * “I just moved to town” * My psychiatric provider retired” * “My new insurance is out of network with my current psychiatrist” * “I can’t afford my behavioral health copay”

Answer 46

YES CONTINUE PSYCHOTROPICS * “I just moved to town” * My psychiatric provider retired” * “My new insurance is out of network with my current psychiatrist” * “I can’t afford my behavioral health copay”

Question 47

Depression Care Model *Good example of a collaborative care model - where Primary care mainly manages patient with anxiety/depression with curbside counseling by psychiatrist*

Answer 47

Question 48

ADHD **ADHD in Primary Care** * Are we expected to initiate ADHD medication in primary care? If so, what needs to be done first? * When do ADHD symptoms usually present? Is rare in? * Be cautious in the time of COVID

Answer 48

* Would not expect primary care to initiate medication for ADHD without neuropsychiatric testing. * Symptoms should have presented themselves in childhood; adult onset rare * Be cautious in the time of COVID

Question 49

Continuation of Stimulants Obtain d\_\_\_\_\_\_ documentation from a _______ **provider** Check (1) before prescribing refills or bridge medications * EKG testing not recommended but it is policy in some locations, why? * Assess for patient’s own history of _____ disease * Assess for family history of sudden cardiac \_\_\_\_\_, conduction issues * Perform _____ drug screen (may want to do it randomly) * ______ level * Monitor \_\_\_\_\_cardia, ang\_\_\_\_\_, palp\_\_\_\_\_\_

Answer 49

Obtain diagnostic documentation from a **psychiatric provider** Check PMP before prescribing refills or bridge medications * EKG testing not recommended but it is policy in some locations (prolonged QT) * Assess for patient’s own history of cardiac disease * Assess for family history of sudden cardiac death, conduction issues * Perform urine drug screen (may want to do it randomly) * TSH level * Monitor tachycardia, angina, palpitations

Question 50

Mood Stabilizers (4)

Answer 50

Lithium Depakote Lamotrigine (Lamictal) Carbamazepine (Tegretol)

Question 51

Lithium Comes in standard (BID/TID) or extended release (usually qd or BID) Narrow therapeutic index (\_\_\_\_-\_\_\_\_ mEq/L) * Lab must be ordered at peak level, which occurs ___ hours after last dose * Run \_\_**-**\_\_ days after initiation or change in dose * Lithium levels change with ______ status… consider summer

Answer 51

Narrow therapeutic index (0.8-1.2 mEq/L) * Lab must be ordered at peak level, which occurs 12 hours after last dose * Run 5-7 days after initiation or change in dose * Lithium levels change with hydration status… consider summer *therapeutic levels every 6 months and 5-7 days after dose change*

Question 52

Signs of Lithium Toxicity * GI = * Neuro: ataxia, con\_\_\_\_\_ , agitation, monoclonic jerks, s\_\_\_\_\_\_ (if severe) * Cardiac = * Some patients may need _____ to excrete severe toxicity * Will need monitoring – send to \_\_\_

Answer 52

* GI: N/V/D * Neuro: ataxia, confusion, agitation, monoclonic jerks, seizures (if severe) * Cardiac: Prolonged qTC * Some patients may need dialysis to excrete severe toxicity * Will need monitoring – send to ER

Question 53

Lithium * Monitor (1) hormone, (1) function and lithium level q __ months * Congenital malformations *(1)* in pregnancy; make sure female patients are taking (1)

Answer 53

* Monitor TSH, renal function and lithium level q 6 months * Congenital malformations *(neural tube defects)* in pregnancy; make sure female patients are taking BC

Question 54

Depakote Comes in standard (BID) or extended release (usually qd or BID) Narrow therapeutic index (\_\_-\_\_\_mg/L) * Lab must be ordered at ____ level, which occurs __ hours after last dose * Run \_\_**-**\_\_ days after initiation or change in dose

Answer 54

Narrow therapeutic index (50-100 mg/L) * Lab must be ordered at peak level, which occurs 12 hours after last dose * Run 5-7 days after initiation or change in dose

Question 55

Signs of Depakote Toxicity * GI = * Neuro: ag\_\_\_\_\_, ______ jerks * Cardiac: \_\_\_\_cardia, \_\_\_\_tension * Pulm: Respiratory \_\_\_\_\_\_\_ * Will need monitoring - send to \_\_\_

Answer 55

* GI: N/V/D, * Neuro: agitation, monoclonic jerks * Cardiac: tachycardia, hypotension * Pulm: Respiratory depression * Will need monitoring - send to ER

Question 56

Depakote Monitoring * Monitor (1) *(bc metabolized by liver)* and Depakote level q\_\_ months if stable; increase monitoring in patients with renal disease * Congenital malformations(\_\_\_\_\_ anomaly) in pregnancy; make sure female patients are taking \_\_\_

Answer 56

* Monitor LFTS *(bc metabolized by liver)* and Depakote level q 6 months if stable; increase monitoring in patients with renal disease * Congenital malformations(Epstein’s anomaly) in pregnancy; make sure female patients are taking BC

Question 57

Lamotrigine (Lamictal) Typically doses used for (1) (50-200 mg) are ____ than those for (1) (up to 500mg) * Interactions: * Depakote (in\_\_\_\_ lamotrigine metabolism) * Tegretol (in\_\_\_\_\_ lamotrigine metabolism) * Oral contraceptives (\_\_\_duce lamotrigine metabolism) * Early concerns that lamotrigine may make contraception ineffective are unfounded * Used often because of low (1) profile

Answer 57

Typically doses used for bipolar disorder (50-200 mg) are lower than those for seizures (up to 500mg) * Interactions: * Depakote (inhibits lamotrigine metabolism) * Tegretol (induces lamotrigine metabolism) * Oral contraceptives (induce lamotrigine metabolism) * Early concerns that lamotrigine may make contraception ineffective are unfounded * Used often because of low side-effect profile

Question 58

Lamotrigine (Lamictal) BE WARY OF **\_\_\_\_\_** upon initiation and after each dose increase (still lifetime risk while on drug) * Bl\_\_\_\_\_, painful, itchy; usually begins in m\_\_\_cutaneous areas (mouth, eyes) and then spreads * Accompanied by f\_\_\_\_, j\_\_\_\_\_ and muscle pain * Re\_\_\_\_\_ if patient has stopped for more than 5 days.

Answer 58

BE WARY OF **RASH** upon initiation and after each dose increase (still lifetime risk while on drug) * Blistering, painful, itchy; usually begins in mucocutaneous areas (mouth, eyes) and then spreads * Accompanied by fever, joint and muscle pain * Retitrate if patient has stopped for more than 5 days.

Question 59

Carbamazepine (Tegretol) Clinical Use today? * Need carbamazepine levels after initiation and _______ after stabilization * __ to \_\_mcg/mL * Dizziness, drowsiness, arrhythmia, hypotension, seizures, coma

Answer 59

Not a great mood stabilizer but still used in some patients today * Need carbamazepine levels after initiation and annually after stabilization * 4 to 12 mcg/mL * Dizziness, drowsiness, arrhythmia, hypotension à seizures, coma

Question 60

Carbamazepine (Tegretol) Important to monitor for what? (1)\* * Taper and D/C treatment if ANC is less than ____ mm3 . Significant interactions with many common drugs: statins, antipsychotics, glucocorticoids, oral anticoagulants

Answer 60

CBC for agranulocytosis (or use Absolute Neutrophil Count ANC) * Taper and D/C treatment if ANC is less than ____ mm3 . Significant interactions with many common drugs: st\_\_\_\_, anti\_\_\_\_\_\_, gluco\_\_\_\_\_\_\_, oral antic\_\_\_\_\_\_\_\_

Question 61

Antipsychotics * Can be used to treat both \_\_\_\_\_\_-spectrum disorders and/or _____ disorder * More recently have been used as adjunctive treatment for \_\_\_\_\_\_\_\_

Answer 61

* Can be used to treat both psychotic-spectrum disorders and/or bipolar disorder * More recently have been used as adjunctive treatment for depression

Question 62

(1) **haldol, thorazine, fluphenazine** * Higher risk of EPS * Higher risk of prolonged qTC (annual EKG recommended) * Occyulogyric crisis may occur *AVOID these old school meds*

Answer 62

First generation Antipsychotics

Question 63

Second generation Antipsychotics **aripirazole, risperidone, quetiapine, clozapine, olanzapine, cariprazine, lurasidone** * _____ risk of EPS but still possible (especially aripiprazole) * Higher risk of ______ disorders; monitor A1c, lipids, weight * Risperidone and lurasidone: can increase prolactin, disrupt m\_\_\_\_\_, cause gyn\_\_\_\_\_\_ * Clozapine requires monthly _____ and input into REMS system * Can cause paralytic \_\_\_\_\_… check for frequency of BMs

Answer 63

* Lower risk of EPS but still possible (especially aripiprazole) * Higher risk of metabolic disorders; monitor A1c, lipids, weight * Risperidone and lurasidone: can increase prolactin, disrupt menses, cause gynecomastia * Clozapine requires monthly ANC and input into REMS system * Can cause paralytic ileus… check for frequency of BMs

Question 64

Continuation of Care When is this appropriate? * Patients can be highly functional on stable antipsychotic/mood stabilizer regimens. * However would likely benefit from connection to psychiatry/therapy in the long term * Ideally, should have some comfort in providing br\_\_\_\_\_ medications if patient is in between care * Can call _______ to confirm past meds * Most psychiatric providers do not have quick lab access and you should work together to monitor ____ and S/\_\_ of medications

Answer 64

* Patients can be highly functional on stable antipsychotic/mood stabilizer regimens. * However would likely benefit from connection to psychiatry/therapy in the long term * Ideally, should have some comfort in providing bridge medications if patient is in between care * Can call pharmacy to confirm past meds * Most psychiatric providers do not have quick lab access and you should work together to monitor levels and S/E of medications

Question 65

When to Refer * “I keep having \_\_\_\_attacks” * “I feel \_\_\_\_less all the time” * “Sometimes I think I’m getting secret _____ through TikTok” * “Every night I have night\_\_\_\_\_ of something that happened when I was seven” * “The only way to help with withdrawal is to \_\_\_\_\_to use… I can’t \_\_\_\_\_”

Answer 65

* “I keep having panic attacks” * “I feel hopeless all the time” * “Sometimes I think I’m getting secret messages through TikTok” * “Every night I have nightmares of something that happened when I was seven” * “The only way to help with withdrawal is to continue to use… I can’t stop”

Question 66

So when should I refer to psychiatry? * W\_\_\_\_\_\_ outcomes with treatment of SSRIs/SNRIs in patients with mild-severe mood disorders * Mood disorders complicated by other diagnoses (p\_\_\_\_\_\_ disorders, disordered ea\_\_\_\_, ps\_\_\_\_\_) * History of multiple _______ or emergency room visits * Bi\_\_\_\_\_ disorder/sch\_\_\_\_\_\_\_\_ spectrum disorders * Stable patients on complex _______ regimens (adjunctive treatments such as lithium, aripiprazole) **It is your responsibility to check with your state’s _____ to understand your scope of practice**

Answer 66

* Worsening outcomes with treatment of SSRIs/SNRIs in patients with mild-severe mood disorders * Mood disorders complicated by other diagnoses (personality disorders, disordered eating, psychosis) * History of multiple hospitalizations or emergency room visits * Bipolar disorder/schizophrenia spectrum disorders * Stable patients on complex medication regimens (adjunctive treatments such as lithium, aripiprazole) **It is your responsibility to check with your state’s BON to understand your scope of practice**

Question 67

Addictions * ______ use disorder within your ___ (Chantix, patches, lozenges, gum, Buproprion) * Can offer mot\_\_\_\_\_\_ interviewing and harm-\_\_\_\_\_ strategies * Patients with active addictions should receive c\_\_\_\_\_ and M\_ \_ * Can be trained and waivered in sub\_\_\_\_\_ (but patient should also be in some sort of counseling/program) - * N\_\_\_\_\_\_ effective for AUD, but patient should be in counseling or a program * Any other drug (K, LSD, heroin, rx drug abuse, etc) should be treated in an ______ setting * Generally, addictions (aside from tobacco and sometimes EtOH) should receive treatment in a sp\_\_\_\_\_ clinic or pr\_\_\_\_\_\_

Answer 67

* Tobacco use disorder within your scope (Chantix, patches, lozenges, gum, Buproprion) * Can offer motivational interviewing and harm-reduction strategies * Patients with active addictions should receive counseling and MAT * Can be trained and waivered in suboxone (but patient should also be in some sort of counseling/program) - * Naltrexone effective for AUD, but patient should be in counseling or a program * Any other drug (K, LSD, heroin, rx drug abuse, etc) should be treated in an addiction setting * Generally, addictions (aside from tobacco and sometimes EtOH) should receive treatment in a specialty clinic or program

Question 68

Crisis Management * “I keep having thoughts of wanting to ____ myself” * “What’s the point of \_\_\_\_\_” * “People would be _____ off without me” * “Next time I see her, I’m going to ch\_\_\_ her” * “I’ve been _____ a lot of my things recently…”

Answer 68

* “I keep having thoughts of wanting to hurt myself” * “What’s the point of living” * “People would be better off without me” * “Next time I see her, I’m going to choke her” * “I’ve been selling a lot of my things recently…”

Question 69

Suicide and Risk Management **NEVER leave patient alone (or end the call) if patient is?**

Answer 69

**NEVER leave patient alone (or end the call) if patient is actively suicidal**

Question 70

High Risk Groups * Age * A\_\_\_\_\_ and young adults * O\_\_\_\_ patients * Gender * _____ are more likely to complete suicide (3x) * Race * American In\_\_\_\_\_ and Al\_\_\_\_\_ Natives have highest risk, followed by non-Hispanic whites, Asian and Pacific Islanders, African Americans and Hispanics * Geographic * Higher rates of suicide in r\_\_\_\_ communities; gap is widening * In urban areas, ______ Americans have a higher suicide rate than in rural areas * May be due to access to firearms

Answer 70

* Age * Adolescents and young adults * Older patients * Gender * Males are more likely to complete suicide (3x) * Race * American Indian and Alaska Natives have highest risk, followed by non-Hispanic whites, Asian and Pacific Islanders, African Americans and Hispanics * Geographic * Higher rates of suicide in rural communities; gap is widening * In urban areas, African Americans have a higher suicide rate than in rural areas * May be due to access to firearms

Question 71

Suicide and Risk Management * My patient is suicidal… what do I do!? * Take a breath and do not panic. * Assess for id\_\_\_\_\_ and in\_\_\_\_ * Is this imminent? What sort of supports does the patient have? Can they name friends or family members that care about them/ that they can call? * Have clinic s\_\_\_\_\_\_ worker assess patient (if available) * Can the patient go to the ER by themselves? * Follow clinic-specific policies and protocols * Confirm patient _______ if this is a telehealth visit

Answer 71

* My patient is suicidal… what do I do!? * Take a breath and do not panic. * Assess for ideation and intent * Is this imminent? What sort of supports does the patient have? Can they name friends or family members that care about them/ that they can call? * Have clinic social worker assess patient (if available) * DO NOT let patient go to ER by themselves; call EMS from the clinic * Follow clinic-specific policies and protocols * Confirm patient location if this is a telehealth visit

Question 72

Suicide and Risk Management * If a patient has ______ suicidality * Confirm there are no firearms or possible weapons in the home * Connect patient to BH services * Create a safety plan * When in doubt, call \_\_\_\_ * If patient is not in the clinic or on a call and leaves a threatening message, call patient’s (1) * This does not violate _____ due to nature of situation

Question 73

Patient Safety Plan Template Fill out with patient, give them a copy and a keep a copy in the cart What is included in the patient safety plan?

Answer 73

Fill out with patient, give them a copy and a keep a copy in the cart

Question 74

Suicide and Risk Management (1) * Mental Hygiene Law 9.46 * Requirement regardless of clinical practice setting - * When patient is “likely to engage in conduct that could seriously harm the patient themselves or others.” * Does not have to specify that plan is to use firearms * Do not have to establish that patient had a firearm * (or google “SAFE Act Reporting)

Answer 74

NY SAFE ACT * Mental Hygiene Law 9.46 * Requirement regardless of clinical practice setting - * When patient is “likely to engage in conduct that could seriously harm the patient themselves or others.” * Does not have to specify that plan is to use firearms * Do not have to establish that patient had a firearm * (or google “SAFE Act Reporting)

Question 75

Referrals to the \_\_\_\_ * Bizarre/nonsensical behavior * Sudden deviation from normal behavior * Manic episodes * Think: acute disturbance of thought - are patients based in reality? * Agitation/aggression * Intoxication/withdrawal * Are they a danger to themselves or others? * Are they psychiatrically impaired and can not care for themselves? * Are they at risk of becoming the above?

Answer 75

Referrals to the ER * Bizarre/nonsensical behavior * Sudden deviation from normal behavior * Manic episodes * Think: acute disturbance of thought - are patients based in reality? * Agitation/aggression * Intoxication/withdrawal * Are they a danger to themselves or others? * Are they psychiatrically impaired and can not care for themselves? * Are they at risk of becoming the above?

Question 76

New York City Resources * “Do you know where I can get help?” * “How do I find a therapist?” * “I want to see someone today.” * “Who can I call late at night?” * “I’m really concerned about my friend…they are acting strange.”

Answer 76

Resources * Where can I get help? * 1888-NYC Well * Text: “WELL” to 65173 * Chat online ([_https://nycwell.cityofnewyork.us/en/_](https://nycwell.cityofnewyork.us/en/)) * Can look up agencies in NYC that offer psychiatry and psychotherapy services * Same day/next day services: * Mindful Care (https://mindful.care/) * Search tools: * ZocDoc, Headway.co, insurance website * Walk in Clinics (for non-emergencies) * Bellevue * Zucker Hillside * Mobile Crisis * Non suicidal/homicidal emergencies * Use NYC Well number