Psychosocial Mental Health Review Ch. 15-- Leik Content

*Abuse: All Types*

Abusive behaviors are multifactorial. They may include physical, emotional, and sexual abuse, and/or neglect. They can happen at any age and during pregnancy (higher risk). A common finding is a delay in seeking medical treatment for the injury. The pattern of the injuries is inconsistent with the history. Elderly who are most likely to be abused are those greater than 80 years old and/or frail. Children with mental, physical, or other disabilities, and stepchildren are more likely to be abused. *Types of abuse are:* physical abuse, sexual abuse, emotional/psychological abuse, neglect, economic abuse, or material exploitation. *Risk Factors That Increase Likelihood of Abuse (All Types)* ■ Increased stress (partner/parent/caregiver). ■ Alcohol/drug abuse. ■ Personal history of abuse, positive family history of abuse. ■ Major loss (financial, job loss, others). ■ Social isolation. ■ Pregnancy (domestic abuse). ■ Elderly abuse. ■ Frail elderly and those with dementia are more likely to be abused. About two-thirds of all elder abuse is perpetrated by family members (usually an adult child or a spouse). Most abused elderly suffer economic abuse. Only certain states have mandatory reporting of partner abuse. Be mindful of institutional abuse of elderly, children, and disabled. *Physical Exam: Abuse (All Types)* ■ Another health provider (witness) should be in the same room during the exam. ■ Interview victim without abuser in the same room. ■ Collect visual evidence of trauma via Polaroid or digital camera to document all injuries. Keep all evidence in a safe place. ■ Look for spiral fractures (greenstick fracture), multiple healing fractures especially in rib area, burn marks with pattern, welts, and so forth. ■ Look for signs of neglect (dirty clothes, inappropriately dressed for the weather, etc.). ■ For partner abuse, focus on developing a plan for safety with the patient when appropriate. Give the patient the phone number of the crisis center and/or safe place. ■ Sexually transmitted disease (STD) testing: - Chlamydial and GC cultures (must use cultures in addition to the Gen Probe). - HIV, hepatitis B, syphilis, herpes type 2. - Genital, throat, and anal area culture and testing must be done. ■ Abused patient is very fearful and quiet when with the "abuser." *Treatment Plan* ■ Prophylactic treatment against several STDs (with parental consent for minors). ■ Health care professionals must report actual or suspected child abuse. *Good Communication Concepts* ■ State things objectively. Do not be judgmental. Example: "You have bright red stripes on your back" instead of "It looks as if you have been whipped on the back." ■ Open-ended questions are preferred. Example: "How can I help you?" instead of "What type of object was used to hurt your back?" ■ Do not reassure patients (stops a patient from talking more about his/her problems). Example: "We will make sure you get help," instead of "Don't worry, everything will be fine." ■ Let the patient vent his/her feelings. Do not discourage patient from talking. Example: "Please tell me why you feel so sad." ■ Validate feelings. Example: "Yes, I understand your anger when someone hits you."

545. A 25-year-old male with *schizophrenia* comes in for a routine annual physical. He is a heavy smoker and has a BMI of 28. The patient has been on olanzapine (Zyprexa) for 10 years. Regarding the patient's prescription, which of the following laboratory tests is recommended for monitoring for adverse effects of atypical antipsychotics? *A)* Fasting blood glucose, fasting lipid profile, and weight *B)* Urinalysis, serum creatinine, 24-hour urine for protein and creatinine clearance *C)* Liver function tests only *D)* CBC with differential, liver function tests, weight

*A) Fasting blood glucose fasting lipid profile weight* Patients on atypical antipsychotics commonly gain weight and are at risk for: ■ obesity ■ hyperglycemia ■ type 2 diabetes. Zyprexa will *increase* lipids (cholesterol, LDL, and triglycerides). Atypical antipsychotics also increase the risk of death among frail elders and older adults living in nursing homes.

157. All of the following are considered selective serotonin reuptake inhibitors (SSRIs) *except*: *A)* Imipramine (Elavil) *B)* Fluoxetine (Prozac) *C)* Sertraline (Zoloft) *D)* Paroxetine (Paxil CR)

*A) Imipramine (Elavil)* Prozac, Zoloft, and Paxil CR are selective serotonin reuptake inhibitors. Elavil is a tricyclic antidepressant.

521. The atypical antipsychotic drugs have many adverse effects. Which of the following side effects is most likely to be seen with this drug class? *A)* Orthostatic hypotension and sedation *B)* Malignant hypertension and headache *C)* Skin hyperpigmentation and alopecia *D)* Severe anxiety and increased appetite

*A) Orthostatic hypotension and sedation* ■Orthostatic hypotension and sedation are common side effects of atypical antipsychotics such as olanzapine (Zyprexa), quetiapine (Seroquel), and risperidone (Risperdal). It is also a common side effect of the older antipsychotics like haloperidol (Haldol). ■Antipsychotics do not cause severe anxiety and hyperphagia (increased appetite). ■They lower anxiety and cause sedation, sleepiness, anorexia, and hypotension and increase the risk of sudden death in frail elders.

86. Which of the following medications is indicated for the treatment of obsessive-compulsive disorder? *A)* Paroxetine (Paxil CR) *B)* Haldoperidol (Haldol) *C)* Lorazepam (Xanax) *D)* Imipramine (Elavil)

*A) Paroxetine (Paxil CR)* Antidepressants are the most common medications used for OCD. Those antidepressants that are approved for OCD by the Food and Drug Administration (FDA) include: ■ clomipram*ine* (Anafranil) ■ fluvoxam*ine* (Luvox) ■ fluoxet*ine* (Prozac) ■ paroxet*ine* (Paxil, Pexeva) ■ sertral*ine* (Zoloft)

501. Which of the following is recommended as *first-line* treatment for essential tremor? *A)* Propranolol (Inderal) *B)* Phenytoin (Dilantin) *C)* Amitriptyline (Elavil) *D)* Fluoxetine (Prozac)

*A) Propranolol (Inderal)* ■Propranolol (Inderal) is approved for "treatment" of essential tremor. It helps control the symptoms. ■Essential tremors are permanent and cannot be cured. ■Before prescribing, order an EKG. ■Do not use betablockers if a patient has second- or third-degree heart block or chronic lung disease.

628. Which of the following drugs is most likely to cause sexual dysfunction in males? *A)* SSRIs *B)* ACE inhibitors *C)* Amphetamines *D)* Atypical antidepressants

*A) SSRIs* A common side effect of SSRIs (e.g., Prozac, Paxil, Zoloft) is sexual dysfunction in males. For depressed males, atypical antidepressants such as bupropion (Wellbutrin) cause less sexual dysfunction

190. All of the following statements are true regarding domestic abuse *except*: *A)* There is no delay in seeking medical treatment *B)* The pattern of injuries is inconsistent with the history reported *C)* Injuries are usually in the "central" area of the body instead of the extremities *D)* Pregnant women have a higher risk of domestic abuse

*A) There is no delay in seeking medical treatment* When assessing for domestic abuse, the most commom body area that is abused is the "swim-suit" area, which is usually covered by clothing. Suspect abusive relationships when the history is inconsistent with the injury. Most victims do not seek medical attention until after several episodes of violence. Studies have shown that the incidence of battery escalates during pregnancy

420. The *first-line* treatment consideration for managing acute alcohol withdrawal delirium includes: *A)* Intubation *B)* Benzodiazepines *C)* Avoidance of physical restraints to decrease agitation *D)* Antipsychotics

*B) Benzodiazepines * Acute alcohol withdrawal delirium is managed with benzodiazepines.

490. You would advise a patient who is on a MAOI (monoamine oxidase inhibitor) prescription to avoid taking one of the following drugs because of increased potential for a serious reaction. Which of the following is this drug? *A)* Alprazolam (Xanax) *B)* Fluoxetine (Prozac) *C)* Erythromycin (E-mycin) *D)* Amoxicillin (Amoxil)

*B) Fluoxetine (Prozac)* Patients taking MAOIs should not also take SSRIs (Prozac), due to the possibility of developing serotonin syndrome. This causes excessive serotonin release in the brain, which will cause symptoms of: ■severe anxiety ■restlessness ■confusion ■muscle twitching. *If not stopped, the patient may develop muscle contractions, renal failure, respiratory failure, coma, and even death.*

428. Which of the following is *not* a characteristic of delirium? *A)* Sudden onset *B)* Patient is coherent *C)* Worse in the evenings *D)* It has a brief duration

*B) Patient is coherent* Characteristics of delirium include an acute and dramatic onset of symptoms that is temporary, and usually will worsen in the evening. May last hours to days. Patient is incoherent and disoriented. Usually brought on by: ■ fever ■ shock ■ drugs ■ alcohol ■ dehydration

528. All of the following conditions are contraindications for bupropion (Wellbutrin, Zyban) *except*: *A)* Anorexia nervosa and bulimia *B)* Seizure disorders *C)* Peripheral neuropathy *D)* Within 14 days after discontinuation of a monoamine oxidase inhibitor (MAOI)

*C) Peripheral neuropathy* Bupropion increases the risk of seizures. *Contraindications are:* ■ seizures ■ anorexia nervosa and bulimia. ■ Within 14 days after discontinuation of a monoamine oxidase inhibitor (MAOI) ■Avoid with any condition that increases seizures, such as after abrupt withdrawal of alcohol or sedatives and certain head injuries. For peripheral neuropathy, atypical antidepressants such as duloxetine (Cymbalta) and TCAs such as amitriptyline (Elavil) are used.

554. Which of the following benzodiazepines has the *shortest* half-life? *A)* Lorazepam (Ativan) *B)* Alprazolam (Xanax) *C)* Triazolam (Halcion) *D)* Clonazepam (Klonopin)

*C) Triazolam (Halcion)* -->*Triazolam* (Halcion) has an average half-life of about 2 hours. --> *Xanax* has a half-life of 12 hours. --> *Ativan* has a half-life of 15 hours. --> *Klonopin* has a half-life of 34 hours.

*Quick Screening Tests for Identification of Alcohol Abuse/Alcoholism*

*CAGE Test* ■ *Positive finding* of at least two (out of four) highly suggestive of alcoholism: - C: Do you feel the need to cut down? - A: Are you annoyed when your spouse/friend comments about your drinking? - G: Do you feel guilty about your drinking? - E: Do you need to drink early in the morning? (an eye-opener). ■ Examples of some quotes using CAGE: - C: "I would like to drink less on the weekends," "I only drink a lot on weekends." - A: "My wife nags me about my drinking," "My best friend thinks I drink too much." - G: "I feel bad that I don't spend enough time with the kids because of my drinking." - E: "I need a drink to feel better when I wake up in the morning." *Short Michigan Alcoholism Screening Test (SMAST) Questionnaire* ■ A 13-item questionnaire. A shorter version of the original MAST Questionnaire (contains 24 items). *Alcohol Use Disorders Identification Test (AUDIT)* ■ A 10-question tool that is used with women, minorities, and adolescents.

43. All of the following patients are at higher risk for suicide *except*: *A)* A 66-year-old White male whose wife of 40 years recently died *B)* A high school student with a history of bipolar disorder *C)* A depressed 45-year-old female with family history of suicide *D)* A 17-year-old teen who has only 1 close friend in school

*D) A 17-year-old teen who has only one close friend in school* Risk factors for suicide include: 1) elderly white males (especially after the death of a spouse) 2) past history of suicide 3) family history of suicide 4) plans for use of a lethal weapon such as a gun or knife 5) female gender has a higher attempt rate, but males have a higher success rate 6) personal history of bipolar disorder or depression.

429. The signs and symptoms of dementia may include all of the following *except*: *A)* Personality changes *B)* Difficulty in verbalizing *C)* Difficulty in recognizing familiar objects *D)* Abstract thinking ability is increased

*D) Abstract thinking ability is increased* Characteristics of dementia include irreversible symptoms with a gradual onset. Short-term memory loss is an early sign of dementia. As symptoms progress, the patient may become: ■incoherent, ■unable to talk ■ unable to walk ■ unable to feed self ■ unable to perform self-care.

85. Carol M. is a 40-year-old bank teller who has recently been diagnosed with *obsessive-compulsive disorder* by her therapist. Her symptoms would include: *A)* Ritualistic behaviors that the patient feels compelled to repeat *B)* Attempts to ignore or suppress the repetitive behaviors, which increase anxiety *C)* Frequent intrusive and repetitive thoughts and impulses *D)* All of the above

*D) All of the above* Signs and symptoms of obsessive-compulsive disorder include: ■ ritualistic behaviors that are repeated ■ increased anxiety with attempting to ignore repetitive behaviors ■ frequent intrusive and repetitive thoughts and impulses.

30. Signs and symptoms of depression include all of the following *except*: *A)* Anhedonia and changes in appetite *B)* Decreased energy and irritability *C)* Apathy and low self-esteem *D)* Apraxia and fatigue

*D) Apraxia and fatigue* Apraxia is a disorder of the nervous system in which the brain is affected and the patient is unable to move the arms/legs when asked to do so. *Common signs of depression include:* ■ anhedonia (loss of interest in activities that the patient finds pleasurable) ■ unintentional weight loss or gain ■ fatigue ■ change in appetite ■ insomnia or hypersomnia ■ feelings of guilt and worthlessness, ■ recurrent thoughts of suicide.

544. Which of the following drugs that are used to treat attention deficit hyperactivity disorder (ADHD) is not classified as an amphetamine/stimulant? *A)* Dexmethylphenidate (Focalin XR) *B)* Mixed salts of amphetamine (Adderall) *C)* Methylphenidate (Ritalin) *D)* Atomoxetine (Strattera)

*D) Atomoxetine (Strattera)* Strattera is classified as a norepinephrine reuptake inhibitor. It is not a stimulant or an amphetamine. Strattera is contraindicated during/within 14 days of taking an MAOI, narrow-angle glaucoma, heart disorder where increases in BP or heart rate will worsen it, or pheochromocytoma. Children and teenagers should be monitored for suicidal thoughts/plans.

290. All of the following statements are false regarding the rehabilitation of alcoholics *except:* *A)* Al-Anon is not designed for family members of alcoholics *B)* Disulfiram (Antabuse) is always effective *C)* Alcoholics Anonymous is not an effective method for treating this condition *D)* Avoid foods or drinks that contain alcohol, such as cough syrups

*D) Avoid foods or drinks that contain alcohol, such as cough syrups* ■ Alcoholics Anonymous is designed for families and is an effective treatment for alcoholism. ■ Antabuse is effective for some patients. ■ The intake of foods/medications that contain alcohol must be avoided.

273. All of the following are true statements regarding elder abuse *except:* *A)* Those aged 80 years or older are at the highest risk for abuse *B)* A delay in medical care is a common fi nding *C)* A new onset of an STD in an elderly patient may signal sexual abuse *D)* Decreased anxiety and depression are common symptoms of abuse in the Elderly

*D) Decreased anxiety and depression are common symptoms of abuse in the elderly* Elder abuse is commonly seen in elderly patients over the age of 80 years. Common signs/symptoms include: ■ anxiety and depression. ■ A new onset of an STD may indicate signs of sexual abuse. ■ These patients will commonly delay treatment for acute/chronic conditions.

641. According to DSM-5, all of the following are some of the criteria that must be present to diagnose a child with autistic disorder. Which of the following criterion is incorrect? *A)* Onset of symptoms before age 3 years *B)* Lack of social interaction or social reciprocity *C)* Stereotyped and repetitive movements such as hand flapping *D)* Depressed affect

*D) Depressed affect* Depression is not included in the criteria for diagnosing autistic spectrum disorders. *Signs and symptoms include:* -->avoidance of eye contact and social interaction -->marked delay or absence of verbal communication -->repetitive movements fixed rituals. Autism can range from mild to severe. Early diagnosis is important. For evaluation, refer the patient for psychological testing by a psychologist who specializes in autistic spectrum disorders.

*SSRIs*

*First-line treatment for:* ■ Major depression, obsessive-compulsive disorder. ■ Generalized anxiety disorder, panic disorder, social anxiety disorder. ■ Premenstrual dysphoric disorder. *Common SSRIs* ■ Fluoxetine (Prozac): Longest half-life of all SSRIs (may last up to 4 weeks) and the first SSRI. ■ Paroxetine (Paxil): Shortest half-life, but was reformulated to Paxil CR (to prolong half-life). ■ Citalopram (Celexa): Has fewer drug interactions compared with other SSRIs. ■ Escitaplopram (Lexapro): Compound derived from citalopram (Celexa). ■ Duloxetine (Cymbalta): Can treat both depression and neuropathic pain. ■ Other SSRIs: Sertraline (Zoloft), fluvoxamine (Luvox). *Side Effects* ■ Loss of libido, erectile dysfunctile (ED), women with sexual dysfunction, anorexia, insomnia. ■ Avoid with anorexic patients and undernourished elderly (depresses appetite more). ■ Paxil: Common side effect is ED. *Contraindications* ■ Avoid SSRIs within 14 days of taking an MAOI (serotonin syndrome). ■ Can induce mania with bipolar patients.

569. Which of the following pharmacologic agents is the *best choice* for an elderly patient with insomnia? *A)* Diazepam (Valium) *B)* Zolpidem (Ambien) *C)* Temazepam (Restoril) *D)* Diphenhydramine (Benadryl)

569. *B) Zolpidem (Ambien)* Ambien has a quick onset of action (15 minutes) and a short half-life of 2 hours. -->Avoid diphenhydramine in the elderly, as there is a higher incidence of adverse effects (confusion, prolonged sedation) in this population. --> Avoid long-acting benzodiazepines such as diazepam (half-life 12 hours) and temazepam (half-life of 10 hours). Hypnotics can be used PRN up to 2 weeks; otherwise, benzodiazepines can cause addiction and withdrawal symptoms.

*Korsakoff's Syndrome (Wernicke-Korsakoff Syndrome)*

A complication from chronic alcohol abuse. A neurologic disorder with signs that include hypotension, visual impairment, and coma. Signs include: mental confusion ataxia stupor coma hypotension Treated with high-dose parenteral vitamins, especially thiamine (vitamin B1).

*Korsakoff's Amnesic Syndrome*

A type of amnesia. Problems with acquiring (and learning) new information and retrieving older information. Symptoms include confabulation, disorientation, attention deficits, and visual impairment. ■ Etiology: Chronic thiamine deficiency damages the brain permanently

*The Baker Act:*

Allows 72 hours (3 days) of involuntary detention for evaluation and treatment of persons who are considered at very high risk for suicide and/or for hurting others.

*ALCOHOLISM*

Compulsive desire to drink alcohol despite personal, financial, and social consequences. With alcohol mdependence, a patient experiences cognitive, behavioral, and physiologic symptoms that are generated from persistent and chronic use. Abrupt cessation causes withdrawal symptoms. Alcohol abuse occurs when a maladaptive behavior pattern occurs from repeated alcohol use. *Definitions* ■ Elevated blood alcohol level greater than 0.08% is illegal for driving (blood alcohol or breathalyzer). ■ Standard drink sizes for the United States (considered as "one drink"): - Beer: 12-ounce bottle. - Wine: 5 ounces. - Liquor/spirits: 1.5 ounces or a "shot" of 80-proof gin, vodka, rum, or whiskey. Dietary Guidelines for Americans (Alcohol Limits) ■ Women: One drink per day. ■ Men: Two drinks per day. ■ Binge drinking: - A pattern of alcohol consumption that brings the blood alcohol level to 0.08% or higher in one occasion (generally within 2 hours). - Males: At least five drinks or more on a single occasion. - Women: At least four drinks or more on a single occasion. ■ Females metabolize alcohol (50%) more slowly than do males. *Alcohol Addiction (Alcoholism)* ■ Continued drinking despite repeated physical, psychological, interpersonal, and social problems. Strong craving for alcohol. Inability to limit drinking. Withdrawal symptoms if stop drinking. *Labs Results* *Gamma Glutamyl Transaminase (GGT)* ■ Lone elevation (with/without alanine transaminase [ALT] and aspartate aminotransferase [AST]) is a possible sign of occult alcohol abuse. *AST/ALT Ratio (Liver Transaminases)* ■ Both AST and ALT are usually elevated (with or without elevated GGT) in alcoholism. ■ Ratio of 2:1 with AST/ALT (AST level is double the level of ALT) is associated with alcohol abuse (alcoholic hepatitis). ■ ALT is more specifi c for the liver than the AST because AST is also found in the liver, cardiac and skeletal muscle, kidneys, and lungs. *Mean Corpuscular Volume (MCV)* ■ Larger size of red blood cells (due to nutritional defi ciencies) that resembles macrocytic anemia (MCV > 100 fl ).

*Insomnia (Sleep Disorder)*

It is thought that 7 to 8 hours of sleep is the ideal. About 40 to 70 million Americans (20% of the population) suffer from either transient (less than 1 week), short-term (1-3 weeks), or chronic (greater than 3 weeks) insomnia. Insomnia in the aged occurs due to changes in sleep pattern, physical activity, health, and increased used of medications. Insomnia can manifest either as difficulty falling asleep (sleep-onset insomnia) or falling asleep but waking up during the night or too early and being unable to go back to sleep. Can have daytime drowsiness, fatigue, tension headache, irritability, and difficulty concentrating/focusing on tasks. Risk Factors Depression, severe anxiety, gastroesophageal reflux disease, female gender, illicit drug use, musculoskeletal illness, pain, chronic health problems, shift work, alcohol, caffeine, and nicotine. Certain medications (SSRIs, cardiac, blood pressure, allergy, steroids) can cause insomnia. *Etiology* Circadian rhythm disorders, psychic issues, mental illness, obstructive sleep apnea, restless leg syndrome, environmental factors, certain medications, idiopathic, and others. *Classifications* ■ Primary insomnia (25%): Not caused by disease, mental illness, or environmental factors. ■ Secondary insomnia: Caused by disease (physical, emotional, mental) or environmental factors. *Treatment Plan* ■ Sleep hygiene (maintain regular sleeping time, nighttime ritual, avoid caffeine/tobacco/heavy meals before bedtime, get out of bed in 30 minutes if not asleep, use bed only for sleep and sex). ■ Home or sleep lab monitoring (polysomnography) (needed to diagnose obstructive sleep apnea). After diagnosis, refer to ENT specialist (otolaryngologist). Medications ■ Over-the-counter antihistamine: Diphenhydramine (Benadryl) can cause excess sedation and confusion in the elderly. It is the most sedating antihistamine. Avoid with elderly. *Benzodiazepines/Hypnotics (Listed Under Psychotrophic Drugs)* ■ Short-acting: Alprazolam (Xanax), triazolam (Halcion), midazolam (Versed). ■ Intermediate-acting: Lorazepam (Ativan), temazepam (Restoril). ■ Long-acting: Diazepam (Valium), clonazepam (Klonopin), chlordiazepoxide (Librium). *Non-Benzodiazepine Hypnotics* ■ Zolpidem (Ambien) for sleep-onset or inability to stay asleep. ■ Eszopiclone (Lunesta) for sleep-onset or inability to stay asleep. ■ Ramelteon (Rozerem) for sleep-onset insomnia (melatonin agonist). ■ Directions: Do not take medication if unable to get from 7 to 8 hours of sleeping time.

*Major and Minor Depression*

Major and Minor Depression Also known as unipolar depression (vs. bipolar depression). Minor depression is a milderform. The criteria of signs and symptoms are the same as major depression except that there are fewer symptoms (at least two, but less than five). Attributed to dysfunction of the neurotransmitters serotonin and norepinephrine. Strong genetic component.

*Acute Serotonin Syndrome*

Occurs from high levels of serotonin accumulating in the body due to the introduction of a new drug (drug interaction) and an increase in the dose. Acute onset with rapid progression. Signs and symptoms are sudden onset of: high fever muscular rigidity mental status changes hyperreflexia/clonus uncontrolled shivering dilated pupils (mydriasis). Higher risk if combining two drugs that both block serotonin (i.e., selective serotonin reuptake inhibitors [SSRIs], monoamine oxidase inhibitors [MAOIs], tricyclic antidepressants [TCAs], triptans, tryptophan). If switching to another drug affecting serotonin, wait a minimum of 2 weeks. Potentially life-threatening reaction.

*Anorexia Nervosa*

Onset usually during adolescence. Irrational preoccupation with and intense fear of gaining weight (even if underweight). Patients tend to be secretive, perfectionistic, and self-absorbed. Marked weight loss (greater than 15% of body weight). Lanugo (face, back, and shoulders). Amenorrhea for 3 months or longer. If purging, dental enamel loss may be present. Severe food restriction or binge eating and purging. Some examples of purging are laxatives, vomiting, and excessive daily exercise. *Complications* ■ Osteopenia/osteoporosis: Due to prolonged estrogen depletion (from amenorrhea) and low calcium intake. Higher risk of stress fractures. ■ Peripheral edema (low albumin from low protein intake). ■ Cardiac complications, the most common cause of death (arrhythmias, cardiomyopathy, hypokalemia, etc.).

*Malignant Neuroleptic Syndrome*

Rare life-threatening idiopathic reaction from typical and atypical antipsychotics. These drugs affect the dopaminergic system of the brain. Usually *develops following initiation or an increase in dose*. Signs and symptoms are sudden onset of: high fever muscular rigidity mental status changes fluctuating blood pressure urinary incontinence. Look for a history of mental illness and prescription of an antipsychotic(s). Potentially life-threatening reaction.

*Alternative Medicine for Depression*

St. Johns wort Amino acid supplements Omega-3 fatty acids Folate & B6 Exercise, yoga, massage, guided imagery, acupuncture, light therapy

*Common Questionnaires in Mental Health:*

■ Beck Depression Inventory - A multiple-choice self-report inventory for evaluating depression. Based on the theory that negative cognitions about the self and the world in general can cause depression. ■ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) - The diagnostic manual for mental and emotional disorders by the American Psychiatric Association. ■ Minnesota Multiphasic Personality Inventory, Second Edition (MMPI-2) - A popular questionnaire that is used to assess for mental illness. ■ Mini-Mental State Exam, Second Edition; Folstein Mini-Mental Exam (MMSE-2) (Table 15.1). - A questionnaire that is used to evaluate an individual for confusion and dementia (Alzheimer's, stroke, others). ■ Geriatric Depression Scale (GDS) - A 30-item (yes/no response) questionnaire. Shorter version contains 15 items. Used to assess depression in the elderly. Self-assessment format.

*SCREENING TOOLS FOR DEPRESSION*

■ Beck Depression Inventory: Contains 21 items. ■ Beck Depression Inventory for Primary Care (99% specificity): Contains 7 items. ■ Two-item question: Ask these two questions: 1) "During the past month, have you felt down, depressed, or hopeless?" 2) "During the past month, have you felt little interest or pleasure doing things?" If answered yes to either question (or both), positive finding.

*Benzodiazepines (Tranquilizers)*

■ Benzodiazepines are indicated for anxiety disorders, panic disorder, and insomnia. ■ Diazepam (Valium) is also used for severe alcohol withdrawal and seizures. ■ Do not discontinue abruptly because it increases risk of seizures. Wean slowly. ■ Example: - Ultra-short acting: Midazolam IV only (Versed), triazolam (Halcion). - Medium-acting: Alprazolam (Xanax), lorazepam (Ativan). - Long-acting: Diazepam (Valium), chlordiazepoxide (Librium), temazepam (Restoril), and clonazepam (Klonopin). Avoid with elderly.

*Antipsychotics: Adverse Effects*

■ Extrapyramidal symptoms. ■ Pill-rolling, shuffl ing gait, and bradykinesia. Caused by chronic use of antipsychotics. ■ Akinesia (inability to initiate movement). ■ Akathisia (a strong inner feeling to move, unable to stay still). ■ Bradykinesia (slowness in movement) when initiating activities or actions that require successive steps such as buttoning a shirt. ■ Tardive dyskinesia: Involuntary movements of the lips (smacking), tongue, face, trunk, and extremities (more common in schizophrenics).

*Special Considerations: Antidepressants SSRIs*

■ FDA Black Box Warnings: Increased risk of suicidal thinking and behavior in children, adolescents, and young adults. ■ Elderly patients: Consider using citalopram (Celexa) and escitalopram (Lexapro). Fewer drug interactions than other SSRIs. May prolong QT interval. ■ Patients with sexual dysfunction caused by an SSRI: Consider adding bupropion (Wellbutrin) to the SSRI prescription. ■ Depressed patient who wants to quit smoking: Consider bupropion (Zyban). Can be combined with nicotine products (patches, gum). ■ Depressed patient with peripheral neuropathy: Consider duloxetine (Cymbalta), which is also indicated for neuropathic pain. ■ Depressed patient with post-herpetic neuralgia and chronic pain: Consider TCAs. ■ Depressed patient with stress urinary incontinence: Consider TCAs.

*Complementary Alternative Treatment for Insomnia*

■ Kava-kava (avoid mixing with alcohol, tranquilizers, hypnotics; will increase sedation). Do not give kava-kava, valerian root, or herbal supplements to children, lactating/pregnant women. ■ Valerian root (sedating, also used for anxiety). ■ Melatonin (also for circadian rhythm disorders such as shift work, jet lag). ■ Chamomile tea. ■ Meditation, yoga, Tai-Chi, acupuncture, regular exercise (avoid 4 hours before bedtime).

*Anticholinergics: Side Effects*

■ Many drug classes have strong anticholinergic effects such as: antipsychotics TCA decongestants antihistamines (e.g., pseudoephedrine). ■ Caution with: benign prostatic hypertrophy (BPH) (urinary retention) narrow angle glaucoma pre-existing heart disease. ■ Use the "SAD CUB" mnemonic to help you remember anticholinergic side effects: - Sedation - Anorexia - Dry mouth - Confusion and constipation - Urinary retention - BPH

*Symptoms of Depression*

■ Mood: Depressed mood most of the time. May become tearful. ■ Anhedonia: Diminished interest or pleasure in all or most activities. ■ Energy: Fatigued or loss of energy. ■ Sleep: Insomnia or hypersomnia. ■ Guilt: Feelings of worthlessness and inappropriate guilt. ■ Concentration: Diminished concentration and difficulty making decisions. ■ Suicide: Recurrent/obsessive thoughts of death and suicidal ideation. ■ Weight: Weight loss (greater than 5% body weight) or weight gain. ■ Agitation: Psychomotor agitation or retardation. *Immediate Goal:* Assess for Suicidal and/or Homicidal Ideation or Plan If patient is considered to be a real and present threat of harm to self or to others: ■ Refer to a psychiatric hospital. Patient must be driven by a family member or a friend. ■ If none are available, call 911 for police. The police can "Baker Act" the patient. A Baker Act proceeding is a means of providing emergency services for mental health treatment on a voluntary or involuntary basis. *Differential Diagnosis* Rule out organic causes such as hypothyroidism, anemia, autoimmune disorders, B12 deficiency.

TCAs.

■ Not considered first-line treatment for depression. ■ Other uses: Post-herpetic neuralgia (chronic pain), stress urinary incontinence. ■ Avoid if patient at high risk of suicide because may hoard pills and overdose(suicide attempt). ■ Overdose will cause fatal cardiac (ventricular arrhythmia) and neurologic effects (seizures). ■ Example: Imipramine (Tofranil), amitriptyline (Elavil), nortriptyline (Norpramine).

Suicide Risk Factors include:

■ Older people who have lost a spouse (due to death or divorce). ■ Plan to use a gun or other lethal weapon. ■ History of attempted suicide and/or family history of suicide. ■ Mental illness such as depression, bipolar disorder. ■ History of sexual, emotional, and/or physical abuse. ■ Terminal illness, chronic illness, chronic pain. ■ Alcohol abuse, substance abuse. ■ Significant loss (divorce, boyfriend/girlfriend, job loss, death of someone close to the person). ■ Females make more attempts compared to males, but males have a higher success rate. ■ Bipolar disorder (also known as manic-depressive disorder). A person with bipolar disorder is at higher risk of suicide during the depression phase of the illness. Look for signs and symptoms of depression and suicide warning signs. Moods cycle between mania and depression. Severe anxiety, rage, and chronic relationship difficulties. *Classic manic symptoms include:* labile moods, euphoria, talkativeness, flight of ideas, grandiosity, and less need for sleep. There are two types of bipolar disorder: Type 1 (classic manic episodes) or type 2 (hypomanic episodes). Strong genetic component. Peak incidence of onset is in the 20s (ranges from age 14 to age 30 years).

*Alcoholic Anonymous (AA)*

■ One of the most successful methods for recovering alcoholics. Founded by Bill W. Person. ■ Patient is paired with a mentor (a recovered alcoholic). Belief in a "higher power." ■ Must follow a 12-step program and attend AA meetings (uses "chip" reward). ■ Support group for family members and friends is called Al-Anon (Al-Anon Family Groups). ■ Support group for teen children is called Alateen.

*MAOIs*

■ Rarely used due to serious food (high tyramine content) and drug interactions. ■ Phenelzine (Nardil), tranylcypromine (Parnate). *Contraindications* ■ Do not combine MAOI with SSRI or TCAs. ■ Wait at least 2 weeks before initiating SSRI or TCA (high risk of serotonin syndrome). *High-Tyramine Foods and MAOIs* ■ Cause the tyramine pressor response (elevates blood pressure, risk of stroke). Avoid combining with fermented foods such as beer, chianti wine, some aged cheeses, fava beans, others. ■ High-tyramine foods can also cause migraine headache in susceptible persons.

*Treatment Plan for Depression*

■ Rule out diseases such as anemia (CBC), diabetes, hypothyroid (thyroid-stimulating hormone [TSH]/thyroid panel), chemistry panel (low potassium for Addison's disease), and Vitamin B12 level (B12 anemia). ■ *First line:* Selective SSRIs. Advise patients that antidepressant effect may take from 4 to 8 weeks (up to 12 weeks) to manifest. ■ After initiation, follow up in 2 weeks to check for compliance and side effects. ■ Wait for at least 4 to 8 weeks before changing medication. ■ Continue SSRI therapy for at least 4 to 9 months after symptoms have resolved (usually on first episode). Frequent relapse means patient may need lifetime treatment. ■ *Second line:* Tricyclic antidepressants or TCAs (amitryptiline/Elavil, nortriptyline/ Pamelor). ■ Prefer bedtime dosing due to sedation. Other uses are post-herpetic neuralgia, chronic pain, stress urinary incontinence Refer for psychotherapy. Cognitive-behavioral therapy can reduce symptoms (comparable to an antidepressant medication) and is usually effective. ■ Psychotherapy plus antidepressants works better than either method alone.

*Acute Delirium Tremens*

■ Sudden onset of confusion, delusions, transient auditory, tactile or visual hallucinations, tachycardia, hypertension, hand tremors, disturbed psychomotor behavior (picking at clothes), and grandmal seizures. ■ Considered a medical emergency. Refer to ED. *Treatment Plan* ■ Benzodiazepines (Librium, Valium), antipsychotics if needed (i.e., Haldol). ■ Vitamins: Thiamine 100 mg IV, folate 1 mg PO/IV daily, and multivitamins with high-caloric diet. ■ Refer to Alcoholics Anonymous (12-step program), therapist, and/or a recovery program. ■ Avoid prescribing recovering alcoholic/addict drugs with abuse potential such as narcotics or any medication that contains alcohol (cough syrups). *Medications* ■ Disulfiram (Antabuse): Causes severe nausea/vomiting, headache, other unpleasant effects. ■ Naltrexone (Vivitrol): Decreases alcohol cravings.

*Smoking Cessation*

■ Tobacco use is the most common cause of preventable death. ■ Discuss smoking cessation at every visit for patients who are smokers. ■ Nicotine patches (also available as chewing gum, inhaler). ■ Patient cannot smoke while on nicotine patches. Do not use with other nicotine products (e.g., gum, inhaler); patient will overdose with nicotine. Nicotine overdose can cause acute myocardial infarctions, hypertension, agitation in susceptible patients. Can be combined with bupropion (Zyban). ■ Bupropion (Zyban) decreases cravings to smoke. Can be combined with nicotine products. Patients can still smoke while on bupropion. Eventually loses desire to smoke and finally quits.