AAFP Behavioral Health

A mother brings her 24-month-old son to your office for evaluation. He is her only child. She is concerned that he might have autism because he rarely verbalizes and seems to avoid eye contact. Which one of the following is NOT true about autism spectrum disorder (ASD)? A history of unusual reactions to sensory stimuli suggests ASD An inability to share suggests ASD A lack of interest in peers suggests ASD Negative findings on the Modified Checklist for Autism in Toddlers (M-CHAT) effectively rules out ASD All major guidelines recommend against general screening for ASD

Negative findings on the Modified Checklist for Autism in Toddlers (M-CHAT) effectively rules out ASD Autism spectrum disorder (ASD) is a syndrome comprising both primary autism and other diagnoses, including Asperger's syndrome and pervasive developmental disorder. It is also associated with developmental disorders, including tuberous sclerosis, Rett syndrome, fragile-X syndrome, and other genetic and neurodegenerative disorders.The prevalence of ASD based on the 2014 National Health Interview Survey was 2.24%, higher than previous estimates and likely due to changes in the survey approach. It is four- to fivefold more common in males than females.Risk factors include advanced parental age; maternal diabetes mellitus, hypertension, or obesity; in-utero exposure to valproate; maternal infections; low birth weight; and preterm delivery. Purported links between vaccines and autism have been debunked.Clinicians should be vigilant for symptoms in preschool children that suggest this disorder, including the following: a delay in speech development, or the absence of speech or even nonverbal communication such as pointing a lack of awareness of others or a lack of responsiveness to other people's facial expressions or feelings little or no imaginative play a lack of interest in peers an inability to share with others unusual or repetitive hand and finger mannerisms unusual reactions to sensory stimuli avoidance of eye contact strong attachments to specific objects significant distress from changes in routines The U.S. Preventive Services Task Force concluded that current evidence is insufficient to assess the balance of benefits and harms of screening for ASD in young children if no concerns about possible ASD have been raised by their parents or a clinician. However, because early intensive interventions have been shown to demonstrate statistically significant improvement in cognitive and language outcomes in children with ASD, many experts, including the American Academy of Pediatrics, recommend screening at the 18-month and 24-month well child visits. All major authorities agree that parental concerns should prompt further evaluation.Structured instruments such as the Checklist for Autism in Toddlers (CHAT) or the parent questionnaire version of the CHAT (M-CHAT) can be helpful for suggesting the diagnosis but may miss children with ASD. Referral to a team familiar with ASD should be considered when the diagnosis remains in question. Evaluation for underlying neurodegenerative, genetic, and other rare conditions should be directed by an experienced clinical team. Parents of children with ASD should be informed that siblings are at increased risk.

You are treating a 53-year-old female for her first episode of moderate major depression. Her initial PHQ-9 score was 16. After 6 weeks of antidepressant treatment at a therapeutic dosage all depressive symptoms have resolved. She is not experiencing any medication-related side effects. Evidence suggests that after achieving symptom remission this patient should continue antidepressants for at least an additional 2 months 6 months 12 months 18 months

6 months Early discontinuation of antidepressants is associated with an early relapse of major depression. If a patient achieves remission of depression symptoms after 6-12 weeks of initial treatment for a first episode of major depression, evidence suggests that antidepressants should be continued for an additional 4-9 months at the same dosage used to achieve remission. Most guidelines recommend continuing medication for a minimum of 6 months after symptom remission. Discontinuing treatment after 2 months would increase the risk of relapse. The risk of depression relapse increases after each subsequent major depressive episode, so extending antidepressant treatment beyond 9 months for patients with a history of multiple episodes of major depression would be reasonable.

A 55-year-old female is diagnosed with mild depression. Her PHQ-9 score is 11. She states that she would rather not take prescription drugs and prefers an alternative treatment. Which one of the following has the best evidence for treatment of depression? Acupuncture Exercise Yoga SAM-e St. John's wort

Exercise Several systematic reviews, including a Cochrane meta-analysis, have reported a significant reduction of depression symptoms with exercise, particularly high-energy aerobic or resistance training. A smaller number of trials suggest that yoga may be an effective intervention as well. A 2017 Cochrane review found that adding music therapy to standard care, including both playing an instrument and listening to music, is more effective than standard care alone for short-term improvement of depressive symptoms.The 2016 Canadian Network for Mood and Anxiety Treatment (CANMAT) guidelines note the conflicting evidence on the efficacy of acupuncture for treatment of major depressive disorder. A 2018 Cochrane review noted that there is very-low-quality evidence that the severity of depression is reduced by acupuncture, either alone or in conjunction with medication, compared to medication alone.The 2016 CANMAT guidelines note that two systematic reviews have found some effectiveness for SAM-e (S-adenosyl-L-methionine) compared with placebo or combined with antidepressants in mild to moderate major depression, although the data is sparse and there are methodologic concerns about the quality of studies. A 2015 comparative effectiveness review by the Agency for Healthcare Quality and Research found one small lower-quality trial that found that SAM-e and escitalopram had similar effectiveness for depressive symptoms over 12 weeks.St. John's wort is an herb of the plant species Hypericum perforatum, which is sometimes used as an alternative or complementary treatment for depression. However, the data on the efficacy of St. John's wort for treating depression is mixed, and has been criticized for the lack of standardized preparations, adequacy of blinding of patients, short study durations, and inclusion of patients not meeting the criteria for major depression. Most studies do show benefit compared with placebo for patients with mild depressive syndromes. However, the evidence is mixed when analyses of St. John's wort compared to placebo are restricted to patients with major depressive disorder. Some studies do suggest that St. John's wort is as effective as SSRIs and low-dose tricyclic antidepressants for patients with mild to moderate major depression.St. John's wort appears to have fewer side effects than standard antidepressants but there is a potential for important drug interactions. Combining St. John's wort with an SSRI poses an increased theoretical risk for serotonin syndrome. In addition, St. John's wort has been shown to induce the activity of cytochrome P-450 3A4 enzymes. Induction of this subset can result in reduced efficacy of medications metabolized by these enzymes, including oral contraceptives, statins, antiretroviral agents, immunosuppressants, anticoagulants, and hormone replacement therapy.

You are aware that some patients in your practice are misusing or abusing prescription opioids and may be addicted. Which one of the following statements about pharmacotherapy for opioid use disorder is true? Opioid agonist treatment should be started before patients discontinue their opioids Buprenorphine/naloxone (Suboxone) is more effective than extended-release naltrexone (Vivitrol) Overdose is not a significant risk in patients taking buprenorphine Any licensed family physician can prescribe methadone for opioid use disorder

Overdose is not a significant risk in patients taking buprenorphine Risk factors for abuse of prescription medication include a personal or family history of substance abuse, pain-related functional disability, unemployment, psychosocial stressors, and a past history of spending time in jail or prison. People who abuse prescription drugs are more likely to be smokers, male, and white. Multiple risk factors increase the likelihood compared to the presence of a single risk factor. In the absence of psychosocial comorbidities and genetic predisposition, patients with pain on stable doses of opioids in a controlled setting are unlikely to abuse opioids or become addicted. Most adolescents who misuse pharmaceutical opioids obtain them from family members or friends.Three medications are approved for treatment of opioid use disorder: oral methadone, oral buprenorphine, and naltrexone administered either orally or by monitored monthly intermuscular injections. Opioid agonist treatment has been consistently shown to be more effective than abstinence for maintenance treatment of opioid use disorder. Naloxone, an opioid antagonist, is sometimes added to buprenorphine to make the product less likely to be abused by injection. Special training and federal certification (a Drug Enforcement Agency waiver or DEA-X number) are required to prescribe buprenorphine for maintenance therapy of opioid dependence. Methadone can only be obtained through federally certified treatment programs. No special prescribing or dispensing requirements are currently in place for injectable naltrexone.Withdrawal symptoms will emerge within 18-24 hours of the first missed dose of a short-acting opioid. Combination opioid agonists/antagonists should not be initiated while patients are currently using opioids, as they can precipitate withdrawal. However, opioid agonists can be started during early withdrawal because they may help relieve acute withdrawal symptoms in addition to their role in long-term treatment.A 2016 Cochrane review concluded that methadone and buprenorphine are equally effective for maintenance therapy for pharmaceutical opioid dependence. A 12-week open-label trial in 2017 found that extended-release naltrexone was as effective as buprenorphine/naloxone in maintaining short-term abstinence from heroin and other opioids. Overdose is not a significant risk in patients taking buprenorphine.Several medications can be used for symptomatic relief of withdrawal symptoms. Clonidine, lofexidine, guanfacine, and tizanidine can help manage autonomic withdrawal symptoms. NSAIDs and acetaminophen can be useful for musculoskeletal pain, and cyclobenzaprine or other antispasmodics for muscle spasms. Increased oral hydration, ondansetron, prochlorperazine, and metoclopramide may be helpful for nausea and vomiting; loperamide and bismuth may help with diarrhea.Compared with women taking methadone during their pregnancy, women treated with buprenorphine tend to have a lower risk of preterm delivery, and their newborns have a higher birth weight, a larger head circumference, a shorter duration of neonatal abstinence syndrome, shorter hospital stays, and a lower morphine requirement. However, methadone may be associated with fewer treatment dropouts than buprenorphine.

A 37-year-old male presents with a 3-week history of depressed mood, insomnia, and loss of appetite. He has no past history of episodes like this. His PHQ-9 score is 9. He is able to work, is not suicidal, and does not use alcohol or recreational drugs. Which one of the following statements is true regarding this scenario? Antidepressant medication is likely to be more effective than cognitive-behavioral therapy Antidepressant medication is likely to be more effective than low-intensity psychological interventions Acupuncture is as effective as psychological treatments for patients with this condition Structured group physical activity is a first-line treatment option

Structured group physical activity is a first-line treatment option The diagnosis of major depression requires either depressed mood and/or loss of interest in pleasurable activities, which are evaluated by the PHQ-9. The diagnosis also requires the presence of five additional symptoms on most days for at least 2 weeks, including guilt, sleep problems, psychomotor retardation or agitation, appetite changes, decreased energy, difficulty concentrating, or suicidal ideation. Instruments such as the PHQ-9 provide a structured way to document the presence and severity of symptoms, which can facilitate the diagnosis and quantify the response to treatment, an approach known as measurement-based care.A PHQ-9 score of 9 is consistent with subthreshold depression, defined as at least one key symptom of depression but with insufficient other symptoms and/or functional impairment to meet the criteria for major depression. The lifetime prevalence of subthreshold depression is estimated to be 10%-24%.Antidepressants are not more effective than placebo for initial treatment of subthreshold depression, and they expose patients to potential side effects. They may be considered in patients with symptoms that worsen or persist despite other treatments. Initial treatment options include psychosocial interventions, such as self-help programs based on principles of cognitive-behavioral therapy (CBT), and structured group physical activity programs. Group CBT and behavioral activation delivered by trained personnel, including trained nurses, are options for patients who decline lower-intensity psychosocial interventions. These interventions are typically delivered 6-10 times over 12 weeks. Watchful waiting with monitoring, also known as active-follow-up, is a reasonable initial strategy for patients with milder symptoms who prefer not to start with a more active intervention. Monitoring is important because 10%-20% of patients may progress to major depression and many others may have persistent symptoms after 12 months.Few studies have evaluated acupuncture specifically for subthreshold depression. A 2018 Cochrane review found that the reduction in severity of depression with acupuncture given alone or in conjunction with medication, compared to medication alone, is uncertain owing to the very low quality of evidence. The effectiveness of acupuncture compared with psychological therapy is also unclear.

You see a 22-year-old college student for a sports preparticipation examination. As part of the routine evaluation you screen for use of tobacco, alcohol, and illicit drugs.Which one of the following screening measures has been shown to have good sensitivity and specificity for detecting illicit drug use and prescription drug misuse in this age group? Urine drug testing The RxCAGE The CRAFFT screen The single question, "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?"

The single question, "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" The U.S. Preventive Services Task Force has issued an I recommendation (insufficient evidence) for screening for illicit drug use in adolescents and young adults. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends that universal screening for substance use, brief intervention, and/or referral to treatment (SBIRT) become a part of routine health care to reduce the health burden related to substance use and substance use disorders. The American Academy of Pediatrics recommends routine substance abuse screening of adolescents.Asking the single question, "How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?" has been shown to be a valid screening method in individuals over the age of 18. A 2010 study showed the single question was 100% sensitive (95% CI 90.6%-100%) and 73.5% specific (95% CI 67.7%-78.6%) for the detection of a drug use disorder. It was less sensitive for the detection of self-reported current drug use (92.9%; 95% CI 86.1%-96.5%) and drug use detected by oral fluid testing or self-report (81.8%; 95% CI 72.5%-88.5%). The Drug Abuse Screening Test (DAST-10) performed similarly in that study. A positive screening score on the DAST-10 instrument on hospital admission has been associated with a higher risk of 30-day readmission to general medicine wards, although many readmissions were not immediately attributable to substance use.The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has a one-question screen for unhealthy alcohol use. The patient is asked how many times in the past year he has had 5 or more drinks in a day, or 4 drinks in 1 day for women. Although a patient with a drug use disorder has twice the odds of screening positive for unhealthy alcohol use compared to one without a drug use disorder, the single screening question for unhealthy alcohol use was not sensitive or specific for the detection of other drug use or drug use disorders in primary care patients. This single question is only 67.6% sensitive and 64.7% specific for the detection of a drug use disorder.For adolescents age 14-18, the NIAAA and American Academy of Pediatrics have said the CRAFFT screen (Car, Relax, Alone, Forget, Family, Friends, Trouble—riding in or driving a car while intoxicated, use of alcohol or drugs to relax, use when alone, forgetting what you've done while intoxicated, having friends or family suggest you cut down, and getting into trouble while using alcohol or drugs) is a useful screening tool for identifying risky substance use. It has not been studied in adults.According to a 2016 estimate, 18.6 million adults misused prescription psychotherapeutic drugs. As part of its definition of illicit drug use, the National Survey on Drug Use and Health includes medication use in any way not directed by a prescribing clinician, including using another person's prescription, using greater amounts than prescribed, or using the prescribed drug more often or longer than directed. A 2019 study of 2339 mostly uninsured, English speaking, minority adults found the RxCAGE (CAGE modified for prescription drug misuse) had a sensitivity of 62.8% and a specificity of 64.3% at a cut score of 1, and a sensitivity of 35.6% and a specificity of 67.7% at a cut score of 2.While urine drug testing has become the standard of care for patients receiving chronic opioid therapy and may be useful for diagnostic purposes, there is no evidence of its utility for population-based screening for drug abuse or misuse.

You are compiling a list of support programs for patients in your practice with mental health conditions, and for their caregivers. Which one of the following statements regarding this type of support program is supported by the best evidence? Community Mental Health First Aid courses have been shown to improve the outcomes of patients with mental health disorders Workplace programs for employees with mental health issues can improve their workplace functioning School-based programs are ineffective for reducing disruptive behaviors The effectiveness of delivery of mental health information and assessment by trained volunteers is similar to that of psychotherapy for patients with mental health disorders Online peer support groups for adolescents and young adults are effective for improving mental health outcomes

Workplace programs for employees with mental health issues can improve their workplace functioning Several studies have investigated programs that enhance social support, create connections with patients, and facilitate family engagement. The Mental Health First Aid course teaches community members to recognize symptoms of different mental disorders and mental health crises, provide initial help, and guide the person to appropriate treatment and support. A 2018 systematic review and meta-analysis of 18 trials found that the training has small to moderate effects for up to 6 months on the knowledge levels and confidence of trainees, but the effect on the mental health of those they help is unclear.A 2016 synthesis of systematic reviews found that interventions provided in the workplace that incorporate aspects of improving both mental and physical health and include multiple components can improve workplace outcomes such as productivity and absenteeism.A 2019 nonsystematic review highlighted different community- and school-based interventions that have helped improve functioning in patients with a variety of conditions, including psychosis, anxiety, depression, substance use, and disruptive behaviors. This review was not structured to allow systematic or generalizable conclusions, however. A 2015 systematic review of online peer-to-peer support for adolescents and young adults with mental health concerns showed a lack of high-quality studies and mixed results on mental health outcomes.A 2017 systematic review and meta-analysis found that befriending, defined as "a supportive and unidirectional relationship that aims to alleviate loneliness and provide social support through the provision of one-to-one companionship" had a small effect on combined patient outcomes of depressive symptoms, mental well-being, social support, and quality of life in varied patient groups. Volunteers are often trained in the components of befriending, but instruction, assessment, and provision of information is generally not considered part of a befriending intervention. Studies comparing befriending to psychotherapy are often excluded from systematic reviews. The data was insufficient to support conclusions about more-specific outcomes.

A 56-year-old female was admitted to your service last night with jaundice and abdominal pain. She is a long-time patient of yours, has a history of heavy drinking for several years, and has been resistant to advice to decrease her alcohol use. This morning she has a headache, nausea, palpitations, and anxiety. Her vital signs include a blood pressure of 150/100 mm Hg, a pulse rate of 104 beats/min, a respiratory rate of 22/min, and a temperature of 37.6°C (99.7°F). She has a fine bilateral upper-extremity tremor without clonus or hyperreflexia. Her skin is warm and she is mildly diaphoretic. A WBC count is unremarkable and other laboratory studies and imaging results are pending. Which one of the following is true in this scenario? The Short Alcohol Withdrawal Scale can be used to assess symptom severity Diazepam (Valium) is preferred over lorazepam (Ativan) Haloperidol is a first-line treatment option if benzodiazepines are contraindicated Anticonvulsant medications may help reduce alcohol craving

Anticonvulsant medications may help reduce alcohol craving This patient is exhibiting symptoms of mild to moderate alcohol withdrawal syndrome (AWS), which typically begins 6-24 hours after the last drink. Symptoms of stage 1 AWS include anxiety, tremor, insomnia, headache, palpitations, and gastrointestinal disturbances. Stage 2 symptoms also include diaphoresis, increased systolic blood pressure, tachypnea, tachycardia, confusion, and mild hyperthermia. Stage 3 AWS, or delirium tremens, may include disorientation, impaired attention, visual and/or auditory hallucinations, or seizures. The Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar) can be used to assess AWS severity in inpatients, while the patient-completed 10-item Short Alcohol Withdrawal Scale (SAWS) can be used in the outpatient setting.Because of their aroused status, patients with AWS should ideally be treated in a quiet environment. Thiamine, 100 mg daily, and folic acid, 1 mg daily, should be used routinely for nutritional supplementation and to reduce the risk of Wernicke's encephalopathy.Patients with mild AWS may only require supportive care. Patients with additional symptoms require pharmacotherapy. Benzodiazepines are first-line medications for AWS, because of their anxiolytic and seizure-prevention properties. There is no evidence that one benzodiazepine or regimen is superior to another. Long-acting, short-acting, front-loading, fixed-dose, and symptom-triggered options are available. Some physicians prefer long-acting agents with a greater half-life, such as diazepam or chlordiazepoxide, which are less likely to cause rebound symptoms. However, longer-acting agents have active metabolites that may accumulate in patients with liver dysfunction. Some experts therefore recommend short-acting benzodiazepines with a shorter half-life, such as lorazepam or oxazepam, in patients with severe liver dysfunction and those at high risk of serious medical consequences following sedation. However, shorter-acting agents carry a greater risk of rebound symptoms and require tapering.Anticonvulsant drugs such as carbamazepine, gabapentin, valproic acid, and oxcarbazepine are potential alternatives to benzodiazepines. They are not as sedating as benzodiazepines, do not have abuse potential, and may be useful in patients with coexisting bipolar disease. They may also reduce craving for alcohol.β-Blockers and α2-agonists such as clonidine can be used as adjunctive treatments to control autonomic hyperactivity, and neuroleptic medications can be used to help control hallucinations. These agents are recommended for adjunct treatment, not as monotherapy. Severe withdrawal could require admission to the intensive-care unit and the use of barbiturates or propofol.

A 26-year-old gravida 1 para 1 sees you for routine follow-up 6 weeks after a vaginal delivery. She begins to cry during the visit and reveals that over the past few weeks she has grown increasingly unhappy and overwhelmed. She says her baby seems to take up all of her time and causes her to feel "trapped" and "tied down." She finds it harder to concentrate on tasks such as making the baby's formula, and her husband complains that she no longer gets things done. Despite being exhausted she has difficulty falling asleep. At times she becomes angry with herself for being "so inept." She says that she sometimes feels afraid to be alone with the baby because of fleeting thoughts of harming him. Which one of the following statements about this patient's condition is true? SSRIs are considered effective for prevention in at-risk patients No medications are FDA approved for treatment A score of 7 on the Edinburgh Postnatal Depression Scale supports the diagnosis Antidepressant therapy can be prescribed even if the mother is breastfeeding Psychotherapy is not as effective as antidepressants

Antidepressant therapy can be prescribed even if the mother is breastfeeding "Baby blues" are very common, usually starting within 2-3 days of delivery. Symptoms are mild and transient, usually lasting less than 10 days, without suicidal ideation. Severe dysphoria, emotional lability, and other typical signs of major depressive disorder that last more than 2 weeks should raise suspicions for postpartum depression.Prevalence estimates vary for postpartum depression, including major and subsyndromal depression, but the prevalence could be as high as 30%. Important risk factors include a history of major depression during a prior pregnancy, antenatal depressive symptoms, a past history of major depression, poor social support due to factors such as living alone or lower socioeconomic status, an unintended pregnancy, and major events or life stressors during the pregnancy, including intimate partner violence. Maternal age over 40 is also a risk factor. Possible consequences of postpartum depression include child abuse and neglect; early cessation of breastfeeding; family dysfunction; adverse effects on cognitive, social-emotional, and behavioral development in the child; and increased costs of medical care. Symptoms often begin within 4 weeks of delivery, as noted in DSM-5 criteria, but they can develop anytime in the first year post partum.The U.S. Preventive Services Task Force recommends screening women for depression in the antenatal period. Instruments that can be used to screen for postpartum depression include the PHQ-9, the Edinburgh Postnatal Depression Scale (EPDS), and the Postpartum Depression Screening Scale. A cutoff score of 11 on the EPDS has been found to maximize the combination of sensitivity and specificity, and a cutoff score of 13 is more specific but less sensitive. Initially positive screens should be followed up with a more detailed evaluation.Psychotherapeutic interventions including home health visits, phone-based peer support, cognitive-behavioral therapy, and interpersonal therapy have shown effectiveness in the prevention of postpartum depression in at-risk women. There is no evidence that SSRIs are effective for this purpose. Cognitive-behavioral therapy has also been shown to be an effective treatment for postpartum depression. Antidepressants are also thought to be effective but a 2014 Cochrane review raised several questions about available studies, including bias, missing information on infant outcomes, high attrition rates, and concerns about representativeness of study samples. There is insufficient evidence that any antidepressant is superior to others. The effectiveness of antidepressants for preventing postpartum depression is unclear. Brexanolone is an FDA-approved medication for postpartum depression but it must be given in a certified health facility due to serious side effects.Well-designed studies on the effect of antidepressant exposure in breastfed infants are lacking but antidepressants can be prescribed for women who are breastfeeding. Risks to the neonate are generally felt to be small. Neonatal exposure to antidepressants is 5- to 10-fold lower from breastfeeding than in utero. Some case studies suggest exposure to fluoxetine might be related to poor feeding, and exposure to citalopram might impair neonatal sleep. Doxepin should generally be avoided due to the long half-life of its main metabolite.

A 75-year-old male sees you for routine follow-up of hypertension. He is accompanied by his wife, who expresses concern that he sleeps excessively, has lost interest in his hobbies, has a decreased appetite, and complains often of various aches and pains. She also says that he has recently started to have difficulties with short-term memory. He is adherent to his medication regimen of lisinopril (Prinivil, Zestril) and hydrochlorothiazide. On examination his blood pressure is 142/84 mm Hg. Which one of the following would be LEAST clinically useful for evaluating the patient's symptoms at this time? A vitamin B12 level Thyroid function testing CT of the brain The Cornell Scale for Depression in Dementia

CT of his brain Depression is common in older adults. Data from the National Institute of Mental Health in 2017 revealed that nearly 5% of individuals over age 50 had an episode of major depression in the previous 12 months. Several different instruments have been studied for depression screening in adults, including the PHQ-2, the Geriatric Depression Scale (GDS), and the Cornell Scale for Depression in Dementia (CSDD). The GDS does not assess for somatic issues, making it useful for screening older adults with physical symptoms. The CSDD is preferred when the possibility of dementia is a concern, as it retains its validity better than the GDS or PHQ-2 in patients with dementia.Dementia and depression frequently occur together, and the differential diagnosis in an older patient may be difficult. In individuals over the age of 65 cognitive impairment can cause depression. Likewise, cognitive impairment due to an underlying dementia may cause depressive symptoms, and determining the underlying cause is critical to administering appropriate treatment. Patients with dementia often underplay their cognitive impairment, whereas the cognitive problems reported by elderly patients with depression are often out of proportion to the findings on objective examination and testing. A key component of the assessment is determining the temporal relationship between depression and cognitive symptoms. The workup should also include assessment for underlying causes of depression or memory impairment, such as thyroid disorders, anemia, vitamin B12 deficiency, vascular disease, alcohol use, and renal impairment. Additional information can be gained from family members, and the psychosocial assessment should cover risk factors such as the recent death of a loved one, lack of social support, and physical disability.CT of the brain could show enlarged ventricles in normal pressure hydrocephalus, which could present with apathy and a decline in thinking skills but not the other symptoms in this patient. Normal pressure hydrocephalus would also present with gait and bladder control difficulties. Although loss of cortical volume is often seen in dementia, CT of the brain is not diagnostic.

A 32-year-old female who recently moved to your town sees you for the first time. Three years ago she was treated for depression and says she got somewhat better for a few weeks but then she was laid off and lost her health insurance and was unable to pay for her medication. She says she has felt more depressed since that time but has recently found another job. She has been sleeping 9-10 hours a night but still feels tired and has trouble concentrating at her new job. She does not use alcohol or tobacco, is not in a relationship, and is not sexually active. She scores 9 on the PHQ-9. She does not have suicidal ideation. A CBC and a TSH level are normal. Which one of the following is true about treatment for this patient's condition? SSRIs are more effective than tricyclic antidepressants Antidepressants are more effective than psychotherapy Antidepressants and cognitive-behavioral therapy combined have been shown to be more effective than antidepressants alone Antidepressant and placebo discontinuation rates are similar

Antidepressants are more effective than psychotherapy The DSM-5 category of persistent depressive disorder (PDD) incorporates four previous diagnoses: persistent subsyndromal depressive symptoms, chronic major depression, recurrent major depression with incomplete remission between episodes, and a major depressive episode in someone with existing dysthymia (double depression).For treatment purposes, PDD can be divided into pure dysthymia and chronic disorders involving major depression. A diagnosis of dysthymia requires a history of depressed mood for most of the day, for more days than not. This must have been present for at least 2 years with no symptom-free period of 2 months or longer. At least two of the following additional symptoms must also be present: appetite changes, sleep changes, low energy or fatigue, low self-esteem, poor concentration or difficulty making decisions, or hopelessness.Unlike with major depression, there is currently no evidence to suggest that cognitive-behavioral therapy or other psychotherapies are effective for treatment of dysthymia. Systematic reviews and meta-analyses have shown that antidepressants are superior to placebo for treatment of dysthymia, with no clear evidence that one antidepressant or antidepressant class is more efficacious than others. All antidepressants are associated with significantly higher discontinuation rates than placebo. Adverse effects were significantly higher for tricyclic antidepressants (TCAs) and SNRIs compared to placebo. TCAs were primarily associated with anticholinergic effects and sedation, but gastrointestinal adverse events were more common with SSRIs.The Institute for Clinical Systems Improvement (ICSI) guideline for treatment of persistent depressive disorder suggests antidepressants for patients with pure dysthymia. However, many patients will not adequately respond to first-line treatment, and stepped-care strategies including augmenting medications are options for these patients. The ICSI guideline also suggests adding psychotherapy to antidepressants in a stepped-care approach, although most evidence suggests that the combination is no better than antidepressants alone for treatment of dysthymia. Some commentaries have suggested that patients with repeated treatment failures and a chronic course of depression require a chronic disease management approach with less emphasis on remission of symptoms and cure and greater emphasis on improving function and quality of life.

You are considering approaches to behavioral health integration in your practice, including working more closely with behavioral health professionals to deliver psychotherapeutic interventions. Which one of the following is NOT true regarding psychotherapy? It can help decrease the risk of relapse for patients with bipolar disorder Adding psychotherapy to treatment with antidepressants provides additional benefit in patients with anxiety disorders Antidepressants are superior to cognitive-behavioral therapy (CBT) for treating mild major depression CBT is effective for treating childhood and adolescent anxiety disorders CBT is superior to usual care alone for treatment of postpartum depression

Antidepressants are superior to cognitive-behavioral therapy (CBT) for treating mild major depression Studies comparing antidepressant treatment with psychotherapy for patients with mild to moderate depression have shown no significant differences in outcome. While pharmacotherapy is likely to be effective more quickly than psychotherapy, treatment effects are likely to persist longer with psychotherapy for depression and anxiety. The relapse prevention effect of cognitive-behavioral therapy (CBT) in depression may last as long as 6 years. The combination of cognitive therapies and antidepressants may be more effective than either one alone for anxiety and panic disorders. A 2017 meta-analysis found that CBT can improve depressive symptoms, mania severity, and relapse rates when added to medication for treatment of bipolar disorder. However, a 2018 systematic review by the Agency for Healthcare Research and Quality found that CBT was no better for depression or mania symptoms than psychoeducation or other active psychosocial measures, although the overall strength of evidence was low.A Cochrane review of 13 studies conducted on outpatient children and adolescents with anxiety disorders of mild to moderate severity showed that a minimum of eight sessions of CBT significantly improved remission of anxiety symptoms by the end of treatment compared with wait-listed controls (number needed to treat = 3). Individual and group CBT appear to be equally effective. Studies comparing CBT to pharmacologic treatment were not included in this review. Lower-intensity approaches have also shown promise, including coaching parents on how to use written materials to help their children, and online CBT-based interventions.CBT alone or in combination with other treatments has been shown to reduce symptoms of postpartum depression better than a variety of usual-care interventions, including antidepressants and referral to subspecialists, as well as compared to wait-listed controls.

A 38-year-old male has had periods of anxiety over the past few days. He asks for a refill of alprazolam (Xanax) which was prescribed by another physician. Further history reveals that he has had episodes like this since his late teens, more often in the spring and summer, and he has had three episodes of depression in the past around the winter holidays. Previous attempts to treat the depression with SSRIs were not helpful, sometimes causing agitation and insomnia. Which one of the following would be most specific for confirming a diagnosis? A brother with bipolar I disorder A history of periods of irritable and labile mood lasting at least 7-10 days Past symptomatic improvement on alprazolam Symptomatic improvement with duloxetine (Cymbalta)

A history of periods of irritable and labile mood lasting at least 7-10 days Mania and hypomania are signature characteristics of a bipolar disorder. Episodes of labile mood are characterized by elation, irritability, and increased energy, plus at least three additional symptoms, or four if the predominant mood is irritability. Additional symptoms can include the following: impulsive goal-directed activities without concern for potential negative consequences, such as impulsive shopping, risky business undertakings, or unsafe sexual behaviors increased activity levels or psychomotor restlessness pressured speech or greater talkativeness a subjective feeling that one's thoughts are racing or jumping from topic to topic increased distractibility by stimuli in the environment exaggerated self-confidence, sometimes to the point of grandiose delusions Hypomanic episodes last at least 4 days and cause an observable change in functioning that may or may not cause impairment. Manic episodes last at least 7 days and are associated with functional impairment. The presence of these defined periods of mood lability confirms bipolar disorder.A first degree relative with a formal diagnosis of bipolar disorder would be a clue to a bipolar spectrum illness but would not be diagnostic. Bipolar disorders often first present with depressive episodes. An early onset of depression, in the late teens or early 20s, particularly in males and particularly with seasonality, should raise suspicion for possible bipolar disorder. Symptomatic improvement with a different class of antidepressants such as an SNRI would not help clarify the diagnosis. Resistance of symptoms to antidepressant treatment and the induction of mixed states characterized by worsening anxiety, insomnia, and agitation may also be seen. Comorbidity with anxiety disorders is common, including generalized anxiety disorder, panic disorder, posttraumatic stress disorder, obsessive-compulsive disorder, and social phobia. Previous improvement with alprazolam could be incidental in manic episodes, or an indication of a coexisting anxiety disorder or phobia, but would not help confirm the diagnosis.

A 21-year-old female presents to your office because of difficulty sleeping, nightmares, sadness, and hopelessness. She has had these problems since she was in a motor vehicle accident 2 weeks ago. She was driving and was wearing her seatbelt, and was not seriously injured, but her 10-year-old brother was unrestrained in the back seat and suffered a traumatic brain injury. The patient has not driven since the accident. She cannot describe the accident but says that her nightmares often include automobile collisions. Which one of the following is the most likely diagnosis? Acute stress disorder Adjustment disorder Generalized anxiety disorder Major depressive disorder Posttraumatic stress disorder

Acute stress disorder This patient was involved in a life-threatening event, has nightmares related to the event, avoids stimuli that remind her of the trauma, and cannot specifically recall the event. These findings are characteristic of acute stress disorder (ASD), which causes significant distress or impairment of functioning in social or occupational areas. ASD is similar to posttraumatic stress disorder (PTSD) in that it is characterized by exposure to a life-threatening event, avoidance of stimuli related to the event, and significant impairment in functioning. However, ASD is more short-lived, with a minimum of 3 days and a maximum of 4 weeks of symptoms. The diagnosis requires the absence of another explanatory cause and the presence of at least 9 of the following 14 symptoms: efforts to avoid external reminders of the event efforts to avoid distressing memories, thoughts, or feelings about or associated with the traumatic event(s) intense or prolonged psychological distress or reactions in response to internal or external cues that resemble an aspect of the traumatic event(s) the inability to remember an important aspect of the event(s) recurrent, involuntary, and intrusive distressing memories flashbacks recurrent distressing dreams related to the traumatic event(s) sleep disturbance problems concentrating hypervigilance an exaggerated startle response irritable behavior and angry outbursts a persistent inability to experience positive emotions an altered sense of reality of one's surroundings or oneself To make a diagnosis of PTSD symptoms must be present for at least 1 month. Adjustment disorder occurs within 3 months of a life stressor and is characterized by distress that is considered excessive given the level of the stressor. It is less severe than PTSD and can be associated with a depressed or anxious mood. Major depressive disorder and generalized anxiety disorder share features with acute stress disorder and PTSD but are not associated temporally with a life-threatening event.The 2017 Department of Veterans Affairs evidence-based guidelines recommend trauma-focused psychotherapeutic interventions for ASD. They found insufficient evidence to recommend pharmacotherapy for the treatment of ASD.

A 12-year-old female is brought to your office by her mother because of the daughter's recent history of feeling sad, frequent crying, difficulty sleeping, and academic troubles. These symptoms started after the patient was not selected for a traveling basketball team last month. She now refuses to play basketball or any other sport and her grades have fallen from mostly As to Cs. Her history is negative for suicidal ideation and there is no past history of depression or other psychiatric diagnoses. Which one of the following would be the most likely diagnosis for this patient? Dysthymic disorder Adjustment disorder with depressed mood Atypical depression Major depressive disorder Bipolar I disorder, depressed

Adjustment disorder with depressed mood Adjustment disorder with depressed mood is characterized by depressive symptoms such as low mood, tearfulness, and hopelessness that start within 3 months of an identifiable stressor. In this patient it is probably due to her failure to make the basketball team. The symptoms are usually out of proportion to the seriousness of the stressor and interfere with normal functions such as school performance and social interaction. Symptoms are not related to bereavement or another psychiatric disorder such as major depression and do not last for more than 6 months. Adjustment disorder with depressed mood is the most common depressive mood disorder in children and adolescents. In the absence of an identifiable stressor, a diagnosis of subsyndromal depressive disorder could be considered.Dysthymic disorder is a chronic form of depression. Patients have a depressed mood most of the day, more days than not, for at least 2 years, without a symptom-free period of more than 2 consecutive months. At least two additional symptoms must be present, including appetite change, sleep change, decreased energy, decreased self-esteem, poor concentration or difficulty making decisions, or hopelessness. The diagnostic criteria require that symptoms are not better explained by a psychotic disorder. Dysthymic disorder can coexist with major depressive disorder. Detailed questioning and administration of instruments such as the PHQ for Adolescents (PHQ-A) or the Beck Depression Inventory can help with the diagnosis.Bipolar I disorder is characterized by a combination of depression with at least one episode of mania.

A 24-year-old female with polycystic ovary syndrome (PCOS) presents with a 4-month history of sadness, anxiety, anhedonia, exhaustion despite sleeping 9 hours daily, and increased appetite. She is not currently sexually active and is not planning to become pregnant in the near future. Her vital signs are normal other than a BMI of 32 kg/m2. She has facial comedonal acne with a few papules, and mild hirsutism. Her medications include metformin (Glucophage) for PCOS and topical tretinoin (Retin-A) for acne. She scores 16 on the PHQ-9 and is not suicidal. Which one of the following medications would be most appropriate for this patient? Bupropion (Wellbutrin) Imipramine (Tofranil) Mirtazapine (Remeron) Paroxetine (Paxil) Tranylcypromine (Parnate)

Bupropion (Wellbutrin) A 2016 systematic review and meta-analysis showed that patients with polycystic ovary syndrome (PCOS) have significantly higher rates of depressive symptoms (odds ratio [OR] = 3.51; 95% confidence interval [CI] 1.97-6.24; Log OR = 1.255; P<0.001) and anxiety symptoms (OR = 2.76; 95% CI 1.26-6.02; Log OR = 1.013; P = 0.011) compared with healthy controls. Prevalence estimates of depression in women with PCOS range from 14% to 67%, with an increased prevalence compared with healthy controls even after controlling for BMI. When selecting an antidepressant for individuals with major depressive disorder who are overweight or obese the potential impact on weight should be considered. This is especially important in patients who exhibit symptoms of atypical depression, such as increased appetite and hypersomnia.While MAO inhibitors have been found to be useful in treating atypical depression, tranylcypromine and phenelzine are associated with weight gain. Mirtazapine and tricyclic antidepressants also promote weight gain, which may also occur with some SSRIs, particularly paroxetine, citalopram, and escitalopram. Fluoxetine, sertraline, buproprion, and the SNRI venlafaxine tend to be more weight neutral. Bupropion has also been associated with modest weight reduction when used by obese patients with major depression.

A 24-year-old male presents with insomnia and says he is "not able to shut his mind off at night." He asks for a refill of alprazolam (Xanax) prescribed by another physician. He has had problems with anxiety since late childhood and has had several impairing depressive episodes that tend to be more severe during the winter months. He does not drink alcohol or use recreational drugs. His mother has had similar symptoms for 15 years.Which one of the following would be the most appropriate next step? Administer the Conners Abbreviated Symptom Questionnaire (ASQ) Administer the Mood Disorder Questionnaire (MDQ) Prescribe lamotrigine (Lamictal) Prescribe an SSRI Refill the alprazolam

Administer the Mood Disorder Questionnaire (MDQ) Depression and anxiety disorders are frequently seen together but the onset of depression in childhood, particularly in males, is a sign of potential bipolar disorder. The presence of manic or hypomanic episodes confirms bipolar disorder. Other clues to bipolar disorder include a first degree relative with a formal diagnosis of bipolar disorder, a clear response to lithium or divalproex, and seasonal mood variation (depressive symptoms during the winter months and elevated moods during the summer months). Further exploration of symptoms to clarify the diagnosis is recommended before prescribing or renewing medications in this scenario, particularly since bipolar disorder can be resistant to antidepressants, and antidepressant treatment without mood stabilizers could induce mania or mixed mood states characterized by worsening anxiety, insomnia, and agitation.The Mood Disorder Questionnaire (MDQ) is a validated self-administered tool that can be used to screen for bipolar disorder. It correctly identifies almost three-quarters of patients with bipolar disorder and screens out bipolar disorder in 9 of 10 patients without the condition. The Hypomania/Mania Symptom Checklist (HCL-32) can also be used in suspected bipolar disorder. It has a sensitivity of 0.80 and a specificity of 0.51 at a cut point of 14. However, neither of these are diagnostic instruments. The DSM-5 criteria for manic or hypomanic episodes can also be used to explore the possibility of bipolar disorder and to follow up MDQ results to confirm the disorder.The Conners Abbreviated Symptom Questionnaire (ASQ) is used to screen children for attention-deficit/hyperactivity disorder and would not be appropriate for this patient.

A 32-year-old male consults you after receiving a warning from his supervisor at work, who pointed out that he seemed distracted and disorganized. He was given a performance improvement plan that includes improving the thoroughness of his work. He does not feel depressed and does not have symptoms of anhedonia. He does not drink alcohol or use recreational drugs and his past medical history is unremarkable. Further history reveals that he had some academic difficulties in high school but was able to obtain an associate's degree after 3 years at a community college. Which one of the following is true about treatment of this patient's problem? Cognitive-behavioral therapy is superior to other forms of supportive psychotherapy Sustained-release stimulants are more effective than immediate-release stimulants Bupropion (Wellbutrin) is a recommended option A baseline EKG is needed before pharmacotherapy can be started

Bupropion (Wellbutrin) is a recommended option Symptoms of attention-deficit/hyperactivity disorder (ADHD) include a lack of attention to detail, difficulty organizing tasks and activities, excessive talking or fidgeting, difficulty relaxing, overworking, forgetfulness, and distractibility. The prevalence of adult ADHD has been estimated to be 2%-3%. Scales such as the Adult ADHD Self-Report Scale Symptom Checklist, Conners Adult ADHD Rating Scales, and Wender Utah Rating Scale can be helpful in making the diagnosis. As with children, documentation from observers of impairment in more than one setting should be obtained before making the diagnosis.The United Kingdom's National Institute for Health and Care Excellence (NICE) recommends environmental adaptations as the first step for treating adult ADHD, including measures such as changes in seating, reducing distractions and noise, wearing headphones, changing lighting, breaking up work into shorter periods of focus, and reinforcing verbal requests with written instructions. NICE recommends offering medication if ADHD symptoms are still causing a significant impairment in at least one domain after a trial of environmental adaptations. They advise adding cognitive-behavioral therapy (CBT) for patients who have benefited from medication but still have symptoms that are causing a significant impairment in at least one domain.A 2018 Cochrane review concluded, based on low-quality evidence, that CBT may be beneficial for adults with ADHD. Short-term reductions in ADHD symptoms were consistent when comparing CBT plus pharmacotherapy to pharmacotherapy alone or to controls who had been placed on a waiting list for treatment. They also found low-quality evidence that CBT may improve comorbid depression and anxiety in adults with ADHD. The evidence was mixed, and sparse, regarding the effectiveness of CBT compared with other supportive psychotherapies for ADHD and for ADHD with depression or anxiety. There was insufficient evidence to make any conclusion about longer-term outcomes, functioning, or adverse effects.Another 2018 Cochrane review of 13 studies involving 2028 participants concluded, based on low- to very low-quality evidence, that amphetamines improved the severity of clinician- or patient-rated ADHD symptoms in the short term but did not improve continued participation in treatment. All amphetamines were equally effective in reducing patient's ratings of symptom severity. Dosage and the use of immediate- versus sustained-release formulations were not associated with changes in outcomes. The review found no evidence that amphetamines improved ADHD symptom severity more than other drug interventions. The relative risk of treatment withdrawal due to adverse effects from amphetamines was 2.7 times that of placebo.Common side effects of amphetamines include appetite loss, abdominal pain, headaches, and sleep disturbance. The patient's pulse rate and blood pressure should be routinely monitored. An EKG is not needed before starting stimulants for adult ADHD if the cardiovascular history and an examination are normal and the person is not taking a medication that poses an increased cardiovascular risk.A 2017 Cochrane review evaluated sustained-release bupropion, 150-450 mg daily, for treatment of ADHD for 6-10 weeks. The overall evidence was of low quality, but the authors concluded that bupropion decreased the severity of ADHD symptoms compared to placebo, with no difference in dropouts due to adverse effects. No head-to-head trials have compared bupropion to amphetamines or methylphenidate. A 2018 meta-analysis also showed that methylphenidate, atomoxetine, and bupropion were superior to placebo for improving clinician ratings of ADHD in adults.

You have diagnosed moderate depression in a 35-year-old female and mild generalized anxiety disorder in a 28-year-old male. Both are long-time patients of yours. Which one of the following is true regarding the treatment of these patients? The effects of pharmacotherapy occur later than those of psychotherapy in anxiety and depressive disorders Pharmacotherapy is more effective than psychotherapy for moderate depression Treatment discontinuation rates are higher for second-generation antidepressants than for psychotherapy in patients with depression or anxiety Cognitive therapies are less effective than pharmacotherapy alone for preventing relapse of depression All second-generation antidepressants are equally effective for treating depressive disorders and anxiety

All second-generation antidepressants are equally effective for treating depressive disorders and anxiety A shared decision-making approach is recommended when choosing from a number of treatment options for mental health disorders. The American College of Physicians recommends that clinicians select between either cognitive-behavioral therapy or second-generation antidepressants to treat patients with major depressive disorder after discussing treatment effects, adverse effect profiles, cost, accessibility, and preferences with the patient (strong recommendation, moderate-quality evidence). Psychotherapy has been shown to be as effective as pharmacotherapy for mild to moderate anxiety and depressive disorders.Overall analyses, including a 2009 Cochrane review, have found that antidepressants are an effective treatment option for adult patients with depression and/or anxiety. They are effective for severe depression, and all second-generation antidepressants (SSRIs and newer agents) are equally effective for major depression and general anxiety disorder. Several analyses have raised concerns about the marginal effectiveness and the balance of benefits and harms of antidepressants for adults with major depression of mild severity. These analyses point out methodologic issues and publication bias in the antidepressant effectiveness literature, including highlighting positive secondary outcomes and minimizing negative primary outcomes.For more severe symptoms, the combination of pharmacotherapy and structured behavioral therapy is superior to either alone. While pharmacotherapy is likely to be effective more quickly than psychotherapy, treatment effects are likely to persist longer with psychotherapy. Up until about 24 weeks of treatment there is not a statistically significant difference in overall discontinuation rates between second-generation antidepressants and psychological therapies. The relapse prevention effect of cognitive-behavioral therapy in depression may last as long as 6 years. The combination of cognitive therapies and antidepressants may be more effective than either one alone for anxiety disorders.

A 32-year-old female informs you that she and her husband have decided to have a child. She was diagnosed with major depression 3 months ago but it has been well controlled with paroxetine (Paxil). She also had an episode of major depression 10 years ago that also responded to paroxetine. She was not pregnant at that time and asks about depression treatment options during her pregnancy. The use of SSRIs during pregnancy is NOT linked to which one of the following? An increased rate of autism An increased rate of stillbirth An increased risk of congenital malformations Persistent pulmonary hypertension of the newborn Persistent neonatal withdrawal effects

An increased rate of stillbirth This patient is in the maintenance phase of depression treatment, and continuing active treatment is indicated to decrease the risk of relapse. A shared decision-making approach is recommended to select treatment options. Structured psychotherapeutic interventions have been shown to be effective for pregnancy-related depression, and referral should be offered as a treatment option. The U.S. Preventive Services Task Force recommends that clinicians provide or refer pregnant or postpartum women at increased risk for perinatal depression to counseling interventions (B recommendation). Risk factors for antenatal depression include lack of a partner or other social support, a history of abuse or domestic violence, a personal history of mental illness, an unplanned or unwanted pregnancy, adverse events in life and high perceived stress, present or past pregnancy complications, and pregnancy loss.No antidepressant seems to be more efficacious than others for treating depression during pregnancy. A population-based cohort study from 1996 to 2007 conducted in Nordic countries did not find an association between SSRI use during pregnancy and stillbirth or neonatal death. Studies have consistently linked paroxetine to an increased risk of ventricular and atrial septal defects. It is considered a pregnancy category D medication, so a treatment change would be indicated in this situation. A few studies suggest a slight association between citalopram use in pregnancy (pregnancy category C) and an increased risk of major congenital musculoskeletal malformations and craniosynostosis. SSRI use during the second or third trimester has been linked to an increased risk of autism spectrum disorders.Infants exposed to antidepressants in utero in the third trimester have a 5%-10% risk for a withdrawal syndrome consisting of irritability, jitteriness, poor feeding, abnormal crying, and poor muscle tone. It is usually mild and lasts only 1-2 days, with no long-term ill effects. Persistent pulmonary hypertension in the newborn has been linked to maternal use of SSRIs during late pregnancy.Regardless of the option chosen, close monitoring is needed to make sure the new treatment is effective. Family physicians should consider encouraging pregnant women taking antidepressants to enroll in the National Pregnancy Registry for Antidepressants. Consultation with colleagues who care for women with high-risk pregnancies may be indicated for women who choose antidepressant treatment during pregnancy.

A 68-year-old female is seen emergently for an episode of loss of consciousness preceded by dizziness. She says that she takes medication for depression but she doesn't remember its name. An EKG shows a prolonged QT interval. Which one of the following is most likely to cause this problem? Bupropion (Wellbutrin SR), 150 mg twice daily Citalopram (Celexa), 40 mg daily Duloxetine (Cymbalta), 60 mg daily Fluoxetine (Prozac), 40 mg daily Sertraline (Zoloft), 150 mg daily

Citalopram (Celexa), 40 mg daily In August 2011, the FDA issued a drug safety communication warning that the antidepressant citalopram should no longer be used at dosages above 40 mg daily. In addition, the FDA has advised that a maximum dosage of 20 mg daily be used in patients with hepatic impairment, those older than 60, poor metabolizers of cytochrome P-450 isoenzyme 2C19, and patients taking concomitant cimetidine (SOR C). Any of these factors can lead to higher blood levels of citalopram. Citalopram has been found to be associated with dose-dependent QT interval prolongation, and dosages greater than 40 mg daily can lead to abnormal heart rhythms, including torsades de pointes. Moreover, studies have failed to demonstrate a benefit from these higher dosages.Citalopram should not be used in patients with congenital long QT syndrome or in patients with conditions placing them at higher risk for developing torsades de pointes, including heart failure, bradyarrhythmias, or a predisposition to hypokalemia or hypomagnesemia. Fluoxetine, sustained-release bupropion, duloxetine, and sertraline have not been shown to be consistently associated with significantly prolonged QT intervals.

An 82-year-old female presents with a 3-month history of sadness, anorexia, a 6-lb weight loss, and insomnia. She has no history of cognitive impairment. Her medical history is notable for hypertension, hypothyroidism, and stent replacement following an ST-elevation myocardial infarction 3 years ago. She had one episode of heart failure shortly after her myocardial infarction but none since. Her current medications include lisinopril (Prinivil, Zestril), 10 mg daily; spironolactone (Aldactone), 25 mg daily; metoprolol succinate (Toprol-XL), 25 mg daily; levothyroxine (Synthroid), 50 µg daily; and aspirin, 81 mg daily. Her TSH and electrolyte levels were normal 6 months ago. Her last mammogram and colonoscopy were at age 80 and she has declined further cancer screening.A physical examination reveals an anxious, frail-appearing female, with a BMI of 19 kg/m2. Her blood pressure is 150/80 mm Hg. She is alert and oriented to person, place, and time. An EKG shows normal sinus rhythm, a PR interval of 0.24 sec, and incomplete right bundle branch block with a QTc of 0.43 seconds. Her PHQ-9 score is 15.Which one of the following would be a first-line treatment for this patient's depressive symptoms? Cognitive-behavioral therapy Bupropion (Wellbutrin) Fluoxetine (Prozac) Mirtazapine (Remeron) Venlafaxine

Cognitive-behavioral therapy A shared decision-making approach to depression treatment should be used for older patients with medical comorbidities. A 2014 meta-analysis of 44 studies found that psychotherapy, including cognitive-behavioral therapy (CBT), life review therapy, or problem-solving therapy, improved depression for at least 6 months in older adults compared with usual care or controls who were placed on a waiting list for treatment. The interventions had a moderate effect size and an approximate number needed to treat (NNT) of 3. A 2017 review found that psychotherapy for depression is also effective in patients with several different comorbidities, and studies indicate that older adults may prefer psychotherapy over medication to treat depression. CBT has also been found to be effective for generalized anxiety disorder in older adults.Psychotherapy may have the most favorable risk/benefit ratio in older patients with comorbidities, but access to psychotherapy could be a problem for some individuals, including the availability of trained providers and logistical barriers to keeping appointments. The 2014 meta-analysis also noted early success in small studies providing problem-solving therapy or behavioral activation to older patients by telemedicine. However, a 2018 study of an integrated telehealth CBT program for depressed rural older adults showed equivocal results for depression.As in younger patients, all antidepressants appear to be equally effective in patients over 65 compared with placebo. Evidence is limited and of low quality regarding the comparative efficacy of antidepressants. A 2019 cohort study suggested that antidepressants have similar safety profiles with regard to the risk of death in older patients in general. However, comorbidities, polypharmacy, and drug interactions should be considered in older patients, as well as the potential for adverse effects such as anticholinergic side effects, falls, and pro-arrhythmic effects. The literature on side effects of antidepressants in older populations is diverse, particularly in patients with heart disease.A 2019 review performed by the Agency for Healthcare Quality and Research that looked at adverse effects of antidepressants in older adults found that the adverse effects of SSRIs overall are similar to those of placebo. SNRIs such as duloxetine and venlafaxine cause adverse effects more often than placebo. A dose-related rise in blood pressure is seen with SNRIs, particularly venlafaxine. Duloxetine is associated with an increased risk of falls during treatment for up to 24 weeks. Both classes of drugs may be associated with higher discontinuation rates than placebo during the first 12 weeks of treatment.Mirtazapine has sedative properties and is associated with weight gain. It would address the patient's depression as well as her insomnia and weight loss. However, a 2011 cohort study found that mirtazapine was associated with an increased risk of sudden cardiac death or ventricular arrhythmia compared with other antidepressants. Mirtazapine is also associated with an increased risk of falls, and the same is true for tricyclic antidepressants, trazodone, and paroxetine. SSRIs, SNRIs, and bupropion are more activating than mirtazapine and can cause insomnia.Antidepressant use in patients with heart failure has been associated with an increased risk for all-cause and cardiovascular mortality. A 2018 randomized, controlled trial of 300 post-acute coronary syndrome patients with depression found that 24 weeks of treatment resulted in a decrease in major adverse cardiac outcomes after 8 years (NNT approximately 8), although 41% of patients treated with citalopram did have an event. Citalopram, particularly at doses greater than 40 mg/day, is associated with a prolonged QT interval and an increased risk for ventricular arrhythmia.

A 24-year-old female presents with intermittent dizziness, muscle cramps, occasional abdominal cramps, and irregular menses for the last year. She tells you that she started exercising daily 6 months ago to lose weight and improve her appearance. She is currently attending law school and does not smoke, drink alcohol, or use drugs, and does not take oral contraceptives because she is not sexually active. She says that she has not been skipping meals in order to lose weight, and that she sometimes eats more than she should. On examination her BMI is 23 kg/m2, her blood pressure is 90/60 mm Hg, and her pulse rate is 84 beats/min. You note calluses on the dorsal aspect of her right hand, but no other skin lesions. Laboratory findings include a hematocrit of 42% (N 37-47), a serum sodium level of 134 mEq/L (N 136-145), a potassium level of 2.9 mEq/L (N 3.4-4.4), and a normal TSH level. Screening with the PHQ-4 is negative.Which one of the following statements is true regarding treatment of this patient's condition? Cognitive-behavioral therapy is a first-line treatment Paroxetine (Paxil) is the only SSRI approved for treatment Topiramate (Topamax) is a potential second-line treatment option Antipsychotic medications can be helpful as a second agent

Cognitive-behavioral therapy is a first-line treatment The patient most likely has bulimia nervosa, suggested by her binge eating with a sense of lack of control, normal body weight, and evidence of attempted compensatory mechanisms such as self-induced vomiting, increased exercise, and abuse of diuretics or laxatives. Calluses on the back of the hands, parotid gland enlargement, and tooth enamel erosion suggest self-induced vomiting. Hypokalemia is a sequalae of diuretic or laxative misuse.Up to 3% of the population may experience an eating disorder and 90% of patients with eating disorders are female. The three major types of eating disorders in order of prevalence are binge eating disorder, bulimia nervosa, and anorexia nervosa. Less than half of affected patients seek treatment despite the fact that symptoms can persist for many years. Bulimia nervosa has a higher remission rate (80%) than anorexia nervosa (50%). Many patients with eating disorders have another coexisting mental health condition.Anorexia nervosa presents with restriction of food intake, low body weight, intense fear of weight gain, and disturbance of body image that is often severe. Patients may have bradycardia, hypotension, hypothermia, or lanugo, and they are at risk for early-onset osteoporosis. Binge eating disorder shares features with bulimia nervosa but patients with this disorder eat until uncomfortably full, eat rapidly and alone, and do not have a history of compensatory mechanisms.Cognitive-behavioral therapy is the preferred treatment for all three eating disorders and has the added advantage of effectiveness for concurrent depression or anxiety disorders that may be present. Family-based psychotherapy may be useful in adolescents with anorexia. Nutritional intervention, sometimes as an inpatient, may be required for anorexia nervosa. Medications are generally not helpful in patients with anorexia other than for treatment of other mental health comorbidities. Second-generation antidepressants, lisdexamfetamine, and topiramate have been shown to be effective in binge eating disorder. Fluoxetine has been shown to be efficacious in treating bulimia nervosa and is currently the only FDA-approved medication for this purpose. Antipsychotic medications have not been effective in the treatment of eating disorders.

You are evaluating a 13-year-old female with a 3-month history of headaches, abdominal discomfort, difficulty sleeping, and increasing nervousness. She has always been a good student but her symptoms have resulted in increased absence from school. A physical examination and laboratory findings are normal. There is no history of bullying, abuse, or alcohol or drug use. Which one of the following is true about treatment of the most likely diagnosis for this patient? Cognitive-behavioral therapy is the mainstay of treatment Benzodiazepines are a second-line treatment option Clomipramine (Anafranil) is a first-line treatment option Fluoxetine (Prozac) is more effective than sertraline (Zoloft)

Cognitive-behavioral therapy is the mainstay of treatment Anxiety disorders have a prevalence of 5%-32% in children and adolescents, depending on the population studied. Some experts believe that depression and anxiety are a continuum, with most affected children exhibiting symptoms of both depression and anxiety. Many children and adolescents with anxiety disorders continue to have anxiety and depression as adults. DSM-5 criteria should be used to determine which specific anxiety disorder the patient has, such as generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, or agoraphobia.Psychological approaches, especially cognitive-behavioral therapy (CBT), are the mainstay of therapy and first-line treatment for childhood and adolescent anxiety disorders. Among pharmacotherapeutic options, SSRIs are regarded as the pharmacologic treatment of choice because of their effectiveness and safety profile. Evidence does not suggest that one SSRI is superior to another. SNRIs such as venlafaxine, duloxetine, and atomoxetine have also shown effectiveness but have less consistent evidence. The few head-to-head studies that have been conducted suggest that CBT is more effective and has fewer adverse effects than pharmacotherapy. Evidence also suggests that the combination of CBT and SSRIs leads to greater improvement than monotherapy.Tricyclic antidepressants such as clomipramine are no longer recommended due to a lack of evidence of effectiveness and the risk of side effects that can be severe. Benzodiazepines are also not recommended due to a lack of evidence of effectiveness and the risk of side effects. The use of buspirone, antipsychotics, hydroxyzine, or pregabalin is also not supported by evidence.General screening for anxiety disorders in children and adolescents is not recommended, and a case-finding approach is suggested instead. Tools such as the Anxiety Disorders Interview Schedule for Children and Parents (ADIS-C/P), the Revised Children's Anxiety and Depression Scale (RCADS), the Child Behavior Checklist (CBCL), and the Spence Children's Anxiety Scale (SCAS) can help identify clinical levels of anxiety among young people and can be useful in monitoring treatment progress.

A 42-year-old female sees you for follow-up 8 weeks after starting citalopram (Celexa), 20 mg daily, for major depression. Laboratory findings 8 weeks ago were normal and she has no other medical problems. Her baseline PHQ-9 score was 18. She reports that her sleep quality, concentration at work, and appetite have all improved. She says she feels "somewhat better." A repeat PHQ-9 score is 10.Which one of the following would NOT be appropriate management? Continue the current medication dosage and follow up in 4 weeks Increase the dosage of citalopram Switch to a different antidepressant Add low-dose lithium Recommend adjunct psychotherapy

Continue the current medication dosage and follow up in 4 weeks A key concept of measurement-based care is regular assessment of symptoms after diagnosis and initiation of treatment. Systematic reviews and randomized, controlled trials suggest using standardized instruments to assess symptoms at regular intervals, and to ensure measurement consistency. The PHQ-9 has been studied in primary care settings for sensitivity to change over time, and a decrease of 5 points from baseline is considered clinically significant.While many depression trials have used 50% improvement in symptoms as the measure of success, the goal of treatment is to achieve remission of depression symptoms. On the PHQ-9 a score ≤4 indicates remission. The STAR*D trial found that a substantial number of patients did not achieve symptom response or remission until after 8 weeks of therapy. Based on multiple trials, including the STAR*D and IMPACT trials, strategies for patients who have not achieved remission include escalation of treatment by increasing the dosage, changing to a different medication, adding another medication, and changing to or adding psychotherapy.Augmenting antidepressants should be done carefully, and patients should be monitored for possible serotonergic side effects or tricyclic antidepressant toxicity, especially cardiac arrhythmias.

A 39-year-old female sees you for the first time. She has a previous history of bipolar I disorder and is on maintenance therapy with maximal doses of divalproex (Depakote). She says she has become increasingly depressed recently and asks if you can provide any treatment for her depression. She moved from several states away 3 months ago and has not seen a psychiatrist in your area. She has not taken any other mood stabilizers in the past. Which one of the following would NOT be recommended for treatment of this patient's bipolar I depression? Discontinue divalproex and start aripiprazole (Abilify) Discontinue divalproex and start lamotrigine (Lamictal) Discontinue divalproex and start lithium Discontinue divalproex and start quetiapine (Seroquel) Add lamotrigine

Discontinue divalproex and start aripiprazole (Abilify) First-line options for bipolar I depression include monotherapy with quetiapine, lithium, lamotrigine, or lurasidone. Monotherapy with one of these agents may be preferred over add-on therapy to limit the degree of polypharmacy, but lurasidone and lamotrigine can be considered as additional treatments in patients taking divalproex. While aripiprazole has been shown to be effective for maintenance therapy and acute mania, it has not been shown to be more effective than placebo for bipolar I depression. Antidepressant monotherapy is not recommended for treatment of bipolar I depression, due to the risk of inducing mania or rapid mood cycling.

Your practice is looking for ways to better identify and improve the care of patients with mental health concerns. Evidence-based components of a collaborative care model for mental health disorders include all of the following EXCEPT documentation of baseline symptom severity the use of validated instruments to monitor treatment response proactive outreach by nurses to deliver brief interventions to patients dissemination of guideline binders disease registries

Dissemination of guideline binders Several studies have demonstrated the effectiveness of collaborative and integrated care models in patients with mental health disorders, including problems other than depression. Measures associated with improved outcomes for primary care patients with depression and other mental health disorders include the use of clinical information systems and disease registries, regular follow-up, patient self-management support, and delivery system redesign that includes care managers, team-based care, planned visits, and proactive follow-up. Successful chronic care models for behavioral health conditions in primary care make use of complex interventions that incorporate multifaceted and ongoing clinician education, nurse case management, and telephone monitoring and counseling by trained nurses or counselors.A consult-liaison relationship between primary and behavioral health care for management of complex patients or those who fail to respond is also an important component of a collaborative care model, but alternating visits between primary care and behavioral health care providers is often not necessary. Establishment of baseline symptom severity with a validated instrument is helpful for making an initial diagnosis and documenting baseline severity, and is important for assessing and quantifying response to treatment at follow-up visits, referred to as measurement-based care.While some medical practices use registries or lists of all screened patients, the evidence at this point suggests that these tracking systems are appropriate for follow-up of patients who have been diagnosed with mental health disorders, but not helpful in improving care for patients who had a negative screen. Primary care office nurses or other staff can be successfully trained to administer validated symptom assessment scales to evaluate response to treatment. Guideline-driven care is important, but simple guideline dissemination and educational strategies alone are generally ineffective for improving outcomes of care.

During a visit to establish care, a 60-year-old female requests a refill of temazepam (Restoril), which she has used for the past several months because of difficulty staying asleep. Her sleep problem started when her husband was being treated for cancer. Other than well controlled hypertension and occasional symptoms from osteoarthritis in her knees, she has no significant medical problems. She is not obese, does not smoke, usually limits her alcohol consumption to two glasses of wine on weekends, and has negative screening questionnaires for depression and anxiety. Her husband has not mentioned that she has been snoring. Which one of the following statements is true regarding this scenario? Most patients with chronic sleep problems have primary insomnia Cognitive-behavioral therapy is generally ineffective Doxepin (Silenor) would be preferred to temazepam for this condition Zolpidem (Ambien) is safe for long-term treatment of this condition

Doxepin (Silenor) would be preferred to temazepam for this condition Insomnia accounts for more than five million visits to family physicians each year. The DSM-5 criteria for insomnia disorder include symptoms occurring 3 or more nights per week for 3 or more months that cause significant functional distress or impairment. These symptoms should not be associated with other disorders such as sleep apnea. Only 6%-10% of persons have insomnia that meets these criteria, which is more common in women and in patients who are older, in poor general health, and/or have lower socioeconomic status.Cognitive-behavioral therapy and other behavioral interventions such as sleep hygiene, stimulus control, and relaxation are considered first-line treatment for insomnia. The overall quality of evidence for pharmacologic treatment is low, but for those who fail to respond pharmacotherapy is an option. Melatonin agonists such as ramelteon can be used to accelerate sleep onset. The so-called "z-drugs" (zolpidem, eszopiclone, and zaleplon) can be used for treating problems with sleep onset and sleep maintenance. Low-dose doxepin can be used for those with difficulty staying asleep, and doxepin and controlled-release melatonin are recommended as first-line agents in older adults.There is insufficient evidence to establish the comparative safety of one pharmacologic treatment over another. The data on melatonin is mixed, and there is insufficient evidence to make recommendations on trazodone or diphenhydramine. The American College of Physicians recommends that the choice to use medications should be based on shared decision making, and prescriptions should be limited to 5 weeks or less. Risks include central nervous system depression effects and next-day psychomotor impairment. Sudden discontinuation of the z-drugs may lead to withdrawal symptoms. Benzodiazepines should not be used due to their potential for abuse.

A 14-year-old female is brought to your office by her mother for evaluation. She was previously outgoing and a good student, but for the last 3 months she has become increasingly tearful and socially withdrawn and her grades have been falling. She is sleeping more and reports a loss of appetite, trouble concentrating, and a lack of energy. She has not thought about suicide. Which one of the following would be most appropriate at this point? Watchful waiting with support Cognitive-behavioral therapy Fluoxetine (Prozac) Venlafaxine (Effexor XR) Escitalopram (Lexapro) plus family therapy

Escitalopram (Lexapro) plus family therapy The annual prevalence of major depressive disorder (MDD) in adolescents has been estimated to be approximately 8%. The PHQ-9 modified for adolescents (PHQ-A) and the Beck Depression Inventory (BDI) are preferred for making the diagnosis. The PHQ-A is used most often because it has a slightly higher positive predictive value than the BDI. The PHQ-A has a sensitivity of 73% and a specificity of 94%. While the positive predictive value of both instruments is relatively low (at least half of patients who test positive will not have major depression), both have very high negative predictive values, meaning that these instruments will not miss many MDD cases.Active support and monitoring, including for suicidal ideation, may be all that is needed for mild adolescent depression. Many milder cases will resolve without additional treatment, although follow-up is recommended after 4-8 weeks to ensure that symptoms are self-limited. For persistent or more severe MDD, studies have consistently shown that the combination of antidepressants and psychotherapy, usually cognitive-behavioral therapy (CBT) or family therapy, is more effective than either treatment used alone. A draft comparative evidence report issued by the Agency for Healthcare Research and Quality indicates that CBT plus antidepressants may help prevent relapse.While drug therapy alone is less effective than combination therapy, it may be used in patients whose families either cannot engage in combination therapy or choose not to. Fluoxetine may be used in children age 9 or older, while escitalopram is appropriate only for those who are 12 or older. Other antidepressants are not approved for use in MDD in this population. Adolescents and young adults starting antidepressant treatment should be monitored for emerging suicidal ideation because of the increase in suicidal thoughts and behaviors associated with use of these drugs in this age group.Several studies have shown that structured online interventions based on CBT principles may be helpful for reducing symptoms of depression in adolescents. A few limited trials indicate that social network-based peer support interventions do not seem to be effective for depressive symptoms, although they may be useful for anxiety.

A 22-year-old male is brought to your office by his girlfriend. Over the last 6 months he has been hearing voices telling him that coworkers are trying to damage his car and steal his belongings. He is occasionally agitated, but at other times goes for long periods without speaking. His girlfriend says he seems depressed. He has not had a haircut in 4 months and has grown an unkempt beard. He is having increasing difficulty concentrating and completing tasks as an electrician's apprentice. He rarely drinks alcohol and does not use recreational drugs.Which one of the following is true regarding drug treatment for this patient's condition? Aripiprazole (Abilify) is more effective than olanzapine (Zyprexa) Fatal agranulocytosis, seizures, and myocarditis are potential side effects of clozapine (Clozaril) Clozapine and olanzapine tend to cause fewer problems relating to metabolic syndrome than other second-generation antipsychotics Haloperidol is less likely than second-generation antipsychotics to cause extrapyramidal side effects, including movement disorders Combination antipsychotic therapy is more effective than monotherapy for symptom remission

Fatal agranulocytosis, seizures, and myocarditis are potential side effects of clozapine (Clozaril) Schizophrenia is a psychotic disorder that typically has an onset from the late teens to the early 30s. The estimated lifetime prevalence of schizophrenia is 0.7%-1.0% and it is more common in males. It is characterized by at least two of the following symptoms, with each of them present for a significant portion of time during a 1-month period: delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior, or a negative symptom, such as diminished emotional expression. One of the symptoms must be delusions, hallucinations, or disorganized speech, and continuous signs of the disturbance, including prodromal symptoms and/or residual symptoms, must be present continuously for at least 6 months. The symptoms must be affecting work, interpersonal relationships, or self-care. Broadly speaking, these symptoms are considered either "positive," such as hallucinations, or "negative," such as flat affect and impairments in cognition. Other diagnoses such as major depressive disorder, bipolar disorder, or schizoaffective disorder must be ruled out, and the symptoms must not be due to the effects of substance use. The Clinician-Rated Dimensions of Psychosis Severity Scale can help clinicians assess the severity of symptoms.The antipsychotic agents are usually divided into three generations. The first generation includes haloperidol, thioridazine, and fluphenazine, while the second generation includes clozapine, olanzapine, risperidone, aripiprazole, ziprasidone, and quetiapine. Brexpiprazole, a serotonin-dopamine activity modulator, is considered a third-generation antipsychotic. The first-generation agents can also be classified according to potency.A 2019 systematic review and meta-analysis concluded that while the overall quality of evidence is low, antipsychotics reduce overall symptoms of psychosis better than placebo, with lower overall discontinuation rates. More patients discontinue the drugs because of a lack of efficacy than because of side effects. In some analyses clozapine, olanzapine, and risperidone were significantly more efficacious for reducing overall schizophrenic symptoms than other antipsychotics. Another analysis showed that oral clozapine and long-acting injectable antipsychotics are more effective than oral olanzapine. However, the overall quality of evidence is low enough to preclude general statements about the comparative efficacy of antipsychotics for schizophrenia. There is also insufficient evidence on the efficacy of antipsychotic polypharmacy compared with monotherapy.The choice of medication is often based on the side-effect profile, availability, and cost. The high-potency agents are more likely to cause extrapyramidal side effects and hyperprolactinemia, while the low-potency drugs more often cause postural hypotension, sedation, and a prolonged QT interval. Side effects also vary significantly among the second-generation, or atypical, antipsychotics. Sedation and sexual dysfunction occur with all of the agents. Clozapine is associated with fatal agranulocytosis, seizures, and myocarditis, and is typically reserved for patients with resistant psychosis. Risperidone is associated with a higher incidence of hyperprolactinemia. Aripiprazole and ziprasidone are least likely to cause metabolic side effects, while olanzapine and clozapine are more likely to cause this type of problem. Brexpiprazole is associated with akathisia, hypertriglyceridemia, and weight gain. Ziprasidone is more prone to cause QT prolongation. These drugs also carry a black box warning about the potential to increase the risk of suicidal thinking in younger patients with depression and other psychiatric disorders.

You are treating a 34-year-old female for her first episode of major depression. She has been adherent to her medication regimen and has been asymptomatic for 12 months. She would like to stop her antidepressant. Which one of the following medications would pose the LEAST risk of antidepressant discontinuation symptoms? Bupropion (Wellbutrin), 150 mg twice daily Escitalopram (Lexapro), 20 mg daily Fluoxetine (Prozac), 20 mg daily Paroxetine (Paxil), 20 mg daily Extended-release venlafaxine (Effexor XR), 150 mg daily

Fluoxetine (Prozac), 20 mg daily Serotonin discontinuation syndrome can occur with abrupt discontinuation of many antidepressants. Patients should be advised of this when starting a medication and should be monitored during the discontinuation period. Symptoms can occur within hours to days of the first missed dose, although the most severe symptoms should resolve within 24 hours. Discontinuation symptoms can be differentiated from relapse based on timing, since relapse occurs weeks after stopping the medication.Tapering antidepressants, especially those with short half-lives such as venlafaxine, can mitigate symptoms of discontinuation (SOR C) but there are no evidence-based regimens for tapering antidepressants. Commonly used strategies taper medications over 2-4 weeks while monitoring for symptoms, with longer tapering intervals for patients on higher doses and those who have been taking the medication for longer periods of time.Fluoxetine has a half-life of 3 weeks, which is the longest among the SSRIs. While discontinuation syndrome can occur with fluoxetine, it is less likely than with the other antidepressants, especially at doses <40 mg daily. The long half-life essentially facilitates a gradual tapering upon discontinuation. Paroxetine (both regular and controlled release) has the shortest half-life of the SSRIs. Patients who have used paroxetine for a long time have a high risk of discontinuation syndrome and should be tapered off the medication (SOR C). The risk of discontinuation symptoms is higher with the other medications listed.

A 23-year-old female consults you because she heard you are "the best physician ever." She tells you she has seen several different physicians in the past who have treated her for "anger issues" and "depression" with SSRIs or mood stabilizers, which did not help much. She currently does not take any medications. She says that she sometimes gets angry or anxious and asks if you could prescribe something to improve her mood. Which one of the following would NOT be consistent with the most likely diagnosis? Affective lability Fear of abandonment Inflated ego Excessive dependency Cutting or other forms of self-injury

Inflated Ego Borderline personality disorder can be devastating emotionally, physically, and economically in terms of public health costs. Symptoms include suicidal behaviors, self-injury, and emotional reactivity and lability. Patients with the disorder have a fear of abandonment, resulting in turbulent relationships. Substance abuse, risk taking, and/or impulsive behaviors often accompany the condition. Patients with borderline personality disorder have an impoverished, poorly developed, and unstable self-image and are prone to excessive self-criticism. The patient's sense of self frequently depends on the attention of others, and the drive to capture others' attention can be seen as clingy or manipulative.Treatment of borderline personality disorder includes both psychological and pharmacologic therapies, although most therapies are effective for just one or two symptoms. Psychosocial treatments include cognitive-behavioral therapy, dialectic behavioral therapy, and transference-based therapy. No pharmacologic treatment improves overall symptoms. Antipsychotics taken for 6 months or less may improve paranoia, dissociation, mood lability, anger, and global functioning. Aripiprazole, olanzapine, lamotrigine, topiramate, omega-3 fatty acids, and valproic acid may help decrease anger, anxiety, depression, and impulsivity, but evidence is limited to lower-quality trials of 6 months or less.

A 25-year-old female has had three panic attacks over the previous 2 months and asks if you can prescribe medication to prevent them. Further history reveals that she has had bouts of abdominal pain, palpitations, headaches, and nervousness for the last 9 months. She does not use alcohol, tobacco, or recreational or illicit drugs. Her past medical history is unremarkable. She is in a stable relationship, has no history of physical or emotional abuse, and uses an IUD for contraception. A physical examination and a TSH level are normal, and a pregnancy test is negative. She scores 10 on the GAD-7.Which one of the following would be a first-line treatment option in this scenario? Valerian root Internet-based cognitive-behavioral therapy Benzodiazepines Hydroxyzine Pregabalin (Lyrica)

Internet-based cognitive-behavioral therapy Anxiety disorders commonly occur with other behavioral health disorders and with each other. For example, one study estimated that generalized anxiety disorder (GAD) co-occurs in 68% of people with panic disorder. Women are 1.5-2 times more likely than men to receive a diagnosis of anxiety disorder. The two-question GAD-2 and the seven-question GAD-7 are useful instruments to detect anxiety disorders in primary care and monitor response to treatment over time.Treatment of anxiety disorders includes psychotherapy and pharmacotherapy. Studies suggest that the combination is more effective for acute treatment of anxiety disorders, and is superior to pharmacotherapy alone for relapse prevention. To avoid relapse, medication should be continued for 12 months after symptoms improve before tapering.Cognitive-behavioral therapy (CBT) has been the most extensively studied psychotherapy for anxiety disorders and is considered first-line treatment. Studies suggest that CBT may be somewhat more effective than pharmacotherapy when used as monotherapy. Other lower-intensity psychotherapeutic options, such as self-help books (bibliotherapy), treatment via telephone or videoconferencing, and internet-based CBT have been shown to be more effective than relaxation controls. In milder cases they may be as effective as face-to-face CBT, and may be cost-effective options, especially for patients who are unwilling or unable to attend traditional in-person CBT sessions.For anxiety disorders, antidepressants have a number needed to treat of 7. SSRIs are considered first-line therapy for GAD and panic disorder. SNRIs are also generally effective, although they may be associated with more side effects and a greater likelihood of treatment discontinuation than SSRIs. Within each class of antidepressants, evidence does not suggest that one agent is more efficacious than others. Tricyclic antidepressants remain a treatment option for adults with panic disorder but are rarely used due to the availability of other agents and higher dropout rates due to side effects. Anxiety symptoms may require higher dosages of antidepressants than those required to treat depression.Benzodiazepines are also effective for reducing anxiety. When used with antidepressants, benzodiazepines may speed recovery from anxiety-related symptoms, but they do not improve longer-term outcomes. Higher dosages may be needed for a treatment response but are associated with an increased risk of tolerance, sedation, confusion, and mortality. Benzodiazepines are not recommended as first-line treatment and should be limited to short-term use for initial symptom control.Second-line pharmacotherapies for GAD include buspirone and hydroxyzine. Buspirone, a 5-HT1A receptor agonist, is FDA-approved for GAD in adults. It is not effective in panic disorder. Hydroxyzine is considered a second-line treatment for GAD. It is more effective than placebo in reducing symptoms of GAD, based on generally lower quality studies. The main side effect is sedation, but it is generally well tolerated.Several studies have examined the efficacy of pregabalin compared with placebo or benzodiazepines for adult GAD. Comparison arms were included. It has demonstrated effectiveness in most studies, although higher doses are often needed. It is considered a third-line treatment because it is associated with significant weight gain, dizziness, and somnolence. Recent studies also suggest concerns about abuse potential in patients with substance abuse disorders and withdrawal syndromes after abrupt discontinuation.Phytotherapeutic options are not recommended for treatment of anxiety, due to the lack of standardization of preparations, mixed evidence of effectiveness, and the potential for serious side effects. Studies of kava (Piper methysticum) have produced inconsistent results, and it has been withdrawn from the market in some countries due to hepatotoxicity. Valerian extract was not effective in placebo-controlled studies.Adjunctive treatments that may be useful in anxiety disorders (mixed evidence, low- to very-low-quality studies) include resistance training, aerobic exercise, acupuncture, adjunctive meditation, and yoga.

A 28-year-old business executive is brought to your clinic by her fiancé for evaluation of a 1-week history of elation and restlessness, and lack of impulse control. She has sometimes been irritable and has had verbal fights with several family members and friends. She has also been getting very little sleep and some nights does not sleep at all. Earlier this week she went on a shopping spree and spent thousands of dollars and yesterday she suddenly quit her job. Further questioning reveals that 6 years ago she had a 3-month episode of excessive fatigue, increased sleepiness, loss of interest in socializing, and feeling hopeless and depressed. She remembers that her symptoms resolved spontaneously once the weather began to warm up. She does not use alcohol or drugs. She takes no oral medications and has an IUD. A pregnancy test is negative. Which one of the following agents has the best evidence of effectiveness for acute and maintenance treatment of this problem? Bupropion (Wellbutrin) Divalproex (Depakote) Lithium Paroxetine (Paxil) Aripiprazole (Abilify)

Lithium This patient is most likely having a manic episode. Given her past history of a potential episode of major depression, she probably has bipolar I disorder. Further questioning and evaluation with instruments such as the Mood Disorder Questionnaire or Hypomania/Mania Symptom Checklist is needed to confirm the diagnosis.A 2018 evidence review by the Agency for Healthcare Research and Quality (AHRQ) concluded that medications that may modestly improve acute mania symptoms in adults with bipolar disorder include lithium and second-generation antipsychotics such as asenapine, cariprazine, olanzapine, quetiapine, risperidone, and ziprasidone. The review found that compared to placebo, second-generation antipsychotics except for quetiapine were associated with more extrapyramidal symptoms and that olanzapine was associated with more weight gain. The 2018 Canadian Network for Mood and Anxiety Treatments (CANMAT)/International Society for Bipolar Disorders (ISBD) guideline includes divalproex, aripiprazole, and paliperidone as first-line treatment for acute mania.With maintenance treatment after mood stabilization and restoration of a euthymic state, 19%-25% of patients will experience a recurrence every year, compared to 23%-40% of those on placebo. Risk factors for recurrence include younger age of onset, psychotic features, rapid cycling, more and more-frequent previous episodes, comorbid anxiety disorders, comorbid substance use disorders, and persistent subthreshold symptoms. First-line maintenance-phase treatment options recommended by the CANMAT/ISBD guideline include lithium, quetiapine, divalproex, lamotrigine, asenapine, aripiprazole, or quetiapine or aripiprazole plus lithium or divalproex. The AHRQ review found that the overall body of evidence for maintenance therapy is limited and insufficient for most medications, with lithium having the best (but still low strength) evidence for lengthening time to relapse in follow-up over 2 years. Long-term use of lithium is associated with tremor, however.Cognitive-behavioral therapy and other types of psychotherapies can also be used as an adjunct to medication for mood maintenance. SSRIs and SNRIs are not indicated for treatment of mania or maintenance therapy in bipolar disorder.

A 28-year-old male asks if there is something he can take to decrease his nervousness before he has to make a presentation at his workplace next week. He has never given a public presentation and is worried about sweating, blushing, and appearing incompetent. He has consistently received good job performance reviews, although he prefers to work alone or in small groups. He has declined opportunities to lead his division despite encouragement from his supervisors. Additional questioning reveals that he has avoided large groups and parties ever since high school because he is concerned that he might say something embarrassing. He has never been married and has only gone on a few dates. He has no other significant past medical history and does not drink or use recreational drugs. He has a positive GAD-2 screen. Which one of the following statements about treatment of this condition is true? Propranolol has been shown to be effective Cognitive-behavioral therapy (CBT) is more effective than SSRIs when used as monotherapy The combination of CBT plus SSRIs is recommended as initial treatment Low-quality evidence supports SSRI use

Low-quality evidence supports SSRI use The patient in this scenario exhibits symptoms of social anxiety disorder. Social anxiety disorder is defined as excessive and persistent fear or anxiety about social or performance situations such as meeting people, going to school, public speaking, or talking to authority figures. Individuals with social anxiety disorder actively avoid these situations. Estimates of lifetime prevalence vary but up to 12% of adults in the United States may have social anxiety disorder at some point in their lives. There is a significant degree of comorbidity between social anxiety disorder and depression, substance-use disorder, generalized anxiety disorder, panic disorder, and posttraumatic stress disorder. The mean age of onset is in the teens, but individuals often go many years before seeking treatment. Children may show their anxiety in different ways from adults, including crying or tantrums.The GAD-2 has reasonable sensitivity and specificity for detecting social anxiety disorder but should be followed up with detailed questioning to confirm the diagnosis and to look for other psychiatric comorbidities. Individual cognitive-behavioral therapy (CBT) is considered first-line treatment for adults with social anxiety disorder. Group CBT may help but is less effective than individual treatment. CBT-based self-help strategies may also be useful as an adjunct treatment. SSRIs are considered first-line pharmacotherapeutic options, although a 2017 Cochrane meta-analysis found only low-quality evidence for treatment and moderate-quality evidence for relapse prevention for SSRIs compared with placebo. A 2013 guideline from Great Britain's National Institute for Health and Care Excellence lists escitalopram and sertraline as first-line pharmacotherapeutic options and venlafaxine and paroxetine as second-line options. A Canada Health guideline includes paroxetine, sertraline, and venlafaxine as first-line options. There is no head-to-head evidence that CBT is superior to SSRIs or that one SSRI is more efficacious than others.The combination of medication and CBT may be used for patients who only partially respond to initial treatment. Benzodiazepines, tricyclic antidepressants, hypericum (St. John's wort), MAO inhibitors, propranolol, and anticonvulsants are not recommended for treatment of social anxiety disorder in adults.

A 47-year-old female presents with generalized anxiety disorder. She is hesitant about taking medication or going to therapy and asks about effective alternatives. Which one of the following options has the BEST evidence of effectiveness for anxiety disorders? Mindfulness-based meditation Yoga Kava St. John's wort Valerian

Mindfulness-based meditation There is a paucity of data and a lack of evidence regarding complementary and alternative treatments for anxiety disorders. Studies of phytotherapeutic options such as kava, valerian, and St. John's wort are generally small and of poor quality, with mixed results. Kava also poses the risk of serious hepatotoxicity. Studies have generally found exercise to be of limited benefit as primary treatment for anxiety disorders. There is more evidence that exercise is beneficial for depressive symptoms and as adjunctive treatment for both depression and anxiety. Studies on yoga for anxiety are also mixed. While studies have mixed results and methodologic limitations, including a lack of standard definitions, most suggest that mindfulness-based meditation can be helpful for anxiety disorders, especially for less severely affected patients.

After serving a jail sentence for his second DUI, a 34-year-old male consults you at the urging of his partner for help with alcohol abstinence. He has already enrolled in Alcoholics Anonymous but is also interested in medication to help him maintain abstinence. Which one of the following statements about pharmacotherapy for alcohol abstinence is true? Acamprosate is effective for helping patients initially achieve abstinence from alcohol Acamprosate is superior to naltrexone (Vivitrol) for maintaining abstinence from alcohol Disulfiram (Antabuse) has shown consistent efficacy in maintaining alcohol abstinence Naltrexone reduces the risk of relapse to heavy drinking Sertraline (Zoloft) is a first-line treatment choice

Naltrexone reduces the risk of relapse to heavy drinking Three medications are approved by the FDA for the treatment of alcohol use disorders: disulfiram, acamprosate, and naltrexone, which is available in both oral and injectable extended-release forms. Disulfiram was approved first but has the least consistent evidence of effectiveness, with much evidence derived from open-label randomized, controlled trials. Consuming even small amounts of alcohol while taking disulfiram causes a clinical syndrome of flushing, headache, respiratory difficulty, nausea, vomiting, and diaphoresis. More severe symptoms may include chest pain, palpitations, blurred vision, confusion, respiratory depression, arrhythmias, myocardial infarction, acute heart failure, unconsciousness, convulsions, and death. Disulfiram is not safe to use in patients with liver dysfunction.Naltrexone has been shown to modestly decrease alcohol use and the number of drinking days. It is more successful in those who are abstinent before starting the medication. Patients commonly exhibit nausea during the first several days of treatment, but this often improves with continued use. Other side effects may include headache, dizziness, nervousness, fatigue, low energy, insomnia, anxiety, difficulty sleeping, abdominal pain or cramps, and joint or muscle pain. Although not addressed in the current labeling, the consensus of a panel of experts is that use should be avoided in patients with serum aminotransferase levels greater than five times the upper limit of normal. Naltrexone can also induce symptoms of withdrawal in patients who chronically use opioids or those with opioid use disorder.Acamprosate is effective for maintaining abstinence from alcohol once there has been a period of sobriety, particularly when used in combination with psychosocial support. Patients may initially experience short-term diarrhea and nausea. Other side effects may include insomnia, anxiety, depression, anorexia, flatulence, dizziness, pruritus, dry mouth, paresthesia, and sweating. It should be avoided in patients with severe renal dysfunction.Current evidence does not suggest that one medication is clearly superior to others in maintaining alcohol abstinence. In head-to-head studies a 2014 review by the Agency for Healthcare Quality and Research found that the risks of headache and vomiting were higher for naltrexone than for acamprosate. None of these medications has been approved for treatment of patients under age 18 and caution is indicated in women of child-bearing age.Antidepressants do not decrease alcohol use in patients without mood disorders, but sertraline and fluoxetine may help depressed patients decrease alcohol use.

You are working with other practices and organizations to try to address disparities in mental health care in your community. Members of which one of the following ethnic groups are considered to be at the highest risk for major depression? Asian Black Hispanic Native American Non-Hispanic white

Native American

A 28-year-old male consults you because he has had difficulty coping with his divorce, which was finalized 2 months ago. His alcohol consumption has increased in frequency and quantity for the last 3 weeks and he is also depressed about his prospects for promotion at work. He scores 12 on the PHQ-9. He tells you that on several days he has had thoughts of hurting himself in some way, or that he would be better off dead. Which one of the following statements concerning suicide is true? The U.S. Preventive Services Task Force recommends assessing suicide risk annually for all patients Patients rarely seek care before taking their own life Direct questioning about suicide increases the risk of suicide No-suicide contracts do not reduce the risk of suicide

No-suicide contracts do not reduce the risk of suicide According to the CDC, more than 48,000 individuals died by suicide in 2018, making it the tenth leading cause of death overall in the United States. Suicide was the second leading cause of death among individuals between the ages of 10 and 34, and the fourth leading cause of death among individuals between the ages of 35 and 54. Death rates from suicide are highest in older adults. Females attempt suicide more than males, but a higher percentage of attempts result in death in males. Half of suicide victims accessed health care services in the month before the suicide.Suicide is associated with a wide spectrum of psychiatric conditions, including depression, anxiety disorders, and bipolar disorder. The U.S. Preventive Services Task Force notes that current evidence is insufficient to assess the balance of benefits and harms of general screening for suicide risk in adolescents, adults, and older adults in primary care (I recommendation). However, patients with a history of mental health conditions, a previous suicide attempt, alcohol or substance abuse, psychosis, hopelessness, restlessness, recent loss, or impulsivity are at increased risk for suicide. Therefore, selected assessment of suicide risk in these individuals is prudent.Asking about suicide and exploring suicidal thoughts does not increase the risk of suicide. Tools to assess suicide risk include the PHQ-9, Suicide Behaviors Questionnaire-Revised (SBQ-R), Columbia-Suicide Severity Rating Scale (C-SSRS), ED-SAFE Patient Safety Screener, and Patient Safety Screener-3 (PSS-3). The four-item Ask Suicide-Screening Questions (ASQ) and the Tri-Factor Screen for Youth Suicide Risk are also available for use in adolescents. When older patients are screened with the Geriatric Depression Scale, answering yes on questions about hopelessness, worthlessness, and feeling life is empty indicate increased suicide risk.Suicidal ideation may involve only passive death wishes, including patients wishing they were dead, "no longer around," or "not a burden to others." Other patients will have active thoughts of attempting suicide, with some only having a specific detailed suicide plan and others actually intending to attempt suicide. Patients with active suicidal ideation should be referred to mental health services for follow-up. They should be referred emergently if the threat is imminent. There is no evidence that no-suicide contracts prevent deaths from suicide, and their use is no longer recommended.

A 36-year-old male sees you for follow-up of his first episode of major depressive disorder. His baseline PHQ-9 3 weeks ago was 15. He smokes a pack of cigarettes per day and expressed an interest in stopping smoking at his initial visit, so you prescribed bupropion (Wellbutrin SR), 150 mg every 12 hours. His PHQ-9 score at this visit is 12. He says that the bupropion is giving him headaches and making him jittery, and asks to be switched to a different antidepressant. Which one of the following alternatives would be most likely to promote long-term smoking cessation? Citalopram (Celexa) Mirtazapine (Remeron) Nortriptyline (Pamelor) Trazodone (Oleptro) Venlafaxine (Effexor XR)

Nortriptyline For individuals with nicotine dependence who wish to stop smoking, bupropion (high-quality evidence, RR 1.6 versus placebo at 6 months) and nortriptyline (moderate-quality evidence, RR 2.0 versus placebo at 6 months) have been shown to facilitate smoking cessation. Studies of other antidepressants have either shown mixed results or a shorter duration of smoking cessation.

A 36-year-old female consults you because of a depressed mood, trouble sleeping, and decreased appetite for 3 weeks. She has no previous history of depression but her mother is being treated successfully for depression and urged her to see you. The patient is in a supportive marriage and is functioning well at work. She does not have anhedonia, guilt, psychomotor retardation or agitation, trouble concentrating, decreased energy, or suicidal thoughts. Which one of the following would be an appropriate management option at this time? Observation only Cognitive-behavioral therapy Sertraline (Zoloft) Venlafaxine (Effexor XR)

Observation Only This patient has minor (subthreshold or subsyndromal) depression, meeting only three of nine DSM-IV depression criteria. Estimates of the lifetime prevalence of subthreshold depression range from 10% to 24%. If persistent it can cause significant functional impairment. At the current time there is no consistent evidence that structured psychotherapy or antidepressants provide significant benefit to patients with minor depression of recent onset, but clinical follow-up is warranted to be sure that symptoms do not progress to a major depressive episode. The United Kingdom's National Institute for Clinical Excellence suggests that individuals with subthreshold depressive symptoms for several months should be offered low-intensity interventions such as self-help based on principles of cognitive-behavioral therapy (CBT), computerized CBT, or a structured group physical activity program. A 2019 study suggests that group behavioral activation with mindfulness sessions may also be helpful for persistent symptoms. A diagnosis of persistent depressive disorder should be entertained if symptoms are present consistently on most days for 2 years.

A mother brings her 8-year-old son to your office for evaluation of attention-deficit/hyperactivity disorder (ADHD). His third-grade teacher reports that he has trouble sitting still and paying attention in class. Which one of the following statements about ADHD in children and adolescents is true? Screening is recommended for all children at the time of primary school entry Documenting behaviors in the school setting alone is adequate for making the diagnosis Eliminating artificial coloring and additives from the diet is recommended Parent training behavioral management programs should be used before medication in children under age 6 Methylphenidate (Ritalin) is more effective than dextroamphetamine (Dexedrine)

Parent training behavioral management programs should be used before medication in children under age 6 The DSM-5 defines four types of attention-deficit/hyperactivity disorder (ADHD): hyperactive/impulsive, inattentive, mixed, and unspecified. Estimates of the prevalence of ADHD in children and adolescents range from 7.2% to 15.5%. The median age of diagnosis is 7 years but approximately one-third of children are diagnosed before age 6. Boys are more than twice as likely as girls to be diagnosed with ADHD. Hyperactivity tends to become less prominent than inattention in adolescents, and learning and language problems and other behavioral disorders commonly coexist with ADHD.Routine screening for ADHD in children is not recommended. Children or adolescents age 4-18 presenting with academic or behavioral problems and symptoms of inattention, hyperactivity, or impulsivity should be evaluated for ADHD. To make a diagnosis, documentation of symptoms and impairment in more than one setting obtained from parents, guardians, teachers, other school personnel, and others involved in the patient's care should be obtained. Several scales are available to help make the diagnosis of ADHD in children. Those narrowly focused on ADHD assessment include the Vanderbilt scales, the Conners Rating Scale-revised (CRS-R), the Conners Abbreviated Symptom Questionnaire (ASQ), ADHD Rating Scales (ADHD-RS-V), and the Swanson, Nolan, and Pelham (SNAP) scale. Broader scales that assess other behavioral conditions in addition to ADHD include the Child Behavior Checklist (CBCL), the Behavior Assessment Scale for Children (BASC), the Brown Attention Deficit Disorder Scales (BADDS), and the Strengths and Difficulties Questionnaire. The Agency for Healthcare Research and Quality (AHRQ) has noted that narrowband scales are more accurate than broadband scales for distinguishing children affected by ADHD from those not affected by ADHD.In children 4-6 years of age with ADHD, evidence-based parent training behavioral management (PTBM) and/or behavioral classroom interventions are the first line of treatment. Preschool programs such as Head Start and ADHD-focused organizations such as Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) can also provide behavioral support. Methylphenidate may be considered if behavioral interventions are not available, or do not provide significant improvement and there is moderate-to-severe continued disturbance. For children 6-12 years of age medications, PTBM, and behavioral classroom intervention should be used. Educational interventions in cooperation with the school system should be considered. For adolescents 12-18 years of age with ADHD, medications should be used, along with evidence-based training interventions and/or behavioral interventions, if available. Cognitive-behavioral therapy may improve ADHD symptoms in children 7-17 years of age. Child or parent training has been shown to improve ADHD symptoms in children 7-17 years of age but does not change academic performance.Currently used stimulants for treating ADHD include methylphenidate, amphetamine, lisdexamfetamine, and dextroamphetamine/amphetamine. A 2018 AHRQ evidence synthesis notes that methylphenidate is effective for children under age 6 with ADHD and that psychostimulants can be effective for children 6-12 years of age and in adolescents. There is no evidence that supports the use of one stimulant over another. The evidence is less strong for the second-line medications atomoxetine, extended-release guanfacine, and extended-release clonidine in school-aged children and adolescents. None of the nonstimulants have FDA approval for use in preschool-aged children.The most common short-term adverse effects of stimulants are appetite loss, abdominal pain, headaches, and sleep disturbance. Diminished growth of 1-2 cm from predicted adult height may occur, and "drug holidays" to allow catch-up growth over school breaks could be considered.Atomoxetine has also been linked to growth delays compared to expected trajectories in the first 1-2 years of treatment, with a return to expected measurements afterwards. Hypotension and rebound hypertension can occur, so it should be gradually tapered. It has also been linked to increased suicidal thoughts.Vital signs should be monitored during pharmacologic treatment. Routine blood tests or EKGs are not needed before starting stimulants, atomoxetine, or guanfacine, unless there is a coexisting condition that is being treated with a medicine that may pose an increased cardiac risk, a family history of premature cardiac death, or signs and symptoms suggesting cardiac disease.There is little or no good evidence to support the use of other interventions for ADHD in children and adolescents, such as mindfulness, cognitive training, diet modification, EEG biofeedback, supportive counseling, cannabidiol oil, social skills training, or omega-3/6 supplementation.

A 56-year-old female is diagnosed with major depression. Her past medical history is notable for chronic hypertension and a history of breast cancer 6 months ago that was treated with segmental mastectomy followed by breast irradiation. Her current medications are enalapril (Vasotec), 10 mg daily, and tamoxifen (Soltamox), 20 mg daily.Which one of the following antidepressants should be AVOIDED in this patient? Citalopram (Celexa) Desvenlafaxine (Pristiq) Mirtazapine (Remeron) Paroxetine (Paxil)

Paroxetine (Paxil) A 2018 Cochrane review found very low certainty that antidepressants are superior to placebo in patients with cancer, based on few studies of low quality. The authors note that use of antidepressants in people with cancer should be considered on an individual basis. Factors to consider when choosing an antidepressant include past response to an agent, patient preference, co-occurring psychiatric and medical illnesses, relative efficacy and effectiveness, cost, half-life, safety, tolerability, anticipated side effects, and the potential for drug interactions. Antidepressants differ in their interactions with the cytochrome P-450 (CYP) system and their metabolism, as well as inhibition of specific CYP enzymes.Tamoxifen is metabolized by the cytochrome P-450 2D6 (CYP2D6) isoenzyme to endoxifen (4-hydroxy-N-desmethyltamoxifen), the active metabolite that may be responsible for much of tamoxifen's antiestrogenic activity. Paroxetine and fluoxetine are strong inhibitors of CYP2D6 and have been shown to decrease tamoxifen's conversion to endoxifen. Although not specifically examined, this theoretically could lead to poorer patient outcomes, so avoiding these antidepressants is recommended. Citalopram, desvenlafaxine, escitalopram, and venlafaxine can be used with tamoxifen, as they do not affect its metabolism.

A 22-year-old male consults you because of anxiety after being fired from his job. He tells you that he missed 3 days of work after taking an unplanned trip to Las Vegas, and he did not sleep during that time. He spent several thousand dollars on gambling and entertainment during the trip A previous history of which one of the following would be consistent with a diagnosis of bipolar II disorder? At least one episode of acute mania One or more periods of impairing manic symptoms that lasted at least 4 days Alternating periods of hypomania and minor depression Recurrent periods of major depression with at least one episode of hypomania Recurrent major depression refractory to adequate trials of at least three antidepressants from different pharmacologic classes

Recurrent periods of major depression with at least one episode of hypomania Bipolar I disorder is defined by the presence of manic episodes that last at least 7 days or are severe enough to require hospitalization, along with a history of one or more episodes of major depression. Bipolar II disorder is defined by a pattern of depressive episodes alternating with hypomanic episodes, but no full-blown manic episodes. Hypomanic episodes last at least 4 days and cause an observable change in functioning that may or may not cause impairment. The initial manifestation of bipolar disorders is usually a depressive episode. Manic episodes can occur first, but the diagnosis of bipolar disorder cannot be made without a history of episodes of mood elevation and mood depression, which can sometimes occur in rapid succession, known as rapid cycling. Occasionally episodes can contain elements of both mania and depression, classified as mixed features. Cyclothymia is characterized by a history of at least 2 years of mood swings that fluctuate between hypomania and depressive symptoms that do not meet the criteria for major depressive disorder.

A 27-year-old female presents to your office because of frequent fatigue, especially early in the work week, in addition to frequent gastrointestinal distress and occasional chest pain and shortness of breath. She seems jittery and asks for some medicine to help her with her nerves. This is the third time you have seen her in the last 6 months with similar vague reports of pain, and she was also recently seen in the emergency department for a twisted ankle after falling down the stairs. You note a small laceration over her left eye, which she attributes to walking into a door at night. She noticeably avoids eye contact when she answers your questions. Physical and laboratory findings were all normal at the two previous visits. Which one of the following would be LEAST appropriate at this point? The GAD-7 The PHQ-15 The Hurt, Insult, Threaten, and Scream (HITS) screen Referral to a mental health professional

Referral to a mental health professional Given the history and nature of the symptoms and the lack of other medical findings, further assessment for intimate partner violence (IPV) is indicated in this case, especially since there is evidence suggesting harm. IPV is underreported, but it is estimated that as many as 30% of women may have experienced IPV in their lifetime. Alcohol consumption, psychiatric illness, a history of violent childhood relationships, and academic and financial underachievement increase the risk of IPV. Several screening tools for IPV are available, including the Hurt, Insult, Threaten, and Scream (HITS) screen and the three-question Partner Violence Screen. While screening has been shown to increase identification of at-risk women, it has not been shown to decrease IPV. Nonetheless, given the prevalence of IPV, the U.S. Preventive Services Task Force recommends screening all women of child-bearing age (B recommendation). Family physicians should know and inform patients of their state's rules for mandatory reporting of IPV.The patient in this case has also described multiple vague symptoms. Somatic symptoms and anxiety for at least 6 months could suggest generalized anxiety disorder, and administering a screening tool such as the GAD-7 or the Zung Anxiety Scale would be reasonable. The PHQ-15 can be used to further screen for somatic symptom disorder (somatization disorder). In a 2009 study of patients 18-70 years old with unexplained somatic complaints, frequent visits, or mental health problems, the PHQ-15 was 78% sensitive and 71% specific for detecting somatoform disorder in patients with three or more somatic symptoms in the previous 4 weeks.Referral to a mental health professional for an anxiety disorder or somatization disorder would be reasonable after a positive screen, although family physicians could also provide treatment for these conditions. Mental health professionals could also help patients deal with the emotional aspects of IPV. Ideally, the family physician would confirm IPV and counsel patients on safety issues prior to referral.

A 32-year-old female consults you in early December because of a depressed mood, increased sleep and appetite, fatigue, and a 5-lb weight gain over the last 3 weeks. While her symptoms do not impair her ability to work, they are interfering with her social relationships. She has had these symptoms several times in the past, starting around the same time of year, and they generally last until mid-March of the following year. The last episode was 2 years ago. The last two episodes were treated with fluoxetine (Prozac) for 6 months, which she says seemed to help some. She has not taken any antidepressants since that time. Her vital signs and a physical examination are normal. CBCs and TSH levels during these episodes were normal. Which one of the following has the LEAST evidence of effectiveness for this problem? Restarting fluoxetine for acute treatment Bupropion (Wellbutrin) for prevention of recurrence Bright light therapy for acute treatment Cognitive-behavioral therapy for acute treatment

Restarting fluoxetine for acute treatment Seasonal affective disorder (SAD) is an umbrella term for mood disorders that follow a seasonal pattern of recurrence, with depressive symptoms during winter months. Patients experience atypical symptoms such as hypersomnolence and increased appetite. Patients with depressive variants experience symptom resolution in the summer months, while those with bipolar disorder experience mania or hypomania in the summer. SAD is more common in women and more common in northern latitudes, due to decreased sunlight exposure during the winter months. Women have a higher prevalence of SAD, especially during the child-bearing years, and the gender difference is even larger than in major depressive disorder.While some features of this case suggest recurrent major depression, the atypical features and seasonality suggest a diagnosis of SAD. While some studies show effectiveness of SSRIs for SAD, Cochrane reviews and subsequent studies have indicated that the overall quality of evidence is insufficient to draw any conclusions about second-generation antidepressants for treatment of SAD. The evidence is stronger for bright light therapy using specific protocols and for cognitive-behavioral therapy (CBT), either alone or in combination. The evidence for bright light therapy and CBT for prevention of recurrent episodes of SAD is inconclusive. A 2015 Cochrane review found limited evidence that bupropion may be more effective than placebo in preventing recurrent SAD.

A 35-year-old female presents with a 3-week history of depressed mood, insomnia, decreased libido, decreased appetite, and trouble concentrating. She has been seen several times in the past year for abdominal pain and headaches, and states that her family has told her that she has become increasingly irritable. She scores 15 on the PHQ-9 and 12 on the GAD-7. She is not suicidal. Which one of the following is NOT true regarding this situation? Major depression and generalized anxiety disorders commonly coexist SNRIs have been shown to be more effective than other antidepressants for treatment Benzodiazepines are recommended only for short-term treatment Cognitive-behavioral therapy is effective for treating this combination of problems

SNRIs have been shown to be more effective than other antidepressants for treatment Studies have shown lifetime comorbidity rates of 40%-60% for anxiety disorders in depressed patients, with the same range of comorbidity of depression in patients with anxiety disorders. Systematic reviews have found no differences in efficacy between classes of antidepressants for patients with both anxiety and depression.A narrative (nonsystematic) review found that the addition of benzodiazepines to antidepressants may improve both speed of response and overall response in patients with comorbid anxiety and depression. Benzodiazepines are effective for treatment of generalized anxiety disorder and for many years were considered first-line treatment. Experts recommend that benzodiazepines be used only for short-term treatment due to concerns about tolerance, side effects such as sedation and cognitive impairment, and withdrawal symptoms. An additional factor is the emergence of evidence of effectiveness for antidepressants which can also be used in conjunction with benzodiazepines.Cognitive-behavioral therapy has been shown to be effective for both major depression and generalized anxiety disorder, even when they occur together.

You are considering ways to identify depression more proactively in your practice. Which one of the following does the U.S. Preventive Services Task Force currently recommend with regard to depression screening? No recommendation either for or against routine screening for depression in primary care Screening adolescents only when they have school performance or behavioral issues Screening only adults with a positive family history, or when there is a clinical suspicion Screening only when adequate systems are in place to ensure accurate diagnosis, effective treatment, and follow-up Screening only patients with a past history of depression

Screening only when adequate systems are in place to ensure accurate diagnosis, effective treatment, and follow-up The U.S. Preventive Services Task Force (USPSTF) 2016 guidelines recommend screening for depression in adults over 18 years of age, and in pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (B recommendation). The USPSTF found insufficient evidence to recommend a specific screening interval (I recommendation). The USPSTF recommendations are consistent with recommendations from the American Academy of Family Physicians. Most guidelines recommend screening at least once using a practical approach, such as including screening as part of routine health maintenance visits.The USPSTF also recommends screening children and adolescents 12-18 years of age for major depressive disorder, with systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up (B recommendation). They concluded that evidence is insufficient to assess the balance of benefits and harms of screening for major depression in children under the age of 12 (I recommendation). The USPSTF found insufficient evidence to recommend a screening interval but the American Academy of Pediatrics Bright Futures guideline recommends annual screening for patients 12-21 years of age.Screening only when there is a positive family history or clinical suspicion is not recommended, given annual prevalence rates of 5%-10% for major depression and the availability of effective treatments. Screening patients with a past history of depression is especially important, however, as the lifetime relapse risk ranges from 50% to 90%, with a higher risk in patients with multiple previous episodes.

A 35-year-old female is brought to the emergency department by her husband because of a 6-hour history of tachypnea, confusion, and agitation. Her husband reports that she was involved in a motor vehicle accident last night when her car was rear-ended. She was seen at an urgent-care clinic where she was diagnosed with "whiplash" and given prescriptions for tramadol for pain and cyclobenzaprine for muscle spasm. The patient also has a history of depression, currently treated with sertraline (Zoloft) and olanzapine (Zyprexa). She does not use alcohol or recreational drugs.On examination the patient's vital signs include a blood pressure of 170/100 mm Hg, a respiratory rate of 28/min, a pulse rate of 120 beats/min, and a temperature of 38.3°C (101°F). She is confused and agitated. Additional findings include dilated pupils, flushing of the skin, diaphoresis, clonus, and hyperreflexia. Which one of the following is the most likely diagnosis? Anticholinergic toxicity Neuroleptic malignant syndrome Serotonin syndrome SSRI discontinuation syndrome

Serotonin syndrome For patients taking psychotropic medications, the possibility of serotonin syndrome, anticholinergic toxicity, or neuroleptic malignant syndrome (NMS) warrants consideration in those who present with altered mental status associated with neuromuscular and autonomic nervous system dysfunction. All three conditions are associated with hyperthermia, hypertension, tachycardia, and tachypnea. The pupils are dilated in serotonin syndrome and anticholinergic syndrome but normal in NMS. Although flushed, the skin and the mucous membranes are dry in anticholinergic syndrome, whereas diaphoresis and sialorrhea are typically seen in serotonin syndrome and NMS. Serotonin syndrome is distinguished by increased neuromuscular tone in the extremities, with hyperreflexia and clonus. Lead-pipe rigidity and reduced reflexes are typically seen in NMS, whereas muscle tone and reflexes are normal in anticholinergic syndrome.SSRI discontinuation symptoms typically appear a few days after abruptly stopping medication, particularly shorter-acting SSRIs. Symptoms are typically mild and last a few days, and can include anxiety or irritability, headache, and gastrointestinal distress. Central nervous system (CNS) infections such as meningitis and encephalitis, alcohol withdrawal, or benzodiazepine withdrawal should also be considered, but are not likely in this scenario.Drugs linked to serotonin syndrome, particularly when used in combination, include: SSRIs and SNRIs some tricyclic antidepressants (clomipramine, imipramine) St. John's wort analgesics such as meperidine, fentanyl, tramadol, and pentazocine antiemetics such as ondansetron and metoclopramide dextromethorphan some antiepileptics (valproate and carbamazepine) MAO inhibitors some antibiotics (linezolid, tedizolid) CNS stimulants, anorectics, and drugs of abuse such as cocaine tryptophan, lithium, fentanyl, and LSD Mechanisms associated with increased risk include inhibition of serotonin reuptake, inhibition of serotonin breakdown, increasing serotonin release, increasing serotonin precursors or agonists, and inhibition of cytochromes CYP2D6 and CYP3A4.Treatment of cases milder than what this patient has includes stopping or decreasing the dosage of serotonergic medications and avoiding combinations of serotonergic drugs. Management of more severe cases of serotonin syndrome involves supportive care, including management of airway, breathing, and circulation. Antipyretics are not helpful but other cooling measures may be needed. Sedation, paralysis, and intubation may also be needed. Physical restraints are not recommended. Pharmacotherapy with cyproheptadine via nasogastric tube and benzodiazepines for anxiety and muscle relaxant effects may be helpful. In severe cases requiring paralysis and intubation, vecuronium can be considered. Chlorpromazine is not recommended due to the risk of neuroleptic malignant syndrome.

A 71-year-old male is diagnosed with major depression. He also has severe degenerative arthritis of the back and knees, managed with chronic NSAID therapy. Which one of the following antidepressants increases bleeding risk and should be AVOIDED in this patient? Bupropion (Wellbutrin) Duloxetine (Cymbalta) Sertraline (Zoloft) Tranylcypromine (Parnate) Vortioxetine (Trintellix)

Sertraline (Zoloft) Serotonin promotes platelet aggregation. By limiting the uptake of serotonin in the blood by platelets, SSRIs may increase the risk for abnormal bleeding. Case-control studies from the early 2000s suggested a markedly increased risk in gastrointestinal bleeding in older patients taking SSRIs. Subsequent case-control studies suggest that the risk in older SSRI users in general may be less than previously thought, but the risk does seem to be increased in older patients taking NSAIDs and in those with decreased kidney function. This increased risk has not been found with other types of antidepressants.

A 30-year-old unmarried male reports nervousness all the time, irritability at home, trouble concentrating, tense muscles in his neck and shoulders, and headaches. He says, "I cannot shut my mind off" at night. He also reports intermittent upper abdominal pain that he has tried to treat with over-the-counter famotidine (Pepcid). He drinks 2-3 beers a week and does not use recreational drugs. He works as an account manager and says he has been worried about his job over the last year. His concerns started gradually after a different supervisor was assigned to his department. Despite having received a good annual performance evaluation 6 months ago he says he now worries constantly that he is not doing a good job.Which one of the following is true regarding the most likely mental health disorder in this patient? A history of panic attacks is one of the diagnostic criteria Substance use rules out the diagnosis Symptoms must be present for at least 6 months to make the diagnosis It is associated with an increased risk of death from suicide

Symptoms must be present for at least 6 months to make the diagnosis Generalized anxiety disorder (GAD) is common in primary care settings, with a lifetime prevalence of 7.7% in women and 4.6% in men. The onset is variable, with a median age of 30. Unmarried individuals with low education levels and poor health may be at increased risk.GAD is characterized by excessive anxiety and worry that is difficult to control, occurring more days than not for at least 6 months and causing significant social, occupational, or other functional impairment. At least three of the following symptoms must also be present: restlessness, difficulty concentrating, fatigue, muscle tension, irritability, and sleep disturbance.GAD is common in patients with major depressive disorder. Patients with both conditions can be more difficult to treat and may have poorer outcomes than patients with either condition alone. Patients may self-treat with alcohol or drugs, and the condition may occur in patients with substance use disorders, but in order to make a diagnosis of GAD anxiety symptoms cannot be due to the use of or withdrawal from substances. A careful history may be needed to elucidate the relationship between the symptoms and possible substance abuse. Panic attacks occur in panic disorder but are not a diagnostic feature of GAD. To make the diagnosis of GAD, other mental health conditions such as posttraumatic stress disorder, panic disorder, delusional disorders, obsessive-compulsive disorder, and social anxiety disorder should be excluded. Medical conditions should also be excluded, such as hyperthyroidism and overuse of caffeine, decongestants, or stimulant medications.GAD and other anxiety disorders are significantly associated with suicidal ideation and attempts, but not with death from suicide.

A 17-year-old male is brought to your clinic by his father due to declining school performance. A brief history leads you to screen the son for alcohol misuse. Which one of the following is true about screening for alcohol use disorders (AUD)? The AUDIT is superior to the briefer AUDIT-C for detecting AUD The U.S. Preventive Services Task Force recommends screening all adolescents for AUD A National Institute on Alcohol Abuse and Alcoholism single-question AUD screen is validated for use in adolescents The CAGE questionnaire is sensitive for episodic heavy drinking The CRAFFT screen can be used to screen adolescents for both alcohol and drug abuse

The CRAFFT screen can be used to screen adolescents for both alcohol and drug abuse In 2016 in the United States, 26% of adults and 4.9% of adolescents reported binge drinking, defined as 5 or more drinks on the same occasion on 1 or more days in the previous month, and 6.6% of adults reported engaging in heavy drinking, defined as 5 or more drinks on the same occasion on 5 or more days in the previous month. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) defines risky use as exceeding the recommended limits of 4 drinks per day or 14 drinks per week for healthy adult men aged 21-64 years or 3 drinks per day or 7 drinks per week for all adult women of any age and men over the age of 65. A drink is defined as 14 g of alcohol, which is generally equivalent to 12 oz of beer, 5 oz of wine, or 1.5 oz of 80-proof liquor.Most hazardous drinkers would not meet DSM-5 criteria for an alcohol use disorder (AUD), and may thus escape clinical attention. The DSM-5 defines AUD as "a maladaptive pattern of alcohol use leading to clinically significant impairment or distress," manifested by two or more of the following within a 12-month period: drinking more, or longer, than intended trying to cut down or stop but not succeeding spending a lot of time drinking or being sick or recovering from the after-effects of drinking being unable to think of anything besides drinking because the desire to drink was so strong drinking that often interferes with taking care of home or family responsibilities, or causes problems at work or school continuing to drink even though it causes trouble with family and friends The U.S. Preventive Services Task Force (USPSTF) recommends screening for unhealthy alcohol use in primary care settings in adults 18 years of age or older, including pregnant women, and providing persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce unhealthy alcohol use (B recommendation). However, the USPSTF concluded that the current evidence is insufficient to assess the balance of benefits and harms of routine screening and brief behavioral counseling interventions for alcohol use in primary care settings in adolescents 12-17 years of age (I recommendation). The American Academy of Pediatrics does recommend routine substance abuse screening of adolescents. The Substance Abuse and Mental Health Services Administration (SAMHSA) recommends that universal screening for substance use, brief intervention, and/or referral to treatment (SBIRT) become a part of routine health care to reduce the health burden related to substance use and substance use disorders.There are several short, simple screening tests that have been shown to have good specificity and sensitivity for identifying alcohol abuse and hazardous drinking. These include a one-question NIAAA screen for adults: "How many times in the past year have you had 5 or more drinks in a day?" (or 4 drinks in 1 day for women). Any answer greater than zero is considered a positive screen. For adolescents, the NIAAA recommends a two-question brief screen: "Do you have any friends who drank beer, wine, or any drink containing alcohol in the past year?" and, "In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol?"The 10-question AUDIT screen has been extensively studied for detection of unhealthy alcohol use and AUD in adolescents and adults, and unhealthy alcohol use (but not AUD) in older adults. The three-question AUDIT Alcohol Consumption Questions (AUDIT-C) instrument has reasonable sensitivity and specificity for unhealthy alcohol use in adolescents, young adults, adults, and older adults, and for AUD in adolescents, adults, and older adults. Both instruments can detect AUD in pregnant women but have not been extensively evaluated for unhealthy alcohol use in this group. Sensitivities and specificities of the AUDIT and AUDIT-C vary from study to study, among different populations, and by the cut point used. A 2019 meta-analysis noted that the AUDIT performs less well in identifying women compared to men, and in countries with a low prevalence of AUD. There is no consensus about whether longer instruments are superior overall to shorter instruments for screening for alcohol use concerns.The TWEAK (Tolerance, Worried, Eye opener, Amnesia, Cut down) or the T-ACE (Tolerance, Annoyance, Cut down, Eye-opener) are other options for detecting AUD in pregnant women. Neither has been validated for screening in adult males, but a 2000 study showed the TWEAK had a sensitivity of 73% and a specificity of 90% in adolescents. Although it has been validated for AUD screening, the CAGE (Cut down, Annoyed, Guilty, Eye opener) questionnaire fails to detect heavy, episodic, or hazardous or risky drinking.The NIAAA and American Academy of Pediatrics recommend the CRAFFT screen as a useful screening tool for risky alcohol and drug use in adolescents. CRAFFT stands for Car, Relax, Alone, Forget, Family, Friends, Trouble—riding in or driving a car while intoxicated, use of alcohol or drugs to relax, use when alone, forgetting what you've done while intoxicated, having friends or family suggest you cut down, and getting into trouble while using alcohol or drugs.

A 29-year-old female reports that for the past few years she has been meticulously cleaning and arranging her house and workspace and checking her work assignments for errors three or four times. Before this started she had often felt concerned about being messy and disorganized. These actions are not as helpful as they seemed to be initially, and she now feels compelled to clean and organize her home and workspace and repeat tasks several times each day. Her past medical history is unremarkable. She does not use alcohol, illicit or recreational drugs, or tobacco, and has no past history of traumatic events or abuse. Which one of the following statements is true about treatment of this condition? Aripiprazole (Abilify) is a first-line treatment option Clomipramine (Anafranil) is more effective than citalopram (Celexa) The combination of SSRIs plus cognitive-behavioral therapy is recommended as initial treatment Treatment should be changed if the patient fails to improve after 4 weeks

The combination of SSRIs plus cognitive-behavioral therapy is recommended as initial treatment Obsessive-compulsive disorder (OCD) is characterized by recurrent, time-consuming, distressing, and unwanted obsessive thoughts, urges, or images, and/or repetitive behaviors or mental rituals performed to reduce anxiety. This may include compulsive hand washing, stereotypical movements, frequent checking of previously completed tasks, or mental acts such as word repetition. Symptoms are often accompanied by feelings of shame and secrecy. Individuals may or may not be aware that the beliefs behind these thoughts and behaviors are not true.The mean age of onset of OCD is in the late teens. A subset of patients, mostly males, have an onset before 10 years of age. New cases rarely develop after the early 30s. The lifetime risk is 2.3%, and is higher in females. An average of 8 years elapses between the time patients meet the diagnostic criteria for OCD and the time the diagnosis is made and they begin treatment.The DSM-5 considers OCD as a distinct entity from other anxiety disorders. The Obsessive-Compulsive Inventory-Revised or the Florida Obsessive-Compulsive Inventory may be useful in making the diagnosis.A combination of medication and psychotherapy is the preferred first-line treatment strategy for both adults and adolescents. Cognitive-behavioral therapy, specifically exposure and response prevention, is the most effective psychotherapy for treating OCD.Clomipramine was the first medication used to treat OCD. It is a tricyclic antidepressant with serotonergic effects similar to those of SSRIs, but it has been replaced by SSRIs as first-line treatment. A 2008 Cochrane review found that the number needed to treat with SSRIs to achieve one remission was 6-12 and all SSRIs appeared to be equally effective. Better clinical responses are associated with higher dosages.It may take weeks to months for these therapies to work. A trial of SSRI therapy should continue for 8-12 weeks, with at least 4-6 weeks at the maximal tolerable dosage. Patients with OCD are at increased risk for suicide, so monitoring during treatment is crucial. Long-term treatment with an SSRI compared to placebo has been shown to be associated with a significantly lower probability of relapse. SSRIs should be maintained at the maximum effective dosage for at least 12 months, and a decrease in dosage for maintenance treatment can be considered after that time.Refractory OCD can be treated with different strategies, including a switch to another SSRI or clomipramine, or augmentation with the atypical antipsychotics risperidone or aripiprazole. The evidence for quetiapine and olanzapine is mixed, however. Monitoring for serotonin syndrome is important in patients on combined pharmacotherapy.

A 26-year-old female presents for evaluation of sudden episodes of dizziness, nausea, sweating, and shakiness that have occurred four times in the last 6 weeks. The episodes have interfered with her daily activities and she is concerned that they will continue. Her past medical history is unremarkable. She does not take any routine prescriptions or over-the-counter medications or supplements. She does not smoke cigarettes or use recreational or illicit drugs, and typically limits her alcohol consumption to two glasses of wine on weekends. She states that her relationship with her long-term boyfriend is very good. Her vital signs are normal and her serum TSH level is also normal. Which one of the following is true concerning the most likely diagnosis? The diagnosis requires that episodes are not the result of substance use Episodes occur exclusively in patients with the disorder Short screening questionnaires are less accurate than longer instruments for detecting this condition Agoraphobia must be present to make the diagnosis The disorder can be diagnosed after one serious episode

The diagnosis requires that episodes are not the result of substance use This patient's symptoms are consistent with panic attacks, and her history is consistent with panic disorder. Panic attacks are unprovoked, intense, unexpected, rapidly occurring episodes of intense fear that usually peak within 10 minutes and last up to an hour. They are a hallmark symptom of panic disorder but accompany many other psychiatric conditions, including other anxiety disorders and major depressive disorder. At least 4 of the following 13 characteristic symptoms must be present to make the diagnosis of panic attack. palpitations, or a pounding or racing heart sweating tremulousness shortness of breath feelings of choking chest pain/discomfort nausea or abdominal distress dizziness, unsteadiness or lightheadedness chills or heat sensations paresthesias derealization or depersonalization fear of losing control or going crazy fear of dying Panic disorder has a lifetime prevalence of up to 6%, and is more common than generalized anxiety disorder. The age of onset is typically in the 20s, and it is more common in women than in men. At least two or more attacks within 1 month are required to make the diagnosis of panic disorder. The diagnosis also requires persistent worry or fear that another attack will occur, or a significant change in behavior. A diagnosis of panic disorder requires that symptoms are not caused by an underlying medical condition such as hyperthyroidism or cardiac arrhythmia, or another psychological problem. The DSM-5 also states that symptoms cannot be caused by substance use, but careful history taking and assessment is required, as panic disorder may be present in those with substance use disorders and some patients may attempt to self-treat their symptoms with alcohol or drugs. Panic attacks may or may not be associated with agoraphobia, but the presence of agoraphobia in panic disorder is associated with increased severity and worse outcomes.The GAD-2 questionnaire has been shown to have sensitivity and specificity in the 70%-90% range for generalized anxiety disorder, panic disorder, and social anxiety disorder, similar in performance to the longer GAD-7 questionnaire. As with any screening instrument, family physicians should be alert to the possibility of false negatives as well as false positives.

You are evaluating screening instruments to help you better identify depression and anxiety in your patients. Which one of the following is NOT true regarding screening instruments for mental health disorders in primary care settings? The Mood Disorder Questionnaire (MDQ) can be used to screen for bipolar disorder The PHQ-2 has high sensitivity for depression The GAD-2 questionnaire can detect several anxiety disorders The GAD-7 can identify panic disorder The question "Do you want help with this?" increases the sensitivity of a two-question anxiety screen

The question "Do you want help with this?" increases the sensitivity of a two-question anxiety screen The Mood Disorder Questionnaire (MDQ) is a validated self-administered tool that can be used to screen for bipolar disorder. It correctly identifies almost three-quarters of patients with bipolar disorder and will screen out bipolar disorder in 9 of 10 patients without the condition. However, it is not a diagnostic instrument. Patients who screen positive must be further assessed before a formal diagnosis is made or treatment is prescribed.The sensitivity of the PHQ-2 for detecting depression in primary care settings is generally in the 70%-90% range. The specificity, however, is generally in the 60%-90% range.The GAD-2 has been shown to have a sensitivity and specificity in the 70%-90% range for generalized anxiety disorder, panic disorder, and social anxiety disorder, similar to the GAD-7. The sensitivity of the GAD-2 for detecting posttraumatic stress disorder is in the 50%-60% range, slightly lower than that of the GAD-7, but the specificities of both are in the 80% range across studies. The GAD-2 does not differentiate between types of anxiety disorders.One study showed that asking, "Do you want help with this today?" increased the specificity of the PHQ-2 to 89%-98% but did not increase the sensitivity. Asking this question can also increase the specificity of the GAD-2 from 77% to 99% but does not improve the sensitivity.The PHQ-4 combines the two questions from the PHQ-2 depression screen and the GAD-2 anxiety screen. Elevated scores have been shown to relate to decreased patient functional status in several mental and physical domains. The sensitivity and specificity of the PHQ-4 are both in the 70%-80% range, which is consistent with the performance of its PHQ-2 and GAD-2 components.

You are considering systematic efforts in your practice to better identify and treat depression and anxiety in patients with chronic disease. Which one of the following statements about these conditions is true? Antidepressants are more effective than placebo for treating depression in cancer patients There is a bidirectional relationship between depression and diabetes mellitus Collaborative care models for depression in adults with coronary artery disease are associated with long-term reductions in major cardiac events Anxiety is more common than depression in patients with heart failure

There is a bidirectional relationship between depression and diabetes mellitus Depression and anxiety are common in patients with chronic diseases. Identification and treatment of these patients could potentially improve patient outcomes and quality of life, but available evidence varies by condition.A 2018 Cochrane review found only a few low-quality studies regarding the treatment of depression in cancer patients, with no difference in effectiveness between antidepressants and placebo.There appears to be a bidirectional relationship between depression and diabetes mellitus. Patients with major depressive disorder have a greater risk of developing type 2 diabetes than the general population (relative risk = 1.49). The prevalence of depressive disorders in patients with diabetes is twice that of patients without diabetes.A 2016 meta-analysis concluded that patients with depression are at increased risk for myocardial infarction and coronary death. This meta-analysis did not examine the effect of treatment on these outcomes. A 2015 systematic review and meta-analysis showed that collaborative care for comorbid depression and coronary heart disease improved quality of life, reduced depression and anxiety symptoms, and was associated with reductions in major cardiac events for up to 12 months, but the reduction of major cardiac events was not sustained over the long term.A 2018 review found that both depression and anxiety are common in patients with heart failure, with depression being somewhat more common. It noted that 21% of heart failure patients had clinically significant depressive symptoms, with one-third having elevated symptoms and 19% meeting the criteria for major depression, minor depression, or persistent depressive disorder (dysthymia). It found that 13% of heart failure patients met the criteria for an anxiety disorder, with up to 30% having clinically significant symptoms of anxiety.

During a health maintenance visit, a 32-year-old female asks you about discontinuing her antidepressant. She has been taking fluoxetine (Prozac), 20 mg daily, for the last year and has been in remission for the last 8 months. Her PHQ-9 score at this visit is 3. Which one of the following is NOT true regarding maintenance therapy and relapse prevention in patients with depression? There is approximately a 30% risk of depression recurrence after a first episode of major depression After achievement of remission, ongoing cognitive-behavioral therapy is effective in preventing long-term relapse of depression Candidates for long-term maintenance therapy for depression include individuals with two or more previous episodes of depression To reduce the risk of relapse, patients with major depression should continue medication for at least 4 months after achieving remission Patients with major depression and prominent anxiety symptoms are less likely to achieve remission and more likely to relapse than those with depression alone

There is approximately a 30% risk of depression recurrence after a first episode of major depression Current evidence-based guidelines recommend treatment of major depression for at least 4-9 months after remission is achieved. Candidates for longer-term maintenance therapy include individuals with two or more previous episodes of depression, those with more severe depression, and those who had difficulty achieving or initially maintaining remission. Ongoing cognitive-behavioral therapy after remission is effective in preventing long-term relapse of depression.Evidence from the STAR*D trial has shown that patients with prominent anxiety symptoms are less likely to achieve remission and more likely to relapse. After a single episode of major depression the risk of recurrence is over 50%, but a trial of antidepressant discontinuation may be warranted after an appropriate period of treatment and remission. After two episodes the relapse rate is as high as 80%, and after three or more episodes the relapse rate may be as high as 90% over the next 15 years, suggesting that ongoing surveillance is critical. One study has shown that in patients with two or more past episodes of major depression, 79.5% were symptom-free after 1 year of treatment (95% CI: 73.2%-85.8%), compared to 56.5% who discontinued treatment (95% CI: 48.9%-64.2%). In patients with at least three past episodes or a chronic course, 71.7% were symptom-free at 2 years with antidepressant treatment (95% CI: 64.6%-78.9%) compared to 14.7% of those not taking antidepressants (95% CI: 7.10%-22.2%). A shared decision-making discussion with patients who have had multiple previous episodes of major depression is useful for determining patient preferences regarding long-term continuation of antidepressants versus a trial of discontinuation.

A 45-year-old National Guard sergeant presents with depression and nightmares following his return from a year-long tour of duty in a war zone. You establish a diagnosis of posttraumatic stress disorder (PTSD).Which one of the following would be the LEAST effective treatment for this patient's PTSD? Trauma-focused cognitive-behavioral therapy Fluoxetine (Prozac) Paroxetine (Paxil) Topiramate (Topamax) Venlafaxine (Effexor XR)

Topomax Posttraumatic stress disorder (PTSD) is characterized by some form of persistent re-experiencing of an event perceived as traumatic, avoidance of stimuli that remind the individual of the trauma, increased negativity or numbed emotional response, and hyperarousal or hyperreactivity. Up to 4% of adults in the United States may experience PTSD in a given year, and up to 8% may experience it in their lifetime. The diagnosis requires 9 of 14 symptoms for at least 1 month.Several screening tools can be used to help identify patients with PTSD, including the GAD-7, the Primary Care PTSD Screen (PC-PTSD), the Trauma Screening Questionnaire, the PTSD Checklist, and the Startle, Physiological Arousal, Anger, Numbness (SPAN) tool. Positive screens should be confirmed by further evaluation using DSM-5 criteria.Results of meta-analyses suggest that the most effective therapies for PTSD are trauma-focused cognitive-behavioral therapies (CBTs). A 2017 Veterans Affairs evidence-based guideline recommends individual manualized trauma-focused psychotherapies that have a primary component of exposure and/or cognitive restructuring, including prolonged exposure, cognitive processing therapy, eye movement desensitization and reprocessing, specific CBT for PTSD, brief eclectic psychotherapy, narrative exposure therapy, and written narrative exposure.PTSD associated with military service may be a complex and heterogeneous condition, especially in those with extended and intense combat trauma, those exposed to a morally compromising experience, and those with severe symptoms. While CBT may still be effective in these patients, longer or more complex treatment regimens may be required.Systematic reviews support the use of sertraline, paroxetine, fluoxetine, or venlafaxine as monotherapy for the treatment of PTSD. Because of the risk of side effects, medications are generally recommended when psychotherapy is not available or is declined by patients. Evidence suggests that topiramate has minimal effectiveness for PTSD and is not a preferred option.

A 72-year-old male sees you for a routine follow-up visit. His medical history includes Parkinson's disease, hypertension, and hypercholesterolemia. His current medications are carbidopa/levodopa (Sinemet), 25/250 mg 3 times daily; lisinopril/hydrochlorothiazide (Zestoretic), 10/12.5 mg daily; and lovastatin, 40 mg daily.The patient's wife is with him and reports that he has seemed more depressed over the past month, with decreased appetite and a loss of interest in some of his hobbies, including reading. His vital signs are normal. A physical examination is notable for a pill-rolling tremor at rest, mask-like facies, bradykinesia, and mild cogwheel rigidity of the upper extremities. His Geriatric Depression Scale-15 score is 7.Which one of the following antidepressants would be preferred for this patient? Bupropion (Wellbutrin) Citalopram (Celexa) Nortriptyline (Pamelor) Tranylcypromine (Parnate) Venlafaxine (Effexor XR)

Venlafaxine (Effexor XR) The presence of Parkinson's disease (PD) is an important risk factor for major depression. Estimates of the prevalence of depression as a symptom in PD range from 7% to 76%, depending on the definition of depression. A 2016 meta-analysis estimated a 17%-23% prevalence of major depression in patients with PD. It is estimated that only 20% of patients with PD with depression receive treatment. This analysis identified several tools that could be used to detect depression in PD patients, including the 15-item Geriatric Depression Scale, the Beck Depression Inventory, the Montgomery-Asberg Depression Rating Scale, and the Unified Parkinson's Disease Rating Scale.A 2016 meta-analysis indicated that SNRIs such as venlafaxine are preferred for major depression in patients with PD, as they are associated with fewer side effects than other classes of antidepressants in this population. The SNRIs duloxetine and desvenlafaxine were not included in this meta-analysis. SSRIs were also effective for depression, in addition to improving some PD motor symptoms and activities of daily living, but they were associated with significantly worsening apathy. Tricyclic antidepressants were effective for treating depression but had more side effects than SNRIs. MAO inhibitors and bupropion were not included in this 2016 meta-analysis, and little data is available on the use of these medications in patients with PD.

Your practice is implementing steps to monitor patients being treated for depression in a more systematic way. In monitoring for potential harms, it is important to consider that antidepressant therapy has been associated with an increased risk of suicidal thoughts and behaviors in each of the following age groups EXCEPT children adolescents adults in their early 20s adults over the age of 65

adults over the age of 65 In 2004, based on an analysis of 24 clinical trials, the FDA issued black-box warnings on the risk of emergent suicidal thinking and behavior (but not death from suicide) in children, adolescents, and young adults treated with antidepressants. Some concerns have been raised about the unintended effects of this warning. Epidemiologic studies found a decrease in antidepressant prescribing after the warning was issued, while depression diagnoses and potentially suicidal actions increased. Some studies conducted after the warning was issued have questioned whether the risk of these behaviors is increased by antidepressant use.Methodologic concerns about both particular studies and the differences between studies before and after the black box warning make the risks and benefits of antidepressant use with regard to suicide in these populations difficult to quantify. However, a reduced risk of suicidal thinking and behavior has been seen with antidepressant treatment in patients over the age of 65, and there is no change in risk in adults 25-64 years of age. Furthermore, irrespective of age, evidence of increased mortality as a result of suicide has not been demonstrated with antidepressant use in any age group.The FDA black-box warning is still in effect. It does not, however, contraindicate antidepressants for use in these populations but notes that "patients of all ages who are started on antidepressant therapy should be monitored appropriately and observed closely for clinical worsening, suicidality, or unusual changes in behavior."