Which patient is at highest risk for SI
A. 30y/o married AA female with previous SI attempt *1 risk factor
B. 35 y/o single Asian male with previous SI
... [Show More] attempt *3 risk factors
C. 38 y/o single AA male who is a manager of a bank *2 risk factors
D. 68 y/o single white male with depression *5 risk factors (age, male, white, depression)
D. 68 y/o single white male with depression *5 risk factors (age, male, white, depression)
Count the risk factors
When interview teenagers (16 y/o) that arrive with their parents what should you do?
interview them separately from parents.
-This helps Build therapeutic rapport with teens by telling them the info is confidential. Parents may be upset but remember you are advocating for the child.
Which Ethnic group has the highest rate of suicide?
Native Americans
Example A patient is being treated for schizophrenia with olanzapine. Which of the following is the most common side effect of olanzapine?
A. Increased waist circumference
B. EPS (not as common in atypical antipsychotics d/t 5HT2A)-receptor antagonism
C. Increased Lipids
D. Metabolic Syndrome
D. Metabolic Syndrome (UMBRELLA ANSWER)
Which antipsychotics have the least weight gain?
Latuda, Abilify, (also least sedating), Geodon-if patient has metabolic syndrome consider switching to one of the medications above. Or if the patient is overly sedated try switching to ABILIFY
Which mood stabilizer have the least weight gain?
Lamictal
-But remember all mood stabilizers cause some weight gain
When presented with a question about typical vs atypical antipsychotic the answer is usually to start of a
atypical
A client presents with complains of changes in appetite, feeling fatigued, problems with sleep-rest cycle, and changes in libido. What is the neuroanatomical area of the brain that is responsible for the normal regulation of these functions?
A. Thalamus
B. Hypothalamus
C. Limbic System
D. Hippocampus
Hypothalamus
A, B, & D are all part of the limbic system so you can rule that out
When a patient is hesitant to participate in treatment you should encourage?
Bring a support person like a husband
Thyroid-Stimulating hormone normal level
0.5-5.0 Mu/L
When T4 and T3 are high and TSH is low what is the diagnosis
HYPERTHYROIDISM, TSH secretion decreases: TSH LOW à key symptoms HEAT INTOLERANCE
Key symptoms of Heat Intolerance
Hyperthyroidism
When T4 and T3 are Low and TSH is high what is the diagnosis
(HYPOTHYROIDISM) TSH secretion increased: TSH HIGH à COLD INTERANCE
Key symptoms of Cold Intolerance
Hypothyroidism
Hyperthyroid can mimic
Mania
Hypothyroid can mimic
Depression
A patient on depakote complains of RUQ pain and has reddish/brown urine
Hepatoxicity
-Check LFTs
Signs of Depakote toxicity
Disorientation, confusion, lethargy
You suspect depakote toxicity what do you do?
Check
-LFT
-Ammonia
-Depakote Level
What herbal supplement can cause hepatoxicity?
Kava Kava
When taking Kava Kava in combinations with other medications you should caution about
Risk of Hepatoxicity and Sedation
TCAs carry a risk of
Hepatotoxicity
Signs of Stevens-Johnson Syndrome
-fever, mouth pain, swelling, burning eyes, blisters, skin pain
two psychotropics known to cause steven johnson syndrome
lamictal and tegretol
What nationality is most suseptible of getting steven johnson?
Asians
When treating asians with tegretal screen for?
HLAB-1502 Allele
What two medications cause agranulocytosis?
Clozaril & Tegretal
Agranulocytosis when to discontinue medication
Less than 1000
When monitoring for agranulocytosis in patients look for s/s of what?
Infection
-Fever, sore throat, fatigue, chills
Before starting any mood stabilizer in a female of childbearing age be sure to check?
HCG
Which two medications may decrease the risk of suicide?
clozaril and lithium
Medications that increase lithium level
NSAID-ibuprofen, INDOCIN
THIAZIDES-hydrochlorithiazide ACE INHIBITORS-lisinopril
Ace inhibitors are treatment of choice for?
Heart Failure
Certain medications are known to increase lithium level, but HOW?
by reducing renal clearance
When educating a patient about lithium teach them about
Hyponatremia
Dehydration-hot days, exercise
Normal Lithium Level
0.6-1.2
Lithium Toxicity
1.5 or above
Discontinue and re-order lithium level
Lithium level of 1.4
Monitor for toxicity
Labs before starting lithium
TSH, BUN, CREATININE, HCG, U/A to check for presence of protein in the urine (4+ protein is concerning for renal impairment)à4+ protein in urine=MONITOR FOR TOXICITY
4+ protein in the urine of a patient on lithium
4+ protein is concerning for renal impairment
4+ protein in urine=MONITOR FOR TOXICITY
Lithium side effects
hypothyroid, leukocytosis, maculopapular rash, t-wave inversion, Coarse Hand Tremor, GI upset (nausea, vomiting, anorexia)
-Some of these are also signs of toxicity
Signs of lithium toxicity
confusion, ataxia, GI upset, palpitation, tremor
NMS
muscle rigidity, mutism (because of muscle rigidity), increased CPK (caused by muscle contraction and muscle destruction), increase WBC, increased WBC, myoglobinuria (also from muscle destruction)
Cherry colored urine in a patient that exercises a lot
test for myoglobinuria may be a sign of rhabdo
Serotonin Syndrome
With any drug that increases 5-HT (e.g., MAO inhibitors, SNRIs, TCAs) hyperthermia, confusion, myoclonus, cardiovascular instability, flushing, diarrhea, seizures.
-Treatment: cyproheptadine (5-HT2 receptor antagonist).
Treatment for NMS
Stop Offending Medication
-Dantrolene (muscle relaxer)
-Bromocriptine (Dopamine D2 agonist).
*In question focus on what they are asking for….dopamine agonist vs muscle relaxer
Treatment for Serotonin Syndrome
Stop Med (1 or more SSRI, SSNRI, TCA, MOAI)
-Cyproheptadine
Triptans
Used for MIGRAINES
-These meds increase serotonin
example SUMATRIPTAN
patient taking Prozac and started on sumatriptan
-call PCP to ask them to switch the migraine med if patient already on SUMATRIPTAN do not start antidepressant without talking to PCP
How long do you wait when switching between an SSRI to an MAOI?
2 weeks
How long do you wait when switching between Prozac and MAOI?
5-6 weeks wash out period
What is the first line treatment for depression and why?
SSRI-First line treatment for depression due to less risk of injury from OVERDOSE
If a cancer patient has depression what should you consider?
Treating with a medication with minimal drug/drug side effects like Lexapro
Patient with depression worries about sexual dysfunction what would be the medication of choice?
Wellbutrin
Primary symptoms of depression include fatigue and low energy what med would you chose?
Wellbutrin
Wellbutrin is contraindicated in patients with
Seizures and anorexia
Which medications are best for neuropathic pain?
SNRI
Gabapentin
TCA
Secondary to the black box warning providers caring for patients on antidepressants should assess for?
Suicidality, frequency, and severity at EVERY appointment
Which meds have the worse serotonin discontinuation syndrome
Those with short half lives
such as zoloft
Symptoms of serotonin withdrawal syndrome
Fever, achiness, soreness, lethargy, fatigue, impaired memory, decreased concentration, GI UPSET
Shits and Shivers
Ages of onset for schizophrenia in males vs females
-MALES 18-25 years
-FEMALE 25-35 years
Schizophrenia increases the risk for
SUICIDE
*HIGH RISK OF SI in SCHIZOPHRENIA*
Just having schizophrenia increases your risk of suicide.
MUST ASK ABOUT SI, EVERYTIME (frequency, severity of thoughts)
What increases the causes or increases the risk or schizophrenia
excessive pruning of synapses
-inadequate synapse formation,
-intrauterine insults such as maternal exposure to toxins, viral agents, maternal substance use, maternal illness, maternal malnutrition, fetal oxygen deprivation,
-first order relative (mom/dad)
MRI or PET scan what is seen in schizophrenia
EVERYTHING DECREASES EXCEPT VENTRICLES
-You will see VENTRICULAR ENLARGEMENT
Stimulants can potentiate the release of what neurotransmitter?
Dopamine which can worsen symptoms of schizophrenia
Assertive Community Treatment (ACT)
a form of rehabilitation post hospitalization, in home treatment
What level of prevention is ACT?
Tertiary
What adjunctive treatment is important in schizophrenia
-social skills training
-Exercise
Exercise for mental health patients can promote
Cognition
Quality of Life
Long-term health
ACT is ideal for patients with a history of
Treatment non-compliance
-Think about making the treatment convenient for them-->bringing it to their home
What diagnosis has the highest risk of Homicidality
Antisocial
In the MMSE how do you test for abstraction?
proverb interpretation (everyone that lives in glass houses shouldn’t throw stones) Are they able to think abstractly
Thought Process-Tangential
means that their response has nothing to do with the question
Circumstantial
means that their response goes in circles instead of getting to the point of the question
Mental Status-Thought Content includes
SI/HI/AH/VH
Another name for MMSE
Folstein Scale
How to assess concentration on MMSE
Serial 7s or perform an activity backwards i.e list the days of the week backwards
Assess ability to learn new material
repeat 3 words after me
Assess ability to recall
repeat 3 words after 5 minutes
Assess fund of knowledge
Who is the president
What is a quick and easy way to assess for neurological issues
Clock drawing test [Show Less]