Psych Clinmed

What is the BIGGEST thing you must do before diagnosing Depression

Assess for a history of mania or hypomania

Contributing mechanisms of Depression

Genetics, Neurotransmitters, hypothalamic-pituitary axis, neuroplasticity, psychosocial stressors

Essential components of depressive disorders

At least 5 sx within a 2wk period

At least one: depressed mood OR anhedonia

Signif. distress/impairment

No other substance/condition causing

No history of mania or hypomania

Major Depressive Disorder Manifestation

SAGECAPS:

Sleep disturbance

Anhedonia

Guilt/worthlessness

Energy lowered

Concentration impairment

Appetite or weight change

Psychomotor agitation/retardation

Suicidal

Major depressive disorder rundown

Depressive sx for at least 2 wks (more clearly episodic, often greater acute severity)

Persistent depressive disorder rundown

depressed at least 2 years, waxes and wanes (can have MDD as part)

Premenstrual Dysphoric Disorder Rundown

Severe premenstrual syndrome; extreme mood swings, anxiety, depression, and irritability

Antenatal depression rundown

Major depression during pregnancy to one year after delivery

Seasonal Affective Disorder rundown

Depression that associates itself with a yearly cycle (most often during the winter)

Potential mimics of Major Depressive Disorder

Thyroid disease

Anemia

Sleep disorders

Neurologic disease

Medication/substance effects

Score of a positive screen on the PHQ 2

3+

PHQ9 grading scale

0-4 minimal

5-9 mild

10-14 moderate

15-19 moderately severe

20-27 severe

Special note of PHQ9 item 9

Anything but a “never” necessitates direct suicide risk assessment

Does the PHQ9 establish a Major Depressive Disorder diagnosis?

No, it merely screens for whether someone should be assessed for depression

What factors increase the need for combination therapy for depression

Severe, persistent, recurrent, or ineffective monotherapy

Early-line Drugs for depression

SSRIs,

SNRIs,

Bupropion,

Mirtazapine

Side effects of SSRIs

GI impacts, Sexual dysfunction, poor sleep

Side effects of SNRIs

raise blood pressure, gi impacts, sexual dysfunction, sleep

In what case are SNRIs especially useful?

In treating depression with comorbid neuropathic pain

Side effects of Bupropion

Activating, AVOID IN SEIZURE/EATING DISORDERS

Less sexual dysfunction

What special case is Bupropion especially helpful in?

Treating depression that manifests as sexual dysfunction

Mirtazapine side effects

Sedating, increased appetite/weight gain

What special cases are Mirtazapine especially useful in?

Insomnia, or treating poor appetite

Later-line antidepressants

Tricyclics, or monoamine oxidase inhibitors

Side effects of Tricyclic antidepressants

Higher toxicity, anticholinergic effects, orthostasis

Monoamine Oxidase Inhibitors side effects

Drug interactions, no dietary tyramine allowed, hypertension crisis/serotonin toxicity

Treatments for SEVERE depression

Electroconvulsive therapy, Transcranial Magnetic Stimulation

Pattern of symptoms specific to Seasonal Affective Disorder

Hibernation-like sx (winter depression+atypical sx)

Crucial diagnostic requirement of Premenstrual Dysphoric Disorder

Sx must cause clinically significant distress/functional impairment

Unique treatment options for Premenstrual Dysphoric Disorder

Symptom/luteal-phase dosing (continuous still an option, though)

Contraceptives

When can perinatal depression occur?

During pregnancy, or the first 12 months pospartum

Baby blues vs perinatal depression

Blues: emotional fluctuation, self-limited, usually a matter of weeks
Perinatal depression: Persists, causes impairment

What is an important Do Not Miss of perinatal depression?

Postpartum psychosis

sx of Postpartum psychosis

Delusions, hallucinations, confusion, disorganized behavior, mania, rapidly changing mental status.

=PSYCH EMERGENCY

What psych condition is postpartum psychosis associated with?

Bipolar spectrum

Clinical pearl when treating perinatal depression

NEVER discontinue effective psych meds at the onset of pregnancy without an individualized risk-benefit assessment

Biggest suicide risks

PRIOR ATTEMPT

Access to lethal means

chronic pain/illness

psychosis

substance use disorder

Acute suicide warning signs

Seeking access to lethal means, hopelessness, feeling trapped, recklessness

Suicide risk assessment

Ideation, plan, intent, means, behavior, safety, protective factors

What constitutes high acute suicide risk concerns

Current intent, inability to maintain safety, recent attempt, preparations, or plans with access to lethal means

elevated/irritable mood

increased energy

racing thoughs

pressured speech

increased confidence

increased goal-oriented behavior

risky/impulsive

Manic episode qualities

Duration required to count as a manic episode

At least one week, or any time if it results in a hospitalization

Less severe than mania,

At least 4 days

NO hospitalization

NO psychosis

insignificant impairment

Hypomania

At least 1 manic episode, depression not req. for diagnosis

Bipolar 1

at least one HYPOmanic episode,

at least one major depressive episode,

AND

no history of manic episodes

Bipolar 2

Mimics of Bipolar Disorder

Hyperthyroidism

Neurologic disease

Drug reaction

Substance use

Hypomania + milder depression

Cyclothymic disorder

Moot stabilizers for bipolar

Lithium

Divalproex/Valproate

2nd gen antipsychotics for bipolar

quetiapine

Aripiprazole

Risperidone

Asenapine

Cariprazine

Lamotrigene for Bipolar

Ineffective for acute mania, but useful for maintenance

Treatment rule for severe mania

combo of stabilizers+2nd gen antipsychotics

What treatments to avoid for bipolar?

Antidepressant MONOtherapy

Uses of lithium in bipolar

Maintenance and acute, REDUCES SUICIDE RISK

Side effects of lithium

Tremor, GI, polydipsia/polyuria, weight gain, hypothyroidism

Monitor in patients taking lithium:

Serum lithium, Renal&Thyroid function, calcium, electrolytes, pregnancy

Risk factors of lithium toxicity

Renal dysfunction

dehydration

hyponatremia

drug interactions

Drug contraindications/interactions of Lithium

NSAIDs

ACE inhibitors/ARBs (hypertension)

Thiazide Diuretics (hypertension)

Valproate/Divalproex uses

Acute mania and maintenance (as a LATER-LINE treatment)

Valproate/Divalproex side effects

GI symptoms, tremor, weight gain, thrombocytopenia, hepatotoxicity,

MAJOR reproductive risk (even for males)

What to monitor while on Valproate/Divalproex

CBC, liver fxn, serum concentration

Lamotrigine uses

Prevents mania, but doesn’t treat accute mania

Lamotrigine major concern

SJS/TEN (Requires slow titration)

Panic Disorder DDxs

Heart attach

Pheochromocytoma

hyperthyroidism

recreational drug rxns

GI

Anxiety general diagnostic criteria

Persistent, excessive anxiety w behavioral disturbances

Ruled out: adjustment, physical condition, drugs, or any other psych condition

Tests to rule out anxiety mimics

CBC, TSH, UA/Drug analysis, EKG, head CT

Psych sx of anxiety

Tension, fear, poor concentration

somatic sx of anxiety

Tachy, hyperventilation, palpitations, tremor, sweat

Screening test for anxiety

GAD-7

GAD-7 ratings

0-4 minimal

5-9 mild

10-4 moderate

15-21 severe

Chronic anxiety with no specific provocation, with 3 or more of the following:

Restlessness, easily fatigued, low concentration, irritability, muscle tension, sleep disturbances

Generalized Anxiety Disorder (GAD)

GAD treatments

1. SSRI/SNRI

2. Buspirone, Gabapentin, Benzos, Beta-blockers

Panic attacks (including physical manifestations), with chronic fear of recurrence

Panic disorder

Panic disorder treatments

1. SSRI/SNRI

2. Benzos

Disproportionate fear of a specific object/situation

Simple phobia

Disproportionate fear of a social “class” of experiences (more global)

Social phobia

Treatments of Simple phobias

for a one-time occurrence: Propranolol 20-40mg 1hr prior to exposure

For chronic: desensitization therapy

Treatments for social phobias

1. SSRIs (paroxetine, sertraline, fluvoxamine) or SNRIs (Venlafaxine)

2. Gabapentin

Preoccupations/rituals that are distressing to the patient

OCD

OCD treatments

1. SSRIs

2. Clomipramine

3. Transcranial Magnetic Stimulation

Flashbacks, intrusive images, and/or nightmares, with behaviors that avoid triggering stimuli, traced back to a traumatic event

PTSD

Time requirement for PTSD

1month

PTSD screening

PC-PTSD-5

PT-PTSD-5 positive screening score

4 or above

Symptoms assessed on the PC-PTSD-5

Intrusive memories/nightmares, avoidance, guilt/blame, hypervigilance, numbing/detatchment

Acute stress disorder qualifying timeframe

3 days to 1 month

Acute Stress Disorder vs PTSD

ASD=3d-1mo

PTSD=1mo and longer

Adjustment disorder vs PTSD and ASD

Stressor doesn’t meet trauma criteria, or sx don’t meet criteria. (“PTSD/ASD Lite”)

PTSD treatments

1. Exposure therapy (+other therapies)

2. SSRIs, beta-blockers (especially prior to anticipated triggering events)

Acute stress disorder treatments

Assess ongoing danger/suicide risk, therapy