Psych / Mental Health (APEA) questions with complete verified solutions

what are the 4 factors that control mood?

1) biology

*neurotransmitters, hormones

2) Psychology

*personality, learned responses, coping mechanisms

3) Physiologic states

*hunger, sleep/rest, exercise

4) Environment

*stress, illness, life events

NOTE

neurotransmitters = messangers

examples of neurotransmitters

-serotonin (5-HT)

-dopamine

-GABA

-norepinephrine

-epinephrine

serotonin (5-HT)

-inhibitory

-function: regulates mood, sleep, appetite (cravings), sex drive, pain, and body temperature

dopamine

-excitatory AND inhibitory

-function: learning, motor control, reward, emotion, and executive functions; pleasure

GABA

-inhibitory

-function: feeling of calmness and relaxation; overall sense of well-being

norepinephrine

-excitatory

-function: increases alertness, attention, and focus; promotes arousal- increased BP and HR

epinephrine

-excitatory

-function: generates the threat response, sympathetic nervous system activation; impacts sleep, stress, appetite, and attention

most common psychiatric disorder

depression

who should be screened for depression

ALL patients, according to the USPSTF guidelines

examples of depression screening tools

-PHQ-2 **

-PHQ-9 **

-geriatric depression screening (GDS)

-beck depression inventory (BDI)

NOTE

PHQ-9 is validated in adults and older adults, including those with cognitive impairment and in nursing home residents

sensitivity vs specificity

-sensitivity = true +

-specificity = true - (ruling out a condition)

The NP is responsible for choosing a depression screening instrument to use with patients in a new clinic. The best test to identify depression is the one with:

high sensitivity

Following a positive PHQ-9 depression screening, which patient is most likely to benefit from lab testing?

a. 27 yo man experiencing their 2nd depressive episode

b. 68 yo woman experiencing her 1st episode of severe depression

c. 42 yo man who is currently getting divorced

d. 65 yo woman who retired 1 month ago

B

lab studies to consider with + depression screening

CBC, chemistry, TSH

labs to consider with depression in special populations

-older adults: FBG, B12, folate

-impaired nutrition: B12, folate

-fertile females: pregnancy test**

-suspected substance use: urine drug screen

NOTE

50% of patients with depression aren't diagnosed r/t the risk questions not being asked

depression screening questions

SIG-E-CAPS

S- sleep issues

I- Interest (decreased)

G- Guilty (worthlessness)

E- Energy (decreased)

C- Concentration difficulties

A- Appetite (increase or decrease*)

P- Psychomotor agitation or irritation

S- Suicidality

anhedonia

little interest or pleasure in doing things

minor depressive disorder dx

-at least 2-4 symptoms from "SIG-E-CAPS"

-anhedonia MUST be present

-symptoms present nearly every day

-symptoms must be causing distress

-no other reason for symptoms

major depressive disorder dx

-at least 5 symptoms

-anhedonia MUST be present

-symptoms present for *most of the day, nearly every day

-symptoms must be causing distress

-no other reason for symptoms

-no manic or hypomanic behavior

NOTE

depressive symptoms must be present 2 weeks or more for diagnosis of minor or major depressive disorders

need and thorough history

most patients with depression have co-morbid conditions. what are the examples of the most common co-morbid conditions in patients who suffer from depression?

-anxiety disorders (GAD, panic)

-PTSD

-bipolar disorder

-OCD

-ADHD

-oppositional defiant disorder

-alcohol or drug use disorders

a patient has a diagnosis of minor depressive disorder. what is the most effective treatment for this disorder?

combination of psychotherapy and pharmacotherapy

the NP is conducting a medication review before initiating for SSRI in a patient who has depression. Which common herb is used to treat depression and can be DANGEROUS in combination with SSRIs?

St. John's Wort --> increased risk of serotonin syndrome with SSRIs

a 29 yo female patient has a diagnosis of depressive disorder. which medication is the best initial choice for her?

Escitalopram (Lexapro)

The patient started taking escitalopram. today, the patient's partner calls the NP with concerns that the patient is not sleeping and is behaving impulsively. what does the NP suspect?

the patient has been misdiagnosed and needs a different treatment

first line treatment for depressive disorders (depression/bipolar/anxiety)

SSRI's --> lexapro, zoloft, etc

a common side effect with SSRIs and bipolar disorder

manic episodes -- can occur with a misdiagnosis of depression and SSRI is prescribed. educate patient and family to watch carefully and notify if manic symptoms occur

before prescribing medication for depression, what condition do we want to screen for?

bipolar disorder !

*b/c the presentation of depression could be the presentation of bipolar disorder

signs and symptoms of mania

-excess energy

-grandiosity

-fast speech

-distractability

-agitation

-hallucinations

-impulsive behaviors

-substance and alcohol misuse

-legal problems

-relationship issues are common*

signs and symptoms of hypomania

not severe enough to significantly affect social or work/school functioning

is bipolar disorder is suspected, what are our first steps

-use a screening tool (Mood Disorder Questionnaire) that screens for manic and hypomanic episodes

-if patient screens +, you must REFER!

how do SSRIs work in our system?

blocks re-uptake of serontonin

-grouped by effect on CYP450 liver enzymes (more CYP450 effect, the higher risk of drug interactions and s/e)

examples of SSRIs with less CYP450 effect (safer)

-sertraline (zoloft)

-citalopram (celexa)

-excitalopram (lexapro)

examples of SSRIs with more CYP450 effect (dirtier/dangerous)

-fluoxetine (Prozac)

-paroxetine (Paxil)

-fluvoxamine (Luvox)

what are the common adverse effects we need to educate patients about when taking SSRIs?

-GI symptoms

*N/V/D, indigestion b/c 90% of serotonin receptors are in the digestive tract !

-Sexual dysfunction

*ejaculatory changes, decreased libido

-Somnolence

-Weight gain

-Elevated liver enzymes (10%)

rule on SSRI / depressive disorder treatment

"start low, and go slow"

SSRIs in pregnancy*

-generally safe

-escitalopram (lexapro) or sertraline (zoloft) usually preferred

-AVOID paroxetine (paxil)

-discuss the risks/benefits

SSRIs with lactation*

-generally, low levels pass into breast milk

-SSRI used in pregnancy can typically* be continued

NOTE

weigh risks of untreated depression in pregnancy/postpartum vs. benefits of treatment

Ms. Q is a 70 yo female who reports foggy thoughts, difficulty concentrating, and poor appetite. She says, "I have no energy to be around people" and is no longer socializing with friends. What is the NP's next step?

screen for depression

after a full evaluation, Ms Q is diagnosed with minor depression. Which of the following antidepressant medications should be avoided in older adults?

doxepin (sinequan) -- tricyclic antidepressant (TCA)

-avoided in older adults d/t increased risk of anticholinergic side effects

first line antidepressants for older adults

SSRIs*

best choices: citalopram, escitalopram, sertralin

AVOID: paroxetine and fluoxetine

-well tolerated, few drug-drug interactions

what class of antidepressants do we really want to avoid in older adults? why?

tricyclic antidepressants (TCAs)

b/c

-highly anticholinergic and cause cause arrhythmias, cognitive changes, and high risk of OD'ing

what are potential side effects of prescribing antidepressants for older adults?

-parkinsonism

-anorexia

-sinus bradycardia

-hyponatremia

-bleeding

-fragility fractures

-QT prolongation

the NP decides to prescribe sertraline for Ms Q (70 yo female) .What is the most appropriate starting dose? typical dose: 50-200 mg, daily)

25 mg, daily

educate that it may take up to 4-6 weeks to feel full effects

a 42 yo patient has been taking escitalopram 10 mg (usual: 10-20 mg) daily for 4 weeks He notices only slight improvement. His PHQ-9 score decreased from 16 to 14. He is tolerating the medication well. What should the NP do first?

increase the patient's dose of escitalopram to 20 mg, daily

how to safely switch antidepressant medications

-SSRI --> SSRI

*taper, stop, wash out 5 half lives

*start new med

-SSRI --> SNRI

*taper, stop, wash out 5 half lives

*start new med

-SSRI --> NDRI (bupropion)

*two options:

-add bupropion to SSRI

-initiate bupropion while weaning SSRI

discontinuing SSRIs

-first episode of depression

consider weaning 6-9 months after recovery

*consider patient hx, preferences

*refer for psychiatric input, prn

-do NOT stop abruptly!*

*discontinuation syndrome

-taper over 2-4 weeks for most SSRIs

-6 weeks or more on SSRI

*anxiety, dizziness, insomnia, flu-like illness

define serotonin syndrome

-caused by excess serotonin through combining mediations that increase serotonin levels (SSRIs, SNRIs, etc)

symptoms of serotonin syndrome

-increased BP, HR, temp

-confusion, restlessness, agitation

-headache, muscle rigidity, N/V, tremors, shivering

shaking, seizures, shivering

examples of serotonin agents

-dextromethorphan -- cough meds

-tramadol

-TCAs

-cyclobenzaprine

-zofran

-others

when are SNRIs (serotonin-norepinephrine reuptake inhibitors) warranted in depression treatment?

when depression is unresponsive to SSRIs

*also, SNRIs are great for pain syndromes (fibromyalgia)

examples of SNRIs

-duloxetine (cymbalta)

-venlafaxine (effexor)

-desvenlafaxine (pristiq)

-milnacipran (savella)

-levomilnacipran (fetzima)

indications for SNRI, duloxetine (cymbalta)

-MDD

-GAD

-fibromyalgia

-diabetic peripheral neuropathy

-chronic musculoskeletal pain

only SNRI that does NOT raise BP!

norepinephrine-dopamine reuptake inhibitors (NDRIs)

bupropion (multiple brand names/uses)

-Wellbutrin : depression, ADHD

-Zyban: smoking cessation

-Contrave (bupropion/naltrexone): weight loss

contraindications to NDRI, bupropion

*seizures, uncontrolled HTN

who is the most likely population to *attempt suicide

adolescents

who is the highest risk for success rate in terms of suicide ideation

older adult males

risk factors for suicidality

-psychiatric disorder

-hopelessness **

-impulsivity

-hx of prior attempt of suicide

-marital status

*highest risk: never married, widowed, separated/divorced

*lower risk: married w/ or w/o children

generalized anxiety disorder (GAD)

-excessive anxiety and worry

-occurring more days than not

-more than 6 months

-difficulty controlling worry

-not attributable to substance misuse or another diagnosis

-excessive or unrealistic worry

diagnosis components of GAD (anxiety)

-clinically significant distress (interferes w/ work, home, relationships)

-at least 3 symptoms:

*restlessness

*muscle tension

*irritability

*impaired concentraion

*easily fatigued

*sleep disturbances

diseases that can MASK as anxiety

-angina, arrythmias, MI

-anemias

-hyperthyroidism

-hypoglycemia

-essential tremors

-asthma, COPD, PE

-carcinoid tumor

drugs that can MASK as anxiety

-caffeine, cocaine

-pseudoephedrine

-theophylline

-drug withdrawal

-benzodiazepines, alcohol

-benadryl

-TCAs

-dopaminergics

first line treatment for anxiety

SSRIs *

other treatment options for anxiety, after SSRIs

-SNRIs (venlafaxine, duloxetine)

-Buspirone (Buspar) --> adjunct to SSRI

-Benzodiazepines

-Short term relief

*hydroxyzine

*propranolol -- situational anxiety

which drug class should be avoided in older adults with anxiety disorders?

benzodiazepines

a nurse working in the ICU has generalized anxiety disorder (GAD. Which medication would be helpful for management of chronic anxiety>

escitalopram (lexapro)

the nurse's colleague is anxious about defending their DNP project next week. Which medication could be taken to relieve anxiety on the day of the presentation?

Propranolol, given 60 minutes before the presentation

PTSD

marked cognitive, affective, and/or behavioral disruption that develops in response to trauma

-diagnosed older than 6 yo

examples of trauma that can cause PTSD

-mass event: conflict/war, pandemic, natural disaster

-near-death experience or severe injury

-professional exposure: first responders, health care workers, caring professionals, soldiers

-assault or body violation

how is PTSD diagnosed?

DSM-5-TR Criterion A-E

who do we screen for PTSD?

-high risk occupations

-new anxiety, fear, insomnia with a hx of trauma

-social isolation, increased substance abuse, or attempts at distraction (excessive work)

how do we screen for PTSD?

primary care PTSD screening (PC-PTSD-5)

* 5 yes/no questions:good reliability/validity

**assess patient's safety (ongoing trauma/suicidality) and other comorbidities

treating PTSD

trauma-focused psychotherapy preferred

a patient has a diagnosis of mild PTSD secondary to a recent MVA. The patient is having intrusive and avoidance symptoms, and sleep disturbances. The patient is not suicidal. Which of the follow treatment options is best?

Escitalopram (Lexapro)

aspects of a *thorough substance use assessment

-type

-amount

-frequency

-consequences of substance use

-patient's perception

-readiness to change**

-past medical history and co-occurring psychiatric disorders

potential substances of abuse

-caffeine

-nicotine

-alcohol

-prescription medications: opioids, stimulants, gabapentin

-marijuana

-illicit drugs: cocaine, opioids, heroin, hallucinogens, inhalants

if the patient is not ready to change in a substance use disorder, what should the provider do?

gently, but sternly educate them!

what do we use to identify/diagnose substance use/misuse disorders?

DSM-5-TR Criteria

tool used for diagnosing alcohol use disorders

AUDIT

Alcohol Use Disorders Identification Test (AUDIT) -- a 10 question tool for risk stratification

*AUDIT-C: 3 items on alcohol consumption

diagnostic criteria for alcohol use disorders in number of drinks

-males younger than 65: 5 drinks/day or more or more than 14 drinks/week

-males and females older than 65: 4 drinks/day or more or more than 7 drinks/week

first line management of alcohol use disorders

-naltrexone : contraindicated w/ chronic opioid use; acute hepatitis, hepatic failure (check and monitor LFT's)

-acamprosate : contraindicated with eGFR < 30 mL/min

Opiate use disorder facts

-2 million prescription opioid abuse (2021)

-500,000 use heroin

-75% of drug overdose deaths involved an opioid

-more than 80,000 deaths

-10x higher than in 1999

-88% involved synthetic opioids

screening tools for opioid use disorders

-current opioids misuse measure (COMM): 17 items

-rapid opioid dependency screen (RODS): 8 items

-Opioid Risk Tool

*primary care: administer prior to prescribing

*self-report to assess for risk for opioid abuse

Prescription Drug Monitoring Program *

before a provider prescribes an opioid, how must every patient be screened?

using the Prescription Drug Monitoring Program

mainstreaming addiction treatment (MAT) act

-DEA schedule III - authority to prescribe or provide or refer for evidence-based treatments

goal of addiction treatment

reduce carvings and control withdrawal symptoms

buprenorphine: partial opioid (preferred to prevent OD)

methadone: an opioid (preferred to prevent OD)

what medication blocks opioid action

naltrexone (used to treat alcohol and opioid use disorders)

what is the reversal agent of opioid overdose

naloxone !

an adult patient presents to the NP to be evaluated for ADHD. What are the core symptoms of ADHD?

-restlessness

-impulsivity

-inattention

-executive dysfunction

rating scales for ADHD assessment

-Adult ADHD self-report scale (WHO)

-Conner's Adult ADHD rating scale

-Wender Utah rating scale

what comprehensive assessments do we want to assess for in patient's suspicious of having ADHD?

-substance use disorders

-age of onset

-comorbidities

how to diagnosis ADHD

DSM-5 Criteria

-symptoms must be present prior to age 12 yo

-symptoms last more than 6 months

-symptoms are evident in 2 different settings

-evidence symptoms interfere with social, academic, or occupational functioning

3 subtypes of ADHD

-predominantly inattentive type: doesn't meet hyperactivity/impulsivity criteria

-predominantly hyperactive/impulsive type: doesn't meet inattention criteria

-combined type: meets criteria for BOTH inattention and hyperactivity/impulsivity

treatment options for ADHD

-referral

-pharmacologic treatment

when do we refer ADHD patients, rather than treat?

-co-morbidities are present

*psychological disorders (ODD, emotional problems)

*neurologic, medical disorders (tics, autism, sleep disorders)

-diagnosis is unclear

-patient does not respond to treatment, as expected

first line treatment for ADHD

stimulants (amphetamines, methylphenidate)

CBT + pharm treatment