PHRX 4040 Psychiatry Module - Exam 1 Study Guide

what does AMI stand for?

any mental illness

define any mental illness (AMI)

mental, behavioral or emotional disorder; vary in impact

what does SMI stand for?

serious mental illness

define serious mental illness (SMI)

mental, behavioral or emotional disorder resulting in serious functional impairment, which substantially interferes with or limits one or more major life activities

describe thought disorders

disturbance in cognition that adversely affects language, thought content, and communication

describe mood disorders

disturbance in the persons mood (can be elevated or depressed)

describe anxiety related disorders

characterized by significant feelings of anxiety (worry about future events) and fear (reaction to current events)

describe personality disorders

maladaptive patterns of behavior, cognition and inner experience, exhibited across many contexts and deviating from those accepted by the individuals culture

what 6 factors are reviewed during an initial psych exam?

- psych symptoms and history

- substance use

- suicide risk

- medical health

- treatment adherence

- previous and current meds and responses

what does SIB stand for?

self injurious behavior

what does SA stand for?

suicide attempt

what does SI stand for?

suicidal ideation

what does HI stand for?

homicidal ideation

what does AH stand for?

auditory hallucinations

what does CAH stand for?

command auditory hallucinations

what does VH stand for?

visual hallucinations

what does AVH stand for?

auditory/visual hallucinations

what does MDD stand for?

major depressive disorder

what does GAD stand for?

generalized anxiety disorder

what does PMDD stand for?

premenstrual dysphoric disorder

what does PTSD stand for?

post traumatic stress disorder

what does OCD stand for?

obsessive compulsive disorder

what does BPD stand for?

boarderline personality disorder

what does SUD stand for?

substance use disorder

what does OUD stand for?

opioid use disorder

what does AUD stand for?

alcohol use disorder

describe DSM-5

handbook used by healthcare professionals to diagnose mental health disorders, but NOT a treatment guideline

describe the connection between mental illness and mass shootings

- common misconception that mental illness is the cause of mass shootings, but less than 1/4 of mass shooters have a diagnosed mental illness

- mental illness may be a factor but it can not be considered a predictor

describe federal gun laws and mental illness

- purchase of firearms is not banned for pts based on diagnosis

- people who are a danger to self or others or have been INVOLUNTARILY hospitalized are held from purchasing

describe state gun laws and mental illness

- more strict

- in CT there is a 6 month ban on purchase and possession based on pts who are hospitalized for mental illness, both voluntary and involuntary

what was the first antipsychotic?

chlorpromazine

what age range is most likely to be treated with a psych drug?

younger pts

what gender is most likely to be treated with a psych drug?

women

what ethnicity is most likely to be treated with a psych drug?

non-hispanic white populations (white > black > hispanic > asian)

what location of pts are most likely to be treated with a psych drug?

nonmetropolitan

what is important to note about the 10 most prescribed psych meds?

they are all also within the top 50 prescribed overall meds in the US

who can prescribe psych meds? (5)

- psychiatrists

- PCPs

- NPs

- PAs

- pharmacists (VA collaborative practice)

who are the main prescribers of psych meds?

psychiatrists were historically the main providers but now the majority of psych meds are prescribed by PCPs

what location has the largest population with mental illness? describe this

- jails and prisons

- have MORE people with mental illness than the largest state psych hospital

describe the epidemiology of depressive disorders in the US

- MDD common in US

- affects 1 in 5 people but only about 60% receive treatment

describe the morbidity of MDD

higher risk of medical comorbidities, especially type 2 diabetes and cardio disease

describe the lifetime risk of suicide in untreated MDD

20%

- suicide ask is increasing

describe the relationship between suicide and MDD in terms of gender

- majority of suicides completed by white males

- females: most common way is poisioning

- males: most common way is via firearms

describe the relationship between suicide and MDD in terms of age

highest rates:

- females = 45-54 yrs

- males = 75+ yrs

describe the relationship between suicide and MDD in terms of means of suicide

most common method of suicide is by using firearms, followed by suffocation then poisoning

describe the spectrum of suicidality (5)

suicidality exists on a spectrum and can include:

- thoughts about death

- passive wish to not wake up in the morning

- belief that others would be better off

- transient but recurrent thoughts of suicide

- specific suicide plan

what considerations can be taken regarding language around suicide?

- avoid language that sensationalizes or normalizes suicide

- do not use the term "committed" but rather use something like "completed suicide"

what terminology should be used when discussing self-harm?

non suicidal self directed violence

what is important to consider when discussing self harm with pts?

- not all self harm is driven by SI

- must ask pt directly about suicide (rather than using broad terms like "hurting themselves")

what pneumonic is used for a suicide risk assessment?

IS PATH WARM

describe the risk factors evaluated during suicide risk assessments (IS PATH WARM)

- ideation

- substance use

- purposelessness

- anxiety

- trapped

- hopelessness

- withdrawal

- anger

- recklessness

- mood change (dramatic)

what are 11 chronic risk factors for completed suicide?

- prior attempts

- family history of completed suicide

- living alone

- recent hospitalizations

- LGBTQ+

- adverse childhood events

- stressful life events

- unemployment

- advancing age

- mental illness

- physical illness

what are 11 acute risk factors for completed suicide?

- SI

- purposelessness

- hopelessness

- recklessness

- feeling trapped

- nonadherance to care

- anger, rage, revenge seeking

- mood and personality changes

- substance use

- insomnia

- access to firearms

what are 8 protective factors against completed suicide?

- social support

- married

- pregnancy

- parenthood

- religion

- effective clinical care

- ability to cope with stress

- life satisfaction

what are 9 risk factors for MDD?

- female

- Native American

- middle aged

- low income or unemployment

- marital problems

- physical disability or medical condition

- stressful life events

- comorbid psych disorder

- first degree relative with depression

describe the link between MDD and genetics

- likely a heritable component

- 2-4x increased lifetime risk

- no causative gene identified

describe the epidemiology of MDD

- most common age group = 18-25 yrs

- increased risk with 2+ races

describe the relationship between medical comorbidities and MDD

medical comorbidities affect 60% of pts with MDD

what are 8 common medical comorbidities seen with MDD?

- cardio and metabolic disorders

- neuro disordres

- inflammatory bowel disease and irritable bowel syndrome

- fibromyalgia and other pain disorders

- COPD

- cancer

- sleep disorders

- osteoporosis

what are 6 specific cardio and metabolic disorders that are common comorbidities with MDD?

- diabetes

- coronary heart disease

- hypertension

- obesity

- metabolic syndrome

- stroke

what are 5 specific neurological disorders that are common comorbidities with MDD?

- alzheimer's

- parkinsons

- vascular dementia

- epilepsy

- MS

what are 5 common psychiatric comorbidities seen with MDD?

- alcohol use disorder

- other substance use disorders

- nicotine dependence

- anxiety disorders

- PTSD

what are 6 key medications (or med classes) that may have an impact on mood?

- benzodiazepines

- beta blockers

- calcium channel blockers

- corticosteroids

- montelukast

- varenicline

what BBW is associated with montelukast (Singular)?

serious neuropsychiatric events including depression, sleep disturbances, suicidal thoughts/behvaior and suicide

what are 2 key disease states which may have an impact on mood?

anemia and hypothyroidism

give an overall description of the monoamine hypothesis

hypothesis states that MDD is due to deficiency in serotonin, norepinephrine and dopamine

give an overall description of the dysregulation hypothesis

MDD hypothesis states that changes in NTs eventually leads to changes in pre and post synaptic receptors

give an overall description of the hypothesis of anatomical structure changes in relation to MDD

- overactivity of amygdala

- reduced size of hippocampus

- enlarged pituitary gland

- reduced activity in prefrontal cortex

what pneumonic is used to remember the subjective clinical features of MDD?

SIG E CAPS

describe the subjective clinical symptoms associated with MDD

(SIG E CAPS)

- sleep disturbance

- intrest (loss of)

- guilt (excessive)

- energy changes

- concentration impairment

- appetite changes

- psychomotor agitation or slowing

- suicidal ideation or actions

what are 3 objective symptoms associated with MDD?

- poor hygiene

- weight changes

- isolation

what is MDD diagnosis based on?

DSM-5

what is the main point seen via DSM-5 for MDD diagnosis?

5 or more of the following symptoms (SIG E CAPS) are present during the same 2 week period and represent a change from previous functioning and at least 1 of the symptoms is either a depressed mood of a loss of interest or pleasure

describe psychotic specifiers seen with MDD

- MDD episode characterized by delusions or hallucinations

- psychotic features may or may not have a relationship with depressed mood

describe seasonal onset specifiers seen with MDD

- recurrent MDD with mood episodes occurring repeatedly at specific times of the year

- frequently in the winter

describe catatonic features seen with MDD

- profound purposeless psychomotor changes or mutism

- may be life threatening if severe

what 2 MDD rating scales are clinician administered? when are they common?

- MADRS and HDRS

- common in clinical trials

what are 2 MDD rating scales that are patient administered?

- beck depression inventory = BDI

- patient health questionnaire (PHQ-9)

describe the beck depression inventory (BDI) and when it is used

- 21 items used to assess frequency of symptoms over the previous 2 weeks

- used in trials to assess depression severity in those with a formal diagnosis

describe when the patient health questionnaire (PHQ-9) is used

used in clinical practice and trials to diagnose, monitor symptom severity and determine the need for treatment

how does PHQ-9 scoring work?

each item is scored from 0 (not at all) to 3 (nearly every day)

what PHQ-9 score would a depression severity of none align with?

0-4

what PHQ-9 score would a depression severity of mild align with?

5-9

what PHQ-9 score would a depression severity of moderate align with?

10-14

what PHQ-9 score would a depression severity of moderately severe align with?

15-19

what PHQ-9 score would a depression severity of severe depression align with?

20-27

describe the onset of MDD

- average age is late 20s

- risk decreases after age 40

- symptoms can develop over days to weeks but may be sudden

describe the duration of MDD

- median time to recovery is 20 wks with adequate treatment

- if untreated may last more than 6 months

- remission periods are usually longer when earlier in disease course

describe the recurrence of MDD (include % recurrence with 1, 2 and 3 episodes)

risk increases with each episode

- 1 = 50% recurrence

- 2 = 70% recurrence

- 3 = 90% recurrence

what initial treatment selection is considered for a mild MDD episode?

- psychotherapy and pharmacotherapy demonstrate similar benefits

- psychotherapy preferred since lower risks

overall, what initial treatment selection is considered for a moderate MDD episode?

- psychotherapy OR pharmacotherapy are appropriate

- combo may be considered but not specified if this combo is actually better

for a moderate MDD episode, what is more efficacious for acute treatment?

pharmacotherapy may be more effective in reducing depressed mood, guild, suicidal thoughts, anxiety and somatic symptoms

for a moderate MDD episode, what is more efficacious for medium term treatment?

structured psychotherapy is more effective in the medium term, 6-12 mo

overall, what initial treatment plan is used for a severe episode of MDD?

combo of psychotherapy and pharmacotherapy

for a severe MDD episode, what should be used if psychotic symptoms are present?

antidepressant + antipsychotic

what treatment can be considered for severe or life-threatening MDD?

ECT

what are 5 examples of non-pharm treatments for MDD?

- cognitive behavioral therapy (CBT)

- transcranial magnetic stimulation (TMS)

- bright light therapy

- exercise

- digital health intervention (DHI)

describe cognitive behavioral therapy (CBT)

form of psychotherapy that works to identify and change negative or unhelpful thought patterns

describe digital health intervention (DHI)

depression treatment through an app that requires a prescription

describe how electroconvulsive therapy (ECT) works and how effective it is for MDD

induces a seizure which can "reset" brain features, 80-90% effective for MDD