Psychiatric Mental Health

Flashcards covering acute conditions, pharmacology, assessment tools, disorders, treatment plans, risk factors, and miscellaneous topics from the lecture notes.

What is Acute Serotonin Syndrome (Serotonin Toxicity)?

A potentially life-threatening condition caused by very high serotonin levels after starting or increasing a serotonergic drug or due to a drug interaction; presents acutely with rapid progression.

What are the Hunter Criteria for Serotonin Syndrome used to diagnose it?

A patient must have taken a serotonergic agent and meet at least one of: change in mental state; spontaneous clonus; inducible clonus with agitation and diaphoresis; ocular clonus with agitation or diaphoresis; tremor with hyperreflexia; or hypertonia with fever >38°C plus ocular or inducible clonus.

What sign involving the pupils can be seen in serotonin syndrome?

Mydriasis (dilated pupils).

Which drug classes increase the risk of serotonin syndrome when combined?

SSRIs, SNRIs, MAOIs, TCAs, opioid analgesics, some OTC cough medicines, triptans, and tryptophan.

What is the required washout time when switching to another drug that affects serotonin?

A minimum washout period of 2 weeks.

What is Malignant Neuroleptic Syndrome (MNS)?

A rare, life-threatening reaction to typical or atypical antipsychotics, with mortality 10-20%.

MNS associated conditions can include withdrawal related syndromes from which therapy?

Parkinson disease therapies such as L-dopa or dopamine agonists can precipitate parkinsonism hyperpyrexia syndrome similar to MNS.

When does Malignant Neuroleptic Syndrome usually develop after initiation or dose increase?

Usually within 1 to 3 days.

Name four signs of Malignant Neuroleptic Syndrome.

High fever, muscular rigidity, bradykinesia, altered mental status, dysautonomia, and urinary incontinence.

What is a Baker Act?

Involuntary commitment allowing 72 hours of detention for evaluation and treatment for persons at very high risk for suicide or harming others.

What is the Beck Depression Inventory II used for?

A self-report inventory for evaluating depression based on negative cognitions about the self and world.

What is the DSM-5-TR used for?

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition-Text Revision; the standard diagnostic manual for mental disorders.

What is the Folstein MMSE used to assess?

Cognitive function to screen for confusion and dementia; assesses orientation, recall, attention/calculation, language, and visuospatial skills.

What does a MMSE score indicate if it is less than 19?

Indicates cognitive impairment.

What is the Geriatric Depression Scale (GDS)?

A self-assessment depression questionnaire for older adults; 30-item version or a shorter 15-item version.

What is the GAD-7 used for?

A seven-item anxiety screening tool; higher scores indicate higher anxiety; cutoffs are 5 mild, 10 moderate, 15 severe.

What is the PHQ-9 used for?

A self-administered questionnaire for depression based on the nine DSM-5 criteria; scored 0-27.

What is the first line medication class for major depression, OCD, GAD, panic disorder, social anxiety, PMDD, and PTSD?

Selective Serotonin Reuptake Inhibitors (SSRIs).

What is Fluoxetine (Prozac) known for among SSRIs?

Longest half-life; first SSRI; useful for noncompliant patients.

What is Paroxetine (Paxil) known for among SSRIs?

Shortest half-life among SSRIs; associated with erectile dysfunction and withdrawal symptoms on abrupt discontinuation.

What is Citalopram noted for among SSRIs?

Has fewer drug interactions compared with other SSRIs.

What is Escitalopram in relation to Citalopram?

A compound derived from Citalopram; an SSRI with similar effects.

Name two other SSRIs besides the first three listed.

Sertraline (Zoloft) and Fluvoxamine (Luvox).

List common SSRI adverse effects.

Loss of libido, erectile dysfunction, anorexia, insomnia.

What is SSRI discontinuation syndrome and which SSRI has the least risk?

Symptoms after abrupt stopping (dysphoria, fatigue, chills, myalgias, headache); fluoxetine has lower risk due to its long half-life; taper over 2-4 weeks.

What are key contraindications and precautions with SSRIs?

Avoid within 14 days of MAOI; can induce mania in bipolar patients; taper to discontinue.

Why should MAOIs be avoided with SSRIs, SNRIs, or TCAs?

High risk of serotonin syndrome; requires a washout period before switching therapies.

What foods are high in tyramine and unsafe with MAOIs?

Fermented foods like aged cheeses, Chianti, beer, and fava beans; can cause hypertensive crisis.

What are SNRI examples and a common dosing caution?

Duloxetine, Venlafaxine, Desvenlafaxine; duloxetine can treat depression, anxiety, fibromyalgia, and diabetic neuropathy; avoid abrupt withdrawal for venlafaxine.

What are MAOIs used for and what are important food/drug interactions?

Phenelzine and Tranylcypromine; depressed & anxiety; avoid combining with SSRIs, SNRIs, TCAs; avoid high tyramine foods; requires washout when switching.

What is the boxed warning associated with antidepressants in older adults?

Increased risk of death in frail elderly patients on antipsychotics; monitor for EPS and metabolic effects.

What are typical antipsychotics commonly associated with in terms of adverse effects?

Extrapyramidal symptoms, tardive dyskinesia, QT prolongation, metabolic changes and rare malignant neuroleptic syndrome.

What lab and monitoring is recommended for atypical antipsychotics?

Monitor BMI/weight every 3 months; baseline and annual EKG for QTc changes; metabolic labs (glucose and lipids) and thyroid testing as indicated.

What are the main adverse effects of lithium?

Renal and thyroid effects; Ebstein's anomaly risk in pregnancy; narrow therapeutic window 0.6-1.2 mEq/L; monitor trough level 12 hours after dose; monitor TSH yearly.

What constitutes Ebstein's anomaly and its relevance to lithium?

A congenital heart defect where the leaflets of the tricuspid valve are displaced downward into the right ventricle that is linked to lithium exposure in pregnancy; important to consider in prenatal care.

What are common uses and concerns with tricyclic antidepressants (TCAs)?

Not first line for depression; used for neuropathic pain and urinary incontinence; risk of overdose causing fatal arrhythmias; anticholinergic effects.

Name four examples of TCAs.

Doxepin, Imipramine, Amitriptyline, Nortriptyline.

What are the main adverse effects of TCAs and a safety consideration?

Anticholinergic effects; avoid in patients at risk of suicide due to pill hoarding and overdose risk.

What are examples of SNRIs and how to they work?

SNRIs increased serotonin and norepinephrine availability; examples include Duloxetine, Venlafaxine, Desvenlafaxine; require gradual tapering to avoid withdrawal.

What is a key consideration when combining MAOIs with other antidepressants?

Wait at least 2 weeks before initiating SSRI or TCA to avoid serotonin syndrome.

What are the indications for benzodiazepines in treatment and a key precaution?

Indicated for anxiety, panic, and insomnia; avoid abrupt discontinuation; taper gradually to reduce withdrawal risk.

How are benzodiazepines categorized by duration?

Ultra-short: Midazolam, Triazolam; Short: Alprazolam, Lorazepam; Intermediate: Temazepam, Clonazepam; Long: Diazepam, Chlordiazepoxide.

What is the general approach to insomnia management?

Sleep hygiene as first line; Cognitive Behavorial Therapy for Insomnia (CBT-I) for chronic insomnia; consider short acting hypnotics with caution; avoid long term dependence.

What are nonbenzodiazepine hypnotics and their primary examples?

Zolpidem (Ambien), Eszopiclone (Lunesta), Ramelteon (Rozerem); rapid onset, lower dependence risk but can cause complex sleep related behaviors.

What are Beneficial Complementary Treatments for depression?

St John’s Wort, omega-3 fatty acids, exercise, yoga, meditation; be aware of herb-drug interactions.

What is St John’s Wort associated with in terms of interactions?

Interacts with SSRIs, TCAs, MAOIs, protease inhibitors, and oral contraceptives; can induce serotonin syndrome and reduce drug efficacy.

What is the Biochemical marker Carbohydrate-Deficient Transferrin used for?

A biomarker for chronic alcohol abuse that indicates recent heavy drinking or relapse; more reliable than GGT/MCV in some cases.

What are common screening tests for identifying alcohol use disorders?

CAGE, T-ACE, Short Michigan Alcoholism Screening Test (MAST 13 items), AUDIT and AUDIT-C.

What is the AUDIT and AUDIT-C used for?

AUDIT is a 10-question alcohol use screening tool with high accuracy; AUDIT-C is a shortened 3-question version.

What medical treatments are used for alcohol dependence?

Disulfiram (Antabuse) to cause aversive reaction; Naltrexone (Vivitrol) to reduce cravings; referral to AA; abstinence strategies.

What is Acute Delirium Tremens and when does it occur?

Sudden onset confusion, delusions, hallucinations, tachycardia, hypertension, tremors; a medical emergency from major alcohol withdrawal.

What is Korsakoff Syndrome and Korsakoff Amnesic Syndrome?

Neurologic consequences of chronic thiamine deficiency seen with chronic alcohol use, malnutrition, malabsorption, eating disorders; Wernicke-Korsakoff-visual problems, hypotension, coma; Korsakoff Amnesia- amnesia with attention deficits and confabulation causing difficultly learning new information; treat with high dose thiamine.

What are common signs of anemia or nutrition issues in alcohol use disorders?

Macrocytosis (MCV >100 fL); thrombocytopenia; elevated triglycerides; AST > ALT with 2:1 ratio suggests alcoholic liver disease.

What is the risk and management for alcohol withdrawal in the ED?

Identify acute delirium tremens; provide thiamine, fluids, electrolytes, and monitor vitals; initiate rehab/therapy.

What is the role of Motivational Interviewing in substance use disorders?

A counseling approach to resolve ambivalence and increase motivation for change.

What are the five principles of Motivational Interviewing?

Express empathy; understand the patient motivations; avoid arguing; adjust to the patient; support self-efficacy.

What are key features of PTSD and its first line treatment?

Trauma related symptoms including flashbacks, nightmares, avoidance; first line is trauma-focused psychotherapy; SSRIs preferred for pharmacotherapy.

What are core features of schizophrenia and a typical management approach?

Psychotic symptoms such as delusions, paranoia, disorganized thinking; treat with antipsychotics and psychiatric evaluation; monitor for QT prolongation and metabolic effects.

What are extrapyramidal symptoms (EPS) and tardive dyskinesia?

EPS include akinesia (difficulty in initiating or performing voluntary movements), akathisia (restlessness, agitation), bradykinesia (slowness of movement); tardive dyskinesia (repetitive, involuntary movements) is a late chronic EPS involving orofacial movements; monitor and manage accordingly.

What mnemonic is used to remember anticholinergic side effects and what does it stand for?

SAD CUB: Sedation, Anorexia, Dry mouth, Confusion/constipation, Urinary retention, BPH.

What is the general safety precaution for all antipsychotics in elderly patients?

Boxed warning for increased risk of death in frail elderly with dementia; monitor metabolic and cardiovascular risks.

What are common interactions between nicotine cessation therapies and other medications?

Bupropion helps with smoking cessation and antidepressant effects but lowers seizure threshold; varenicline (Chantix) reduces cravings but has neuropsychiatric risks; avoid combining nicotine patches with other nicotine products.

What is the recommended approach to prescribing when a patient has a history of suicidality and is starting antidepressants?

Conduct suicide risk assessment; monitor closely for suicidal ideation especially in first weeks; limit quantities of potentially lethal medications.

What is the role of omega-3 fatty acids in depression treatment?

No major drug interactions; potential benefits; high doses may increase bleeding risk.

What is the role of exercise and sleep hygiene in sleep disorders?

Regular exercise and proper sleep hygiene improve sleep quality; CBT-I often preferred for chronic insomnia; limit evening screen time.