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Psychiatric Mental Health

Acute Serotonin Syndrome (Serotonin Toxicity)

  • Definition: Acute onset of serotonin toxicity from elevated serotonin levels due to a new serotonergic drug or increased dose. Progresses rapidly.

  • Timing: About 60% of cases occur within 6 hours of a dose change or overdose.

  • Diagnosis (Hunter Toxicity Criteria Decision Rules): patient must have taken a serotonergic agent and meet one of:

    • change in mental state

    • spontaneous clonus

    • inducible clonus plus agitation and diaphoresis

    • ocular clonus plus agitation or diaphoresis

    • tremor plus hyperreflexia

    • hypertonia plus temperature > 38°C (100.4°F) plus ocular clonus or inducible clonus

  • Pupils: may be dilated (mydriasis).

  • Higher risk when combining two drugs that both block serotonin (e.g., SSRIs, SNRIs, MAOIs, TCAs, opioid analgesics, OTC cough medicines, triptans, tryptophan).

  • Washout when switching to another drug affecting serotonin: minimum washout time = 2\ \text{weeks}.

  • Severity: Acute serotonin syndrome is potentially life-threatening. Refer to ED.

Malignant Neuroleptic Syndrome

  • Definition: Rare, life-threatening idiopathic reaction from typical and atypical antipsychotics.

  • Commonly seen with high-potency, first-generation antipsychotics (e.g., chlorpromazine, haloperidol).

  • Mortality: 10–20%.

  • Other context: can also occur in Parkinson disease (parkinsonism hyperpyrexia syndrome) due to withdrawal or changes in dopaminergic therapy.

  • Onset: usually 1–3 days after initiation or rapid dose increase.

  • Signs/symptoms: sudden high fever, muscular rigidity, bradykinesia, mental status changes, dysautonomia (fluctuating BP), urinary incontinence.

  • History to look for: mental illness history and antipsychotic prescription.

  • Management: This is potentially life-threatening; refer to ED or call 911.

Suicide Risk Factors

  • Older individuals recently experiencing significant loss (spouse death/divorce).

  • Access to lethal means (gun or other weapons).

  • History of suicide attempts or family history of suicide.

  • Mental illness: depression, bipolar disorder, personality disorders, psychotic disorders, PTSD.

  • History of traumatic brain injury.

  • History of abuse (sexual, emotional, physical) and neglect.

  • Terminal illness or chronic illness with chronic pain.

  • Substance use disorders (alcohol or other drugs).

  • Age distribution: higher risk in ages 15–24 or over 60.

  • Life events: significant losses (divorce, job loss, bereavement).

  • Gender differences: females attempt more often; males die more often; older adult males with recent partner loss are at highest risk.

Mental Health Evaluation

At-Risk Patients

The Baker Act

  • Definition: Involuntary commitment legislation allowing 72 hours (3 days) of involuntary detention for evaluation and treatment for persons at very high risk for suicide and/or harming others.

  • Note: Legislation name varies by state.

Common Mental Health Questionnaires

  • Beck Depression Inventory-II (BDI-II): a self-report inventory for evaluating depression; based on negative cognitions about self/world causing depression.

  • Diagnostic and Statistical Manual of Mental Disorders, 5th Edition-Text Revision (DSM-5-TR): diagnostic manual for mental/emotional disorders used by APA.

  • Folstein Mini-Mental State Exam (MMSE): questionnaire to evaluate confusion/dementia (e.g., Alzheimer’s, stroke).

  • Geriatric Depression Scale (GDS): 30-item yes/no questionnaire; shorter 15-item version; self-assessment for older adults.

  • Generalized Anxiety Disorder 7-Item (GAD-7) Scale: screening tool for anxiety. Scores: 0–21; higher = higher anxiety. Severe ≥ 15, moderate 10–14, mild 5–9.

  • Patient Health Questionnaire–9 (PHQ-9): self-administered depression screen scoring DSM-5 criteria (0–3 per item).

  • Note: A MMSE-style test may describe tasks (e.g., spell world backward) and identify the tool’s name.

Folstein Mini Mental State Exam (MMSE) – Key Components and Scoring

  • Orientation: date, location.

  • Immediate Recall: recall three unrelated words (e.g., pencil, apple, ball).

  • Attention/Calculation: e.g., count backward from 100 by 7s; spell "world" backward.

  • Writing/Copying: write a sentence; copy intersecting pentagons.

  • Scoring: maximum 30; score < 19 indicates impairment.

Selective Serotonin Reuptake Inhibitors (SSRIs)

  • First-line treatment for: major depression, OCD, GAD, panic disorder, social anxiety, PMDD, PTSD.

  • Common SSRIs: Fluoxetine, Paroxetine, Citalopram, Escitalopram, Sertraline, Fluvoxamine.

  • Notable effects: loss of libido, erectile dysfunction, anorexia, insomnia. Paroxetine associated with erectile dysfunction; SSRIs may suppress appetite.

  • Tapering/discontinuation:

    • Wean SSRIs over 2–4 weeks prior to discontinuation.

    • Paroxetine: highest risk of discontinuation symptoms; may require 3–4 weeks or longer off therapy.

    • Fluoxetine: least likely to cause discontinuation syndrome due to long half-life; taper 1–2 weeks.

    • Abrupt discontinuation: may cause dysphoria, fatigue, chills, myalgias, headaches, dizziness, GI distress. Discontinuation syndrome occurs in ~20\%–30\%.

  • Important tips:

    • Paroxetine and venlafaxine have short half-lives; gradual tapering recommended; abrupt cessation avoided.

    • Among SSRIs, Paroxetine most likely to cause erectile dysfunction.

  • Contraindications: Avoid SSRIs within 14 days of MAOI due to risk of serotonin syndrome; may induce mania in bipolar patients.

  • Monitoring: Monitor psychiatric medications; metabolic and QS features.

Psychiatric Medications – Adverse Effects & Monitoring

Atypical Antipsychotics

  • Adverse effects: weight gain/obesity, diabetes type 2; monitor BMI, weight every 3 months; annual ECG for QTc changes.

Typical Antipsychotics

  • Adverse effects: dyslipidemia (elevated lipids/triglycerides), extrapyramidal symptoms (EPS), tardive dyskinesia; QT prolongation; rare malignant neuroleptic syndrome.

Monitoring for Antipsychotics

  • Labs: fasting glucose, lipid panel; boxed warnings for frail elderly—higher mortality with antipsychotics.

  • EPS monitoring: dystonia, parkinsonism, akathisia, tardive dyskinesia; annual QTc monitoring via ECG.

Anticonvulsants

  • Adverse effects: Stevens–Johnson syndrome (Lamotrigine).

  • Monitoring: patient to report rashes; monitor serum concentrations (e.g., carbamazepine, valproic acid).

Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)

  • Adverse effects: may precipitate acute narrow-angle glaucoma; nicotine use reduces bioavailability (~33%); venlafaxine requires tapering to avoid withdrawal.

  • Monitoring: avoid with uncontrolled narrow-angle glaucoma; do not use within 5 days before or 14 days after MAOI, linezolid, selegiline, IV methylene blue.

Tricyclic Antidepressants (TCAs)

  • Adverse effects: anticholinergic; contraindicated in pregnancy (Category X).

  • Monitoring: avoid combining with SSRIs or MAOIs due to risk of serotonin syndrome; annual QTc monitoring.

  • Not first-line for depression; also used for postherpetic neuralgia, migraine prophylaxis; overdose risk high (fatal arrhythmias).

Lithium

  • Indications: bipolar disorder; monitor thyroid and renal function due to potential organ toxicity; narrow therapeutic window (0.6 to 1.2 mmol).

  • Monitoring: TSH annually; serum trough level 12 hours after last dose; watch for Ebstein’s anomaly risk during pregnancy; caution in dehydration/sodium depletion.

Tricyclic Antidepressants – Details

  • Not first-line for general depression.

  • Other uses: postherpetic neuralgia, urinary incontinence.

  • Overdose: risk of ventricular arrhythmias and seizures.

  • Examples: Doxepin, Imipramine, Amitriptyline, Nortriptyline.

  • Tips: TCAs are used for herpetic neuralgia and migraine prophylaxis (not acute treatment).

Monoamine Oxidase Inhibitors (MAOIs)

  • Rarely used due to serious food and drug interactions.

  • Examples: Phenelzine, Tranylcypromine.

  • Interactions: Do not combine with SSRIs, TCAs, MAO-B inhibitors (selegiline), serotonin receptor agonists (sumatriptan, zolmitriptan).

  • Contraindications: Do not combine MAOI with SSRI/SNRI or TCA; wait at least 2 weeks before starting SSRI or TCA to reduce serotonin syndrome risk.

  • Diet interactions: High-tyramine foods can cause hypertensive crisis; avoid fermented foods (beer, Chianti, aged cheeses, fava beans).

High-Tyramine Foods and MAOIs

  • Tyramine-rich foods can cause a pressor response, increasing BP and stroke risk; also linked to migraines in susceptible individuals.

Benzodiazepines

  • Indications: anxiety disorders, panic disorder, insomnia (not always first-line).

  • Severe alcohol withdrawal and seizures: Diazepam, Chlordiazepoxide.

  • Tapering: do not discontinue abruptly; gradual taper.

  • Examples by duration: ultra-short (Midazolam, Triazolam), medium (Alprazolam, Lorazepam), long (Diazepam, Chlordiazepoxide, Temazepam, Clonazepam).

Abuse

  • Abuse is multifactorial, including physical, emotional, sexual abuse, neglect, and economic exploitation.

  • Higher risk in older adults (>80) who are frail; children with disabilities and stepchildren more likely to be abused.

  • Types: physical, sexual, emotional/psychologic, financial, neglect.

  • Common finding: delay in seeking medical treatment.

  • IPV (Intimate Partner Violence) is intentional control by a partner; key to diagnosis is asking direct questions.

  • Abuser pattern: abuser often answers questions; interview together and then separately.

  • Risk factors increasing abuse: increased caregiver stress, substance use, personal/family history of abuse, major life losses, social isolation, pregnancy, elder abuse.

  • Mandatory reporting: varies by state; report suspected abuse of children, elders, or disabled persons per local laws.

Physical Exam – Abuse (All Types)

  • Use two-person examination when abuse suspected; an observer present.

  • Interview victim without abuser present.

  • Use photography to document injuries with a scale; keep evidence secure.

  • Use abuse assessment tools with body maps.

  • Look for red flags: spiral fractures, multiple healing fractures, patterned burns, welts.

  • Look for neglect signs: dirty clothing, inappropriate weather-appropriate attire.

  • For partner abuse: create a safety plan; provide crisis center or safe place contact information.

  • STI testing: chlamydia, gonorrhea (cultures + Gen-Probe), HIV, hepatitis B, syphilis, herpes type 2; cultures for genital, throat, anal sites.

Abuse – Communication & Planning

  • Abused patients may be fearful and quiet in presence of abuser.

  • Abuser often answers questions for the patient and displays controlling behavior.

  • Strategy: interview together and separately; ensure patient safety and support.

  • Treatment planning: STI prophylaxis (with parental consent for minors); educate on cycle of abuse; safety issues and escape plan.

  • Mandatory reporting: child abuse must be reported; elder abuse varies by state; abuse of a disabled person must be reported to appropriate authorities.

  • Good communication: objective statements, open-ended questions, do not reassure in ways that suppress discussion; validate feelings; let patient vent.

Alcohol Use Disorder

  • Definition: Compulsive desire to drink despite consequences; may be mild, moderate, or severe per DSM-5-TR.

  • Dependence: physical, behavioral, and physiologic symptoms; abrupt cessation causes withdrawal.

  • Abuse: maladaptive pattern of drinking.

  • Legal limit for driving: Blood alcohol level > 0.08\%.

  • Standard drink sizes (US): Beer 12 oz, Malt liquor 8–9 oz, Wine 5 oz, 80-proof liquor 1.5 oz.

  • Dietary guidelines: Women 1 drink/day; Men 2 drinks/day.

  • Binge drinking: BAC ≥ 0.08% on one occasion; males ≥5 drinks; females ≥4 drinks on one occasion.

  • Metabolism: Women metabolize alcohol ~50% slower than men; greater risk of liver damage.

  • Excessive use: third-leading preventable cause of death in the US.

  • Screening tips: ask who is most likely to become alcoholic; note female abstinence patterns.

Labs for Alcohol Use

  • Gamma-glutamyl transferase (GGT): may indicate occult alcohol abuse (ALT/AST can be elevated).

  • AST/ALT ratio: often elevated in alcoholism; ratio AST:ALT ≈ 2:1 is suggestive of alcohol-related liver disease.

  • Mean corpuscular volume (MCV): may be elevated (>100 fL) due to folate deficiency; macrocytosis.

  • Lipids: triglycerides can be high due to altered hepatic lipid synthesis; very high TG risk pancreatitis.

  • Platelets: alcohol can cause thrombocytopenia and bleeding risk.

  • Additional: RBCs may show macrocytosis; albumin and nutrition status may be affected.

Carbohydrate-Deficient Transferrin (CDT)

  • Biomarker for chronic alcohol abuse (2–3 weeks or longer). Elevated CDT with elevated ALT/AST supports chronic heavy drinking.

  • CDT detects binge or daily heavy drinking; useful for relapse monitoring.

  • CDT is superior to GGT or MCV for detecting chronic alcohol abuse and alcohol-related liver disease.

  • Tips: GGT elevation can indicate occult alcohol abuse; AST/ALT ratio ≥ 2 is more likely with alcoholism.

Quick Screening Tests for Alcohol Use / Abuse

  • CAGE: 4-item screen; positive if at least 2 are positive: Cut down, Annoyed by criticism, Guilty about drinking, Eye-opener.

  • T-ACE: Similar to CAGE but with first question altered; 2+ positive suggests risk. (T) How many drinks does it take to make you feel high?

  • Short Michigan Alcoholism Screening Test (SMAST-15): 13 items; shorter version; time-consuming to score.

  • Alcohol Use Disorders Identification Test (AUDIT): 10 questions; highly accurate across populations (~92%).

  • AUDIT-C: 3-question short form of AUDIT.

Treatment Plan for Alcohol Use Disorder

  • Pharmacologic: Disulfiram (Antabuse) causes severe nausea/vomiting, headache; Naltrexone (Vivitrol) reduces cravings.

  • Behavioral: Refer to 12-step programs (Alcoholics Anonymous), therapists, and recovery programs; avoid drugs with abuse potential; avoid alcohol-containing meds.

  • 12-step programs: AA supports recovery with mentor support; Al-Anon for families; Alateen for teen children of alcoholics.

Acute Delirium Tremens (DTs)

  • Features: sudden confusion, delusions, transient hallucinations (auditory, tactile, visual), tachycardia, hypertension, tremors, psychomotor agitation, seizures.

  • Context: associated with major alcohol withdrawal; medical emergency; refer to ED.

Korsakoff Syndrome & Wernicke–Korsakoff Syndrome

  • Cause: chronic thiamine (vitamin B1) deficiency due to chronic alcohol abuse; neurological sequelae.

  • Wernicke’s: hypotension, visual impairment, coma; signs include mental confusion, ataxia, stupor.

  • Korsakoff’s syndrome: amnestic disorder with anterograde and retrograde memory deficits; confabulation, attention deficits; permanent brain damage if untreated.

  • Treatment: high-dose thiamine IV; treat promptly.

Korsakoff Amnesic Syndrome

  • Type of amnesia from chronic thiamine deficiency; difficulties acquiring new information and retrieving older memories; confabulation and disorientation.

Anorexia Nervosa

  • Onset: typically adolescence.

  • Mortality: ~5% overall; death rate 5–10x higher than general population.

  • Core features: intense fear of gaining weight; distorted body image; secrecy; perfectionism; restricted intake; BMI < 18.5; lanugo; amenorrhea ≥ 3 months; possible dental enamel loss with purging.

  • Complications: osteopenia/osteoporosis from estrogen depletion; REDS (relative energy deficiency in sport); edema from malnutrition; cardiac complications are leading cause of death (arrhythmias, cardiomyopathy).

  • Treatment: refer to eating disorders therapist or inpatient ED unit; specialized treatment plans.

  • Treatments to avoid in eating disorders: Bupropion contraindicated due to seizure risk.

  • Tips: recognize signs (lanugo, edema, amenorrhea, BMI < 18.5).

Bipolar Disorder

  • Definition: mood instability with episodes of mania and depression; onset commonly in 20s (range 14–30).

  • Types: Bipolar I (manic episodes) and Bipolar II (hypomania).

  • Suicide risk: 10–15% die by suicide; comorbidity with substance use; risk higher during depressive phases; may have psychotic features.

  • Management: bipolar patients require psychiatric management; medications include mood stabilizers, anticonvulsants, and antipsychotics.

  • Medications listed (examples): Lithium salts; Divalproex (Valproate/Depakote); Lamotrigine (Lamictal); Carbamazepine (Tegretol); second-generation antipsychotics (aripiprazole, risperidone, quetiapine, olanzapine).

Insomnia (Sleep Disorder)

  • Typical prevalence: 7–8 hours ideal; 40–70 million Americans have transient to chronic insomnia.

  • Symptoms: difficulty falling asleep, staying asleep, or early morning awakening; daytime fatigue, irritability, cognitive difficulties.

  • Etiology: circadian rhythm disorders, psychiatric illness, environmental factors, medications, jet lag, noise; medical conditions contributing (OSA, restless legs, etc.).

  • Classification:

    • Primary insomnia

    • Insomnia with medical condition

    • Episodic (1–3 months)

    • Short-term (acute) (<3 months)

    • Persistent (≥3 months, ≥3 nights/week)

  • Treatment:

    • Sleep hygiene first-line: regular schedule, nighttime routine, avoid caffeine/tobacco/heavy meals before bed, use bed only for sleep/sex, if not asleep within 30 minutes, get out of bed.

    • Avoid screens in bed to reduce blue light exposure affecting melatonin.

    • CBT-I (cognitive behavioral therapy for insomnia) recommended for chronic insomnia; may be combined with meds.

    • Refer to sleep lab for suspected sleep apnea; if diagnosed, refer to otolaryngology.

  • Medications:

    • Diphenhydramine (Benadryl) is a sedating antihistamine to avoid in older adults.

    • Benzodiazepines/hypnotics: short-acting (triazolam, midazolam); intermediate (lorazepam, temazepam, clonazepam); long-acting (diazepam, chlordiazepoxide, etc.).

    • Non-benzodiazepine hypnotics with quick onset (15–30 min): Zolpidem (Ambien), Eszopiclone (Lunesta); Ramelteon (Rozerem, melatonin receptor agonist) for sleep onset; Temazepam/lorazepam for both onset and maintenance.

    • Avoid long-term use due to dependence; taper when stopping.

  • Alternatives:

    • Buspirone (BuSpar) for chronic anxiety; not as-needed.

  • Complementary/Alternative Treatments: avoid kava-kava due to liver injury risk; valerian root; melatonin; chamomile; meditation, yoga, tai chi, acupuncture, exercise; beware herb-drug interactions.

  • Tips: valerian may interact with benzodiazepines/hypnotics; more questions on alternative treatments today.

Major & Minor Depression (Unipolar Depression)

  • Also called Major Depressive Disorder (MDD); severity categorized as mild, moderate, severe based on symptom count/severity; strong genetic component; associated with serotonin and norepinephrine dysfunction.

  • Symptoms (SIG-E-CAPS):

    • Sleep disturbances

    • Interest loss

    • Guilt/guilty feelings

    • Energy depletion

    • Concentration difficulties

    • Appetite changes

    • Psychomotor changes (agitation/retardation)

    • Suicidal ideation

  • Immediate goal: assess suicidality/homicidality.

  • Differential: rule out organic causes (hypothyroidism, anemia, autoimmune disorders, B12 deficiency, etc.).

  • Screening & Labs:

    • CBC, chemistry panel, TSH, folate, B12, UA; screen for organic causes; drug screening if risk.

  • Treatment plan:

    • Psychotherapy; CBT; antidepressants; combination therapy often superior to either alone.

    • First-line meds: SSRIs; expect antidepressant effect in 4–8 weeks (up to 12 weeks);

    • In older adults or those with renal/hepatic impairment, start at low dose and titrate slowly; follow up in 2 weeks for adherence/side effects.

    • Other antidepressants: SNRIs (duloxetine, venlafaxine); TCAs (amitriptyline, nortriptyline).

    • TCAs: bedtime dosing due to sedation; avoid in suicidal patients due to overdose risk; boxed warning for elderly with dementia on antipsychotics.

    • SSRIs for chronic anxiety disorders as well (social anxiety, PD, etc.).

  • Special considerations with SSRIs:

    • Boxed warning: increased suicidality in children, adolescents, young adults (18–24, especially early treatment months).

    • Older adults: consider citalopram or escitalopram due to fewer drug interactions; may prolong QT interval.

    • If sexual dysfunction occurs, add bupropion or switch to SNRI or atypical antidepressant.

    • Bupropion can aid smoking cessation (Zyban) and is sometimes added to SSRIs; avoid in eating disorders due to seizure risk.

    • Duloxetine useful for neuropathic pain; TCAs for neuropathic pain, stress urinary incontinence; avoid in potential overdose risk.

  • Antipsychotics: monitor EPS and metabolic syndrome; antipsychotics carry risk of metabolic disturbances; pregnancy considerations; baseline and annual labs including A1C, lipids, and EKGs for some patients.

  • Anticholinergic effects: many drugs have anticholinergic side effects; use SAD CUB mnemonic (Sedation, Anorexia, Dry mouth, Confusion/Constipation, Urinary retention, BPH).

Complementary/Alternative Treatments for Depression

  • St. John’s wort: interacts with SSRIs, TCAs, MAOIs, and many other drugs; can cause breakthrough bleeding with birth control; interactions with protease inhibitors; avoid in certain populations.

  • Amino acid supplements (5-HTP, L-tryptophan): risk of serotonin syndrome when combined with SSRIs/MAOIs; potential interactions with triptans.

  • Omega-3 fatty acids: generally safe; no major drug interactions; high-dose may affect bleeding risk.

  • Folic acid and Vitamin B6: generally safe; used in some regimens.

  • Exercise, yoga, mindfulness, massage, acupuncture, light therapy, and CBT-based approaches as adjuncts.

St John’s Wort – Important Interactions

  • Interacts with SSRIs, SNRIs, TCAs, MAOIs, protease inhibitors, and oral contraceptives; can reduce or enhance effects of many medications; risk of serotonin syndrome when combined with SSRIs/MAOIs.

Serotonin Syndrome – Quick Reference

  • Serotonin syndrome can occur with SSRIs, MAOIs, SNRIs, TCAs, triptans, dextromethorphan, and other serotonergic agents.

  • Monitor for mental status changes, autonomic instability, neuromuscular abnormalities (clonus, hyperreflexia).

Omega-3 Fatty Acids, Folate, Vitamin B6, and Other Supplements

  • Generally no major interactions; used as adjuncts in some regimens.

Exercise and Mindfulness – Behavioral Interventions

  • Exercise and mindfulness can be effective non-pharmacological treatments for depressive symptoms.

Motivational Interviewing

  • A counseling method to resolve ambivalence and evoke internal motivation for healthier behaviors.

  • Evidence supports reducing substance use, smoking cessation, and other risky behaviors.

Five Principles of Motivational Interviewing

1) Express and listen with empathy (reflective listening).
2) Understand the patient’s own motivations.
3) Avoid argument or direct confrontation.
4) Adapt to the patient rather than oppose.
5) Support self-efficacy (Bandura).

E-Cigarettes and Vaping (EVALI)

  • E-cigarettes deliver nicotine via aerosol; vitamin E acetate in some products linked to EVALI; THC-containing vapes also implicated.

  • CDC/FDA warn that vaping is not safe for youth, young adults, or pregnant patients; awareness of symptoms: dyspnea, chest pain, GI symptoms, fever.

Smoking Cessation

  • Tobacco is a leading preventable cause of death; discuss cessation at every visit.

  • Nicotine replacement therapy (gum, patches) interactions: do not use patches with gum simultaneously; do not smoke while using patches.

  • Bupropion (Zyban) reduces cravings; can be combined with nicotine products; contraindicated in seizure disorders, eating disorders, abrupt ethanol withdrawal, benzodiazepine withdrawal, significant brain pathology, or severe stroke; may increase suicidal ideation risk in depressed patients.

  • Varenicline (Chantix): 12-week course (or longer) can reduce cravings; may be combined with nicotine patches; psychiatric history should be considered due to possible neuropsychiatric effects; FAA prohibits pilots/air traffic controllers from using it due to potential neuropsychiatric symptoms.

  • Adverse effects: neuropsychiatric effects; may impair driving/heavy machinery.

Other Smoking Cessation Details

  • Do not combine nicotine patches with gum; do not smoke while using patches.

  • Zyban can be used with nicotine products; aim to eventually quit.

Electronic Cigarettes (E-Cigs) – Safety & Q&A

  • EVALI risk: major cause of vaping-related lung injury; symptoms include respiratory symptoms and GI symptoms; CTD and CDC data highlight risk.

Motivational Interviewing – Summary

  • Five principles summarized above; effective for substance use disorders and other unhealthy behaviors; focuses on building intrinsic motivation rather than imposing external changes.

Additional Notes and Pearls

  • Pearls: patients recovering from depression may gain energy and become suicidal again; monitor closely when refilling meds; safest option is gradual dosing and close follow-up.

  • When prescribing hazardous medications (benzodiazepines, hypnotics, narcotics, TCAs), use minimal effective dose and close follow-up; overdoses can be fatal.

  • In depression management with older adults, consider comorbidity and functional status; adjust dosing accordingly.

Quick Mental Health References and Formulas

  • Serotonin syndrome diagnostic rule (summary): serotonergic agent + one of the Hunter criteria features.

  • Alcohol BAC threshold for driving: \text{BAC} > 0.08\%.

    AST:ALT ratio often elevated in alcoholic liver disease: approximate ratio \frac{AST}{ALT} \approx 2:1.

  • Lithium therapeutic window: 0.6 \text{ to } 1.2\ \text{mmol/L}; require regular trough levels (12 hours post-dose).

  • Boxed warnings: Suicide risk in young patients on SSRIs; elderly patients on antipsychotics have increased mortality risk in some settings.