PSYCH MENTAL HEALTH RECORDINg side notes

PHQ - 2 is for depression

• questions

  • if it is positive then we do a PHQ 9

Major depressive disorder

• first line

  • SSRI Sertraline (zoloft)

    • 2 SSRIs that are safe in older adults

      • zoloft and lexapro

      • Dangerous in older adults

        • fluoxetine - long half-life

        • Paxel (most sedating) 3:29

    • What SSRI would you avoid with someone who has anxiety?

      • Prozac - nervousness is a known side effect

    • In a pediatric patient for whom therapy has not helped, what is the first line for depression

      • prozac

  • SNRI - (Duloxetine (Cymbalta), Venlafaxine (Effexor)

    • DO NOT USE WITH uncontrolled HTN

      • cause increase in BP due to norepi

    • Key education

      • 4-6 weeks to start working

        • after that we can increase dose or check out the underlying conditions

        • Usually we keep them on these for 6-12 months after symptoms are gone

      • Sides

        • GI issues - no need to stop, they will disappear

        • sexual issues

        • weight gain

  • Tricyclic antidepressants - Nortriptyline (pamelor)

    • not first line

    • cause

      • weight gain and ECG changes

      • NONE IN OLDER ADULTS

  • Bupropion (Wellbutrin)

    • Avoid in patients with anxiety and insomnia because it stimulates

    • can be used for smoking cessation

    • can be used with SSRI for low libido

  • Herbal supplements

    • St john’s wort for depression

      • Do not take with any SSRI or SNRI due to serotonin syndrome

  • Signs of Seratonin syndrome

    • shivering

    • tachy

    • agitation

    • EMERGENCY prompt referral to ED

Anxiety

• pneumonic

  • WATCHERS

• First line

  • SSRI or SNRI

  • adjunct med

    • buspar or buspiroe

• screening

  • GAD 2 if score is above 3 then GAD 7

PTSD

• Medication and therapy first line

  • first line

    • SSRI

Insomnia

• first line  

  • education about sleep hygiene

  • then therapy

  • then meds

    • benedryl / melatonin

    • Ambien but sides are a lot

      • BOX warning for sleep driving

Bi polar

• characterised

  • extreme mood episodes

    • mania like bipolar 1 then they get depressed

• First line

  • Lithium

    • narrow therapeutic range 0.6-1.2

      • anything at 1.5 or greater is toxic

      • signs of lithium toxicity

        • N/V

        • tremors

        • hyperactive reflexes

        • vision changes

      • What gland to watch

        • Thyorid cause lithium can lead to hypothyroid

Antipsychotics -

• typical or first gen

  • halodol

• Atypical second gen

  • serequel or zyprexa

• Weight gain hyperlipids, hyperglycemia

Most psych meds are liver metabolism with CYP450 enzyme or CYPA4 and CYP2C19

• don’t play with digoxin and warfarin