CLASS 4: MENTAL HEALTH

I.ANXIETY DISORDER
In General
Definition

Comorbid Conditions
 Depression, Eating Disorders, Insomnia, OCD, Panic Disorder, PTDS, Substance Abuse,
Social Phobias
Assessment
History

Physical Findings
 Shaking, sweating, poor concentration, irritable, aggressive, unsteady gait (can’t focus)
Diagnosis
Diagnostic Criteria (DSM-V)
 Excessive anxiety and worry (apprehensive expectation), occurring more days than not
for at least six months, about a number of events or activities (such as work or school
performance).
 The individual finds it difficult to control the worry.
 The anxiety and worry are associated with three (or more) of the following six symptoms
(with at least some symptoms having been present for more days than not for the past six
months):
o Note: Only one item is required in children.
o Restlessness or feeling keyed up or on edge
o Being easily fatigued
o Difficulty concentrating or mind going blank
o Irritability
o Muscle tension
o Sleep disturbance (difficulty falling or staying asleep, or restless, unsatisfying
sleep)
 The anxiety, worry, or physical symptoms cause clinically significant distress or
impairment in social, occupational, or other important areas of functioning.
 The disturbance is not attributable to the physiological effects of a substance (eg, a drug
of abuse, a medication) or another medical condition (eg, hyperthyroidism).
 The disturbance is not better explained by another mental disorder
Differentials
 Afib: PE
 Arrhythmias: Breathing issues and funny feelings
 Asthma: Breathing issues
 Delirium
 Dementia
 Drugs (Caffeine, cocaine, nicotine, decongestants, synthroid, lithium, theophylline,
antiHTN, TCA-trazadone)
 CHF: Breathing issues
  COPD: Breathing issues
 GERD: Globus sensation
 Hyper/hypothyroidism: Causes similar feelings
 Hypoxia
 Infections: Pneumonia, influenza
 Respiratory distress
 Adjustment disorder, Depression, Hypochondriasis, Obsessive compulsive disorder,
Panic disorder
Plan
Nonpharmacologic
 Counseling is huge
 Check creatinine and BUN before starting SSRI
 Check CBC for white count and platelets before starting Remeron
Pharmacologic
 SSRIs: first line (Celexa, Lexapro, Paxil, Prozac, Zoloft); start low go slow to monitor
for side effects; consider morning dosing to avoid interfering with sleep
 Celexa (Escitalopram):
o Comes in tablet form.
o Start dosing at 10 mg and reevaluate in 1 month but can bump them up at 2 weeks
with max dosing 40mg
o Can start feeling benefits in first 2 weeks but usually feel better in 4-6 weeks.
o Black Box: QT interval
o BEERS List
 Lexapro (Citalopram)
o Comes in liquid form
o Start at 5mg and max dosing is 20mg
o No Black Box
 Paxil (Paroxetine)
o Comes in liquid form
o Start at 20 mg with max 40mg once daily
o Not that common with many side effects. Weight gain is big one
 Prozac (Fluoxetine)
o Comes in liquid form
o Great activator for someone with no energy, so don’t take at night. Longer half
life (like 70 hours) helps minimize med dosing for elderly
o Black Box warning
o BEERS lis
 Zoloft (Sertraline)
o Start at 12.5mg or 25mg with max 100mg and send them to psych after that
dosage.
o GI side effects
 Side Effects
o Weight gain (Paxil)
o Sexual (Celexa-can’t orgasm and decreased libido)
o Suicidal ideation (Black box for all SSRIs but Celexa most common)
 o Cardiac (Celexa- QT interval prolongation)
o Headaches often when giving too much early on
o GI-nausea usually goes away 7 days, take with food; also helps with starting low
o Orthostatis (Trazadone)
o Hangover (Trazadone)
 Benzodiazepines: need to worry about addiction; good for covering things like flying but
only give four tablets for trip
 Remeron
o Start at 7.5mg and after two weeks go up to 15mg
o An antidepressant/appetite stimulant with low side effect profile often in geriatric
population for depression
o Give at bed time cause it makes you sleepy without hangover
 SNRI
 Considered second line after SSRI used once exhausted with SSRI
 Advise patients they must taper off these medications-cymbalta is worst to stop abruptly-
because they get flu like symptoms-high temperature, delirium.
 Wellbutrin (Bupropion)
o Used for smoking cessation
o Causes big buzz
o Start once daily 37.5mg then 75mg daily then 75 mg BID then, once stable,
switch to 150mg XL due to XL’s more consistent dispensing system and the fact
BID interrupts with sleep
 Cymbalta (Duloxetine)
o Expensive so know insurance coverage of it
 Atypicals
o If on them like Risperdal, must check glucose A1c to avoid creating glucose
intolerance
o Refer if you are considering using atypicals
Diagnostics
o None mentioned
Patient Education
o None mentioned
Referral
 When anxiety significantly interferes with day to day life.
 Challenge is finding someone to refer to
Follow Up
 If nonpharm intervention, follow-up in 4-6 weeks
II. DEPRESSION
In General
Notes
o Know that if considering depression first rule out medical reasons first
Definition
o SIGECAPS
Comorbid Conditions
o Anxiety, substance abuse, bipolar
Clinical Presentation
 o Doesn’t make eye contact, fatigue, random aches and pains (with negative work-up),
headaches, bowel changes, stomach aches, insomnia (flag to go digging); can be
dissheveled, ungroomed, flat affected, act like they don’t care (in the sense of not
engaging), disinterested, patient looks sad, down, etc
o Risk factors for depression: SES, death in the family, death of spouse, death of animals,
new family illness, family history, substance abuse, age (30-64 is highest risk),
unemployment, bullying, drug use, LGBT, stress, bad relationships, date rape, obesity,
abuse (can also be in past and they just haven’t dealt with it), learning disability, post
partum depression (under-diagnosed), stressful life event, early onset dementia, females
more at risk. Older men over age of 80 have higher risk of completed suicide; women in
general have more attempts but are unsuccessful…men use firearms, women use poison
(overdose)
o Hardest part about treating patient with depression is diagnosing them
o Most common psychiatric disorder in primary care and people present with somatic
complaints.
o what do you think with untreated depression—ultimate risk is suicide but before that,
quality of life is decreased, not taking care of chronic illnesses, untreated depression has
increased risk of morbidity
Assessment
History
o none mentioned
Physical Findings
o Flat affect
o Constipation
Diagnosis
Criteria
o A major depressive episode manifests with five or more of the following symptoms for at
least two consecutive weeks; at least one symptom must be either depressed mood or loss
of interest or pleasure:
o Depressed mood most the day, nearly every day
o Loss of interest or pleasure in most or all activities, nearly every day
o Insomnia or hypersomnia nearly every day
o Significant weight loss or weight gain (eg, 5 percent within a month) or decrease
or increase in appetite nearly every day.
o Psychomotor retardation or agitation nearly every day that is observable by others
o Fatigue or low energy, nearly every day
o Decreased ability to concentrate, think, or make decisions, nearly every day
o Thoughts of worthlessness or excessive or inappropriate guilt, nearly every day
o Recurrent thoughts of death or suicidal ideation, or a suicide attempt
Differentials
o Hypothyroid, spinal cord injury, concussion, disabling illness, cardiac, cancer, UTI, lyme
disease
o Medications (BB, infertility drugs, Accutane (oral isotretinoin), birth control)
o B12
Plan
Nonpharmacologic
 o Same as anxiety
o Bright lights may help
o If traditional measures don’t help, consider ECT. ECT never prescribed in primary care-
memory loss is big issue
Pharmacologic
o SSRI is first line treatment- start low and slow
o Same as anxiety
Diagnostics
o None mentioned
Patient Education
o Educate treatment can take 4-6 weeks to be effective for depression and 2 weeks for
anxiety
Referral
o None mentioned
Follow Up
o None mentioned
III. SUBSTANCE ABUSE
In General
Notes
o Biggest challenge is patient denial/hiding it
o Challenges with opioids/benzs: accessible from prescriber-sports injuries
o If you don’t feel comfortable prescribing-send patient to pain clinic
o Challenge with addicts is lying that prevents diagnosis and the need to actively attend
treatment
Definition
o None mentioned
Comorbid Conditions
o ADHD, Anxiety, Depression, Eating Disorders, Pain, Personality Disorders, Psych
Disorders
Clinical Presentation
o These patients often are good at hiding their problems
Assessment
History
o Family history of substance abuse is huge and must starting teaching immediately
Physical Findings
o Jaundice, hepatomegaly, yellow/grey skin color, track marks, esophageal varices (in
hardcore alcoholics)
Diagnosis
Criteria
o No questions on DSM criteria
Differentials
o Hypothyroid
o Hypoglycemia
o Dementia
Plan
Nonpharmacologic
 o Insurances usually only pay for 72 hours of treatment-so finding money is the real
problem
o Treatment is done as team
o Antabuse is a band aid but its available
Pharmacologic
o None mentioned
Diagnostics
o None mentioned
Patient Education
o None mentioned
Referral
o Need to refer active users for treatment
Follow Up
o None mentioned
IV. EATING DISORDERS
In General
Notes
o Women 10x more likely to have eating disorder than men with white women more likely
than colored women
o Early teens and young adult most common
o Bulimia is more common than anorexia, but anorexia associated with 10 fold increase in
premature death-most often suicide
o Risk factors: females, teenagers, sports (gymnastics, cheerleading, dance, ballet,
wrestling, crew)
o Ostopenia is side effect
Definition
o Concern with body shape and weight
Comorbid Conditions
o Anxiety, depression, OCD, phobias, PTSD, separation anxiety
Assessment
History
o None mentioned
Physical Findings
o Anorexia
o When was your last period-red flag is irregular menses and amenorrhea
o VS: tachycardia with bradycardia more concerning and needing check for
potassium followed by EKG (often use caffeine to up HR for exam)
o Lanugo
o Cardiac Assessment for murmurs
o Neuro assessment for muscle wasting, motor weakness, DTR latency
o Bulimia
o Russell sign: scarring on back of fingers from inducing vomiting
o Teeth erosion
o Salivary or parotid gland enlargement due to vomiting
o Esophageal rupture is rare but possible
Diagnosis
Criteria
o
Differentials
o Peptic ulcer, adrenal insufficiency, cancer, AIDS, depression, OCD, GERD,
malabsorption
Plan
Nonpharmacologic
o Cognitive behavior therapy-First line treatment
o Food logs-try one food per week
o Contract that provides they go to hospital if weight drops past certain number
o Pink Paper if bradycardia, hypokalemia
o Check bone density, vitamin D for osteopenia
o Check metabolic panels (K, BUN, creatinine); prealbumin for snapshot of past 10 day
nutrition; TSH; urinalysis for toxic screen; pregnancy (if amenorrhea)
Pharmacologic
o SSRI: first line pharm-need more frequent BP and cardiac monitoring (don’t do celexa or
remeron that can cause weight gain)
Diagnostics
o Labs to determine amenorrhea
Patient Education
o None mentioned
Referral
o Eating disorders referred out to ED clinics so they cant split providers
o GYN for amenorrhea
o Dental for teeth
Follow Up
o None mentioned