| Bipolar 1: Manic +/- major depression
Bipolar 2 : Major depression with at least one episode of hypomania | What is the difference between Bipolar 1 and 2 |
| 2/3 have multiple relapses. Mose within 2 years. | What is the relapse rate for Bipolar? |
| Depression and anxiety ( 25% will be Bipolar) Social anxiety
Substance abuse ( 70%)
Suicide attempt ( 50%)
Thyroid disease. | What comorbidities are associated with Bipolar? |
| 3 jobs, 3 marriages and 3 antidepressants | What is the Rule of 3 for Bipolar? |
| DIGFAST 3/7 Screen with MDQ Positive > 7/13
Distractability
Irritability
Grandiosity
Flight of Ideas
Agitation: Periods of mania confirms Dx
Sleep
Talkativeness | How do you diagnose Bipolar? |
| MDQ + > 7/13
PHQ9
Ask about suicide
Ask about psychosis, hallucination and delusion: may need hospitalization.
CBC, BMP, TSH, urine tox screen | How do you evaluate Bipolar |
| Lithium
Monitor Cr, TSH and level Q 3mo. EKG Q 6 mo
SE: Hypothyroid 35%, nausea, tremor polyuria, wt gain, cognitive impairment.
Drug interaction: Thiazide, ACE and NSAIDS increase lithium level. | What is first line treatment Mania? |
| Trazodone, Steroid, SSRI, Albuterol and caffeine | Which drug can precipitate mania? |
| Depakote and Olanzapine ( Zyprexa)
SE: Olanzapine: EPS, Somnolence, increase prolactin and metabolic syndrome. | What is second line treatment of mania? |
| Quetiapine ( Seroquel)
Dose: 50 mg QHS x 4 days then 100 mg QHS
Monitor levels, lipid, A1C and BP
Least EPS, moderate metabolic syndrome. | What is the first line treatment of Bipolar depression? |
| Olanzapine ( Zyprexa)
Works better in conjunction with Fluoxetine
Monitor EPS, Somnolence, prolactin and metabolic syndrome.
Lurasidone: Least metabolic SE, or wt gain. | What is the second line treatment of Bipolar depression? |
| Lamotrigine (Lamictal)
Prevents recurrence
Caution: Steven-Johnson syndrome. Need 6 wk titration to prevent.
SE: Dyspepsia, insomnia. | Which drug is used for Bipolar maintanance? |
| Autonomic dysfunction, high fever, extrapyramidal symptoms, lead pipe rigidity
Caused by neuroleptics and depletion of dopamine
Treated by stopping offending drug and Bromocriptine | What is Neuroleptic Malignant Syndrome? |
| Hyperthermia, Hypertension, Tachycardia and Tachypnea, agitation, hyperreflexia and clonus, diaphoresis, vomit, diarrhea
Due to therapeutic, drug interaction of OD of seratonin.
Triggers: Amphetamine, cocaine, detromethorphan, cyclobenzaprine, triptans, fentanyl, lithium
Treatment: supportive. Cyproheptadie is antidote, serotonin antagonist. | What is Serotonin Syndrome? |
| Do you feel depressed. F/u with PHQ 9.
Always screen for Bipolar with Question of elevated mood for > 2 wk.
Screen for substance use. | How do you screen for depression? |
| DSM4: > 5 sx for > 2wk
SIG EM CAPS; Sleep, Interest, Guilt, Energy, Mood, Concentration Appetite, Psychomotor, Suicide. | How do you Dx depression |
| PHQ 9
Decrease of 5 pts is significant. 50% decrease in depression scale. Goal to < 4.
See every 2 wk for 2 mo. then monthly
If no response by 3 mo, switch to another agent of augment with Wellbutrin or Buspar. | How do you monitor treatement of depression |
| Treat for at least 9 mo for first episode and monitor with goal to get PHQ9 to < 4. Recurrence is high: 50%, with 2 episodes 70% and with 3 episodes 100%. | How long to you treat depression. |
| Sertaline ( Zoloft), Citalopram ( Celexa)- good with anxiety, escitalopram ( Lexapro)
If partial response can augment with Wellbutrin
Can add Buspar, gabapentin or hydroxyzine for anxiety. | What is the first line treatment of depression? |
| Sexual dysfunction: High/Paxil, Low/Wellbutrin
Wt gain: High/Mirtazapine, Low/Wellburin
Somnolence: High/Trazadone Low/Sertaline
N/V: Venlafaxine
Diarrhea: Sertaline
HTN: Venlafaxine | SSRI SE |
| Screen with GAD 2: Over the last few weeks have you felt nervous, anxious or on edge?
Follow + reponse with GAD 7.
Score > 10 is diagnostic.
Always screen for depression and substance use.
screen for anemia and thyroid. | How do you diagnose anxiety? |
| CBT best
ID and remove triggers( caffeine, stimulants) Encourage sleep and physical activity
Demystify: normal part of life, too much is disabling.
Meds to help rebalance brain. | How do you approach treatment for anxiety? |
| SSRI
Citalopram ( Celexa) 10 mg/d
Sertaline ( Zoloft) 25 mg/d | What is the first line treatment for anxiety? |
| SNRI ( Venlafaxine)
Buspar
Hydroxyzine
Gabapentin | What is second line treatment for anxiety? |
| Eval: GAD 7, PHQ 9, TSH, CBC, CMP, tox screen, EKG if CP
Treat: Citalopram or Ecitalopram, Venlafaxine. | How do you evaluate and treat Panic disorder? |
| Untreated depression, substance abuse, trans gender, psychosis, PTSD, Age 20-24 or > 65, male, NA, white, recent illness, chronic disease, limited social support. | What are the RF for suicide? |
| Thoughts of harm, Plan?, Means?, intention to follow through? what kept from doing it?
Social support? previous attempts, Psych illness or FHx.
If positive for plan and means to ED for eval. | How do evaluate for suicide? |
| Hx of frightening experience that in past month caused
1. nightmares, 2. tried to avoid thinking about it, 3. on edge or hypervigilant, 4. felt detached from others or surroundings, 3/4 is positive screen. | PTSD screening |
| Sexual assault, DV, substance abuse, mood disorder, hx of suicide | What are RF for PTSD |
| HITS
Hurt, Insult, Threaten, Scream OR
3 Question: Have you been hurt, Do you feel safe, Partner making you feel unsafe?
Screen during well adult exam. | How do you screen for Domestic Violence? |
| SOS-DoC
Support/safety
Options
Strengths - validate,
Document
Continuity- follow up | How do you manage DV? |
| Emotionaly labile, Self injury, fear of abandonment, turbulent relationships, substance abuse, impulsive | What are main features of Borderline personality disorder? |
| At least 6 mo of inattention and hyperactivity. Childhood ADHD presents in 30 % of adults.
R/O: thyroid, mood disorder, substance use and sleep apnea
Meds which can contribute: steroids, antihistamine, anticonvulsants caffeine and nicotine. | Adult ADHD definition |
| Functional impairment at work, home and relationships. | How do you evaluate ADHD? |
| Stimulants: Dextroamphetamine and methylphenidate
Nonstimulant: Atomoxetine ( Strattera): presynaptic NE inhibitor) Monitor liver function
Antidepressants: Wellbutrin and Desipramine
Cognitive Behavioral treatment. | How do you treat ADHD? |
| Substance abuse hx, HTN, Bipolar, arythmie, psychosis, anorexia and Tourette. | What are the contraindication to stimulant ? |
| 30% have comorbid psych disorder. Treat that first. | ADHD comorbidities |
| Impulsive thoughts leading to anxiety and needing to perform compulsive acts to reduce the anxiety.
80% associated with GAD. | OCD def |
| Citalopram. | How do you treat OCD? |
| Baseline and Q 3 mo: WT, BP, Fasting glucose, A1c, Lipids- annually,
Baseline EKG for QT interval: > 500 abnormal | How do you monitor pt on Antipsychotics? |
| Psychotic sx for > 1 mo and
Positive sx > 6 mo: hallucination, delusion, diorganized speech, and
Negative sx 6 mo: catatonic, emotional flattening and lack motivation. | How do you dx Schizophrenia? |
| Advanced paternal age and dopamine and serotonin imbalance. | What is implicated in cause of schizophrenia? |
| Second generation antipsychotics
Risperidone and olanzapine are best due to lower extrapyramidal SE. | How do you treat schizophrenia? |
| Loss contact with reality
Delusions of persecution of somatic and thought disorganization. | What is the definition of psychosis? |
| Schizophrenia, trauma, Bipolar, Delusion disorder, substance use, Delerium, Meds: steroid, anticholinergic, CO poisoning, Bupropion | What is the differential of psychosis? |
| Asses risk of harm to self or others and if positive, hospitalize.
Check MSE
Chem 14, CBC, RPR UA drug screen, B12 and HIV, CT/MRI head, consider heavy metal screen. | How do you evaluate psychosis? |
| Psych: depression, anxiety and PTSD
Sleep apnea 20%
GERD
Substance abuse. | Insomnia: comorbidities |
| CBT/ sleep hygiene
Sleep initiation: Melatonin 3-5mg 1 hour before bed. Ramelteon ( melatonin receptor agonist) low risk of abuse
Sleep maintenance: Zolpidem ER, Doxepin 3-6 mg, Gabapentin 100-300 mg QHS, Mirtazapine 7.5 mg.
Benadryl not recommended due to anticholinergic effects and adverse effects on cognition. Avoid > 60
Avoid Benzo receptor angoinist: Eszopidon, Zaleplon and Zolpiden ( Ambien) habit forming
Caution with Trazodone ( Can amplify mania) | How do you treat insomnia |
| Impaired sleep > 3x/wk causing impairment. | What is the definition of insomnia? |
