Major depressive disorder

Complications?

• Top reason for disability in the US
• Complication: death by suicide

Anxiety

What are different types?

Types:

• Panic disorder
• GAD
• OCD
• social anxiety
• PTSD

Screening tools for depression

Screening tools:

• PHQ-2
• PHQ-9
• Depression Inventory
• Zung Depression Scale
• Mood Disorder Questionnaire

PCP first to identify anxiety/depression treatment

Important to screen, early detection & identification, assessment, treatment, referral

Anxiety and Depression

Nuerobiology?

Structures involved

cerebral cortex, frontal lobes, brain stem, basal nuclei, limbic system, endocrine system, genetic factors, environmental factors

Depression

Deficiency in NT

Dysregulation of brain circuits in different parts of the brain

• problems processing in the areas of amygdala & prefrontal cortex

Anxiety

dysfunction in circuits of amygdala

chronic stress= atrophy of hippocampus and amygdala

What are NT involved in mental health

Seratonin

NE

Dopamine

GABA

Achy

What is the goal of treatment for depression?

Remission of MDD

Titrate to optimal doses reach remission

Achieving remission may take up to 14 weeks

Use other options if available (therapy)

Augment with exercise and cognitive behavioral therapy

Treatment of Anxiety

What is first line of treatment for GAD, Panic Disorder, and PTSD?

GAD

• First line drug is SSRI

Panic Disorder

• First line of drug is Antidepressants
  • Citalopram, Sertraline, Paroxetine, Fluoxetine, Desvenlafaxine, Vilazodone, Vortioxetine, Venlafaxine

PTSD

• First-line treatment: Sertraline, Paroxetine
• Clonidine, propranolol, prazosin

Goals for treatment of Anxiety

Reduction of symptoms

Self management of symptoms w/out medications

Understanding etiology/contributing symptoms

Patient education

• Providing coping skills

What is insomnia?

Timing

• Transient - Few days
• Short term- 2-3 weeks
• Chronic
• Sleep hygiene measures should always be tried first

Special Populations

What are considerations for Children & Adolescents?

What are consideration for older adults?

Children & Adolescents:

• SSRI approved for kids
  • Fluoxetine
  • Escitalopram
  • Fluvoxamine
  • Sertraline
• Use half the adult dose
• Assess for SI- can increase risk w/ Q drug initiation and dose titration

Older Adults

• Start low and go slow
• Avoid Benzos
• Consider medical comorbidities & Drug interactions

Special Populations

What are considerations for pregnant females?

Antidepressants can cause:

• mild congenital abnormalities
• low-birth weight
• premature deliveries
• cardiac malformations
• PAROXETINE during first trimester= pulmonary HTN in newborns

Untreated depression = poor neonatal outcomes & poor self care

• screen for post partum depression

Discuss risk & benefits before pregnancy

What are nonpharmacological tx for depression?

• Exercise
• CBT
• Exposure therapy
• Eye movement desensitization and reprocessing
• Psychotherapy

What is Lithium:

Therapeutic Index

Half Life

and Steady State

TI: .6-1.5

15-36 hours- long half life

5-7 days

What are screening tools for ADHD?

DSM-V Diagnostic Criteria:

• Persistent pattern across settings of inattention
• Hyperactivity
• Impulsivity

Screening Tools

• Vanderbilt for Children
• WHO Adult ADHD Self Report Scale & Diagnostic Interview for ADHD in Adults (DIVA2.0)

What are causes of ADHD

Genetics & Environmental?

Genetics

• 28% of ADHD accounted for genetics

Environmental Factors

• Low birth weight
• Prenatal complications
• Malnutrition

What are Evidence Based Guidelines for ADHD treatment by AAP?

American Academy of Pediatrics

• Children
  • Children < 5 behavioral therapy
  • Children > 6 first line treatment is stimulants
  • Children 6-11 CBD therapy + medications
• Adolescents
  • First line tx behavioral therapy

** can start intermediate release then titrate to start them on XR

Rationale Drug Selection for Preschoolers

• BEHAVIORAL THERAPY FIRST
• Dextroamphetamine FDA approved
• AAP guidelines: methylphenidate safe & effective in preschool age group
  • use short term formulas to allow for more precise dosing & adjustments

Rationale Drug Selection for School Age Children

• STIMULANTS first line drug
• Choice based on formulation, duration of action, & parent preference
• If one class of medications does not work, change to another class
• PERMIT DRUG HOLIDAYS IF NOT GAINING WEIGHT (spring break, winter break, weekends)
• MONITOR FOR ADEQUATE SLEEP

Rationale Drug Selection for Adolescents & Adults

Teens

• stimulants first
• long acting meds
• protentional for abuse & diversion

Adults

• Stimulants first
• Atomoxetine second line
• Long acting alpha agonist may be used as adjunctive to treat sleep issues BC SE IS DROWSINESS

What are nonpharmacologic treatments for Migraines?

How can the patient keep track of migraines?

Migranol: feverfew, riboflavin, magnesium, vitamins

Acupuncture

Aromatherapy

Hypnosis

Reflexology

Massage

Yoga

Ice

Do a migraine diary

What do you educate patients regarding migraines

Use nonpharmacologic measures

Need to create migraine diary for effect track of medication effectiveness

Expectations of treatment

• Medication administration, ADR, Interactions, Max dose, medication overuse headache
• OTC should not be used unless part of the treatment plan

What is a tension HA?

How long does it last?

What is the goal of therapy?

• Band like pressure
• Persistent dull pain
  • PAIN IS NOT MADE WORSE BY EXCERCISE
• Last 30 minutes - 7 days
• Goal: decrease frequency & severity

What medications would you consider to Tx Tension HA?

What are nonpharmacologic methods of treatment?

• Mild analgesics (Tylenol NSAIDs, ASA)
  • Acetaminophen for pregnant people

PREVENTION MEDICATIONS

• Beta Blockers
• Tricyclic Antidepressants
• SNRIs

NON PHARM

• Stress management
• Exercise
• Heat/Ice
• Acupuncture
• Trigger point injections
• Biofeedback

What are cluster HA?

Where is the pain located?

What are the goals of therapy?

• Intense HA for 15 minutes- 2 hours
• Occurs in clusters, intense pain, not true known cause
• Pain around one eye, excessive lacrimation & redness in eye on the side of the HA
• Goal: relief pain & decrease length of cluster

What are medications to treat Cluster HA?

What are preventative Tx & Nonpharmacological?

• Tx w/ 100% O2 for 15-30 minutes
• Ergo
  • Suppositories
  • Intranasal
  • IM Dihydroergotamine
• Sumatriptan

PREVENTATIVE TX

• Verapamil
• Divalproex
• Lithium

NON PHARM

• Avoid ETOH
• Avoid Tobacco, stress, vigorous activity

What do you need to monitor for Cluster HA?

What do you need to educate?

• SI
• Headache diary trend

PT EDUCATION

• Diagnosis
• Self admin of medications
• ETOH avoidance

What are Live vaccines?

• Intranasal flu vaccine
• MMR
• Oral polovirus
• Rotavirus
• Varicella Virus Vacccine
• Herpes Zoster Vaccine
• Typhoid Vaccine
• Yellow Fever Vaccine
• BCG

What are contraindications of Live Vaccines

Immunocompromised patients

Pregnant mothers

• PREGNANCY SHOULD BE AVOIDED ONE MONTH AFTER VACCINATION

Patients with fever illness

What are inactivated vaccines?

Diphtheria, tetanus, and pertussis vaccine
Haemophilus B conjugate vaccine
Inactivated poliovirus vaccine
Hepatitis B virus (HBV) vaccine
Hepatitis A virus (HAV) vaccine
Human papillomavirus (HPV) vaccine
Influenza vaccine
Pneumococcal vaccine

Meningococcal polysaccharide vaccine
Lyme disease vaccine
Typhoid vaccine
Cholera vaccine
Japanese encephalitis virus vaccine
Plague vaccine
Rabies vaccine

What are things to consider and education about inactive vaccines?

• inactivated vaccines are killed viruses
• may be coadministered with other vaccines
• no need to restart series if patient gets off schedule - catch-up schedule used instead