Dec 9, 2022
This podcast, Elizabeth Hopfenspirger, DNP, a psychiatric and family practice nurse practitioner with Lakeview Clinic, discusses various mental health topics, primarily in the adult patient, but also touches on some pediatric issues. Today's discussion will focus on the following areas of mental health - depression, anxiety, mixed disorders, ADHD and psychosis.
Enjoy the podcast.
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SHOW NOTES:
*See the attachment for additional
information.
The state of mental
health care in the US is not ideal
- Lack of
resources
- Lack of practitioners
- social, physical, economic and
environmental challenges
CASE REVIEW
#1
- 18 year old female with predominantly anxiety
- Respectful curiosity: listening and asking questions without
judgement
- Medication for generalilzed anxiety
disorder
- High intensity
aerobic exercise can improve anxiety symptoms.
- Trauma? ADHD/Learning difficulties? Sleep? Appette and
restriction of food/eating disorders? Substance use/abuse?
- SSRI:
bupropion>fluoxetine?Sertaline?escitalopram>fluvoxamine>paxil
(most activating to least activating)
- For pure anxiety - Elizabeth prefers escitalopram, citalopram and
sertaline
- Trauma and trauma therapy: Trauma can be anything (death of a
loved one, MVC, etc.)
- Trauma therapy (EMDR: eye movement
desensitization reprocessing)
- IFS (internal family systems - recognizing
and connecting with your own history and younger self)
- ART (acceleraed resolution therapy)
- Substance use: What is the substance doing for the patient? Why
are they using? Helps to direct therapy and arrive at
diagnosis.
- ADHD (attention deficit hyperactivity disorder)
- sometimes missed or ignored
- PCPs have discomfort treating at times
- trial of stimulant may be beneficial
- Suicide ideation and other adverse effects while first starting
certain meds is real, but rare
- Article resources:
Walkup, et.al (https://pubmed.ncbi.nlm.nih.gov/18974308/)
Wetherell, et.al (https://pubmed.ncbi.nlm.nih.gov/23680817/)
Critz-Christoph, et.al (https://pubmed.ncbi.nlm.nih.gov/21840164/)
Trauma therapy : https://www.emdria.org/
CASE REVIEW
#2
- 32 year old male with depression
- Labs? Physical activity? Testosterone concerns?
- Lifestyle and sexual function
- Post-retirement? (identity and purpose has changed/gone)
- Consider bupropion if no seizures or other contraindications.
Consult with neurologist if significant history
- Sexual dysfunction an issue? Vortioxetine can be an option wich
may help enhance libido
- Physical activity (natural endorphins) and exposure to nature are
improtant
- Screen time? Smart phone and other screen time has dopaminergic
effects; too much 'negative' screen time can be detrimental
(If AHDH is poorly treated, screen addiction may
increase.)
CASE REVIEW
#3
- 65 year old male with mixed depression and
anxiety, off meds for many months
- Find as many of patient's historical records as possible
- Meeting a patient "where they are at". How motivates is the
patient to get better?
- Are they coasting (teenagers)? Are they taking an active role in
getting better?
- may need to wait to push/empower patient
until after giving medication and psychotherapy some time
- where is the patient in their
willingness to change and get better?
- Meds in this ager group (and many others)
to avoid: TCAs and MAOIs
- IF DM, HTN, CAD and other co-morbidities, fluoxetine is less
likely to have interactions and adverse
effects
-
Article
resources:
Prochasa and DiClemente - Stages of Change https://www.ncbi.nlm.nih.gov/books/NBK556005/)
Psychosis
-
Caplyta (stimulating) if more depressed with psychotic features
- Zyprexa (sedating) if more manic/psychotic
Genetic testing for
optimization of medications is an option
- Serves
as a 'guide' for medication choice
- SLC6A4 gene, for instance, is responsible for serotonin reuptake
into the presynaptic neuron
What to do while waiting
for SSRI and SNRI to "work"?
- Hydroxyzine,
benzodiazepine
- Sleep medication:
- Doxylamine, Trazadone or Remeron (older
patients)
- Sleep medication: lunesta, sonata
Polypharmacy
- Is
polypharmacy present and patients feeling poorly with persistent
symptoms? May need thoughtful/ careful deprescribing.
Nontraditional/novel
treatment options
- Nontraditional/novel options for
treatment resistant depression, PTSD treatment, chronic pain,
etc.
- Ketamine
- Psilocybe
Psychiatry & Primary
Care
- Incorporating psychiatry into our own primary
care practices is anxiety provoking but inevitable in this day and
age of healthcare
- We can learn new things and leverage our existing resources to
better help our patients
- Time with our patients is a barrier
- Ask the patient: what is the most pressing issue for you today?
What is the most distressing thing for the patient? Then consider
Maslow's Hierarchy of Needs and build up from
there.
- Article resources:
Maslow Hierarcy of Needs (https://www.simplypsychology.org/maslow.html)
Please check out the additonal show notes for additional information/resources.