MENTAL HEALTH

NOT TO DIAGNOSE DEPRESSION BUT TO INDICATE SEVERITY OF DEPRESSIVE SYMPTOMS

PHQ2 FIRST SCREEN

PHQ9 MORE VALID

18 YEARS UP , INCLUDE PREGNANT AND POST PARTUM WOMEN

"Staff-assisted depression care supports" refers to clinical staff that assists the primary care clinician by providing some direct depression care and/or coordination, case management or mental health treatment.

USPTSF UPDATE

ANTIDEPRESSANTS

PSYCHOTHERAPY OR BOTH

CBT PREGNANT AND POSTPARTUM

CORNELL SCALE FOR DEPRESSION IN DEMENTIA (CSDD)

GO444

ANNUAL DEPRESSION SCREENING

TIME ALLOCATION 15 MINUTES

TOTAL RVU: 0.51

RVU FOR 2023 IS $33.06

It is the leading cause of disability among adults in high-income countries and is associated with increased mortality due to suicide and impaired ability to manage other health issues.

MULTIFACTORIAL:

GENETIC UP TO 40% OR 1.5-3 X MORELIKELY

ENVTL 60-70% ESP ADVERSE EVENTS IN CHILDHOOD

PRESENT W 5 OR MORE OF FOLLOWING:

DEPRESSED MOOD

ANHEDONIA: LOSS OF PLEASURE OR INTEREST IN THINGS

CHANGE IN APPETITE

(CHANGE IN SLEEP PATTERN)

FATIGUE/LOW ENERGY

SLUGGISH OR AGITATED

POOR SELF IMAGE/THOUGHTS OF WORTHLESSNESS, OR GUILT

DIFFICULTY CONCENTRATING

SUICIDAL IDEATION

GENETIC : IMPAIRED NOREPINEPHRINE SEROTOININ, DOPAMINE GABA /GLUTAMATE /NMDA( NMDA IS A RECEPTOR OF GLUTAMATE- PLAYS AN INTEGRAL ROLE IN SYNAPSE PLASTICITY ( MEMORY FORMATION)

PPTX: SEROTONIN LOW LEVELS, IN SOME CASES REDUCED NOREPINEPHRINE & DOPAMINE

WHO ESTIMATED BY 2020 DEPRESSION WILL BE LEADING CAUSE OF OVERALL DISEASE BURDEN ACROSS THE GLOBE IN ALL GENDERS AND AGE GROUPS

ADULTS-6.7 %

FEMALES>MALES

HIGHEST YOUNG-18-25

HIGHEST MIXED RACEE

ADOLESCENTS-12.8%

FEMALES>MALES

HIGHEST MIXED RACEE

COMBO OF DYSTHMIC DISORDER AND CHRONIC MAJOR DEPRESSIVE DISORDER

MUST BE DEPRESSED FOR AT LEAST 2 YEARS

MUST HAVE 2 OF THIS CRITERIA

APPETITE CHANGE >OR<

INSOMNIA OR HYPERSOMNIA

LOW ENERGY

POOR SELF ESTEEM

POOR CONCENTRATION

HOPELESSNESS

SEROTONIN: CALM RELAXED

NOREPI + DOPAMINE+> PRODUCTIVITY AMBITION CONCENTRATION PLEASURE

GABA CALM

NMDA EXCITES

16 MILLION ADULTS IN US ANNUALLY

HI INCIDIENCE IN FIRST WORLD

MORE COMMON IF FIRST DEGREE RELATIVE

BIGGEST SINGLE RISK FACTOR FOR SUICIDE

20% DIE ON DAY OF PCP VISIT, 40% WEEK OF VISIT 70% MONTH OF VISIT

PSYCHOSOCIAL STRESSORS

POST PARTUM CHRONIC ILLNESS ESP BACK PAIN

FAM HISTORY

SUBSTANCE/ALCOHOL ABUSE

RETIREMENT

AGING

MENOPAUSE

LOSS - DEATH, DIVORCE JOB

ISOLATION

ILLNESSES

PERCEIVED SOCAL SUPPORT

>2 WEEKS

ANOREXIA OR WT GAIIN

GI OR OTHER SOMATIC PROBLEMS

SLEEP DISTURBANCE

APATHY

ANXIETY, IRRITABILITY, CRIES EASILY, RESTLESS

AGGRESSION

HYPERACTIVITY

POOR SELF ESTEEM /GUILT/WORTHLESS

SUICIDAL THOUGHTS/DEATH THOUGHTS- PLAN

WITHDRAWAL OR CLINGINESS

BIPOLAR

SUBSTANCE ABUSE

PHYSICAL: DM LIVER OR RENAL FAILURE, BRAIN DX

HYPOTHYROID

B12 DEFICIENCY

DEMENTIA

SCREENING TOOLS

PHQ2/9 TO START

HAMILTON

PROMIS

BECKS

GAIL

ZUNG

GERIATRIC DEP SCALE

SEE OTHER CARD

CSSD ( DEMENTIA PTS) CORNELL SCALE

EKG ( IF PLAN FOR TCA)

TSH /T4

URINE DRUG SCREEN

FBS, B12, VIT D, FOLATE LEVELS

GENETIC TESTING FOR PSYCHOTROPICS METABOLIZED BY CYP450 SYSTEM

MAINTAIN HIGH INDEX SUSPICIO IF ATTEMPTED SUICIDE OR FAMILTY HISTORY, WT LOSS OR CHRONIC ILLNESS

ASK ABOUT DRUG/ALCOHOL USE

IDENTIFY:

RISK

PLAN

LETHALITY

AVAILABILITY

INTENT

ESTABLISH:

SAFE ENVT

“COMMITMENT TO TREATMENT” STATEMENT

PROVIDE

SUICIDE HOTLINE

KNOW NJ INVOLUNTARY COMMITTMENT LAWS AND NP SCOPE OF PRACTICE

PSYCHOEDUCATION: CBT

ONGOING: INFO ABOUT ILLNESS SYMPTOMS

ASK :

INTERPERSONAL RELSHIPS

SUPPORT SYSTEM

WORK HEALTH

DISCOURAGE MAJOR LIFE CHANGES WHILE IN DEPRESSIVE STATE

SET REALISTIC ATTAINABLE GOALS

AVOID ALCOHOL

PSYCHOTHERAPY CBT

THIS IS TREATMENT OF CHOICE,

WORKS WELL WITH MEDS

ECT -RAPID RX RESPONSE, CATATONIA,STUPOR , MANIA SEVERE SUICIDALITY, SEVERE NUTRITIONAL COMPROMISE, PREGNANT + SUICIDAL

LIGHT THERAPY -SAD, 30 MINS ARTIFICIAL WHITE LIGHT

TMS- RESISTANT DEP.

VAGUS NERVE STIMULATION

DETERMINE CO EXISTING SUBSTANCE USE DISORDERS

SSRI - PAXIL, PROZAC, LEXAPRO , ZOLOFT, CITALOPRAM , VIIBRYD(LESS SEX S/E) VORDIOXITINE ( COGNITIVE ) CAN BE GOOD OPTION,

ATYPICAL ANTIDEPRESSANTS

SNRI -FETZIMA, EFFEXOR PRISITQ, CYMBALTA

TCA-OD DEADLY -PRESCRIE SMALLEST AMOUNT-AMITRYPTILLINE

NDRI ??

MAOI

BUPROPRION-HELPS W SEX DRIVE

SARI- TRAZODONE -SHORT HALF LIFE TAKE AT NIGHT

NASSA

REMERON -APPETITE STIMULANT

MULTIMODAL - TRINTELLIX/VORTIOXETINE

WHAT WORKS FOR ONE FAMILY MEMBER WORKS FOR ANOTHER

• PT MUST BE ASSESSED FOR SUICIDE RISK AFTER STARTING MED_ 2 WEEKLY F/U-GET BETTER-MORE ENERGY TO ACT

PSYCHIATRIST OR PSYCH APN FOR ECT.MAKE APPT AND REFERRAL DURING PT VISIT URGENT

INPATIENT SEND TO ER W RELATIVE OR CALL 911:

UNABLE TO SELF CARE AT HOME

SUICIDAL OR HOMICIDAL IDEATION AND PLAN -ESP IF VIOLENT

LACK OF SUPPORT

COEXISTENCE OF SUBSTANCE USE DISORDER

PPTX:

EMERGENT: HIGH RISK OF HARM TO SELF OR OTHER

URGENT REFERRAL

ASAP/ROUTINE

NO RESPONSE TO RX, COMPS

EVEN THO MEDS TAKE 4 WEEKS TO WORK

2 WEEK F/U

STAY ON ANTI DEP 4-6 MONTHS FIRST EPISODE

SUBS EPISODE 2 YEARS,

RECURRENT -LIFELONG

IF SOME SYMPTOM RELIEF AFTER FEW WEEKS KEEP INCREASING DOSE TO MAX DOSE

INCREASED SUICIDE RISK AT START OF A/D MED THERAPY

BIPOLAR SEEK TREATMENT DURING DEPRESSIVE PHASE - ADEQUATE SCREENING AS A/DEP MEDS CAN CAUSE MANIA

FAILURE WITH MULITPLE MEDS CONSIDER BIPOLAR AS DX

MENTAL AND PHYSICAL SENSATION

DREAD

FOREBODING

PANIC

TRIGGERED BY EMOTIONAL OR PHYSIOLOGICAL STIMULI

ACUTE OR CHRONIC

MOST COMMON PSYCHIATRIC DISORDER IN US

WOMEN>MEN

AVERAGE AGE OF ONOSET 11 YEARS OLD

SEPARATION ANXIETY MOST COMMON REASON SCHOOL REFUSAL AGED 9

TYPES :

GAD

SEPARATION ANXIETY DISORDER

SELECTIVE MUTISM

PHOBIA

SOCIAL ANXIETY DISORDER

PANIC DISORDER,

AGORAPHOBIA

SUBSTAN/MED INDUCED DISORDER

BEHAVIORAL: RESPONSE TO STIMULI

GENETIC: FIRST DEGREE RELATIVE

BIOLOGIC: GABA NOREPI, SEROTONIN POORLY REGULATED

AUTONOMIC SYSTEM RESPONDS WRONG TO STIMULI

FUNCTIONAL CEREBRAL PATHOLOGY CAUSES ANXIETY

HYPOTHALAMIC PITUITARY ADRENAL AXIS -HIGHLY IMPLICATED

ORGANIC : ENDOCRINOPATHIES, CARDIORESPIRATORY, ANEMIA

WITHDRAWAL OR USE OF:

ALCOHOL

ANTIHYPERTENSIVES

CAFFEINE

ILLICIT DRUGS

OCS

NSAIDS

WITHDRAWAL FROM SSRI

FAMILY HX

PSYCHOSOCIAL

JOB/SCHOOL

MARITAL

MEDICAL/FINANCIAL

PSYCHIATRIC

MDD

PTSD

SCHIZO/PSYCHOSES

PERSONALITY DISORDERS

APPREHENSION

RESTLESS, EDGY, DISTRACTIBILITY

INSOMNIA

SOMATIC : FATIGUE HEADACHES PARASTHESIAS, PALPS, CHEST PAIN

DYSPNEA, HYPERVENTILATION

N+V

DIARRHEA

EXCESSIVE RUMINATION

DEREALIZATION

5-9MILD

10-14 MOD

15-21 SEVERE

AT LEAST 3 OF THESE SYMTPOMS OVER AT LEAST 6 MONTHS

OCD

ODD

ADD

PTSD

BIPOLAR

DELIRIUM

SUBSTANCE WITHDRAWAL

HYPERTHYROID, HYPERPITUITARY ,CUSHINGS, MENOPAUSE

ANEMIA

ASTHMA

COPD

PE OR PNEUMOTHORAX

TSH

CBC

URNE DRUG SCREEN

DIRECT ATTN TO ARRHYTHMIAS, THYROID, DRUGS

PSYCHOLOGIC TESTING

PROMIS FOR EMOTIONAL DISTRESS-ANXIETY

HAMILTON ANXIETY SCALE

ZUNG ANXIETY SELF ASST

GAD TEST

PSYCHOTHERAPY

EDUCATION ABOUT DX RX PLAN + PROGNOSIS

RELAXATION TECHNIQUES

CBT

RECONDITIONING: EXPOSURE RESPONSE

REGULAR EXERCISE,\DIET

LIMIT CAFFEINE INTAKE

SERIAL OFFICE VISITS

BENZODIZEPINES UNTIL SSRI KICKS IN XANAX MOST ADDICTIVE CLONAZEPAM, LORAZEPAM ( USED FOR ALC WITHDRAWAL)

SSRI- 2-4 WEEKS, FULL RESPONSE 12 WEEKS

SNRI

BUSPAR -FIRST LINE NOW MAINT DOSE 20-30 MG DAY

ADJUNCT - CAN USE GABAPENTIN

PANIC DISORDER:

SSRI OR SNRI

TCA- PERFORM RISK ASST, CAN BE LETHAL IN OD

BENZO

BETA BLOCKER

SUBSTANCE ANXIETY DISORDER -HYDROXYZINE

HYDROXYZINE-Activity at muscarinic, serotonergic (5HT2), and dopaminergic receptors in the hippocampus, cerebral cortices, and whole brain may produce anxiolytic effects

SYMPTOMS THAT WORSEN DESPITE RX

SUBSTANCE ABUSE

DISABLING SX

PSYCH

REGULAR F/U IMPORTANT

TCA- PERIODIC SERUM LEVELS

BASELINE AND FOLLOW UP EKG

LOWER DOSES

FULL BENEFIT CAN TAKE 2- 3 MONTHS

MOD IMPROVEMENT 4-8 WEEKS

GENETICS TO FINE TUNE TREATMENT OF CHOICE

TEST GENE, CORRELATE W PHENOTYPE

PHARMACOGENES MORE SAFETY THAN EFFICACY- HOW WILL SIDE EFFECTS BOTHER YOU?

MANY DIFFERENT KITS , NOTHING STANDARDISED

TELLS YOU PHARMACOKINETICS,HOW YOU METABOLIZEB HOW SENSITIVE CYP 450 CYTOCHROMES

PHARMACODYNAMICS: BDNF SEROTONNI RECEPTOR SUBTYPES

NOT RECOMMENDED BY APA , COST

WASTE OF MY TIME THIS PRESENTATIONF

3

30% remission with citalopram 40

mg/day

•

Level 2

switch: 25% achieved remission on

bupropion SR (283 mg/day), sertraline (135

mg/day) or venlafaxine XR (193 mg/day)

•

Level 2

augmentation: 30% achieved

remission: bupropion SR (267 mg/day) or

buspirone 40 mg/day

•

Also at level 2

:

Switching or augmenting witH cbt EQUALLY EFFECTIVE ASMEDICATION

VILAZODONE

SSRI AND PARTIAL AGONISM OF 5HTIA PRESYNAPTIC RECEPTOR

lESS SEXUAL S/E

VORTIOETINE

SSRI, LOTS OF AGONIST, IMPROVES COGNITIVE FUNCTION

DEXTROMORPHAN BUPROPRION

DEXTRO- SIGNALLING GLUTAMATE ( REMEMBER GLUTAMATE /GABA N/T

KICKS IN EARLY

INSURANCE COVERS IF MULTIPLE FAILED ANTIDEPRESSANTS

LATEST FDA APPROVED

THETA BURST STIMULATION- 10X DAY FOR 5 DAYS -80% REMISSION

S ENANTIOMER OF KETAMINE

INTRANASAL

FDA APPROVED

BECOMES A MAINTENANCE RX

BLACK BOX: DISSOCIATION, ADDICTION

CERTIFIED CLINIC-DOT , DONT TAKE HOME CRAZY

NOT WORTH LEARNING

SEVERAL NEGATIVE RCTS

ATYPICAL ANTIPSYCHOTICS,LITHIUM, THYROID MEDS

BEST EVIDENCE BASED:

APIPRAZOLE BREXPIPRAZZOLE

OLANZAPINE-FLUOXETINE COMBO

QUETIAPINE XR

S/E EPS , > BG

HERBS

ST JOHNS WORT, WORKS BUT INTERACTS W MULTIPLE MEDS

SAMe

works like lexapro and imipramine, NO DDI , S/E GI UPSET

OMEGA 3 FATTY ACIDS -LACK OF EVIDENCE

KAVAKAVA- WORKS FOR GAD,STUDIES NO BENEFIT

CAN BE SHORT COURSE

VALERIAN-

INSOMNIA AND ANXIETY- STUDIES VARIABLE IN CONCENTRATION -NO EVIDENCE

MELATONIN INSOMINA

AMMEND TRIAL -MEDITERRANEAN DIET, NUTS LEGUMES AVOID PROCESSED FOODS VEG,LEAN MEATS , NUTS FRUIT

REMEMBER 90% OF SEROTONIN RECEPTORS IN THE GUTD

USE TOOL IN COVID

GAD 7 SCREENING TOOL

PHQ9

BIPOLAR QUESTIONS

HAVE YOU BEEN TOO HAPPY WHERE PEOPLE NOTICED

HAVE YOU GOT INTO LOTS OF FIGHTS WITH PEOPLE

HAVE YOU EVER NOT NEEDED SLEEP AND STLL HAD LOTS OF ENERGY

INCREASED SINCE 2020? IMPACT OF COVID

ASK

PLAN INTENT TO ACT, ACCESS TO MEANS

FIREARMS IN HOME

WHAT ARE PROTECTIVE FACTORS, EG FAMILY

PAST SUICIDAL ATTMEPS OR IDEATION

FREQUENCY DETAIL PERSISTENCE OF THOUGHT

INTENT TO DIE….WHY?

WILLINGNESS TO ACCEPT RESOURCES

NEW/ENDURING STRESSORS LOSS,HUMILIATION, REJECTION, TRAUMA

SUBSTANCE USE

HOW TO MANAGE FEELINGS WHEN THEY OCCUR WALK, CALL A FRIEND

WHAT WILL YOU DO IF SUICIDAL FEELINGS GET STRONGER… GO TO ER

PRESENCE OF PROTECTIVE FACTORS

HOW ELSE CAN YOU MANAGE YOUR REACTION TO_______________

COLLABORATIVE , DOCUMENTED

CARING CONTACTS

FOLIC ACID MAY BE LOW!

STUDIES SHOWED FOLIC ACID HELPFUL

NOW FIRST LINE

USED AS AUGMENTER

PEGABALIN , PROPANOLOL ,

LAMOTRIGINE FOR DEPRESSION W IRRITABILITY-NOT MOST EVIDENCE BASED

ELDERLY - AVOID TCAS , CARDIAC S/E

START LOWDONT STOP

VORDIOXITINE ( COGNITIVE ) CAN BE GOOD OPTION,

TREAT ELDERLY FOR DEPRESSION F

BD1 -PRESENCE OF AT LEAST ONE EPISODE OF MANIA

BPII- AT LEAST ONE EPISODE OF HYPOMANIA AND DEPRESSION

MANIA-

WEEKS TO MONTHS LONG

SEVERE FUCNTIONAL IMPAIRMENT

HOSPITALIZATION

ELEVATED OR IRRITABLE MOOD'

RISKY BEHAVIOR

LOW SELF ESTEEM

PRESSURED SPEECH- WHOLELIST AND THEY HAVE TO MEET 3 OF CRITERIA

HYPOMANIA

DAYS TO WEEKS

ELEVATED, EXPANSIVE OR IRRITABLE FOR AT LEAST 4 DAYS

SYMPTOMS NOT SEVERE ENOUGH O CAUSE MARKED IMPAIRMENT

LASTS MONTHS TO YEARS

DEPRESSION LASTS LONGER THAN ANY MANIA AND OCCURS MORE FREQUENTLY

5 OR MORE SYMPTOMS OVER 2 WEEKS

DEPRESSED MOOD +

LOSS OF INTEREST ALWAYS PRESENT

INSOMINA /HYPERSOMNIA

SUICIDAL

WT LOSS/GAIN

AGITATION

FATIGUE

LABELLED BY DSM 5 AS MANIC OR HYPOMANIC W MIXED FEATURES OR DEPRESSED WIHT MIXED FEATURES

RAPID CYCLING- 4 OR MORE EPISODES IN A YEAR, NEEDS SPECIALIST RX

MOOD DISORDER QUESTIONNAIRE MDQ

IS IT IMPACTING FUNCTIONIN IN WORK SOCIAL AND FAMILY ROLES

OTHER PSYCH COMORBIDITIES SUBSTANCE ABUSE PD GAD PTSD

STRONG FAMILY TRAIT

MOOD STABILISERS

LITHIUM -NARROW THERAPEUTIC INDEX/THYROID/RENAL

SODIUM VALPROATE ( DIVALPROEX OR DEPAKOTE

CARBAMAZEPINE-EFFICACY

LAMICTAL

ATYPICAL ANTIPSYCHOTICS

APIPRAZOLE

OLANZAPINE- FLUOXETINE-EFFICACY

SEROQUEL -QUETIAPINE-EFFICACY

RISPERDAL

USU MS AND AA TOGETHER

NO ANTIDPRESSANT MONOTHERAPY ! MAY MAKE MANIA WORSE

PREGNANCY LURASIDONE SAFEST - CLASS B

SUICIDE RATES HIGH

SLEEP DISORDERS AFFECT 50-70 MILLION US RESIDENTS

WOMEN >MEN

ONLY 1% OF PATIENTS TELL THEIR PROVIDER

•Dissatisfaction with sleep quantity or quality that results in clinically significant distress in social, occupational, or other areas of functioning

DIAGNOSIS REQUIRES 3 MAIN COMPONENTS

1. PERSISTENT SLEEP DIFFICULTY

2. ADEQUATE SLEEP OPPORTUNITY

3. ASSOCIATED DAYTIME DYSFUNCTION

PRE DISPOSING

FEMALE

LIVE ALONE

FAM HISTORY

CAFFEINE, ALCOHOL INTAKE

OSA

PRECIPITATING

MAJOR STRESSORS

COMORBIDITIES

PERPETUATING

DISTRESS OVER POOR SLEEP

MALDAPTIVE SLEEP HABITS

SLEEP PERFORMANCE ANXIETY

DIFFICULTY FALLING ASLEEP

DIFFICULTY STAYING ASLEEP

FALSE PERCEPTION THAT NOT SLEEPING AT ALL

ICSD CRITERIA

30 MINS FOR ALL THREE-FALLNG ASLEEP, WAKING IN NIGHT, EARLY WAKING

3 X WEEK

IMPAIRED SOCIAL /FAMILY INTERACTIONS

IRRITABILITY

SLEEP DISSATISFACTION

POLYSOMNOGRAPHY IS OSA SUSPECTED

ITS A SLEEP STUDY

SPOTS SLEEP DISORDERS

NOCTURNAL SEIZURES, REM NARCOLEPSY LIMB MOVEMENT

CIRCADIAN RHYTHM DISORDERS

SHIFT WORKER

PARASOMNIA -ABNORMAL SLEEP BEHAVIORS /PHYSIOLOGY

RESTLESS LEG SYNDROME

COMORBIDITIES

CHF

NEURO -CENTRAL SLEEP APNEA

COPD, OSA

ANXIETY DEPRESSION

GERD

CBT FIRSTLINE

CBT FOCUSES ON

SLEEP HYGIENE'

STIMULUS CONTROL

SLEEP CONSOLIDATION

COGNITIVE RESTRUCTURING

BEDROOM FOR SLEEP AND SEX

EXERCISE

RELAXATION

SLEEP RESTRICTION

PHOTOTHERAPY FOR DELAYED SLEEP

CHRONOTHERAPY FOR CIRCADIAN RHYTHM DISORDERS

NON BENZO: BZRAS

ZOLPIDEM OR ZOLPIDEM ER

ZALEPLON

ESZOPICLONE

BENZOS BZRA

TEMAZEPAM -RESTORIL SLEEP ONSET AND SLEEP MAINTENANCE

TRIAZOLAM

ESTAZOLAM

DORAS

SUVOREXANT

TRAZODONE- SEROTONIN MODULATOR

NO SEDATION NEXT DAY?

RAMELTEON MELATONIN RECEPTOR AGONIST

-USED FOR ICU PSYCHOSIS ALSO. AND SLEEP ONSET INSOMNIA

ADULTS

SLEEP ONSET: NON BENZO BZRA, DORA OR RAMELTEON

SLEEP MAINTENANCE-DORA EG SUVOREXANT

CHRONIC

CBT ALL BZRAS DORA DOXEPIN RAMELTEON

TREATMENT NOT EFFECTIVE

SLEEP MEDICINE SPECIALIST

BZRAS NO!

FIRST CHOICE RAMELTEON ( MELATONIN RECEPTOR AGONIST

PATTERN OF CONTROLLING COERCIVE BEHAVIOR BY ONE PERSON/PARTNER OVER ANOTHER

REMEMBER IT CAN BE PARENT TO OFFSPRING OR VICE VERSA

ECONOMIC CONTROL

SOCIAL ISOLATION

EMOTIONAL ABUSE

STALKING

SEXUAL ASSAULT

PHYSICAL ABUSE

MURDER

NO RACE AGE INCOME DISPARITIES

RULE OF THUMB-ENGLAND COMMON LAW- CAN BEATWIFE WITH STICK NO WIDER THAN THUMB

4-15% WOMEN IN ER 2/2 DOMESTIC VIOLENCE

POWER IMBALANCE MAINTAINED TO EXERT CONTROL

VICTIM - DELAY SEEKING RX, PTSD DEPRESION GUILT SELF BLAME

PATIENT BARRIERS- RELUCTANT TO DISCLOSE, CULTURE/RELIGION, POOR INTERACTIONS IN PAST

HEALTHCARE BARRIERS-FINANCIAL, ACCESS TO CARE

PROVIDER BARRIERS-FAILURE TO SCREEN, KNOWLEDGE DEFICIT,LACK OF RESOURCES

FIRST SEEK CARE IN ED- REPEATED VISITS TO ER FOR PHYSICAL INJURIES -RED FLAG

VICTIMS ANXIOUS, POOR EYE CONTACT, FEARFUL OF OTHERS , DENY ABUSE

APPEARANCE PERFECT OR DISHEVELLED

PARTNER REFUSES TO LEAVE ROOM, SPEAKS FOR THE PATIENT…but DONT JUMP TO CONCLUSIONS

BILATERAL INJURIES ESP TO EXTREMITIES

INJURIES AT MULTIPLE SITES

FINGERNAIL SCRATCHES

CIGARETTE BURNS

ABRASIONS MINOR LACERATIONS, WELTS

SUBCONJUNCTIVAL HEMORRHAGE-STRUGGLE SIGN

PATTERN INJURIES ???MARKS OR PATTERNS UNDER THE SKIN

PSYCHOLOGICAL

DEP AND ANXIETY-TREATMENT INEFFECTIVE IF IPV NOT RECOGNISED

PTSD

INSOMINA

ALTERATION OF PERCEPTION OF SELF OR ABUSER

ALL PTS SHOULD BE SCREENED FOR IPV

HAVE TOU EVER BEEN THREATENED CONTROLLED OR FORCED TO DO THINGS IF YES BY WHOM,

ARE YOU AFRAID OF YOUR PARTNER OR ANYONE ELSE?

COMPILE A LIST OF RESOURCES AND RELATED BROCHURES AND HAVE THEM AVAILABLE TO AID IN THE EDUCATION OF PATIENT RE IPV

DOCUMENT SCREENING WAS COMPLETED

DOCUMENT INJURIES

DOCUMENT THE EXPLANATION GIVEN IS INCONSISTENT WITH INJURY

DO NOT CHALLENGE THE PATIENT

MGT

RESOURCES

https://www.nj.gov/dcf/reporting/how/

NOT THEIR FAULT

DO NOT TRY TO VERIFY W PARTNER OR OTHER FAMILY MEMBERS

FOCUS ON PT SAFETY AND APPROPRIATE REFERRALS

ADDRESS URGENT AND NON URGENT ISSUES

PROVIDE EDUCATION AND SERVICES

DONT PRESCRIBE MEDS THAT CAN AFFECT PT ABILITY TO RESPOND IF IN HARM

PROVIDE SPECIALIST REFERRAL

DOCUMENT ACCURATELY-PT STATES

DOCUMENT INJURIES PRECISELY AND USE A BODY MAP TO DIAGRAM, PHOTOS IF POSSIBLE ?????

SEVERE INJURIES -REFER TO ER

988

phq9 does not synch with suicide risk, do not use it as a tool

use aap.org/suicideprevention

use risk assessment ASQ COLUMBIA

WHAT TO DO IF POSITIVE -NOT EMERGENCY IN VAST MAJORITY, IS DISTRESS SIGN

DONT RELY ON SCREEENING TOOL ONLY, ASK PT TO WALK YOU THROUGH WHAT LEADS THEM TO THAT THOUGHT. SUICUDAL NARRATIVE

MOST SUICIDAL TENDENCIES ONLY LAST FEW HOURS

IF +

GET FURTHER SUICIDE RISK ASST DEEPER

PREVENTION ORIENTED RISK PREVENTION

ASK THEM WHAT KEEPS THEM ALIVE - CAMS FORM/QUESTIONNAIRE

DONT JUST ASK HOW THEY FEEL ,ASK RE SUBSTANCE USE, PREVIOUS ATTEMPTS, PROTECTIVE FACTORS

FIND YOUR LOCAL CRISIS CENTER

SECURE FIREARMS, LOCK UP MEDS

NEVER WORRY ALONE, ALWAYS GET CONSULTATION

NATIONAL INSTITUTE OF ALCOHOL ABUSE DEFINITION

ALCOHOL LEADING CAUSE OF ATTRIBUTABLE DEATH, DRINK DRIVING, POISONING, LIVER DX

MEN>4 DRINKS A DAY OR 14 DRINKS A WEEK

WOMEN +>65 >3 DRINKS A DAY OR 7 DRINKS A WEEK

CAGE DOESNT P/U HEAVY DRINKING

USE aUDIT C

NALTREXONE

LABS LFTS BASELINE + QMONTHLY

NALTREXONE IM 380 MG MONTHLY

ACAMPROSATE TID- SAFE IN PTS WITH LIVER DX, NOT FOR RENAL DX

DISULFRAM- CANT HAVE LIVER DX, PSYCHOTIC DISORDERSS, OR SEIZURE DISORDERS- DISULFRAM RISKY

TREMOR

DELIRIUM TREMENS- AUTONOMIC HYPERACTIVITY, TACHYCARDIA, HYPERTHERMIA, DIAPHORESIS

HALLUCINATIONS

SEIZURES

HYPERVENTILATION

SPIDER ANGIOMAS

FLUSHED FACIES

PARALYSIS OF EXTRA OCULAR MUSCLES - WERNICKES ENCEPHALOPATHY

PRRO DENTITION

SKULL OR FACIAL TRAUMA(FALLS)

ASCITES

MELENA

THINNING HAIR

GYNECOMASTIA

OFTEN NEED INTUBATION

SIMILAR TO ALCOHOL

DEVELOP 2 -10 DAYS LATER

MILD NON LIFE THREATENING

FLU LIKE ILLNESS

RHINORRHEA

D+V

DILATED PUPILS

LASTS 3-10 DAYS

IV DRUG ABUSERS RISK OF OM ENDOCARDITIS, HEPATTITIS SEPTIC EMBOLI, HIV

APPERANCE

SCARS NEEDLE MARKS

CNS STIMULANTS

MILD

NOT LIFE THREATENING

DEPRESSION

EXCESSIVE SLEEP

HUNGER

DYSPHORIA

PSYCHOMOTOR DEPRESSION

LASTS WEEKS -DEPRESSION

VS ALL OK

HYPOGLYCEMIA-ETOH -LIVER DX MAY HAVE REDUCED GLYCOGEN STORES

ABGS -MIXED ACID BASE DISORDERS ALCOHOLIC KETOACIDOSIS AND RESP ALKALOSIS

CBC- CHRONIC ALCOHOL-> MYELOSUPPRESSION, THROMBOCYTOPENIA, ANEMIA , MEGALOBLASTIC ANEMIA B12 AND FOLATE DEF. > MCV SUGGEST THIS CONDITION

CMP- ACIDOSIS ANION ND DELTA GAPS - LOW BUN-AD, ELEVATED LIPASE IF PANCREATITIS

SERUM AMMONIA -HEPATIC ENCEPHALOPATHY

LFTS + CALCIUM, AND MAG -ALCOHOLIC PANCREATITIS -> LO CALCIUM

UA-KETONES-ALC KETOACIDOSIS

CK RHABDO FROM ADRENERGIC HYPERACTIVITY FROM W/DRAWAL

PT -USEFUL INDEX OF LIVER FUCNTION-RISK OF COAGULOPATHY

TOX SCREEN

EKG- PROLONGED QTc INTERVAL IN ALC WIHDRWAL

LIBRIUM

HYPOGLYCEMIA -D50W 25 ML -50 ML AND THIAMINE IV

CLONIDINE LO DOSE-REVERSE CENTRAL ADRENERGIC DISCHARGE-RELEIVES TACHYCARDIA , TACHYPNEA, TREMOR AND ALC CRAVING

AGITATED IV OR IM HALDOL-CAREFUL HALDOL < SEIZURE THRESHOLD

ONLY WORKS IF PT IS MOTIVATED

BUPRENORPHINE MED TAPER -PARTIAL OPIOID AGONIST

USE COWS SCALE FOR WITHDRAWAL

METHADONE AND BUPRENORPHINE ARE LONG TERM OPIOID AGONIST

CLONIDINE-LO DOSE ALPHA AGONIST

MALADAPTIVE PATTERN OF SUBSTANCE USE THAT LEADS TO IMPAIRMENT OR DISTRESS AT WORK /SCHOOL/FAMILY.SOCIAL/PHYSICAL

CHRONIC AND RELAPSING

BRAIN PATHWAYS CHANGE-LEAD TO MORE ADDICTION

MULTIFACTORIAL

BRAIN REWARD- N/TRANSMITTERS; DOPAMINE, NOREPI, ENDOGENOUS OPIOIDS ( ENDORPHINS) GABA SEROTONIN ACETYLCHOLINE AND ADRENERGIC SYSTEMS

ABUSE-1 OR MORE IN 12 MONTHS:

FAILURE TO FULFILL ROLES OR OBLIGATIONS

HAZARDOUS SITUATIONS

LEGAL PROBLEMS

SOCIAL/INTERPERSONAL PROBLMES

DEPENDENCE

3OR MORE IN 12 MONTHS

TOLERANCE

WITHDRAWAL

INCREASED USE

ATTEMPTS TO CUT DOWN

EXCESS TIME ON ACTIVITIES TO OBTAIN DRUG

REDUCED SOCIAL/WORK

CONTINUED USE DESPITE KNOWLEDGE OF ADDICTION

PHYSICAL

APPETITE CHANGE

SLEEP PATTERN CHANGE

COLD SWEATY PALMS, SHAKING HANDS

RED WATERY EYES

HYPER OR HYPOACTIVE

RUNNY NOSE HACKING COUGH

PUFFY FACE, BLUSHING OR PALENESS

PSYCH

USU +

MOODY IRRITABLE POOR GROOMING TEMPER TANTRUMS

CHRONIC DISHONESTY

CAGE

DAST ( DRUG ABUSE SCREENING TEST)

MILD TREMOR

COJUNCTIVAL IRRITATION

NASAL IRRITATION-COCAINE

AFTERSHAVE /MOUTHWASH SYNDROME ( COVER UP)

LABILE BP

TACHYCARIDA

SEE OTHER SCREEN

ALSO SIMPLER HERE FROM PPTX

CBC DIFF

CMP

TOX-URIE OR BLOOD

HIV

SYPHILLIS

TSH

-HCG IF NEEDED

INPATIENT DETOX-IF PT MOTIVATED

AA-12 STEP EFFECTIVE

NA

PSYCHOTHERAPY

MGT OF COMORBIDITIES

PHARM TO REDUCE CRAVINGS

THERAPEUTIC RELATIONSHIP

WITHDRAWAL- DEPENDS

CRAVINGS

NALTREXONE

ACAPROSATE

DISULFRAM- CAREFUL NO LIVER PROBLEMS