Welcome to the psychiatry

clerkship!
2013-2014

Clerkship Director: Adriana Foster, MD

[email protected]
Psychiatry clerkship orientation goals
• Describe clerkship objectives/ expectations
• Describe the resources provided on the clerkship
website
• Identify self-study areas
• Describe:
▫ mental status exam,
▫ psychiatric interview,
▫ basic psychopharmacology
Clerkship Objectives (C.O.)
C.O. 1. Patient care

A.Perform a thorough psychiatric interview of a patient with

mental illness
B.Perform and describe a mental status examination.
C.Appraise the information obtained in a psychiatric interview.
D.Formulate a psychiatric differential diagnosis
E.Recognize the need for clinical testing (i.e., neurocognitive
disorder evaluation, diagnostic testing)
F. Appraise the appropriate treatment modalities for psychiatric
disorders.
G.Demonstrate the ability to educate patients and their
families/support systems about diagnoses, and subsequent care
or mental disorders.
C.O. 2 Medical Knowledge
A. Recognize the pathophysiology, epidemiology, clinical picture, and principles of
treatment for the following disorders:
Psychiatric aspects of medical disorders
Neurocognitive disorders
Psychotic disorders
Bipolar and depressive disorders
Anxiety disorders and trauma/stressor related disorders
Personality disorders
Substance use disorders
Childhood and adolescent psychiatric disorders
B. Appraise the indications, contraindications, and possible side effects of the following
drug classes in formulating a treatment plan:
Antipsychotic
Anti-anxiety
Mood stabilizers
Antidepressants
Sedative/hypnotics
Other drug classes that display psychiatric side effects
C. Distinguish the indications for the major types of psychotherapy
occurring in individual or group format: supportive; cognitive; behavioral;
psychodynamic.
D. Demonstrate an understanding of social history within the bio-psycho-
social formulation of mental illness.
E. Demonstrate an understanding of the epidemiology of suicide risk.
C.O. 3 Practice-Based Learning and
Improvement
A. Demonstrate genuine intellectual curiosity and desire to
learn, focused inquisitiveness in asking questions, and
enduring persistence in the pursuit of learning.
B. Choose and appraise medical literature that
pertains to at least 1 (one) of their patients’
mental illness
C. Complete a mid-rotation feedback form
including goals for self-improvement
D. Accept constructive criticism and modify behavior
based on feedback.
C.O. 4 Interpersonal and
Communication Skills
A. Give an oral presentation of a patient in a succinct and organized
manner using findings from the psychiatric interview and mental status
exam.
B. Write complete histories and physicals and progress notes in a
succinct and organized manner using findings from the psychiatric
interview and physical exam.
C. Communicate empathically with patients with mental illness and their
families or support system members
D. Communicate with others in a respectful, professional and non-judgmental
manner and demonstrate effective listening skills
E. Recognize barriers to communication if they occur during a psychiatric
interview.
F. Educate patients assuring their understanding on healthy behavior change
when appropriate (i.e., substance use, treatment adherence)
G. Educate patients assuring their understanding on medical risk and benefits
when appropriate (i.e., medication side effects)
C.O. 5 Professionalism
A.Students will demonstrate utmost respect for all with
whom they interact (patients and their families and
support system, colleagues and team members)
B.Describe the importance of protecting patient privacy
and identifying personal health information, including
when and when not to share information; Required
institutional training and assessment
C.Maintain appropriate professional appearance and composure.
D.Recognize and address personal limitations, attributes or behaviors
that might limit one’s effectiveness as a physician and seek help
when needed.
E.Demonstrates sensitivity and responsiveness to a diverse patient
population, including but not limited to diversity in gender, age,
race, religion, disabilities and sexual orientation.
C.O. 6 Systems-based Practice

A. Demonstrate the ability to work within a

multidisciplinary patient care team, with an
understanding of the physicians’ role as team
leader and the importance of ancillary staff.
B. Examine medical errors and quality problems
using a health systems approach and describe
available methods to minimize them.
Your job during the clerkship
• Enjoy every day! People will tell you amazing life
stories in the next month!!!
• Study from Day 1: Departmental and NBME
exam can be difficult!!!
• Log ALL patients seen
• Observe safety and confidentiality rules
• Respect/learn from your team: attending, SW,
psychologists; counselors, occupational
therapists, peer support specialists, nurses
• Report any problems EARLY to your attending,
clerkship director or coordinator.
TO DO/NOT TO DO
NOT TO DO:
Be late
DO: Call in late after you already
Ask for contact numbers for missed part of the day
attending/resident Be overly familiar with patients
Arrive on time or early on and staff
wards/clinics Self disclosure (with minimal
Ask many questions exceptions)
Ask for feedback on your Break any confidentiality
interviews and write-ups barriers
Offer to present cases or short (5 Contact the site preceptor for
min) literature reviews appeals
Log ALL patients seen in One45
Respect and advocate for your
patients
Psychiatric Interview
Adriana Foster, MD
 =
It takes some
skill….
Psychiatric Interview
= Skill to encourage disclosure of personal
information for a professional purpose

Empathy → rapport → therapeutic alliance

 OUTLINE OF PSYCHIATRIC CASE PRESENTATION

Chief Complaint: patient’s words

HPI and psychiatric history: course/treatment
Psychiatric review of systems: symptoms inventory and duration
Depressive and bipolar, psychosis, anxiety, obsessive-compulsive and trauma-related, substance &
alcohol use, neurocognitive, neurodevelopmental, personality, and other disorders.
Suicidal: thoughts, plan, intent, means (has gun?), personal and family history of suciide
Dangerous Legal
Medical/Family/Social history
Developmental: pre-natal history/sibs/raised by/family life/events/trauma
Mental status exam. Cognitive exam (for example MOCA, MMSE) in the last 5 minutes.

PRESENTATION
Differential diagnosis: most likely 2-3 and why?; specific examples and factors for and against
R/O Depressive and bipolar, psychosis, anxiety, obsessive-compulsive and trauma-related,
substance & alcohol use, neurocognitive, neurodevelopmental, personality, and other disorders
Formulation:
Biologic: genetic d/o/ substance/medical
Psychologic: relate childhood / development to current conflicts.
Social-cultural:
+prognosis: function at work, hobbies, stable relationships, faith, volunteer: reflect ego strength
- prognosis: poor relationships, impulsivity, bad work history, non-adherence
Treatment
State goals of each of the following (include patient’s goals):
Medication: why / side-effects / complications / compliance problems.
Therapy: individual / group
supportive / insight: behavioral / cognitive / psychodynamic
Chief Complaint
• What brought the patient in? Patient’s own
words
• Why now and not 6 months ago?
• What happened in the past week?
• Past 24 hours?
HPI: Course & treatment
When started: child, adolescent, adult
What led to first treatment:
--Suicide attempt?
▫ Hospitalization?
▫ Who initiated it: Patient? Family? School?
Legal system? Military? Social services?
What worked best: medication; ECT;
psychotherapy; peer groups; AA; alternative
medicine?
Is family or other support involved?
Psychiatric review of systems
= symptom inventory, sequence & duration
 Depressive or bipolar
 Psychosis
 Anxiety, obsessive-compulsive and trauma-related
disorders
 Substance & alcohol use
 Neurocognitive disorders
 Other disorders: Neurodevelopmental, Somatic symptom,
Factitious, Impulse control, Dissociative, Sexual
dysfunctions, Feeding and Eating, Sleep-Wake,
Disruptive, impulse control and conduct disorders
 Personality
Explore temporal relationships: cause vs. co-morbidity.
Ask about development

• Early childhood: who raised the patient?

• School years: academic –special education or
high achiever, activities, drugs, legal system,
missing school due to illness…
• How available were the parents?
• Abuse
• Away from home: job, college, marriage
• Relationships throughout development
 Ask about strengths
• What did you use to enjoy before you became ill?
• What are you good at?
• How has your illness and its treatment affected your
▫ physical activities
▫ relationships with family and friends
▫ job and hobbies
▫ feelings about yourself
▫ spiritual/religious beliefs
• What is the most difficult thing about your illness
and its treatment?
• Any positive experience with your illness/treatment?
Interventions
Affirmation =”I see”
Advice/praise =“I’m so proud of you that you stopped
smoking!”
Empathic validation: “It hurts to be treated that way”
Encouragement to elaborate: “tell me more about your
mother”
Clarification = pull together patient’s verbalizations into a
more coherent way
Confrontation = addresses something patient does not
want to accept. Reflects back to patient a denied or
suppressed feeling.
Interpretation = one of most expressive forms of
treatment; therapist’s decision making; makes something
conscious that was previously unconscious.
Q1: This person is dealing with:
check all correct answers
• Transference
• Financial hardship
• Resistance
• Denial
• Anger against therapist
Q2: The therapist is offering:
check all correct answers
• A confrontation
• An interpretation
• Empathic validation
• Re-framing
• Encouragement to elaborate
During a psychotherapy session in which the therapist
has had multiple previous visits with the patient, the
therapist says to the patient: “I sometimes become
concerned that when I suggest you try to speak up,
you may in fact speak up just for me because it is
what I seem to want—the same way you always do
others’ bidding and neglect your own wishes. It
seems that you did this for your parents and your
bosses and some of your friends as well as for me.”
This statement typifies therapist comments made
during:
A. Psychodynamic psychotherapy
B. Cognitive psychotherapy
C. Supportive psychotherapy
D. Group psychotherapy
E. Twelve-step substance abuse programs
Content vs..
Process
• What information we get vs..
• How we get it …. Diagnostic vs..
dynamic
• Diagnostic: happens early
• Dynamic interview =
extended process; elicits bio-
psycho-social and cultural
aspects of the illness
Mental Status Exam
Psychiatry Chief Resident
Identifying Information
• Age
• Sex
• Ethnicity
• Marital Status
Orientation
• Person
• Place
• Time
• Situation
Appearance & Behavior
• Appearance: • Behavior:
▫ Apparent age ▫ Toward interviewer
▫ Body habitus ▫ Eye contact
▫ Clothing ▫ Attentiveness
▫ Grooming ▫ Level of
▫ Odor consciousness
▫ Scars
▫ Tattoos/Piercings
Psychomotor
• Retarded
• Accelerated/Agitated
• Involuntary movements
▫ Organic vs. medication-induced?
Speech
• Spontaneous/Nonspontaneous
• Volume
• Rate
• Tone
• Articulation
• Speech latency
• Paucity of speech content
• Pressured
Mood & Affect
• Mood • Affect
▫ Subjective ▫ Objective – patient’s
▫ Elicited from the expression of mood
patient themselves ▫ Flat/Blunted
▫ Depressed, sad, ▫ Constricted/Restricted
dysphoric, euphoric, ▫ Full
anxious, angry, ▫ Expansive/Broad
irritable, happy,
▫ Congruent/incongruent
hostile… with mood
- Appropriate/
Inappropriate
▫ Labile/Stable
Thought Process
• Speed: RapidSlow • Incoherent/Word salad
• Linear/Goal directed/Logical • Clang associations
• Tangential • Neologisms
• Circumstantial • Perseveration
• Flight of ideas • Echolalia
• Looseness of association/ • Thought blocking
Derailment
Thought Content
• Preoccupations • Delusions
• Obsessions ▫ Grandiose, persecutory,
• Phobias somatic, nihilistic, religious,
• Overvalued Ideas jealousy, erotomanic, culture-
bound, control (thought
• Suicidality broadcasting or insertion)
• Homicidality ▫ Mood congruent/incongruent
▫ Bizarre/Non-bizarre
▫ Ego-syntonic/dystonic
Perception
• Hallucinations and Illusions
▫ Sensory system: Auditory, visual (hypnogogic,
hypnopompic), tactile, olfactory
▫ Depersonalization/derealization=detachment
• Dreams
▫ Nightmares, recurrent dreams
▫ Fantasies, daydreaming
Insight & Judgment
• Insight
▫ Patient’s understanding of their illness
• Judgment
▫ Examples of harmful behaviors
▫ Test an imaginary situation
 Stamped addressed envelope
▫ Abstraction
 Proverb
Memory, Attention & Concentration
• Serial 7’s
• WORLD  DLROW
• Immediate and delayed recall
MINI-MENTAL STATE (Folstein, 1975 – proprietary)
ORIENTATION
▫ What is the (year) (season) (date) (day) (month)?
▫ Where are we: (state) (county) (town) (hospital) (floor)?
REGISTRATION Temporal
▫ Name 3 objects: One second to say each. Ask the patient all three after you have
said them. Give 1 point for each correct answer. Then repeat them until he/she
learns all three. Count trials and record:
ATTENTION AND CALCULATION Frontal
▫ Serial 7’s. One point for each correct. Stop after five answers. Alternatively spell
“world” backwards.
RECALL Temporal
Ask for the three objects repeated above. Give one point for each correct.
LANGUAGE Fronto-temporal
▫ Repeat the following “No ifs, ands or buts.” (1 pt.) Follow a 3-stage command:
“Take a paper in your right hand, fold it in half, and put it on the floor” (3 pts.)
▫ Name a pencil, and watch (2 pts.) Occipital
▫ Read and obey the following: Close your eyes (1 pt.) Write a sentence (1 pt.)
Copy design (1 pt.) Parietal
CONSCIOUSNESS RAS
Alert; drowsy; stupor ; coma.

http://enotes.tripod.com/MMSE.pdf
Executive function - frontal
= ability to think abstractly, plan, initiate and sequence,
monitor and stop complex behavior; insight, judgment
Bedside measures
• Luria Motor Test: alternate hand movements; fist,
cut; slap.
• Word Fluency Test: “tell me 5 words starting with the
letter “A”
• Similarities: ability to apply abstract concepts.
• Proverb interpretation: conceptual thinking ability
• Clock Drawing: “This circle represents a clock face.
Please put the numbers, so that it looks like a clock
and then set the time to 10 minutes past 11” (parietal
and frontal lobes involved)
5 point scale (Shulman):

5 points: perfect clock

4: minor visual-spatial errors

3: inaccurate representation
of 10 past 11 with good
visual-spatial representation

2: moderate visual-spatial
disorganization, such as
accurate representation of 10
past 11 is impossible

1: severe visual-spatial
disorganization

0: no reasonable
representation of a clock
http://www.m
ocatest.org/d
efault.asp
MSE Example
• ID/Appearance/Behavior: 30-something obese
WM with well-groomed beard casually and
appropriately dressed in sports jersey and
backwards cap; cooperative with interviewer,
poor eye contact; inappropriate laughter
• Orientation: Not assessed, however most likely
oriented to person and place at least
• Psychomotor: No abnormal movements, no
psychomotor agitation/retardation
MSE Example (ctd.)

• Speech: Spontaneous w/ normal volume, rate,

tone; normal articulation
• Mood: Variable – euthymic to broad at
beginning, dysphoric (“life sucks”) towards end
• Affect: Variable but appropriate and mood-
congruent – full at beginning, restricted at end
• Thought Process: + looseness of associations; +
clang associations; + neologisms
Psychopharmacology Basics
Adriana Foster, MD
Antidepressants: SSRIs
Action: inhibit 5HT reuptake
Side Effects:
GI 5HT3 receptors activation
Sexual D2, Ach blockade, 5HT reuptake inhibition
Endocrine SIADH; hyponatremia more frequent in older
Discontinuation sdr.
Pregnancy paroxetine - class D
Increased suicidal behavior in children & adolescents
Serotonin syndrome with other serotonergic agents:
neuromuscular-myoclonus, autonomic instability, mental status,
GI symptoms
CYP450 interactions: fluoxetine, paroxetine, fluvoxamine-most,
citalopram and sertraline-least
Antidepressants
SNRIs: venlafaxine, duloxetine, desvenlafaxine
BP elevation at higher dose

NDRI (NE, DA reuptake inhibitor):

Bupropion: dose dependent seizures; CI in eating d/o

Mirtazapine: Selective α2 adrenergic antagonism with

increase in serotonergic and noradrenergic activity;
5HT2c and 5HT3 receptor blockade → 5HT1A
activation; sedation, weight gain, neutropenia

5HT2 antagonists/reuptake inhibitors:

Nefazodone: sedation, visual trails, MANY drug
interactions CYP450 3A4, hepatic failure-rare
Trazodone (metabolite mCPP a strong serotonin
agonist-anxiogenic and induces anorexia),
priapism
 Antidepressants
TRICYCLICS: inhibit NE and 5HT uptake and less DA
 Sedation, anticholinergic toxicity (treat with bethanechol), CV-
arrhythmias (order EKG >40 years old, avoid in heart disease)
 Lethal in overdose: wide-complex arrhythmia, seizure,
hypotension
 Nortriptyline therapeutic window: 50-150 ng/ml

MAOIs: Inhibit MAO-A and B which metabolize NE, 5HT and

DA; nonselective-phenelzine, tranylcypromine (selective:
selegiline; reversible-RIMA: moclobemide)
 Serotonin syndrome with SSRIs, SNRIs, triptans
 Hypertensive crisis with adrenergic agents, meperidine and
high monoamine content foods; treat with phentolamine,
chlorpromazine, nifedipine; DO NOT GIVE β BLOCKERS
 Require low monoamine diet
 GENERIC BRAND ANTIDEPRESSANT NAMES AND FDA APPROVED INDICATIONS

Sertraline Zoloft Major depression,(MDD), OCD (adult and child), PTSD, social
anxiety d/o, panic d/o, premenstrual dysphoric d/o (PMDD)

Fluoxetine Prozac (weekly available) MDD (adults, children, adolescents), panic, OCD, bulimia nervosa,
PMDD
Fluvoxamine Luvox (XR) OCD
Paroxetine* Paxil (CR) MDD, OCD (adult, child and adolescent), social anxiety,
Generalized anxiety disorder (GAD), PTSD, PMDD

Citalopam** Celexa MDD

Escitalopram Lexapro MDD (adults and adolescents), GAD
Venlafaxine Effexor (XR) MDD, panic, social anxiety d/o, GAD
Des-venlafaxine Pristiq MDD

Duloxetine Cymbalta MDD, neuropathic pain, fibromyalgia

Bupropion Wellbutrin (SR, XL), Zyban MDD, Smoking cessation

Mirtazapine Remeron MDD,

Nefazodone n/a MDD
Trazodone Desyrel MDD
Phenelzine Nardil MDD
Tranylcypromine Parnate

Selegiline Emsam (patch), Deprenyl (oral)

Amitriptyline Elavil MDD

Nortriptyline Pamelor MDD
Antipsychotics
1st generation DISCUSS/MONITOR RISK
D2 blockade
 Movement d/o: Parkinsonism (at 80% blockade)
treat with anticholinergics, akathisia (tx with β
blockers or benzos), acute dystonia (IM antichol.),
tardive dyskinesia (eliminate offending agent)
 NMS: rigidity, hyperthermia, tachycardia, ↑CPK,
AMS, potentially lethal! – supportive measures
 Anticholinergic
 Sexual (increased prolactin)
 Retinitis pigmentosa: chlorpromazine and
thioridazine
 QT prolongation black box: thioridazine
Antipsychotics
2nd generation DISCUSS/MONITOR RISK
Risperidone, paliperidone, olanzapine, quetiapine,
ziprasidone, aripiprazole, iloperidone, asenapine
D2 (also D3 and D4) , 5HT2 blockade, glutamate?
 Metabolic: wt gain and direct effect on triglycerides,
serum leptin
 Sexual
 Movement: risperidone anticholinergic treatment
 Orthostatic hypotension: titrate slowly (quetiapine,
iloperidone)
 QT prolongation: ziprasidone, iloperidone
CLOZAPINE minimal D2 blockade (D1, D2, D3, D4),
5HT2A (also 5HT2C, H1, M1, α1)
Five black box warnings
1. Agranulocytosis: do not give or d/c if WBC is <3,500 or ANC
< 2,000, MONITOR these numbers weekly x 6mo, twice/mo x
6 mo., then monthly for lifetime
2. Cardiovascular events: myocarditis, pulmonary emboli
3. Patients with neurocognitive disorders: increased risk of
death –blanket warning for ALL 2nd generation antipsychotics
4. Orthostatic hypotension
5. Seizures

Advantages
 Indicated in refractory schizophrenia (failed ≥ 2 antipsychotics)
 Improvement continues long term: at 6 mo., one year and 5
years
 It decreases suicide risk and violence in patients with
schizophrenia
 Along with quetiapine, used in psychosis in Parkinson’s
patients because it does not induce EPS
GENERIC BRAND ANTIPSYCHOTIC NAMES AND FDA APPROVED INDICATIONS

Fluphenazine Prolixin (oral, IM, Schizophrenia

decanoate)
Haloperidol Haldol (oral, IM, Schizophrenia
decanoate)
Trifluoperazine Stelazine Schizophrenia
Thioridazine Mellaril Schizophrenia
Chlorpromazine Thorazine Schizophrenia, MDD
Risperidone Risperdal (oral, long Schizophrenia (+ children 13-17), bipolar mania (+ children 10-
acting inj.) 17)and irritability in autism; long acting risperidone is approved for
schizophrenia and bipolar I disorder.

Paliperidone Invega (oral, long acting Schizophrenia and schizoaffective disorder

inj.)
Olanzapine Zyprexa (oral, IM, long Schizophrenia, acute treatment of mania and mixed episodes of
acting injection) bipolar d/o, maintenance tx. Of bipolar; acute agitation in
schizophrenia and bipolar mania for the short acting IM injection.
Adults and children over 13 years old.

Quetiapine Seroquel Schizophrenia, , acute treatment of mania and mixed episodes of

bipolar d/o, maintenance tx. Of bipolar; adjunct treatment of MDD

Ziprasidone Geodon (oral, IM) Schizophrenia, schizoaffective and bipolar mania (the latter
indication + children 10-17)
Aripiprazole Abilify (oral, IM) Schizophrenia, , acute treatment of mania and mixed episodes of
bipolar d/o, maintenance tx. Of bipolar; adjunct treatment of MDD;
irritability in autism; acute agitation in schizophrenia for short acting
IM formulation
Iloperidone Fanapt Schizophrenia
Asenapine Saphris Schizophrenia, acute manic and mixed episode
Clozapine Clozaril, FazaClo Refractory schizophrenia
Lurasidone Latuda Schizophrenia
Mood stabilizers
Lithium:
 Serotonin effect; Li protects rat cerebral cortex and
hippocampus from glutamate induced cell death
 Anti-suicidal effect in bipolar d/o
 Side effects:
 Lethal in overdose: therapeutic window 0.6-1.2 MEq/L; >
3.5 mEq/l fatal
 Long term: hypothyroidism, renal insufficiency
 NSAIDs, ACE inhibitors, thiazide diuretics, tetracycline, salt
restriction ↑ levels
 Theophylline, caffeine, osmotic diuretics ↓ levels
 Can use K sparing diuretics to treat nephrogenic diabetes
insipidus (amiloride)
 Pregnancy class D: Epstein anomaly rare 1/2,000 births
Mood stabilizers
• Valproate
▫ Increases brain GABA levels, modulates glutamate
▫ Risk of pancreatitis and liver failure
▫ Drug interactions: increases levels of drugs metabolized through
glucuronidation (lamotrigine, lorazepam)
▫ Pregnancy class D: neural tube defects (3-5% spina bifida risk )
• Lamotrigine
▫ Inhibits Na channels; stabilizes neuronal membranes; modulates
glutamate
▫ Risk of Stevens Johnson sdr 3/1,000
• Carbamazepine
▫ Blocks Na channels, modifies adenosine receptors; inhibits glutamate;
increases extracellular serotonin
▫ Agranulocytosis, hyponatremia, induction of other drugs’ hepatic
metabolism
▫ Pregnancy class D: neural tube defects
Benzodiazepine Anxiolytics
GABA-A agonists
Effects:
 Anxiolytic: anxiety, insomnia, acute agitation,
withdrawal syndromes
 Hypnotic: useful in anesthesia
 Anticonvulsant: seizure control
 Muscle relaxation
• All are pregnancy category D drugs; fetus with possible
congenital abnormalities; fetus may suffer withdrawal
• Dependence, tolerance, withdrawal
• In patients with liver failure give lorazepam, oxazepam,
temazepam metabolized by glucuronidation only
 Valproate Depakote (ER) Mania (mixed episodes and high number of illness manic episodes >10
predict response to valproate), migraine, seizures

Carbamazepine Carbatrol, Tegretol XR, Seizures, trigeminal neuralgia and (Equetro only) manic and mixed
Equetro episodes of bipolar disorder

Oxcarbazepine Trileptal seizures

Lamotrigine Lamictal seizures
Gabapentin Neurontin Seizures, post-herpetic neuralgia
Topiramate Topamax Seizures, migraine
Alprazolam Xanax Various benzodiazepines are approved by FDA as hypnotics, to treat
Diazepam Valium (oral, IV) anxiety disorders (panic, GAD, social anxiety), and in the case of
clonazepam, as adjunct in treatment of acute mania)
Lorazepam Ativan (Oral, IM, IV)
Oxazepam Serax
Temazepam Restoril

Hydroxyzine Vistaril
Benztropine Cogentin (oral, IM)
Diphenhydramine Benadryl (oral, IM)

Buspirone Buspar GAD

Naltrexone Revia (oral, long acting Adjunct in treatment of alcoholism
injectable)
Disulfiram Antabuse Alcohol dependence
Buprenorphine and Suboxone Opiate dependence
Naloxone
OTHER SOMATIC TREATMENTS
• FDA approved
▫ ECT: triggers seizures in normal neurons by
application of pulses of current through the scalp
that propagate to the entire brain.
▫ VNS: stimulation of left vagus nerve; pulse
generator in L chest wall
▫ TMS: pulsatile high-intensity electromagnetic field
induces focal electrical currents in the underlying
cerebral cortex
• Not FDA approved
Light therapy, neurosurgery in OCD, deep brain
stimulation for OCD and refractory depression
Foster personal EEG collection
Vagus Nerve Stimulation (VNS)
• FDA approved for epilepsy; FDA
approved for Treatment Resistant
Depression 2005

• Pulse generator implanted in left

chest wall area, connected to leads
attached to left vagus nerve

• Mild electrical pulses applied to CN X

for transmission to the brain

61
Case vignette
A 28 years old man with schizophrenia is
brought to the ER by family due to refusal to eat
and to leave his room, agitation and paranoia.
He is treated in the hospital and he is placed in
a personal care home. His antipsychotic
medication is changed within the month after
discharge due to side effects. Within the same
week he completes suicide by hanging.
Suicide risk
95% of suicide completers are mentally ill:
 80% have mood d/o
 10% have schizophrenia
 5% have delirium/dementia
 25% alcohol dependence + other illness
Completers: male, 40-59 yo, high lethality
Attempters: , <35 yo, low lethality
10% of attempters will complete suicide
Native American >Caucasian> Asian >African American
and Hispanic (CDC data 2012: 17.3 to 5 per 100,000 people)
↓ CSF 5-HIAA (serotonin metabolite) associated with
violent suicide
Suicide Risk
Mood disorders: 15-20%
▫ Bipolar mixed highest risk
▫ Delusional depression
Schizophrenia: 5-10% (young male, insight,
high IQ, command hallucinations)
▫ 3 wks -3 mo. from hospitalization
Substance abuse:
▫ Young male, multiple substances, recent
loss, co-morbid, previous OD
WHAT WORKS TO DECREASE RISK: LI,
CLOZAPINE, ECT, psychotherapy!!
SUICIDE RISK ASSESSMENT

Current thoughts of suicide (IDEATION);

Do you wish you were dead or wish that you went to sleep and not wake up?
Do you want to die?
Reasons: Is it to:
Get attention, revenge, reaction;
Stop the pain?
Suicide plan and intent;:
Do you have any plans?
What plans to you have?
Access to suicide means:
Do you have a gun?
Past suicide thoughts and attempt:
Have you ever made a suicide attempt? Tried to end your life?
An INTERRUPTED attempt: stopped by someone else: for example, pt holding pills in their
hand, someone grabs them by the hand; noose round neck but has not started to hang and is
stopped; pointed gun toward self, someone else takes the gun; An ABORTED attempt is
stopped by the person after they took steps toward making an attempt
PREPARATORY BEHAVIOR: did this include anything beyond verbalizing a thought? For example
collecting pills, getting a gun, giving away valuables or writing a suicide note?
Family history of suicide
 Major Depression Male

Bipolar Depression Living alone

Alcohol abuse and dependence Over age 65

Drug abuse and dependence White

Schizophrenia Separated, widowed or divorced

Eating disorders Being unemployed or retired

Antisocial personality disorder Occupation: health-related occupations higher

(dentists, doctors, nurses, social workers) ; especially
high in women physicians
PTSD

Borderline personality disorder

PREVENTION:
1) Antidepressant treatment;
2) Psychotherapy: cognitive-behavioral, interpersonal or dialectic behavioral therapy;
3) Means restrictions: Firearm safety; jumping site barriers; detoxification of domestic gas; improvements in the catalytic converters in motor
vehicles; restrictions on pesticides; reduce lethality of prescriptions; lower toxicity antidepressants; Medications in blister packs; Restrict sales of lethal
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Sources:
• Allen Frances, MD, Ruth Ross, MA, DSM IV case studies, A clinical
guide to differential diagnosis, American psychiatric press, 1996.
• Glen O. Gabbard, MD, Psychodynamic Psychiatry in Clinical Practice,
Fourth Edition, American Psychiatric Publishing, 2005.
• Harold Kaplan, MD, Benjamin Sadock, MD, Kaplan and Sadock’s
Synopsis of Psychiatry, 10th edition, Williams and Wilkins, 2007.
• Davidson B et al, Assessment of the Family, Systemic and
Developmental perspectives, Child and Adolescent Psychiatric Clinics
of North America, 10(3), 415-429, 2001.
• www.youtube.com
• Wedding, D, Stuber, M, Behavior and Medicine, 5th edition, Hogrefe
Publishing, 2010.
• www.psychiatryonline.org
• Posner K et al, Columbia-Suicide Severity Rating Scale from Oquendo
et al Risk Factors for Suicidal Behavior: Utility and Limitations of
Research Instruments, in M.B. First [Ed] Standardized Evaluation in
Clinical Practice, pp. 103-130, 2003.
• American Psychiatric Association, Desk Reference to Diagnostic
Criteria from DSM V, APPI, 2013.