Psychosocial Mental Health

Common SSRIs (Ranked from Most to Least Energizing)

Primary treatment for major depressive disorder, OCD, anxiety, and premenstrual dysphoric disorder.

• Fluoxetine (Prozac) – Longest half-life; potential interaction with warfarin.
• Sertraline (Zoloft) – Well-tolerated with moderate activation.
• Citalopram (Celexa) – Minimal drug interactions; risk of QT prolongation (max dose 20 mg for elderly).
• Escitalopram (Lexapro) – Similar to citalopram but more potent.
• Paroxetine (Paxil) – Shortest half-life; highly sedating with strong anticholinergic effects and higher risk of erectile dysfunction; numerous drug interactions.

Most effective for mood stabilization and enhancement.
⚠ May trigger mania in bipolar disorder; avoid combining with MAOIs.
⚠ 40% likelihood of sexual side effects.

Common SNRIs

• Venlafaxine (Effexor) – May elevate blood pressure.
• Duloxetine (Cymbalta) – Effective for neuropathic pain; not recommended for individuals with alcohol use due to liver risk.
• Desvenlafaxine (Prestiq) – Similar to venlafaxine with fewer interactions.

Particularly effective for mood stabilization and enhancing focus.
⚠ 40% probability of sexual side effects.

SDRI (Selective Dopamine Reuptake Inhibitor)

• Bupropion (Wellbutrin) – Contraindicated for individuals with seizure disorders or bulimia.
• Often prescribed alongside SSRIs to enhance therapeutic effects.

Most effective for boosting mood in cases where SSRIs alone are insufficient.
⚠ 20% likelihood of sexual side effects.

Tricyclic Antidepressants (TCA)

TCAs are no longer considered first-line treatments for depression due to their significant side effect profile and overdose risk. Instead, they are more commonly prescribed for off-label uses such as postherpetic neuralgia, migraine prevention, and stress incontinence.

TCAs should be avoided in individuals at high risk for suicide, as overdose can be fatal due to cardiac arrhythmias and neurological toxicity. They are also contraindicated in patients with known cardiovascular disease and are generally not recommended for elderly patients, aligning with the BEERS criteria, due to heightened risk of adverse effects.

Common side effects include:

• Anticholinergic effects (dry mouth, constipation, urinary retention)
• Orthostatic hypotension
• Cardiac conduction abnormalities
• Cognitive impairment, particularly in older adults
• Exacerbation of glaucoma or benign prostatic hyperplasia (BPH)

Examples of TCAs:
Imipramine, Amitriptyline, Nortriptyline

Symptoms of Depression

• S – Sleep disturbances (insomnia or excessive sleep)
• I – Interest loss in activities, irritability (anhedonia)
• G – Guilt or feelings of worthlessness
• E – Energy depletion, persistent fatigue
• C – Cognitive impairment, trouble concentrating
• A – Appetite changes, weight gain or loss
• P – Psychomotor changes, either agitation or slowed movements
• S – Suicidal thoughts, frequent or obsessive
• M – Mood changes, persistent sadness, tearfulness
• Major Depression: Five or more symptoms
• Minor Depression: Two to five symptoms

Rule Out:

• Hypothyroidism
• Anemia
• Autoimmune conditions
• B12 deficiency

Signs in Teenagers:

• Declining academic performance
• Behavioral issues
• Social withdrawal
• Increased mood swings

Stopping Antidepressants

• Discontinuation after SSRI, SNRI, or TCA use for over six months
• Symptoms usually last less than a week
• Gradual tapering over six weeks helps minimize effects
• Uncomfortable but not dangerous

Common Withdrawal Symptoms (FINISH)

• F – Flu-like symptoms
• I – Insomnia
• N – Nausea
• I – Imbalance (dizziness, coordination issues)
• S – Sensory disturbances
• H – Hyperarousal (anxiety, agitation)
• H – Headache

Signs of Anxiety

• W – Worry
• A – Apprehension
• T – Tense muscles
• C – Concentration difficulties
• H – Heightened irritability or hyperarousal
• E – Exhaustion or fatigue
• R – Restlessness
• S – Sleep disturbances

Criteria: Presence of at least three symptoms on most days for over six months.

Goals for Treating Anxiety & Depression

• Sustained symptom relief for at least 4-5 months, focusing on full recovery and overall well-being.
  • Typically accomplished through a combination of therapy, social support, and medication.
  • Gradual medication tapering is recommended.
• Extended treatment may be necessary for individuals experiencing a second or recurrent episode.

Key Questions Before Prescribing Medication

• Which symptoms are the most distressing or disruptive?
• Which medication options best target these specific symptoms?

Medications for Anxiety Management

• Benzodiazepines – Prefer long-acting forms to minimize risk of dependence.
  • When discontinuing, reduce dosage by 25% per week.
• Buspirone (BuSpar) – Low risk for abuse.
  • Effective with consistent use (3x daily for at least six weeks).
  • Not suitable for as-needed use or sleep aid.

Monoamine Oxidase Inhibitors (MAOIs)

• Significant interactions with certain foods and medications.
• Includes Phenelzine (Nardil) and Tranylcypromine (Parnate).
• Avoid combining with SSRIs, TCAs, or triptans.
• Can cause dangerous blood pressure elevation and increase stroke risk when consumed with fermented foods (e.g., beer, wine, aged cheese).

Alcohol Use Screening

• C: Have you ever felt the need to cut back on drinking?
• A: Do you get annoyed when others comment on your alcohol consumption?
• G: Have you ever felt guilty about your drinking?
• E: Do you ever drink early in the day to steady yourself or get going?

🔹 Two or more “yes” answers strongly indicate potential alcohol misuse.
🔹 Dependence is evident if someone continues drinking despite negative consequences.

Adverse Effects of Antipsychotics

• Motor Symptoms:
  • Pill-rolling tremor, shuffling walk, slowed movement
  • Extrapyramidal side effects:
    • Akinesia: Difficulty starting movements
    • Akathisia: Intense urge to move, restlessness
    • Bradykinesia: Slowed movement, especially in sequential tasks (e.g., buttoning a shirt)
    • Tardive dyskinesia: Uncontrolled lip-smacking, tongue rolling, facial, trunk, and limb movements
• Metabolic Risks:
  • Higher likelihood of weight gain, Type 2 diabetes, high cholesterol, metabolic syndrome, and thyroid dysfunction

Suicide Awareness & Risk Factors

• Statistics:
  • Men account for nearly 80% of completed suicides.
  • Women attempt suicide 2-3 times more frequently.
  • The highest completion rate is among men aged 75+.
  • Asking about suicidal thoughts does not increase the risk of suicide.
• Key Risk Factors:
  • Elderly individuals who have lost a spouse
  • Access to firearms or other lethal means
  • History of previous suicide attempts
  • Mental health disorders (e.g., bipolar disorder, depression)
  • Past emotional, physical, or sexual abuse
  • Terminal or chronic illness with persistent pain
  • Significant personal loss
  • Bipolar disorder carries the highest risk during depressive phases
• Essential Screening Questions:
  1. Are you considering harming yourself?
  2. If so, do you have a plan?
  3. If yes, do you have access to the means?
• Intervention Based on Risk Level:
  • Immediate danger: Urgent psychiatric evaluation and hospitalization
  • High risk but not imminent: Intensive mental health treatment

Serotonin Receptor Functions

• 5-HT1A → Mood regulation, key target for antidepressants
• 5-HT1C & 5-HT2C → Involved in cerebrospinal fluid production
• 5-HT1D → Plays a role in migraine relief (D = defense against migraines)
• 5-HT2 → Linked to agitation, anxiety, and panic responses (2 = too much stress)
• 5-HT3 → Triggers nausea, vomiting, and diarrhea (3 = GI upset, N/V/D)

Alternative Treatments for Depression

• St. John’s Wort
  • Interferes with SSRI, TCA, MAOI
  • Reduces the efficacy of digoxin and birth control
• 5-HTP & L-Tryptophan
  • May interact with SSRI, MAOI, dextromethorphan, and triptans
• Omega-3 Fatty Acids
  • No significant drug interactions
  • High doses may increase bleeding risk
  • Discontinue one week before surgery
• Folate & Vitamin B6 → Potential benefits in mood regulation
• Non-Pharmaceutical Approaches
  • Exercise, yoga, massage, guided imagery, acupuncture, light therapy
• Kava-Kava & Valerian Root
  • Used for anxiety and insomnia
  • Should not be combined with benzodiazepines, sedatives, or CNS depressants

Emotions and Their Chemical Drivers
Monoamine System

• Serotonin (5-HT)
  • Promotes a sense of well-being
  • Induces calmness
  • Reduces impulsivity
  • Lowers sex drive
  • Decreases aggression
  • Increases appetite
• Dopamine
  • Heightens worry
  • Boosts vigilance
  • Increases motivation
• Norepinephrine
  • Improves focus
  • Enhances ambition
  • Boosts productivity

Condition	Cause	Signs/Symptoms	Diagnosis	Treatment Options	Concerns
Bipolar Disorder	Strong genetic influence	Type 1: Classic manic episode – mood swings, euphoria, excessive talk, grandiosity, minimal sleep, increased energy, disinhibition, potential psychotic episodes, higher substance abuse. Type 2: Hypomanic episode – absence of mania and major depression	Peak onset in 20s	Medications: Lithium (risk to kidney and thyroid), anticonvulsants (valproate, carbamazepine), antipsychotics (for manic episodes), benzodiazepines (for agitation, insomnia, anxiety)	High suicide risk during depressive phase
Acute Serotonin Syndrome	Excess serotonin due to new medications or dosage changes	Rapid onset of high fever, muscle rigidity, mental confusion, hyperreflexia, uncontrolled shivering, dilated pupils, fast heartbeat, diarrhea	Rapid progression; often a reaction to combining SSRI, MAOI, or TCAs	Wait at least 2 weeks before switching medications	Life-threatening condition
Malignant Neuroleptic Syndrome	Unknown cause, often due to antipsychotics affecting dopamine	Sudden onset of high fever, muscle rigidity, confusion, blood pressure fluctuations, urinary incontinence	Requires immediate diagnosis, often from antipsychotics	Life-threatening condition requiring immediate intervention
Depression	30-40% genetic, 60-70% environmental influences	Symptoms: fatigue, guilt, decreased interest, changes in appetite, sleep issues, agitation, suicidal thoughts, and chronic pain; Seasonal affective disorder often in winter	Screen for hypothyroidism, anemia, autoimmune disorders, B12 deficiency; CBC, CMP, TSH, B12, Folate, Urinalysis, EKG (if prescribing medications affecting QT interval)	Cognitive Behavioral Therapy, SSRIs (4-12 weeks for effect), TCAs (sedation, avoid if suicidal), consider Wellbutrin for sexual side effects	Suicide risk, comorbidities such as PTSD, anxiety, and alcohol/drug disorders
Alcoholism	Compulsive drinking despite negative consequences	Binge drinking: Men – 5+ drinks, Women – 4+; Symptoms: Delirium tremors – confusion, hallucinations, high heart rate, blood pressure, tremors, seizures	GGT, AST/ALT ratio (2:1), MCV > 100	AA, Al-Anon support groups, Benzos (Librium, Valium), Antipsychotics (Haldol), Disulfiram (Antabuse), Naltrexone (Vivitrol), Acamprosate (Campral)	High blood alcohol levels (0.8%+) impair driving; risk for chronic issues like Korsakoff’s syndrome
Korsakoff’s Syndrome	Long-term alcohol abuse leading to thiamine (B1) deficiency	Neurological issues: low blood pressure, visual impairments, confusion, lack of coordination, stupor	High doses of thiamine, preferably parenteral	Parenteral vitamins (thiamine), avoid brain damage progression	Wernicke’s encephalopathy (brain damage due to thiamine shortage)
Korsakoff’s Amnesic Syndrome	Permanent brain damage from prolonged thiamine deficiency	Impaired memory, inability to learn new information, confusion, disorientation, attention deficits, visual issues	Diagnosis confirmed by symptoms of amnesia and brain damage	No cure, but thiamine supplementation may prevent further damage	Permanent brain damage from untreated deficiency

Condition	Cause	Signs/Symptoms	Diagnosis	Treatment Options	Concerns
Insomnia	Disruptions in sleep cycles, psychological factors, mental health disorders, sleep apnea (OSA), restless legs syndrome (RLS), environmental factors, medication use, or unknown causes	Trouble falling asleep, waking up too early, or being unable to return to sleep; daytime sleepiness, headaches, fatigue, irritability, difficulty focusing	Can be classified as primary (no underlying cause), secondary (due to another condition), or based on duration: short-term (<3 months) or chronic (≥3 months, 3+ nights per week)	Sleep hygiene (consistent bedtime, avoiding caffeine); referral to a sleep lab (polysomnography for sleep apnea); antihistamines (caution with elderly); benzodiazepines and non-benzodiazepines (e.g., Zolpidem, Eszopiclone, Ramelteon); complementary therapies like melatonin, yoga, acupuncture, and exercise (avoid 4 hours before bed)	Associated risk factors: depression, anxiety, GERD, female gender, substance use (alcohol, nicotine, illicit drugs), chronic health issues, shift work, certain medications (SSRIs, blood pressure meds, steroids)
Schizophrenia	Genetic predisposition, environmental influences	Hallucinations (mainly auditory), delusions, disorganized behavior and speech, emotional flatness, impaired social skills, and poor planning and organization	Typically diagnosed in late adolescence to early adulthood (16-30 years); requires psychiatric evaluation	Antipsychotic medications, with careful monitoring for potential heart risks (QT prolongation); some medications may require an EKG to check for heart irregularities	Medication side effects can include heart problems, sedation, and metabolic disturbances
Anorexia Nervosa	Excessive fear of weight gain, distorted body image perception	Severe weight loss (BMI <18.5), hair growth on face and body (lanugo), absent menstrual cycles for 3+ months, bloating, dry skin, low blood pressure, slow heart rate, hypothermia, dental erosion from purging, excessive exercise, laxative use	Diagnosis based on DSM-V criteria (refusal to maintain healthy weight, extreme fear of gaining weight, body image distortion)	SSRI as first-line treatment, avoid Wellbutrin (increases seizure risk); nutritional rehabilitation, psychotherapy, medical monitoring; possible calcium and vitamin D supplementation	Long-term risks include bone loss (osteopenia/osteoporosis), heart issues (arrhythmias, cardiomyopathy), low potassium, and potential brain damage

Condition	Cause	Signs/Symptoms	Diagnosis	Treatment Options	Concerns
Bulimia Nervosa	Often secretive behavior; self-induced vomiting, excessive use of laxatives and diuretics. Typically, the person maintains a normal or slightly above-average weight.	Damage to the teeth, especially the lingual surfaces from gastric acid exposure; hypokalemia due to laxative and diuretic overuse. The person often exhibits cycles of binge eating and compensatory behaviors like vomiting, excessive exercise, or fasting.	DSM-V criteria: Binge eating within a 2-hour window, a sense of losing control, and recurrent compensatory actions at least once per week for 3+ months.	Cognitive-behavioral therapy (CBT), SSRIs (except Wellbutrin), and supportive care for managing the psychological and physical effects of the disorder.	Comorbid conditions, including anxiety, depression, and substance abuse, may complicate recovery.
Post-Traumatic Stress Disorder (PTSD)	Trauma-related, such as combat, sexual assault, myocardial infarction (MI), stroke, or prolonged ICU stay.	Flashbacks, nightmares, intrusive memories, avoidance of trauma-related reminders, hypervigilance, and feelings of detachment from others.	Diagnosis often involves PTSD assessment tools, including a checklist, and the presence of symptoms for at least 1 month after the traumatic event.	First-line treatment includes SSRIs like paroxetine or sertraline, possibly combined with mirtazapine for sleep disturbances. Cognitive behavioral therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR).	Higher rates of comorbid conditions, such as depression, anxiety, and substance abuse, make treatment more complex.
Anxiety Disorders	Situational stress, phobias, obsessive-compulsive disorder (OCD), generalized anxiety disorder (GAD), panic disorders, and social anxiety.	Excessive worry, fear, panic attacks, avoidance behaviors, and physical symptoms like increased heart rate and sweating. Panic disorder is more common in women, with associated agoraphobia.	Generalized anxiety disorder (GAD) involves persistent worry for 6+ months; panic disorder is diagnosed with recurrent panic attacks; OCD involves intrusive thoughts and compulsive behaviors.	Medications include SSRIs, SNRIs, and buspirone (for GAD). Benzodiazepines can be used for short-term relief but carry a risk of dependence. Cognitive behavioral therapy (CBT) and other forms of psychotherapy are recommended.	Herbal remedies like kava-kava, valerian root, and passionflower may interact with medications.
Munchausen Syndrome	Factitious disorder where individuals intentionally produce or exaggerate physical or psychological symptoms to receive medical care.	Patients may self-harm or fabricate symptoms to gain attention, often in medical settings. In Munchausen by proxy, a caregiver (typically a parent) intentionally causes harm to a child to seek medical attention.	Diagnosis is primarily clinical, with a pattern of inconsistent or fabricated medical history and symptoms.	Treatment involves psychiatric intervention and psychotherapy to address the underlying need for attention or approval.	It can be difficult to diagnose due to the deceptive nature of the disorder, and it often requires long-term psychological support.

Quitting Tobacco: Strategies and Considerations

• Nicotine Gum Usage: Follow the “chew and park” method—chew slowly until a nicotine taste emerges, then place the gum against the cheek until the taste fades. Repeat this cycle several times before discarding after 30 minutes.
• Nicotine Patches: Should not be combined with other nicotine products, as excessive nicotine intake may lead to acute heart attack, high blood pressure, and agitation.
• Bupropion (Zyban): Helps reduce smoking cravings. Patients can continue smoking while taking the medication, but over time, they naturally lose the desire to smoke. Not suitable for individuals with a history of seizures, eating disorders (anorexia/bulimia), sudden withdrawal from alcohol or benzodiazepines, stroke, or brain tumors. May increase suicide risk.
• Varenicline (Chantix): Typically prescribed for 12 weeks, with patients advised to quit smoking within 1 to 4 weeks of starting. Not recommended for those with a history of mental instability or suicidal thoughts. Pilots and air traffic controllers are prohibited from using this medication.

Understanding and Addressing Abuse

• Types of Abuse: Can be physical, emotional, sexual, financial, or material exploitation.
  • Can occur at any stage of life, with an increased risk during pregnancy.
  • Injuries that don’t match the provided history may indicate abuse.
• Risk Factors for Abuse:
  • Heightened stress levels
  • Substance abuse (alcohol or drugs)
  • Personal or family history of abuse
  • Significant loss (e.g., job, loved one)
  • Social isolation
  • Pregnancy
  • Elderly individuals, especially those with frailty or dementia
• Physical Examination Considerations:
  • Ensure another healthcare professional is present during the exam.
  • Conduct interviews separately—first with the suspected abuser, then alone with the patient.
  • Gather photographic evidence with a ruler for scale, and document statements verbatim.
  • Watch for signs such as spiral fractures, multiple healing fractures, burns, welts, and neglect.
  • Develop a safety strategy for individuals experiencing partner violence.
  • Conduct STI screenings as needed.
• Communication and Assessment:
  • Remain objective and nonjudgmental in discussions.
  • Abusers often dominate conversations.
• BATHE Method for Patient Interaction:
  • Background – How are things at home, work, or school? Any recent changes?
  • Affect/Anxiety – How do you feel about your home life, job, or general well-being?
  • Trouble – What concerns you the most?
  • Handling – How are you coping with these challenges?
  • Empathy – Acknowledge their feelings (e.g., “That sounds really difficult”).
• SOAP Approach for Support:
  • Support – Validate their experience without downplaying its severity. Explore available support systems.
  • Objectivity – Be mindful of your own responses to their story.
  • Acceptance – Recognize and respect the patient’s priorities.
  • Present Focus – Stay in the moment and work on immediate solutions, such as creating a safety plan.

Diagnostic Criteria for Substance Use Disorder

• Diagnosis requires at least two of the following symptoms within the past 12 months:
• Loss of Control:
  • Using the substance in greater quantities or for a longer duration than intended.
  • Persistent desire to quit or unsuccessful attempts to cut down.
• Time and Effort:
  • Spending excessive time acquiring, using, or recovering from the substance.
  • Experiencing intense cravings or a strong urge to use.
• Impact on Responsibilities & Relationships:
  • Failing to meet key obligations at work, school, or home.
  • Continuing use despite ongoing social or interpersonal conflicts caused by substance use.
• Risky Behavior & Lifestyle Changes:
  • Engaging in substance use in dangerous situations.
  • Neglecting or reducing participation in social, occupational, or recreational activities due to substance use.
• Tolerance:
  • Needing higher doses to achieve the same effect.
  • Experiencing a reduced effect with the same dose.
• Withdrawal:
  • Developing specific withdrawal symptoms upon stopping.
  • Using the same or a different substance to avoid withdrawal symptoms.

Miscellaneous Facts About Substance Abuse

• Frequently associated with underlying mood disorders.
• Prescription medication misuse is most prevalent among young adults aged 18–25.
• Long-term marijuana use may contribute to the development of COPD.
• Buprenorphine combined with naloxone serves as an alternative to methadone for treatment.
• MDMA (Ecstasy or Molly) can cause dangerous hyperthermia and rapid heart rate, which may be life-threatening.