1. Office of Evaluation, Accreditation and CQI
Clinical Grading
Office of Evaluation, Accreditation and CQI

2. What were the changes in grading last year?
Establish a “B Cutoff”
A and pass cutoffs already existed
Revise the evaluation form to make it simpler
Prior form did not have numeric or letter grades on it (same as current version)
Implement retake policy
Change score conversion table so that 70%ile = 90

3. Impact of the grading changes and curriculum updates on NBME Scores
Note: + indicates change from previous year

4. What was the impact of the changes on grades?

5. MCG NBME Raw Score Cutoffs
MCG policy: Minimum raw score to be eligible to pass a clerkship (all other scores considered) is at the 5th percentile nationally; minimum raw score to be eligible for an A (all other scores considered) is at the 70th percentile; minimum raw score to be eligible for a B (all other scores considered) is at the 30th percentile nationally.

6. NBME Subject Exam Conversion
The 70th percentile raw score is set to convert to a 90.
The 30th percentile raw score is set to convert to a 70.
A linear relationship is then created for all other converted scores.
The raw score is neither a percent correct nor a percentile; which is why the conversion is needed.
Conversion and cutoffs are calculated using the Quarter 1 national data for the first three months of an academic year and the Academic Year national data for the balance of the academic year.

7. MCG Retake Policy
Students will be permitted to re-take 1 subject exam with the possibility of raising the grade by 1 letter grade.
(This policy applies to exams that students have passed, but would like to attempt to improve their performance on). Academic Year national data is used to calculate cutoffs and conversion scores on the retake.
Students may retake up to two NBME subject exams if they fail, with the potential of raising the grade to a C.

8. Welcome to the psychiatry clerkship!
Clerkship Director:
Krystle Graham, DO, FAPA

9. Psychiatry clerkship orientation goals
Describe clerkship objectives/ expectations
Describe the resources provided on the clerkship website
Identify self-study areas
Perform:
mental status exam
psychiatric interview

10. Clerkship Objectives (C.O.) C.O. 1. Patient care
Perform a thorough psychiatric interview of a patient with mental illness
Perform and describe a mental status examination.
Appraise the information obtained in a psychiatric interview.
Formulate a psychiatric differential diagnosis
Recognize the need for clinical testing (i.e., neurocognitive disorder evaluation, diagnostic testing)
Appraise the appropriate treatment modalities for psychiatric disorders.
Demonstrate the ability to educate patients and their families/support systems about diagnoses, and subsequent care or mental disorders.

11. 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.
Demonstrate an understanding of social history within the bio-psycho- social formulation of mental illness.
Demonstrate an understanding of the epidemiology of suicide risk.

12. C.O. 3 Practice-Based Learning and Improvement
Demonstrate genuine intellectual curiosity and desire to learn, focused inquisitiveness in asking questions, and enduring persistence in the pursuit of learning.
Choose and appraise medical literature that pertains to at least 1 (one) of their patients’ mental illness
Complete a mid-rotation feedback form including goals for self-improvement
Accept constructive criticism and modify behavior based on feedback.

13. C.O. 4 Interpersonal and Communication Skills
Give an oral presentation of a patient in a succinct and organized manner using findings from the psychiatric interview and mental status exam.
Write complete histories and physicals and progress notes in a succinct and organized manner using findings from the psychiatric interview and physical exam.  
Communicate empathically with patients with mental illness and their families or support system members
Communicate with others in a respectful, professional and non-judgmental manner and demonstrate effective listening skills
Recognize barriers to communication if they occur during a psychiatric interview.
Educate patients assuring their understanding on healthy behavior change when appropriate (i.e., substance use, treatment adherence)
Educate patients assuring their understanding on medical risk and benefits when appropriate (i.e., medication side effects)

14. C.O. 5 Professionalism  
Students will demonstrate utmost respect for all with whom they interact (patients and their families and support system, colleagues and team members)
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
Maintain appropriate professional appearance and composure.
Recognize and address personal limitations, attributes or behaviors that might limit one’s effectiveness as a physician and seek help when needed.
Demonstrates sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, race, religion, disabilities and sexual orientation.

15. C.O. 6 Systems-based Practice
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.
Examine medical errors and quality problems using a health systems approach and describe available methods to minimize them.

16. 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.

18. TO DO/NOT TO DO
NOT TO DO: Be late Call in late after you already missed part of the day Be overly familiar with patients and staff Self disclosure (with minimal exceptions) Break any confidentiality barriers Contact the site preceptor for appeals
DO: Ask for contact numbers for attending/resident Arrive on time or early on wards/clinics Ask many questions Ask for feedback on your interviews and write-ups Offer to present cases or short (5 min) literature reviews Log ALL patients seen in One45 Respect and advocate for your patients

19. Psychiatric Interview
Krystle Graham, DO, FAPA

20. =
It takes some skill….

21. Psychiatric Interview
= Skill to encourage disclosure of personal information for a professional purpose Empathy → rapport → therapeutic alliance

22. 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
WHAT KINDS OF THINGS HERE DO YOU SEE THAT YOU DON’T NORMALLY ASK ABOUT IN AN INTERVIEW FOR OTHER SPECIALTY?
Setting of the interview will influence how much you ask about:
ER: CC, HPI, dangerousness to self/others, substance, MSE
C&L: reason for consult, HPI psych and medical, current prescription medication, substance abuse, MSE
Psychotherapy evaluation: social, developmental, family , past psych including past psych treatments

23. 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?

24. 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?
Take a detailed account of previous treatments; it will show not only medication refractory status but patterns of behavior…non-adherence with drugs
Listen to the patient: some people (5-7 % of Caucasians ) may be poor CYP450 metabolizers and they can only take very small amounts of meds w/o developing side effects. A man stated he will only take reserpine for his schizophrenia: reserpine blocks DA receptors.

25. 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.
This is the new part that students will need to master in this clerkship
Knowing the major characteristics of these diseases and their treatment = meeting clerkship objectives!!!!
Which illness came first? examples of stereotypes; avoid labeling people as drug users only…
alcohol and drug dependence as co morbidity of bipolar d/o (risk is 7X higher to have substance abuse);
if you use hallucinogens (LSD, PCP) and you persist having psychotic sy more than one mo. from the drug use, you likely have primary psychosis
Adolescents treated for ADHD with stimulants do not have more substance abuse than non-ADHD adolescents.

26. 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

27. 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?
This will help understand the whole person and allow you to do the bio-psycho-social-cultural formulation

28. 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.

29. Q1: This person is dealing with: check all correct answers
Transference
Financial hardship
Resistance
Denial
Anger against therapist
Response: resistance
Why each??? (all are plausible responses…)

30. Q2: The therapist is offering: check all correct answers
A confrontation
An interpretation
Empathic validation
Re-framing
Encouragement to elaborate
Answer: confrontation
Affirmation=”I see”
Advice/praise=“I’m 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 pt a denied or suppressed feeling.
Interpretation= one of most expressive forms of treatment; therapist’s decision making; makes something conscious that was previously unconscious.

31. 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

32. Content vs.. Process Diagnostic vs.. dynamic
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

33. Mental Status Exam
Krystle Graham, DO, FAPA

34. Identifying Information
Age
Sex
Ethnicity
Marital Status

35. Orientation
Person
Place
Time
Situation

36. Appearance & Behavior Apparent age Body habitus Clothing Grooming Odor
Scars
Tattoos/Piercings
Behavior:
Toward interviewer
Eye contact
Attentiveness
Level of consciousness

37. Psychomotor Retarded Accelerated/Agitated Involuntary movements
Organic vs. medication-induced?

38. Speech Spontaneous/Nonspontaneous Volume Rate Tone Articulation
Speech latency
Paucity of speech content
Pressured

39. Mood & Affect Subjective Elicited from the patient themselves
Depressed, sad, dysphoric, euphoric, anxious, angry, irritable, happy, hostile…
Affect
Objective – patient’s expression of mood
Flat/Blunted
Constricted/Restricted
Full
Expansive/Broad
Congruent/incongruent with mood
- Appropriate/
Inappropriate
Labile/Stable

40. Thought Process Speed: RapidSlow Linear/Goal directed/Logical
Tangential
Circumstantial
Flight of ideas
Looseness of association/
Derailment
Incoherent/Word salad
Clang associations
Neologisms
Perseveration
Echolalia
Thought blocking

41. Thought Content Preoccupations Obsessions Phobias Overvalued Ideas
Suicidality
Homicidality
Delusions
Grandiose, persecutory, somatic, nihilistic, religious, jealousy, erotomanic, culture- bound, control (thought broadcasting or insertion)
Mood congruent/incongruent
Bizarre/Non-bizarre
Ego-syntonic/dystonic

42. Perception Hallucinations and Illusions Dreams
Sensory system: Auditory, visual (hypnogogic, hypnopompic), tactile, olfactory
Depersonalization/derealization=detachment
Dreams
Nightmares, recurrent dreams
Fantasies, daydreaming
Hallucinations….delirium? PTSD? Narcolepsy?

43. Insight & Judgment Insight Judgment
Patient’s understanding of their illness
Judgment
Examples of harmful behaviors
Test an imaginary situation
Stamped addressed envelope
Abstraction
Proverb

44. Memory, Attention & Concentration
Serial 7’s
WORLD  DLROW
Immediate and delayed recall

45. 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.
Attn and Conc are frontal
Fronto-temporal: fluency, comprehension, repetition, naming, reading comprehension and writing, prosody (intonations that accompany language)
RAS maintains consciousness, alertness

46. 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)
Clock drawing: 85% sensitivity and specificity, good inter-rater reliability, good concurrent and predictive validity, In combination with MMSE, verbal fluency test and informant reports: detection of early dementia. It will show neglect if parietal lobe lesion is present. Frontal/executive function is responsible for the sequence of drawing the numbers, and showing the time, it is a complex task.

47. 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

49. 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

50. 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

51. MSE example (ctd)
Thought content: + paranoid delusions, appears to respond to internal stimuli, grandiose, denies suicide or homicide thoughts.
Insight and judgment : limited
Attention is difficult to maintain, concentration: shows difficulty, memory not formally tested.

52. Psychopharmacology Basics
Krystle Graham, DO, FAPA

53. 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
There will be increased serotonin available in the presynaptic neurons
Paroxetine : risk of cardiovascular and other congenital malformations may be higher with paroxetine than with other antidepressants

54. 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
-m-CPP (meta-chlorophenyl)piperazine 5HT2A/2C agonist/antagonist MDMA similarities

55. 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: 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

56. 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
Duloxetine
Cymbalta
MDD, neuropathic pain, fibromyalgia
Bupropion
Wellbutrin (SR, XL), Zyban
MDD, Smoking cessation
Mirtazapine
Remeron
MDD,
Nefazodone
n/a
Trazodone
Desyrel
Phenelzine
Nardil
Tranylcypromine
Parnate
Selegiline
Emsam (patch), Deprenyl (oral)
Amitriptyline
Elavil
Nortriptyline
Pamelor
Vilazodone
Viibryd

57. 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
Movement - nigrostriatal pathway
Flow of information in frontal lobe - mesocortical
Pleasure and reinforcement pathways in nucleus accumbens and striatum (cocaine) mesolimbic.
Tuberoinfundibular - prolactin-inhibiting
Schizophrenia: Overstimulation of D2 receptors in mesolimbic and mesocortical systems (“dopamine excess” theory).

58. 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
These drugs are approved by FDA to treat schizophrenia as well as bipolar disorder, to address acute manic or mixed episodes (olanzapine, risperidone, aripiprazole, ziprasidone, asenapine, quetiapine) or maintenance (olanzapine, risperidone, aripiprazole, ziprasidone, quetiapine). Quetiapine and aripiprazole are also approved as adjunctive treatment of major depressive disorder!!! One will have the balance the risk of metabolic syndrome with using this drugs. They are a safer alternative than Li and antiepileptics for bipolar women who are pregnant.

59. CLOZAPINE minimal D2 blockade (D1, D2, D3, D4), 5HT2A (also 5HT2C, H1, M1, α1)
Five black box warnings
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
Cardiovascular events: myocarditis, pulmonary emboli
Patients with neurocognitive disorders: increased risk of death –blanket warning for ALL 2nd generation antipsychotics
Orthostatic hypotension
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

60. GENERIC BRAND ANTIPSYCHOTIC NAMES AND FDA APPROVED INDICATIONS
Fluphenazine
Prolixin (oral, IM, decanoate)
Schizophrenia
Haloperidol
Haldol (oral, IM, decanoate)
Trifluoperazine
Stelazine
Thioridazine
Mellaril
Chlorpromazine
Thorazine
Schizophrenia, MDD
Risperidone
Risperdal (oral, long acting inj.)
Schizophrenia (+ children 13-17), bipolar mania (+ children )and irritability in autism; long acting risperidone is approved for schizophrenia and bipolar I disorder.
Paliperidone
Invega (oral, long acting inj.)
Schizophrenia and schizoaffective disorder
Olanzapine
Zyprexa (oral, IM, long acting injection)
Schizophrenia, acute treatment of mania and mixed episodes of 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
Asenapine
Saphris
Schizophrenia, acute manic and mixed episode
Clozapine
Clozaril, FazaClo
Refractory schizophrenia
Lurasidone
Latuda

61. 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 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
In Ebstein malformation of the tricuspid valve, the septal leaflet of the tricuspid valve is displaced toward the apex of the heart and is attached to the endocardium of the RV rather than at the tricuspid annulus. As a result, the upper portion of the RV is physiologically within the right atrium. This "atrialized" portion of the RV is thin-walled and does not contribute to RV output. The portion of the ventricle below the displaced tricuspid valve is diminished

62. 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

63. 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

64. Buprenorphine and Naloxone
GENERIC BRAND NAMES OF OTHER PSYCHOTROPIC DRIGS AND THEIR FDA APPROVED INDICATIONS*
Lithium
Eskalith, Lithobid
Bipolar disorder
Valproate
Depakote (ER)
Mania (mixed episodes and high number of illness manic episodes >10 predict response to valproate), migraine, seizures
Carbamazepine
Carbatrol, Tegretol XR, Equetro
Seizures, trigeminal neuralgia and (Equetro only) manic and mixed episodes of bipolar disorder
Oxcarbazepine
Trileptal
seizures
Lamotrigine
Lamictal
Gabapentin
Neurontin
Seizures, post-herpetic neuralgia
Topiramate
Topamax
Seizures, migraine
Alprazolam
Xanax
Various benzodiazepines are approved by FDA as hypnotics, to treat anxiety disorders (panic, GAD, social anxiety), and in the case of clonazepam, as adjunct in treatment of acute mania)
Diazepam
Valium (oral, IV)
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 injectable)
Adjunct in treatment of alcoholism
Disulfiram
Antabuse
Alcohol dependence
Buprenorphine and Naloxone
Suboxone
Opiate dependence

65. 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
ECT syncronous firing of brain neurons with cellular mechanisms coming into play to end the seizure
VNS affects limbic structures and thus monoamine equilibrium in the brain
DBS wire through small hole in the skull, internal capsule for OCD, researched in depression; stimulus issued through a pacemaker like device in the chest
TMS reaches primarily frontal cortex (approx 2 cm under the scalp)

66. Foster personal EEG collection
Applying a current leading to synchronous firing of all neurons in the brain. The cellular mechanisms that come into play to end the seizure are believed to lead to ECT effectiveness (75% ECT CORE study on >400 pts vs 33% medication effectiveness in STAR*D study step 1 citalopram)

67. 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
Affects limbic structures and thus the monoamine balance in the brain
Fink-ASCP2003.ppt

68. 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.
To tie this over to the next topic, MEDICATION is only ONE PIECE of the puzzle and alone is not the most important part of psychiatric treatment.

69. 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, 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

70. Suicide Risk Substance abuse:
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!!

71. 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

72. Psychiatric risk factors resulting in suicide:
Socio-demographic risk factors:
(From CDC data 2012 per 100,000 people) 
Major Depression
Male
Bipolar Depression
Living alone
Alcohol and drug use disorders
Completers: male, yo, high lethality
Attempters: ♀, <35 yo, low lethality
10% of attempters will complete suicide
Native American >Caucasian> Asian >African American and Hispanic
White
Schizophrenia
Separated, widowed or divorced
Eating disorders
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:
Antidepressant treatment;
Psychotherapy: cognitive-behavioral, interpersonal or dialectic behavioral therapy;
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 hypnotics (i.e. Barbiturates).

73. 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), , 2001.
Wedding, D, Stuber, M, Behavior and Medicine, 5th edition, Hogrefe Publishing, 2010.
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 , 2003.
American Psychiatric Association, Desk Reference to Diagnostic Criteria from DSM V, APPI, 2013.