CRE ReviewDR. SHARLEEN GILL PGY-3 RESIDENT UBC PSYCHIATRY (FRASER TRACK)

CRE Structure

MSE

Diagnosis

Management plan

Admission Orders

Answer series of short-answer questions related to case – often child or geri

The UBC-developed CRE consists of 6 cases: 2 video clip cases 4 paper cases

Pharmacotherapy Review

Common Mistakes - Pharmacotherapy

Lack of specificity E.g. “Start an SSRI”

“Provide something for sleep”

Lack of dosing knowledge

Ordering medications that are not indicated E.g. PRN Loxapine on every patient

Need to specify name of the medication, titration schedule, target dose, side effects & issues to watch for, 2nd line options

List the most COMMON and most SERIOUS side effects

Pharmacotherapy

Need to know when and how to use 1-2 medications from each drug class safely Antidepressants

Benzodiazepines

Mood stabilizers

Antipsychotics

Depression & Anxiety

What is first-line treatment?

What are second line options?

What are common side effects?

What to do about side effects?

What to do if first Rx is unsuccessful?

Antidepressants Sertraline (Zoloft)

Start at 25 mg daily, then increase by 25 mg q7d

Effective dose range: 100-200 mg

Aim higher for anxiety: 150-200 mg

Max dose: 200 mg

Citalopram (Celexa) Start at 10 mg daily, then increase by 10 mg q7d

Effective dose range: 10-20 mg

Aim higher for anxiety: 30-40 mg

Max dose: 40 mg

Escitalopram = same schedule, ½ dosing

Fluoxetine (Prozac) Start at 20 mg daily, then increase by 20 mg q7d

Effective dose range: 40-80 mg

Aim higher for anxiety: 60-80 mg

Max dose: 80 mg

SSRI Side Effects Most common:

Headache

GI

Insomnia or sedation

Anxiety

Sexual (anorgasmia, ↓libido)

More serious, but rare: Serotonin syndrome

Increased risk of GI bleeds

Hyponatremia (SiADH)

Increased risk of SI in children

QT prolongation

Switch to mania

Non-SSRI 2nd line agents

Venlafaxine Start at 37.5 mg PO daily, then titrate by 37.5 mg q1 week

Dose range: 150 to 225 mg

Side effects: same as SSRI, ↑BP, withdrawal sx

Mirtazipine Start at 7.5 mg PO qHS, then increase by 7.5 mg q7d

Effective dose range: 30 to 45 mg

Side effects: sedation, increased appetite

Wellbutrin Start at 150 mg PO daily, then increase by 150 mg q7d

Effective range: 300 to 450 mg

Side effects: anxiety, altered seizure threshold

Can use for sexual side effects

If unsuccessful…

Optimize

Switch

Augment (Lithium, T3, atypical antipsychotic, stimulant)

Combine (add another antidepressant)

Antipsychotics

Indications?

Antipsychotics - Indications

Acute mania

Acute depression

Bipolar maintenance

Psychosis

Augmentation of antidepressants for depression/anxiety

Acute aggression or agitation

Antipsychotic Agents

Risperidone Start at 1 mg PO qHS, then increase by 1 mg q4-7days

Target dose: 2 to 6 mg PO qHS

Olanzapine Start at 10 mg PO qHS, then increase by 5 mg q4-7days

Target dose: 10 to 20 mg PO qHS

Antipsychotic Side Effects

Most common: Sedation

Weight gain

Metabolic changes

Dizziness (orthostatic hypotension)

Other anticholinergic effects (dry mouth, blurred vision, constipation, etc.)

EPS (acute dystonia, akathisia, Parkinsonism)

Rare but serious: QT prolongation

NMS

Tardive dyskinesia

Agranulocytosis (Clozapine)

NMS

FARM acronym Fever

Autonomic dysregulation (↑ HR/BP, diaphoresis)

Rigidity

Mental status changes

Bipolar Disorder

First line agents for acute mania?

First line agents for acute depression?

What to use for maintenance?

Acute Mania Rx

Lithium

Epival

Olanzapine

Risperidone

Quetiapine

Aripiprazole

Ziprasidone

Asenapine

Paliperidone

Most can be used as adjunctive with Lithium or Epival

Acute Bipolar Depression Rx

Monotherapy: Lithium

Lamotrigine

Quetiapine

Combination: Olanzapine + SSRI

Lithium/Epival + SSRI

Lithium/Epival + Bupropion

Lithium + Epival

Bipolar Disorder Maintenance Rx

Can continue same medications used in acute for maintenance

Mood Stabilizers

Lithium Start 300 mg PO BID, increase by 300 mg q5d as indicated by serum

levels

Usual dose range: 900-1200 mg

Epival Start 20mg/kg/day (avg. 500 mg TID)

Titrate based on serum level

Target dose: 60mg/kg/day (avg. 1500-2000mg)

Epival Side Effects

Common Sedation

Dizziness

GI

Derm

Serious Hepatitis

Pancreatitis

Thrombocytopenia & platelet dysfunction

Monitor CBC & LFTs q4months x 1 year, then q6months

Lithium Side Effects

Common GI

Weight gain

Tremor

Derm (rash, acne, hair loss)

Serious Diabetes insipidus (polyuria + polydipsia)

Thyroid

Parathyroid

CVS (T wave flattening/inversion, arrhythmias)

Lithium Toxicity

Symptoms: (1) GI N&V, diarrhea, abdo pain

(2) Cardiac T-wave flattening, arrhythmias

(3) Neuro coarse tremor, ataxia, headache, slurred speech, confusion, coma

Lithium Monitoring

Kidney (Cr, BUN)

Thyroid (TSH)

Parathyroid (Ca)

Serum levels

When to monitor: Every 6 months

Dosage change

Anything that could affect lithium levels (acute sickness, kidney issues, drugs which affect renal clearance)

Pharmacotherapy: Special Considerations

Start at half the normal dose in the elderly and children, and titrate more slowly

Use your judgment for how quickly to titrate (e.g. q7days in the community, can be q3-4 days in hospital or acute setting)

Management & Order Writing

Management Plan (1) Biological regular medications, PRN’s, how to treat side effects,

medical conditions that are relevant or need optimization (e.g. thyroid dx)

(2) Psychological psychotherapy, support and rapport building, psychoeducation, family/marital therapy, counselling

(3) Social housing, finances, Plan G for medications, SW to see, vocational training, family support groups, patient support groups, **lifestyle interventions (exercise, self-care, diet, avoid substances)

(4) Investigations Baseline labs: CBC, lytes, Cr, BUN, LFTs, TSH, B12, fasting glucose & lipid

panel for AAP’s, ECG

Monitoring for AAP’s & Lithium

Weight/BMI monitoring

Drug levels if toxicity or compliance issues

(5) Collateral family/friends, old records

Management Plan Tips

Level of detail is important

Identify the treatment setting for initial management and follow-up

Identify whether voluntary or involuntary

Use Canadian medications & Canadian guidelines

Admission Orders

How to write?

Admission Orders (1) Admit to Dr. Blank under Psychiatry. Specify whether involuntary

or voluntary, # of certs or Extended Leave

(2) Admitting dx (DSM based)

(3) Diet – DAT for most

(4) Activity Level = Level of Observation (start at Level I for most, maybe Level II if voluntary settled patient); may need restraints PRN or seclusion room PRN if very agitated

(5) Vital Signs – Routine for most; increase frequency for starting Clozapine, if orthostatic hypotension suspected with AAP’s, any medical instability

(6) Investigations

(7) Drugs PRN agitation, sleep, anxiety

Regular

Treatment for side effects if necessary

PRN’s

Most effective for agitation is use of an atypical antipsychotic + benzodiazepine combination

Don’t need to start AAP for everyone; if patient is settled, may use just a benzo or small dose of Quetiapine

Always include route, frequency, and maximum dosage

Dose depends on size of patient

Frequency depends on level of agitation and suspected need for usage Highly agitated: q1-2h prn

Settled: q4-6h or BID prn

PRN’s

Antipsychotics Haldol 2.5 to 10 mg PO/IM q1-2h PRN (M: 20 mg/day)

Loxapine 5 to 25 mg PO/SC/IM q1-2h PRN (M: 60 mg/day)

Quetiapine 12.5 to 25 mg PO 1-2h PRN (M: 200 mg/day)

Olanzapine 5 to 10 mg PO/IM/SL q1-2h PRN (M: 20 mg/day)

Benzodiazepines Ativan 1 to 2 mg PO/SL/IM q1-2h PRN (M: 6mg/day)

EPS Cogentin 1-2 mg PO/IM q6h PRN (M: 6 mg/day)

PRN’s for Sleep

Zopiclone 3.75 to 7.5 mg PO qHS PRN

Melatonin 6 mg PO/SL qHS PRN

Trazodone 25 to 50 mg PO qHS PRN

Quetiapine 25 to 50 mg PO qHS PRN

Avoid short-acting benzo’s

Consider side effect profile

Consider medication interactions

Intended for short-term use only

Mental Status Examination

MSE Common Mistakes

Lack of specific descriptions E.g. “Speech is normal”

Not including pertinent negatives

Putting items into the wrong sections E.g. putting hallucinations into Thought Content instead of Perception

Putting items together that should be separate E.g. “Insight and judgment are fair”

Lack of supporting evidence or examples

MSE Tips

Be as descriptive as possible

There are several components to each section so make sure to include as much of them as possible/applicable Appearance

Speech rate, rhythm, volume, intonation, prosody,

Affect quality, intensity, range, reactivity, lability, appropriateness

Comment on the absence of an enquiry i.e. “Cognition not formally assessed”

And suggest what to do about it in plan

i.e. “MMSE or MOCA required”

Diagnosis

Common Mistakes in Diagnosis Inconsistency between DSM 4 & 5 use correct terms

Lack of specificity E.g. “psychosis”

If there are sufficient criteria to make a specific diagnosis, then make it

Not providing supporting evidence for EACH diagnosis

Incorrect Axis placement or leaving out Axes E.g. delirium/dementia on Axis III instead of Axis I

Deferred or absent Axis IV & V

Not including Axis II/personality If there are prominent traits on hx, should include

Do not need to do GAF, but should do statement about function

Example: What are your provisional/preferred and differential diagnoses to be ruled out with further history and investigations? Provide evidence from the case to support your choices.

Provide supporting evidence for EACH diagnosis

Diagnosis One Plus supporting evidence

Diagnosis Two Plus supporting evidence

Diagnosis Three Plus supporting evidence

Use supporting evidence from the case (think of the criteria & then find symptoms that match them from the case, more criteria = more pts)

Provide as much evidence as possible of specific symptoms (lots of points!)

Do not put things that go AGAINST the diagnosis if you are asked to provide support only (e.g. This is less likely because….)

Use very specific terms & correct terminology from DSM 4/5

E.g. Major neurocognitive disorder due to a medical condition, rather than listing medical conditions or psychosis secondary to medical condition

Don’t state dementia if using DSM 5

Read carefully & stick to what the question asks you

Do not need to provide management, investigations, etc. if you are just asked to provide diagnosis & supporting evidence

DSM Dx – Axis I

MOOD D/OMDD

Dysthymic d/o (Persistent

Depressive d/o)

Depressive d/o NOS

BAD I

BAD II

Cyclothymic d/o

BAD NOS

Mood d/o d/t GMC

Substance-Induced Mood d/o

Mood d/o NOS

ANXIETY D/OSocial Phobia (Social

anxiety d/o)

Panic d/o +/- Agoraphobia,

Specific Phobia

OCD

Acute Stress d/o

PTSD

GAD

Anxiety d/o d/t GMC

Substance-Induced Anxiety d/o

Anxiety d/o NOS

Schizophrenia

Schizoaffective Disorder

Schizophreniform Disorder,

Brief Psychotic Disorder

Delusional Disorder

Shared Psychotic Disorder

Psychotic Disorder d/t GMC

Substance-Induced Psychotic d/o

Psychotic d/o NOS

(Mood) d/o w/ psychotic features

PSYCHOTIC D/O

DDx of Psychosis

DSM Diagnosis Tips

Axis II – careful with diagnosing PD’s, based on a brief, cross-sectional i/vGenerally, safe to “query” traits or pd’sThis reflects your understanding of the longitudinal

nature of personality Axes III/IV/V: the rest of the known info that helps us

understand patient’s presentation, NOT a list of possible contributing factors i.e. don’t put down a laundry list of possible medical complications if

there is no reason to suspect them

Axis V: Give a range of 10 for GAF i.e. 31-40

Quick Tips

Go for High Yield: Know the BIG diagnoses (mood, psychosis, anxiety, substance),

BIG drugs & toxidromes Review the smaller diagnoses/drugs

Don’t memorize the psychopharmacopia (Low Yield) Take a hit on the dose of parnate… you lose just 1/100!!!

Follow Directions Carefully! People miss easy points for stuff they know but don’t stop

to jot down (commonly: admit order, med S/E’s, follow-up)

Take Notes during the Videos, especially quotes or other “pieces of evidence” relevant to the question

Quick Tips Cont’d

Don’t kitchen-sink it: points off for over-inclusiveness

If there is NO evidence or NO reasonable reason to suspect a particular dx, then you’re being overinclusive, and will lose points

Don’t judge: careful about “labels” such as malingering, borderline, drug-crazed psycho, Hanibal Lectoresque, etc

Summary

Know how to use medications safely

Be as specific as possible & include as much detail as possible

Be thorough & don’t leave things out

Do what you would do for a real-life patient

Any questions?