Get Psyched! Mental Health Care in Everyday Practice with Elizabeth Hopfenspirger, DNP

Ridgeview Podcast: CME Series

This podcast, Elizabeth Hopfenspirger, DNP, a psychiatric and family practice nurse practitioner with Lakeview Clinic, discusses various mental health topics, primarily in the adult patient, but also touches on some pediatric issues. Today's discussion will focus on the following areas of mental health - depression, anxiety, mixed disorders, ADHD and psychosis.

Enjoy the podcast.

Objectives:Upon completion of this podcast, participants should be able to:

• Describe different implemention stratgies in how to better establish a therapeutic relationship with the patient.
• Recognize how many psychotropics medications are on a "spectrum".
• Realize that treatment choice depends on several variables - including presenting symptoms and underlying organic issues.

This activity has been planned and implemented in accordance with the accreditation criteria, standards and policies of the Minnesota Medical Association (MMA). Ridgeview is accredited by the Minnesota Medical Association (MMA) to provide continuing medical education for physicians.

CME credit is only offered to Ridgeview Providers & Allied Health staff for this podcast activity. After listening to the podcast, complete and submit the online evaluation form. Upon successful completion of the evaluation, you will be e-mailed a certificate of completion within approximately 2 weeks. You may contact the accredited provider with questions regarding this program at [e-mail].

Click the link below, to complete the activity's evaluation.

CME Evaluation

(**If you are listening to the podcasts through iTunes on your laptop or desktop, it is not possible to link directly with the CME Evaluation for unclear reasons. We are trying to remedy this. You can, however, link to the survey through the Podcasts app on your Apple and other smart devices, as well as through Spotify, Stitcher and other podcast directory apps and on your computer browser at these websites. We apologize for the inconvenience.) DISCLOSURE ANNOUNCEMENT

The information provided through this and all Ridgeview podcasts as well as any and all accompanying files, images, videos and documents is/are for CME/CE and other institutional learning and communication purposes only and is/are not meant to substitute for the independent medical judgment of a physician, healthcare provider or other healthcare personnel relative to diagnostic and treatment options of a specific patient's medical condition; and are property/rights of Ridgeview Medical Center & Clinics. Any re-reproduction of any of the materials presented would be infringement of copyright laws.

It is Ridgeview's intent that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts. It is not assumed any potential conflicts will have an adverse impact on these presentations. It remains for the audience to determine whether the speaker’s outside interest may reflect a possible bias, either the exposition or the conclusions presented.

Ridgeview's CME planning committee members and presenter(s) have disclosed they have no significant financial relationship with a pharmaceutical company and have disclosed that no conflict of interest exists with the presentation/educational event.

Thank-you for listening to the podcast.

SHOW NOTES: *See the attachment for additional information.

The state of mental health care in the US is not ideal- Lack of resources - Lack of practitioners - social, physical, economic and environmental challenges

CASE REVIEW #1- 18 year old female with predominantly anxiety - Respectful curiosity: listening and asking questions without judgement - Medication for generalilzed anxiety disorder- High intensity aerobic exercise can improve anxiety symptoms. - Trauma? ADHD/Learning difficulties? Sleep? Appette and restriction of food/eating disorders? Substance use/abuse? - SSRI: bupropion>fluoxetine?Sertaline?escitalopram>fluvoxamine>paxil (most activating to least activating) - For pure anxiety - Elizabeth prefers escitalopram, citalopram and sertaline - Trauma and trauma therapy: Trauma can be anything (death of a loved one, MVC, etc.) - Trauma therapy (EMDR: eye movement desensitization reprocessing) - IFS (internal family systems - recognizing and connecting with your own history and younger self) - ART (acceleraed resolution therapy) - Substance use: What is the substance doing for the patient? Why are they using? Helps to direct therapy and arrive at diagnosis. - ADHD (attention deficit hyperactivity disorder) - sometimes missed or ignored - PCPs have discomfort treating at times - trial of stimulant may be beneficial - Suicide ideation and other adverse effects while first starting certain meds is real, but rare- Article resources: Walkup, et.al (https://pubmed.ncbi.nlm.nih.gov/18974308/) Wetherell, et.al (https://pubmed.ncbi.nlm.nih.gov/23680817/) Critz-Christoph, et.al (https://pubmed.ncbi.nlm.nih.gov/21840164/) Trauma therapy : https://www.emdria.org/

CASE REVIEW #2- 32 year old male with depression - Labs? Physical activity? Testosterone concerns? - Lifestyle and sexual function - Post-retirement? (identity and purpose has changed/gone) - Consider bupropion if no seizures or other contraindications. Consult with neurologist if significant history - Sexual dysfunction an issue? Vortioxetine can be an option wich may help enhance libido - Physical activity (natural endorphins) and exposure to nature are improtant - Screen time? Smart phone and other screen time has dopaminergic effects; too much 'negative' screen time can be detrimental (If AHDH is poorly treated, screen addiction may increase.)

CASE REVIEW #3- 65 year old male with mixed depression and anxiety, off meds for many months - Find as many of patient's historical records as possible - Meeting a patient "where they are at". How motivates is the patient to get better? - Are they coasting (teenagers)? Are they taking an active role in getting better? - may need to wait to push/empower patient until after giving medication and psychotherapy some time - where is the patient in their willingness to change and get better? - Meds in this ager group (and many others) to avoid: TCAs and MAOIs - IF DM, HTN, CAD and other co-morbidities, fluoxetine is less likely to have interactions and adverse effects- Article resources: Prochasa and DiClemente - Stages of Change https://www.ncbi.nlm.nih.gov/books/NBK556005/)

Psychosis- Caplyta (stimulating) if more depressed with psychotic features - Zyprexa (sedating) if more manic/psychotic

Genetic testing for optimization of medications is an option - Serves as a 'guide' for medication choice - SLC6A4 gene, for instance, is responsible for serotonin reuptake into the presynaptic neuron

What to do while waiting for SSRI and SNRI to "work"?- Hydroxyzine, benzodiazepine - Sleep medication: - Doxylamine, Trazadone or Remeron (older patients) - Sleep medication: lunesta, sonata

Polypharmacy- Is polypharmacy present and patients feeling poorly with persistent symptoms? May need thoughtful/ careful deprescribing.

Nontraditional/novel treatment options- Nontraditional/novel options for treatment resistant depression, PTSD treatment, chronic pain, etc. - Ketamine - Psilocybe

Psychiatry & Primary Care- Incorporating psychiatry into our own primary care practices is anxiety provoking but inevitable in this day and age of healthcare - We can learn new things and leverage our existing resources to better help our patients - Time with our patients is a barrier - Ask the patient: what is the most pressing issue for you today? What is the most distressing thing for the patient? Then consider Maslow's Hierarchy of Needs and build up from there.- Article resources: Maslow Hierarcy of Needs (https://www.simplypsychology.org/maslow.html)

Please check out the additonal show notes for additional information/resources.