APEA Mental Health in Primary Care 2 — Questions and Answers
Question 1: A 42-year-old patient with bipolar I disorder presents to primary care reporting 4 days of decreased need for sleep, grandiosity, and pressured speech. The most appropriate management is:
- Start an SSRI immediately for mood stabilization
- Consult psychiatry urgently; avoid SSRIs (can precipitate mania); ensure mood stabilizer is at therapeutic levels (Correct answer)
- Prescribe benzodiazepines as the primary treatment
- Reassure the patient that this is a normal mood variation
Correct answer: Consult psychiatry urgently; avoid SSRIs (can precipitate mania); ensure mood stabilizer is at therapeutic levels
Active mania requires urgent psychiatric consultation and mood stabilizer optimization. SSRIs are contraindicated during manic episodes as they can worsen or precipitate mania.
Bipolar I disorder is characterized by at least one manic episode lasting 7 days or longer. SSRIs and other antidepressants without mood stabilizer coverage can trigger manic switch. First-line mood stabilizers include lithium, valproate, and second-generation antipsychotics such as olanzapine, aripiprazole, and quetiapine. Primary care NPs should recognize manic episodes and involve psychiatry in management.
Question 2: When prescribing bupropion for depression in primary care, which contraindication is most important to assess before initiation?
- History of seasonal allergies
- History of seizure disorder, eating disorders such as anorexia or bulimia, or concurrent MAOI use (Correct answer)
- History of controlled hypertension
- Prior use of SSRIs
Correct answer: History of seizure disorder, eating disorders such as anorexia or bulimia, or concurrent MAOI use
Bupropion is contraindicated in patients with seizure disorders (lowers seizure threshold), active eating disorders (increased seizure risk from electrolyte disturbances), and concurrent or recent MAOI use (risk of hypertensive crisis).
Bupropion (NDRI) contraindications include current or prior seizure disorder; eating disorders including anorexia nervosa and bulimia nervosa; and concurrent or recent MAOI use within 14 days. Advantages of bupropion include no sexual dysfunction, weight neutral or promoting weight loss, and effectiveness for smoking cessation — making it a preferred alternative when SSRIs cause intolerable sexual side effects.
Question 3: Adult ADHD is most accurately diagnosed using which approach in primary care?
- A single blood test measuring dopamine levels
- Comprehensive clinical evaluation including DSM-5 criteria with 5 or more inattentive and/or hyperactive-impulsive symptoms present before age 12 for 6 months or longer (Correct answer)
- IQ testing alone
- Sleep study to rule out narcolepsy first
Correct answer: Comprehensive clinical evaluation including DSM-5 criteria with 5 or more inattentive and/or hyperactive-impulsive symptoms present before age 12 for 6 months or longer
Adult ADHD diagnosis requires DSM-5 criteria: 5 or more inattentive and/or hyperactive-impulsive symptoms, present before age 12, in 2 or more settings, causing significant impairment.
DSM-5 ADHD criteria for adults (17 or older): 5 or more inattentive symptoms and/or 5 or more hyperactive-impulsive symptoms, present before age 12, in 2 or more settings, impairing, and not better explained by another mental disorder. Rating scales support but do not replace clinical diagnosis. First-line treatment: stimulants (methylphenidate, amphetamine salts); alternatives for comorbid anxiety or contraindications include atomoxetine and guanfacine.
Question 4: A 68-year-old patient with new-onset confusion, agitation, disorientation, and visual hallucinations that developed over 2 days is most likely experiencing:
- Major depressive disorder with psychotic features
- Delirium — acute onset, fluctuating course, and attention disturbance (Correct answer)
- Late-onset schizophrenia
- Normal cognitive aging
Correct answer: Delirium — acute onset, fluctuating course, and attention disturbance
Delirium presents with acute onset confusion, fluctuating course, attention disturbance, and often perceptual disturbances — distinguishing it from dementia (gradual onset) and psychiatric disorders.
DSM-5 delirium: disturbance in attention and awareness with acute onset, fluctuating course, and additional cognitive disturbance not better explained by preexisting dementia. Common causes include infection, metabolic derangements, medications, alcohol or drug withdrawal, and hypoxia. Treatment: address underlying cause; avoid Beers Criteria medications; consider low-dose haloperidol for severe agitation if needed.
Question 5: A patient is prescribed sertraline for MDD and returns 2 weeks later reporting no improvement. The appropriate next step is:
- Discontinue sertraline and switch to a different drug class
- Counsel the patient that SSRIs require 4-6 weeks for full effect; assess tolerability, adherence, and any worsening symptoms including suicidality (Correct answer)
- Double the dose immediately
- Add an antipsychotic as augmentation
Correct answer: Counsel the patient that SSRIs require 4-6 weeks for full effect; assess tolerability, adherence, and any worsening symptoms including suicidality
At 2 weeks, SSRIs have not yet reached full therapeutic effect. The correct response is to reinforce the 4-6 week timeline, assess medication tolerability, confirm adherence, and screen for suicidality.
FDA black box warning: antidepressants may increase suicidal ideation in children, adolescents, and young adults (24 and younger) during the first months of treatment. All patients starting antidepressants should be seen within 1-2 weeks and counseled to contact the provider immediately if suicidality worsens. Dose adjustment or augmentation is considered only after a full 6-8 week trial at therapeutic dose with adequate adherence.
Question 6: A patient asks about mental health benefits of regular exercise. The evidence base supports aerobic exercise as an adjunct treatment for which mental health conditions managed in primary care?
- Exercise has no proven mental health benefits
- Exercise has strong evidence as adjunct treatment for depression and anxiety, reducing symptom severity comparably to pharmacotherapy in mild to moderate cases (Correct answer)
- Exercise only benefits severe psychotic disorders
- Only yoga — not other forms of exercise — reduces anxiety
Correct answer: Exercise has strong evidence as adjunct treatment for depression and anxiety, reducing symptom severity comparably to pharmacotherapy in mild to moderate cases
Strong evidence supports aerobic exercise as an effective adjunct treatment for depression and anxiety, with effects comparable to antidepressants in mild to moderate cases.
Multiple RCTs and meta-analyses demonstrate significant antidepressant and anxiolytic effects of regular aerobic exercise at 150 minutes per week of moderate intensity. Mechanisms include increased BDNF, HPA axis normalization, endorphin release, neurogenesis, and improved sleep quality. NPs should prescribe exercise as a component of all depression and anxiety treatment plans.
APEA Mental Health in Primary Care 2
A 42-year-old patient with bipolar I disorder presents to primary care reporting 4 days of decreased need for sleep, grandiosity, and pressured speech.
The most appropriate management is: