Managing Complex Mental Health Disorders: Ethical Considerations and Clinical Approaches, Exams of Nursing

Download Managing Complex Mental Health Disorders: Ethical Considerations and Clinical Approaches and more Exams Nursing in PDF only on Docsity! 1 / 145 NR607 Final Exam Questions with Correctly Solved Answers 1.The PMHNP (Psychiatric Mental Health Nurse Practitioner) is providing care to a 29-year-old client who presents with persistent sadness and hopeless- ness for the last two months. She is having difficulty sleeping and has a decreased appetite. This is the patient's first contact with the healthcare system about her concerns. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Primary Care Rationale: This is the client's initial contact with the healthcare system about her concerns 2.The client has experienced depressive symptoms. The PMHNP prescribes a selective serotonin reuptake inhibitor (SSRI). PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Pharmacologic Intervention Rationale: The PMHNP is prescribing psychopharmacotherapy for the client 2 / 145 3.The PMHNP provides the client with some mindfulness techniques to try at home. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Psychotherapy Rationale: The PMHNP is utilizing a psychotherapeutic approach to help the client gain insight 4.Two weeks after starting on the SSRI, the client begins to experience suici- dal ideations and develops a plan to kill herself. A friend brings the client to the emergency room. The PMHNP meets the client at the emergency room and collaborates with the physician to coordinate care. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Crisis Intervention Rationale: Suicidal ideation with a plan is a psychiatric emergency requiring imme- diate intervention. 5.The client is admitted to the psychiatric and behavioral health unit at the local hospital for a 72-hour observation where the PMHNP works with her team providing treatment. The client remains hospitalized for a week while 5 / 145 Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Case Management Rationale: Case management involves oversight and/or coordination of care. 8.Over the course of 2 months, the client's condition improves. She is dis- charged from intensive outpatient treatment and begins weekly appointments with the PMHNP at the PMHNP's clinic. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Community-Based Care Rationale: Community-based care is provided in a non-hospital community setting. 9.A global pandemic limits face-to-face mental health visits, the PMHNP deter- mines that the patient requires ongoing mental health treatment. The PMHNP arranges to meet with the client via weekly interactive video sessions. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention 6 / 145 Crisis Intervention 7 / 145 Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Telehealth Rationale: Telehealth services utilize telecommunication technology to deliver treat- ment to clients. 10.The PMHNP owns the private practice that is providing services to the client. PMHNP role: Acute PMHNP Care Telehealth Case Management Primary Care Pharmacologic Intervention Crisis Intervention Partial Hospitalization/Intensive Outpatient Tx Community-Based Care Self-Employment Psychotherapy: Self- Employment Rationale: The PMHNP is providing direct services through her own private practice. 11.Code of Ethics for Nurses: -Respect for the Individual -Commitment to the Healthcare Consumer -Advocacy for the Healthcare Consumer -Responsibility and Accountability for Practice -Duties to Self and Others -Contributions to Healthcare Environments -Advancement of the Nursing Profession -Collaboration to Meet Health Needs -Promotion of the Nursing Profession 12.How the PMHNP does Code of Ethics: Respect for the Individual: -ap- proaches professional relationships with compassion, caring, & respect, acknowl- edging the dignity & worth of each individual. -helps instill hope & empowers those with PMH disorders. 10 / 145 -recognizes signs & symptoms of psychiatric disorders in the workplace & reports peer observations or concerns to leadership. -helps address problems faced by colleagues that may impact patient safety or violate public trust, including substance abuse. 18.How the PMHNP does Code of Ethics: Advancement of the Nursing Profes- sion: -contributes to advancing the professing through practice, education, admin- 11 / 145 istration, & knowledge development. -maintains knowledge of & apply evidence-based practice guidelines, including risk assessment & management. -participates in continuous quality improvement. -pursues continuing education. 19.How the PMHNP does Code of Ethics: Collaboration to Meet Health Needs: -promotes community, national, & international efforts to meet health needs through collaboration with other healthcare professionals. -engages in partnerships with other specialty nurses, government agencies, profes- sional nursing organizations, & mental health organizations to promote prevention, treatment, & recovery. 20.How the PMHNP does Code of Ethics: Promotion of the Nursing Profes- sion: -advocates for environments that respect human rights, customs, & spiritual beliefs of individuals, families, & communities. -engages in interactions & collaborations to articulate nursing values & maintain the integrity of the profession. -participates in policy development & implementation that recognizes PMH disorders as treatable & ensures that nursing care is delivered with respect to human needs & values without prejudice. 21.Person A: "I can't believe you deal with these people every day. Schizo- phrenics would drive ME crazy!" PMHNP: "Actually, schizophrenia is a chronic treatable disease, much like diabetes or other physical illnesses. Patients who have mental illness deserve compassion and care." How the PMHNP applied ethical principles: -Respect for the Individual -Commitment to the Healthcare Consumer -Advocacy for the Healthcare Consumer -Responsibility and Accountability for Practice -Duties to Self and Others -Contributions to Healthcare Environments -Advancement of the Nursing Profession -Collaboration to Meet Health Needs -Promotion of the Nursing Profession: Respect for the Individual Rationale: Respect for the individual affirms the worth and dignity of those with PMH disorders by advocating to overcome negative stigmas towards PMH diagnoses to ensure access to care. 12 / 145 22.The client presents to the emergency department with hallucinations and is threatening self-harm. The PMHNP signs an involuntary admission order for emergent psychiatric care. How the PMHNP applied ethical principles: -Respect for the Individual -Commitment to the Healthcare Consumer -Advocacy for the Healthcare Consumer -Responsibility and Accountability for Practice -Duties to Self and Others -Contributions to Healthcare Environments -Advancement of the Nursing Profession -Collaboration to Meet Health Needs -Promotion of the Nursing Profession: Commitment to the Healthcare Consumer Rationale: The PMHNP demonstrates a commitment to the healthcare consumer by balancing the client's human rights with safety, including coercive measures when the client was unable to maintain their own safety. 23.The PMHNP is sharing sexually explicit memes with a client that she saw earlier today in a group session. How the PMHNP applied ethical principles: -Respect for the Individual -Commitment to the Healthcare Consumer -Advocacy for the Healthcare Consumer -Responsibility and Accountability for Practice -Duties to Self and Others -Contributions to Healthcare Environments -Advancement of the Nursing Profession -Collaboration to Meet Health Needs -Promotion of the Nursing Profession: Advocacy for the Healthcare Consumer Rationale: This is an unethical scenario. The PMHNP recognizes the power differen- tial in the therapeutic relationship and understands that any sort of sexual activity or intimacies with current clients, their close family members, guardians, or significant others is unethical. 15 / 145 -Respect for the Individual 16 / 145 -Commitment to the Healthcare Consumer -Advocacy for the Healthcare Consumer -Responsibility and Accountability for Practice -Duties to Self and Others -Contributions to Healthcare Environments -Advancement of the Nursing Profession -Collaboration to Meet Health Needs -Promotion of the Nursing Profession: Contributions to Healthcare Environments Rationale: The PMHNP recognizes signs/symptoms of psychiatric disorders in the workplace reporting peer observations to leadership. The PMHNP helps address problems faced by colleagues that impact client safety or violate public trust, includ- ing substance abuse. 27. The PMHNP gives a presentation at a national conference on best practices in depression treatment. How the PMHNP applied ethical principles: -Respect for the Individual -Commitment to the Healthcare Consumer -Advocacy for the Healthcare Consumer -Responsibility and Accountability for Practice -Duties to Self and Others -Contributions to Healthcare Environments -Advancement of the Nursing Profession -Collaboration to Meet Health Needs -Promotion of the Nursing Profession: Advancement of the Nursing Profession Rationale: The PMHNP contributes to advancing the professing through practice, education, administration, and knowledge development. 28.The PMHNP is a member of the American Nurses Association (ANA) and National Alliance on Mental Illness (NAMI) and regularly participates in workgroups that seek to expand access to care for healthcare consumers with PMH disorders. How the PMHNP applied ethical principles: -Respect for the Individual -Commitment to the Healthcare Consumer 17 / 145 -Advocacy for the Healthcare Consumer -Responsibility and Accountability for Practice 20 / 145 -Document informed consent conversation in the medical record, including all con- sent forms. 32.exceptions to informed consent: -incapacitation -situations involving life-threatening emergencies in which there is no time for informed consent -client's voluntary waiver of informed consent -When a client is incapable of informed consent due to the nature or severity of their mental illness •PMHNP must determine if a client has the capacity to make medical decisions 33.steps in evaluating a client's capacity for decision-making.: 1. Assess for communication barriers: language, hearing or vision impairments, dysarthria 2.Evaluate for reversible causes of incapacity: infection, medications or other substances, acute neurologic & psychiatric disorders 3.Identify values & cultural influences that may impact client decision making 4.Ask questions: determine the client's ability to understand the tx & how tx applies to their situation. 5.Identify a surrogate if needed: healthcare advance directive, medical power of attorney, spouse, adult children, other close relatives 6.Document 34.formal assessment tool to assist in determining capacity: Aid To Capacity Evaluation (ACE) 35.Practice Settings for complex mental health care: -mental health settings -primary care -pediatrics -family and internal medicine -home health care -hospitals -schools -prisons 36.Legal & Ethical Implications in the Tx of Clients with Complex Disor- ders: -mental illness can impair a client's capacity to make informed decisions for themselves -side effects of some mental health txs may lead clients to choose nonadherence to tx recommendations 21 / 145 -client's psychiatric symptoms may compromise their safety or the safety of others. -ethical dilemmas may arise when clients' wishes differ from treatment recommen- dations or when interprofessional team members disagree about the best course of action in the treatment of a client 22 / 145 37.Mental Health America's 2015 position statement stipulates that:: profes- sionals must respect the client's fundamental rights of the client for dignity, auton- omy, & self-determination while addressing concerns about the safety & well-being of the client & others. 38.six key core skills that are critical to ethical decision-making in mental health care: 1. Ability to identify ethical issues 2.Ability to understand how one's values, beliefs, & sense of self, including implicit biases, impact client care 3.Ability to recognize personal limits to knowledge & expertise & willingness to practice within limits 4.Ability to recognize situations that present a high risk for ethical dilemmas 5.Willingness to seek information & consultation in difficult ethical or clinical situa- tions 6.Ability to build ethical safeguards into one's practice 39.Unrepresented clients: clients without advance directives and available family or friends to make decisions -State laws and institutional policies typically take one of three approaches in choosing a decision-maker •the physician or provider •an ethics committee •court-appointed guardian 40.Yolanda is a 20-year-old client who was referred to the PMHNP by her college health clinic for symptoms consistent with bipolar II disorder. She initiates the interview by stating that she is not willing to take any medications but is willing to engage in counseling or other therapies. Which of the following is the most appropriate action? provide additional education document refusal of treatment initiate treatment without informed consent: provide additional education Rationale: The client should receive education about the risks, benefits, and appro- priateness of pharmacological treatment. If, after receiving education, the client still refuses medication therapy, it is important to document the education provided and the client's refusal of treatment. 41.Kevin is a 48-year-old with a 20-year history of schizophrenia. He has decided to stop pharmacological treatment due to the intolerable adverse effects of his medications. Kevin and the provider have discussed the 25 / 145 therapy, the PMHNP should document the education provided and the client's refusal of treatment. 26 / 145 44.Fritz is a 25-year-old who has been brought to the emergency department by the police after threatening a server at a restaurant. The PMHNP on call has treated Fritz for schizophrenia in the past. He has a history of poor treat- ment adherence. While in the emergency department, he admits to auditory hallucinations. He becomes agitated and begins throwing items around the examination room. Which of the following is the most appropriate action? provide additional education document refusal of treatment initiate treatment without informed consent: initiate treatment without informed consent Rationale: The client does not have the capacity to provide consent at this time due to active hallucinations and agitation. For the safety of the client and staff, treatment should be initiated without obtaining informed consent. 45.Acute inpatient care: short-term treatment to provide care for acutely ill clients who are unable to meet basic needs due to a mental health condition or are at risk of harming themselves or others -focus is crisis stabilization -may be voluntary or involuntary 46.Voluntary Admission: -when a client & provider agree that client's symptoms meet criteria for inpatient hospitalization & the client may benefit from admission -client will sign consent form agreeing to a hospital stay in a locked unit -not require a psychiatric hold •if client requests discharge & provider determines the client is not yet safe, the provider may initiate an emergency involuntary hold 47.Involuntary Admission: -when a client does not agree to hospitalization -an evaluation by a mental health professional indicates that the client may be at high risk of harming themselves or others -Other terms denoting an involuntary admission include involuntary commitment, psychiatric hold, or civil admission -most states, clients can be held for up to 72 hours involuntary if deemed an imminent threat •Providers must perform & document a detailed eval & a risk assessment. 48.Involuntary civil commitment: -legal intervention directed by a judge to order a person with serious symptoms of continued danger to self or 27 / 145 others, grave disability, or serious deterioration to either remain in a psychiatric hospital or attend supervised outpatient treatment for a period of time 30 / 145 He does not have active thoughts of killing himself. He should be provided with resources for follow-up as well as information for the National Suicide Prevention Lifeline. 53.Rudy is a 42-year-old who was brought to the emergency department by his social worker. He was lethargic and disoriented when she found him at his "regular" spot in an encampment of unhoused individuals. Rudy was admitted for dehydration and his labs indicated severe malnutrition. Rudy has a history of schizophrenia with poor treatment adherence. He has no family in the area and has been living without housing for several years; his social worker endorsed that before this point, he had appeared healthy and had utilized available services for meals. Once medically stable, Rudy stated that he did not remember where to get food, and he was not sure how he got so sick. He does not wish to remain in the hospital. Does Rudy require an emergency psychiatric hold? yes no varies according to state legislation: varies according to state legislation Rationale: Rudy meets the criteria for a psychiatric hold in most states. He has a history of mental illness with poor treatment adherence, has no family support, and has been unable to care for himself; he meets the criteria for a gravely disabled individual and may be detained involuntarily for further evaluation. 54.Nnenna is a 22-year-old who was brought to the emergency department by the police after a car crash. The police officers state that Nnenna was crying and repeating, "just let me die" and the officers were concerned for her mental wellbeing. Nnenna's blood alcohol content is 0.12 g/mL. Upon interview, Nnenna has gross motor impairment and impaired judgment. She denies suicidal ideations, but she states it might be better for her to just die because her parents are going to be so upset after they find out about the accident. Nnenna's boyfriend met her in the emergency department and reported that she frequently drinks excessive amounts of alcohol. He plans to stay with her in her apartment overnight if she is released. Does Nnenna require an emergency psychiatric hold? yes no varies according to state legislation: varies according to state legislation 31 / 145 Rationale: Nnenna meets the criteria for a psychiatric hold in some states. She is legally impaired due to alcohol consumption, and her boyfriend reports that she frequently drinks excessive amounts of alcohol. She also crashed her vehicle and states that she wants to die. 55.Miguel is a 64-year-old who was arrested at a nearby supermarket after pulling a knife out of his jacket pocket and threatening an employee who refused to allow him to enter without a mask. After finding a prescription bottle for lithium in his belongings, police requested a psychiatric evaluation to determine if he should be transferred to a psychiatric facility. During the interview, Miguel is alert, oriented, and calm. He appears focused and his speech is measured and clear. He states that he has been living with bipolar 2 disorder for about 30 years, takes his medications regularly, and sees a mental health professional every month. Does Miguel require an emergency psychiatric hold? yes no varies according to state legislation: no Rationale: Miguel does not meet the criteria for an emergency psychiatric hold. Although Miguel exhibited dangerous behavior in the supermarket, he does not display symptoms of mania that would indicate that his behavior is related to his mental health diagnosis. 56.Bart is a 39-year-old client with no known medical or psychiatric history who was brought to the emergency department by the police after assaulting two people in a parking lot. He states that the people he attacked were demons sent to hurt him, and he was acting in self-defense when he attacked them. Bart endorses that he has been receiving messages from God for the past few days and, although he has tried to ignore the communication, he was forced to follow the commands in the messages. He states that he continues to receive messages; he becomes agitated when a phlebotomist enters the room and strikes at her, stating, "look! There's another demon! Why don't you believe me?" Does Bart require an emergency psychiatric hold? yes no varies according to state legislation: yes 32 / 145 Rationale: Bart meets the criteria for an emergency psychiatric hold. He presents a danger to others. 57.Khoudia is a 34-year-old who delivered her second child one month ago. She presents to the emergency department with her husband and newborn. Her obstetrician called a referral to the emergency department after com- pleting the Ask Suicide-Screening Questions tool which indicated an acute positive screen. Khoudia endorses frequent thoughts about killing herself in the past week and states she has been overwhelmed by the baby's care. She states she has a plan to wait until the baby is asleep and then sit inside the garage with the car running. Khoudia refuses to be admitted to the hospital because she is breastfeeding; her husband voices a plan to hide the car keys and stay awake all night to keep her safe. Does Khoudia require an emergency psychiatric hold? yes no varies according to state legislation: yes Rationale: Khoudia meets the criteria for an emergency psychiatric hold. She pre- sents a danger to herself; her husband's safety plan, while admirable, is not realistic to keep her safe. The client should be provided with a breast pump and storage for breastmilk so that she may continue to breastfeed. 58.Psychiatric Advance Directives (PAD): -unique legal documents that guide a client's treatment preferences if they are having a mental health crisis and are unable to make decisions -may contain advance instructions, a health care power of attorney, or both -help protect a client's autonomy by detailing their preferred medications and treat- ment modalities, and by giving advance consent for treatment or admission -useful for clients who experience episodes of acute psychosis, catatonia, mania, or delirium 59.state laws regarding Psychiatric Advance Directives (PAD): - https://nrc-pad.org/states/ 60.Ethical Use of Restraints and Seclusion: -Clients at risk of imminent harm to themselves or others may require temporary seclusion or restraint until their condition is stabilized -Laws differ from state to state 35 / 145 intervention to keep the client and others from harm 36 / 145 70.Types of Psychiatric Emergencies: -Risk of harm to others -Risk of harm to self -unable to meet their own basic needs for food, clothing, or shelter due to a psychological impairment -Serotonin syndrome -Neuroleptic malignant syndrome (NMS) -Agranulocytosis -Lithium toxicity -Suicidality -Acute psychosis -Agitation and aggression -Mania -Substance-related concerns -Decompensation r/t personality disorders -Severe anxiety -Medication-related emergencies 71.Risk factors for suicide: -Hx of substance abuse -Physical disability or illness -Losing a friend or family member to suicide -Ongoing exposure to bullying behavior -Mental health condition -Recent death of a family member or a close friend -Access to harmful means -Relationship problems -Previous suicide attempts 72.Ask suicide-screening questions (ASQ) suicide risk screening tool: https://www.nimh.nih.gov/sites/default/files/documents/researc h/re- search-conducted-at-nimh/asq-toolkit-materials/asq-tool/screen- ing_tool_asq_nimh_toolkit.pdf 73.Assessment During a Psychiatric Emergency: -gather info about pt before the exam to facilitate a rapid assessment; from family, medical records, emergency medical technicians or law enforcement, nursing staff. -PMHNP may need to collaborate with emergency medicine team to determine if theres a physical cause for acute psychiatric symptoms -psychiatric history 37 / 145 •Risk assessment •Physical risk •Risk of harm to others 40 / 145 •Assessment of risk, rationale, intervention, and follow-up 41 / 145 81.Art is a 52-year-old who presents to the clinic for a routine follow-up appointment. He has a history of schizophrenia with a lack of insight, im- pulsivity, and previous violent behavior. As the interview begins, Art states that he has had homicidal ideations toward his brother and nephew. He states that the two men have "disrupted his thinking" by "creating a new theory of family," and he is worried that the only solution is to kill them both. Currently, Art is calm and cooperative with disorganized thought content and fixed delusions; his appearance is slightly disheveled. He denies substance use and does not appear inebriated. He denies a specific plan to kill his brother and nephew and denies access to firearms. He endorses that he stopped taking his medications two weeks ago because he no longer needs them and does not think he needs additional assistance at this time. Which of the following is the most a: begin the involuntary admission process Rationale: The most appropriate management strategy for Art is to begin the invol- untary admission process. Art has homicidal ideations and a history of impulsivity and prior violence. He does not recognize the need for treatment. Therefore, the process for involuntary admission should be implemented. Consideration should also be made as to whether Art's family should be notified of his threats. Because Art is currently calm and cooperative, de-escalation techniques are not necessary. 82.Amir is a 28-year-old who was brought to the ED by law enforcement after his mother called 911 due to his bizarre behaviors. When the police arrived, Amir was agitated and wandering the street naked. He refused to follow directions and became combative with officers when approached. He was handcuffed and transported by a squad car. Before transfer, his mother told police that Amir had a history of schizophrenia with treatment nonadherence and marijuana use. During the ride to the ED, Amir was calm and cooperative. He was transferred to a gurney in the triage area without incident, but after transfer to an exam room, Amir began screaming and threatening the PMHNP and staff member. Amir tried to punch and spit at them when they approached the bedside. Which of the following are the most appropriate management strategies for Amir? Select all that apply. -begin the involuntary admission process -use de-escalation techniques: -use de-escalation techniques 42 / 145 -request additional staff support -medicate with intramuscular lorazepam 0.5 mg -remove objects from the room, such as monitors, tray tables, or other equipment, 45 / 145 know why this keeps happening." Hailey denies medical or psychiatric his- tory; the PMHNP notes bilaterally linear scarring on her arms. Hailey admits to self-injury behaviors and states she has been using cutting as a coping mechanism for years. She confirms that she did not intend to kill herself today and has never experienced suicidal ideations. Which of the following is the most appropriate recommendati: discharge to home with resources for crisis care and recommendations for outpatient psychiatric services Rationale: The client did not have suicidal thoughts during the self-harm episode. The self-harm episode was not lethal in nature, nor was there intent for lethality. The client should be provided psychiatric care resources for follow-up. 86.Mary Ellen is a 42-year-old who presents to the clinic with low energy and "feeling down." She states she has been increasingly fatigued for the past two months since she was laid off from her job due to downsizing. She reports that she presented for care because she felt "down in the dumps" as it was her sister's death anniversary. She had thoughts about harming herself somehow over the past few days but denied specific plans, stating, "sometimes it just seems like it would be easier not to be here." She has a previous history of a suicide attempt as a teenager, after which she received several years of therapy; she has not received mental treatment for about 20 years. She also reports using occasional marijuana and alcohol socially; she currently appears sober. Mary Ellen lives with her husband with whom she states she has a poor relationship; he has not been supportive of her mental health needs in t: recommend voluntary admission Rationale: Mary Ellen has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempts and has a lack of support resources. Currently, she may benefit from voluntary admission for evaluation and treatment. 87.Deshawn is a 32-year-old who presents to a rural ED with symptoms of worsening depression, insomnia, reduced appetite, and thoughts of jump- ing off a tall bridge. Deshawn has a history of major depressive disorder (MDD) and has been treated by his primary care provider for two years with sertraline 50 mg daily. Because the rural hospital has no psychiatric staff on call, the PMHNP was asked to provide a telemedicine consult. Deshawn 46 / 145 was agreeable to meeting with the PMHNP via video conference. On the call, Deshawn endorsed depressive symptoms but stated that he did not want to die and that "jumping off a bridge would be a terrible way to go." He denied other active plans for suicide. Which of the following are the most appropriate recommendations to the care team for Deshawn's treatment and disposition? 47 / 145 Select all that apply. -discharge to home with resources for crisis care -increase sertraline to 75 mg daily: -discharge to home with resources for crisis care -increase sertraline to 75 mg daily -recommend follow-up with telepsychiatry Rationale: The client is not having active suicidal thoughts and does not have a plan; therefore, the most appropriate recommendations for Deshawn include discharge to home with resources for crisis care, increasing his sertraline dose to 75-100 mg daily, and due to the limited resources in Deshawn's area, it is appropriate to recommend follow-up with telepsychiatry. 88.Antonia is a 26-year-old who presents to the ED with acute suicidal thoughts for several days. She denies a plan at this time. She has a history of major depressive disorder (MDD) and generalized anxiety disorder (GAD), for which she takes paroxetine 20 mg daily and clonazepam 0.5 mg as needed. She endorses a suicide attempt by taking "a handful" of medications at age 16. Antonia reports recent stress in her life, including a breakup with her girlfriend and an unstable work environment. She states that she came to the ED tonight because she "wasn't feeling like I could trust myself 100%." Which of the following is the most appropriate recommendation to the care team for Antonia's treatment and disposition? Select all that apply. -discharge to home with resources for crisis care & recommendation for follow-up -increase sertraline to 75 mg daily -23-hour observation in the ED with Q15 minute checks -recom: recommend voluntary admission Rationale: Antonia has had suicidal thoughts, and she does not have a plan; she has a history of suicide attempt and MDD and GAD. She is also under acute stress. At this time, she may benefit from voluntary admission for evaluation and treatment. 89.Antonia agrees to voluntary admission for evaluation and treatment. After searching the hospital system, the PMHNP finds that there is not an available inpatient bed for Antonia and that a bed may not be available for 50 / 145 • Tremor 51 / 145 •Seizure -Mental changes •Agitation •Pressured speech -Autonomic instability •Mydriasis • Tachycardia •Hypertension •Shivering •Diaphoresis •Diarrhea 93.Serotonin Syndrome Tx: -discontinuing the causative medication -intensity of supportive tx depends on severity of symptoms •Mild cases typically resolve within 24 hrs •severe cases may require hospitalization for stabilization 94.Neuroleptic Malignant Syndrome (NMS): -rare, life-threatening adverse effect caused by antipsychotic meds -may occur due to: •disruption of dopamine receptors in the anterior hypothalamus •direct toxicity to muscle cells •Psychological stressors that activate the ANS may also play a role in triggering NMS -onset of symptoms may occur 1-2 weeks after starting or changing the causative medication -Symptoms: •mental status changes •agitation •confusion •catatonia •muscle rigidity ("lead pipe" rigidity) •hyperthermia •excessive salivation •autonomic instability (labile blood pressure & heart rate) •elevated Serum creatine kinase (CK) levels 95.Neuroleptic Malignant Syndrome (NMS) Tx: -immediate intervention to stabi- lize vital signs, reduce fever, and control agitation -frequently admitted to ICU 52 / 145 -causative agent should be discontinued immediately -symptoms typically resolve 1-2 weeks after tx is initiated 96.Serotonin Syndrome vs NMS: -Serotonin Syndrome •Dilated Pupils •Headache •Shivering •Dysrhythmias •Hyperreflexia •Clonus -NMS •Drooling •Catatonia •Rapid changes in BP •Increased serum creatine kinase (CK) •Hyporeflexia -Both •Agitation •High BP •High fever •Confusion •Rigid muscles 97.Agranulocytosis: -Clozapine-induced agranulocytosis (CLIA) •potentially life-threatening •occurs in less than 1% of clients prescribed clozapine •cause unknown; may be genetic -Onset of symptoms any time following initiation of clozapine, most common after 4-5 weeks of drug therapy -symptoms of CLIA: •fever and chills •increased heart rate •sudden hypotension •muscle weakness and fatigue •mouth ulcers •sore throat -Diagnosis: absolute neutrophil counts (ANC) less than 100/mcL. 55 / 145 SNRIs 56 / 145 -inhibit 5-HT reuptake -inhibit NE reuptake (‘ energy, focus) -increase DA in prefrontal cortex (‘ cognition) NDRIs -inhibit DA reuptake (‘alertness, motivation) -inhibit NE reuptake (‘energy) 106. Psychotic symptoms: Positive Symptoms: -Hallucinations -Delusions -Thought disorder -Hostility -Excitability 107. Psychotic symptoms: Motor Symptoms: -Motor delay -Dyscoordination -EPS •Parkinsonism •Dyskinesia 108. Psychotic symptoms: Affective Symptoms: -Depression -Anxiety -Suicidality 109. Psychotic symptoms: Cognition: -Attention -Working memory -Verbal memory -Visual memory -Executive functioning -Processing speed -Social conditioning 110. Psychotic symptoms: Negative Symptoms: -Affective flattening -Alogia -Anhedonia -Amotivation -Asociality 111. Symptoms of Psychosis: Hallucinations: -Perceptual experiences in the absence of external stimuli •Auditory: hearing things that are not there (may include command hallucinations in which voices direct the client to perform actions, often related to self-harm or violence towards others) • Visual: seeing things that are not there 57 / 145 • Tactile: feeling sensations in the body in the absence of stimuli •Olfactory: smelling things that are not there •Gustatory: tasting things that are not there 112. Symptoms of Psychosis: Delusions: -Fixed false, irrational beliefs •Persecution: delusions related to being threatened, victimized, or spied on •Reference: delusions related to receiving personal messages from tv, radio, or actions of others •Somatic: delusions related to the body, including illness or the presence of foreign objects (e.g. Sometimes people believe there are objects in their bodies; for example, they might think they are infested with insects.) •Grandeur: delusions related to beliefs of special abilities or powers •Control: delusions that actions and thoughts are controlled by others 113. Symptoms of Psychosis: Thought Disorder: -Impairment in the process of thinking and difficulty organizing thoughts in a logical pattern •incoherent speech •loose associations •meaningless words •perseveration 114. Symptoms of Psychosis: Disorganized behavior: -Disordered or impaired behavior or communication •childlike silliness •unpredictable agitation •inappropriate clothing for the weather •poor hygiene 115. Schizophrenia: -complex chronic disorder -affecting approximately 3.5 million people in the United States -healthcare costs exceeding $155 billion -Symptoms typically emerge between late teens & early 30s -Many experience exacerbations of psychotic symptoms interspersed with periods of remission or recovery -response rates to antipsychotic good, tx adherence remains problematic -Common comorbid conditions: dementia, liver disease, AIDS, heart failure, type 2 diabetes 60 / 145 Mor- tality: -dx of schizophrenia is associated with a risk of increased morbidity, prema- ture mortality, & reduced life expectancy of 10-20 yrs due to poor physical health & 61 / 145 chronic comorbid conditions -(-) symptoms (avolition, apathy) contribute to sedentary behavior •reduced physical activity, and poor eating habits, impact development of obesity & comorbidities (diabetes, cardiovascular disease, hypertension) -Residential & financial instability creates challenges in accessing care & medica- tion •resulting in a cycle of relapse & hospitalization for acute management -morbidity & mortality associated with variety of factors: alcohol, tobacco, other substance use & metabolic syndrome -Common causes of death: suicide, cancer, cardiovascular disease 122. Schizophrenia Impairments Associated with Treatment: Adverse Effects (AEs): -Antipsychotics work by blocking the action of dopamine -associated with numerous AEs •can cause distress, reduce quality of life, lead to nonadherence to tx -longer the tx with antipsychotics, greater the risk for AEs -Extrapyramidal Adverse Effects •Akathisia •Dystonia •Drug-Induced Parkinsonism • Tardive Dyskinesia 123. extrapyramidal system (EPS): -primary function is to help coordinate muscle movement -EPS helps maintain posture and regulates involuntary motor movements -Antipsychotic meds can cause AEs in the EPS due to dopamine blockage or depletion in the basal ganglia 124. Akathisia: -The subjective feeling of restlessness with a compelling urge to move -May include repetitive movements: •finger tapping, rocking, crossing/uncrossing legs -Onset is usually within four weeks of starting or increasing medication -Management may include: •discontinuing or reducing the antipsychotic dose •switching to alternative antipsychotics •beta-blockers •benzodiazepines •anticholinergics •Mirtazapine may be used at a low dose 125. Dystonia: -Involuntary contraction or contortion of muscles 62 / 145 -May be painful and potentially dangerous if throat muscles are involved 65 / 145 bolic effects -2 meds recently FDA approved to tx schizophrenia & reduce risk for metabolic comorbidities •Lumateperone: modulates serotonin, dopamine, & glutamine neurotransmission •Olanzapine-samidorphan: addition of samidorphan (opioid receptor blocker) miti- gates weight gain commonly seen in clients taking olanzapine 131. Schizophrenia Impairments Associated with Treatment: Sexual Dysfunc- tion: -Antipsychotic medication often associated with sexual dysfunction •contributes to significant distress and tx nonadherence -Switching pts to aripiprazole or adding aripiprazole may help decrease sexual dysfunction -Quetiapine, ziprasidone, & olanzapine below 15 mg/day are associated with lower levels of sexual dysfunction 132. Schizophrenia Impairments Associated with Treatment: Treatment Resis- tance: -Treatment-resistant schizophrenia (TRS) is defined as active, persistent symptoms that impair functioning for over 3 months after at least 6 weeks of appropriate med therapy with 2 different antipsychotic meds -may not be diagnosed until treatment adherence has been confirmed. 133. Schizophrenia Impairments Associated with Treatment: Treatment Non- adherence: -Med nonadherence rates for clients with schizophrenia are compara- ble to med nonadherence rates associated with other chronic disorders, including coronary heart disease, diabetes, and asthma -risk factors for antipsychotic medication non-adherence: •Client £History of nonadherence £Poor insight into the disease process £Substance use £Cognitive impairment or developmental disability £Negative attitude •Medication £Adverse effects 66 / 145 £Continued symptoms •Environment £Lack of social support £Lack of therapeutic alliance 67 / 145 £Practical difficulties getting or taking medications •Society £Illness stigma £Stigma r/t med AEs 134. Long-Acting Antipsychotic Medications (LAIs) to Improve Treatment Ad- herence: -LAIs can: •improve client outcomes •reduce the # of hospitalizations & ED visits •reduce healthcare costs for pts with schizophrenia -pts dont have to remember to take QD med -more stable drug plasma level -strong evidence supports use, but used in less than 10% of pts -Barriers to use of LAIs: •logistical issues; cost of tx and availability of staff to provide injections •client perception of LAI •client aversion to needles 135. Medications available in long-acting depot injections (LAIs):: • haloperidol •risperidone •paliperidone •aripiprazole •olanzapine. 136. in treatment-resistant cases.: clozapine -Patients should be offered a clozapine trial if they have a partial or non- response to two antipsychotic trials, assuming those antipsychotic trials are an adequate dose and duration (four to eight weeks) 137. Talitha is a 26-year-old who presents to the clinic for a medication refill. At age 19, during her sophomore year of college, Talitha began having auditory hallucinations. She was prescribed olanzapine which helped with symptoms. After 6 months, Talitha stopped taking the medication because she felt well and had a relapse, during which the hallucinations returned, and the "voices" became threatening. Talitha developed paranoid symptoms. She was voluntar- ily hospitalized and was prescribed risperidone, which helped her symptoms but caused sleep disturbances. She was switched to aripiprazole, and the voices returned. Two years ago, she was restarted on olanzapine monotherapy 15 mg daily and has been adhering to the medication regimen since. Talitha denies substance use or other psychiatric history. 70 / 145 99213 99215 99205 71 / 145 99204 99203: 99215 Rationale: Talitha is an established client with one chronic illness with exacerbation, requiring a medication change; therefore, Talitha's visit qualifies as 99215: estab- lished client with a high level of medical decision making. 141. Eric is a 37-year-old who presents to the clinic with new symptoms. Past psychiatric history: Eric was diagnosed with schizophrenia at age 22. At that time, he had symptoms of paranoia, auditory hallucinations, avolition, and social withdrawal. He was prescribed aripiprazole 10 mg with good results. Over the past 15 years, his dose has been titrated up to 15 mg daily with mild, tolerable adverse effects. Eric has no history of relapse of symptoms before this point. Eric denies substance use or other psychiatric history. During the appointment, Eric endorses his symptoms have returned. He has begun having auditory hallucinations, and he worries that everyone around him is "out to get him." Upon further inquiry, Eric states that his dad, with whom he lived, died six months ago and Eric no longer has reliable housing. He tries to remember to take his medications daily, but states "I don't always have them with m: schizophrenia; multiple episodes, currently in acute episode Rationale: The most likely diagnosis for Eric is schizophrenia; multiple episodes, currently in acute episode. Eric has had a history of auditory hallucinations which resolved. At this time the hallucinations have returned, this is a second acute episode. 142. Which of the following is the most appropriate pharmacologic manage- ment strategy for Eric? -switch to aripiprazole lauroxil 441 mg intramuscular injection once monthly -switch to aripiprazole lauroxil 662 mg intramuscular injection once monthly -switch to aripiprazole lauroxil 882 mg intramuscular injection once monthly- : switch to aripiprazole lauroxil 441 mg intramuscular injection once monthly Rationale: The most appropriate pharmacologic management strategy for Eric is to switch to aripiprazole lauroxil 441 mg intramuscular injection once monthly. Eric had good symptom control with 72 / 145 aripiprazole, but recent life changes have made it difficult to adhere to medication therapy. Switching to a long-acting injectable is an appropriate management strategy. without concerns of opioid overdose, a potentially life-threatening interaction. 75 / 145 What is the most likely diagnosis for Skylar at this time? -schizophrenia; multiple episodes, currently in partial remission -schizophrenia; first episode, currently in partial remission -schizophrenia; continuous -s: schizophrenia; first episode, currently in full remission Rationale: The most likely diagnosis for Skylar is schizophrenia; first episode, currently in full remission. Skylar has not had a relapse of symptoms since their diagnosis, which meets the specifiers for first episode in full remission. 148. Which of the following are the most appropriate pharmacologic manage- ment strategies for Skylar? Select all that apply. -continue risperidone 6 mg daily -switch to aripiprazole 10 mg daily -discontinue all antipsychotic medications -prescribe valbenazine 40 mg daily: -continue risperidone 6 mg daily -prescribe valbenazine 40 mg daily Rationale: The most appropriate pharmacologic management strategies for Skylar include continuing risperidone 6 mg daily and prescribing valbenazine 40 mg daily. Skylar has had good symptom control with risperidone, but is experiencing symp- toms of tardive dyskinesia (TD) as evidenced by their AIMS score of 2; a score of 2 or greater indicates TD. The APA recommends treating moderate to severe TD symptoms associated with antipsychotic therapy with a vesicular monoamine transporter 2 (VMAT2) such as valbenazine 149. select the most appropriate ICD-10-CM codes for Skylar s diagnosis.: - F20.9 and G24.09 Rationale: F20.9 Schizophrenia reflects Skylar's diagnosis that is being treated at today's visit. On the ICD 10 webpage you will see this synonym for the code: Schizophrenia in remission. G24.09 Other drug induced dystonia corresponds to the new diagnosis- tardive dyskinesia. 150. Which of the following is the appropriate E/M code for this visit? 76 / 145 99214 99213 77 / 145 99215 99205 99204 99203: 99215 Rationale: Skylar is an established client with one chronic illness and a newly diagnosed second chronic illness who needs prescription drug management. The new onset TD warrants additional decision making. Therefore, Skylar's visit qualifies as 99215: established client with high level medical decision making. 151. Treatment-Resistant Depression (TRD): -subset of MDD -characterized by a lack of improvement despite the provision of traditional and first-line therapeutic options -criteria are 2+ unsuccessful trials of antidepressant pharmacotherapy -Inaccurate TRD diagnosis can lead to pseudo-resistance •pts prescribed suboptimal med trials D/C their meds because of adverse side effects 152. Management of TRD: Nutraceuticals: -adjunctive txs that may improve symp- toms in clients with TRD -Omega-3 fatty acids •thought to tx depression by decreasing chronic inflammation -L-methylfolate •active form of folate that crosses the blood-brain barrier •reduces inflammation, reduces loss in gray matter, & helps regulate serotonin, dopamine, & norepinephrine -Other agents associated with improvement in depressant symptoms: •zinc •magnesium •coenzyme Q10 153. Management of TRD: Electroconvulsive Therapy (ECT): - procedure that applies electrical stimulation to the brain through transdermal electrodes attached to the head to trigger seizure activity •sedated under general anesthesia & given a muscle relaxant during procedure -Use limited to clients with: • TRD •elevated suicide risk • pts with catatonia, psychosis, bipolar disorder, or dementia that have not responded to typical tx 80 / 145 the 1st pre- scribed antidepressant -most clients who were labeled tx resistant failed to receive an adequate medication trial -some pts may experience med efficacy in the first 6 weeks of a tx, however, full med benefits may not be evident until 10 or 12 weeks of tx -Prescribers should work with their clients to: 81 / 145 • assess reasons for inadequate response & increase meds to maximum dose rather than discontinue a med prematurely -Pts are more likely to achieve remission with an adequate trial of the 1st prescribed med than switching meds •only 25% of pts respond to a 2nd med 159. stepwise approach based on the STAR*D study to manage clients with TRD: Treatment Decision Process -Initial Evaluation and Management •Not all depressions are equal •A screening tool is used to assess symptoms and severity •Rule-out medical diagnosis (hypothyroidism, anemia, etc.) •Assess for comorbidities •Substance abuse •OCD/PTSD/anxiety •SSRI based on above factors -Wait/Reassure - minimum of 4 weeks •Adequate Response - Continue presenting tx •Inadequate Response - Next steps include: £adherence £barriers (cost, cognition) £repeat depression screen £educate £onset of action/dosing £increasing medication dose £consider adding psychotherapy -Wait/Reassure - minimum of 2-4 weeks •Adequate Response - Continue presenting tx •Inadequate/Partial Response: £Medication adherence £Barriers £Repeat depression screen £Increase medication (up to max amount recommended) £Psychotherapy adherence -Wait/Reassure - minimum of 4 weeks •Not Effective?: 82 / 145 £Re-evaluate £Switch to different SSRI/serotonin and norepinephrine reuptake inhibitors (SNRI) (remission success of 25 percent) 160. Harry is a 48-year-old who presents to the outpatient mental health clinic for an initial evaluation of symptoms of depression. Harry has been prescribed bupropion XL 300 mg daily by his primary care provider and has been taking it for the past five years. Harry endorsed that at first, the medication "worked really well," but states he has been feeling more down lately and is concerned that the medication is no longer working. He stated that about eight months ago, he changed to a new position at work that was "overwhelming." He had no time to participate in his hobbies, which include reading, racquetball, and golf. He states that since his promotion, "I have no time to do anything but work, eat, and sleep, so I tend to eat and sleep a lot more than I used to." Harry states that his wife of 18 years has become frustrated with him because he has no energy to participate in raising their children, but Harry: -switch to bupropion 150 mg twice daily -recommend follow-up with a primary provider -recommend initiating psychotherapy Rationale: The most appropriate initial treatment for Harry is to switch to bupropion 150 mg twice daily, recommend follow-up with the primary provider, and recommend initiating psychotherapy. Because the client has had gastric bypass surgery, his abil- ity to absorb extended-release medications may be impaired. Since the medication initially worked to control his symptoms, it is reasonable to begin by switching to the same medication in an immediate release format. Harry should follow up with his primary provider to obtain a complete physical, including lab work for possible deficiency of vitamin D or B12. Because of the client's recent increase in daily stressors, psychotherapy may also be appropriate at this time. 161. Bettina is a 24-year-old who presents to the mental health clinic after a referral from her primary care provider. She endorses symptoms of depres- sion that began "when I was still in college," including excessive sleepiness, withdrawal from social activities, the guilt associated with "leaving my friends hanging," and anhedonia. Bettina states that she saw a counselor through the college health service, which helped her symptoms somewhat, but she was unable to continue with counseling after graduation two years ago. She made an appointment with her primary care provider to discuss medications for depressive symptoms and was prescribed 85 / 145 depressive symptoms -Symptoms: •fatigue & lack of energy •psychomotor agitation or retardation 86 / 145 •increased difficulty with concentration & decision-making -The Cornell Scale for Depression in Dementia •screening tool •provides input from both the client & caregiver -SSRIs •may help slow functional decline in clients with dementia •improvement of depressive symptoms is typically minimal •AEs may be significant for older adults Nonpharmacologic interventions shown to reduce depressive symptoms in clients with dementia •animal therapy •cognitive stimulation •physical activity 165. conducting the Cornell Scale for Depression in Dementia: 166. Dementia Comorbidities: Anxiety: 167. Dementia Comorbidities: Dementia-Related Psychosis: 168. Dementia Comorbidities: Disordered Sleep: 169. Social determinants of health: -Health Care Access and Quality -Neighborhood and Built Environment -Social and Community Context -Economic Stability -Education 170. importance of gender-affirming psychotherapy during gender transition- : -Trans Youth with Supportive Parents •77% reported life satisfaction •33% reported life dissatisfaction •70% described mental health as very good or excellent •15% described their mental health as poor •23% report suffering depression •75% report not suffering depression -Trans Youth with Unsupportive Parents •64% reported low self-esteem •13% reported high self-esteem •0% faced no housing problems •55% faced housing problems. •4% did not attempt suicide •57% attempted suicide 87 / 145 171. Structural stigma in U.S. drug policies: Punitive Policies: -pregnant women anonymously tested for drug use: •prevalence of use similar between Black & White women £Black women 10x more likely to be reported to law enforcement -Indigenous women suffer from higher SUD rates compared to other racial & ethnic groups •disproportionately affected by criminalization laws at the federal, state, & tribal levels. -Consistent use of medication for OUD tx during pregnancy is significantly lower for women of color. 172. Trauma responses: how the nervous system responds to trauma: - Flee -Fight -Freeze -Collapse 173. Trauma-informed care: -Safety -Trust & Transparency -Peer Support -Empowerment & Choice -Cultural, Historical, & Gender Awareness 174. Trauma-informed care: Safety: -most fundamental principle to avoiding re- traumatization -Creating a physical setting & client-provider interactions that generate physical & psychological safety are foundational to providing trauma- informed care. 175. Trauma-informed care: Trust and Transparency: -Establishing a trusting re- lationship or therapeutic alliance is critical to the trauma- informed approach. •kind, respectful interactions •empowering intake procedures •transparency in discussions of treatment goals & modalities appropriate to the client's developmental level. 176. Trauma-informed care: Peer Support: -Providing opportunities for connect- ing with other trauma survivors may help to establish safety, foster hope, and promote healing through shared experience. -Collaboration: Empowering the client to play an active role in decisions about their treatment 90 / 145 (ACEs) •can have long-lasting effects on mental health •increase risk of developing mental disorders later in life 184. SDOMH: Discrimination & Mental Health Stigma: -Experiencing discrimi- nation or stigma against serious mental illness, SUDs, or other forms of mental disorders 91 / 145 •lead to chronic stress, low self-esteem, isolation, and prevent timely diagnosis, tx, & support 185. SDOMH: Access to Reimbursement for Mental Healthcare: -Limited access to & reimbursement for mental healthcare services can prevent timely dx, tx, & support. •exacerbating mental health issues 186. SDOMH: Criminalization of Mental Health Behaviors: -Failure of the justice system to recognize the behaviors of poorly treated serious mental illness & SUDs can worsen mental health outcomes 187. SDOMH: Physical Environment: -Living in unsafe, violent, or unhealthy phys- ical environments •contribute to chronic stress & negatively impact mental health 188. SDOMH: Social & Cultural Factors: -Cultural norms, social norms, & societal expectations can negatively shape individual experiences & mental health outcomes 189. SDOMH: Social Media: -Hurtful social media communication may lead to high stress & suicides •especially among youth 190. Structural Racism and Racial Trauma: -refers to how institutions, policies, & practices systematically disadvantage some racial or ethnic groups while privileging others -Structural Racism in Mental Health Services •Black men 4x more likely dx'd with schizophrenia than White males. •Black, Indigenous, & People of Color (BIPOC) youth with behavioral & mental health conditions are more likely to be directed to the juvenile justice system than to specialty care institutions compared to non- Latinx white youth. •Providers are less likely to be located in low-income neighborhoods with Black and Latinx residents compared to high-income neighborhoods with less than 1% of Black or Latinx residents. •Black people make up 12% of the country's population but 33% of the total prison population. •BIPOC are less likely than Whites to own their homes regardless of their level of education, income, location, marital status, & age. •Black people are less likely than Whites to hold jobs that offer retirement savings prioritized by the U.S. tax code. £creates a persistent wealth gap between White & Black communities where the median savings of blacks are 21.4% of the median savings of whites. 92 / 145 191. effects of structural racism on mental health: -Racial & ethnic minority groups consistently experience higher rates of psychological distress, mental illness, & poor mental health outcomes than their White counterparts 95 / 145 19 pa- tients in the VA system with no hx of mental illness 2 years prior to infection: -depression: 39% increase -anxiety: 35% increase -sleep problems: 41% increase 96 / 145 204. Racial Trauma Assessment: -Often PTSD assessment tools are used • provide few racial-trauma-specific prompts and it is unknown if they were validated using people of color •tend to measure the impact of a specific traumatic event, not the accumulation of lifetime events -Race-Based Traumatic Stress Symptom Scale (RBTSSS) •assesses symptoms associated with experiences of racism trauma •has a complex scoring system •measures only a single event •does not adhere to the DSM-5 framework for diagnosing trauma -UConn Racial/Ethnic Stress and Trauma Survey (UnRESTS) •easy-to-use •culturally informed tool for assessing racial trauma within a DSM-5 framework •lengthy & requires provider administration. -Racial Trauma Scale (RTS) •newly developed self-report measure to quantify and assess trauma symptoms specific to racial discrimination 205. Racial Trauma Scale (RTS): 9-Item Short-Form Research Version -scored by adding all items -Total scores range from 9 to 36 -three subscales: (a)Lack of Safety: 3, 5, 9 (b)Negative Cognitions: 2, 6, 7 (c)Difficulty Coping: 1, 4, 8 206. Racial Trauma-Informed Interventions: -principles of trauma- informed care: •Empowerment • Trustworthiness •Collaboration •Choice •Safety -healing ethno-racial trauma (HEART) framework (4 phases) •I. Establish sanctuary space for clients experiencing ERT •II. Acknowledge, reprocess, & cope with symptoms of ERT 97 / 145 • III. Strengthen & connect individuals, families, & communities to survival strategies