3. Mental health disorders Flashcards
Anxiety symptoms
fear
restlessness
irritability
difficulty cocentrating
phyiscal
tremors
palpitations
muscle tension
excessive sweating
shortness of breath
insomnia
Anxiolytic drugs
Benzodiazepines
5-HT3 agonist
Antidepressant
Antiepileptic
Antipsychotic
Beta-blockers (help with the physical symptoms of anxiety such as tremors, palpitations and muscle tension)
- propanolol
- oxprenolol
Benzodiazepines mechanism of action
Acts on binding sites on GABA-a receptors to enhance binding of GABA.
GABA is an inhibitory neurotransmitter causing widespread CNS depressant effects: reduced axiety, muscle relaxation, anticonvulsant, sedation
Benzodiazepine uses
- severe anxiety (short term)
- muscle spasm
- seizures
- insomnia
Benzodiazepines caution/contraindication
Should be avoided in elderely patients, if ESSENTIAL, half the dose and use it for half the required period
Should be avoided in mild liver impairement as their sedative effects, can cause hepatic coma.
if ESSENTIAL, can offer a short-acting benzodiazepine.
Should never be used in severe liver impairement
Benzodiazepine side effects
As a CNS depressant it causes:
- drowsiness
- reduced alertness
- confusion
- Ataxia (affects coordination, balance, speech)
- Muscle weakness
- May also have a paradoxical effect: increasing anxiety, hostility and aggression
- Must avoid alcohol as it is also a CNS depressant
Benzodiazepine side effects
- Respiratory depression
This effect is enhanced if co-prescribed with opioid, can be fatal.
Patients must report signs and symptoms of slow breathing, sedation, blueish lips and skin
Patients taking methadone must be monitored for ~ 2 weeks
- Dependence and tolerance
Must be gradually withdawn to prevent benzodiazepine withdrawal syndrome
Increased risk with shorter-acting benzodiazepines
Benzodiazepine interactions
Interacts with other CNS depressants:
alcohol, opioids, antihistamines, antipsychotics, barbiturates, Z drugs
Attention deficit hyperactivity disorder
Symptoms:
Inattention: short attention spam, easily distracted
Hyperactive and Impulsiveness: unable to sit still, acting without thinking
ADHD treatment
First line: Methylphenidate OR lisdexamfetamine (or dexamfetamine if patient cannot tolerate long effect profile)
Alternative: Atomoxetine - non stimulant
Methylphenidate and amfetamines mechanism of action
stimulate CNS and increase dopamine levels in the brain
How is methylphenidate prescribed
Methylphenidate modified release preparations must be prescribed by brand.
Methylphenidate and amfetamines side effects
- growth restriction - can stunt growth so treatment breaks over school holidays can be had
- psychiatric disorders. Monitor psychiatric symptoms
- CVS effects, like tachycardia, increased BP. So contraindicated in CVD, severe hypertension, hyperthyroidism.
- insomnia
- tics and tourette’s syndrome (vocal and motor tics that last longer than a year)
- reduced apetite AND weight loss
Methylphenidate and amfetamines interactions
Methylphenidate and amfetamines are serotonergic drugs.
So increased serotonin syndrome with:
SSRI’s, TCA’s, MAOI’s, Lithium, MAO-B inhibitors, methadone, St John’s Wort, 5-HT1 agonists, 5-HT3 receptor antagonist e.g ondanestron
Serotonin drugs increases serotonin (5-HT) or act on serotonin 5-HT receptors
What is bipolar disorder
extreme mood swings varying from extremely happy to extremely sad, and can last for several weeks or months
Bipolar disorder symptoms
- Mania - high mood:
high energy
risky, harmful acts
overly ambitious acts
- Depression: low mood
Bipolar disorder treatment
For acute episodes and maintenance:
* Lithium
* Valproate
* 2nd generation Antipsychotic (olanzapine OR quetiapine, risperidone for acute episodes only)
Antidepressants should not be given in acute episodes, as they elevate moood and can worsen mania
Lithium prescribing
Patients must carry their alert card at all times
Patients must be maintained on the same brand, different brands have different bioavailabilities
Lithium and NSAIDS
Use of NSAIDs and lithium should be avoided together if possible. As NSAIDs reduce lithium excretion leading to lithium toxicity
Lithium therapeutic index and monitoring
0.4-1 mmol/L
treat patient and not level
Blood samples are taken 12 hours after dose. In the first year, blood levels are taken every 3 months and every 6 months thereafter, UNLESS the patient’s blood lithium has been affected.
Usually affected by sodium and water intake.
Lithium toxicity signs
G: gastro-intestinal effects, V+D
R: renal effects - polyuria and hypOnatraemia
E: eyes blurred vision
E: extrapyramidal symptoms, e.g tremor
N: nervous sytem, e.g confusion, drowsiness
Lithium is nephrotoxic and can cause nephrogenic diabetes insipidus where much water is lost
Lithium is renally cleared, HypOnatraemia, diuretics, intercurrent illness, diarrhoea, vomiting, predisposes to lithium toxicity due to loss of electrolytes.
High fluid intake dilutes blood sodium levels = psuedo hypOnatraemia
Low fluid intake predisposes to lithium toxicity
Lithium counselling
hyPERnatraemia can also cause lithium levels to fall so patients must maintain their salt and fluid inake
Lithium side effects
- Hypothryroidism: patients must report signs such as weight gain, cold intolerance
MONITOR: TFT - Nephrotoxicty: patients must report signs of polyuria, polydipsia
MONITOR: RFT - Prolong QT interval
MONITOR: cardiac function, ECG, - Benign intracranial hypertension
patient must report signs of: persistent headaches, visual disturbances - Lowers seizure threshold
caution: epilepsy
Lithium and pregnancy/breastfeeding
Lithium is teratogenic
Females of childbearing potential must take effective contraception
It is also present in breastmilk
Lithium interactions
HypOnatraemia predisposes to lithium toxicity.
1. Therefore lithium interacts with hypOnatraemic drugs: : diuretics,
lithium is renally cleared, so taking a drug that reduces renal excretion, lithium accummulates, increasing risk of toxicity.
2. Therefore lithium interacts with nephrotoxic drugs:
ACE inhibitors/ARBS, NSAIDs
-
hyponatraemia also causes lithium levels to fall as lithium excretion increases= therapuetic failure.
So interacts with common otc products with high sodium content, like effervescents, sodium antacids, like gaviscon -
Lithium is a serotonergic drug. Interacts with drugs that increase serotonin = incressing risk of serotonin syndrome.
Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John’s wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist -
QT prolongation
Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron
Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline.
Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes
- Increased risk of Neurotoxicity when taking with antipsychotics and TCA
Depression symptoms
helpless
pessimistic
low-self esteem
suicidal thoughts
Insomnia
Weight gain or weight loss
fatigue
Depression treatment
Mild:
1st line: CBT
Moderate - severe depression
1st line: SSRI and CBT
Other antidepressants: SNRI (Duloxetine, Venlafaxine)
Antidepressants should be taken for at least 6 months. They take a few weeks to work, depression may become worse before it gets better.
If a patient is at risk of suicide, patient must be reviewed after 1 week
Severe depression and rapid response:
Electroconvulsive therapy
types of antidepressants
Selective Serotonin Reuptake Inhibitors
paroxetine
sertraline
flovaxmine
Tricyclic antidepressants
amitryptiline
clomipramine
doselupin
doxepin
Monoamine oxidase inhibitor:
phenelzine
isocarboxazid
tranylcypromine
Antidepressant side effects
- Drowsiness
caution: Driving - Suicidal ideation and behaiviour
- HypOnatraemia, especially elderly patients
- Withdrawal reactions (high risk with paroxetine, venlafaxine as they have shorter half lives)
Serotonin syndrome
Trio of symptoms
- neuromuscular hyperactivity: tremeor, muscle rigidity
- altered mental state: confusion, agitation, mania
- dysregulated autonomic dysfunction: tachycardia, labile blood pressure, urination, hyperthermia
Switching antidepressants
Must have washout period, to prevent serotonin syndrome
Switching from MAOI to another antidepressant:
Wait 2 weeks
No washout period for moclobemide
Switching from SSRI to another antidepressant:
Wait 1 week
Wait 2 weeks from sertraline
Wait 5 weeks from fluoxetine
Switching from TCA to another antidepressant:
Wait 1 - 2 weeks
Wiat 3 weeks from clomipramine, imipramine
Selectivee Serotonin Reuptake Inhibitor mechanism of action
Selectively blocks the reuptake of 5-HT (serotonin) form the synaptic cleft, to increase concentration of serotonin
SSRI’s in children
Fluoxetine is the only SSRI that can be given safely to children under the age of 12
SSRI’s side effects
SIGHSQA
S- serotonin syndrome
I-increased risk of bleeding
G - gastrointestinal upset, N V D
H - hypersensitivity (skin rash)
S - seizure threshold reduced
Q - QT interval prolongation
A - apetite and weight gain or loss
Sertraline and CVD
Sertraline is safe in MI and unstable angina
SSRI’s interactions
- Fluoxetine, Fluvoxamine and sertraline are enzyme inhibitors, increasing drug levels and increasing risk of toxicity
- Fluoxetine, Fluvoxamine and sertraline Interacts with grapefruit juice as it is an enzyme inhibitor = sertraline levels
-
HypONatraemia risk increased when interacting with hyponatraemic drugs
antidepressants, carbamamzepine, desmopressin, diuretics, NSAIDs -
Increased risk of bleeding when taken with other drugs that also have this side effect
alcohol anticoagulants, warfarin, DOACs, corticosteroid, venlafaxine -
Interacts with drugs that increase serotonin = incressing risk of serotonin syndrome.
Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John’s wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist -
QT prolongation
Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron
Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline.
Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes
Tricycline and related antidepressants mechanism of action
Blocks the reuptake of serotonin (5-HT) and noradrenaline from synaptic cleft
Also block muscarinic receptors, leading to antimuscarinic effects
TCA side effects
Typically taken once at night as they are sedating
TCAS
T - TCAs> SSRI’s in overdose, as they are more sedating, antimuscarinic, cardiotoxic
C - Cardiac effects, e.g arrhythmias. Should not be used in arrhythmias, or heart block.
A - Antimuscarinic effects: (cant see, cant pee, cant spit, cant shxt)
S - seizures
TCA’s interactions
-
Interacts with hypOnatraemic drugs, increasing risk of hyponatraemia:
antidepressants, carbamazepine, desmopressin, diuretics, NSAIDs -
Interacts with antimuscarinic drugs, to increase antimuscarinic effects:
antihistamine, antimuscarinic e.g hyoscrine, antipsychotic -
Interacts with other CNS depressants, to increase risk of CNS depressant effects like sedation
alcohol, antihistamine, benzodiazepines, barbiturates, opioids, z-drugs, -
Interacts with other hyPOtensive drugs, to increase risk of hypotension
ACE inhibitor, arbs, alpha-blockers, CCBS, levodopa, MAO-B inhibitor, dopamine-receptor antagonist, antipsychotic, diuretic, nitrate, PPDIEtype 5 inhibitor, SGLT2 inhibitor -
Interacts with drugs that increase serotonin = increasing risk of serotonin syndrome.
Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John’s wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist -
QT prolongation with clomipramine
Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron
Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline.
Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes
Monoamine oxidase inhibitors mechanism of action
Block the enzyme monoamine oxidase, therefore monoamines accumulate (serotonin, noradrenaline and dopamine)
Monoamine oxidase inhibitors side effects
Rarely used
- hypertensive crises: due to increase of sympathomimetics = raise in blood pressure
Also associated with intracranial bleeding
Should not be used in cerebrovascular disease, e.g strokes, severe CVD - Hepatotoxic
- Postural hypotension
Should be stopped if palpitations, or headaches become frequent
Monamine oxidase interactions
-
Interacts with drugs that increase blood pressure, to increase the risk of hypertensive crises
ephedrine, pseudoephedrine, phenyephrine, oxymetazoline, xylometazoline, OTC decongestants, adrenalone, noradrenalone, amfetamines, methylphenidate, beta2 agonists -
Interacts with drugs that increase serotonin = increasing risk of serotonin syndrome.
Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John’s wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist
MAOI counselling
Patients should avoid tyramine rich foods or dopa-rich foods, such as cheese.
Must avoid stale food and alochol and eat fresh food
What is Schizophrenia
a type of psychosis, there is no disctinction between thoughts and reality
Schizophrenia symptoms
Positive symptoms: - antipsychotic drugs better target them
Hallucinations
Delusions
Disturbed thoughts and speech
Negative symptoms:
apathy
social withdrawal
poor hygiene
catatonia
Schizophrenia treatment
1st line: Oral antipsychotic monotherapy
For resistant schizophrenia (where 2+ antipsychotic drugs have been tried inl 2nd gen):
Offer clozapine AND oral antipsychotic
For non-adherence:
Offer depot injections
For acute episodes:
Offer IM antipsychotic - must be lower than oral dose. Repeat dose and review daily
Prescribing antipsychotic in elderly
In dementia: there is an increased risk of stroke and death
Associated with postural hypotension, hyperthermia, hypothermia
Prescribing antipsychotic in learning disability
If no psychotic symptoms:
reduce dose or discontinue antipsychotic and review
Prescribing antipsychotic in unlicensed high doses
First try alternatives such as clozepine
Monitoring: ECG, pulse, blood pressure, temp
Increase gradually
Stop if no improvement
Antipsychotic drugs mechanism of action
1st generation: block dopamine-2 receptors in the mesolimbic pathway. This treats the positive symptoms in schizophrenia
2nd generation: blocks dopamine-2 receptors and other receptors. Can cause a wider range of side effects
Types of antipsychotic drugs
1st generation:
Phenothiazines
Composed of Group 1 (most sedating, ending in -promazine e.g chlorpromazine), Group 2 and Group 3
Butyophenone
Haloperidol
Thioxanthene
Flupentixol
2nd generation:
Amisulpride
Aripiprazole
Clozapine (most effective)
Olanzapine
Quetiapine
risperidone)
Antipsychotic side effects
-
Extrapyramidal symptoms:
Dystonia, Akathisia, tardive dyskinesia
More commonly caused by 1st generation antipsychotics: group 3 phenothiazines, haloperidol and depot injections -
Hyperprolactinaemia (except aripiprazole), as they Inadvertently block regulation of prolactin secretion
breast enlargement or pain, breast milk secretion, reduces bone density menstrual disturbance
- more commonly caused by 1st gen antipsychotics and 2nd gen amisulpride, sulpride and risperidone
monitoring: prolactin levels
-
Metabolic effects - more commonly caused by 2nd generation antipsychotics
Hyperglycaemia, Weight gain (common with clozapine and olanzapine), Abnormal lipids
monitor: fasting blood glucose, weight, lipids
-
Cardiovascular effects:
Tachycardia, arrhythmias, prolonged QT interval (pimozide), postural hypotension (clozapine, quetiapine) -
Neuroleptic malignant syndrome:
If this occurs, drug must be STOPPED
muscle rigidity, fluctuating consciousness, hyperthermia, automic dysfunction
More antipsychotic drug side effects
Antimuscarinic effects
Seizures
Sedation
Sexual dysfunction
Photosensitivity, avoid direct sunlight
Clozapine side effects
Clozapine can cause fatal toxicity, blood levels should be monitored when a patient has signs of toxicity or there are interactions
B M I
B -blood disorders (neutropenia, agrunlocytosis)
Patients must report signs and symptoms of an infection: fever, sore throat, mouth ulcer
monitoring: leucocyte, WBC
M - mycocarditis - inflammation of heart muscle
signs include tachycardia
I - intestinal obstruction
As clozapine can impair persistalisis and cause constipation and fecal impaction.
Patient must report constipation, before taking another dose
Chlorpromazine side effect
Contact sensitisation
Must avoid direct contact, do not crush tablets. Handle solutions with care
Phenothiazines side effect
- Hepatoxicity
- Acute dystonic reactions
Antipsychotic drugs interactions
-
QT prolongation - pimozide
Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron
Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline.
Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes
-
Interacts with antimuscarinic drugs, to increase antimuscarinic effects:
antihistamine, antimuscarinic e.g hyoscrine, antipsychotic, TCAs -
Interacts with other CNS depressants, to increase risk of CNS depressant effects like sedation
alcohol, antihistamine, benzodiazepines, barbiturates, opioids, z-drugs, -
Interacts with other hyPOtensive drugs, to increase risk of hypotension
ACE inhibitor, arbs, alpha-blockers, CCBS, levodopa, MAO-B inhibitor, dopamine-receptor antagonist, antipsychotic, diuretic, nitrate, PPDIEtype 5 inhibitor, SGLT2 inhibitor
Drug given for inapropriate sexual behaiviour
Benperidol
TCA risk of fatality in overdose
Lofepramine has the lowest risk of fatality on overdose compared to other TCA’s. Amitriptyline and Dosulepin have a high risk of fatality in overdose
