4.3 Mental health disorders

Question 1

A 43-year-old woman is referred to psychiatry following repeated episodes of hypomaniac behaviour interspersed with periods of depression. Her past medical history includes psoriasis and a deep vein thrombosis 11 years ago. Which one of the following medications is most likely to worsen her psoriasis?

• Sodium valproate
• Quetiapine
• Lithium
• Valproaic acid
• Fluoxetine

Answer 1

Psoriasis: exacerbating factors

The following factors may exacerbate psoriasis:

• trauma
• alcohol
• drugs: beta blockers, lithium, antimalarials (chloroquine and hydroxychloroquine), NSAIDs and ACE inhibitors, infliximab
• withdrawal of systemic steroids

Streptococcal infection may trigger guttate psoriasis.

Question 2

You receive a fax from psychiatry concerning a 30-year-old man. The consultant requests that the patient should be started on quetiapine. The patient has no significant past medical history of note and had been referred after complaining of psychotic symptoms. You note from the computer that the patient had a full blood count, urea and electrolytes, liver function tests and fasting blood glucose in the past two weeks after complaining of being tired all the time. Following BNF advice, which additional tests are required as a baseline?

• Fasting lipids, weight, blood pressure, thyroid function tests
• Weight, blood pressure, prolactin
• Fasting lipids, weight, blood pressure, prolactin
• Fasting lipids, weight, thyroid function tests
• Fasting lipids, blood pressure, prolactin

Answer 2

Fasting lipids, weight, blood pressure, prolactin

An ECG and cardiovascular risk assessment should also be considered depending on the history of the patient.

Antipsychotics: monitoring

The monitoring requires for patients taking antipsychotic medication are extensive. This is on top of the clinical follow-up that such patients clearly require. The BNF advises the following*:

TestFrequency

Full blood count (FBC), urea and electrolytes (U&E), liver function tests (LFT)

at the start of therapy

annually

clozapine requires much more frequent monitoring of FBC (initially weekly)

Lipids, weight

at the start of therapy

at 3 months

annually

Fasting blood glucose, prolactin

at the start of therapy

at 6 months

annually

Blood pressure

baseline

frequently during dose titration

Electrocardiogram

baseline

Cardiovascular risk assessment

annually

*please see the BNF for more details. There are a number of specific recommendations for individual drugs, the above is a general summary