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Pre Reg Pharmacy > Chapter 4 - Mental Health > Flashcards

Chapter 4 - Mental Health Flashcards

1
Q

Give examples of SSRIs

A 
Sertraline
Citalopram
Escitalopram
Fluoxetine 
Paroxetine
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2
Q

Give examples of SNRIs

A

Duloxetine

Venlafaxine

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3
Q

Give examples of TCAs

A 
Sedating:
Amitriptyline
Doulepin 
Trazadone
Clomipramine

Non-sedating
Nortriptyline
Imipramine
Lofepramine

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4
Q

Give an example of a 5HT1A receptor antagonist

A

Buspirone

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5
Q

What are some symptoms of anxiety?

A 
Worry
Fear
Fatigue 
Sleep disturbance
SOB
Trembling
Poor concentration 
Irritability 
Increased HR
Restlessness 
Muscle tension
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6
Q

Give some examples of anxiety disorders

A 
General anxiety disorder 
OCD
PTSD
Social anxiety 
Phobias
Panic disorder
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7
Q

Name some drugs/substances that can cause anxiety

A 
Some antidepressants 
Beta blockers
Corticosteroids 
Salbutamol
Theophylline

Caffeine
Alcohol
Some herbal medicines e.g. St Johns Wort, ginseng, ma huang

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8
Q

What drugs are usually used for acute anxiety?

A

Buspirone

Benzodiazepines

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9
Q

What is first line for chronic anxiety?

A

Psychological interventions e.g. CBT

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10
Q

When is drug treatment offered in chronic anxiety?

A

Severe anxiety

Anxiety not responding to psychological interventions

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11
Q

What are the treatment options for generalised anxiety disorder?

A

First line - SSRI (sertraline, escitalopram, paroxetine)

Second line - SNRI (duloxetine, venlafaxine)

If these are contraindicated or not tolerated - pregabalin

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12
Q

When should drug treatment in anxiety be monitored?

A

Initially every 2-4 weeks for the first 3 months

Then every 3 months thereafter

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13
Q

Why is an additional risk associated with SSRIs and SNRIs in <30 year olds?

A

Increased risk of self harm and suicidal thoughts

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14
Q

When should benzodiazepines be issued for anxiety in primary care?

A

Short term during crises

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15
Q

When is buspirone indicated?

A

Short term use in anxiety

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16
Q

What MRHA advice is associated with benzodiazepines?

A

Use of benzodiazepines with opioids increase the risk of potentially fatal respiratory depression

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17
Q

What are the side effects of diazepam?

A 
Sedation 
Respiratory depression 
Hypotension 
Paradoxical side effects 
Withdrawal syndrome, tolerance and dependence
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18
Q

What paradoxical side effects may be seen in diazepam?

A 
Talkativeness
Excitability 
Irritability 
Aggression 
Suicide ideation
Antisocial behaviour
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19
Q

What are the main interactions with diazepam?

A

Antihypertensives, vasodilators, diuretics - increased hypotensive effects

Alcohol and opioids - respiratory depression

CYP 450 inhibitors and inducers - affects serum concentrations

Phenytoin

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20
Q

Why shouldn’t benzodiazepines be used long term?

A

Risk of tolerance (reduced effectiveness)

Risk of dependence

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21
Q

What withdrawal symptoms are associated with benzodiazepines?

A 
Rebound insomnia
Seizures
Hallucinations 
Delerium
Anxiety
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22
Q

How are benzodiazepines withdrawn?

A

Convert to diazepam

Reduce gradually

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23
Q

What 3 behaviours is ADHD characterised by?

A

Hyperactivity
Impulsivity
Inattention

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24
Q

What non-drug treatments are available for ADHD?

A

Regular exercise
Balanced diet
Controlling environmental factors e.g. noise, distractions
Giving written rather than verbal requests
In school/work have shorter periods of focus and longer breaks
CBT

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25
Q

Who should initiate ADHD drug treatments?

A

Specialist

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26
Q

When can a GP be involved in the drug treatment of ADHD?

A

Once the dose has been stabilised by a specialist
The GP can then continue and monitor drug treatment
Under a shared care agreement

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27
Q

What are the first line drugs for ADHD and what do you do if one doesn’t work after a 6 week trial?

A

Methylphenidate
Lisdexamfetamine

After trialling one for 6 weeks, if there is no improvement try the other

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28
Q

What drug treatments are available for ADHD?

A 
Methylphenidate 
Lisdexamfetamine
Dexamfetamine (if lisdexamfetamine worked but isn’t tolerated)
Atomoxetine
Guanfacine (specialist)
Antipsychotics (specialist)
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29
Q

What are some advantages of m/r formulations over immediate release formulations in ADHD?

A

Longer duration of action
Improved adherence
Don’t need to take to work/school (reduced stigma, less storage and administration issues)
Reduced risk of drug diversion

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30
Q

When are immediate release preparations used alone in ADHD?

A

When flexible dosing is required e.g. when drugs are initiated and may need to be titrated often

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31
Q

Why is a combination of an immediate release and modified release preparation sometimes used in ADHD?

A

The immediate release preparation increases the duration of the modified release preparation

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32
Q

What should be done if a person is experiencing tachycardia or arrhythmias when on ADHD drug treatment?

A

Reduce the dose

Refer to a specialist

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33
Q

What should b done if a person taking guanfacine is experiencing sustained hypotension or fainting episodes?

A

Reduce the dose

Or switch to another stimulant

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34
Q

What schedule is methylphenidate?

A

Schedule 2 CD

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35
Q

What schedule is lisdexamfetamine?

A

Schedule 2 CD

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36
Q

What is the API in elvanse?

A

Lisdexamfetamine

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37
Q

What is the API in concerta?

A

Methylphenidate

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38
Q

What is the API In xaggitin?

A

Methylphenidate

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39
Q

What is the API in equasym?

A

Methylphenidate

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40
Q

What is the maximum licensed dose of methylphenidate?

A

60mg (except concerta which is 54mg)

Specialists can go up to 90mg

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41
Q

Can methylphenidate be given in patients with arrhythmias?

A

No

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42
Q

What monitoring should be carried out for children on ADHD treatment?

A

BP, HR (due to CVD effects)
Psychiatric disorders, suicide ideation
Appetite, weight, heights

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43
Q

Why should m/r methylphenidate be prescribed by the brand?

A

Different brands are not always interchangeable

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44
Q

Can immediate release methylphenidate be prescribed generically?

A

Yes

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45
Q

What is bipolar disorder?

A

A long term mental illness characterised by episodic depressed and elevated moods

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46
Q

How is an acute manic phase treated in bipolar disorder?

A

Benzodiazepines e.g. lorazepam
Antipsychotics e.g. olanzapine

If these are not adequate, add a mood stabiliser e.g. lithium, sodium valproate

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47
Q

What is the maintenance treatment in bipolar disorder?

A

Antipsychotics e.g. olanzapine

If there are frequent relapses, add a mood stabiliser e.g. lithium, sodium valproate

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48
Q

What oral antipsychotics can be used in bipolar disorder?

A

Olanzapine
Quetiapine
Rivastigmine
Aripiprazole

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49
Q

How should antipsychotics be withdrawn?

A

Gradually

If the patient is continuing other antipsychotics, withdraw over 4 weeks

If the patient is not continuing other antipsychotics, withdraw over 3 months

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50
Q

When are mood stabilisers used in bipolar disorder?

A

In the acute treatment of mania

Prophylaxis of bipolar disorder

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51
Q

What are some contraindications to lithium salts?

A 
Addison’s disease 
Personal/family history of Brugada syndrome 
Dehydration 
Low sodium diet
Untreated hypothyroidism
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52
Q

What does lithium interact with OTC?

A

NSAIDS - Increases serum concentrations of lithium

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53
Q

Does lithium interact with diuretics?

A

Yes, increased risk of toxicity

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54
Q

What are the signs of lithium intoxication?

A 
GI effects - vomiting and diarrhoea 
CNS effects - confusion, drowsiness 
Muscle weakness
Tremor
Vision changes
Polyuria, incontinence 
Hypernatraemia
More serious effects:
Renal failure 
Seizures
Coma 
Sudden death
Circulatory failure
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55
Q

How long does it take for the symptoms to occur in lithium toxicity?

A

12 hours

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56
Q

What serum lithium concentration indicates toxicity?

A

2mmol/L

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57
Q

How is lithium toxicity managed?

A

May need haemodialysis if there is renal failure or neurological symptoms

Increase urine output (avoid diuretics)

Supportive treatment e.g. correct electrolyte imbalance, control of seizures

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58
Q

Does lithium require therapeutic drug monitoring?

A

Yes - it has a narrow therapeutic window

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59
Q

When should samples be taken after a dose of lithium?

A

12h

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60
Q

What is the optimal lithium range in most adults?

A

0.4-1mmol/L

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61
Q

What is the desired concentration of lithium in acute mania?

A

0.8-1mmol/L

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62
Q

What should be monitored when on lithium?

A 
Renal function 
Cardiac function 
Thyroid function 
Body weight
Electrolytes
FBC
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63
Q

Should lithium be stopped suddenly?

A

No, withdraw gradually over at least 4 weeks, ideally over 3 months

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64
Q

What symptoms should patients be aware of when on lithium?

A

Lithium toxicity
Hypothyroidism
Renal dysfunction (polyuria, polydipsia)
Intercranial hypertension (sudden onset persistent headache, vision changes)

65
Q

What advice should patients taking lithium he given regarding their food and drink?

A

Maintain an adequate fluid intake

Don’t make changes to salt intake

66
Q

Are lithium citrate and lithium carbonate interchangeable?

A

Lithium carbonate tablets (204mg)

No

Lithium citrate liquid (520mg)

67
Q

List some physical symptoms of depression

A 
Affected sleep
Affected appetite 
Constipation 
Aches and pains
Lack of energy
68
Q

List some psychological symptoms of depression

A 
Low mood
Low self esteem
Lack of interest
Anxious 
Sad
Tearful 
Guilty
Suicidal thoughts
69
Q

How is depression classified?

A

Based on symptoms and how they affect day to day life

70
Q

Who should have pharmacological treatment for depression?

A

Mild depression for several months

Mild depression and a history of more severe depression

Moderate or severe depression

71
Q

Do antidepressants usually worsen sleep?

A

No - they usually improve sleep

72
Q

Why shouldn’t healthcare professionals recommend or prescribe St Johns Wort?

A

It has many interactions (including antidepressants)

The amount of API varies between batches

73
Q

St Johns Wort interacts with many medications. If St Johns Wort is stopped, what happens to the concentration of these drugs?

A

Their concentration usually increases
Because St Johns Wort is an enzyme inducer
Although it can also act as an inhibitor.

74
Q

What are the three main classes of drugs used in depression, and which is most effective?

A

SSRI
TCA
MAOI

These all have a similar efficacy

75
Q

What are some main issues associated with SSRIs?

A

Hyponatraemia
Serotonin syndrome
Increased risk of bleeding (co-prescribe a PPI)

76
Q

What are some main issues associated with TCA?

A

More dangerous in overdose (cardiotoxicity)

Increased antimuscarinic side effects

Increased sedation (although this may be a benefit in insomnia) - take at night

77
Q

What are some main issues associated with MAOI?

A

Lots of food and drug interactions

Risk of hypertensive crisis

78
Q

Can sertraline be given after a recent MI?

A

Yes

79
Q

Why are SSRIs usually first line?

A

Less side effects
E.g. less sedation, antimuscarinic side effects

Less dangerous in overdose

80
Q

Should citalopram be offered first line if a patient is also taking amiodarone?

A

No - both drugs increased the QT interval

81
Q

When would you give a PPI in patients taking SSRIs?

A

When they are at an increased risk of bleeding, e.g. elderly, use of NSAIDs

82
Q

When should SNRIs be avoided?

A

CrCl <30

Uncontrolled hypertension

83
Q

When are TCAs usually taken?

A

At night due to their sedative effects

84
Q

Which TCA is most dangerous in overdose?

A

Dosulepin (should be initiated by a specialist)

85
Q

Which TCA has the highest incidence of antimuscarinic side effects?

A

Amitriptyline

86
Q

Give some examples of antimuscarinic side effects

A 
Constipation 
Dry mouth
Sedation 
Urinary retention 
Blurred vision
87
Q

What are the cardiotoxic effects that are associated with TCA overdose?

A

Tachycardia
Slowed cardiac conduction
Postural hypotension

88
Q

Can mitrazapine be used in a 16 year old?

A

No - minimum age 18 years

89
Q

Can mirtazapine be used after a recent MI?

A

Yes

90
Q

What is the first line antidepressant for children?

A

Fluoxetine

91
Q

What foods interact with MAOIs?

A

Red wine
Cheese
Certain meats and fish
Over ripe fruit

92
Q

What is the risk when SSRIs and MAOIs are taken together?

A

Serotonin syndrome

93
Q

Do antidepressants work straight away?

A

No, may take a few weeks

94
Q

How long should an antidepressant be trialled for before deciding it doesn’t work?

A

4 weeks

6 weeks in the elderly

95
Q

What withdrawal symptoms are associated with antidepressants?

A 
Anxiety 
Insomnia 
Restlessness 
Irritability 
Altered sensations e.g. electric shocks
96
Q

How soon do withdrawal symptoms usually occur after suddenly stopping an antidepressant?

A

Within 5 days

97
Q

How long should it take to withdraw an antidepressant after being in it for 8+ weeks?

A

4 weeks

98
Q

Which antidepressants can be associated with hyponatraemia?

A

All, especially SSRIs

99
Q

List some symptoms of hyponatraemia

A 
Headaches
Nausea and vomiting 
Confusion 
Drowsiness 
Seizures 
Coma
100
Q

Which antidepressants are associated with an increased risk of suicidal thoughts and behaviour?

Which patient groups are more at risk of this?

A

All antidepressants

Groups at an increased risk:
Children/young adults 
People with a history of suicidal thoughts or behaviour 
People at the beginning of treatment
People who have had their dose changed
101
Q

Which drugs can cause serotonin syndrome?

A 
Ondansetron
SSRI, SNRI, TCA, MAOI
St Johns Wort
Tramadol
Triptans
102
Q

What are the symptoms of serotonin syndrome?

A

Neuromuscular - tremor, rigidity, rhabdomyolysis

Autonomic dysfunction - diarrhoea, tachycardia, BP changes, hyperthermia, shivering

Altered mental state - confusion, headache, agitation, hallucinations, mania

103
Q

If the first line antidepressant (SSRI) isn’t effective, what are the options?

A

Increase the SSRI dose

Or switch to mirtazapine

104
Q

Should TCAs or venlafaxine be used in mild depression?

A

No, use only in severe depression

105
Q

Can a GP prescribe an MAOI?

A

No, it can only be initiated by a specialist

106
Q

What antidepressant should be used in a patient taking NSAIDs?

A

Mirtazapine

Avoid SSRI, SNRI - high bleeding risk

107
Q

What antidepressant should be used in a patient taking warfarin?

A

Mirtazapine

Not SSRI, SNRI - increased risk of bleeding

108
Q

What antidepressant should be used in a patient taking heparins?

A

Mirtazapine
TCA

Avoid SSRI, SNRI - Increased risk of bleeding

109
Q

What antidepressant should be used in a patient with epilepsy?

A

SSRI

But all antidepressants can reduce the seizure threshold

110
Q

What antidepressant should be used in a patient taking a triptan?

A

Mirtazapine
Trazadone

Avoid SSRI, SNRI, MAOI - Increased risk of serotonin syndrome

111
Q

What is the mechanism of SSRIs?

A

Inhibit the reuptake of serotonin

112
Q

When are SSRIs contraindicated?

A

When a person enters a manic phase (stop treatment)
Poorly controlled epilepsy

Cautioned in an increased risk of bleeding

113
Q

What are the side effects of SSRIs?

A 
Hyponatraemia 
Hepatic dysfunction 
Insomnia
Bleeding
Serotonin syndrome 
SJS
Sexual dysfunction
114
Q

What is the mechanism of SNRIs?

A

Inhibit the reuptake of serotonin and noradrenaline

115
Q

When are TCAs contraindicated?

A

Immediate recovery after MI
Arrhythmias
During the manic phase of bipolar disorder

116
Q

What are the side effects of TCAs?

A

Anticholinergic side effects
QT interval prolongation
Sedation

Many others

117
Q

How is overdose of TCAs managed?

A

Activated charcoal within 1 hour to reduce absorption

Then supportive treatment

118
Q

What drug can be used to managed inappropriate sexual behaviour?

A

Benperidol, a first generation antipsychotic

119
Q

List some positive symptoms of schizophrenia

A

Hallucinations
Delusions
Interference with thinking

120
Q

List some negative symptoms of schizophrenia

A

Apathy
Lack of interest, enthusiasm or concern
Social withdrawal

121
Q

Why are patients with schizophrenia at an increased risk of CVD?

A

Stress
Lifestyle factors - smoking, poor diet, alcohol, lack of exercise

Antipsychotic medications can cause
Weight gain
Increased lipids
Insulin resistance

122
Q

Should schizophrenia be managed in primary or secondary care?

A

Started in secondary care

Remain in secondary care for 12 months or until stabilised - whichever is longer

Then can be transferred to primary care under a shared care agreement

123
Q

List some first generation antipsychotics

A

Haloperidol
Prochlorperazine
Chlorpromazine
Zuclopenthixol

124
Q

How do first generation antipsychotics work?

A

Block dopamine D2 receptors

125
Q

What are two main side effects that occur with first generation antipsychotics, and less so with second generation antipsychotics?

A

EPSEs

Hyperprolactinaemia

126
Q

Give some examples of second generation antipsychotics

A 
Olanzapine 
Risperidone
Quetiapine 
Aripiprazole
Clozapine
127
Q

What are the four main EPSEs seen with antipsychotics?

A

Akathisia (restlessness)

Dyskinesia (uncontrolled muscle spasm)

Pseudo-parkinsonism (bradycardia, tremor)

Tardive dyskinesia (abnormal involuntary 
movements)
128
Q

How are the EPSEs associated with antipsychotics managed?

A

Akathisia - reduce antipsychotic dose

Dyskinesia - give antimuscarnic e.g. procyclidine

Pseudo-parkinsonism - give antimuscarnic e.g. procyclidine

Tardive dyskinesia - stop antipsychotic, this is the most serious EPSE and is potentially irreversible

129
Q

What are some side effects that occur with second generation antipsychotics, and less so with first generation antipsychotics?

A

Weight gain
Insulin resistance
Increased lipids and cholesterol

QT interval prolongation
Arrhythmias/tachycardia
Postural hypotension

Rash (may be SJS)

130
Q

What are some main side effects that occur with both first and second generation antipsychotics?

A 
QT interval prolongation 
Hyperprolactinaemia
Sedation
Sexual dysfunction 
Lowered seizure threshold 
Increased risk of VTE
Increased risk of NMS
131
Q

Which antipsychotics have the greatest tendency to cause weight gain?

A

Olanzapine

Clozapine

132
Q

Which antipsychotic has the lowest tendency to cause insulin resistance and diabetes?

A

Haloperidol

Aripiprazole out of the second generation antipsychotics

133
Q

What are some symptoms of hyperprolactinaemia?

A 
Galactorrhoea 
Menstrual cycle irregularities 
Sexual dysfunction 
Breast enlargement 
Increased risk of breast cancer 
Increased risk of osteoporosis
134
Q

List some symptoms of NMS

A 
Fever
Sweating 
Confusion 
Muscle rigidity 
Fluctuating consciousness 
Hyperthermia 
Fluctuating BP
Tachycardia 
Raised CK and LFTs
135
Q

Are antipsychotics better at managing the positive or negative symptoms of schizophrenia?

A

Positive

136
Q

Which type of antipsychotics are better at managing negative symptoms?

A

Second generation antipsychotics

137
Q

When should clozapine be used in schizophrenia?

A

When 2 antipsychotics have been tried (at least one second generation)

138
Q

When can two antipsychotics be prescribed?

A

This should be avoided due to the side effects.
Two antipsychotics can be used:

When changing antipsychotics during titration

When clozapine has failed, use clozapine and another antipsychotic

139
Q

Should antipsychotics be prescribed for schizophrenia in elderly patients with dementia?

A

Avoid if possible
Only prescribe if the patient is in considerable distress or a danger to themselves or others

This is due to a small increased risk of stroke and death

140
Q

List some antipsychotics that can be administered as a depot injection

A

Haloperidol
Zuclopenthixol

Risperidone
Olanzapine
Quetiapine

141
Q

Should a test dose be administered for antipsychotic depot injections?

A

Yes

142
Q

What needs to be monitored whilst taking antipsychotics?

A 
Weight
Fasting glucose, HbA1c, lipids
BP
Prolactin levels
FBC, U&Es, LFT
143
Q

Can antipsychotics be taken during pregnancy and breastfeeding?

A

Pregnancy - can take if benefit outweighs risk, the risk is increased if taken in the third trimester

Breastfeeding - avoid

144
Q

What patient advice should be given with antipsychotic use?

A

Photosensitisation can occur, especially with high doses - avoid direct sunlight

Effects of alcohol are advanced

Drowsiness may occur

145
Q

How is antipsychotic poisoning managed?

A

Phenothiazides
Supportive:
To manage EPSEs give procyclidine
To manage arrhythmias correct electrolyte abnormalities, hypoxia and acidosis

Second generation
Give activated charcoal within 1 hour to reduce absorption
Then so supportive treatment

146
Q

What should pharmacy staff professionals be aware of when dispersing chlorpromazine?

A

Can cause skin sensitisation - avoid direct contact

147
Q

Should flupentixol be given in the evening?

A

No - although it can cause drowsiness, it can also cause alertness

148
Q

Who can be sold prochlorperazine OTC?

A

Patients over 18 years with nausea and vomiting associated with previously diagnosed migraines

149
Q

List some antipsychotics with antimuscarinic side effects?

A

Prochlorperazine
Chlorpromazine
Clozapine

150
Q

Does concurrent use of aripiprazole and hepatic inducers/inhibitors affect the dose of aripiprazole?

A

Yes

If using alongside a hepatic inducer, double the dose of aripiprazole

If using alongside a hepatic inhibitor, half the dose of aripiprazole

151
Q

Does BP need to be measured when taking olanzapine?

A

Yes

152
Q

Does BP need to be measured when taking aripiprazole?

A

No - it doesn’t affect the BP as much as other antipsychotics do

153
Q

Which antipsychotics are affected by smoking?

A

Olanzapine

Clozapine

154
Q

What is the MRHA advice associated with clozapine?

A

Risk of intestinal obstruction, faecal impaction
Paralytic ileus

Monitor blood for toxicity and agranulocytosis

155
Q

What symptoms should patients look out for when taking clozapine?

A

Constipation - may be intestinal obstruction

Flu like symptoms - may be agranulocytosis

156
Q

When and why should blood tests be carried out when taking clozapine?

A

Risk of toxicity
Risk of agranulocytosis

Monitor routinely
Also monitor when there is an increased risk of toxicity:
Start/stop smoking/change to e-cigarettes
Acute infection
Taken too much
Taking drugs that increase blood clozapine

157
Q

When is the risk of clozapine toxicity increased?

A

Start/stop smoking/change to e-cigarettes
Acute infection
Taken too much
Taking drugs that increase blood clozapine

158
Q

Which side effect of clozapine can hyoscine be used to manage?

A

Hypersalivation

Pre Reg Pharmacy (36 decks)

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