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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
Who should initiate ADHD drug treatments?
Specialist
26
When can a GP be involved in the drug treatment of ADHD?
Once the dose has been stabilised by a specialist The GP can then continue and monitor drug treatment Under a shared care agreement
27
What are the first line drugs for ADHD and what do you do if one doesn’t work after a 6 week trial?
Methylphenidate Lisdexamfetamine After trialling one for 6 weeks, if there is no improvement try the other
28
What drug treatments are available for ADHD?
``` Methylphenidate Lisdexamfetamine Dexamfetamine (if lisdexamfetamine worked but isn’t tolerated) Atomoxetine Guanfacine (specialist) Antipsychotics (specialist) ```
29
What are some advantages of m/r formulations over immediate release formulations in ADHD?
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
30
When are immediate release preparations used alone in ADHD?
When flexible dosing is required e.g. when drugs are initiated and may need to be titrated often
31
Why is a combination of an immediate release and modified release preparation sometimes used in ADHD?
The immediate release preparation increases the duration of the modified release preparation
32
What should be done if a person is experiencing tachycardia or arrhythmias when on ADHD drug treatment?
Reduce the dose | Refer to a specialist
33
What should b done if a person taking guanfacine is experiencing sustained hypotension or fainting episodes?
Reduce the dose | Or switch to another stimulant
34
What schedule is methylphenidate?
Schedule 2 CD
35
What schedule is lisdexamfetamine?
Schedule 2 CD
36
What is the API in elvanse?
Lisdexamfetamine
37
What is the API in concerta?
Methylphenidate
38
What is the API In xaggitin?
Methylphenidate
39
What is the API in equasym?
Methylphenidate
40
What is the maximum licensed dose of methylphenidate?
60mg (except concerta which is 54mg) Specialists can go up to 90mg
41
Can methylphenidate be given in patients with arrhythmias?
No
42
What monitoring should be carried out for children on ADHD treatment?
BP, HR (due to CVD effects) Psychiatric disorders, suicide ideation Appetite, weight, heights
43
Why should m/r methylphenidate be prescribed by the brand?
Different brands are not always interchangeable
44
Can immediate release methylphenidate be prescribed generically?
Yes
45
What is bipolar disorder?
A long term mental illness characterised by episodic depressed and elevated moods
46
How is an acute manic phase treated in bipolar disorder?
Benzodiazepines e.g. lorazepam Antipsychotics e.g. olanzapine If these are not adequate, add a mood stabiliser e.g. lithium, sodium valproate
47
What is the maintenance treatment in bipolar disorder?
Antipsychotics e.g. olanzapine If there are frequent relapses, add a mood stabiliser e.g. lithium, sodium valproate
48
What oral antipsychotics can be used in bipolar disorder?
Olanzapine Quetiapine Rivastigmine Aripiprazole
49
How should antipsychotics be withdrawn?
Gradually If the patient is continuing other antipsychotics, withdraw over 4 weeks If the patient is not continuing other antipsychotics, withdraw over 3 months
50
When are mood stabilisers used in bipolar disorder?
In the acute treatment of mania | Prophylaxis of bipolar disorder
51
What are some contraindications to lithium salts?
``` Addison’s disease Personal/family history of Brugada syndrome Dehydration Low sodium diet Untreated hypothyroidism ```
52
What does lithium interact with OTC?
NSAIDS - Increases serum concentrations of lithium
53
Does lithium interact with diuretics?
Yes, increased risk of toxicity
54
What are the signs of lithium intoxication?
``` 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 ```
55
How long does it take for the symptoms to occur in lithium toxicity?
12 hours
56
What serum lithium concentration indicates toxicity?
2mmol/L
57
How is lithium toxicity managed?
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
58
Does lithium require therapeutic drug monitoring?
Yes - it has a narrow therapeutic window
59
When should samples be taken after a dose of lithium?
12h
60
What is the optimal lithium range in most adults?
0.4-1mmol/L
61
What is the desired concentration of lithium in acute mania?
0.8-1mmol/L
62
What should be monitored when on lithium?
``` Renal function Cardiac function Thyroid function Body weight Electrolytes FBC ```
63
Should lithium be stopped suddenly?
No, withdraw gradually over at least 4 weeks, ideally over 3 months
64
What symptoms should patients be aware of when on lithium?
Lithium toxicity Hypothyroidism Renal dysfunction (polyuria, polydipsia) Intercranial hypertension (sudden onset persistent headache, vision changes)
65
What advice should patients taking lithium he given regarding their food and drink?
Maintain an adequate fluid intake Don’t make changes to salt intake
66
Are lithium citrate and lithium carbonate interchangeable?
No Lithium carbonate tablets (204mg) = Lithium citrate liquid (520mg)
67
List some physical symptoms of depression
``` Affected sleep Affected appetite Constipation Aches and pains Lack of energy ```
68
List some psychological symptoms of depression
``` Low mood Low self esteem Lack of interest Anxious Sad Tearful Guilty Suicidal thoughts ```
69
How is depression classified?
Based on symptoms and how they affect day to day life
70
Who should have pharmacological treatment for depression?
Mild depression for several months Mild depression and a history of more severe depression Moderate or severe depression
71
Do antidepressants usually worsen sleep?
No - they usually improve sleep
72
Why shouldn’t healthcare professionals recommend or prescribe St Johns Wort?
It has many interactions (including antidepressants) | The amount of API varies between batches
73
St Johns Wort interacts with many medications. If St Johns Wort is stopped, what happens to the concentration of these drugs?
Their concentration usually increases Because St Johns Wort is an enzyme inducer Although it can also act as an inhibitor.
74
What are the three main classes of drugs used in depression, and which is most effective?
SSRI TCA MAOI These all have a similar efficacy
75
What are some main issues associated with SSRIs?
Hyponatraemia Serotonin syndrome Increased risk of bleeding (co-prescribe a PPI)
76
What are some main issues associated with TCA?
More dangerous in overdose (cardiotoxicity) Increased antimuscarinic side effects Increased sedation (although this may be a benefit in insomnia) - take at night
77
What are some main issues associated with MAOI?
Lots of food and drug interactions Risk of hypertensive crisis
78
Can sertraline be given after a recent MI?
Yes
79
Why are SSRIs usually first line?
Less side effects E.g. less sedation, antimuscarinic side effects Less dangerous in overdose
80
Should citalopram be offered first line if a patient is also taking amiodarone?
No - both drugs increased the QT interval
81
When would you give a PPI in patients taking SSRIs?
When they are at an increased risk of bleeding, e.g. elderly, use of NSAIDs
82
When should SNRIs be avoided?
CrCl <30 | Uncontrolled hypertension
83
When are TCAs usually taken?
At night due to their sedative effects
84
Which TCA is most dangerous in overdose?
Dosulepin (should be initiated by a specialist)
85
Which TCA has the highest incidence of antimuscarinic side effects?
Amitriptyline
86
Give some examples of antimuscarinic side effects
``` Constipation Dry mouth Sedation Urinary retention Blurred vision ```
87
What are the cardiotoxic effects that are associated with TCA overdose?
Tachycardia Slowed cardiac conduction Postural hypotension
88
Can mitrazapine be used in a 16 year old?
No - minimum age 18 years
89
Can mirtazapine be used after a recent MI?
Yes
90
What is the first line antidepressant for children?
Fluoxetine
91
What foods interact with MAOIs?
Red wine Cheese Certain meats and fish Over ripe fruit
92
What is the risk when SSRIs and MAOIs are taken together?
Serotonin syndrome
93
Do antidepressants work straight away?
No, may take a few weeks
94
How long should an antidepressant be trialled for before deciding it doesn’t work?
4 weeks | 6 weeks in the elderly
95
What withdrawal symptoms are associated with antidepressants?
``` Anxiety Insomnia Restlessness Irritability Altered sensations e.g. electric shocks ```
96
How soon do withdrawal symptoms usually occur after suddenly stopping an antidepressant?
Within 5 days
97
How long should it take to withdraw an antidepressant after being in it for 8+ weeks?
4 weeks
98
Which antidepressants can be associated with hyponatraemia?
All, especially SSRIs
99
List some symptoms of hyponatraemia
``` Headaches Nausea and vomiting Confusion Drowsiness Seizures Coma ```
100
Which antidepressants are associated with an increased risk of suicidal thoughts and behaviour? Which patient groups are more at risk of this?
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
Which drugs can cause serotonin syndrome?
``` Ondansetron SSRI, SNRI, TCA, MAOI St Johns Wort Tramadol Triptans ```
102
What are the symptoms of serotonin syndrome?
Neuromuscular - tremor, rigidity, rhabdomyolysis Autonomic dysfunction - diarrhoea, tachycardia, BP changes, hyperthermia, shivering Altered mental state - confusion, headache, agitation, hallucinations, mania
103
If the first line antidepressant (SSRI) isn’t effective, what are the options?
Increase the SSRI dose | Or switch to mirtazapine
104
Should TCAs or venlafaxine be used in mild depression?
No, use only in severe depression
105
Can a GP prescribe an MAOI?
No, it can only be initiated by a specialist
106
What antidepressant should be used in a patient taking NSAIDs?
Mirtazapine Avoid SSRI, SNRI - high bleeding risk
107
What antidepressant should be used in a patient taking warfarin?
Mirtazapine Not SSRI, SNRI - increased risk of bleeding
108
What antidepressant should be used in a patient taking heparins?
Mirtazapine TCA Avoid SSRI, SNRI - Increased risk of bleeding
109
What antidepressant should be used in a patient with epilepsy?
SSRI But all antidepressants can reduce the seizure threshold
110
What antidepressant should be used in a patient taking a triptan?
Mirtazapine Trazadone Avoid SSRI, SNRI, MAOI - Increased risk of serotonin syndrome
111
What is the mechanism of SSRIs?
Inhibit the reuptake of serotonin
112
When are SSRIs contraindicated?
When a person enters a manic phase (stop treatment) Poorly controlled epilepsy Cautioned in an increased risk of bleeding
113
What are the side effects of SSRIs?
``` Hyponatraemia Hepatic dysfunction Insomnia Bleeding Serotonin syndrome SJS Sexual dysfunction ```
114
What is the mechanism of SNRIs?
Inhibit the reuptake of serotonin and noradrenaline
115
When are TCAs contraindicated?
Immediate recovery after MI Arrhythmias During the manic phase of bipolar disorder
116
What are the side effects of TCAs?
Anticholinergic side effects QT interval prolongation Sedation Many others
117
How is overdose of TCAs managed?
Activated charcoal within 1 hour to reduce absorption Then supportive treatment
118
What drug can be used to managed inappropriate sexual behaviour?
Benperidol, a first generation antipsychotic
119
List some positive symptoms of schizophrenia
Hallucinations Delusions Interference with thinking
120
List some negative symptoms of schizophrenia
Apathy Lack of interest, enthusiasm or concern Social withdrawal
121
Why are patients with schizophrenia at an increased risk of CVD?
Stress Lifestyle factors - smoking, poor diet, alcohol, lack of exercise Antipsychotic medications can cause Weight gain Increased lipids Insulin resistance
122
Should schizophrenia be managed in primary or secondary care?
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
List some first generation antipsychotics
Haloperidol Prochlorperazine Chlorpromazine Zuclopenthixol
124
How do first generation antipsychotics work?
Block dopamine D2 receptors
125
What are two main side effects that occur with first generation antipsychotics, and less so with second generation antipsychotics?
EPSEs | Hyperprolactinaemia
126
Give some examples of second generation antipsychotics
``` Olanzapine Risperidone Quetiapine Aripiprazole Clozapine ```
127
What are the four main EPSEs seen with antipsychotics?
Akathisia (restlessness) Dyskinesia (uncontrolled muscle spasm) Pseudo-parkinsonism (bradycardia, tremor) ``` Tardive dyskinesia (abnormal involuntary movements) ```
128
How are the EPSEs associated with antipsychotics managed?
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
What are some side effects that occur with second generation antipsychotics, and less so with first generation antipsychotics?
Weight gain Insulin resistance Increased lipids and cholesterol QT interval prolongation Arrhythmias/tachycardia Postural hypotension Rash (may be SJS)
130
What are some main side effects that occur with both first and second generation antipsychotics?
``` QT interval prolongation Hyperprolactinaemia Sedation Sexual dysfunction Lowered seizure threshold Increased risk of VTE Increased risk of NMS ```
131
Which antipsychotics have the greatest tendency to cause weight gain?
Olanzapine | Clozapine
132
Which antipsychotic has the lowest tendency to cause insulin resistance and diabetes?
Haloperidol Aripiprazole out of the second generation antipsychotics
133
What are some symptoms of hyperprolactinaemia?
``` Galactorrhoea Menstrual cycle irregularities Sexual dysfunction Breast enlargement Increased risk of breast cancer Increased risk of osteoporosis ```
134
List some symptoms of NMS
``` Fever Sweating Confusion Muscle rigidity Fluctuating consciousness Hyperthermia Fluctuating BP Tachycardia Raised CK and LFTs ```
135
Are antipsychotics better at managing the positive or negative symptoms of schizophrenia?
Positive
136
Which type of antipsychotics are better at managing negative symptoms?
Second generation antipsychotics
137
When should clozapine be used in schizophrenia?
When 2 antipsychotics have been tried (at least one second generation)
138
When can two antipsychotics be prescribed?
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
Should antipsychotics be prescribed for schizophrenia in elderly patients with dementia?
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
List some antipsychotics that can be administered as a depot injection
Haloperidol Zuclopenthixol Risperidone Olanzapine Quetiapine
141
Should a test dose be administered for antipsychotic depot injections?
Yes
142
What needs to be monitored whilst taking antipsychotics?
``` Weight Fasting glucose, HbA1c, lipids BP Prolactin levels FBC, U&Es, LFT ```
143
Can antipsychotics be taken during pregnancy and breastfeeding?
Pregnancy - can take if benefit outweighs risk, the risk is increased if taken in the third trimester Breastfeeding - avoid
144
What patient advice should be given with antipsychotic use?
Photosensitisation can occur, especially with high doses - avoid direct sunlight Effects of alcohol are advanced Drowsiness may occur
145
How is antipsychotic poisoning managed?
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
What should pharmacy staff professionals be aware of when dispersing chlorpromazine?
Can cause skin sensitisation - avoid direct contact
147
Should flupentixol be given in the evening?
No - although it can cause drowsiness, it can also cause alertness
148
Who can be sold prochlorperazine OTC?
Patients over 18 years with nausea and vomiting associated with previously diagnosed migraines
149
List some antipsychotics with antimuscarinic side effects?
Prochlorperazine Chlorpromazine Clozapine
150
Does concurrent use of aripiprazole and hepatic inducers/inhibitors affect the dose of aripiprazole?
Yes If using alongside a hepatic inducer, double the dose of aripiprazole If using alongside a hepatic inhibitor, half the dose of aripiprazole
151
Does BP need to be measured when taking olanzapine?
Yes
152
Does BP need to be measured when taking aripiprazole?
No - it doesn’t affect the BP as much as other antipsychotics do
153
Which antipsychotics are affected by smoking?
Olanzapine | Clozapine
154
What is the MRHA advice associated with clozapine?
Risk of intestinal obstruction, faecal impaction Paralytic ileus Monitor blood for toxicity and agranulocytosis
155
What symptoms should patients look out for when taking clozapine?
Constipation - may be intestinal obstruction Flu like symptoms - may be agranulocytosis
156
When and why should blood tests be carried out when taking clozapine?
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
When is the risk of clozapine toxicity increased?
Start/stop smoking/change to e-cigarettes Acute infection Taken too much Taking drugs that increase blood clozapine
158
Which side effect of clozapine can hyoscine be used to manage?
Hypersalivation

Pre Reg Pharmacy (36 decks)

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