Chapter 4 - Mental Health Flashcards
Give examples of SSRIs
Sertraline Citalopram Escitalopram Fluoxetine Paroxetine
Give examples of SNRIs
Duloxetine
Venlafaxine
Give examples of TCAs
Sedating: Amitriptyline Doulepin Trazadone Clomipramine
Non-sedating
Nortriptyline
Imipramine
Lofepramine
Give an example of a 5HT1A receptor antagonist
Buspirone
What are some symptoms of anxiety?
Worry Fear Fatigue Sleep disturbance SOB Trembling Poor concentration Irritability Increased HR Restlessness Muscle tension
Give some examples of anxiety disorders
General anxiety disorder OCD PTSD Social anxiety Phobias Panic disorder
Name some drugs/substances that can cause anxiety
Some antidepressants Beta blockers Corticosteroids Salbutamol Theophylline
Caffeine
Alcohol
Some herbal medicines e.g. St Johns Wort, ginseng, ma huang
What drugs are usually used for acute anxiety?
Buspirone
Benzodiazepines
What is first line for chronic anxiety?
Psychological interventions e.g. CBT
When is drug treatment offered in chronic anxiety?
Severe anxiety
Anxiety not responding to psychological interventions
What are the treatment options for generalised anxiety disorder?
First line - SSRI (sertraline, escitalopram, paroxetine)
Second line - SNRI (duloxetine, venlafaxine)
If these are contraindicated or not tolerated - pregabalin
When should drug treatment in anxiety be monitored?
Initially every 2-4 weeks for the first 3 months
Then every 3 months thereafter
Why is an additional risk associated with SSRIs and SNRIs in <30 year olds?
Increased risk of self harm and suicidal thoughts
When should benzodiazepines be issued for anxiety in primary care?
Short term during crises
When is buspirone indicated?
Short term use in anxiety
What MRHA advice is associated with benzodiazepines?
Use of benzodiazepines with opioids increase the risk of potentially fatal respiratory depression
What are the side effects of diazepam?
Sedation Respiratory depression Hypotension Paradoxical side effects Withdrawal syndrome, tolerance and dependence
What paradoxical side effects may be seen in diazepam?
Talkativeness Excitability Irritability Aggression Suicide ideation Antisocial behaviour
What are the main interactions with diazepam?
Antihypertensives, vasodilators, diuretics - increased hypotensive effects
Alcohol and opioids - respiratory depression
CYP 450 inhibitors and inducers - affects serum concentrations
Phenytoin
Why shouldn’t benzodiazepines be used long term?
Risk of tolerance (reduced effectiveness)
Risk of dependence
What withdrawal symptoms are associated with benzodiazepines?
Rebound insomnia Seizures Hallucinations Delerium Anxiety
How are benzodiazepines withdrawn?
Convert to diazepam
Reduce gradually
What 3 behaviours is ADHD characterised by?
Hyperactivity
Impulsivity
Inattention
What non-drug treatments are available for ADHD?
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
Who should initiate ADHD drug treatments?
Specialist
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
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
What drug treatments are available for ADHD?
Methylphenidate Lisdexamfetamine Dexamfetamine (if lisdexamfetamine worked but isn’t tolerated) Atomoxetine Guanfacine (specialist) Antipsychotics (specialist)
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
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
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
What should be done if a person is experiencing tachycardia or arrhythmias when on ADHD drug treatment?
Reduce the dose
Refer to a specialist
What should b done if a person taking guanfacine is experiencing sustained hypotension or fainting episodes?
Reduce the dose
Or switch to another stimulant
What schedule is methylphenidate?
Schedule 2 CD
What schedule is lisdexamfetamine?
Schedule 2 CD
What is the API in elvanse?
Lisdexamfetamine
What is the API in concerta?
Methylphenidate
What is the API In xaggitin?
Methylphenidate
What is the API in equasym?
Methylphenidate
What is the maximum licensed dose of methylphenidate?
60mg (except concerta which is 54mg)
Specialists can go up to 90mg
Can methylphenidate be given in patients with arrhythmias?
No
What monitoring should be carried out for children on ADHD treatment?
BP, HR (due to CVD effects)
Psychiatric disorders, suicide ideation
Appetite, weight, heights
Why should m/r methylphenidate be prescribed by the brand?
Different brands are not always interchangeable
Can immediate release methylphenidate be prescribed generically?
Yes
What is bipolar disorder?
A long term mental illness characterised by episodic depressed and elevated moods
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
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
What oral antipsychotics can be used in bipolar disorder?
Olanzapine
Quetiapine
Rivastigmine
Aripiprazole
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
When are mood stabilisers used in bipolar disorder?
In the acute treatment of mania
Prophylaxis of bipolar disorder
What are some contraindications to lithium salts?
Addison’s disease Personal/family history of Brugada syndrome Dehydration Low sodium diet Untreated hypothyroidism
What does lithium interact with OTC?
NSAIDS - Increases serum concentrations of lithium
Does lithium interact with diuretics?
Yes, increased risk of toxicity
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
How long does it take for the symptoms to occur in lithium toxicity?
12 hours
What serum lithium concentration indicates toxicity?
2mmol/L
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
Does lithium require therapeutic drug monitoring?
Yes - it has a narrow therapeutic window
When should samples be taken after a dose of lithium?
12h
What is the optimal lithium range in most adults?
0.4-1mmol/L
What is the desired concentration of lithium in acute mania?
0.8-1mmol/L
What should be monitored when on lithium?
Renal function Cardiac function Thyroid function Body weight Electrolytes FBC
Should lithium be stopped suddenly?
No, withdraw gradually over at least 4 weeks, ideally over 3 months
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)
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
Are lithium citrate and lithium carbonate interchangeable?
Lithium carbonate tablets (204mg)
No
Lithium citrate liquid (520mg)
List some physical symptoms of depression
Affected sleep Affected appetite Constipation Aches and pains Lack of energy
List some psychological symptoms of depression
Low mood Low self esteem Lack of interest Anxious Sad Tearful Guilty Suicidal thoughts
How is depression classified?
Based on symptoms and how they affect day to day life
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
Do antidepressants usually worsen sleep?
No - they usually improve sleep
Why shouldn’t healthcare professionals recommend or prescribe St Johns Wort?
It has many interactions (including antidepressants)
The amount of API varies between batches
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.
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
What are some main issues associated with SSRIs?
Hyponatraemia
Serotonin syndrome
Increased risk of bleeding (co-prescribe a PPI)
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
What are some main issues associated with MAOI?
Lots of food and drug interactions
Risk of hypertensive crisis
Can sertraline be given after a recent MI?
Yes
Why are SSRIs usually first line?
Less side effects
E.g. less sedation, antimuscarinic side effects
Less dangerous in overdose
Should citalopram be offered first line if a patient is also taking amiodarone?
No - both drugs increased the QT interval
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
When should SNRIs be avoided?
CrCl <30
Uncontrolled hypertension
When are TCAs usually taken?
At night due to their sedative effects
Which TCA is most dangerous in overdose?
Dosulepin (should be initiated by a specialist)
Which TCA has the highest incidence of antimuscarinic side effects?
Amitriptyline
Give some examples of antimuscarinic side effects
Constipation Dry mouth Sedation Urinary retention Blurred vision
What are the cardiotoxic effects that are associated with TCA overdose?
Tachycardia
Slowed cardiac conduction
Postural hypotension
Can mitrazapine be used in a 16 year old?
No - minimum age 18 years
Can mirtazapine be used after a recent MI?
Yes
What is the first line antidepressant for children?
Fluoxetine
What foods interact with MAOIs?
Red wine
Cheese
Certain meats and fish
Over ripe fruit
What is the risk when SSRIs and MAOIs are taken together?
Serotonin syndrome
Do antidepressants work straight away?
No, may take a few weeks
How long should an antidepressant be trialled for before deciding it doesn’t work?
4 weeks
6 weeks in the elderly
What withdrawal symptoms are associated with antidepressants?
Anxiety Insomnia Restlessness Irritability Altered sensations e.g. electric shocks
How soon do withdrawal symptoms usually occur after suddenly stopping an antidepressant?
Within 5 days
How long should it take to withdraw an antidepressant after being in it for 8+ weeks?
4 weeks
Which antidepressants can be associated with hyponatraemia?
All, especially SSRIs
List some symptoms of hyponatraemia
Headaches Nausea and vomiting Confusion Drowsiness Seizures Coma
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
Which drugs can cause serotonin syndrome?
Ondansetron SSRI, SNRI, TCA, MAOI St Johns Wort Tramadol Triptans
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
If the first line antidepressant (SSRI) isn’t effective, what are the options?
Increase the SSRI dose
Or switch to mirtazapine
Should TCAs or venlafaxine be used in mild depression?
No, use only in severe depression
Can a GP prescribe an MAOI?
No, it can only be initiated by a specialist
What antidepressant should be used in a patient taking NSAIDs?
Mirtazapine
Avoid SSRI, SNRI - high bleeding risk
What antidepressant should be used in a patient taking warfarin?
Mirtazapine
Not SSRI, SNRI - increased risk of bleeding
What antidepressant should be used in a patient taking heparins?
Mirtazapine
TCA
Avoid SSRI, SNRI - Increased risk of bleeding
What antidepressant should be used in a patient with epilepsy?
SSRI
But all antidepressants can reduce the seizure threshold
What antidepressant should be used in a patient taking a triptan?
Mirtazapine
Trazadone
Avoid SSRI, SNRI, MAOI - Increased risk of serotonin syndrome
What is the mechanism of SSRIs?
Inhibit the reuptake of serotonin
When are SSRIs contraindicated?
When a person enters a manic phase (stop treatment)
Poorly controlled epilepsy
Cautioned in an increased risk of bleeding
What are the side effects of SSRIs?
Hyponatraemia Hepatic dysfunction Insomnia Bleeding Serotonin syndrome SJS Sexual dysfunction
What is the mechanism of SNRIs?
Inhibit the reuptake of serotonin and noradrenaline
When are TCAs contraindicated?
Immediate recovery after MI
Arrhythmias
During the manic phase of bipolar disorder
What are the side effects of TCAs?
Anticholinergic side effects
QT interval prolongation
Sedation
Many others
How is overdose of TCAs managed?
Activated charcoal within 1 hour to reduce absorption
Then supportive treatment
What drug can be used to managed inappropriate sexual behaviour?
Benperidol, a first generation antipsychotic
List some positive symptoms of schizophrenia
Hallucinations
Delusions
Interference with thinking
List some negative symptoms of schizophrenia
Apathy
Lack of interest, enthusiasm or concern
Social withdrawal
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
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
List some first generation antipsychotics
Haloperidol
Prochlorperazine
Chlorpromazine
Zuclopenthixol
How do first generation antipsychotics work?
Block dopamine D2 receptors
What are two main side effects that occur with first generation antipsychotics, and less so with second generation antipsychotics?
EPSEs
Hyperprolactinaemia
Give some examples of second generation antipsychotics
Olanzapine Risperidone Quetiapine Aripiprazole Clozapine
What are the four main EPSEs seen with antipsychotics?
Akathisia (restlessness)
Dyskinesia (uncontrolled muscle spasm)
Pseudo-parkinsonism (bradycardia, tremor)
Tardive dyskinesia (abnormal involuntary movements)
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
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)
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
Which antipsychotics have the greatest tendency to cause weight gain?
Olanzapine
Clozapine
Which antipsychotic has the lowest tendency to cause insulin resistance and diabetes?
Haloperidol
Aripiprazole out of the second generation antipsychotics
What are some symptoms of hyperprolactinaemia?
Galactorrhoea Menstrual cycle irregularities Sexual dysfunction Breast enlargement Increased risk of breast cancer Increased risk of osteoporosis
List some symptoms of NMS
Fever Sweating Confusion Muscle rigidity Fluctuating consciousness Hyperthermia Fluctuating BP Tachycardia Raised CK and LFTs
Are antipsychotics better at managing the positive or negative symptoms of schizophrenia?
Positive
Which type of antipsychotics are better at managing negative symptoms?
Second generation antipsychotics
When should clozapine be used in schizophrenia?
When 2 antipsychotics have been tried (at least one second generation)
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
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
List some antipsychotics that can be administered as a depot injection
Haloperidol
Zuclopenthixol
Risperidone
Olanzapine
Quetiapine
Should a test dose be administered for antipsychotic depot injections?
Yes
What needs to be monitored whilst taking antipsychotics?
Weight Fasting glucose, HbA1c, lipids BP Prolactin levels FBC, U&Es, LFT
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
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
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
What should pharmacy staff professionals be aware of when dispersing chlorpromazine?
Can cause skin sensitisation - avoid direct contact
Should flupentixol be given in the evening?
No - although it can cause drowsiness, it can also cause alertness
Who can be sold prochlorperazine OTC?
Patients over 18 years with nausea and vomiting associated with previously diagnosed migraines
List some antipsychotics with antimuscarinic side effects?
Prochlorperazine
Chlorpromazine
Clozapine
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
Does BP need to be measured when taking olanzapine?
Yes
Does BP need to be measured when taking aripiprazole?
No - it doesn’t affect the BP as much as other antipsychotics do
Which antipsychotics are affected by smoking?
Olanzapine
Clozapine
What is the MRHA advice associated with clozapine?
Risk of intestinal obstruction, faecal impaction
Paralytic ileus
Monitor blood for toxicity and agranulocytosis
What symptoms should patients look out for when taking clozapine?
Constipation - may be intestinal obstruction
Flu like symptoms - may be agranulocytosis
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
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
Which side effect of clozapine can hyoscine be used to manage?
Hypersalivation
