CLINICAL- MENTAL HEALTH Flashcards
In order to be diagnosed as being mentally ill what do your symptoms need to cause?
Symptoms need to cause “clinically significant distress” or problems functioning in daily life.
Whether they are or not can be down to the discrepancy of the service provider.
Its down to how well the individual copes- they may have the symptoms but cope with them well enough to maintain a high level of functioning.
In mental health, its all about offering people _____ of treatment!
CHOICE
What does “positive” symptoms mean in schizophrenia?
Experiences that are IN ADDITION to reality: i.e. adding something that is not usually there
What does “negative” symptoms mean in schizophrenia?
Loss of normal responses or experience
Delusions is a characteristic symptom of schizophrenia. What are delusions?
Beliefs of things that are not real:
May be paranoid delusions (e.g. being followed, spyed on, tricked)
or Grandiose delusions (beliefs of self importance, special powers)
What are Hallucinations?
When patients hear voices
May also be smell, taste and touch
The symptoms of Schizophrenia have to last for a significant duration: Continuous signs of the disturbance have to last for at least __ months
last at least 6 months
What are the positive symptoms of Schizophrenia?
Hallucinations
Delusions
Thought Disorder
Passivity Phenomena
What are the negative symptoms of schizophrenia?
Slowed down thought and movement
Social withdrawal
Lack of interest in previously pleasurable things
How common is depression?
One of the most common mental health disorders in UK
1 in 6 will be affected at some point in their life!!
What are the 3 key symptoms of depression?
Lowered Mood
Anergia (lack of energy/ motivation: note the erg: energy)
Anhedonia (lack of pleasure in things previously found pleasurable)
What is the monoamine hypothesis in depression?
Suggests a biological basis for depression:
A depletion in the levels of serotonin, noradrenaline and/or dopamine in the CNS
This forms the basis of most pharmacological approaches in depression.
What is the widely used screening tool in depression?
PHQ-9
Asks patients to rank from 0 (not at all) to 3 (nearly every day) on a number of experiences they may have had in last 2 weeks such as Feeling tired or having little energy
What makes prescribing in psychiatry confusing?
You can't look at one drug and think the diagnosis must be X: the drugs in psychiatry may be used for different conditions. Antidepressants Antipsychotics Anxiolytics Mood stabilisers
With antidepressants we may start to see changes after 1 week, with significant improvement after week __. If there is no improvement evident by week __, change the choice of treatment.
Usually start to see improvements by week 3.
If no improvement evident by week 4, change the drug choice.
How do SSRI’s work?
Selective serotonin re-uptake inhibitors
Block serotonin re-uptake: serotonin is a chemical that makes us feel happy
Can you think of examples of SSRIs?
Citalopram
Fluoxetine
Sertraline
Can you think of examples of TCA’s?
Amitriptyline
Imipramine
Whats the first line treatment of depresion? Why?
SRRI’s
Due to their safety in overdose and better tolerability than TCA’s or MAOIs
What can happen when a patient first starts an SSRI?
May increase anxiety initially
Risk of suicide greatest in first 2 weeks of starting an antidepressant
What are the disadvantages of TCA’s when compared to SSRI’s?
TCA’s generally have more side effects than SSRI’s.
TCA’s are more toxic in overdose than SSRI’s- Risks of Cardiac toxicity and seizures if patients overdose on TCA’s.
How long should antidepressants be continued for after recovery?
Should continue for 6 months after recovery!
Note: Depression often reoccurs (i.e. the patient relapses)
Are antidepressants addictive?
NO!!
Just like medicines used for any long term condition like diabetes or asthma.
Just because a patient doesn’t feel as well when they don’t take them doesn’t mean they’re addictive; would be the same case with diabetic medication.
But antidepressants shouldn’t be stopped or changed suddenly
Why should antidepressants not be changed or stopped suddenly?
Discontinuation effects can occur.
but patients don’t exhibit drug seeking behaviour which shows antidepressants aren’t addictive!
What are the discontinuation effects seen if antidepressants are swapped or stopped all of a sudden?
Flu-like symptoms Insomnia Nausea Imbalance/ unsteadiness Sensory disturbance e.g. visual, electric shock sensations Anxiety or agitation
1/3 of patients will not respond to their first antidepressant.
What are our options if they don’t respond?
Try switching to another drug
Or augmenting (enhancing the effects) with another drug (e.g. Lithium or a recognised antidepressant combination)
Or Non-drug options such as Psychological intervention (CBT) or ECT (Electro convulsion therapy).
The rationale behind antipsychotics is blocking dopamine. But this can be complex and cause some of the side effects on these drugs.
Blocking some of the dopamine pathways in the CNS is therapeutic.
Blocking other pathways can cause side-effects such as Parkinsons like symptoms
ATYPICAL antipsychotics are meant to be more selective in the pathways they targets so less of the Extrapyramidal (EPSE) side effects seen with these!
Typical antipsychotics: What does Blockage of the MESOLYMBIC dopamine pathway cause?
Reduction of POSITIVE symptoms of schizophrenia
[Think Lymbic= Limbo= positive as its fun!]
(there is hyperactivity in the mesolymbic pathway in schizophrenia: causing positive symptoms: therefore we want to block this)
Typical antipsychotics: What does Blockage of the MESOCORTICAL dopamine pathway cause?
Blocking this pathway increases negative symptoms
So we don’t want to block this pathway
However if a patients symptoms are predominantly Positive: treatment with a Typical antipsychotic is fine.
Says this in BNF!
Typical antipsychotics: What does Blockage of the Nigrostriatal dopamine pathway cause?
Causes movement side effects
EPSE’s occur (all listed in BNF)
Typical antipsychotics: What does Blockage of the Tuberoinfundibular dopamine pathway cause?
Causes an increase in prolactin
This is bad as it can cause:
Amenorrhea (missed period)
Sexual dysfunction
What kind of side effects do TYPICAL antipsychotics predominantly cause?
EPSE's: Acute dystonias (e.g. grimacing) Akathisia (restlessness) Parkinsonism Tardive Dyskinesia (these are listed in BNF: but learn that these are normally caused by TYPICALS)
Prolactin increase: sexual dysfunction
What kind of side effects do ATYPICAL antipsychotics predominantly cause?
Weight Gain
Hyperglyceamia/ diabetes
Metabolic syndrome
Atypical vs Typical: its down to patient choice: same efficacy
Which side effects would patients prefer? A higher risk of movement disorders or a higher risk of metabolic disorders
Should we combine antipsychotics if one single one doesn’t work?
Guidelines say DO NOT combine antipsychotics
Also don’t argument (enhance effects) with Clozapine
Only combine if swapping antipsychotics; but make sure patient is taken off one!
How do we swap antipsychotics?
Decrease first drug and increase the other over a 6 week period to swap (cross-tapering)
but often one or the other isn’t completed and people end up on a combo by accident!
Treatment with an antipsychotic is an individual therapeutic trial for each patient. What should we monitor?
MONITOR SYMPTOMS
MONITOR ADVERSE EFFECTS
What side effects do both Typical and Atypical antipsychotics cause?
Anticholinergic side effects
Cardiovascular side effects
Sedation
Can you think of any examples of TYPICAL antipsychotics?
Chlorpromazine
Haloperidol
Flupentixol
Can you think of any Atypical antipsychotic examples?
Clozapine
Amisulpride
Quetiapine Olanzapine
What is Tardive Dyskinesia?
Uncontrolled movements of the face, tongue moving backwards, jaw movements, Grimacing.
Its one of the EPSE’s associated with taking typical antipsychotics
Its caused by over sensitising of dopamine pathways
Why is Clozapine (an atypical) said to have a dirty/rich pharmacology?
It has a very different receptor binding profile to the other antipsychotics
It hits loads of different receptors
It has extensive histamine and muscarinic block as well as 5HT2A and 5HT2C
Whats Clozapine known for?
Working where other antipsychotics have failed. Its a very effective antipsychotic.
But theres a problem with it:
It carries a serious risk of Blood disorders along with other serious side effects: its side effects can be disabling.
Thats why patients have to have a blood test each month before receiving next batch (you saw this at the Clozapine clinic at trafford!!)
It can be used but with these very strict monitoring conditions!
What does NICE recommend for people with newly diagnosed schizophrenia?
Offer oral antipsychotic in combination with psychological intervention.
The choice of antipsychotic should be made by the service user and HCP together
The likely benefits and side effects of each drug should be discussed
NICE recommends to start low and go slow when initiating antipsychotic treatment. What does this mean?
Give low doses at the start of treatment and slowly titrate upwards in accordance to BNF
How long should we trial a patient on an antipsychotic for?
The medication should be trialled at an optimal dose for 4-6 weeks.
As pharmacists we should look out for combinations of antipsychotics prescribed as this is not recommended.
Look out for Benzodiazepines (diazepam etc) and hypnotics: these can be addictive and should only be used short term if possible
