CNS: Mental Health Disorders Flashcards
What are some psychological symptoms of anxiety? (5)
Restlessness Worry Fear Difficulty concentrating Irritability
What are some physical symptoms of anxiety? (5)
Heart palpitations Shortness of breath Excessive sweating Insomnia Trembling/shaking
What two drugs are recommended for acute anxiety?
Benzodiazepines
Buspirone
What is the mechanism of action of busprione?
It is a 5HT-1A agonist
What can be given for the management of chronic anxiety (lasting > 4 weeks)?
Antidepressants; combined with a benzodiazepine if the antidepressant takes too long to produce an effect
What are the first-line drug classes for generalised anxiety disorder (GAD)?
SSRIs and SNRIs
What are some examples of SSRIs?
Sertraline Paroxetine Citalopram Escitalopram Fluoxetine
Which SSRI can be used for moderate to severe depression in children?
Fluoxetine (licensed in children aged 7 and up)
What can be used in GAD if first-line treatment options are ineffective/not tolerated?
Pregabalin
What is the first-line treatment for panic disorder?
SSRIs
What can be used for second-line treatment of panic disorder? (2)
Clomipramine
Imipramine
What drug class be used as first-line therapy for OCD, PTSD and social anxiety disorder?
SSRIs
What drug be used as second-line therapy for OCD?
Clomipramine
What drug be used as second-line therapy for social anxiety disorder?
Moclobemide
What is one of the main uses of benzodiazepines?
Short-term relief of severe anxiety that causes unacceptable distress
Which three benzodiazepines are short-acting?
Lorazepam
Oxazepam
Temazepam
What are some examples of long-acting benzodiazepines?
Clonazepam
Chlordiazepoxide
Diazepam
What is the mechanism of action of benzodiazepines?
Binds allosterically to GABA-A receptors, which enhances the effect of GABA → increased levels of Cl- into the neuron (inhibitory effect)
What is an important caution of all benzodiazepines?
Paradoxical increase in hostility and aggression
What are some side effects of benzodiazepine overdose? (6)
Drowsiness
Dysarthria (speech difficulties)
Ataxia (impaired coordination)
Nystagmus (uncontrollable movement of the eyes)
(Sometimes) respiratory depression and coma
What dispensary warning label should be present on all benzodiazepines?
“This medicine may make you sleepy. If this happens, do not drive or use tools or machines. Do not drink alcohol.”
Why should benzodiazepines only be used short term? (2)
Risk of tolerance and dependence
What should be offered to patients with GAD before drug treatment?
Psychological treatment
What are symptoms of benzodiazepine withdrawal?
Anxiety Insomnia Weight loss/loss of appetite Tremors Sweating Tinnitus
When can benzodiazepine withdrawal occur?
Within a day of stopping a short-acting benzodiazepine
Within 3 weeks of stopping a long-acting benzodiazepine
How should a benzodiazepine be withdrawn in patients who were using it long term? (3)
- Gradually (over 1 week) convert to equivalent dose of diazepam ON
- Reduce diazepam by 1-2 mg every 2-4 weeks
- Reduce further, then stop
What are some important benzodiazepine drug interactions? (2)
Increased sedation and and CNS depressant effects when taken with other sedatives e.g. alcohol, opioids, antihistamines, antidepressants, antipsychotics, barbiturates, Z-drugs
Increased plasma conc. when taken with CYP inhibitors e.g. amiodarone, diltiazem, macrolides, fluconazole
What risk is associated with short-acting benzodiazepines?
Greater risk of withdrawal symptoms
What two benzodiazepines are very occasionally used for the control of panic attacks?
IV diazepam and IV lorazepam
What is ADHD?
Attention Deficit Hyperactivity Disorder; characterised by hyperactivity, impulsivity and inattention
What is the first-line drug management for ADHD?
Methylphenidate or lisdexamfetamine
What is the second-line drug management for ADHD?
Atomoxetine
How long should ADHD medicines be trialed for before trying an alternative?
6 weeks
What is the mechanism of action of methylphenidate?
Dopamine and noradrenaline reuptake inhibitor
What are some side effects of methylphenidate? (4)
Loss in appetite/weight
Increased heart rate/blood pressure
Tourette’s syndrome
Growth restriction (in children)
What needs to be monitored in patients taking methylphenidate and lisdexamfetamine and atomoxetine? (6)
Pulse Blood pressure Height Weight Appetite Psychiatric symptoms
What is important to remember when dispensing methylphenidate?
Modified release preparations should be prescribed by brand
What is the mechanism of action of lisdexamfetamine?
Promotes the release of dopamine and noradrenaline from the presynaptic neuron
What are some side-effects of lisdexamfetamine? (4)
Loss in appetite; anorexia
Increased heart rate/blood pressure
Tourette’s syndrome
Growth restriction (in children)
What are some signs of a lisdexamfetamine overdose?
Wakefulness, hyperactivity and paranoia
followed by exhaustion, convulsions, hyperthermia and coma
What is the mechanism of action of atomoxetine?
Noradrenaline reuptake inhibitor
What are some side effects of atomoxetine? What should patients be made aware of?
QT prolongation (avoid other drugs that do this)
Suicidal ideation - patients should report any suicidal thoughts/self harm
Hepatotoxicity - patients should report signs of liver damage
What is bipolar disorder?
A long-term mental illness characterised by extreme depressed and elated moods
What are the two types of episodes experienced in bipolar?
Depression and mania
What is mania?
Abnormal and persistent [physical and mental] hyperactivity
What is hypomania?
A milder form of mania
What is the aim of antimanic treatment? (2)
To manage an acute episode
To prevent the reoccurrence of further episodes
When treating co-existing bipolar disorder, when should antidepressants be avoided? (3)
In patients with:
Rapid-cycling bipolar disorder
Recent history of mania/hypomania
Rapid mood fluctuations
What can be used to treat acute episodes of mania?
Antipsychotics, e.g. risperidone, olanzapine, quetiapine
What can be used in the initial stages of treatment of mania [for behavioural disturbance and agitation]?
Short-term benzodiazepines e.g. lorazepam
When treating acute manic episodes, what can be added to antipsychotics if the response is inadequate? (2)
Lithium or sodium valproate
What can be used for the initial treatment of severe, acute mania?
An antipsychotic AND lithium or valproate
What can be used long-term to prevent the reoccurrence of mania? (2)
Olanzapine, if a previous episode was responsive to it;
+/- lithium or sodium valproate if they have frequent relapses/severe impairment
What is asenapine?
A second-generation antipsychotic used for treatment of moderate to severe manic episodes
How long should the withdrawal period of antipsychotics be if the patient is taking other antimanics?
4 weeks
How long should the withdrawal period of antipsychotics be if the patient is NOT taking other antimanics?
3 months
What is carbamazepine licensed for in the management of bipolar disorder?
Preventing the reoccurrence of acute episodes in patients who are unresponsive to lithium therapy
When can valproate be used for the treatment of manic episodes associated with bipolar disorder? (2)
As monotherapy when lithium is contraindicated or not tolerated
As adjunct therapy when lithium alone is ineffective
What does the MHRA advise re: valproate in women?
It should not be used in women of childbearing potential, unless:
There are no alternative options
Conditions of the Pregnancy Prevention Programme are met
What can be changed if a patient on valproate for bipolar experiences frequent relapse or functional impairment? (2)
Lithium OR olanzapine can replace valproate as monotherapy; or can be added to the valproate
What can be added as adjunct therapy when increasing the dose of valproate is not sufficient in managing an acute manic episode?
An antipsychotic e.g. risperidone, olanzapine, quetiapine
How long might it take for the prophylactic effect of lithium to occur after initiating treatment?
6-12 months
What is lithium indicated for? (3)
Prophylaxis and treatment of bipolar disorder
Resistant depression
Aggressive/self-harming behaviour
What are some symptoms of depression? (6)
Apathy Low-self esteem Suicidal thoughts Low energy Changes in weight/appetite Insomnia
What drug class is first-line for treating depression?
SSRIs (selective serotonin reuptake inhibitors)
e.g. citalopram, escitalopram, fluoxetine, sertraline, paroxetine
Why are SSRIs favoured over other classes for the treatment of depression? (4)
Better tolerated
Safer in overdose
Which antidepressant is safe to use in patients with unstable angina or who have had a recent MI?
Sertraline
What are some examples of tricyclic antidepressants (TCAs)?
Amitriptyline Clomipramine Dosulepin Imipramine Lofepramine Nortriptyline
Why are TCAs less likely to be used to treat depression? (4)
More toxic in overdose More likely to be discontinued due to side-effects More sedating (than SSRIs) More antimuscarinic/cardiotoxic side-effects (than SSRIs)
Why are monoamine oxidase inhibitors (MAOIs) rarely used to treat depression?
They have many drug- and food-drug interactions
What is an example of a reversible MOAI?
Moclobemide (short-acting and does not require a washout period)
What is a washout period?
The length of time between stopping one drug and starting another one for the same indication; usually to make sure drugs with long half-lives are fully cleared from the body before initiating new treatment
How long do SSRIs take to work?
2 weeks
How should SSRIs be monitored for efficacy after initiating?
Review every 1-2 weeks after starting treatment
Wait at least 4 weeks (6 weeks in elderly) before deeming ineffective
How long should treatment of depression using SSRIs last?
At least 6 months (12 months in elderly)
How long should treatment of anxiety using SSRIs last?
At least 12 months (higher risk of relapse)
How long should treatment of recurrent depression using SSRIs last?
At least 2 years
What steps can be taken if a patient’s depression fails to respond to SSRI treatment? (2)
Increase dose; or
Switch to a new SSRI or mirtazapine
What second-line drugs are can be used if SSRIs are ineffective?
Lofepramine […]
