Ix/Mx Psych Conditions Flashcards
Ix - What initial investigations would you do for a patient presenting presenting with symptoms of depression?
”- Clinical history
- Rule out other psychiatirc disorders and organic causes for depression with a systems review
- Suicide Risk assessment and monitoring should be carried out on all patients
- Diagnostic questionnaires - not mandatory but allow formal assessment of severity
- PHQ-9, HADS and Beck’s depression inventory “
Ix What other investigations aside could you do to exclude other causes of depression?
“1) Blood Tests
- FBC – Rule out Anaemia
- Thyroid Function Tests – Rule out Thyroid disease
- U&Es, LFTs & Calcium – Rule out Metabolic disturbances which can cause mood disturbances e.g. Hypercalcemia
2) Imaging
- Will very rarely be done
- Where you suspect intracranial cause with rapid personality change & unexplained headache
- CT or MRI should be first choice”
Mx - What is the management of mild-moderate depression?
“1) Watchful waiting - consider this and reassess patient in 2 weeks
2) Antidepressants (NOT FIRST LINE) - Unless depression has lasted a long time, past Hx of moderate-severe depression, failure of other interventions
3) Self-help programmes - IPT, Behavioural activation, Counselling, Psychodynamic therapy
4) Computerised Cognitive Behavioural Therapy - educating patients about depression and challenging negative thoughts “
Mx - What is the management of moderate-severe depression?
“1) Psychiatry referral - indicated if suicide risk is high, depression severe, recurrent depression, unresponsive to initial treatment
2) Antidepressants (First Line) - SSRIs (citalopram, Fluoxetine, Sertraline), TCAs, SNRIs, MAO Inhibitors (Specialist only)
3) Adjuvants - above medication can be augmented with lithium or antipsychotics
4) Psychotherapy - CBT, IPT
5) Social support
6) Electroconvulsive therapy (ECT) - Indications:
- acute treatment of severe depression which is life-threatening
- rapid response required
- depression with psychotic features
- severe psychomotor retardation or stupor
- failure of other treatments.”
Ix - What investigations could you do to assess if someone has BPAD?
”- Based of clinical history (screen for mood - previously and now - esp if they are depressed currently)
- Self-rating scales e.g. Mood Disorder Questionnaire
- Blood Tests (Similar to depression)
- FBC - Routine
- Thyroid function Tests - Thyroid dysfunction can mimic manic states
- U&Es - Baseline renal function before Lithium therapy
- LFTs - Baseline hepatic function before starting mood stabilizers.
- Glucose & Calcium - Biochemical disturbances can mimic mood symptoms.
- Urine drug tests
- Illicit drugs can cause mania
- Pregnancy test
- ECG
- CT head
- Rule out a space occupying lesion causing mania like symptoms e.g. Disinhibition”
Mx - What 3 things must you do when you suspect someone has BPAD? (As a GP or Junior Doctor)
“1) Refer all patients for a specialist mental health assessment
2) Full risk assessment
- Assess risk of suicide
- Assess suicidal ideation – do you ever think about suicide
- Assess suicidal intent
3) Mental Health Act Implementation
- May be required if:
- Risky behaviour causing harm to patient or others
- Significant psychotic component
- Impaired judgement
- Severe psychomotor agitation”
“Mx - What is the pharmacological management of a patient with:
1) Acute manic/mixed episode
2) Bipolar depressive episode
3) Long-term management of BPAD.
3b) What must we do before and during offering this treatment? What are the side effects?”
“1) Acute manic/mixed episode
- 1st Line - Offer oral anti-psychotic
- Olanzapine, risperidone, quetiapine, haloperidol
- 2nd Line - Second antipsychotic offered
- 3rd Line - Mood stabilizers
- Lithium added or if not suitable, sodium valporate
- Additionally - if patient is receiving inadequate sleep - Benzodiazepine added
2) Bipolar depressive episode (Avoid anti-depressants)
- 1st - Atypical anti-psychotics offered
- Olanzapine alone
- Olanzapine + Fluoxetine (SSRI)
- Quetiapine alone
- 2nd - Mood Stabilisers - lamotrigine or lithium
3) Long-term management of BPAD
- 4 weeks after an acute episode has resolved
- 1st Line - Lithium - to prevent relapses
- Lithium ineffective - sodium valproate may be added
- Alternatively - olanzapine/quetiapine
3b) Lithium - TFTs, U&Es and baseline ECG (need to be checked once stable every 3 months)
Lithium has a narrow therapeutic window with renal excretion and can become toxic if not monitored
Side effects - polydipsia, polyuria, fine tremor, weight gain, oedema, hypothyroidism, Impaired renal function, memory problems and teratogenicity (1st trimester - so avoided here)”
Mx - What is the management when antipsychotic drugs have been ineffective and the patient has severe uncontrolled mania?
“ECT (not first line)
Also used when time of intervention is an issue “
Mx - What psychological and social management options can be offered to a patient with BPAD?
“1) Psychological
- CBT for bipolar depression
- IPT – inter-personal psychotherapy
- Mindfulness
- Psychoeducation – about illness, relapse signatures, medication
- Social support, self-help groups and calming activities may be of benefit
- These are not good for treating manic episodes
- Still helpful tools after manic episodes
- Family intervention
2) Social Interventions (Aid with several factors)
- Family
- Housing
- Finance
- Employment
- General coping strategies – importance of regular structured activities”
Ix - Investigations for Schizophrenia?
“1) Blood Tests
- FBC – Anaemia, infection & assessing FBC when on Antipsychotics
- TFTs – Rule out thyroid dysfunction
- Glucose or HbA1c
- 2nd Generation antipsychotics cause metabolic syndrome
- Serum calcium – Calcium disorders can cause psychosis
- U&Es & LFTs – Assessing renal and liver function before prescription
- Cholesterol – 2nd Generation antipsychotics cause metabolic syndrome
- Vitamin B12 & Folate – Deficiencies can cause psychosis
2) Urine Drug Test - Illicit drug use can cause psychosis
3) ECG - Antipsychotics can prolong QT interval
4) CT scan - Rule out SOL as cause of Psychosis
5) EEG - Temporal lobe epilepsy can mimic psychosis (Auditory hallucinations)”
Mx - Management for Schizophrenia?
“1) At risk or first episode (exclude organic causes)
- Think about where this patient should be safely managed - depends on risk and insight
- Risk and no insight - admit
- Risk assessment & Implementation of MHA 1983 if required
- Assess risk of suicide
- Risk of unintentional harm to themselves
- Risk of harm to others
- High Risk - Same day specialist mental health assessment - may need compulsory admission
- Low Risk - Refer to Early intervention in Psychosis Team (N-step)
2) Biological, Psychological & Social Mx
- Biological
- 1st Line - Atypical antipsychotics considered
- Respiridone & Olanzapine
- Consider Depot formulations (Injections - slow release) if patient preference or non-compliance
- Treatment resistant schizophrenia - use Clozapine
- Titrate to maximum effective dose and adjust dose according to response/tolerability
- Assess over 2-3 weeks
- If effective continue at established dose if not effective, consider changing drug
- Adjuvants
- Benzodiazepines - provide short-term relief of behavioural distrubance, insomnia, aggression and agitation
- Antidepressants/Lithium can be used to augment antipsychotics
- ECT - Use in patients who are resistant to pharmacological treatments (effective for catatonic schizophrenia)
- Pschological
- CBT
- Strongly recommended by NICE - reduces residual symptoms
- Family intervention
- Family psychoeducation reduces relapse rates
- Art therapy
- NICE recommends art therapy for alleviating negative symptoms in young patients.
- Social skill training
- Uses behavioural approach to improve interpersonal, self-care and coping skills needed in everyday life
- Social
- Support groups & peer groups - Rethink/SANE
- Supported employment programmes
- Recommended by NICE for Schizophrenic patients returning to work”
“What are the side-effects of Clozapine?
”- Associated with:
- Agranulocytosis (1%)
- Neutropenia (3%)
- Reduced seizure threshold (3%)
- Should carefully monitor patients on this
- Routine FBC essential”
Panic DIsorder - Investigations?
”- Psychiatric history
- Mental Status Examination
- Risk assessment (to patients self and others/at home)
1) Blood Tests
- FBC - Anaemia
- TFT - Thyroid dysfunction
- Blood glucose - Hypoglycaemia
2) Urine
- Illicit drug screen
- Urine Metanephrines (Phaechromocytoma)
3) ECG “
What is the Stepwise approach in the Management of Panic Disorder?
”- NICE - Stepwise approach to treatment is recommended
1) Step 1:
- Recognition and diagnosis
- Identify any co-morbidities (Depression or Substance misuse)
2) Step 2:
- Treatment in primary care
- NICE recommend either CBT or drug treatment
- 1st line
- SSRIs
- If contraindicated or no response after 12 weeks, then a TCA (imipramine or clomipramine) should be offered (NO BENZOS)
- Self-help methods such as books, support groups and promoting exercise also help
3) Step 3:
- Review and consideration of alternative treatments
4) Step 4:
- Review and referral to specialist mental health services
5) Step 5:
- Care in specialist mental health services”
Agoraphobia, Social & Specific - Management?
“• Advise avoidance of anxiety inducing substance ie caffeine
• Screen for significant co-morbidities such as substance misuse and personality disorders
1) Agoraphobia - CBT including graduated exposure and deseensitization, SSRIs - 1st Line
2) Social Phobia - CBT (Incl. graduated exposure), Pharm - SSRI, SNRI, MAOI(if no effect), Psychodynamic therapy (if decline both)
3) Specific Phobia - Exposure - self-help or CBT, Benzos in short term “
Mx - What is the bio-psychosocial management of PD?
