Lecture 11: Patient safety in mental health Flashcards
How do treat acute depression?
- Discuss the choice of drug with the patient; include - potential therapeutic effects, possible adverse effects, likelihood of discontinuation, likely time to respond - suggest SSRI as first choice, mirtazapine if sedation is required
- Start antidepressant - Titrate to recognise theapeutic dose. Assess efficacy after 2 weeks
- If no effect - assess weekly for a further 1-2 weeks, if still no response consider increasing dose. If still no effect then switch to a different antidepressant - titrate to therapeutic dose. Assess over 3-4 weeks. Increase dose if necessary. If no effect again, consider third choice options - mirtazapine, vortioxetine, agomelatine. If no effect, refer to suggested treatments for refractory depression.
- If the antidepressant is effective, continue for 6-9 months at full treatment dose. Consider longer term treatment
- If the antidepressant is poorly tolerated, switch to a different antidepressant. Titrate to therapeutic dose. Assess efficacy after 3-4 weeks
What is the treatment for treatment resistant depression?
Lack of response to current antidepressant - known as pseudo TRD. Eg hypothyroidism, nonadherance, ‘latent’ bipolarity
If true TRD, and no improvement at all or intolarable adverse effects, then switch to another antidepressant drug of the same class or another class. If partial and unsatisfying improvement - augmentation strategies eg other antidepressants, lithium, atypical antipsychotic or combination with pscychotherapy CBT.
If still partial or unsatisfying improvement and nonresponse to 2/3 adequate antidepressant trials then try neurostimulation eg rTMS or ECT, antidepressants with innoactice mechanism of action
What are the safety issues in antidepressant use?
- Switching/ cross titration - occurs when no response seen or intolerable side effects. Consult specialised literature for potential switching regimes
- Discontinuation (withdrawal) effects - electric shocks, flu like symptoms, disturbed sleep, GI issues, ataxia/ sensory vasomotor
- Serotonin syndrome - likely during augmentation, or when treating resistant depression. It ranges in severity and presentation. Symptoms include; Neuromuscular hyperactivity/ abnormality (tremor, clonus, rigidity). Autonomic dysfunction/ instability (tachycardia, hyperthermia, cold sweats)
Altered mental state (agitation, confusion) - Poly pharmacy - more morbidity, more side effects, potential for CYP interactions ie 2D5
- Co morbidities - at the receptor level (psychoropic response) different organs (kinetics- e.g Na+ excretion)
- Children & adolescents - increase in self harm/ suicidal thoughts/ aggression
What are the factors assosicated with high risk of SSRI/ SNRI withdrawal symptoms?
- Short half life drug (paroxetine, venlafaxine)
- Anticholinergic effects of the drug
- Drug has no active metabolites (paroxetine)
- Exposure to the drug >1 year
- Rapid tapering (<1-2 months) or sudden discontinuation of antidepressant
What are the safety issues with lithium?
Lithium is very effective in the maintenance treatment of bipolar effective disorder, recurrent depression and self injurious behaviour.
Most people receiving lithium are in the community
Lithium has a narrow therapeutic index, with a high potential for toxicity and therefore careful monitoring is required for safe use. Consequently, if lithium treatment is not managed properly there is a potential risk of significant harm.
Need to monitor frequency and plasma levels and pregancy (teratogenicity)
What are the safety issues in antipsychotic use?
- Metabolic syndrome: diabetes, dyslipidaemia
- Thromboembolism
- Myocarditis and cardiomyopathy
- QTC elongation - arrythmias, sudden death esp at high doses
- Higher risk of seizures
- Neuroleptic malignant syndrome (muscel rigidity and rapid rise of body temperature and confusion) Usually reversible but death from renal or cardiovascular failure can happen in 10-20% of cases
- Clozapine - propensity for leukopenia/ agranulocytosis
What are life style / health promotion advice?
- Need to be especially pro active in people taking SGAs - you need to actively enagage when dispensing APs
- Tailor your advice - make it relevant/ realistic
- Sign post to appropriate servives - advocacy , housing, social work
- Substance use: consider role/impact of this. Don’t automatically try to stop/prohibit.
What is High Dose Antipsychotic Therapy (HDAT)?
High Dose Antipsychotic Therapy (HDAT) is defined by the Royal College of Psychiatrists as either: a total daily dose of a single antipsychotic which exceeds the upper limit stated in the BNF or A total daily dose of two or more antipsychotics which exceeds the BNF maximum as calculated by percentage.
When / why does HDAT happen?
Acute psychotic episode (switching)
Relapse prevention / poor concordance (oral + depot)
Acute disturbance / emergency tranquillisation (PRN use oral or IM)
Treatment resistance / refractory (augmentation)
What are the monitoring parameters for antipsychotics?
BASELINE TESTS AND EVERY 3 MONTHS
- ECG
- Pulse / Heart rate
- Blood Pressure
- Temperature
- FBC
- LFTs
- U&Es also Ca, Mg – electrolytes associated with homeostasis
Discuss clozapine?
Up to 60% success in those who have failed to respond to other antipsychotics
Possibility of developing serious side effects - agranulocytosis, neutropenia
Co ordinated clozapine central monitoring system
Patient must have a valid blood resuly before supply. If no blood then no drug
What are the dispensing arrangements for clozapine?
Regular monitoring of WBC, especially neutrophils
Neutropjil count coded green, amber and red
Medication is supplied when result is green ie neutrophil count > 2x10*9/ L
0-18 weeks = weekly bloods
Next 18 weeks - fortnightly bloods
Thereafter ie duration of treatment - monthly
Gradual titration of dose starting from 25mg daily up to 900mg (max), however, break in treatment of >48hours, MUST re-titrate from starting dose i.e 25mg.
What are clozapine specific safety issues?
- Red or amber result
- Management of leukopenia/ agranulocytosis
- Missed doses > 48 hours
- CYP induction / inhibition
- Co-prescribing esp with neutropenic drugs eg carbamzapine
- One stop dispensing
- Other medicines via GP10 Rx or depot (different supply routes)
What drugs cause dependence/ tolerance?
Mostly drugs which act on dopamine, noradrenaline/ GABA receptors or transmitters ie the pleasurable pathways eg benzos, opiods
Long term/ repeat prescriptions - consider the need and impact on patient
Need to withdraw gradually to prevent rebound at cellular level and to avoid relapse at behavioural level
Discuss benzodiazapine dependance/ tolerance
Shorter acting benzodiazapenes tend to be more problematic
To withdraw or stop - need to convert current benzodiazapine dose to diazapam dose equivalemt
Gradual reduction by 1/8th or 1/6th of total daily dose every fortnight - over 6 months
