Management Flashcards
What should you educate people about in panic disorder?
CBT is 1st line treatment - what particular technique?
Which anti-depressants are evidence based?
Caffeine!
Eseoteric exposure - e.g. hyperventilate then relax
SSRI and TCA only
Anorexia Nervosa Psychoeducate on? Out patient management is better, inpatient needed when? Weight gain tips... What's better CBT-E or SSRI?
Psychoed - high mortality rate, need to maintain safety. Laxatives - wean them.
Inpatient - BMI <14, rapid weightloss, physical obs (BP, postural, hypothermia, bradycardia/tachycardia), ECG, bloods - electrolytes, FBC, glucose
Weight gain: Dietician, multivitamins, reflex hypoglycaemia. 0.5-1kg per week
CBT-E (6-12 months), limited evidence for SSRI. Depression and OCD can get better with weight.
Bulaemia nervosa
Physically
Treatment = self help. Are SSRIs any good?
If above not working…?
Physically Look for same complications as AN
SSRIs help binging and purging, but long term?
Not working - offer CBT-E
Mania
College vs. NICE
College states Li, Valp and Carb are level 1 evidenced. Olanz > valp at RCT level.
NICE say antipsychotic - haloperidol, risperidone, olanzapine, quetiapine
Valporate is good for mixed episodes. How strong is the evidence?
Any other agents got evidence in mixed?
A post hoc analysis of Li vs valproate.
Olanzapine has level 2 evidence.
If mania not responding
? compliance
? drug/alcohol
Combine mood stabiliser or augment with anti-psychotic
If sure of diagnosis consider ECT
Bipolar depression - not currently on treatment
What does RANZCP recommend?
Is carbemazepine good for depression?
How about NICE?
College says start a mood stabiliser - Li, valproate, lamotrigene
NOT carbamazepine
NICE state fluoxetine and olanzapine, then quetiapine, then lamotrigene or olanzapine alone
BPAD not responding to 1st line treatment
College says make sure Li has been trialled, 2MS and an antidepressant.
?diagnosis, ? thyroid, Ca levels –> ECT
Is CBT any good in BPAD depression?
Yes - STEP-BD showed more people recovered and faster with CBT added. SSRI’s did not confer any advantage over placebo.
NICE say offer CBT
Bipolar depression currently on treatment
What does RANZCP recommend?
What about NICE
RANZCP - optimise mood stabiliser, add a 2nd mood stabiliser
NICE - Optimise Li / valp. Add olanz + fluoxetine, seroquel, or olanzapine alone. If augmentation not helped –> use lamotrigene and stop the other augmenting agents
SSRIs and SNRIs are used in Bipolar depression. What about the other classes?
RANZCP says avoid the others - they can destabilise the illness. Stop SSRI/SNRI 2-3months once well and just continue the mood stabiliser.
Long term maintenance of BPAD
Psychology?
Medication - RANZCP vs NICE
CBT decreases relapse - identify distortions that patient has about self secondary to illness
Medication - Li is the gold standard has MA and Cochrane review.
College says Li and carb only evidence based.
NICE says valproate, olanzapine, or seroquel if it was useful in acute phase
Is there any evidence for supported employment programs in BPAD?
NICE say offer them
What about rapid cycling BPAD drugs?
Rapid cycling = >4 episodes a year
Valproate - open label trial, Li&valp in case series
Major depressive disorder RANZCP college guidelines state:
Start with SSRI or CBT/IPT = level 1
If it’s a severe depression use a TCA / venlafaxine = level 1
If that doesn’t work…
Add in psychology / SSRI = (STARD)
Switch SSRI to venlafaxine (STARD)
… still not working…
NICE say you can switch to TCA, MAOI augment with olanzapine / seroquel / AVANZA
… still not working…
?drug / alcohol ? diagnosis ?organic ?ECT
How long do you treat depression for?
Single episode 6 months, recurrence or high risk relapse
What about TMS for depression?
NICE say it’s of uncertain efficacy. Reserve for trials
PTSD guidelines - published by…?
Heavily advocate for what types of psychotherapy?
Is there a role for SSRI?
Should I treat depression straight up?
Should I treat drug / alcohol problems straight up?
The Australian Centre for Post Traumatic Mental Health
EMDR or TF-CBT - imaginal vs. in-vivo exposure
If trauma therapy not working add SSRI
- if it doesn’t work try another SSRI then augment with AP
- if meds help continue for at least 12 months
Treat depression if it’s risky, otherwise it might get better with psychology
Treat drug/alcohol co-morbidities at the same time as giving trauma therapy
What is treatment resistant schizophrenia?
Why might it be treatment resistant?
What should we offer treatment resistant illness?
Failure to respond to 2 adequate (6 week) trials of antipsychotic medication, one of which was an atypical. If not compliant = depot
Drugs, compliance, depression, side effects - EPSEs
Offer clozapine and CBT
If you don’t respond to clozapine NICE say add another anti-psychotic.
OCD
What is 1st line treatment
What if 1st line don’t work?
Anything you should teach the family?
NICE say offer CBT - with exposure and response prevention or SSRI they are equally effective.
If it doesn’t work add an SSRI - high dose fluoxetine
If that doesn’t work try climipramine (Anafril)
Psych education for family = don’t reinforce the behaviour
Dementia
What type of scan should I do?
Which types of dementia should I treat with AChEi?
NICE says MRI - picks up microvascular changes
Offer AChEi to mild / moderate Alzheimers (e.g. 10 to 20 on MMSE). Don’t give it to anyone else for cognitive Sx
What nice non-medical things can you do for people with BPSD (NICE recommends it!)
NICE recommends anti-psychotics only if risky or severe BPSD, why?
Can I use AChEi to treat BPSD?
Music therapy, aromatherapy, massage, pet therapy
They increase the risk of strokes / death
Use of AChEi in Alzheimers - yes if BPSD hasn’t responded to anti-psychotic. In DLB - yes regardless of response to anti-psychotic
When can I prescribe memantine (NICE)
How does it work?
In mild / moderate Alzheimers where AChEi not tolerated, or severe Alzheimers.
It’s an NDMA antagonist
What did the CATIE study teach us?
2nd gen: Olanz, risp, quetiapine, ziprazidone vs 1st gen: perphenazine
olanzapine had longest time to discontinuation. Risperidone was best tolerated. 1st gen wasn’t inferior and didn’t cause more EPSEs
In phase 2 clozapine was the best vs olanzapine, quetiapine, risperidone
