Management

Question 1

What should you educate people about in panic disorder?
CBT is 1st line treatment - what particular technique?
Which anti-depressants are evidence based?

Answer 1

Caffeine!
Eseoteric exposure - e.g. hyperventilate then relax
SSRI and TCA only

Question 2

Anorexia Nervosa
Psychoeducate on?
Out patient management is better, inpatient needed when?
Weight gain tips...
What's better CBT-E or SSRI?

Answer 2

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.

Question 3

Bulaemia nervosa
Physically
Treatment = self help. Are SSRIs any good?
If above not working…?

Answer 3

Physically Look for same complications as AN
SSRIs help binging and purging, but long term?
Not working - offer CBT-E

Question 4

Mania

College vs. NICE

Answer 4

College states Li, Valp and Carb are level 1 evidenced. Olanz > valp at RCT level.

NICE say antipsychotic - haloperidol, risperidone, olanzapine, quetiapine

Question 5

Valporate is good for mixed episodes. How strong is the evidence?
Any other agents got evidence in mixed?

Answer 5

A post hoc analysis of Li vs valproate.

Olanzapine has level 2 evidence.

Question 6

If mania not responding

Answer 6

? compliance
? drug/alcohol
Combine mood stabiliser or augment with anti-psychotic
If sure of diagnosis consider ECT

Question 7

Bipolar depression - not currently on treatment
What does RANZCP recommend?
Is carbemazepine good for depression?
How about NICE?

Answer 7

College says start a mood stabiliser - Li, valproate, lamotrigene
NOT carbamazepine
NICE state fluoxetine and olanzapine, then quetiapine, then lamotrigene or olanzapine alone

Question 8

BPAD not responding to 1st line treatment

Answer 8

College says make sure Li has been trialled, 2MS and an antidepressant.
?diagnosis, ? thyroid, Ca levels –> ECT

Question 9

Is CBT any good in BPAD depression?

Answer 9

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

Question 10

Bipolar depression currently on treatment
What does RANZCP recommend?
What about NICE

Answer 10

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

Question 11

SSRIs and SNRIs are used in Bipolar depression. What about the other classes?

Answer 11

RANZCP says avoid the others - they can destabilise the illness. Stop SSRI/SNRI 2-3months once well and just continue the mood stabiliser.

Question 12

Long term maintenance of BPAD
Psychology?
Medication - RANZCP vs NICE

Answer 12

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

Question 13

Is there any evidence for supported employment programs in BPAD?

Answer 13

NICE say offer them

Question 14

What about rapid cycling BPAD drugs?

Answer 14

Rapid cycling = >4 episodes a year

Valproate - open label trial, Li&valp in case series

Question 15

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…

Answer 15

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

Question 16

How long do you treat depression for?

Answer 16

Single episode 6 months, recurrence or high risk relapse

Question 17

What about TMS for depression?

Answer 17

NICE say it’s of uncertain efficacy. Reserve for trials

Question 18

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?

Answer 18

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

Question 19

What is treatment resistant schizophrenia?
Why might it be treatment resistant?
What should we offer treatment resistant illness?

Answer 19

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.

Question 20

OCD
What is 1st line treatment
What if 1st line don’t work?

Anything you should teach the family?

Answer 20

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

Question 21

Dementia
What type of scan should I do?
Which types of dementia should I treat with AChEi?

Answer 21

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

Question 22

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?

Answer 22

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

Question 23

When can I prescribe memantine (NICE)

How does it work?

Answer 23

In mild / moderate Alzheimers where AChEi not tolerated, or severe Alzheimers.

It’s an NDMA antagonist

Question 24

What did the CATIE study teach us?

Answer 24

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