Management

Question 1

What are the questions that need to be asked with non-response to pharmacological treatment?

Answer 1

OH-/illicit drug use
Are they taking it
Taking it correctly
Reasonable length of time, reasonable dose

Question 2

What are the side effects of lithium?

Answer 2

Early: Dry mouth, metallic taste, N, polydipsia, fine tremor, polyuria, fatigue
Late: Diabetes insipidus, hypothyroid, arrhythmia, ataxia, weight gain, dysarthria

Question 3

What are the signs & symptoms of Lithium toxicity?

Answer 3

Li levels >1.5

Early: Blurred vision, anorexia, N&V, diarrhoea, coarse tremor, ataxia, dysarthria, muscle weakness, polyuria,
Late: Confusion, renal failure, fits, coma, death, arrhythmia

Question 4

What are the classes of antidepressants?

Answer 4

Monoamine re-uptake inhibitors
Receptor antagonists
Monoamine Oxidase Inhibitors

Question 5

What are the different types of monoamine re-uptake inhibitors?

Answer 5

Tricyclics: Amitriptyline
SSRIs: Citalopram, Fluoxetine
NorA re-uptake inhibitors: Reboxetine
SNRI: Venlafaxine
NorA & specific serotonin antidepressants: Mirtazapine

Question 6

What are common SE of SSRIs?

Answer 6

Headache
Weight gain
Drowsiness (take at night)
Nausea/ loss of appetite
Indigestion/diarrhoea/ constipation
Loss of libido/ erectile dysfunction
Dizziness/ dry mouth/ blurred vision/ sweatiness
Inc suicidal risk in first 2weeks of use

Question 7

Why are MAOIs rarely used?

Answer 7

Poor tolerability
Interactions
Diet restrictions: Breakdown tyramine in the gut found in cheese, redline, Bovril & can lead to hypertensive crisis

Question 8

What are the main SE which can occur with all antidepressants?

Answer 8

Suicidal ideas
Serotonin Syndrome
HypoN- SSRI worst

Question 9

How long should antidepressants be used for?

Answer 9

6-9m post-recovery
Multiple episodes consider for 2years
Use: 4-6weeks before considering changing drug

Question 10

What are the indications for prescribing Lithium?

Answer 10

Mood stabiliser-Treatment & prophylaxis of:
Mania
Recurrent depression
Bipolar
Aggressive/ Self-mutilating behaviour

Question 11

What are the baseline investigations that need to be done before starting Lithium?

Answer 11

Physical
Weight
Bloods: U&E, TFT, Ca, FBC
ECG
Pregnancy test

Question 12

What monitoring needs to be done for a patient on Lithium?

Answer 12

Lithium levels:
12hours after initial dose
7-10days initially then 3m when stable
Every 6m: Bloods: U&E, TFT, Ca, Weight, ECG

Question 13

What are the causes of Lithium toxicity?

Answer 13

Drugs: NSAIDs, Diuretics, ACEi
Renal failure
UTI
Dehydration

Question 14

How is Lithium toxicity managed?

Answer 14

STOP Li!
IV fluids
Start diuresis/dialysis

Question 15

What are classed as low & high intensity interventions?

Answer 15

Low: Advice, CBT based self-help
High: CBT, IPT, Behavioural activation, couples therapy

Question 16

What are the SE of Mirtazapine?

Answer 16

Sedative

Weight gain

Question 17

What needs to be checked when starting an SNRI?

Answer 17

Check BP
ECG
Contraindicated: CV issues

Question 18

What combination of antidepressants should NOT be taken together? Why?

Answer 18

SSRI + TCA/MAOI

Causes: Serotonin Syndrome

Question 19

What are the effects of antipsychotics (depending on receptor type)?

Answer 19

Anticholinergic: Dry mouth, blurred vision, constipation, urinary retention
Antiadrenergic: Postural hypoT, Sexual dysfunction
Antihistamine: Sedation, anti-emetic

Question 20

What investigations need to be done before starting an antipsychotic?

Answer 20

Bloods: FBC, U&E, LFT, RBS/HbA1c, Lipids & Cholesterol, Prolactin
Weight
BP & Pulse
ECG (Prolonged QTc which can lead to Torsade des Pointes)

Question 21

What are the SE of antipsychotics?

When do they occur?

Answer 21

1st gen: NEURO/MOTOR SE
D2 antagonists
Tardive dyskinesia, Tx= gradual dose reduction, benzos, tetrabenazine
Parkinsonism, Tx= anticholinergics (Procyclidine)
Acute dystonia, occur within 72hrs of Tx
Akathisia, occurs within 60d of Tx, Mx= Beta blockers & benzos
2nd gen: METABOLIC SE
5HT/D2 antagonists
Hyperglycaemia
Weight gain
Dyslipidaemia

Question 22

When should Clozapine be offered in Schizophrenia?

Answer 22

Illness not responded to Tx despite use of adequate doses of >2 different drugs
>1 drug should be a non-clozapine 2nd gen
Acts on D2 & D4 receptors & subtypes of serotonin receptor

Question 23

What are the SE of Clozapine?

Answer 23

Agranulocytosis (REGULAR FBC)
Weight gain
Salivation
Sedation
Myocarditis
Paralytic ileus
Lower seizure threshold

Question 24

What drugs have an effect on the 5HT neurotransmitter?

Answer 24

LSD (hallucinations)

Clozapine

Question 25

What drugs have an effect on the Glutamate neurotransmitter?

Answer 25

Phencyclidine

Question 26

What are the risks of antipsychotic use in older people?

Answer 26

``` Inc stroke risk Inc CV risk Parkinsonian SE Falls Additional deaths ```

Question 27

What are the SE of antipsychotics related to increased Prolactin?

Answer 27

``` Asymptomatic Amenorrhoea Galactorrhoea Gynaecomastia Impotence Weight gain Osteoporosis ```

Question 28

What are the EPSE of antipsychotics?

Answer 28

Acute: Parkinsonism: rigidity, bradykinesia, tremor Acute dystonia: Trismus, tongue protrusion, spasmodic tortocollis, opisthotonus, oculogyric crisis, grimacing Akathisia: restlessness, restless leg syndrome Chronic: Tardive dyskinesia: Chewing, sucking, grimacing, darting tongue Choreoathetoid movements

Question 29

What should be done when starting/stopping someone on SSRIs?

Answer 29

Start: Initiate then review at 2weeks If <30yo or suicide risk review at 1week Stop: Reduce tablets over 4weeks unless Fluoxetine

Question 30

What are the contraindications of Lithium?

Answer 30

Addison's Cardiac insufficiency Fhx/Phx: Brugada syndrome

Question 31

What drugs can interact with Lithium?

Answer 31

``` Diuretics: Amiodarone, Bendroflumethiazide ACEi NSAIDs: Ibuprofen, Diclofenac Carbamazepine Chlorpromazine, Citalopram, Clopamide Macrolides ```

Question 32

What is the mechanism of action of Lithium?

Answer 32

Widely distributed in the CNS Interacts with a number of neurotransmitters and receptors Decreasing norE release and inc serotonin synthesis

Question 33

What is the mechanism of action for SSRIs?

Answer 33

Selectively inhibiting the re-uptake of serotonin at 5HT receptors.

Question 34

What are the indications for SSRIs?

Answer 34

``` Depression Bulimia (Fluoxetine only) OCD Panic PTSD (Sertraline) ```

Question 35

What are the contraindications of SSRIs?

Answer 35

Poorly controlled epilepsy | Mania/manic phase

Question 36

What drugs do SSRIs interact with?

Answer 36

``` Diuretics Chlorpromazine Macrolides Haloperidol, Risperidone Lithium ```