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Psychiatry > Management > Flashcards

Management Flashcards

1
Q

What is IAPT?

A

Improving access to psychological therapies - initiative to increase evidence based treatments for anxiety and depression by primary care organisations

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2
Q

What is CBT?

A

Treatment based on idea that disorder isnt based on life events but how these are viewed - short term therapy - focussed on here and now - to help with symptom relief

Challenges automatic and negative thoughts

Can be individual / groups / self-help via books or computer

8-12 sessions

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3
Q

Give some examples of behavioural therapies?

A

Relaxation training

Systemic desensitization

Flooding

Exposure and response prevention

Behavioural activation

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4
Q

What are behavioural therapies based on?

A

Operant conditioning - behaviour is reinforced if it has positive consequences for the individual, and prevents negative consequences

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5
Q

What is relaxation training ?

A

Use techniques to cause muscle relaxation during times of stress or anxiety

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6
Q

What is systemic desensitization?

A

For phobic anxiety disorders - individual is greatly exposed to a hierarchy of anxiety-producing situations

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7
Q

What is flooding therapy?

A

Patient is rapidly exposed to phobic object without any attempt to reduce anxiety beforehand (unlike systemic desensitization) - continuing exposure until anxiety diminishes - not commonly used

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8
Q

What is exposure and response prevention?

A

Used in OCD - exposed to situations which cause them anxiety and prevented from performing compulsive action

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9
Q

What is behavioural activation?

A

Patients avoid doing certain things as they feel they will not enjoy them or fear of failure in completing them - instead make realistic plans to carry out enjoyable activites - used in depressive illness

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10
Q

When is psychodynamic therapy used?

A

Dissociative disorders, psychosexual disorders, PDs, chronic dysthymia, recurrent depression

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11
Q

What is psychodynamic therapy based on?

A

Childhood experiences, past relationships and unresolved conflicts influence someones current situation

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12
Q

How does psychodynamic therapy work?

A

Unconcious is explored using free association - client says whatever comes to their mind and this is interpreted.

Conflicts and defences are explored - client develops insight to change

1-5 sessions per week for up to years

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13
Q

What is psychoeducation?

A

Delivery of information to people in order to help them understand and cope with their mental illness

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14
Q

What is counselling?

A

Less technically complicated than other therapies - done by active dialogue between counsellor and client

Can be sympathetic listening or active advice on problem solving

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15
Q

What is supportive psychotherapy?

A

Psychological support given by mental health professionals to patients with chronic and disabling mental illnesses - active listening, providing reassurance, explaining illness, providing guidance to difficulties

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16
Q

What is problem solving therapy?

A

Mix of counselling and CBT for mild anxiety and depressive disorders

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17
Q

What is interpersonal therapy?

A

Used to treat depression and eating disorders - focus on interpersonal problems - bereavement, relationship difficulties, interpersonal deficit

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18
Q

What is eye movement desensitization and reprocessing?

A

For PTSD

Client recalls emotionally traumatic materia whilst focusing on external stimulus (e.g. following a moving finger)

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19
Q

What is dialectical behavioural therapy?

A
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20
Q

Which therapies are recommended for:

Adverse life events

Depression

PTSD

Schizophrenia

Eating disorders

Anxiety disorders

Substance misuse

Borderline personality disorder?

A
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21
Q

What are antidepressants used for?

A
  • Moderate to severe depressive episodes
  • Anxiety / panic attacks
  • OCD
  • Chronic pain
  • Eating disorders
  • PTSD
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22
Q

Give some examples of SSRIs

A

Citalopram

Escitalopram

Fluoxetine

Paroxetine

Sertraline

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23
Q

What SSRI is given for panic disorder?

A

Citalopram

Escitalopram

Paroxetine

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24
Q

What SSRI is given for social phobia?

A

Escitalopram

Paroxetine

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25
Q

What SSRI is given for bulimia nervosa?

A

Fluoxetine

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26
Q

What SSRI is given for OCD?

A

Most

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27
Q

What SSRI is given for PTSD?

A

Paroxetine and sertraline

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28
Q

What SSRI is given for GAD?

A

Paroxetine

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29
Q

How do SSRIs work?

A

Increase the concentration of serotonin in the synaptic cleft by inhibiting reuptake from the synaptic cleft into pre-synaptic neurones

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30
Q

What are the side effects of SSRIs?

A

Nausea

Dyspepsia

Bloating

flatulence

Diarrhoea / constipation

Sweating

Tremors

Rashes

Sexual dysfunction

Somnolence

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31
Q

What are the symptoms of SSRI discontinuation syndrome?

A

GI symptoms

Chills

Insomnia

Hypomania

Anxiety

Restlessness

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32
Q

What drugs are contraindicated with SSRIs?

A

Warfarin

Heparin

NOACs

NSAIDs

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33
Q

What is serotonin syndrome?

A

Life-threatening complication of increased serotonin activity, usually within minutes of taking medication

Cognitive features - headache, agitation, hypomania, confusion

Autonomic effects - shivering, sweating, hyperthermia, confusion

Somatic effects - myoclonus (muscle twitching), hyperreflexia and tremor

MANAGE by stopping offending drug

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34
Q

Give 2 examples of SNRIs?

A

Venlafaxine

Duloxetine

(used after SSRIs)

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35
Q

Give an example of a NASSA?

A

Mirtazapine

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36
Q

When to review patients after initiating antidepressants?

A

2 weeks after

If <30 or at increased risk then after 1 week

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37
Q

What should be co-prescribed with NSAID and SSRI (if you have to prescribe together)?

A

PPI

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38
Q

Does fluoxetine dose need to be gradually titrated down when stopping like other SSRIs (over 4 weeks)?

A

No

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39
Q

Should citalopram / escitalopram be prescribed in patients with congential long QT?

A

No

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40
Q

Name some TCAs?

A

Amitriptyline

Clomipramine

Imipramine

Lofepramine

Dosulepin

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41
Q

What are the indications for TCAs?

A

Depression

Nocturnal enuresis

Neuropathic pain

Migraine prophylaxis

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42
Q

Give some examples of MAOI?

A

Phenelzine

Isocarboxide

Moclobemide

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43
Q

When are MAOI used?

Side effects?

A

Third line for depression

Postural hypotension, arrhythmias

Drowsiness / insomnia, headache

Increased appetite, weight gain

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44
Q

What foods should be avoided when on MAOIs? Why?

A

Foods with tyramine e.g. cheese, pickled herring, liver, bovril, marmite and red wine

Causes hypertensive crisis

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45
Q

What are the clinical features of a hypertensive crisis?

A

Headache

Palpitations

Fever

Convulsions

46
Q

What are antipsychotics also known as?

A
47
Q

Neuroleptics

A
48
Q

What are the difference between 1st gen and 2nd gen antipsychotics?

A

Extent to which they cause extrapyramidal side effects

49
Q

Give some examples of 1st gen antipsychotics?

A

Haloperidol

Chlorpromazine

Flupentixol

Fluphenazine

Sulpiride

50
Q

Name some atypical antipsychotics?

A

Olanzapine

Risperidone

Quetiapine

Amisulpride

Aripriprazole

Clozapine

51
Q

What is used first line in schizophrenia according to NICE?

A

Atypical antipsychotics

52
Q

What is the advantage of using clozapine?

A

Only antipsychotic found to be superior in efficacy to other antipsychotics (used in treatment-resistant schizophrenia)

53
Q

When are antipsychotics used?

A

Patients with delusions and hallucinations (psychotic symptoms)

Schizophrenia

Depression, mania, delusional disorder, acute and transient psychotic disorders, delerium and dementia (if present with psychotic symptoms)

54
Q

When should clozapine be prescribed for schizophrenia?

A

Third line (after trying 2 different antipsychotics)

55
Q

What is the mechanism of action of typical antipsychotics?

A

Block dopamine receptors in brain

56
Q

What is the mechanism of action of atypical antipsychotics?

A

Block specific dopaminergic receptors (D2 receptors)

Serotonergic effects

57
Q

What are the side effects of antipsychotics?

A
58
Q

EPSE

Anti-muscarinic (can’t see - blurred vision, can’t wee - urinary retention, can’t spit - dry mouth, can’t shit - constipation)

Anti-histaminergic (sedation and weight gain)

Anti-adrenergic (postural hypotension, tachycardia and ejactulatory failure)

Increased prolactin: sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea)

Hypercholesterolaemia

Neuroleptic malignant syndrome

Prolonged QT: concern in haloperidol and pimozide - torsades de pointes causing sudden death

A
59
Q

What are the specific side effects of clozapine?

A

Hypersalivation (pillow soaking with saliva)

Agranulocytosis

60
Q

Which side effects are more common with atypical/ typical antipsychotics?

A

Typical antipsychotics = EPSE and hyperprolactinaemia

Atypical antipsychotics = anti-cholinergic, metabolic side effects

61
Q

What are the EPSE seen with typical antipsychotics?

A

PAD-T

Parkinsonism: bradykinesia, increased rigidity, coarse tremor, masked fancies (expressionless face), shuffling gait (takes weeks /months to occur)

Akathisia: unpleasant feeling of restlessness (in first months, treatment = reduce dose and give temporary propanolol)

Dystonia = acute painful contractions of muscles (spasms) off muscles in neck, jaw and eyes (oculogyric crisis) occurs in days

Tardive dyskinesia = late onset (years) of choreoathetoid movement (abnormal, involuntary movements) - may be irreversible - chewing and pouting of jaw

62
Q

When is neuroleptic malignant syndrome seen?

A

Pts on antipsychotic medication

When dopaminergic drugs (e.g. levodopa) is stopped suddenly

63
Q

How does neuroleptic malignant syndrome (NMS) present?

A

RAAH!

Rigidity

Altered mental state (confusion)

Autonomic instability (tachycardia, fluctuating BM)

Hyperthermia

64
Q

What are the investigations for NMS?

A

CK (usually raised)

FBC (leucocytosis)

LFTs (deranged)

65
Q

What is the management of NMS?

A

Stop antipsychotics

Monitor vital signs

IV fluids to prevent renal failure

Cooling

Medications = dantrolene (muscle relaxant), bromocriptine (dopamine agonist), benzodiazepines

66
Q

What are some complications of NMS?

A

PE

Renal failure

Shock

67
Q

When should antipsychotics be used with caution?

A

CVD (take ECG)

Parkinson’s disease (may be exacerbated)

Epilepsy

Depression

Myasthenia gravis

Prostatic hypertrophy

Susceptibility to closed angle glaucoma

Blood dyscrasias

68
Q

Name some contraindications to antipsychotics?

A

Comatose state

CNS depression

Phaeochromocytoma

69
Q

What should be monitored when on antipsychotics?

A

FBC, U&E, LFTS (at start and annually)

Amisulpride and sulpiride do not require LFT monitoring

Clozapine = differential WBC testing weekly for 18 weeks, fortnightly for a year, then monthly

Fasting blood glucose (baseline, 4-6 months then yearly)

Clozapine and olanzapine = baseline after 1 month then every 4-6 months

Blood lipids (baseline, 3 months, yearly)

ECG (before initiation then monitoring if on haloperidol and pimozide)

BP (before initiation)

Prolactin (baseline, 6 months, yearly)

Weight (waist size and BMI - baseline, 3 months, yearly)

Creatine phosphokinase (baseline CK then if NMS is suspected)

70
Q

What is the general advice when stopping antipsychotics?

A

Continue for 1-2 years following episode (some up to 5 years)

If stopping then taper over 3 weeks rather than abruptly

71
Q

How are antipsychotics administered?

A

Usually oral

Some IM injection

Some depot injection

Started on lowest dose and titration to lowest dose to be effective

72
Q

How often are depot injections given?

Give some examples of typical and atypical depot injections?

A

1-4 weekly

Typical = flupentixol, fluphenazine

Atypical = risperidone, olanzapine, aripiprazole

73
Q

What should be avoided when prescribing antipsychotics?

A

Use a loading dose of antipsychotics

Routinely initiate regular combined antipsychotic meciation (except when changing medication)

Stop abruptly

74
Q

What are mood stabilizers?

A

Drugs used to prevent depression and mania in bipolar affective disorder and schizoaffective disorder

75
Q

What can be given in acute severe manic episodes?

A

Stop antidepressant

Give antipsychotic (if not on or check compliance and dose) or mood stabiliser (if not on - or check levels - valproate if not childbearing or lithium if adherence likely) consider short term benzos

76
Q

When is lithium indicated?

A

Bipolar affective disorder (first line prophylaxis)

Acute manic episode (if atypical antipsychotic ineffective)

Depression (prevents antidepressant-induced hypomania)

77
Q

What are some side effects of lithium?

A

“GI & LITHIUM”

GI disturbances

Leucocytosis

Impaired renal function

Tremor (fine) / teratogenic / thirst (polydipsia)

Hypothyroidism / hair loss

Increased weight / fluid retention

Urine increase

Metallic taste

78
Q

What are some signs of lithium toxicity?

A

Tremor (coarse)

Oliguric renal failure

ataXia

Increased reflexes

Convulsions / coma / consciousness decreased

79
Q

What is the therapeutic window for lithium?

A

0.4 - 1.0 mmol / L

Toxic is >1.5 mmol / L

80
Q

When to avoid lithium prescription?

A

Renal failure

Pregnancy (teratogenic)

Breast feeding

81
Q

When to prescribe lithium with caution?

A

QT prolongation

Epilepsy (decreased seizure threshold)

Diuretic therapy

82
Q

When is lithium contraindicated?

A

Untreated hypothyroidism

Addison’s disease

Brugada syndrome (heart disease with increased risk of sudden cardiac death)

83
Q

What monitoring is required with lithium?

A

Before treatment = U&Es, eGFR (lithium has renal excretion and is nephrotoxic), TFTs, pregnancy, baseline ECG

Lithium levels = 12 hours, then weekly until therapeutic (0.4-1) stable for 4 weeks, then 3 monthly (and during illness)

U&Es = every 6 months

TFTs = every 12 months (ask about symptoms)

84
Q

What is the dosage of lithium?

A

Lithium carbonate (given for 18 months) start at 400mg at night - titrate between 400-1200mg/day to keep plasma between 0.5 and 1.0

ORALLY

85
Q

When should lithium not be prescribed?

A

Never in child bearing age = teratogenic - congenital heart defects

Never in severe renal failure

Never prescribe NSAIDS, diuretics (particularly thiazides) or ACE inhibitors without careful thought

Not if adherence is a problem

Never withdraw abruptly (can precipitate relapse)

86
Q

When can lithium toxicity occur?

What is the management?

A

Dehydration, drugs, diuretics (thiazide)

Managment = high intake of fluid (osmotic diuresis)

87
Q

What is sodium valproate used for?

What are some side effects?

A

Mood stabiliser

Side effects = weight gain, aggression, thrombocytopaenia, teratogenic (neural tube defects and spina bifida)

88
Q

What to check before initiating sodium valporate?

A

FBC

Monitor LFTs and PT (for first 6 months)

Pregnancy test

Weight / BMI

89
Q

What are the indications of carbamazepine?

A

Mania (not first line)

Prophylaxis of bipolar affective disorder

Alcohol withdrawal

90
Q

What are some side effects of carbamazepine?

A

GI disturbances

Dermatitis

Dizziness

Leucopaenia, thrombocytopaenia

91
Q

What are some contraindications to carbamazepine?

A

Contraindication = cardiac disease and blood disorder, pregnancy

92
Q

What are the indications of lamotrigine?

What are some side effects?

A

Bipolar depression (less teratogenic than other mood stabilisers)

GI disturbances, rash, headache and tremor, don’t use with carbamazepine (neurotoxicity)

93
Q

What drugs are first line in anxiety?

A

SSRIs

94
Q

What drugs can be used as hypnotics?

A

Benzodiazepines

Low dose amitriptyline

Z drugs (zopiclone, zolpidem, zaleplon)

95
Q

What are the indications for benzodiazepines?

Give some examples?

A
96
Q

How does benzo overdose appear and what is the management?

How to wean patients off benzos?

A

Ataxia, dysarthria, nystagmus, coma, respiratory depression

IV flumazenil

Wean off

97
Q

What are the indications for ECT?

A

Euphoric (persistent mania)

Catatonic

Tearful (treatment resistant depression)

98
Q

What are some side effects of ECT?

What are some contraindications?

A

Short term = peripheral nerve palsy, arrhythmia, headaches

Long term = amnesia

Contraindications = MI (< 3 months ago), cerebral aneurysm, raised ICP, stroke (< 1 month ago)

99
Q

What is the difference between advanced statements and advanced directives?

A

Statement = not legally binding - express wishes

Directive = legally binding - only refuse treatment (but not food / drink by mouth or basic hygiene)

100
Q

What is a section 2 used for? How long does it last? Can it be renewed? When can it be appealed? Can treatment be refused?

A

Admission for assessment and response to treatment

28 days

Non-renewable

Appealed up to 14 days

Treatment cant be refused

Signed by 2 doctors and ASW (1 doctor must be known to pt)

101
Q

When is section 3 used? How long does it last? Can it be renewed? Can treament be refused?

A

Admission for treatment (known to services) - requires formal diagnosis

Lasts 6 months

Renewable

Treatment can be given against will until end of 3 months

Appealed within 6 months

102
Q

What is the mental capacity act (2005)?

A

Identifies those who lack capacity to consent / reduce treatment

  • Best interests
  • Try and get patient to decide themselves (e.g. interpreters, multiplie times)
  • Eccentric decisions are allowed
  • Least restrictive intervention
  • Presumption of capacity
103
Q

What are the two types of lasting power of attorney?

A

Property and affairs (financial)

Personal welfare

104
Q

What are the components of advanced care planning?

A

Advanced statement = verbally or written allowing patient to make general statements for wishes if they were to lose capacity

Advanced decision = legal document with specific refusal of treatment (cant refuse drink / food by mouth) - signed by patient and witnessed

Lasting power of attorney

105
Q

Where can deprivation of Liberty safeguard be used and why?

A

Care homes, hospitals and supported living

DoL must be applied for

106
Q

Who is an independent mental capacity advocate? IMCA

A

Appointed to person who lacks capacity but has no one to speak on their behalf

107
Q

What is the mental health act used for?

A

In England and Wales allows people with a mental disorder to be sectioned (those who do not consent / lack capacity)

Under the influence of drugs / alcohol are specifically excluded

Pts under section are called formal / involuntary

108
Q

What is a section 4? Who can enforce it? How long does it last?

A

Used in emergency when section 2 would involve unacceptable delay

Enfored by GP or AMHP or nearest relative

Lasts 72 hours

109
Q

What are the other emergency sections? How long do they each last? Who can enforce them?

A

Section 5.2 = holding order for inpatients on any ward (not A&E), no right to appeal, lasts 72 hours, doctor - must then be assessed for S2/S3/discharge/informal

Section 5.4 = holding order for inpatients on MH ward, no right to appeal, lasts 6 hours, nurse

Section 135 = police officer appeals for court order to break into property to remove person to place of safety, lasts 72 hours

Section 136 = police officer can take someone who appears to have a mental disorder from a public place to a place of safety, lasts 72 hours

110
Q

What is a community treatment order?

A

Allows pts who are on S3 and well enough to leave hospital for treatment in community (decision made by responsible clinician)

111
Q

What is a section 117?

A

Deals with aftercare responsibilities after a patient has been detained on section 3

112
Q

What is forensic pathology?

A

Assessment and treatment of mentally disordered individuals

Psychiatry (13 decks)

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