Management Flashcards
What is IAPT?
Improving access to psychological therapies - initiative to increase evidence based treatments for anxiety and depression by primary care organisations
What is CBT?
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
Give some examples of behavioural therapies?
Relaxation training
Systemic desensitization
Flooding
Exposure and response prevention
Behavioural activation
What are behavioural therapies based on?
Operant conditioning - behaviour is reinforced if it has positive consequences for the individual, and prevents negative consequences
What is relaxation training ?
Use techniques to cause muscle relaxation during times of stress or anxiety
What is systemic desensitization?
For phobic anxiety disorders - individual is greatly exposed to a hierarchy of anxiety-producing situations
What is flooding therapy?
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
What is exposure and response prevention?
Used in OCD - exposed to situations which cause them anxiety and prevented from performing compulsive action
What is behavioural activation?
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
When is psychodynamic therapy used?
Dissociative disorders, psychosexual disorders, PDs, chronic dysthymia, recurrent depression
What is psychodynamic therapy based on?
Childhood experiences, past relationships and unresolved conflicts influence someones current situation
How does psychodynamic therapy work?
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
What is psychoeducation?
Delivery of information to people in order to help them understand and cope with their mental illness
What is counselling?
Less technically complicated than other therapies - done by active dialogue between counsellor and client
Can be sympathetic listening or active advice on problem solving
What is supportive psychotherapy?
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
What is problem solving therapy?
Mix of counselling and CBT for mild anxiety and depressive disorders
What is interpersonal therapy?
Used to treat depression and eating disorders - focus on interpersonal problems - bereavement, relationship difficulties, interpersonal deficit
What is eye movement desensitization and reprocessing?
For PTSD
Client recalls emotionally traumatic materia whilst focusing on external stimulus (e.g. following a moving finger)
What is dialectical behavioural therapy?
Which therapies are recommended for:
Adverse life events
Depression
PTSD
Schizophrenia
Eating disorders
Anxiety disorders
Substance misuse
Borderline personality disorder?
What are antidepressants used for?
- Moderate to severe depressive episodes
- Anxiety / panic attacks
- OCD
- Chronic pain
- Eating disorders
- PTSD
Give some examples of SSRIs
Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertraline
What SSRI is given for panic disorder?
Citalopram
Escitalopram
Paroxetine
What SSRI is given for social phobia?
Escitalopram
Paroxetine
What SSRI is given for bulimia nervosa?
Fluoxetine
What SSRI is given for OCD?
Most
What SSRI is given for PTSD?
Paroxetine and sertraline
What SSRI is given for GAD?
Paroxetine
How do SSRIs work?
Increase the concentration of serotonin in the synaptic cleft by inhibiting reuptake from the synaptic cleft into pre-synaptic neurones
What are the side effects of SSRIs?
Nausea
Dyspepsia
Bloating
flatulence
Diarrhoea / constipation
Sweating
Tremors
Rashes
Sexual dysfunction
Somnolence
What are the symptoms of SSRI discontinuation syndrome?
GI symptoms
Chills
Insomnia
Hypomania
Anxiety
Restlessness
What drugs are contraindicated with SSRIs?
Warfarin
Heparin
NOACs
NSAIDs
What is serotonin syndrome?
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
Give 2 examples of SNRIs?
Venlafaxine
Duloxetine
(used after SSRIs)
Give an example of a NASSA?
Mirtazapine
When to review patients after initiating antidepressants?
2 weeks after
If <30 or at increased risk then after 1 week
What should be co-prescribed with NSAID and SSRI (if you have to prescribe together)?
PPI
Does fluoxetine dose need to be gradually titrated down when stopping like other SSRIs (over 4 weeks)?
No
Should citalopram / escitalopram be prescribed in patients with congential long QT?
No
Name some TCAs?
Amitriptyline
Clomipramine
Imipramine
Lofepramine
Dosulepin
What are the indications for TCAs?
Depression
Nocturnal enuresis
Neuropathic pain
Migraine prophylaxis
Give some examples of MAOI?
Phenelzine
Isocarboxide
Moclobemide
When are MAOI used?
Side effects?
Third line for depression
Postural hypotension, arrhythmias
Drowsiness / insomnia, headache
Increased appetite, weight gain
What foods should be avoided when on MAOIs? Why?
Foods with tyramine e.g. cheese, pickled herring, liver, bovril, marmite and red wine
Causes hypertensive crisis
What are the clinical features of a hypertensive crisis?
Headache
Palpitations
Fever
Convulsions
What are antipsychotics also known as?
Neuroleptics
What are the difference between 1st gen and 2nd gen antipsychotics?
Extent to which they cause extrapyramidal side effects
Give some examples of 1st gen antipsychotics?
Haloperidol
Chlorpromazine
Flupentixol
Fluphenazine
Sulpiride
Name some atypical antipsychotics?
Olanzapine
Risperidone
Quetiapine
Amisulpride
Aripriprazole
Clozapine
What is used first line in schizophrenia according to NICE?
Atypical antipsychotics
What is the advantage of using clozapine?
Only antipsychotic found to be superior in efficacy to other antipsychotics (used in treatment-resistant schizophrenia)
When are antipsychotics used?
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)
When should clozapine be prescribed for schizophrenia?
Third line (after trying 2 different antipsychotics)
What is the mechanism of action of typical antipsychotics?
Block dopamine receptors in brain
What is the mechanism of action of atypical antipsychotics?
Block specific dopaminergic receptors (D2 receptors)
Serotonergic effects
What are the side effects of antipsychotics?
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
What are the specific side effects of clozapine?
Hypersalivation (pillow soaking with saliva)
Agranulocytosis
Which side effects are more common with atypical/ typical antipsychotics?
Typical antipsychotics = EPSE and hyperprolactinaemia
Atypical antipsychotics = anti-cholinergic, metabolic side effects
What are the EPSE seen with typical antipsychotics?
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
When is neuroleptic malignant syndrome seen?
Pts on antipsychotic medication
When dopaminergic drugs (e.g. levodopa) is stopped suddenly
How does neuroleptic malignant syndrome (NMS) present?
RAAH!
Rigidity
Altered mental state (confusion)
Autonomic instability (tachycardia, fluctuating BM)
Hyperthermia
What are the investigations for NMS?
CK (usually raised)
FBC (leucocytosis)
LFTs (deranged)
What is the management of NMS?
Stop antipsychotics
Monitor vital signs
IV fluids to prevent renal failure
Cooling
Medications = dantrolene (muscle relaxant), bromocriptine (dopamine agonist), benzodiazepines
What are some complications of NMS?
PE
Renal failure
Shock
When should antipsychotics be used with caution?
CVD (take ECG)
Parkinson’s disease (may be exacerbated)
Epilepsy
Depression
Myasthenia gravis
Prostatic hypertrophy
Susceptibility to closed angle glaucoma
Blood dyscrasias
Name some contraindications to antipsychotics?
Comatose state
CNS depression
Phaeochromocytoma
What should be monitored when on antipsychotics?
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)
What is the general advice when stopping antipsychotics?
Continue for 1-2 years following episode (some up to 5 years)
If stopping then taper over 3 weeks rather than abruptly
How are antipsychotics administered?
Usually oral
Some IM injection
Some depot injection
Started on lowest dose and titration to lowest dose to be effective
How often are depot injections given?
Give some examples of typical and atypical depot injections?
1-4 weekly
Typical = flupentixol, fluphenazine
Atypical = risperidone, olanzapine, aripiprazole
What should be avoided when prescribing antipsychotics?
Use a loading dose of antipsychotics
Routinely initiate regular combined antipsychotic meciation (except when changing medication)
Stop abruptly
What are mood stabilizers?
Drugs used to prevent depression and mania in bipolar affective disorder and schizoaffective disorder
What can be given in acute severe manic episodes?
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
When is lithium indicated?
Bipolar affective disorder (first line prophylaxis)
Acute manic episode (if atypical antipsychotic ineffective)
Depression (prevents antidepressant-induced hypomania)
What are some side effects of lithium?
“GI & LITHIUM”
GI disturbances
Leucocytosis
Impaired renal function
Tremor (fine) / teratogenic / thirst (polydipsia)
Hypothyroidism / hair loss
Increased weight / fluid retention
Urine increase
Metallic taste
What are some signs of lithium toxicity?
Tremor (coarse)
Oliguric renal failure
ataXia
Increased reflexes
Convulsions / coma / consciousness decreased
What is the therapeutic window for lithium?
0.4 - 1.0 mmol / L
Toxic is >1.5 mmol / L
When to avoid lithium prescription?
Renal failure
Pregnancy (teratogenic)
Breast feeding
When to prescribe lithium with caution?
QT prolongation
Epilepsy (decreased seizure threshold)
Diuretic therapy
When is lithium contraindicated?
Untreated hypothyroidism
Addison’s disease
Brugada syndrome (heart disease with increased risk of sudden cardiac death)
What monitoring is required with lithium?
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)
What is the dosage of lithium?
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
When should lithium not be prescribed?
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)
When can lithium toxicity occur?
What is the management?
Dehydration, drugs, diuretics (thiazide)
Managment = high intake of fluid (osmotic diuresis)
What is sodium valproate used for?
What are some side effects?
Mood stabiliser
Side effects = weight gain, aggression, thrombocytopaenia, teratogenic (neural tube defects and spina bifida)
What to check before initiating sodium valporate?
FBC
Monitor LFTs and PT (for first 6 months)
Pregnancy test
Weight / BMI
What are the indications of carbamazepine?
Mania (not first line)
Prophylaxis of bipolar affective disorder
Alcohol withdrawal
What are some side effects of carbamazepine?
GI disturbances
Dermatitis
Dizziness
Leucopaenia, thrombocytopaenia
What are some contraindications to carbamazepine?
Contraindication = cardiac disease and blood disorder, pregnancy
What are the indications of lamotrigine?
What are some side effects?
Bipolar depression (less teratogenic than other mood stabilisers)
GI disturbances, rash, headache and tremor, don’t use with carbamazepine (neurotoxicity)
What drugs are first line in anxiety?
SSRIs
What drugs can be used as hypnotics?
Benzodiazepines
Low dose amitriptyline
Z drugs (zopiclone, zolpidem, zaleplon)
What are the indications for benzodiazepines?
Give some examples?
How does benzo overdose appear and what is the management?
How to wean patients off benzos?
Ataxia, dysarthria, nystagmus, coma, respiratory depression
IV flumazenil
Wean off
What are the indications for ECT?
Euphoric (persistent mania)
Catatonic
Tearful (treatment resistant depression)
What are some side effects of ECT?
What are some contraindications?
Short term = peripheral nerve palsy, arrhythmia, headaches
Long term = amnesia
Contraindications = MI (< 3 months ago), cerebral aneurysm, raised ICP, stroke (< 1 month ago)
What is the difference between advanced statements and advanced directives?
Statement = not legally binding - express wishes
Directive = legally binding - only refuse treatment (but not food / drink by mouth or basic hygiene)
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?
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)
When is section 3 used? How long does it last? Can it be renewed? Can treament be refused?
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
What is the mental capacity act (2005)?
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
What are the two types of lasting power of attorney?
Property and affairs (financial)
Personal welfare
What are the components of advanced care planning?
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
Where can deprivation of Liberty safeguard be used and why?
Care homes, hospitals and supported living
DoL must be applied for
Who is an independent mental capacity advocate? IMCA
Appointed to person who lacks capacity but has no one to speak on their behalf
What is the mental health act used for?
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
What is a section 4? Who can enforce it? How long does it last?
Used in emergency when section 2 would involve unacceptable delay
Enfored by GP or AMHP or nearest relative
Lasts 72 hours
What are the other emergency sections? How long do they each last? Who can enforce them?
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
What is a community treatment order?
Allows pts who are on S3 and well enough to leave hospital for treatment in community (decision made by responsible clinician)
What is a section 117?
Deals with aftercare responsibilities after a patient has been detained on section 3
What is forensic pathology?
Assessment and treatment of mentally disordered individuals
