Management of Mental Health Flashcards
What are the principles of psychotherapy?
Develop therapeutic relationship Listen to patient's concerns Empathetic approach Provide info, support, advice Allow expression of emotion Encourage self-help
What are the most commonly used forms of psychotherapy?
CBT
Psychodynamic psychotherapy
What are the types of psychological therapies?
Type A - psychological treatment as an integral part of mental health care
Type B - eclectic psychological therapy and counseling
Type C - formal psychotherapies e.g. CBT, psychoanalytic/psychodynamic therapies, systemic and family therapy
What is transference?
Unconscious transfer of feelings and attitudes from the past into the therapist
What is psychotherapy?
The systematic use of a relationship between a patient and a therapist, as opposed to physical and social methods, to produce changes in feelings, cognition and behaviour.
What are common characteristics of all psychotherapies?
Intense confiding relationship with a helpful person
Rationale containing explanation of the patient’s distress
Provision of new information about the nature and origins of the patient’s problems and ways of dealing with them
Development of hope in the patient that they will be helped
Opportunities to experience success during treatment, enabling increased sense of mastery
Facilitation of emotional arousal
What are the principles of psychodynamic psychotherapy?
Less freq treatment - once or twice weekly sessions, may be brief from 4 months to a year.
Focuses of unconscious and past experience to determine current behaviour. Talk about childhood relationships, reveal unconscious psych.
What are the principles of psychoanalytic psychotherapy?
Regular sessions
Unconscious patterns brought into awareness, view of changing these
Verbalise thoughts through free association, fantasy and dreams.
What are the basic principles of CBT?
Based on learning theory, exposure to reduce avoidance and permit habituation.
Behavioural techniques for anxiety, OCD, PTSD.
Addresses role of dysfunctional thoughts and beliefs, very structured, problem orientated and time limited therapy.
Very active, homework to complete e.g. experimenting with new behaviours, identifying negative thoughts
Between 5-20 weekly sessions, last 1 hour
Can be individual, group, self help via books or computers
What are examples of behavioural therapies?
Relaxation training - for stress related and anxiety disorders
Systemic desensitisation - for phobic anxiety disorders, gradually exposed to hierarchy of anxiety-producing situations
Flooding - rapid exposure to phobic object without any attempt to reduce anxiety prior, continue exposure until diminishes
Exposure and response prevention - for OCD and phobias, repeatedly exposed but prevented from performing compulsive actions.
Behavioural activation - for depressive illness, making realistic and achievable plans to carry out activities, then gradually increasing amount of activity
What is the rationale for psychodynamic therapy?
Based upon the idea that childhood experiences, past unresolved conflicts and previous relationships influence individuals current situation
What is psychoeducation?
Delivery of information to help cope with mental illness
Inform of causes, health services to help them, self help
May be in groups or individually
What is counselling?
Relief of distress
Active dialogue between councillor and client
For e.g. adjustment disorder, mild depression, grief, trauma, prior to decision making
Helps client find own solutions to problems, whilst being supported to do so and being guided by appropriate advice
What is supportive psychotherapy?
Psychological support for those with chronic or disabling mental illness
Helps people cope
Listening, reassurance, providing explanation, guidance
What is problem solving therapy?
Structured combination of counselling and CBT
Learn to actively deal with life problems, select a solution and review its effect.
What is interpersonal therapy?
Used to treat depression and eating disorders.
Focus is on interpersonal problems e.g. bereavement, relationship difficulties
Overlap with CBT and psychodynamic therapy
What is EMDR?
Eye movement desensitisation and reprocessing
Recalling emotionally traumatic material whilst focusing on an external stimulus, stimulates both sides of the brain e.g. following finger side to side
What is DBT?
Dialect behavioural therapy
For those with borderline PD
CBT and group skills training for alternative coping strategies rather than self harm when faced with emotional instability
What is CAT?
Cognitive analytic therapy
Combines cognitive theories and psychoanalytic approaches to an integrated therapy
What are the forms of psychotherapies?
Individual
Couples
Family
Group - offers support network for those with similar difficulties
What is the rationale for antidepressants?
Moderate to severe depressive episodes and dysthymia Anxiety, panic attacks OCD Chronic pain EDs PTSD
What is the basis of the function of antidepressants?
The monoamine hypothesis
Enhances the activity of monoamine neurotransmitters noradrenaline and serotonin
What are the classes of antidepressants?
SSRIs
SNRIs - serotonin and noradrenaline reuptake inhibitor
TCA - tricyclic antidepressant
MAOI - monoamine oxidase inhibitor
NARI - noradrenaline reuptake inhibitor
SARI - serotonin antagonist and reuptake inhibitor
NASSA - noradrenaline serotonin specific antidepressant
What is the action of MAOIs?
Prevent breakdown of dopamine, noradrenaline and serotonin.
What do TCAs do?
Block reuptake of serotonin and noradrenaline in synaptic cleft?
What are examples of SSRIs?
Citalopram, fluoxetine, sertraline
What are the indications for SSRIs?
Depression Panic disorder - citalopram Social phobia - paroxetine BN - fluoxetine GAD - paroxetine
What is the mechanism of action of SSRIs?
Inhibit reuptake of serotonin from the synaptic cleft into the pre-synaptic neurones
SSRIs increase concentration of serotonin in the synaptic cleft
What are the side effects of SSRIs?
Nausea, dyspepsia, bloating STRESS Sweating, tremor, rashes Extrapyramidal side effects Sexual dysfunction Somnolence Stopping SSRIs - chills, insomnia, anxiety, restless
What are the cautions of SSRIs?
History of mania, epilepsy
Cardiac disease, glaucoma
Diabetes
GI bleeding, hepatic impairment, renal impairment
What are the contraindications of SSRIs?
Mania
What are some common doses of SSRIs?
Sertraline - 50-200mg/day
Fluoxetine - 20-60mg/day
What is the route for SSRIs?
Oral
What are examples of SNRIs?
Venlafaxine 75mg a day
Duloxetine 60-120mg/day
What is the indication for SNRIs?
Second or third line in treatment of depression and anxiety disorders
More rapid onset and more effective
What is the mechanism of action of SNRIs?
Prevent reuptake of NA and serotonin but do not block cholinergic receptors and therefore many anti-cholinergic side effects
What are the side effects of SNRIs?
Nausea Dry mouth Headache Dizziness Sexual dysfunction Hypertension
What are the cautions to SNRIs?
Similar to SSRIs
What are the contraindications of SNRIs?
Conditions associated with high risk of cardiac arrhythmias, uncontrolled hypertension
What are NASSAs?
Noradrenaline-serotonin specific antidepressants e.g. Mirtazapine
What are the indications for NASSAs?
Second line depressed patients
Who would benefit from weight gain
Suffer from insomnia
What is the mechanism of action of mirtazapine?
Weak noradrenaline reuptake inhibiting effect
Anti-histaminergic properties and is an alpha 1 and 2 blocker
Therefore increases appetite and is a sedative
What are the side effects of mirtazapine?
Increase in appetite Weight gain, dry mouth Postural hypotension Oedema, drowsiness, fatigue Tremor, dizziness, abnormal dreams Anxiety, arthralgia, myalgia
Who is mirtazapine cautioned in?
Elderly, cardiac disorders Hypotension, urinary retention Susceptibility to glaucoma History of seizures, blood disorders Pregnancy and breast feeding
What are NARIs?
Noradrenaline reuptake inhibitors
Reboxetine
What is the indication for NARIs?
Second or third line for major depression
What is the mechanism of action for NARIs?
Highly specific noradrenaline reuptake inhibitor
What are the side effects of NARIs?
Nausea, dry mouth Constipation Anorexia, tachycardia Palpitations Vasodilatation Postural hypotension Headache, dizziness, chills
Who are NARIs cautioned in?
Cardiovascular disease Epilepsy Bipolar disorder Urinary retention Pregnancy Avoid abrupt withdrawal
What are SARIs?
Trazodone
What are the indications for trazodone?
Depressive illness
Particularly where sedation is required
Anxiety, dementia with agitation, insomnia
What are important warning for prescribing SSRIs?
Do not co-prescribe NSAIDs, but if you have to give a PPI as well.
Do not co-prescribe SSRIs and heparin/warfarin
Do not stop SSRIs suddenly, dose gradually reduced over 4 week period - but not necessary with fluoextine
Do not prescribe citalopram in congenital long QT syndrome/
Who should SNRIs not be used in?
Those with cardiac disease and uncontrolled hypertension
BP measurement should be taken before starting venlafaxine, and monitored regularly after.
What are some examples of tricyclic antidepressants?
Amitriptyline, clomipramine
Nortiptyline
What are the indications for TCA?
Depressive illness
Nocturnal enuresis
Neuropathic pain
Migraine prophylaxis
What is the mechanism of action of TCAs?
Inhibit reuptake of adrenaline and serotonin in the synaptic clef
Also have affinity for cholinergic receptors and serotonin receptors - contributes to side effects.
What are the side effects of TCAs?
Anticholinergic - dry mouth, constipation, urinary retention, blurred vision
CV - arrhythmias, postural hypotension, tachycardia, syncope, sweating
Hypersensitivity reactions - urticarial, photosensitivity
Psychiatric - hypomania, mania, confusion
Metabolic - appetite, weight gain
Endocrine
Neurological - convulsions, movement disorders
Headache, sexual dysfunction, tremor
When are TCAs cautioned?
Cardiac disease History of epilepsy Breastfeeding, pregnancy Elderly Hepatic impairment Thyroid disease Phaeochromocytoma Hx mania Concurrent ECT
When are TCAs contraindicated?
Recent MI Arrhythmias, heart block Mania Severe liver disease Agranulocytosis
What is an example of TCA dosage?
Amitriptyline 50-200mg/day
What is the route of TCAs?
Oral - tablet or solution
What are examples of MAOIs?
Irreversible - phenelzine
Reversible - moclobemide
What are the indications for MAOIs?
Third line depression
Atypical or treatment resistant
Social phobia
What is the mechanism of action?
Inactive monoamine oxidase enzymes that oxidise monoamine neurotransmitters
What are the side effects of MAOIs?
CV - postural HTN, arrhythmias Neuro - drowsy, insomnia GI - appetite, weight gain Sexual - anorgasmia Hepatic Hypertensive reactions with tyramine containing foods
When are MAOIs cautioned?
Avoid in agitated or excited patients, or give with a sedative for up to 2-3 wks
Thyrotoxicosis
Hepatic impairment
Pregnancy, breast feeding
If changing to another antidepressant, need a washout period of up to 6 weeks
What foods should be avoided with MAOIs?
Tyramine rich foods as MAOIs also metabolise tyramine.
Cheese, pickled herring, liver, Bovril, Oxo, marmite, some red wine.
Can cause hypertensive crisis - headache, palpations, fever, convulsions, risk of coma.
What are examples of typical antipsychotics?
Haloperidol
Chlorpromazine
Zuclopenthixol
What are examples of atypical antipsychotics?
Olanzapine Risperidone Quetiapine Aripiprazole Clozapine
What is the indication for antipsychotics?
Mainstay of treatment for schizophrenia, for delusions and hallucinations.
What are the indications for clozapine?
Third line treatment for schizophrenia
Should only be prescribed after failing to respond to two other antipsychotics - treatment resistant schizophrenia
What is the mechanism of action of antipsychotics?
Reduce abnormal transmission of dopamine through blocking dopamine receptors
Atypicals have a specific dopaminergic action blocking D2 receptors and serotonergic effects
How is a first-episode schizophrenia treated with antipsychotics?
Agree on choice
Titrate to minimum effective dose, adjust
Assess over 2-3 weeks
Continue if working
Change if not, consider depot if not compliant
Not effective - clozapine
What are some of the additional side effects of antipsychotics?
Have an affinity for muscarinic, 5HT, histaminergic and adrenergic receptors
Have extrapyramidal side effects
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, ejaculatory failure
Increase in prolactin
Neuroleptic malignant syndrome
Prolonged QT interval
What are the specific side effects of clozapine?
Hypersalivation - patients may wake up with their pillows soaking with saliva
Agranulocytosis
What are the EPSEs?
Parkinsonism - bradykinesia, rigidity, coarse tremor, masked facies, shuffling gait
Akathisia - unpleasant feeling of restlessness - reduce dose and give propranolol
Dystonia - acute painful spasms of neck, jaw and eye muscles, occurs within days
Tardive dyskinesia - late onset, choreoathetoid abnormal involuntary movements, chewing and pouting of the jaw
What are the cautions of antipsychotics?
CV disease - ecg Parkinson's - exacerbated Epilepsy Depression Myasthenia gravis
What are the contraindications of antipsychotics?
Comatose states
CNS depression
Phaeochromocytoma
What needs to be monitored whilst taking antipsychotics?
FBC, U&Es, LFTs - at start then annually
Clozapine needs WBC weekly for 18 weeks
Fasting blood glucose
Blood lipids - baseline, 3 months then yearly
ECG before initiating
Advised for haloperidol
Mandatory for pimozide
Check for long QT
BP
Prolactin
Weight
Physical health
Creatine phosphokinase - baseline CK, then measure if neuroleptic malignant syndrome is suspected
How should antipsychotics be stopped?
Continue for 1-2 years following an episode of psychosis, even up to 5 years to prevent relapse
Taper medication over period of approx 3 weeks, relapse rate in first 6 months after abrupt withdrawal is double
What is the route of antipsychotics?
Oral
Short acting IM injection
Depot injection every 1-4 weeks
Dose increases only take place after 1-2 weeks of assessment if poor/no response
What is the difference between typical and atypical antipsychotics?
Typical - more extrapyramidal side effects, metabolic syndrome less likely, weight gain less likely
Less likely to cause Type 2 diabetes, stroke in elderly, tardive dyskinesia, high prolactin levels.
What is it important not to do when prescribing antipsychotics?
Do not use loading dose
Do not routinely initiate regular combined antipsychotics
Do not prescribe without significant cardiovascular hx
Do not stop abruptly
What are mood stabilisers?
Prevent depression and mania in bipolar affective disorder and schizoaffective disorder.
Atypical antipsychotics have a rapid onset of action compared to mood stabilisers so can be used in acute severe manic episodes.
What is the treatment guideline of acute mania or hypomania?
Stop antidepressant
Is the patient taking antimanic medication?
No - consider an antipsychotic if symptoms severe or mood stabiliser - valproate if not childbearing.
If taking antipsychotic, check compliance and dose, consider increasing dose, add mood stabiliser.
What are the indications for lithium?
First line bipolar affective
Also effective in acute manic episode and as an adjunctive treatment for depression.
What is the mechanism of action of lithium?
Some evidence bipolar patients have a raised intracellular conc of sodium and calcium, and lithium can decrease these, as lithium handled in similar way to sodium.
Decreased activity of sodium dependent messenger systems.
What are the side effects of taking lithium?
GI disturbances
LITHIUM Leucocytosis Impaired renal function Tremor - fine Teratogenic Thirst - polydipsia Hypothyroidism Increased weight, fluid retent Urine increase Metalic taste
What are the signs of lithium toxicity?
TOXIC Tremor - coarse Oliguric renal failure AtaXia Increased reflexes Convulsions/coma
Toxic levels >1.5mmol/L
Therapeutic levels - 0.4-1.0
What are the contraindications and cautions of lithium?
Avoid in renal failure
Avoid in preg, breastfeeding as teratogenic
Caution with QT prolongation, epilepsy and diuretic therapy
Contraindicated in untreated hypothyroidism, Addison’s, Brugada syndrome
When should lithium levels be monitored?
Before treatment started - U&Es, eGFR, TFT, pregnancy status, baseline ECG.
Levels monitored 12 hours following first dose, then weekly until therapeutic level stable for 4 weeks.
Then check every 3 months.
U&Es checked every 6 months.
TFTs every 12 months.
What should you not do when prescribing lithium?
Do not prescribe unless specialist.
Do not give to women of childbearing age.
Do not give in severe renal failure.
Do not prescribe NSAIDs, diuretics, ACEi without careful thought.
Do not withdraw lithium abruptly as can precipitate relapse
How can lithium toxicity be enhanced?
4Ds
Dehydration
Drugs - ACEi, NSAIDs, diuretics
Depletion of sodium
What is the management of lithium toxicity?
Stop immediately
High intake of fluid provided, including IV NaCl therapy to stimulate osmotic diuresis
In most severe cases, renal dialysis may be needed
What are the indications for sodium valproate?
Comparable efficacy to lithium as a mood stabiliser
If lithium is ineffective or unsuitable
Can be used with lithium for rapid cycling
What is the mechanism of sodium valproate?
Inhibits catabolism of GABA
Decreases turnover of arachidonic acid and activates extracellular signal-regulated kinase
What are the side effects of sodium valproate?
GI disturbances
VALPROATE
Very fat - weight gain Aggression LFTs rise Platelets low Reversible hair loss Oedema Ataxia Tremor/tiredness/teratogenic Emesis
What are the contraindications for sodium valproate?
Avoid in pregnancy - can cause neural tube defects
Hepatic dysfunction
Porphyria
What is the route and dosage of sodium valproate?
250-500mg, titrated upwards
Oral, IV only used for epilepsy
What is the indication for carbamazepine?
Mania not first line
Prophylaxis of bipolar affective disorder if unresponsive to lithium
Alcohol withdrawal
What is the mechanism of action of carbamezapine?
Blocks voltage dependent sodium channels, inhibits repetitive neuronal firing
Decreases glutamate release and turnover of dopamine and noradrenaline
What are the side effects of carbamezapine?
GI disturbances, dermatitis, dizziness, hyponatraemia, blood disorders e.g. leucopenia, thrombocytopenia
What are the contraindications of carbamezapine?
Caution in cardiac disease and blood disorders
Contraindicated in AV conduction abnormalities and acute porphyria (metabolic disorder causes nervous symptoms)
Avoid in pregnancy
Potent enzyme inducer so e.g. COCP metabolised faster
What are the indications for lamotrigine?
Used to treat bipolar depression
Does not treat or prevent manic episodes
What is the mechanism of action of lamotrigine?
Inhibition of sodium and calcium channels in presynaptic neurones and subsequent stabilisation of neuronal membrane
What are the SEs of lamotrigine?
GI disturbances, rash, headache, tremor
What are the contraindications of lamotrigine?
Combination of lamotrigine and carbamezapine may cause neurotoxicity
What monitoring is required on lamotrigine?
LFTs, FBC and U&Es prior to starting
Do not routinely measure plasma levels unless evidence of ineffectiveness, poor adherence or toxicity.
What is the dosage of lamotrigine?
Must be initiated very gradually beginning at 25mg daily.
Avoid abrupt withdrawal unless serious stevens johnson rash
What drugs can be used as hypnotics?
Benzodiazepines
Low dose amitriptyline
Zopiclone, Zolpidem, Zaleplon
What are examples of benzos?
Long acting >24 hours - diazepam, nitrazepam, clonazepam
Short acting <12 hours - lorazepam, midazolam
What are the indications for benzos?
Insomnia, short term use
Anxiety disorders - panic disorder, phobic anxiety disorder, short term relief
Delirium tremens and alcohol detoxification
Acute psychosis
Violent behaviour
What is the mechanism of action of benzos?
Enhance effect of inhibitory neurotransmitters, increase frequency of Cl channels
What are the SEs of benzos?
Drowsiness Light headedness Confusion and ataxia Amnesia Paradoxical inc in agitation Muscle weakness Respiratory depression
What are the cautions and contraindications of benzos?
Respiratory depression and hepatic impairment
What are the common routes for benzos?
PO
IM, IV and PR if non compliant and status epilepticus
What are the clinical features of a benzo overdose?
Ataxia Dysarthria Nystagmus Coma Respiratory depression A-E approach, IV flumazenil
What is benzodiazepine withdrawal syndrome?
May develop at any time up to 3 weeks after stopping a long acting benzodiazepine
May occur within a day in the case of a short acting one
Effects include insomnia, anxiety, loss of appetite, tremor, muscle twitching, sweating, tinnitus, perceptual disturbances
Seizures - rare
What is discontinuation syndrome?
Antidepressants are not addictive but they can be difficult to stop
Syndrome characterised by sweating, shakes, agitation, insomnia, headaches, irritability, nausea, vomiting, paraesthesia, clonus
What can be used to treat extra pyramidal side effects?
If too much acetylcholine in relation to dopamine and cannot increase dopamine activity - use acetylcholine receptor antagonists e.g.
procyclidine, benzatropine, trihexphenidyl
What beta blockers are used as an anxiolytic?
Act by reducing autonomic nervous sytem activation
Propranolol
Dangerous in overdose, contraindicated in asthma
What is pregabalin?
Binds to voltage gated calcium channels, reduces neuronal activity - CNS depressant
Used in anxiety, neuropathic pain and epilepsy
Causes sedation and weight gain
What is buspirone?
Non sedating anxiolytic that can be used for GAD
Does not cause dependence, but its anxiolytic effect develops more slowly
Side effects include nausea, headache, light headedness, dizziness
What are the Z drugs?
Zopiclone, zolpidem, zaleplon
Work like benzos, enhance GABA transmission, mainly used as hypnotics as have shorter half lives.
What should you not do when prescribing anxiolytics and hypnotics?
Use readily
Prescribe benzos long term - should not be prescribed for more than 2-4 weeks
Withdraw anxiolytics abruptly
Do not forget alternatives - antidepressants have secondary anxiolytic effects and are safer for long term use
What is ECT?
Passage of small electrical current through the brain to induce a therapeutic modified epileptic seizure
GA given, muscle relaxant e.g. suzamethonium give
Bilateral with electrodes on each side, or non dominant cerebral hemisphere - unilateral ECT
6-12 treatment sessions delivered twice a week
What basic observational changes are noticed in ECT?
EEG changes - seizure
Pulse and BP rise
Cerebral blood flow increases by 200%
What is the seizure threshold?
The minimum electrical stimulus required to induce a seizure, used in calculating the electrical current dose.
What drugs raise the seizure threshold?
Anaesthetic drugs, anticonvulsants, benzodiazepines, barbiturates
What drugs decrease the seizure threshold?
Antipsychotics
Antidepressants
Lithium
What are the main indications for ECT?
Euphoric, Catatonic, Tearful
Prolonged or severe mania
Catatonia
Severe depression - treatment resistant, suicidal ideation or serious risk to others, life threatening e.g. will not eat or drink
How is consent given for ECT?
Written informed consent
For patients detained under MHA - requires independent second opinion
What are the short term side effects of ECT?
PC DAMS
Peripheral nerve palsies
Cardiac arrhythmias, confusion
Dental and oral trauma
Anaesthetic risks - laryngospasm, sore throat, N+V
Muscular aches, headaches
Short term memory impairment, status epilepticus
What are the long term side effects of ECT?
Anterograde and retrograde amnesia
Deficit is greater in those who receive bilateral ECT vs unilateral
What can ECT precipitate in bipolar?
A manic episode
What are the contraindications to ECT?
MI < 3 months Major unstable fracture Aneurysm - cerebral Raised ICP e.g. intracranial bleed, SOL - the only absolute contraindication Stroke <1 month ago, history of status epilepticus Severe anaesthetic risk
