Mental Health Flashcards
1
Q
Affective Disorders
A
- Affect- now VS Mood (longer tone)
- Unipolar affective disorders - depressie episodes, commonly recurrent. Multifactorial (genetic + evnironmental)
- Bipolar affective disorder - 2+ episodes in which patients mood and activity levels are signfiicantly disturbed, sometimes elevation of mood and increased energy/activity and others a lowering mood and decreased energy/activity. BPI (manic or mixed), BPII (depressive + at least one episode hypomania, abnorml but no hosp), BPIII - depressive + hypomania onyl when takign ATD
- Mania = symptoms at least 1 week = elevate ood, increased energy, feelings wlel being, increased sociability, over optimism, overfamiliarity, increased libido, irritability, decreased need for sleep, flight of ides, +-hallucination/delusions…
2
Q
Obsessive Compulsive Disorder
A
- OCD = recurrent obsessional thoughts or compulsive acts, almost invariable distressing + patient often tries unsuccessful to resist them. Functional + considerable stress, ruminatios, rituals.
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Aetiology -
- Bio model (dysfunction orbito-striatal area + dorsolateral prefrontal cortex and underactive serotonergic and overactive glutaminergic).
- Cognitive behavioural model - intrusive thoughts develop to obsession -> more anxiety -> motivates suppression -> ritual behavioural developed ot further reduce anxiety
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Management:
- Psychological - CBT focusing on exposure and response prevention
- Pysical - TCAs/SSRIs, deep brain stimulation, psychosurgery (severe + not responding)
3
Q
Approach to disturbed/violent patient
A
- reassurance, explanation, medication, physical restraint, monitoring
- Verbal de-escalation
- Medications - short acting benzos unless elderly/delerious. Give meds sequentially than together
- Physical restraint - maintian safety + administer IM meds. Adequately trained psychiatric nurses + security staff. Drs not trained
- Monitoring - BP, RR, O2 sats etc wher emeds used.
4
Q
Alcohol abuse + misuse
A
- Problem drinker -> heavy drinker -> binge drinker -> alcohol dependence
- Psychological + social problems - depression, anxiety, domestic violence, child abuse, employment…
- Guidelines - Up to 21 men a week, up to 14units a week women.
- Diagnostic - Elevated y-GT and MCV
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Alcohol dependence synrome -
- Pattern of repeated self-administration that causes tolerance, withdrawal + compulsive taking. Uusally develops after 10yrs hevay drinking men, 3/4women.
- Start to miss meals, restless without it, withdrawl fits, mornign vom etc.
- Diagnosis by 3 symptoms: Tremor, sweating, nasuea, tahcycardia, HBP, anxiety, [sychomotor agitation, ehadache, insomnia, malaise, hallucinations etx. Multifactorial
- Mx -
- Psycho (identify early, cut down, CBT, motivation enhancement therapy, education)
- Drug treatments - Correct electrolytes, dehydration, parenter thaimine, proph phenytoin or carbamzepine if history withdrawl fits. Diazepam/ chlordiazepoxide orally. Add benxo if uncontrolled. To prevent dependence - naltrexone (reduce risk relapse), acamprostate, disulfiram, oral thiamine.
- Delerium Tremens - Most serious withdraway state 1-3days after alcohol cessation. Disororientated, agitated, tremor, hallucinations, sweat. tachycardic, pyrexial and ocmplications including heaptic disease/ WK syndrome..
5
Q
Anxiety
A
- Psychiatric or endocrine (HyperT, hypoghlycaemia, phaeochromocytoma)
- GAD - Anxiety generalised + persistent but not restricted to, or even strongly predominating in, any environmental cirucmstances. Can have physcial symptoms - hyperventialtion, pale, sweaty,restless…
- Mixed anxiety + depressivve disorder - both present, neither predominate so not seperate.
- Phobic disorders- intense fear triggered by sitmulus, or gorup of sotmuli that are predictable and normally cause no particular concern to others so avoidane of stimulus. Knows its irrational but cant control. May be after emotional sock or classically conditions. Agoraphobia )market place), social phobia, simple phobias.
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Managament:
- Psychological - relxation, anxiety management (imagery), biofeedback, behaviour therapies, CBT
- Drug treatments - cessations recreaitonal drugs. Benzos (agonists GABA), SSRIs (lower dose than depression), Antipsychotics (severe/refractory cases), Beta blockers (peirpheral symptoms)
- Acute stress reaction - severe, lastign few dats (intiially numb, dazed)
- Adjustment disorder -can be after acute stress and mor eprolonged (6m)
- Normal grief (shock, disbelief, emotiona phase, acceptance, resolution). Patho s excessive/prolonged/denial
- PTSD - protracted response to stressful event/situation of exceptionally threatening nature, likely to cause distress. Fashbscks, insomnia, anxiety etc. CBT good, SSRIs, venlafaxine.
6
Q
Depression
A
- Depression = mild, moderate, or severe with or without somatic symtpoms. Severe ones divided accordign to presence or absence of psychotic symptoms
- Features (phys, psych, behavioural) - low mood, loss of interest/employment, poor conc, reduced energy, ideas guilty, feelings worthlessness, hopelessness, irritability, social iso, reckles sbehaviours.. Can lead to disturibed sleep, poor appetitie, motor retardation, loss libido, constipation, menstrual cycle changes
- Screening - last month down/depressed/hopless, or little interest or pelasure in doing things.
- More frequent - physical disease, social stres,s interpersonal difficulties.
- Dysthymia - mild/mod depressive illness lasts intermittently 2+ years with tiredness, low mood, lack pleasure, low self esteem, feelings discouragement. Mood relapses/remits
- Seasonal Affective disorder - recurrent episodes depressive illness during winter months in N,hemisphere. Hypersomnia, increased appetite, weight gain, profound fatigue. Bright light therapy in mornign or early evening or SSRIs.
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Puerperal affective disorders:
- Maternity blues - brief ep, emotional lability, iritability, tearfullness 2-3days postpartum spontaneously resolves.
- Postpartum psychosis - usually within 2weeks after dleivery, classical psychosis features and disorientation and confusion.
- Non-psychotic postnatal depressive disorders - 1st postpartum year especially within3m. RFs are 1st preg, poor relationship with partner, ambivalence, emotional perosnality traits.
- DDx - psychiatric or organic (secondary) affective illnesses.
- Ix - hsiotry guides tests.
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Mx - phsycial (stop drugs, reg exercise, ATDs-SSRIs, ECT), psychological - education, follow up, CBT, psychotherapies), social (finance, employment, housing, children)
- Psych - CBT, inteprersonal therapy, couple/family therapy.
7
Q
ATDs and other treatments
A
- SSRIs - less A/Es than TCA (no weight gain), but can cause SE liek nausea, dry mouth, diarrhea etc. Watc for serotonin syndrom when 2+ durgs increasing serotonin as leads to confusion, tremor, tachycardia, HBP. Cant stop suddently or headache, dizzy, anxiety etc/
- TCAs -potential action of monoamines, NA, Serotonin but inhibitor their reuptake into nerve terminas. A/Es, wieght gain, antimsucaricin, CV. Toxic in overdose so not for those suicidal.
- SNRIs - serotonin and NA reuptake inhibitors. Velafaxine , duloxetine
- Tetracyclics - Trazodone - serotonin antagonist and reuptake inhibitor for anxiety/depression + insomnia. monitor BP, can be dizzy
- Mirtazapine - T-HT2+T-HT3 recepto antagonist nd potent A2-adrenergic blocker. Increased NA and serotonin transmission. Can aid sleep low doses. Weight gain
- NA reuptake inhibitors (NRIs) - Reboxetine, ATD and panic disorder and ADHD. Insomniamantimuscarinic
- Monamine oxidase inhibitors - irreversible inibitors of monoamine oxidase A/B -. increase NA, dopaimine, H-HT. Rare as S/E can produce dangerous hyerptensive reactions with foods with tyramine (cheese, red wine) or dopamine (broad beans). Also reatx with pethidine-> liver damage
- RIMA - reverisble inhibitors monoamine oxidase A -mocloevemide
- Selective irreversible inhibitor Monoamine oxidase b - Selegilline. for pakrinsons
- Melatonin Receptor agonist and serotonin receptor antagonist - Agomelatine
- If 2 trials fails can augmentaitonw hich is 2 cncomitant drugs
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Other ATDS teatment :
- ECT - electroconvulsive therapy for life-threatenign depressive illness particularly with psychotic symptoms. GA, electric current scross 2electrodes on scalp to induce seize, 2xweek 3-6weeks. Free serious S/E
- Rare: Transcranial magnetic stimulation, psychosugery occaisonal for sever eintractable deprrivess illnes sif all else fails and vagal nerve and deep brain stimualtion
- Social treatment - groups, educational programes etc
8
Q
ATDs
A
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TCA: Block serotonin and NA reuptake, increasing noradrenergic and serotoninergic Neurotransmission. Eg amitriptyline
- Amitryptyline, Lofepramine, Clomipramine, Dosulepin, Trazodone
- Sedating, antimuscarinic effects, toxic in overdoses, quicker onset than SSRIs
- Dosulepin highly cardiotoxic/fatal in overdose. Do not use as Lofepramine safest.
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SSRIs : blocks serotonin re-uptake, increasing serotonergic neurotransmission. Eg, cirtraline
- Fluoextine, Sertraline, Citalopram Escitalopram, Paroxetine
- May increase agitation/anxiety, sexual dysfunction, increased risk of GI bleeds, less sedating, safer in CHD and overdose
- Es/citalopram cause QT prolongation.
- WIthdraal syndrome with paroxetine
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SNRI (Serotonin/NA reuptake inhibitor) : Blok serotonin, NA and possibly dopamine reuptake, increasing serotonergic and noradrenergic Neurotransmission.
- Venlafaxine, Duloxetine
- Raise BP at higher doses, sexual dysfunction, toxic in overdose, non-sedating
- Venlafaxine – SSRI action only up to 150mg/day, high risk of withdrawal effects
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NaSSa= (Noradrenaline and specific serotonergic antidepressant): Block re-synaptic a2-adrenoreceptors increasing NA and serotonergic neurotransmission. Eg, aptazapine
- Mirtrazapine
- Weight gain, sedation, safer in overdose
- More sedating at lower doses
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MAOI ( mono-amine oxidase inhibitor) : Block enzymatic breakdown of NA, serotonin and dopamine and tyramine increasing neurotransmission. Eg Phenelzine.
- Phenelzine, Tranylcypromine
- Interaction with foods
- Specialist use only
- Other: Agomelatine, vortioxetine. Both licensed of major depression only and can cause liver toxicity. Nice approved.
Be careful - in first few weeks risk suicidal thoughts, risk hyponatraemia due to inappropriare secretio ADH.
9
Q
Anti-psychotics
A
Anti-Psychotics: Increase in dopamine causes positive symptoms of schizophrenia eg, mania. Deficit in dopamine causes negative and cognitive symptoms of schizoprohrenia eg, apathy, motivation. Weight gain is a common S/E antipsychotics
- First generation: Act predominantly by blocking dopamine D2 receptors. Not selective for any of the 4 dopamine pathways in the brain so cause a range of side effects eg, epse, elevated prolactin. Eg, haloperidol, etc.
- Second generation: Atypical ones, act on a range of receptors, including Serotonin receptors. More idstinct clinical profiles and side effects. Eg, clozapine
- Adverse effects of atypical antipsychotics = Weight gain, clozapine associated with agranulocytosis and hyperprolactinaemia.
- Clozapine = most effective antipsychotic but S/Es = Hypersalivation, hyperthermia, tachycardia, constipation, seizures, myocarditis, agranulocytosis. need blood monitoring for neutropenia and agranulocytosis. Fatalities form bowel impaction.
- Monitoring for antipsychotics: Baseline ECG, bloods, weight , Bp
10
Q
Antimuscarinics
A
- For antipsychotic-induced parkinsonism/EPSEs: Procyclidine, trihexyphenidyl, orphenadrine
- For hypersalivation – hyoscine hydrobromide – patches or sublingual tablets.
11
Q
Mood stabilisers
A
Drugs for bipolar and mania. Depression is recurrent episodes of low and bipolar is both low and high episodes outside of normal range.
- Acute phase – benzodiazepines (lorazepam short term), antipsychotics
- Long term – carbamazepine, valproate, lamotrigine, lithium
Lithium: Narrow therapeutic index, close monitoring, tests. Signs toxicity - loss app, nausea, diarrhea, muscle weaknnes, twitching, dorwsines, coarse tremor, ataxia. Interacts with NSAIDs, thiazide diuretics, ACE inhibitors.
12
Q
Hypnotics
A
- Benzodiazepines: Temazepam (short acting) = act on receptors associated with GABA an inhibitory transmitter. High potential for dependency
- Z drugs: Zaleplon, zolpidem zopiclone.
- Others = Promethazine (antihistamine), melatonin ((pineal hormone)
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13
Q
Anxiolytic short term
A
(as long term is CBT and SSRIS):
- Benzodiazepines: Diazepam (long acting), lorazepam (short acting), chlordiazepoxide (alcohol detox, oxazepam for liver impairment)
- Others: Buspirone (low pot for dependency), pregabalin (antiepileptic licensed for GAD and neuropathic pain) and barbiturates which are no longer recommended.
14
Q
Dementia drugs
A
- Mild to moderate Alzheimer’s: Acetylcholinesterase inhibitors – donepezil (1st line) and rivastigmine/Galantamine (2nd line).
- Severe – or if AChei not tolerated then memantine (glutamine receptor antagonist)
- Behavioural and psychological symptoms: AChEis, memantine, antipsychotics, antidepressants, benzodiazepines
15
Q
Memory Drugs
A
- Acetylcholinesterase inhibitors: prevents Ache from breaking down Ach. Licensed for midl to moderate Alzheimer’s.
- S/E = loss appetitie, nausea, vomiting, diarrhoea, dizzy, bradycardia, insomnia.
