Mental Health

Question 1

DDx for new-onset psychosis

Answer 1

Primary/Psychiatry
- Schizophrenia spectrum
Secondary/Organic

Question 2

Ix to differentiate between organic & functional cause

Answer 2

1. bloods - FBC, U+Es, LFTs, TFTs, Bone profile (calcium), Mg&PO4, VitB12 and folate, CRP, Prolactin
2. urine drug screen
   urine MC&S
   urine - pregnancy
3. ECG
4. CXR
   Brain imaging - CT, MRI, PET
   CSF analysis
   NMDA receptor antibodies

Question 3

Purpose of Ix in pyschiatry

Answer 3

1. To determine DDx/ co-morboities

2. To determine base- line results before starting ANY psychotrophics + drug monitoring.

Question 4

DDx for depression

Answer 4

• Infections ( post viral infections)
• Thyroid disorder
• Adrenal dysfunction
• Autoimmune disorder
• Early dementia
• Brain tumour (neurological issue)
  Medication

Question 5

DDx for mania

Answer 5

• Thyroid disorder
• Infections
• Intoxication
• Drug SE e.g. steroids
• Agitated delirium
• ?brain tumour

Question 6

DDx for psychosis

Answer 6

• Autoimmune
• Brain tumour
• Encephalopathy
• Dementia
• Endocrine

Question 7

Causes of delirium

Answer 7

D - drugs
E- epilepsy, electrolyte imbalance
L- liver failure, low O2
I - Infection
R - Retention
I - Intracranial
U - Uraemia
M - metabolism

Question 8

Why do you monitor antipsychotics?

Answer 8

1. General health measures
2. Metabolic side effects of drugs ( weight gain, glucose intolerance, altered lipids)
3. Risk of neuroleptic malignant syndrome ( a rare but LIFE THREATINING reaction to neuroleptic medications)
4. Other potential side effects ( hyperprolactinemia, altered thyroid function, cardiac abnormalities)

Question 9

Why is ECG monitoring essential in psychiatry?

Answer 9

querying prolonged QT interval —> Torsade de points

Question 10

What medications can cause pronlonged QT interval?

Answer 10

Amitriptylne, 
citolopram, 
MOST antipsychotics, 
lithium 
antibitoics

Question 11

How often do you monitor when prescribing antipsychotics?

Answer 11

baseline:
fasting glucose, lipid profile, FBC, LFTs, U&e, eGFR, CPK, weight, BMI, pulse, blood pressure and prolactin if indicated, TFTs (with quetiapine only), ECG

3 monthly: lipid profile and weight checks

4-6 monthly: plasma glucose checks

6 monthly: prolactin

Annually - repeat baseline bloods

Question 12

Examples of antipsychotics

Answer 12

risperidone
quetiapine
olanzapine
clozapine

Question 13

What is clozapine?

Answer 13

2nd generation (atypical) antipsychotic

Question 14

What is a risk of cloazapine?

How do monitor this?

Answer 14

Risk of neutropenia and agranulocytosis

Monitoring:
• Check FBC at baseline
• Weekly FBC for 18 weeks
• Fortnightly FBC for remainder of 1st year
• Monthly FBC thereafter
• In addition to monitoring for metabolic side effects

Question 15

Side effects of clozapine

Answer 15

Hypersalivation 
Constipation
Sedation
More prone to getting epilepsy
Tachycardia (in first 2 months --> further assessment)
Prolonged QT
myocarditis

Question 16

If myocarditis/cardiomyopathy suspected clozapine, what should you do?

Answer 16

Clozapine should be stopped and patient referred urgently by cardiologist

Question 17

What is lithium?

Answer 17

Mood stabiliser

Question 18

Baseline monitoring for lithium - tests

Answer 18

ECG, TFTs, eGFR & calcium.

Question 19

When do you monitor lithium levels and what other tests do you monitor after initiation?

Answer 19

6 monthly: ECG, TFT, eGFR

3 monthly: Lithium levels (1 week after initiation or dose change, 3 monthly when dose
stable)

Question 20

What is sodium valproate?

Answer 20

Antiepileptic medication, used as a mood stabiliser and for acute mania

Question 21

When & What do you monitor in sodium valproate?

Answer 21

6 months: BMI, weight, FBC & LFT, fasting

Annual: FBC, LFTs, eGFR, TFTs

Levels not routinely checked

Question 22

Side effect of sodium valproate

Answer 22

teratogenic