Mental health

Question 1

What are signs of opioid dependency? What are risk factors?

Answer 1

Drug seeking behaviour, prev excess use, withdrawal symptoms. RF: mental illness, negative life events, unemployment, social isolation, poverty, substance use in peers.

Question 2

What are the diagnostic criteria of depression?

Answer 2

Low mood or anhedonia + 4 of: weight loss/gain, insomnia/hypersomnia, fatigue, inability to concentrate, feelings of worthlessness/guilt, thoughts of death, psychomotor agitation or retardation.

Question 3

How are antidepressants started and monitored? How are they stopped?

Answer 3

Review at 2-4 weeks, check lifestyle and increase if needed. If no response, switch. Continue 6-12mo. Wean 25-50% every 1-4 weeks, down to half tab for 2 weeks. Slow wean SNRI, anxiety, or long treatment.

Question 4

What are common side effects of SSRIs, SNRIs and TCAs?

Answer 4

Sexual difficulty, sedation/fatigue, anticholinergic esp TCA (tremor, dry mouth), GI symptoms, weight gain esp TCA.

Question 5

What are the 5 diagnostic features of PTSD? Timing?

Answer 5

Exposure to death/injury or sexual violence; event persistently re-experienced (nightmares, flashbacks, intrusions); avoidance of thoughts/people/places related; negative changes to mood and cognition; hyperarousal (poor sleep, irritable, reckless). For >1mo, otherwise acute stress disorder.

Question 6

How is PTSD treated?

Answer 6

Trauma focussed CBT (support, debrief). Eye movement desensitisation and reprocessing. Emotional regulation skills. Sleep hygiene. SSRIs maybe as adjunct.

Question 7

What are the differentials in someone with psychotic symptoms?

Answer 7

Mania, postpartum psychosis, psychotic depression, personality disorder. Brain lesion, HIV, neurosyphilis, heavy metal toxicity, hyperthryoid, electrolyte abnormality, lupus, withdrawal/intoxication.

Question 8

What are the diagnostic criteria for diagnosis of schizophrenia?

Answer 8

At least 2 with psychosis over 1mo: delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms , with continuous symptoms for 6mo and functional decline.

Question 9

What are 4 differentials of schizophrenia - features/criteria.

Answer 9

Brief psychotic disorder < 1mo. Schizoaffective disorder - separate mood disorder + 2 weeks of psychotic symptoms. Schizophreniform disorder: psychosis >1mo but overall symptoms < 6mo. Substance induced psychotic disorder - psychosis after substance use.

Question 10

What are 5 types of side effects of antipsychotics?

Answer 10

EPSE - akathisia (restlessness) esp haloperidol; parksinonism; tardive dyskinesia (repetitive choreiform movements); metabolic SE esp olanzapine/quetiapine/risperidone; prolactinaemia (eridones)

Question 11

What are the features of neuroleptic malignant syndrome?

Answer 11

Related to antipsychotics, develops over days. EPSE, temp dysregulation, confusion, hypertension, hyporeflexia, leadpipe rigidity. Treat w bromocriptine.

Question 12

What regular monitor is required for patients on antipsychotics?

Answer 12

CVD risk 3mo (1mo first), BP + HbA1c + lipids + weight/waist 6mo, ECG + FBE + prolactin annually. Check for EPSE and sexual dysfunction.

Question 13

What monitoring is done regularly for a patient on lithium? What meds can interact?

Answer 13

Levels 8-12h post dose and renal fx 3-6mo. TFT, ca + weight annual. Meds: ACEI , NSAIDs, thiazides.

Question 14

What are the symptoms of acute lithium toxicity? What tests to do and what levels concerning?

Answer 14

GI (N/V/D), CNS tremor, hyperreflexia, seizure; CV: QT prolongation, hypotension. Check ECG, UEC + Li. Li level not always correlate, but monitor - 2.5-3.5 rigid, drowsy, >3.5 is severe.

Question 15

What are the risk factors for chronic lithium poisoning? What complication can occur? How is it managed?

Answer 15

Age >50, dehydration, renal impairment, thyroid dysfunction, drugs (ACE, NSAID, Thiazide). Can cause nephrogenic diabetic insipidus - thirst, urine, high sodium. Maintain hydration, may need haemodialysis.

Question 16

Lithium in pregnancy - risks, monitoring.

Answer 16

Risk foetal heart defects, regular monitoring - U/S baby heart, monitor for relapses, avoid abrupt cessation. Not for use in breastfeeding.

Question 17

What are criteria for admission in the setting of an eating disorder?

Answer 17

HR < 40 or >120 (< 50 kids), SBP < 90 (< 80 kids) or postural drop of 20, Prolonged QT, Temp < 35, hypokalaemia < 3, neutropaenia < 1, rapid weight loss.

Question 18

What are 5 screening questions for an eating disorder? What is 1st line treatment?

Answer 18

Make yourself sick because uncomfortably full? Worry lost control over how much you eat? Lost more than one stone (6kg) in 3mo? Believe fat when others say thin? Food dominate life? Family based therapy or CBT.

Question 19

What are the risks of clozapine? What monitoring is required?

Answer 19

Neutropaenia, agranulocytosis, myocarditis, cardiomyopathy. Initially: daily temps, weekly FBE, ECG, troponin and CRP for 4mo. Later do monthly checks. Annual echo. Clozapine level 6mo when stable.

Question 20

What are the diagnostic features of borderline personality disorder?

Answer 20

Efforts to avoid abandonment, unstable and intense relationships, unstable self image, impulsivity, recurrent suicidal behaviour, affective instability (mood reactivity), feelings of emptiness, inappropriate intense anger, transient paranoid ideation or dissociative symptoms.

Question 21

What are the criteria for acute mania?

Answer 21

Elevated/expansile/irritable mood, accelerated speech, racing thoughts, reduced need for sleep, distractibility, increase in goal directed activity. Grandiose ideas, reckless actions, increased sex drive. Lasting 1 week or hospitalised.

Question 22

How is bipolar treated? Pharm + nonpharm.

Answer 22

If acute mania - olanzapine, risperidone. Lithium, valproate, lamotirgine, carbamazepine - stabilisers. Ongoing monitoring, relapse prevention plan, psychology, lifestyle management. Avoid SSRI as monotherapy.

Question 23

What factors are considered in assessing suicidality?

Answer 23

Static vs dynamic. Plans, means of harm (access to weapons), previous attempts, family or peer history of suicide, substance use, actions of settling affairs.

Question 24

What is involved in a safety plan for suicidality/mental health crisis?

Answer 24

Identify warning signs, identify coping strategies + reasons to live, involve family/friends for distraction or solutions, contact clinicians, restrict access to lethal means.

Question 25

What are the 5 features of trauma informed care?

Answer 25

Optimise sense of safety, foster capacity to soothe physiological arousal, validate concerns, collaborate/empower decision making, develop therapeutic relationship.

Question 26

What are the systemic, individual and professional barriers to CVD in the setting of severe mental illness?

Answer 26

S: poor integration between sectors, short consults, poor funding. I: medications SE, fear of judgement, mistrust of system, financial barrier, poor health literacy. P: stigma, focus on psych issues, limited guidance.

Question 27

What is OCD? What are 5 types of obssession in OCD? How is OCD treated?

Answer 27

Intrusive/unwanted thought/image + repetitive behaviour/mental act compelled to avoid discomfort. Preventing harm, symmetry, contamination, repugnant (sex, violence), hoarding. CBT w exposure and response prevention component. SSRI at high dose. 3rd line is psych for clomipramine.

Question 28

What is complicated grief and risk?

Answer 28

Grief impacting function, >6 mo - feelings of purposelessness, intense guilt, not improving. Thought of death reuinting is red flag for suicide.

Question 29

What are the symptoms of serotonin syndrome (mild > severe) ? What are 5 differentials?

Answer 29

CNS: confusion > agitation/distress. Autonomic: tachycardia, dry membranes > hyperthermia, HTN, fever. Neuromuscular: tremor, hyperreflexia, babinski > clonus. DDx: NMS, CNS infection, withdrawal, sepsis, amphetamine use.

Question 30

How is serotonin syndrome managed? Mild and severe.

Answer 30

Stop drugs. Supportive care - consider benzos or cyproheptadine. If severe, emergency, discuss w toxicology, cool IV fluids, sedation and seizure management.