Mental Health Flashcards
Anxiety
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
At least 6 months of excessive worry about everyday issues that is disproportionate to any inherent risk, causing distress or impairment
Contributing factors
- Increase in minor life stressors
- Presence of physical or emotional trauma
- Genetic factors
RF:
- Family history of anxiety
- Female
- Increased stress
- History of physical or emotional trauma
- Comorbid depression
- Substance misuse/dependence
- Other anxiety disorder
- Divorced/separated
- Living alone
- Being lone parent
CLINICAL FEATURES
excessive worry for at least 6 months
6 core symptoms:
- Muscle tension- common
- Irritability- common
- Restlessness- common
- Sleep disturbance
- Fatigue
- Poor concentration
other:
- Headache
- Sweating
- Dizziness
- GI symptoms
- Trembling
INVESTIGATIONS
Clinical Diagnosis but can exclude others
Hyperthyroidism through doing TFTs- anxiety & symptoms may be sign of thyroid disease
Urine drug screen
MANAGEMENT
- Step 1- education & monitoring
- Step 2- low intensity psychological intervention
- Step 3- CBT or pharmacology
1st line = CBT along with relaxation/mindfulness/sleep hygiene/ exercise
1st line drug: SSRI sertraline
2nd line: Another SSRI or SNRI (duloxetine or venlafaxine)
if cant tolerate SSRI or SNRI: pregabalin
COMPLICATIONS
- Comorbid depression
- Comorbid substance misuse
PROGNOSIS
With proper treatment, a decrease in symptoms, improved psychosocial functioning, and a reduction in over-utilisation of medical care can be achieved
GAD may recur under physical or emotional stress
Depression
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Major depressive disorder MDD: Episodic mood disorder primarily characterised by depressed mood and anhedonia lasting for at least 2 weeks
- F>M
- 3rd decade of life
- Affects 5-10% of patients in primary care setting
- 1/5 nursing home residents without dementia are diagnosed with depression
Cause: Lack of monoamines (serotonin, noradrenaline, dopamine)
RF:
- Female
- Recent childbirth
- Stress
- Trauma
- Co-existing medical conditions
- Personal or family history of depression
CLINICAL FEATURES
- Depressed mood- most of the day, nearly every day, for 2 weeks
- Anhedonia- diminished interest or pleasure in all activities for 2 weeks
other:
- Sleep disturbance (insomnia or hypersomnia)
- Guilt/worthlessness feelings
- Fatigue
- Diminished concentration or cognition
- Weight change due to appetite change
- Agitation (change in activity)
- Suicidal ideation
MDD is diagnosed by : Depressed mood OR anhedonia + 4 other symptoms of depression for min. 2 weeks
INVESTIGATIONS
Exclude:
- FBC (anaemia)
- TFTs (hypothyroidism)
- Metabolic panel
Patient Health Questionnaire 9 (PHQ-9)
‘less severe’ depression: (mild depression)= a PHQ-9 score of < 16
‘more severe’ depression: (moderate and severe depression)= a PHQ-9 score of ≥ 16
Hospital anxiety and depression HAD scale
MANAGEEMNT
Mild: consider drugs but
guided self-help
group cognitive behavioural therapy (CBT)
group behavioural activation (BA)
individual CBT
individual BA
group exercise
group mindfulness and meditation
interpersonal psychotherapy (IPT)
selective serotonin reuptake inhibitors (SSRIs)
counselling
short-term psychodynamic psychotherapy (STPP)
- SSRIs (e.g. citalopram or sertraline, fluoxetine)
- Alternatively SNRIs (venlafaxine, duloxetine)
- Or MAO inhibitors (isocarboxazid)
- Or TCAs (amitriptyline)
Fluoxetine for adolescents and children
Sertraline post MI
Should be continued for at least 6 months after remission of symptoms to decrease risk of relapse
When stopping them, doses should be reduced gradually over 4 weeks
Cognitive Behavioural Therapy (CBT)
Lifestyle:
- Exercise
- Nutrition
- Sleep hygiene
- Social support
- Stress reduction
COMPLICATIONS
- Self harm
- Weight gain from antidepressants
- Sexual adverse effects of SSRIs
PROGNOSIS
in first episode, remission may take several months, should be continued for a minimum of 9 to 12 months after remission
SSRI side effcts
- GI side effects
- If used with NSAIDS there’s high risk of GI bleeding (co-prescribe PPI)
- Erectile dysfunction
- Hyponatraemia (SIADH)
- Citalopram prolongs QT interval
Opiate overdose
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
- Codeine
- Dimorphine
- Fentanyl
- Loperamide
usually Heroin and Morphine
RF:
- Renal impairment- can’t excrete drug
- Mental health conditions
- Alcoholics
CLINICAL FEATURES
- Bilateral miosis (pinpoint pupils)
- Resp depression (bradypnoea)
- Altered mental status
- Constipation
- Needle track marks
- Rhinorrhoea
INVESTIGATIONS
Toxicology screen
Therapeutic trial of naloxone- may show reversal of overdose signs
MANAGEMENT
- Airway management & oxygen
- IV naloxone
Paracetomol overdose
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Max dose: 2 x 500mg tablets, 4x in 24 hours (max is 4g in 1 day)
two types;
Acute overdose or staggered overdose
Hepatotoxicity
patients at increased risk :
- Chronic alcohol use
- HIV
- p450 inducers (SCARS)
- Malnourished patients (e.g. anorexia)
Prognostic based on Arterial pH (<7.30) → bad
CLINICAL FEATURES
Patients may initally present asymptomatic or mild GI symptoms
- nausea & vomiting
- RUQ pain
- jaundice (may signify acute liver failure)
- hepatomegaly
- altered conscious level
INVESTIGATIONS
Toxicology screen
- Serum paracetamol concentration (whether treated or not based on nomogram)
- LFTs (ALT may be elevated)
- PT may be prolonged
- pH <7.3 is bad
TREATMENT
- If <1 hour after ingestion and not staggered overdose- activated charcoal
- If ingestion <4 hours ago- wait until 4 hours to take a level then treat with N-acetylcysteine based on level
- If ingestion 4-15 hours ago- take immediate level and treat based on level
- If staggered overdose (over >1 hour time period) or ingestion >15 hours ago/timing uncertainty then IV N-acetylcysteine
liver transplant
If pH <7.3 more than 24 hours after ingestion
Aspirin/salicylate toxicity overdose
- aetiology: define, types, risk factors, stages
- clinical features
- investigations
- management
- prognosis + complication
Mixed resp alkalosis (due to hyperventilation) and raised anion gap metabolic acidosis (due to toxicity and acute renal failure)
Affects kidneys as nephrotoxic
CLINICAL FEATURES
- tinnitus
- nausea and vomiting
- lethargy
- tachypnoea (hyperventilation)
- diaphoresis- excessive sweating
- hyperthermia
- agitation
- seizures
- coma
INVESTIGATIONS
Toxicology screen
- ABG (mixed resp alkalosis and metabolic acidosis with raised anion gap)
- Salicylate levels- repeat every 2 hours until peak level
Classified according to peak salicylate levels:
- Mild <300 mg/L
- Moderate 300-700 mg/L
- Severe >700 mg/L
MANAGEMENT
- Activated charcoal → can be used within 1 hour of overdose
- IV Sodium bicarbonate → alkalizes urine to increase aspirin elimination in urine. MUST be IV if give oral can cause gut to breakdown more aspirin so more poisoning
- Haemodialysis → if pulmonary oedema and severe metabolic acidosis
TCA overdose/Tricyclic and tetracyclic antidepressant
CLINICAL FEATURES
- dry mouth and dry hot skin
- dilated pupils
- agitation
- blurred vision
- arrhythmias (prolonged QT interval and QRS widening)
- convulsions
- altered mental status
INVESTIGATIONS
Toxicology
ECG → wide QRS >100ms associated with seizures and >160ms with ventricular arrhythmias
MANAGEMENT
IV sodium bicarbonate
