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Clinical - Rosie > Mental health > Flashcards

Mental health Flashcards

1
Q

What are the core symptoms of depression?

A
  1. Depressed mood - this varies little from day to day and is often unrelated to circumstances; however; this symptom can show a characteristic diurnal variation with mood being worse in the morning and lifting slightly as the day goes on.
  2. Loss of interest and enjoyment - including in activities that are normally enjoyable for that person; patient often experiences loss of libido and lack of emotional reactivity to surroundings and events they would normally find pleasurable
  3. Reduced energy - leading to increased fatigue and diminished activity (sometimes patients can also experience psychomotor retardation)
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2
Q

How should we screen/identify people for depression?

A

To help identify people who are suffering from depression it is recommended to use the patient-health-questionnaire 2 (PH-2):

  • over the past two weeks, how often have you had little interest or pleasure in doing things?
  • Over the past two weeks, how often have you felt down, depressed or hopeless?
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3
Q

What drugs are known to possibly cause drug-induced depression?

A

Psychiatric ADRs, including depression can occur with use of centrally acting medicines such as opiates, antiepileptics (e.g. carbamazepine, sodium valproate) and many antiparkinsonian treatments.

Corticosteroids have been clearly linked with a wide range of psychiatric ADRs, including mood disorders and suicidal ideation

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4
Q

Antidepressant medication should be offerred to who?

A

Patients with moderate to severe depression

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5
Q

Why are SSRIs the antidepressant of choice?

A

They have a more favorable risk-benefit ratio than the other class

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6
Q

How long should maintenance treatment be continued for?

A

Once a patient finds an antidepressant that works and is well tolerated it should be continued for at least 6 months after remission from the acute episode.

This maintenance treatment period should be extended to 12 months for older adults and to 24 months for people who have recently had two or more depressive episodes that ave caused considerable functional impairment.

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7
Q

Why is fluoxetine not the SSRI of choice, especially in older adults?

A

Has more drug interactions that other SSRIs, the active metabolite has a long half-life and there is therefore risk of accumulation. Insomnia and agitation are possible worse than with other SSRIs

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8
Q

What is the only antidepressant licensed for use use in children?

A

Fluoxetine

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9
Q

Why is fluvoaxamine rarely used?

A

Rarely used because it is poorly tolerated and it has more drug interactions than other SSRIs

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10
Q

What needs to be taken into account when starting and stopping paroxetine?

A

More drug interactions that other SSRIs, care should be taken when stopping it because of the risk of withdrawal symptoms due to its short half life.

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11
Q

Which SSRI has the fewest drug interactions and is usually the SSRI of choice?

A

Sertraline

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12
Q

Which antidepressant in the preferred in patients who have suffered a myocardial infarction or who have unstable angina?

A

Sertraline

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13
Q

What key monitoring is required with venlafaxine?

A

Blood pressure - especially at higher doses.

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14
Q

What treatment options are there for treatment resistant depression?

A

MAO Phenelzine
Augmentation of existing antidepressant treatment with lithium, an atypical antipsychotic or another antidepressant e.g. mirtazapine.

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15
Q

When in electroconvulsive therapy considered?

A

Treatment option for acute severe depression that has not responded to medicines.
It is also an option if a person’s depressive illness is life-threatening and a rapid improvement in clinical condition is required.

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16
Q

What should be considered when starting antidepressants in elderly?

A

Due to PK changes usually require lower doses
More sensitive to adverse effects - increased risk of falls
May take longer to respond to treatment
Older adults take numerous medicines - increasing the potential for drug interactions.

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17
Q

What dose of fluoxetine is advised in children? How should this be given?

A

The dose of fluoxetine is usally 10mg daily, for which the syrup (20mg/5ml) should be used.

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18
Q

What antidepressants are often consifered the first choice in pregnancy?

A

TCAs (amitriptyline and imipramine) are often consifered the choice when starting an antidepressant in pregnancy - based on cumulative data demonstrating no evidence of increased birth defects.

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19
Q

What has fluoxetine and paroxetine been linked with when used in pregnancy?

A

Small increased risk of congenital cardiac effects.

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20
Q

All antidepressants used throughout pregnancy carry the risk of what’?

A

Carry the risk of neonatal withdrawal or toxicity - should be monitored for signs of this.

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21
Q

Which drug is the drug of choice durign breast feeding?

A

levels of sertraline are low and so it is usually recommended first line.

TCAs can also be used in breast feeding

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22
Q

Which SSRIs should be avoided in breast feeding?

A

Levels of citalopram and fluoxetine in breast milk are high and so use of these medicines are generally avoided.

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23
Q

What might be signs of hyponatremia?

A

Drowsiness, confusion or convulsions.

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24
Q

How might use of antidepressants be affected by bledding disorders?

A

SSRIs block uptake of serotonin into platelets which leads to reduced platelet aggregation and prolonged bleeding time. Where possible SSRIs should be avoided in patients at risk of GI bleeding e.g. those taking aspirin or NSAIDS or those with a history of bleeding.

If patient requires both then a PPI should be offered.

Patients prescribed heparin or warfarin should not be started on an SSRI.

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25
Q

What is the problem with antidepressant use in epilepsy?

A

Almost all antidepressants are known to decrease to the seizure threshold to varying extents.

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26
Q

Which antidepressants are thought to be the least pro-convulsive, for use in epilepsy?

A

The SSRis

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27
Q

What is serotoin syndrome? Outline the symptoms

A

Serotoin syndrome is an acute, rare and potentially lifethreateniing condition caused by excess central serotonin activity. Usually caysed by use of one or more serotenergic medicines.

Symptoms include agitation, restlessness, confusion, neuromuscular hyperactivity, autonomic instability, sweating, diarrhoea, tremors, shivering and hyperthermia.

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28
Q

What is mirtazipine?

A

A presynaptic alpha2-antagonist

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29
Q

What side effects of mirtazipine might actually be useful in some patients with depression?

A

Increased appetite and weight gain

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30
Q

Why is St Johns wart not recommended for use in people with depression?

A

In the UK it is not regulated as a medicines and preparations are not standardised, so the amount of active ingredient varies between preparations.

31
Q

Symptoms of schizophrenia are usually divided into two groups, what are these?

A

Positive symptoms - experiences which are in addition to reality
Negative symptoms - loss of normal responses/experiences

32
Q

What are the characteristic symptoms of Schizophrenia?

A

Delusions, hallucinations, disorganized speech, grossly disorganised behavior, negative symptoms.

33
Q

What is the dopamine hypothesis in terms of schizophrenia?

A

Drugs which increase dopamine in the CNS produce psychotic-like symptoms in some instances. Our current pharmacological treatments block dopamine receptors.

34
Q

What are the possible causes of depression?

A

Genetic, psychological (e.g. adverse life events), drug induced, concurrent chronic illness

35
Q

What influences our choice of antidepressant?

A 
Safety 
Effectiveness
Tolerability 
Cost
PREVIOUS ANTIDEPRESSANT HISTORY
36
Q

Outline the SSRI side effect profile

A

GI, sexual dysfunction, increased anxiety initial

37
Q

Outline side effects associated with TCAs

A

Postural hypotension, sedation, anticholinergic

TCAs generally have more side effects than SSRIs

38
Q

Why can mirtazipine be used in combination with other antidepressants?

A

Different mode of act to SSRIs and SSNRI

39
Q

What issues are associated with MAOIs?

A 
Dietary restrictions (interacts with tyramine e.g. cheese or red wine) and other drug interactions. 
Leads to hypertensive crisis.
40
Q

Are antidepressants addictive?

A

No - but can cause withdrawal symptoms, important to counsel patient on this and explain it is not the same thing.

41
Q

How does NICE recommend that decide which antipsychotic to use in schizophrenia?

A

The choice of antipsychotic should be made by the service user and healthcare professional together, takign into account the views or the patient and carer. Provide information about the likely benefits and possible side effects of each drug. TREATMENT WITH ANTIPSYCHOTC MEDICATION SHOULD BE CONSIDERED AN EXPLICITY INDIVIDUAL THERAPEUTIC TRIAL.

42
Q

How long should an antipsychotic be trialed for?

A

4-6 weeks once at optimum dosage.

43
Q

The use of antidepressants in patients with subthreshold or mild symtpoms is not advised because the risk-benefit ratio is poor, BUT should be considered for people with……?

A

A past history of moderate or severe depression
Initial presentation of subthreshold depressive symptoms that have been present for - long period (at least 2 years) or symptoms that persist after other interventions.

44
Q

Using DSM-IV what is meant by subthreshold depression?

A

Fewer than 5 symptoms

45
Q

Using DSM-IV what is meant by mild depression?

A

Few, if any, symptoms in excess of 5 required to make the diagnosis and symptoms result in only minor functional impairment.

46
Q

Using DSM-IV what is meant by moderate depression?

A

Symptoms of functional impairment are between mild and severe

47
Q

Using DSM-IV what is meant by severe depression?

A

Most symptoms and the symptoms markedly intefer with functioning.

48
Q

What are the three commonly used depression questionnaries?

A

PHQ-9, HADS and BDI-II

49
Q

A PHQ-9 score of X is when interventions should be considered

A

12 or less.

50
Q

At what age does schizophrenia normally present?

A

between the ages of 18-30 years

51
Q

Outline what monitoring should occur in patients with a severe mental illness such as schizophrenia

A

Monitoring at baseline and then at least every 12 months thereafter - depending on medication.

U&Es, LFTs, FBC, thyroid function, lipid profile, prolactin, weight and height, blood pressure, pulse

52
Q

What is fluoextine associated with a lower risk of dicontinuation symptoms?

A

Its long half lie

53
Q

When SSRIs are not appropriate, what is the first line alternative for depression?

A

Mirtazipine

54
Q

In patients with liver disease what is the 1st choice antidepressant?

A

Paroxetine (and then citalopram)

55
Q

In patients with renal impairment, what is the 1st choice antidepressant

A

Citalopram or sertrlaine.

56
Q

How soon after starting an antidepressant can a response be expected?

A

Patient may see a slight response within the first week. Patients usually respond within 2-4 weeks to some extent but not always fully. However early response is a good predictor of overall response.

57
Q

The maximum citalopram dose is 40mg, in what patient groups in this max dose lowered?

A

Elderly (over 55), liver dysfunction, low body weight

58
Q

What are the three options for switching over antidepressants

A
  1. Gradual withdrawal and then switch once stopped
  2. Cross tapering
  3. Immediate switch
59
Q

How would you switch from one SSRI to another?

A

Cross tapering is not necessary. Can usually start the new antidepressant the next day. UNLESS fluoxetine - becuase of its long half life a wash out period of a couple of days is needed.

60
Q

How would you switch from a TCA to an SSRI?

A

Either gradual withdrawl and then switch once stopped TCA. OR cross taper where the dose of the TCA is slowly reduced than then the SSRI introduced. This increases the risk of side effects.

61
Q

What are the negative symptoms associated with schizophrenia and how might these be affected by treatment with 1st generation/typical antipychotics?

A

Negative symptoms are those that lead to a decrease or loss of normal function, including lack of emotion, apathy, or non-existent social functioning, lack of motivation, reduced speech.

The first generation antipsychotics are very beneficial for the positive symptoms of schizophrenia but have no effect on the negative symptoms.

62
Q

What are first generation antipsychotics? Include examples

A

D2 antagonists, chlopromazine, loxapine, haloperiodol

63
Q

What are the second antipsychotics (atypical)? Give examples

A

5HT2A/D2 antagonists - more blockade of 5HT2A than D2.

Clozapine, risperidone, olazapine

64
Q

What is the only 3rd generation antipsychotic that exisits? how does it work?

A

Aripiprazole - partial dopamine antagonist

65
Q

What are the side effects typically associated with typical antipsychotics?

A

EPS e.g. tardive dykineasia, other side effects include sexual dysfunction, increased prolactin.

66
Q

Whatare the side effects typically associated with atypical antipsychotics?

A

Metabolic side effects - hyperglycemia, weight gain and hyperlipdiemia.

67
Q

What possible differential diagnoses should be considered before diagnosing depression?

A

Oral contraceptive pill
Anemia - check Hb, B12 and folate levels
Hypothryoidism - check TSH and T4 levels. Have they gained weight?

68
Q

What is trifluperazine?

A

First generation typical antipyschotic

69
Q

How can we manage EPS side effects caused by typical antipyschotics?

A

Reduce dose or stop medication - although sometimes can be irreversible

70
Q

How would you switch someone from fluoxetine to citalopram?

A

Reduce fluoxetine dose slowly
Stop fluoxetine - no wash out period requried, and start citalopram the next day when the fluoxetine dose would have been.

71
Q

Does depression affect men or women more?

A

Twice as common among women vs men

72
Q

What % of people with long-term health conditions experience depression?

A

Approx. 20%

73
Q

What score in the PHQ-9 questionnaire is the recommended threshold for considering intervention?

A

Score of 12

74
Q

You review a drug chart and notice a patient has been prescribed tramadol and sertraline, what do you do and why?

A

Switch tramadol to alternative analgesics, such as codeine. Risk of serotonin syndrome if not switched!

Clinical - Rosie (16 decks)

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