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Mental health Flashcards

1
Q

Those with a severe mental health problem have a 20 year lower average life expectancy than those without.

True or false?

A

False

10-15 years

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2
Q

What are the core symptoms of depression?

A

Persistent low mood

Anhedonia- don’t get the same enjoyment out of certain activities

Anergia- tiredness

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3
Q

What are the physical symptoms of depression?

A

Sleep disturbance

Appetite alteration

Lack of concentration

Weight gain/loss

Self harm

Pain

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4
Q

How long must the symptoms of depression be present for, before you consider a diagnosis?

A

2 weeks

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5
Q

What diagnostic test scores are used in depression?

A

Hamilton D score

ICD10 (list of 10 depressive symptoms, and based on the number of symptoms you get a severity of the depression)

The score tests are not really used in practice

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6
Q

Name examples of TCAs

A

Amitriptyline
Imipramine
Dosulepin
Lofepramine

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7
Q
  1. What is the mechanism of action of a TCA?

2. . What is the main problem with these?

A
  1. Inhibits reuptake of serotonin and noradrenaline from synaptic cleft, so increases availability for neurotransmission
  2. They also block a wide array of receptors e.g. muscarinic, histamine, dopamine, adrenergic so cause a lot of side effects
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8
Q

Name examples of SSRIs

A

Fluoxetine
Citalopram
Paroxetine

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9
Q

What class is citalopram?

A

SSRI

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10
Q
  1. How does venlafaxine work?

2. How is it different from TCAs?

A
  1. Serotonin and noradrenaline re uptake inhibitor

2. Weaker antagonist of muscarinic and histamine receptors so have fewer side effects

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11
Q

How does reboxetine work?

A

Noradrenaline reuptake inhibitor

Increases these monoamines for neurotransmission which are thought to improve mood etc

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12
Q

How does mirtazapine work?

A

Alpha adrenoreceptor antagonist (receptor blocker)

Increases these monoamines for neurotransmission which are thought to improve mood etc

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13
Q

Receptor blockers have sedative properties. What are two common antidepressants that cause sedation?

A

Mirtazapine and trazadone

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14
Q

Muscarinic receptor blockers cause atropine-like effects. What are these?

A
  1. Blurred vision
  2. Dry mouth
  3. Constipation
  4. Difficulty in micturition (urination)
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15
Q

What are the side effects in alpha adrenoreceptor blockers?

A

Postural hypotension and tachycardia

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16
Q

Name a reversible monoamine oxidase inhibitor

A

Moclobemide

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17
Q

Name 2 irreversible monoamine oxidase inhibitor s

A

Phenelzine

Isocarboxazid

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18
Q

How do monoamine oxidase inhibitors work?

A

Inhibits the enzyme that breaks down monoamines e.g. noradrenaline, serotonin so they are more available for neurotransmission

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19
Q

What was found in rat studies with chronic treatment of monoamine oxidase inhibitors?

A

Alters receptor sensitivity

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20
Q

How should you treat mild depression?

A

SSRIs are not that effective and do not perform much better than placebos

Try psychological therapies, however there is a waiting list and it is expensive.

Lifestyle modifications can be appropriate, particularly if there are triggering factors/trauma

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21
Q

How do you treat moderate-severe depression?

A

SSRIs are fairly well tolerated and more effective

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22
Q

When does treatment for depression start to work?

A

Within 1-2 weeks, however response will be gradual over several weeks and months

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23
Q

What proportion of people fail on their first antidepressant?

A

1/3

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24
Q

What is the disadvantage of a single drug trial over a meta-analysis?

A

Single drug trial- any variables can throw off results.

However, when you pull data in a meta-analysis and look at trials all together, it is a lot more powerful

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25
Q

What did antidepressant studies find in single drug trials compared to meta-analysis?

A

Single drug trial tested antidepressant compared to placebo, and found that the drug starts to work at 2-4 weeks.

However, meta-analysis comparing lots of drugs and people found it is actually 1-2 weeks

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26
Q

What must you discuss with the patient when deciding on a drug treatment for depression?

A 
Side effects- even though a lot work on the serotenergic pathway, different drugs have different side effects 
Benefits
Lifestyle
PMH e.g. cardiac events
Any history of overdose?
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27
Q

Why are TCAs not first line?

A

Side effects

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28
Q

What are the side effects of TCAs?

A 
Anticholinergic
Cardiac effects - arrhythmias, changes in ECGs
Nausea
Sedation
Seizures
Sexual dysfunction
Overdose
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29
Q

What are the main side effects of SSRIs?

A

Nausea

GI effects

30
Q

How long do you take antidepressants for?

A

Remember, you are only treating the symptoms!

For first episode, continue for 6-9 months after remission

However, if multiple episodes, take for 2 years after last episode

Individual to the patient!

31
Q

What factors do you need to take into account when stopping an antidepressant?

A

The drug
Duration of treatment
Speed of stopping
Dose

Antidepressant discontinuation syndrome

32
Q

How would you stop Piroxitine and why?

A

Stopped slowly due to short half life

33
Q

Why is weaning off fluoxetine easier?

A

It has an active metabolite

34
Q

What are the symptoms of antidepressant discontinuation syndrome?

A

FINISH

Flu-like symptoms
Insomnia
Nausea
Instability
Sensory disturbance (can feel mini shocks in the brain)
Hyperarousal
35
Q

Why may an antidepressant no longer work for someone?

A

Illness progression - what are the stresses on an individual at that time rather than tolerance

36
Q

The risk of relapse is high and increases with each episode. True or false?

A

True

37
Q

The chances of staying well are increased with antidepressants. True or false?

A

True

38
Q

How long do you need to have symptoms of schizophrenia for before a diagnosis is considered?

A

6 months

39
Q

What is the difference between positive and negative symptoms?

A

Positive = in addition to that person’s normal state

Negative= things that have been taken away from that person’s life

40
Q

What are the positive symptoms of schizophrenia?

A

Delusions
Hallucinations
Thought disorder

41
Q

What are the negative symptoms of schizophrenia?

A

Anhedonia

Blunted affect

Poverty of speech

Avolition- decrease in motivation to initiate and perform self-directed purposeful activities

Asociality - lack of motivation to engage in social interaction

Cognitive dysfunction- decision making, executive function

Memory loss- particularly if you have been very unwell with a lot of positive symptoms in previous episode. Can lose the ability to know what to do on a daily basis

42
Q

What theory is schizophrenia based on?

A

Dopamine theory

Model that attributes symptoms of schizophrenia - hyperactive dopaminergic signal transduction

43
Q

What are the side effects of antipsychotics and what drugs cause them?

A

Prolactin elevation- haloperidol and amisulpride but not with clozapine

Anticholinergic effect - hypotension, sedation with clozapine

QT prolongation with clozapine

Weight gain however less with amisulpride and haloperidol

Extrapyramidal side effects, can be dose related

If on a higher dose, more likely to experience cardiac side effects

44
Q

What is the danger of QT prolongation?

A

Torsades de pointes and death

45
Q

Name some extra pyramidal side effects

A
  1. Dystonia - twitches and abnormal fixed postures
  2. Pseudo-parkinsonism - tremor, bradykinesia
  3. Akathisia- walking up and down. Sometimes you think it is worsening of symptoms however it can be a side effect of a medicine
  4. Tardive dyskinesia - stiff movement of face and body
46
Q
  1. What are the symptoms of dystonia?
  2. What is the speed on onset?
  3. What is the treatment option?
A
  1. Oculogyric crisis - prolonged involuntary deviation of the eyes

Torticollis- asymmetrical head/neck position

  1. Hours-years
  2. Switch drug
    Use anticholinergic
47
Q
  1. What are the symptoms of pseudo-parkinsonism?
  2. What is the speed of onset?
  3. What is the treatment option?
A
  1. Tremor
    Bradykinesia
  2. Days- weeks
  3. Reduce dose
    Switch drug
    Use anticholinergic
48
Q
  1. What are the symptoms of akathisia?
  2. What is the speed of onset?
  3. What is the treatment option?
A
  1. Restlessness
  2. Hours-weeks
  3. Reduce dose
    Switch drug
    Something unlicensed
49
Q
  1. What are the symptoms of tardive dyskinesia?
  2. What is the speed of onset?
  3. What is the treatment option?
A
  1. Orofacial dyskinesias. Handiform hand movements
  2. Months-years
  3. Stop anticholinergic.
    Reduce dose
    Switch drug
50
Q

What is the ideal schizophrenia treatment pathway?

A
  1. Antipsychotic 1 for 8 weeks
  2. Antipsychotic 2 for 8 weeks
  3. Clozapine - not first line due to level of monitoring required and also clinician reluctance
51
Q
  1. What is the plasma range for clozapine?
  2. Clozapine comes with a high risk of seizures, especially at higher levels. At what level is seizure prophylaxis needed?
A
  1. 0.35-0.5 mg/L however some patients will respond to lower and higher levels
  2. When it exceeds 0.6 mg/L
52
Q

What are clozapine levels affected by?

A

CYP450 inducers

CYP1A2 is a major isoenzyme involved in clozapine metabolism

53
Q

What is the interaction between smoking and clozapine?

A

Smoke contains aromatic hydrocarbons affecting isoenzymes

Induces CYP1A2 which will decreases plasma levels of clozapine (metabolism increases)

This is more of a problem with heavy smokers, as when they are admitted into hospital, they cannot smoke so clozapine levels start to rise. Reduce dose

Even with NRT you need to be worried about this interaction

54
Q

If a schizophrenic person is on the maximum clozapine dose of 900mg and the plasma levels are still not high enough, what could be the reason why?

A

Super rapid metabolisers

55
Q

If a schizophrenic person is on a high dose and still need to boost plasma levels AND have negative symptoms, what would be an appropriate treatment option?

A

Fluvoxamine as it interacts with clozapine to increase plasma levels as well as exerting anti-depressant effect.

Don’t necessarily go for a higher dose

56
Q

What is the monitoring requirements for clozapine?

A
  • Seizures
  • Pneumonia
  • Constipation- this can be dangerous due to toxins in the body causing atrophy and necrosis of tissue due to straining and pushing into blood vessels. If bowel habits change, they need to let you know.
  • Blood tests once a week for the first 12 weeks and then once a month for life. Pancytopenia (deficiency in WBCs especially neutrophils, RBCs and platelets)

However, neutrophil range can change with exercise so time of day is important as well as looking at trends.

57
Q

What is the green category for neutrophil range in clozapine?

A

> 2.0 10^9/L

58
Q

What are the symptoms of mania in bipolar disorder?

A
  • Hallucinations
  • Change in perception e.g. seeing things in very bright colours, hyperfocusing on textures and patterns
  • Drastic changes in mood
  • Doesn’t sleep for days on end
  • Aggressive
  • Sexually disinhibited
  • Spending sprees
  • Stress
  • Less sleep
59
Q

What is hypomania?

A

Some symptoms but not full mania

60
Q

How do you treat mania long-term?

A
  • Antipsychotics e.g. risperidone, olanzapine
  • Mood stabilisers - lithium and valproate
  • Less carbamazepine is used due to interactions and drowsiness s/e
  • Treatment depends on symptoms
61
Q

How do you treat newly diagnosed mania?

A
  • Usually start on BDZ for a few days to calm down the body and then look into appropriate antipsychotic
  • Not taken long term due to tolerance, addiction, drowsiness
62
Q

Why do people become toxic on lithium?

A
  • Error in dosing
  • 1st order kinetics - doubling dose will double serum level so a lot more predictable than other drugs reaching a target
  • NSAIDs
  • At higher risk if they have Addison’s disease, dehydration, changes in sodium levels e.g. low
63
Q

What analgesic class does lithium interact with and what should you do?

A

NSAIDs can double the dose of lithium in some cases. Therefore, you need to reduce the lithium dose if an NSAID is necessary and measure lithium levels after 5 days (when it reaches steady state).

Should avoid OTC NSAID unless medical advice however pain should be controlled with specialist clinic

64
Q

What is 200 mg lithium carbonate equal to in lithium citrate?

A

520 mg

65
Q

What is 520mg lithium citrate equal to in lithium carbonate?

A

200 mg

66
Q

What is 200 mg lithium carbonate equal to Priadel liquid?

A

5 mL

67
Q

What is 520mg lithium citrate equal to in Priadel liquid?

A

5 mL

68
Q

What things must you consider when prescribing lithium?

A
  • Prescribe by brand name and in milligrams
  • Note formulation and strength- carbonate or citrate
  • Look at the purple book
  • 1st order kinetics- doubling dose will double serum level so a lot more predictable than other drugs when reaching a target level
69
Q

What must you consider when prescribing sodium valproate to a woman of child bearing age?

A
  • Evaluate the woman’s intention to and likelihood to become pregnant
  • Inform patient it is associated with foetal malformations e.g. neural tube defects
  • inform prescription of contraceptive is advised and offer them a choice
  • 5mg folic acid is advised
  • document the discussion and the patient’s decision (including any refusals)
70
Q

Biopolar depression is generally more severe than unipolar depression.

A

True- comes with a high risk of suicide

71
Q

What is a treatment regimen for bipolar?

A

Fluoxetine + olanzapine + quetiapine

But depends on existing treatments

CDM (17 decks)

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