Mental Health Flashcards
What is personality?
Set of emotional & behavioural traits that are stable and predictable
What is a personality disorder?
Severe disturbance in behavioural tendencies of the individuals personality that differs from expectations of a persons culture
Onset in adolescence & early adulthood
What factors are linked to personality disorders?
Dysfunctional early environment = preventing adaptive perception/response/defence
Childhood sexual abuse ± Neglect ± Emotional abuse
Genetic link
Why are personality disorders not diagnosed in children?
Because the personality is not complete, and symptomatic traits may not persist into adulthood
What are the features of paranoid personality disorder?
- Pervasive distrust & suspicion
- Believe others are exploiting/decieving them
- Information confided in others will be used maliciously
- Believe there are hidden meaning in remarks or events
- Pathological jelousy (Othello syndrome)
What are the features of Schizoid personality disorder?
- Withdrawal from affection/social/other contacts
- Self isolation
- Limited capacity to experience pleasure & express feelings
What are the features of Shizotypal personality disorder?
- Odd behaviour - Magical thinking
- Odd perceptions/appearance
- Eccentic disorganised thought
- Lack delusions/hallucinations
What are the features of Antisocial personality disorder?
- Act outside social norms
- Disregard feelings of others + Criminal behaviour
- Unable to modify behaviour in response to adverse events e.g. punishment
- Low threshold for violence - blame others for actions
What are the features of Emotionally Unstable personality disorder/Borderline PD?
- Impulsive/Unpredictable
- Act w/o appreciating consequences - black & white thinking
- Outburst of emotion
- Tend to have unstable relationships - suicide attempts/self harm
What are the features of Histrionic personality disorder?
- Shallow and labile affect
- Theatrical
- Lack of consideration for others/Egocentric
- Tend to be stubborn/cautious/rigid
What are the features of Narcissistic personality disorder?
- Affects Males > Females
- Grandiose delusions
- Lack empathy
- Love admiration + Loathe criticism
What are the features of Anxious/Avoidant personality disorder?
- Feelings of tension & apprehension
- Insecurity & Inferiority
- Yearn to be accepted and liked - Sensitive to rejection
- Exaggerate potential risks and dangers
What are the features of Dependent personality disorder?
- Rely on others to take decisions - Difficulty with independence
- Fear of abandonment
- Reliance on authority figures
If you suspect a patient has a personality disorder, what other differentials can be considered?
- Depression
- Schizophrenia
- Psychosis
- Delirium
- Head trauma
- Hyper/Hypothyroid
How are personality disorders managed?
- Psychotherapy
- DBT
- CBT
- Crisis management - If risk of harm to self or others
What are the topics to cover in a Psych Hx?
- Presenting complaint
- Past Psych Hx
- Risk assesment
- PMHx
- DHx
- FHx
- Personal & Psychosocial Hx
- Social Hx
- Forensic Hx
- Pre-morbid personality
What are the key aspects of the presenting complaint in a psych Hx?
- Why did you come in today?
- When did it start?
- When did you last feel better/Different to this?
- What triggered this episode?
- Is it getting any better over time? Worse? Same?
- Does anything make it worse or better?
When doing a psych systems review - what must you ask Q’s about?
- Depression
- Anxiety
- Psychosis
- Mania
- Self harm - Risk assesment
When asking about a patients past Psych Hx, what are the key Q’s to ask?
- When were you last well?
- Have you ever had a mental health diagnosis?
- Did you have any treatment?
- Have you had any contact with mental health services?
- Do you have a care coordinator?
- Have you ever previously been admitted for a psychiatric condition? - Informal/Detained?
- Have you ever been detained by the police for a psychiatric condtion?
When asking about PMHx in the Psych history, what are the key Q’s?
- Thyroid dysfunction?
- Epilepsy?
- Head injury - details & recovery
- Any LoC with the head injury
- Any post traumatic amnesia - How long for?
- Any post traumatic epilepsy?
- Any heart problems?
- Any high Cholesterol?
- Do you have DM?
When asking about DHx in the psych Hx what are the key questions to be asked?
- What medications are you currently taking?
- Adherence?
- Any recent changes to your medications?
- Any drug allergies?
- Any Non-prescribed medications? (OTC/Herbal)
- Any ilicit drug use?
- Do you drink alcohol?
When asking about FHx in the psych Hx what are the key Q’s?
- Tell me about your family - Mother/Father/Siblings
- What are their ages/occupations?
- What is your relationship to them?
- Does anyone in your family have any mental health problems?
When asking about FHx in the personal & psychosocial Hx what are the key Q’s?
- Were you a planned pregnancy?
- Any birth trauma/maternal trauma or drug use?
- Gestation when born
- Who provided your childcare?
- Developmental milestones reached?
- School - Social & Academic achievement?
- Relationships - Current? Stable? Any trauma etc
- 1st sexual experience?
- Any children?
- Any abuse suffered as a child?
When asking about SHx in the psych Hx what are the key Q’s?
- What are your current living arrangements?
- What is your current occupation?
- What are your relationships at work like? Performance?
- Are you financially stable?
- Are your friends and family supportive?
- ADLs
When asking about Forensic Hx in the psych Hx what are the key Q’s?
- Any contact with the police?
- Have you ever been to prison?
- How do you think the contact with police has impacted you/others?
When asking pre-morbid personality, what Qs should be asked?
- How do you see yourself?
- How do you think others see you?
What are the differential diagnoses to consider for a patient presenting with anxiety?
- GAD
- Panic disorder
- Phobia
- PTSD
- OCD
- Depression
- ACS
- Arrythmia
- Hyperthyroidism
What are the differential diagnoses to consider for a patient presenting with psychosis?
- Schizophrenia
- Bipolar disorder
- Depression
- Shizoaffective disorder
- Depression with psychosis
- Delirium
- Dementia
- Drugs/Alcohol
- Epilepsy (Temporal lobe)
- SoL
- SLE
What are the differential diagnoses to consider for a patient presenting with Low mood?
- Depression
- Seasonal Affective disorder
- Bipolar disorder
- Post natal depression
- Hypothyroidism
- Anaemia
- Drug side effects
- SoL
What are the differential diagnoses to consider for a patient presenting with memory loss?
- Dementia - Alzheimers/Vascular/FTD/LBD/Mixed
- Depression
- Delirium
- Degenerative CNS cause - Huntingdons/MS
- Vitamin deficiency - B12/Folate/Thiamine
- Electrolyte imbalance
- Encephalitis
What are the differential diagnoses to consider for a patient presenting with Eating disorders?
- Anorexia nervosa
- Bulimia Nervosa
- Depression
You are presented with a patient with a Hx suggestive of depression, explain to them what the diagnosis is and how it will be managed?
[Causes]
- Stressful events + personality + female gender
- Low levels of neurotransmitters in brain (Dopamine/NA/5-HT)
[Diagnostic criteria]
- >2wk Hx causing significant impairment in function
- Core symptoms:
- Persistent sadness/low mood nearly every day
- Anhedonia
- Fatigue
- Other symptoms:
- Nihlism/Guilt
- Suicidal ideation
- Decreased concentration/apetite/mood/weight
- Increased sleep
- Psychomotor retardation
- Psychosis -> Depression w/psychosis
[Investigations]
- TFTs - Normal
- FBC - Normal
- U&E - Normal
- PHQ9 - Positive screen
- Vitamin B12 - Normal
- ECG - Normal, for antidepressants
- BP + Pulse + BMI
[Management]
- Mild to moderate:
- CBT - self help
- Moderate to severe:
- SSRI - Sertraline
- Children - Fluoxetine
- High intensity CBT
- SSRI - Sertraline
- Severe:
- Mental health assesment
- ECT
A patient is prescribed an SSRI - Citalopram/Sertraline/Fluoxetine, you are asked to explain this medication to them. How would you go about this?
[Indication]
- 1st line treatment for moderate to severe depression
- Panic disorder
- OCD
[How it works]
- Alters balance of some of the chemicals in your brain - NT
- Affects the uptake of 5-HT from the synaptic cleft, so increases amount of 5-HT available.
- Improves mood and physical symptoms of depression
[How to take it]
- Tablet - OD orally
- Best taken on a full stomach
- Can take up to 6 weeks for effects to start
- Take for at least 6 months after symptoms stop, then taper it down slowly before stopping
- If due to recurrent depression - wait 2 years after symptoms stop to withdraw
[Side effects]
- GI Upset
- Change to apetite
- Weight Loss/Gain
- Skin rash - due to hypersensitivity
- If elderly - can lead to confusion (Due to low Na+)
- Can cause increased suicidal thoughts
[Contraindications]
- Epilepsy
- Peptic ulcer disease
- Hepatic impairment
[Withdrawal]
- Stomach upset
- Flu like symptoms
- Insomnia
[Overdose]
- Serotonin syndrome (Excess 5-HT)
- Autonomic hyperactivity - HTN + Tachycardia + Hyperthermia
- Tremor + Agitation + Irritability
- Sweating + Diarrhoea
- Delirium
- Hyper-reflexia
[Monitoring]
- Before starting - ECG (QTc) + U&E
- Review symptoms after 2-6 weeks
You are asked to take a mental health Hx from a patient presenting with x symptoms. How would you go about this?
[Introduction]
- Introduce self & Wash hands
- Patient name & DOB & Age
- I am here to speak to you about your current experiences in addition to your past experiences, and how they are impacting on your symptoms. The questions could be very personal, is that ok?
- Anything that you say will be kept b/w myself and your medical team.
[Presenting complaint]
- Why did you come in today?
- When did it start?
- When did you last feel better/Different to this?
- What triggered this episode?
- Is it getting any better over time? Worse? Same?
- Does anything make it worse or better?
[Systems review]
- Depression
- Anxiety
- Psychosis
- Mania
- Self harm - Risk assesment
[Past psychiatric review]
- When were you last well?
- Have you ever had a mental health diagnosis?
- Did you have any treatment?
- Have you had any contact with mental health services?
- Do you have a care coordinator?
- Have you ever previously been admitted for a psychiatric condition? - Informal/Detained?
- Have you ever been detained by the police for a psychiatric condtion?
[PMHx]
- Thyroid dysfunction?
- Epilepsy?
- Head injury - details & recovery
- Any LoC with the head injury
- Any post traumatic amnesia - How long for?
- Any post traumatic epilepsy?
- Any heart problems?
- Any high Cholesterol?
- Do you have DM?
[DHx]
- What medications are you currently taking?
- Adherence?
- Any recent changes to your medications?
- Any drug allergies?
- Any Non-prescribed medications? (OTC/Herbal)
- Any ilicit drug use?
- Do you drink alcohol?
[Social Hx]
- What are your current living arrangements?
- What is your current occupation?
- What are your relationships at work like? Performance?
- Are you financially stable?
- Are your friends and family supportive?
- ADLs
[If any time]
- FHx - Assessing attachment
- Personal & Psychosocial Hx
- Forensic Hx
You are asked to take a mental health Hx from a patient presenting with x symptoms, including a mental state exam. How would you go about this?
[Introduction]
- Introduce self & Wash hands
- Patient name & DOB & Age
- What I am going to be doing is asking you questions to assess your state of mind, is that ok?
- I just want to let you know that anything that you say will be kept b/w myself and your medical team
[Presenting complaint]
- Why did you come in today?
- When did it start?
- When did you last feel better/Different to this?
- What triggered this episode?
- Is it getting any better over time? Worse? Same?
- Does anything make it worse or better?
[Past psychiatric review]
- When were you last well?
- Have you ever had a mental health diagnosis?
- Did you have any treatment?
- Have you had any contact with mental health services?
- Do you have a care coordinator?
- Have you ever previously been admitted for a psychiatric condition? - Informal/Detained?
- Have you ever been detained by the police for a psychiatric condtion?
[PMHx]
- Thyroid dysfunction?
- Epilepsy?
- Head injury - details & recovery
- Any LoC with the head injury
- Any post traumatic amnesia - How long for?
- Any post traumatic epilepsy?
- Any heart problems?
- Any high Cholesterol?
- Do you have DM?
[DHx]
- What medications are you currently taking?
- Adherence?
- Any recent changes to your medications?
- Any drug allergies?
- Any Non-prescribed medications? (OTC/Herbal)
- Any ilicit drug use?
- Do you drink alcohol?
[Social Hx]
- What are your current living arrangements?
- What is your current occupation?
- What are your relationships at work like? Performance?
- Are you financially stable?
- Are your friends and family supportive?
- ADLs
MSE
[General Inspection]
- Patients appearance & behaviour
- Kempt/Unkempt
- Any abnormal movements
- Appropriate behaviour
- Level of anxiety/restlessness/agitation
- Assess rapport
- Distractibility
- Eye contact
- Facial expressions
[Speech]
- Assess the speech of the patient - As it is an external presentation of the internal thought process
- Rate
- Rhythm
- Volume
- Quantity
- Fluency
- Abnormal associations
- Any evidence of formal thought disorder? - opinion based on speech
[Mood & Affect]
- Objective based on what you see - how do they appear (Affect)
- Low
- High
- Euthymic - Normal
- Subjective based on a scale of 1-10 -> Ask patient to describe their mood
- Enjoyment -> None/Increased
- Energy -> Increased/Decreased
- Biological symptoms - Sleep -> Increased/Decreased
- Biological symptoms - Appetite -> Increased/Decreased
- Concentration & memory -> Increased/Decreased
- Libido -> Increased/Decreased
[Suicide risk]
- Ask about thoughts of the future
- Any Hopelessness?
- Thoughts of suicide? or self harm?
- Suicide
- Any thoughts of life not worth living? Hopelessness?
- Harming yourself?
- Wanting to kill yourself?
- Any plans to kill yourself?
- Any protective factors?
- Any hope for the future?
- Risky behaviour
[Thought]
- Depression
- Poverty of thought
- Thinking is v slow & laboured (Takes patient a long time to answer)
- Mania
- Pressured thought
- Spuriously connecting words/rhyming/flight of ideas (going on lots of tangents, but there is a process)/often funny
- Psychosis
- Loss of association
- Derailment/Difficult to follow train of thought
- Cognitive impairment
- Circumstantiality - Patient talking around the point, going off topic
- Meandering speech covering up for impairment
Content of the thoughts
- Normal thoughts
- Triggered by internal/external stimulus
- Obsessions
- Any recurrent intrusive thoughts (Unpleasant)
- Recognise as their own - they don’t want them
- Generates anxiety
- Try to resist = compulsive actions to reduce impact of the thoughts (Compulsion)
- Delusions
- Fixed false belief out of keeping with Social/Cultural/Education/Religious norms or background
- Challenge the belief to ensure it is fixed - If I told you it was due to your mood what would you say?
Specific content delusions
- Persecutory
- Ask if they want to harm anyone else?/Do you feel anyone wants to harm you?
- Do you feel the need to carry a weapon?
- Mood congruent - Delusions related to mood disorders
- Depressive -> Nihilistic/Guilt (Negative)
- Manic -> Most common in grandiose
- Classic schizophrenia - Thought insertion/Thought extraction/Control/Reference
[Perception]
- Any unusual experience?
- Have you heard or seen something you cant explain?
- Normal
- Any sensory experience with external stimulation
- Illusion
- Misinterpretation of an external stimulation
- Hallucination
- Perception w/o any external stimulation
- Look for distractibility
- Challenge - Continues to believe it
- Auditory -> Common in psychosis
- Mood disorder - talking to YOU
- Schizophrenia - one or two talking ABOUT you
- Visual -> Organic/drugs cause but can also happen in mental illness
- Olfactory/Gustatory (Taste) -> Epileptic activity but can happen with mental health
- Somatic/Tactile -> Rare/Drug use (Amphetamines or alcohol withdrawal)
[Cognition]
- Orientation
- Time
- Place
- Person - What is your name & DOB
- If not oriented -> Full cognitive assessment with Mini-ACE or MOCA
[Insight]
- Do you think you are ill?
- Do you think it is a physical or mental illness?
- Also question insight into the severity of the illness?
- What treatment do you think you need?
- Are you willing to engage in treatment/services?
What are the possible formal thought disorders?
Poverty of thought (slow, decreased speech)
- depression
Pressure of thought (lots of words but makes sense)
- Mania
Total loss of association (completely disjointed, lapsed concentration)
- Schizophrenia
Circumstantiality (meandering around the point, covering up memory impairment)
- Cognitive impairment
What biological symptoms would you expect in a MSE on a patient with depression?
- Enjoyment -> None + Anhedonia
- Energy -> Decreased
- Sleep -> Early morning wakening + Diurnal variation in mood
- Biological symptoms - Appetite -> Classically reduced/Can be increased in SAD
- Concentration & memory -> Decreased
- Libido -> Decreased
What biological symptoms would you expect in a MSE on a patient with Mania?
- Enjoyment -> Excess
- Energy -> Increased
- Biological symptoms - Sleep -> Decreased
- Biological symptoms - Appetite -> Often decreased “Dont have time to eat”
- Concentration & memory -> Decreased (But they think its great)
- Libido -> Increased
You are presented with taking a Hx from a patient who has recently attempted to commit suicide. How would you go about doing this?
[Introduction]
- Introduce self & Wash hands
- Patient name & DOB & Age
- I am here to speak to you about your current experiences in addition to your past experiences, and how they are impacting on any symptoms you are currently having.
- I just want to let you know that anything that you say will be kept b/w myself and your medical team
- How are you feeling today?
- Im really sorry that things got so bad for you that you had to do this, but I will need to ask some questions about the suicide attempt
[Before]
- Prior events/Mood – What happened before that made you feel like you had to harm yourself?
- Had you been feeling this way for some time now?
- Plan – Did you plan to harm yourself?
- What plans did you make?
- How long did you plan this?
- Precautions – Did you try to make sure you wouldnt be found?
- Did you want to be found?
- Preparation – Did you make a note or make a will in preparation?
- Did you tell anyone before you did it or did you seek help afterwards?
- Did you regret it after you had harmed yourself?
[During]
- Can you talk me through exactly what happened? I know this might be difficult:
- How
- Where
- When
- DId you expect to die?
- Were you under the influence of drugs?
- Were you under the influence of alcohol?
[After]
- How were you discovered?
- Did you tell anyone?
- Did you want to be found?
- How do you feel now after what has happened? Do you feel anger/regret?
- Do you still have thoughts of wanting to harm yourself/suicide?
- What are your thoughts of the future?
[ICE]
- How has your mood affected your day to day life?
- Why do you think you feel the way you do?
- Is there anything in particular you are scared/worried about?
- Is there anything in particular you feel you need help with?
[Background]
PMHx/Psych Hx:
- Do you have any medical illness
- Do you have a diagnosis of any psychiatric illness?
- Have you ever tried to commit suicide or self harm before this?
DHx:
- Are you currently taking any medication?
- Do you have stores of medication at home?
FHx:
- Has anyone in your family ever tried to harm themselves?
SHx:
- Are you currently working? What do you do?
- How are things at work? Any problems?
- Who is at home with you?
- Do you have support from family/friends?
- Any children or dependents at home?
- Do you drink alcohol? How much in a week?
- Do you take any recreational drugs?
- Do you think you need help? Would you be prepared to accept help?
[Follow up]
- If high risk:
- In light of what you have told me today, I dont think it would be safe to let you go home, however I would need to discuss this with my seniors to come up with a plan with yourself on how we can move forward
- If low risk:
- I would like to see you again next week. Can we arrange a time to meet?
- Is there anything you would like to talk about? If not now then think about it and we can discuss it next time we meet.
[Conclusion]
- Summary
- Thank you, I hope we can work together to get you feeling better.
[Management]
- Full Hx + MSE
- Collaborative Hx from family/friend
- Plan if in patient admission required
- Provide contact details for crisis team/mental health team
- Formulation
What are the red flags for a suicide attempt?
- Violent method used
- Planning in place
- Ongoing suicidal intent
- Previous suicide/self harm
- Access to means
- Recent adverse life event
You are presented with a patient with a Hx suggestive of depression in a child, explain to them what the diagnosis is and how it will be managed?
[Causes]
- Stressful events + personality + female gender
- Bullying/Family disruption/Abuse
- Low levels of neurotransmitters in brain (Dopamine/NA/5-HT)
[Diagnostic criteria]
- >2wk Hx causing significant impairment in function
- Core symptoms:
- Persistent sadness/low mood nearly every day
- Anhedonia
- Fatigue
- Other symptoms:
- Nihlism/Guilt
- Suicidal ideation
- Decreased concentration/apetite/mood/weight
- Increased sleep
- Bad behaviour at school/home
- Psychomotor retardation
- Psychosis -> Depression w/psychosis
[Investigations]
- Clinical diagnosis
- TFTs - Normal
- FBC - Normal
- U&E - Normal
- PHQ9 - Positive screen
- Vitamin B12 - Normal
- ECG - Normal, for antidepressants
- BP + Pulse + BMI
- Pregnancy test is female
[Management]
- CAMHS referral
- Address sources of distress
- Remove opportunities for self harm
- CBT/Interpersonal therapy
- Family therapy
If moderate to severe:
- Fluoxetine
A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?
A 15-year-old girl, at a private school, presents with poor concentration. She lives with her biological mother and a 13-year-old sister. Her mother describes her as an outgoing and straight-A student until about 2 months ago. Her grades have slipped from As to Cs, and she has been feeling sad and irritable. She has started avoiding her friends, and has been worrying about her appearance and her grades. She states that she feels dumb, and that her classmates don’t like her. Recently, she started to think that life was not worth living, and wished she would fall asleep and never wake up. Her boyfriend broke up with her about 3 months ago. The last time she felt this sad was 5 years ago when her parents divorced.
- Depression
- Bipolar disorder
- Anxiety disorder
- Bereavement
- ADHD
- Substance abuse
- PTSD
A patient presents with the following Hx, what is the most likely diagnosis? What are the differential diagnosis?
A 9-year-old boy presents with a change in his behaviour over the past 4 weeks, from being an outgoing child who loved school to frequently complaining of stomach aches and refusing to go to school. He lives with his biological parents and a 5-year-old sister. He is attending a local school. His parents say that he has been unkind to his 5-year-old sister, and frequently screams at her. He used to like to play outside after school, but recently has stayed in his room a lot and played video games. He cannot identify any precipitants, but his parents recall that his mother was hospitalised for surgery about 3 months ago.
- Depression
- Bipolar disorder
- Anxiety disorder
- Bereavement
- ADHD
- Substance abuse
- PTSD
A patient is prescribed an TCA - Amitryptiline/Imipramine/Lofepramine, you are asked to explain this medication to them. How would you go about this?
[Layout]
- Check what the patient knows
- Brief history
- Do they know what the drug is?
- Indication & Action of the drug
- Side effects
- How to take it
- Monitoring requirements
[Indication & Action of the drug]
- Indications:
- 2nd line treatment for moderate to severe depression, after SSRI
- Treatment for neuropathic pain
Actions:
- Inhibit the re-uptake of Serotonin (5-HT) + Noradrenaline (NA) from the synaptic cleft
- increase the availability for neurotransmission
- Improve mood & physical symptoms of moderate to severe depression
- Also help with neuropathic pain
- Block receptors - Muscarinic + Histamine (H1) + Adrenergic (Alpha) + Dopamine (D2)
- Causes the side effects
[Side effects]
Blockage of antimuscarinic receptors:
- Dry mouth
- Constipation
- Urinary retention
- Blurred vision
Blockage of H1 and Alpha receptors
- Sedation
- Hypotension
- Blockage of Dopamine receptors
- Breast changes
- Sexual dysfunction
Cardiac adverse events
- Arrythmias
- ECG changes -> Prolonged QT interval & QRS duration
- Risk of Torsades des Pointes
Neurological SE:
- Convulsions
- Hallucinations
- Mania
Sudden withdrawal can cause:
- GI Upset
- Neurological & flu like symptoms
- Sleep disturbance
[Overdose effects]
Very dangerous, they cause Serotonin syndrome:
- Severe hypotension
- Arrythmias
- Convulsions
- Coma
- Respiratory failure
[Complications/Contraindications]
- Caution for patients with:
- Elderly - risk of fall
- Epilepsy
- Cardiovascular disease
- Prostatic hypertrophy
- Glaucoma
- C/I:
- Must not be given with MOAI -> Can lead to HTN/Hyperthermia/Serotonin syndrome
[How to take it]
- Tablet/Oral solution
- Take dose once a day
- Dose can be adjusted after at least 6-8wks treatment
- 2 weeks supply to reduce risk of serious overdose
- Carry on for at least 6 months after they feel better
- If recurrent depression -> 2yrs
- Effect time
- Few weeks
- Improves sleep and appetite
[Monitoring Requirements]
- Review symptoms 1-2 wks after starting treatment
- ECG - assess for any QT interval changes before starting treatment
- Risk of Torsades des Pointes
What is Serotonin syndrome?
How is it managed?
Syndrome caused by excess serotonin, from SSRI + TCA + SNRI + MOAI
- Autonomic hyperactivity - HTN + Tachycardia + Hyperthermia
- Tremor + Agitation + Irritability
- Adbominal pain
- Sweating + Diarrhoea
- Delirium/Altered Mental state
- Hyper-reflexia
[Management of Serotonin syndrome]
- Discontinue medication
- Benzodiazepines for agitation
- Severe -> Cyproheptadine - Serotonin antagonist
- Active cooling
A patient is prescribed an SNRI - Venlafaxine/Duloxetine, you are asked to explain this medication to them. How would you go about this?
[Introduction]
- Check what the patient knows
- Brief history
- Do they know what the drug is?
- Indication & Action of the drug
- Side effects
- How to take it
- Monitoring requirements
[Indication & Action of the drug]
Indications
- Major depression where SSRI’s are ineffective or not tolerated
- Generalised anxiety disorder
Action:
- Serotonin (5HT) and Noradrenaline (NA) re-uptake inhibitor (SNRI)
- Interferes with these NT at the synaptic cleft
- Increases bioavailability of monoamines for NT - improve mood and physical symptoms in moderate to severe depression
- *Weaker antagonist of muscarinic & histamine receptors than TCA’s
- Fewer anti-muscarinic SE than TCAs
[How to take it]
- Orally
- Take tablet every day - orally
- Treatment started at low dose and titrated up according to response
- Continue taking it for 6 months after they stop feeling better to stop the depression from coming back
- If recurrent depression -> 2 years
- Refer them for psychological therapy - long term benefits
- Effect time -> Should improve symptoms over a few weeks, particularly sleep and appetite
[Important Side Effects]
- GI upset
- Dry mouth/nausea
- Change in weight
- Diarrhoea/constipation
- Neurological effects – Headache
- abnormal dreams
- Insomnia
- Confusion
- Convulsions
Sudden withdrawal can cause:
- GI Upset
- Neurological & flu like symptoms
- Sleep disturbance
Serious SE:
- Hyponatraemia
- Serotonin syndrome
- May increase suicidal thought and behaviour
- Prolongs QT interval + Increased risk of ventricular arrhythmia
- Risk of Torsades des Pointes
[Complications/Contraindications]
- Use with caution in:
- Elderly
- Patients with pre-existing arrhythmia
- Dose reduction may be required in Hepatic/Renal impairment
[Monitoring requirements]
- Review symptoms 1-2 weeks after treatment and regularly there-after
- Dose should not be adjusted after 6-8 weeks of therapy