Mental Health

Question 1

What is the ICD-10 definition of depression?

Answer 1

At least 2 of:

Persistent low mood
Anhedonia
Anergia

Present most of the time for at least 2 weeks.

Question 2

What are the biological symptoms of depression?

Answer 2

Poor sleep (early morning waking)
Reduced appetite
Anergia
Sexual dysfunction
Tiredness

Question 3

What are the psychological symptoms of depression?

Answer 3

Suicidal thoughts
Low mood
Worthlessness
Hopelessness
Poor concentration
Guilt

Question 4

How should mood symptoms be exploded?

Answer 4

Detail of mood: how bad, when, triggers, pattern over the day, getting worse or better?

Associated symptoms: anxiety, psychosis, elation, guilt, worthlessness, drug and alcohol

Negative cognitions: about the world, about self, about future (RISK ASSESS)

Somatic symptoms: loss of interest, early morning waking, weight, appetite

Question 5

Outline the management of depression

Answer 5

Mild to moderate: consider watchful waiting for 2 weeks, then low intensity psychosocial interventions inc. self-help and group CBT. Consider drug treatment only in patients with a hx of moderate to severe depression, or long term subthreshold depression.

Persistent mild/moderate depression: antidepressant OR high-intensity psychological intervention

Moderate to severe depression: antidepressant AND high intensity psychological intervention.

Question 6

What are the side effects of MAOIs?

Answer 6

Orthostatic hypotension, dry mouth, sexual dysfunction, weight gain

Question 7

What are the side effects of SSRIs?

Answer 7

GI upset, nausea, sexual dysfunction, short term can increase anxiety, citalopram prolongs QTc, increased risk of suicide in short term, discontinuation syndrome

Question 8

What are the side effects of TCAs?

Answer 8

Weight gain, sedation, nausea, sexual dysfunction, QTc prolongation, anticholinergic SEs

Question 9

What differentials should be considered in a history of low mood?

Answer 9

Major depressive disorder: negative cognitions, guilt, worthlessness, hopelessness

Psychotic depression: nihilistic delusions and hallucinations

Bipolar affective disorder: past mania

Co-existent anxiety

Schizoaffective: paranoid delusions, running commentary 3rd person hallucinations

Question 10

What symptoms are important to ask about in history of mania?

Answer 10

Elated mood
Energy levels
Grandiosity
Restlessness
Appetite
Libido

REFLECT BACK TO PATIENT (examiner) THE SYMPTOMS YOU SEE

Question 11

What are the 5 features of dependence on alcohol?

Answer 11

Compulsion - “do you have cravings?”
Control - “do you find it difficult to control your drinking?”
Withdrawal - “do you get shakes when you dont drink?”
Tolerance - “do you have to drink more?”
Primacy - “is drinking your main priority

Question 12

What is the differential for psychosis?

Answer 12

Acute psychosis but not long enough to qualify for schizo

Schizophrenia
Schizoaffective
Psychotic depression
Bipolar depression
Delusional disorder

Question 13

How long must symptoms be persisting for diagnosis of schizophrenia?

Answer 13

1 month period of delusions, hallucinations, disorganised speech, negative symptoms etc, associated with continuous problems over 6 month period

Question 14

What is first line management of schizophrenia?

Answer 14

Antipsychotic + cbt

Question 15

What investigations are important before starting antipsychotic medication?

Answer 15

Weight + waist circumference
Pulse and BP
Blood glucose (ideally fasting)
Lipids
LFTs
FBC
Prolactin level
ECG and/or cardiac risk assessment!!!!

Question 16

Which antipsychotic is most likely to cause hyperprolactinaemia?

Answer 16

Risperidone

Question 17

Which antipsychotic causes most weight gain/

Answer 17

Olanzapine + clozapine

Question 18

Which antipsychotic has least SEs?

Answer 18

Aripiprazole

Question 19

Which antipsychotic is most likely to cause orthostatic hypotension?

Answer 19

Quetiapine

Question 20

What are the SEs of atypical antipsychotics?

Answer 20

Weight gain + metabolic syndrome
Hyperprolactinaemia
Sedation
Dry mouth
Postural hypotension

Question 21

What are the SEs of typical antipsychotics?

Answer 21

QTc prolongation

EPSEs (Parkinsonism, dystonia, akithasia, tardive dyskinesia)

Question 22

What are the SEs of clozapine?

Answer 22

Postural hypotension, agranulocytosis, weight gain, deranged LFTs

Question 23

What are the characteristic features of Alzheimer’s disease?

Answer 23

Medial temporal lobe neurofibrillary tangles, amyloid plaques and neuron loss

Memory loss (short term and names first), later can cause behavioural abnormalities and cognitive impairment)

Slowly progressive

Question 24

What are the characteristic features of vascular dementia?

Answer 24

Stepwise progression

Executive functions such as planning tend to be more affected than memory

Question 25

What are the characteristic features of Lewy-body dementia?

Answer 25

Parkinsonism

Progressive cognitive decline with prominent executive and visuospatial impairment

Lewy bodies (alpha synnuclein proteins) in the brain

REM sleep disorder, parkinsonism, visual hallucinations

Fairly rapidly progressive

Question 26

What are the characteristic features of frontotemporal dementia?

Answer 26

Change in personality and social behaviour, or primary aphasia

Question 27

What are the 7 As of dementia?

Answer 27

Anosognosia - lack of insight
Amnesia - loss of memory
Apathy - lack of interest
Agnosia - unable to recognise objects using the senses
Aphasia - loss of language
Apraxia - loss of coordination and difficulty with ADLs
Altered impressions - misinterpretation of sense information

Question 28

What drugs are used in dementia - example of each class with SEs, MoA and which dementias they are useful in.

Answer 28

AChE inhibitors - rivastigmine, donepazil and galantamine. SEs include CARDIAC ARRHYTHMIAS, nausea, vomiting, headaches, insomnia. Can be used for Alzheimer’s or Parkinson’s (rivastigmine)

Memantine - glutamate antagonist, used in Alzheimers

Question 29

What is the differential for suspected dementia?

Answer 29

V - stroke, subdural haematoma
I - Cerebral abscess, meningitis, encephalitis, UTI, chest infection
T - head injury, pain causing delirium
A - autoimmune encephalitis, SLE
M - Cushing’s, thyroidism, hypercalcaemia, hypo-glycaemia
I - Drug side effects
N - brain mets or primary

C - Down’s
D - Alzheimers, CJD, MSA, PSP
F - Depression (pseudodementia)

Question 30

What are the counselling points for lithium?

Answer 30

Exact mechanism unknown

Tablet, capsule or liquid taken once per day

Take it lifelong usually

Takes 1-2 weeks to begin working

Need FBC, U+Es, TFTs, bHCG in women, ECG. Check litium level every week until stable for 4 weeks, then 3 monthly. TFTs, U+Es and Ca every 6 months

SEs: GI (abdo pain + nausea, metallic taste), fine tremor, diabetes insipidus (polydipsia, polyuria, weight gain). In overdose, D+V, dizziness, ataxia, worsening tremor, drowsiness + restlessness).