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7118 - Clinical Therapeutics for Core Conditions > Mental Health > Flashcards

Mental Health Flashcards

1
Q

Describe the categories of depressive symptoms

A
  • psychological (affecting mood and perception) - low mood, anxiety, apathy, low self-esteem, guilt, sexual dysfunction, negative thinking, anhedonia (inability to feel pleasure in normal pleasurable activities)
  • physical (also called somatic or biological) - fatigue, poor appetite, sleep disturbances, weight loss, pain, GI disorders, hypersomnia.
  • cognitive (affecting concentration and memory) - poor concentration and poor memory
  • behavioural - agitation, withdrawal, retardation, self neglect
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2
Q

what is depression now recognised as an independent risk factor for?

A

coronary heart disease

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3
Q

/how long to antidepressants take to work?

A

start having an effect after 2 weeks however NICE does not recommend a dose increase or change of drug until 3-4 weeks

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4
Q

How long should a patient stay on anti-depressants?

A

at least 6 months or high risk of relapse. Patients with recurrent episodes of depression should stay on for about two years

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5
Q

Why are SSRI’s first line?

A
  • as efficacious as other classes
  • cheaper
  • better adverse profile
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6
Q

Antidepressants should be prescribed for patients with

A
  • mild to mod depression
  • history of mild to mod depression
  • pt who initially present with sub - threshold depressive symptoms that have been present for at least two years
  • with sub-threshold depressive symptoms or mild depression when other treatment interventions have failed.
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7
Q

Tricyclic antidepressants work by….

A
  • inhibit the reuptake of serotonin and noradrenaline.
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8
Q

Side effects of tricyclic antidepressants include

A
  • cardio toxicity, antimuscarininc effects (dry mouth, constipation, urinary retentions, confusion) and sedation (which can be good in patients who have insomnia)
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9
Q

TCA’s should be avoided or used with cautions in

A
  • patients with cardiovascular disease
  • elderly patients
  • patients with glaucoma
  • patients with a history of bipolar affective disorder
  • males with BPH
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10
Q

SSRI’s work by….

A

selectively inhibit the reuptake of serotonin from the synapse into the pre-synaptic neurone, this increasing the availability of serotonin.

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11
Q

When should SSRI’s be taken?

A

They should be taken in the morning to prevent insomnia but paradoxically they have been known the cause sedation.

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12
Q

Sid effects of SSRI’s

A
  • nausea and vomiting (usually on initiation)
  • anorexia
  • hyponatraemia
  • loss of libido
  • they are less cardio toxic that TCA’s but have a risk of increasing the QT so should not be taken with other medicines that increase the QT. Their maximum daily doses have been reduced.

Paroxetine is rarely used now due to withdrawal symptoms on cessation. This is due to short half life.

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13
Q
  • MOA’s work by….
A

combine irreversibly with the monoamine oxidase enzyme responsible for breaking down neurotransmitters in the brain.

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14
Q

MOA’s side effects and initiation

A

only initiated by specialists in resistant depression this is due to risk of life-threatening interactions with sympathomimetics and food rich in tyramine or tyrosine (e.g. most cheeses, alcoholic drinks, chocolate). Other S/E’s similar to TCA’s

They can be useful when anxiety of obsessional thoughts are prominent features of major depressive episode.

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15
Q

SNRI’s

A

Venlafaxine - does not cause sedation or anticholinergic effects however it does have cardiovascular effects

Duloxetine - effective at low doses. Well tolerated and not cardiotoxic and it is also licenses in urinary incontinence and diabetic neuropathy. BP monitoring is recommended in patients with cardiovascular disease.

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16
Q

Mirtazpeine

A

noradrenaline and serotonin specific antidepressant

  • good in patients with agitation and insomnia and it does not cause anorexia or sexual dysfunction.

Main side effect is weight gain (most common cause of discontinuation) dry mouth and constipation

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17
Q

Reboxetine

A

Noradrenaline reuptake inhibitor
Weak anticholinergic effects
Not licensed for elderly and rarely used in practice

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18
Q

Trazadone

A

reuptake inhibitor
also antagonises 5HT2A receptors.
It is sedative but has ow incidence of anticholinergic effects
It does not appear cardiotoxic

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19
Q

if switching from a MOA to another antidepressant we should leave

A

2 weeks

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20
Q

from switching from SSRI to MOA we should leave

A

5-6 weeks

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21
Q

withdrawal effects from TCA’s

A

N & V & D & flu-like symtoms, fatigue, anxiety, agitation, sleep disturbances

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22
Q

withdrawal effects from SSRI’s

A

N & V & D & dizziness, electric shock like sensations, anxiety, agitation and low mood

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23
Q

effects of serotonin syndrome

A 
restless/agitation
profuse sweating
tremor
shivering
myoclonus
confusion
convulsions
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24
Q

agomelatine

A

releases both noradrenaline and dopamine in the pre-frontal cortex (which is involved with mood, cognisiton and anxiety)

  • synthetic analogue of melatonin and is believed to restore cardadian rhythms.
  • weight gain and sexual dysfunction don’t appear to be associated with the drug but LFT’s should be monitored.
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25
Q

what antidepressant is also licensed for diabetic neuropathy?

A

duloxetine

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26
Q

which class and drugs should be avoided in tyramine rich foods?

A

MOA’s

Phenelazine, moclobemide

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27
Q

Which class and drugs should be avoided in patients with BPH?

A
  • TCA’s

amitriptyline
noritiptyline

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28
Q

max dose of citalopram in elderly is

A

20mg

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29
Q

Causes of dementia….

A

1) Alzheimers disease - 50% of cases. Tau proteins. Both plaques an tables are thought to contribute to a reduced function and nerve cell death. Acetylcholine is reduced and brain skins (especially areas associated with memory)
2) Vascular dementia - poor circulation to therein or strokes. May be acute and subside or progress.
3) Lewy body dementia - abnormal deposits (lower bodies) of a protein (alpha-synuclein|) in the brain.

Other) picks disease, hunting tons disease, aids dementia, cruetz jakob disease.

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30
Q

Treatment options include acetylcholinesterase inhibitors and NMDA receptor agonists

A

Donepezil - ACI
Galantine - ACI
Rivastigmine - ACI
Memantanine

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31
Q

Which drug can be used in moderated to severe alzheimers disease?

A

Memantine

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32
Q

Which drug can be used in patients with idiopathic parkinson disease?

A

rivastigmine

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33
Q

Which drug comes in a patch?

A

rivastigmine

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34
Q

ACI’s

A

increase the acetylcholine in the brain

Common side effects: N, V, anorexia, diarrhoea, dizziness, headache and syncope.

They have a vagotonia effect on the heart and can cause bradycardia so are cautioned in abnormalities. Is syncope or seizures could be heart block.

Cautioned in asthma and COPD - anticholinergics are also used in these conditions.

Can cause ulcer/stomach upset. Cautioned with other drugs that cause the same or a pt with a history. May need PPI.

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35
Q

Behavioural or psychological symptoms of dementia?

A

What exactly is happening?
Antecedents
Behaviour
Consequences

When is it happening?
Time of day
Frequency

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36
Q

What can be used to challenge non-cognitive symptoms such as hallucinations?

A

risperidone

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37
Q

When should antipsychotics never be used and why?

A

Lewy body dementia

May precipitate irreversible parkinsonism and induce autonomic disturbance.

38
Q

Which acetylcholinesterase drug is best?

A

They’re all equally good just depends on the patient

39
Q

antipsychotics should be reviewed every

A

3 months

40
Q

elderly dose of lorazepam

A

0.5mg QDS PRN. Max 2mg daily

41
Q

antidepressants which anticholinergic side effects should be avoided in depression

A

for example tricyclic antidepressants and related drugs due to their adverse effects on cognition e.g. increased confusion, sedation and falls risk

42
Q

Causes of delirium

A

constipation, ADR’s, physical health co-morbidities e.g. poorly controlled glucose, pain, sleep deprivation

43
Q

donepazil is cautions in COPD

A

true

44
Q

lewybody dementia is associated with which condition?

A

parkinson

45
Q

use of antipyscotics in parkinsons disease has been associated with an increased risk of

A

stroke

46
Q

Recognised side effects of donepezile (ACI)

A

syncope
anorexia
dizziness

47
Q

Two main symptoms of psychosis are…

A

hallucinations - where a person hears (auditory), sees (visual|) and in some cases feels (sensory) or smells (olfactory) or tastes (gustatory) things that are not there
delusions - when people believe things that when are examines rationally are not true for example they are a member of the CID

48
Q

symptoms of schizophrenia can be positive or negative symptoms. What are they…

A

Positive symptoms (clinical features of acute schizophrenia)

  • delusions
  • hallucinations
  • thought disorders
  • movement disorders

negative symptoms

  • flat affect
  • social withdrawal
  • apathy - lack of feeling, emotion, interest and concern
  • self neglect
  • lack of motivation
49
Q

How long should antipsychotics be given for and how do they usually works?

A

2 years

dopamine antagonists

50
Q

Antipsychotics can be divided into typical and atypical.

What are the differences?

A

Typical
- Haloperidol, chlorpromazine, levomepromazine, zuclopentixol, sulpiride, flupentixol. (HCLZS)

They cause extrapyridimal side effects, sedation, weight gain, neuroleptic malignant syndrome.
Effective against positive symptoms
causes sustained rise in prolactin serum levels
significant rise in tar dive dyskinesia

Atypical

  • clozapine, olanzapine, risperidone, quetiapine, amisulpririse, aripiprazole (CARAQO)
  • extra pyramidal side effects are weak. They are usually absent at therapeutic doses but can be seen at high doses.
  • effective against positive symptoms
  • can be effective against negative symptoms (especially clozapine)
  • weight gain (increase in appetite) more common with atypical than typical
  • sedative
  • impaired glucose tolerance (check BM every 6 months)
51
Q

What do extrapyramidal side effects include?

A

The extrapyramidal symptoms include acute dyskinesias and dystonic reactions, tardive dyskinesia, Parkinsonism, akinesia, akathisia, and neuroleptic malignant syndrome.

52
Q

Hyperprolactinaemia - antipsychotics

A

Dopamine and serotonin control prolactin levels.

This can cause hirtuism, gynacomastia, sexual dysfunction, infertility, irregular or no period, and possible breast cancer and osteoporosis.

More common with typicals

Reduce dose or change antipsychotic or add prolactin lowering agents e.g. cebergoline.

53
Q

cardiac effects - antipsychotics

A

postural hypotension - most typicals, phenothiazine

tachycadia - clozapine, risperidone, chlorpromazine

prolonged AT - pimozide, phenothiazine, haloperidol.

54
Q

Neuroleptic malignant syndrome - antipyscotics

A

rare but life threatening
seen within two weeks of initiation or dose increase

raised temp, sweating, fluctuating BP, muscle rigidity, tachycadis, raised creatinine kinase, increased risk of PE.

more prevalent with typical or combination

55
Q

clozapine side effects

A
  • neutropenia, agranulocytsis - patients require regular blood tests. once a week for the first 18 weeks and then fortnightly for up to one year and then every 4 weeks after that.
  • hypotension
  • tachycadia
  • weight gain
  • seizures
  • hypersalivation
  • sedation

smoking can reduce clozapine level by 50% so if a patient gives up smoking they may need their dose reducing.

56
Q

Riker scale

A

Score 4-7

57
Q

when should we avoid antipsychotics

A

in parkinson disease and lewy body dementia

58
Q

Why can’t we use diazepam or chlorpromazine IM

A

Diazepam - eratic absorption

chlorpromazine - crystallises in the tissue

59
Q

How long should we leave between doses when patient is having an episode? And what should we monitor

A

an hour ideally

usually parameters e.g. RR, HR, BP

60
Q

first line agent in UK for rapid tranquillisation?

A

lorazepam

61
Q

How long do we leave between IM olalzaparin fan benzodiazepine and why

A

1 hour and sedation and risk of cardiorespiratory depression

62
Q

Hyperprolactinaemia is more common with typical or atypical?

A

TYPICAL

63
Q

Does cigarette smoking increase or decrease levels of clozapine?

A

Decrease

When patients stop smoking the levels shoot up

64
Q

Bipolar 1 and 2

A

1 - mania and depression (7 days or more)

2- hypomania and depression (4 days or more)

65
Q

Which drugs can cause bipolar?

A

-illicit
-corticosteroids - minor elevation and euphoria but depression is more common
-levodopa elevation and manic symptoms
-methylphenidate - mania and psychosis
-antidepressants - switch someone to mania from depression
-betablockers - ones that cross the BBB can cause depression
- contraceptives - can cause depression
mefloquine - depression and psychosis

66
Q

What should patients go on if they have episode of mania whilst on antidepressants?

A

Antidepressant stopped

Go on mood stabiliser - haloperidol, quetiapine, olanzapine or risperidone

67
Q

What do we give if lithium is not effective

A

valproic acid

68
Q

what other drugs can be given in acute mania

A

lorazepam but longer acting benzos may be required.

once acute mania is treated we need something more long term

69
Q

What do patients require baseline of before initiating lithium?

A

eGFR
FBC
TFT
ECG

70
Q

What is the usual starting dose for lithium

A

400mg ON

200mg in elderly

71
Q

Advise whilst on lithium

A

drink plenty of fluids
don’t intake too much salt
low sodium is not good with lithium (increase levels)

72
Q

target ranges whilst on lithium

A

0.4-1.0
0.8-1 whilst having a manic episode
prophylaxis 0.4-0.8 mol/L

73
Q

When should lithium levels be taken?

A

12 hours post dose

  • 5-7 days after initiation
  • After any dose change
  • AKI
  • if interacting drugs are started or stopped
  • signs of toxicity
74
Q

When do we check lithium levels once a patient is stable?

A

every 3 months

eGFR, THT’s, and calcium levels every 6 months

75
Q

Side effects and toxicity of lithium

A 
Side effects:
GI disturbances
tremor
weight gain
urinary frequency
hypercalcaemia
hyper/hypothyroidism

Toxic effects usually level >1.5.
Levels >2 are a medical emergency. Symptoms N and V, confusion, convulsion, renal failure, coma. Patients require daily levels and maybe dialysis to remove the drug.

76
Q

pharmacodynamic and pharmacokinetic interactions

A
  • drugs that lower sodium can increase lithium levels e.g. diuretics (especially thiazides)
  • antidepressants and tramadol increase the risk of serotonin syndrome.
  • NSAIDS inhibit renal prostaglandins and reduce blood flow to through the kidneys, thus increasing the risk of raised lithium levels. low dose aspirin appears to be less risk.
  • ACE and ARB reduce renal excretion of lithium
77
Q

Depakote (valproic acid)

A
  • 250mg TDS (max dose 2g daily)
  • monitor LFT’s regular in th first 6 months as this is when they are most likely to go off. Also FBC.
  • Side effects: N, V, hallucinations, alopecia, thrombocytopenia, headache.
  • Eliminated through the kidneys as ketone bodies thus potentially causing false positive in urine tests of patients with diabetes.
  • child bearing age
78
Q

Carbemazapine

A

prophylaxis of manic-depressive episodes who are unresponsive to lithium but they should not be used in acute episodes

  • LFT’s & FBC
  • N, V, dizziness, dry mouth, hyponatraemia, urticarial and hepatic dysfunction
  • Cautions in cardiac disease, child bearing aged (neural tube defects), and with other medicines as it is a potent enzyme inducer.
79
Q

Lamotrigine

A
  • licensed for the prevention of depressive episodes associated with bipolar disorder.
  • Doses should be titrated slowly due to the risk of hypersensitivity syndrome.
  • side effects; N, V, SJS, blood disorders.
80
Q

Patients with Bad prescribed antidepressive agent should also be prescribed antigenic agent

A

SSRI first line

81
Q

Antidepressants should be avoided in patients who have

A

rapid-cycling BAD, a recurrent hypomanic episode, recurrent functionally impairing rapid mood fluctuations

we can consider stopping antidepressants once a patient has been symptom free for 8 weeks

82
Q

Last line therapy

A

Electro-Convulsive therapy.

83
Q

Which of the following can increase lithium levels?

A

bendroflumethiazide
candasartan
ibuprofen

84
Q

Three potential side effects of lithium

A

hypothyroidism
hyperthyroidism
weight gain

85
Q

Main 4 extrapyramidal side effects

A

1) Akathisia (restlessness)
2) Tardive dyskinesia - involuntary repetitive movements e.g. sticking out tongue
3) dystonic reactions - sustained repetitive muscle contractions resulting in twisting and repetitive movements or abnormal fixed postured
4) parkinosium - tremor, bradykinesia, rigidity

86
Q

Name a drug that can increase lithium levels

A

Candesartan

87
Q

Score to assess for delerium in critically ill patients

A

CAM-ICU

88
Q

List a TCA

A

Amitriptyline

Nortiptyline

89
Q

Which antidepressant is believed to help restore normal circadian rhythms ?

A

Agomelatine

90
Q

List a moa inhibitor

A

Meobemide

Phenelezine

91
Q

Lithium tablets to liquid

A

200mg tablet = 509mg liquid

92
Q

Benzoz with antidepressants

A

Sometimes used whilst waiting for antidepressant to kick in

7118 - Clinical Therapeutics for Core Conditions (31 decks)

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