mental health disorders Flashcards
which class of drugs are the most commonly used anxiolytics/hypnotics?
give a few examples
benzodiazepines
temazepam, diazepam, loprazolam, nitrazepam
when and for who are short acting hypnotics usually prescribed for?
people with short term insomnia [caused by emotions or illness]
the elderly
ppl who do not want to be sedated during the day
which hypnotics should be avoided in the elderly? and why?
z drugs [zolpidem and zopiclone]
benzodiazepines
bc can make them confused and increase risk of falls and injury
which hypnotics are normally used for dental pain?
diazepam or temazepam
are the Z drugs [zolpidem/zopiclone] short or long acting?
are they licensed for long term use?
short acting and not licensed for long term use
which hypnotic can be used for insomnia in the ELDERLY? and why?
clomethiazole [non benzodiazepine hypnotic]
bc doesnt cause hangover effects
which antihistamines are available otc for occasional insomnia?
what are the side effects?
promethazine hydrochloride
can cause drowsiness the nest day, headaches, psychomotor impairment and antimuscarinic effects
why is alcohol a poor hypnotic?
bc it is a diuretic so the constant urination affects sleep. it can also worsen sleep disorders
which drug is a pineal hormone and licensed for adults OVER 55 years for insomnia?
melatonin
how does buspirone work?
how long does response to treatment take?
acts as specific serotonin [5ht1a] receptors. used for insomnia
response to treatment can take up to 2 weeks
which insomnia should barbiturates be used in?
can they be used for the elderly?
severe insomnia in pt already taking barbiturates
no - avoid
give an example of a short and long acting barbiturates and their indications?
long acting: phenobarbital. uses are epilepsy
short acting: thiopental sodium used as an anaesthetic
what can help alleviate the PHYSICAL symptoms of anxiety eg tremor, palpitations?
beta blockers
how can you avoid a pt becoming dependant on benzodiazepines?
lowest dose for shortest period of time
list the names of the SHORT acting benzodiazepines
LLATOM
lormetazepam loprazolam alprazolam temazepam oxazepam midazolam
in which pt are short acting benzodiazepines considered for insomnia?
elderly
ppl with liver impairment
give some examples of LONG ACTING benzodiazepines?
DCCN
diazepam
chlordiazepoxide
clobazam
nitrazepam
give an example of an intermediate acting benzo?
lorazepam
how can you withdraw benzodiazepines?
gradually reduce dose
for short acting benzos, tapering can take 2-4 weeks
for long acting benzos, tapering can take months or more
what can occur with abrupt withdrawal of benzodiazepines?
confusion, ataxia, toxic psychosis and convulsions
what is benzodiazepine withdrawal syndrome and what are some symptoms?
can develop when a pt is starting to be withdrawn from benzodiazepines.
symptoms include insomnia, anxiety, loss of appetite, tremor, tinnitus etc
when can benzo withdrawal syndrome occur for a pt taking a long acting benzo?
when can it occur for a pt taking a short acting benzo?
long: at any time up to 3 weeks of stopping
short: the next day from stopping
what is the protocol for withdrawal of LONG TERM benzos?
transfer pt to equivalent dose of diazepam taken preferably at night
reduce dose by 1-2mg every 2-4 weeks
if withdrawal symptoms occur maintain pt on that dose until symptoms lessen
reduce dose further [in smaller steps if needed] and then completely stop
what 2 drugs are normally used for panic attacks?
IV diazepam and IV lorazepam
what are some indications of benzos?
epilepsy severe insomnia severe anxiety muscle spasm alcohol withdrawal
which type of benzos are recommended for elderly/hepatic impairment?
what do they carry a greater risk of?
short acting
greater risk of withdrawal symptoms
what are the cautions of benzodiazepines? [4]
avoid prolonged use
avoid abrupt withdrawal
ppl with history of drug/alcohol dependance
paradoxical effects
what are paradoxical effects of benzodiazepines and list some examples?
they are when benzos produce the opposite effects to what they are intended
increased anxiety, aggression, talkativeness
what are the side effects of benzodiazepines? [8]
decreased alertness anxiety ataxia and confusion dizziness and drowsiness fatigue GI disorders and sleep disorders muscle weakness hypotension altered mood, tremor, suicidal thoughts
what are the 3 contraindications of benzos?
- pulmonary insufficiency [lung problems bc can cause respiratory depression]
- sleep apnoea
- unstable myasthenia gravis [muscle weakness]
what is the risk of benzos in pregnancy?
neonatal withdrawal symptoms
when may you use benzos during pregnancy?
when there is a clear indication eg epilepsy
are benzos safe in breastfeeding pt?
avoided if possible, as traces are found in breastmilk
what is the pt and carer advice regarding benzodiazepines?
- drowsiness can affect performance of skilled tasks
- effects enhanced by alcohol
can benzos be given in hepatic impairment?
what is the risk?]
which benzos are preferred?
when must you avoid giving benzos?
if treatment is necessary, use short acting [LLATOM]
risk: benzos can precipitate coma esp long acting
AVOID in severe impairment
what is ADHD?
attention deficit hyperactivity disorder
behavioural syndrome characterised by hyperactivity, impulsitivity and inattention
what is the drug treatment of ADHD?
- methylphenidate or lisdexamfetamine 1st line treatment
- atomoxetine or dexamfetamine alternative
which drug is used 1st line for ADHD for ppl with drug misuse?
atomoxetine
what are the side effects of atomoxetine? [6]
- agitation
- irritability
- side effects
- suicidal thoughts
- self harming
- unusual behaviour changes
what is bipolar disorder and mania?
chronic condition where pt has lows [depression] and highs [mania]
what are the symptoms of mania in bipolar disorder?
more talkative
have grand ideas abt themselves or unrealistic plans
increased energy
less sleep
what is hypomania?
pt still on a high but not as much as mania
what are the symptoms of depression in bipolar?
low mood loss of enjoyment abnormal sadness poor motivation feeling guilty poor concentration sleeping problems
what drugs can be used to manage bipolar?
antipsychotics benzos lithium valproate carbamazepine
how long for must you continue long term treatment of bipolar after a pt has a manic episode?
what if the pt has risk of factors for relapse?
2 years from last manic episode
5 years if pt has risk of factors for relapse
when must you avoid giving antidepressants for bipolar disorder?
when pt has rapid cycling bipolar, recent history of hypomania or rapid mood fluctuations
when are benzos used in bipolar disorder?
what must you avoid with benzos?
for agitation or behavioural disturbance
avoid long term use
give examples of anti-psychotic drugs used in bipolar disorder?
what must be added to them if response to these drugs is inadequate?
olanazpine, quetiapine, risperidone
add lithium or valporate if response inadequate
what should be done when discontinuing a pt from anti-psychotics?
reduce dose gradually over 4 weeks
when is carbamazepine used in bipolar disorder
prophylaxis of bipolar disorder
when are valproate considered in bipolar disorder?
for prophylaxis of bipolar and in pt with rapid cycling manic depressive illness
what are the uses of lithium in bipolar?
prophylacis, treatment of mania and hypomania and depression in bipolar
what are the 2 forms of lithium>?
are they bioequalivent?
lithium citrate and lithium carbonate
no
what are the indications of lithium? [4]
prophylaxis and treatment of: mania bipolar disorder recurrent depression aggressive or self harming behaviour
what are the contraindications of lithium?
- uncontrolled hypothyroidism [lithium can cause hypothyroidism]
- low sodium salts [can increase lithium conc]
- dehydration
- significant renal impairment
- cardiac disease
- addisons disease
what are the cautions of lithium? [4]
- avoid abrupt withdrawal
- diuretic treatment
- QT interval prolongation
- review doses in diarrhoea, elderly, vomiting, surgery, intercurrent infection
what should be monitored with lithium?
thyroid function every 6 months
when would you only maintain a pt on lithium for?
maintain pt after 3-5 years only if benefits persist
what are the side effects of lithium?
LITHIUM
levels [therapeutic levels] increased urination [renal dysfunction] thirst, tremor, teratogenic hypothyroidism interactions [NSAIDs, ACEi, ARB, diuretics, antacids] upset stomach [diarrhoea, N&V] muscle weakness skin effects [acne, psoriasis]
others:
CNS [drowsiness/confusion], electrolyte imbalance, cardiomyopathy, arrhythmia, lower seizure threshold, leucocytosis, memory loss, vision disorders, intracranial hypertension, QT interval prolongation!
what are the signs of lithium overdose?
[baso the side effects]
heart block arrythmia renal failure fine tremor CNS disturbance muscle weakness coma and sudden death GI disturbance visual disturbance
is lithium ok for breastfeeding pt?
avoid bc its present in the milk
is lithium ok for pregnant women?
which trimesters are not suitable for lithium?
when would you need a dose increase of lithium during pregnancy?
avoid if possible esp in 1st trimester
dose increase in 3rd and 2nd trimester but return to normal on delivery
what should be monitored before a patient is initiated on lithium?
Full blood count thyroid renal electrolytes cardiac
when would you need to monitor lithium blood concentrations in a pt?
every week after initiation and after every dose change until pt stable
then every 3 months
what are the 2 therapeutic ranges of lithium serum concentration?
- 4-1mmol/L [lower range] for elderly pt and for maintenance
- 8-1mmol/L [upper range] for acute episodes of mania and for pt who previously relapsed
how long should you withdraw lithium for?
over a period of 4 weeks to 3 months
what is the pt and carer advice of lithium? [6]
- report signs of lithium toxicity
- report hypothyroidism, renal dysfunction
- report benign intracranial hypertension [eg headache/visual disturbance]
- maintain adequate fluid intake
- avoid dietary changes that will reduce or increase sodium levels
- give pt lithium treatment pack
must lithium be brand specific?
yes
which drugs INCREASE lithium concentration? [6]
ace/arb diuretics [loop/thiazide] metronidazole NSAIDs amiodarone tetracyclines
which drugs DECREASE lithium concentration? [5]
- sodium containing antacids [bc contain high salt]
- carbonic anhydrase inhibitor diuretic [eg dorzalamide]
- osmotic diuretic [eg mannitol]
- theophylline
- urinary alkalinising agents for cystitis
which drugs INCREASE neurotoxicity with lithium? [5]
- carbamazepine
- antipsychotics
- SSRIs
- triptans
- CCB
how do most drugs prolong QT interval prolongation with lithium?
by causing hypokalaemia
which drugs INCREASE RISK OF serotonin syndrome with lithium? [5]
- SSRIs [eg citalopram]
- monoamine oxidase inhibitors
- tramadol
- st johns wort
- sumatriptan
