Mental health disorders Flashcards
Anxiety treatment
- Benzodiazepines are indicated for short-term relief of anxiety that is causing unacceptable distress (for 2-4 weeks only). An example is Diazepam
- They can slow down the grieving process and are used in children only for acute anxiety in situations involving fear (e.g. fear of surgery).
Symptoms of diazepam overdose
drowsiness, ataxia, dysarthria, nystagmus + coma
For chronic anxiety
Chronic - (longer than 4 weeks) it may be appropriate to use an antidepressant.
- Patients with generalised anxiety disorder (a form of chronic anxiety), should be offered psychological treatment followed by an SSRI (sertraline).
- Duloxetine and Venlafaxine (serotonin and noradrenaline re-uptake inhibitors) can also be used.
- If a patient cannot tolerate the above/treatment is ineffective, then pregabalin can be considered
Attention deficit hyperactivity disorder (ADHD)
If a child has severe and persistent symptoms of ADHD, then CNS stimulants including Atomoxetine + Methylphenidate can be prescribed
- If a child has moderate symptoms of ADHD they can be treated with CNS stimulants when psychological interventions have been unsuccessful or are unavailable.
- Treatment for ADHD often needs to continue into adolescence and may need to be continued into adulthood.
- If the patient does not respond to Atomoxetine and Methylphenidate, then Dexamfetamine and Lisdexamfetamine are an alternative for children.
ADHD - what can be used in children for whom stimulants are not suitable, not tolerated or ineffective
Guanfacine, a non-stimulant alpha2-adrenoceptor agonist
- Therapeutic response to guanfacine should be evaluated every 3 months for the first year, and then atleast yearly, when prescribed for extended periods.
Atomoxetine - monitoring requirements
Monitor for appearance or worsening of anxiety, depression or tics. Pulse, BP, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment and 6 months thereafter.
Atomoxetine - patient/carer advice
Suicidal ideation: following reports of suicidal thoughts and behaviour, patients and their carers should be informed about the risk and told to report worsening suicidal thoughts/behaviour, irritability, agitation or depression.
Atomoxetine - hepatic impairment
Recognise and report symptoms such as abdominal pain, unexplained nausea, malaise, darkening of urine or jaundice
Dexamfetamine + Lisdexamfetamine
Cautions:
- Tics and Tourette syndrome: discontinue use if tics occurs.
- Growth restriction in children may occur during prolonged therapy, monitor height and weight (drug-free periods may allow catch-up in growth.. withdraw slowly to avoid inducing depression,renewed hyperactivity)
- Overdose: wakefulness, excessive activity, paranoia, hallucinations, HTN, exhaustion, convulsions, coma and hyperthermia
Bipolar disorder and Mania
Bipolar disorder is a condition that affects moods, which can swing from one extreme to another. People with bipolar disorder often have periods or episodes of:
- Depression – feeling very low and lethargic
- Mania – feeling very high and overactive
used to treat mania or hypomania.
Antimanic drugs
Antidepressant drugs are used to treat co-existing depression but should be avoided in patients with
rapid-cycling bipolar disorder, a recent history of hypomania or with rapid mood fluctuations.
- Long term treatment of bipolar disorder
should continue for atleast 2 years from the last manic episode and up to 5 years if the patient has risk factors for relapse.
Benzodiazepines may be helpful in
• Benzodiazepines (e.g. Lorazepam) may be helpful in initial stages of treatment for behavioural disturbance or agitation. But they should not be used for long-periods due to the risk of dependence
Antipsychotic drugs
- Antipsychotic drugs (normally olanzapine, quetiapine or risperidone) are useful to treat acute episodes of mania or hypomania. If they are effective in controlling manic episodes, they can be used for the long-term management of BIPOLAR DISORDER.
- Antipsychotic drugs can be given as monotherapy or in combination with lithium or valproate, if patient has frequent relapses or continuing functional impairment.
- For severe acute mania, an antipsychotic drug may be used concomitantly with lithium or valproate.
Carbamazepine
• If patients are unresponsive to a combination of prophylactic drugs, Carbamazepine may be used under specialist supervision for the prophylaxis of bipolar disorder (manic-depressive disorder).
• It is used in patients with rapid-cycling manic-depressive illness (4 or more episodes per year)
- The dose of this drug should not normally be increased if an acute episode of mania occurs.
Valproate
- Valproate includes Sodium Valproate and Valproic acid (semi-sodium salt). Valproic acid is available as Depakote and Convulex which are licensed for manic episodes associated with bipolar disorder.
- Sodium Valproate is available as Epilim and Epilim Chrono which are licensed for epilepsy + mania
- If the patient has frequent relapses or continuing functional impairment, consider switching therapy to lithium or olanzapine or adding lithium or olanzapine to valproate.
- If a patient taking valproate experiences an acute episode of mania that is not improved by increasing the valproate dose, consider adding olanzapine, quetiapine or risperidone.
Lithium
Lithium salts are used as a mood-stabiliser in bipolar disorder, but it can take 6-12 months for the effect to be seen.
Cautions: Long-term use of lithium has been associated with thyroid disorders and mild cognitive and memory impairment… hence long-term treatment should be undertaken with careful assessment of risk and benefit and thyroid function should be monitored every 6 months.
Driving and skilled tasks: this drug may impair performance of skilled tasks (e.g. driving).
Renal function should also be monitored every 6 months.
The bioavailability of preparations vary, therefore lithium should ALWAYS BE PRESCRIBED BY BRAND (e.g. Priadel or Camcolit).
Dose equivalence and conversion: for Priadel liquid: 520mg of Lithium Citrate Tetrahydrate is equivalent to 204mg of Lithium Carbonate.
Patients should be issued with a lithium treatment pack and advised to maintain adequate fluid intake and avoid changing the amount of salt in their diet.
Depression
• Antidepressants should only be used for moderate to severe illness. However, if psychological therapy is ineffective in patients with mild depression, drug treatment may be considered.
- Alternatively, drug treatment for mild depression may be considered if the patient has a history of moderate-severe depression or if they have social/medical problems.
- Most antidepressant drugs are equally effective, so the choice of antidepressant depends on the patient’s needs, co-morbidities, risk of suicide and previous response to antidepressant therapy.
Antidepressants take 2 weeks for the full effect to be seen, and during this time there may be an increase in agitation, anxiety and suicidal ideation. When initiating treatment, patients should be assessed every 1-2 weeks.
Treatment should be continued for atleast 4 weeks (6 weeks in elderly) before considering a change in treatment.
Following remission, antidepressant treatment should be continued at the same dose for atleast 6 months (12 months in elderly). Therapy should continue for atleast 2 years in patients with a history of recurrent depression.
SSRIs (e.g. Sertraline) are the first-line treatment option since they are safer in overdose than other antidepressants.
TCA’s have a similar efficacy to SSRIs but are more likely to be discontinued due to side effects. Furthermore, they are more toxic (harmful to the body) in overdose.
MAOIs have dangerous interactions with certain foods + drugs and are reserved for specialist use.
What drugs should be used in caution in depression
Although anxiety is often present in depressive illness (and may be the presenting symptom), the use of an antipsychotic/anxiolytic may mask the true diagnosis. Hence, these drugs should be used in caution but are sometimes added to manage agitation.
St John’s wort
St John’s wort is a popular herbal remedy available OTC for treating mild depression. It SHOULD NOT be prescribed or recommended for depression because it can induce drug metabolising enzymes and has many interactions with conventional (common) drugs.