Mental health disorders Flashcards
1
Q
What condition is the serotonin receptor agonist Buspirone contra-indicated in?
A
Epilepsy
2
Q
What is the MHRA alert regarding Benzodiazepines?
A
risk of potentially fatal respiratory depression - should only co-prescribe opioids + benzos if no other alternative option
3
Q
How long do benzos have to have been taken for in order to be weaned off?
A
> 2 weeks - risk of benzodiazepine withdrawal
4
Q
What is an associated risk of an elderly person taking benzos?
A
Increased risk of falls
5
Q
What CD schedule are Benzos?
A
CD4 - 1
6
Q
What are the indications of use of Chlordiazepoxide?
A
Short term use in anxiety
Treatment of alcohol withdrawal
7
Q
What are some of the licensed indications for Diazepam?
A
- muscle spasicity
- tetanus
- status epilepticus
- premedication
- anxiety
- sedation in dental procedures
8
Q
Intravenous Diazepam holds a risk of what?
A
Severe thrombophlebitis (reduced by using emulsion form)
9
Q
What drugs can be used to treat anxiety?
A
Benzos or Buspiron (serotin agonist)
10
Q
What age and gender is ADHD most commonly diagnosed in?
A
3-7 years most common in men
11
Q
What are the 2 first line drug treatments for ADHD?
A
Lisdexamfetamine mesilate and methylphenidate hydrochloride
12
Q
If a patient does not respond to Lisdexameftamine or Methylphenidate, what other non stimulant drug can be trialled?
A
Atomoxetine (centrally acting sympathomimetic)
13
Q
What are the monitoring requirements associated with Methylphendiate?
A
BP, pulse, psychiatric symptoms, appetite, weight, height at initiation ad following dose adjustment then every 6 months thereafter
14
Q
What CD schedule is methyphenidate?
A
CD2
15
Q
What drug class is useful in the acute stages of mania?
A
Antipscychotics e.g. Olanzapine, risperidone, qutiapine
16
Q
What drug class is Asenapine and when is it used?
A
Second generation antipsychotics, used for moderate - severe manic episodes associated with bipolar disorders
17
Q
How many weeks should antipsychotics be discontinued over?
A
4 weeks if continuing on the antimania drugs or up to 3 months otherwise
18
Q
What anti-epileptic drug(s) can also be used to prevent bipolar disorder?
A
Carbamazepine
Valporate - treats manic episodes associated with bipolar + prophylaxis
19
Q
what is the indication for lithium in bipolar disorder?
A
treatment and prevention of mania, hypomania and depression
20
Q
How long after initiation of lithium therapy can it take for the full prophylactic responce to be seen?
A
6 - 12 months
21
Q
What 2 side effects of valporate lead to immediate withdrawal of the drug?
A
Pancreatitis and hepatic dysfunction
22
Q
What false positive on laboratory tests can valporate cause?
A
Ketones
23
Q
Contra-indications to lithium therapy
A
dehydration, low sodium diet, cardiac disease, untreated hypothyroidism, addisons
24
Q
Long term lithium therapy is associated with what endocrine disorder?
A
Thyroid disorders - monitor TFTs every 6 months
25
Side effects of lithium
1. GI disturbances ( particularly at initiation)
2. Metlic teaste
3. Weight gain
4. Ankle oedema
5. Polyuria and polydipsia (due to ADH inhibition)
6. Neurotoxicity {paeaesthesia, ataxia, tremor, cognitive impairment}
7. QT prolongation
8. hypersalivation
26
Signs of litium toxicity
-Early signs: non-specfic, restlessness, apathy, confusion, drowsiness
-Following signs: Vomiting, diarrhoea. ataxia, weakness, dysarthria,muscle twitching,trmor,visual disturbance
Severe signs: Convulsion, coma, renal failure, hypotension, cardiac arrhythmia
27
Causes of Lithium toxicity
reduced renal function, dehydration, interacting medications (diuretics/NSAIDS), infection
28
Monitoring requirements for lithium therapy
1. Lithium levels weekly at initation, 3 monthly for 1 year then 6 monthly or after doses changes thereafter
2. U&Es ( 3 monthly)
3. Cardiac / ECG (annual)
4. TFT ( 6 monthly)
5. Body weight (annual)
6. Calcium (annual)
6. FBC (annual)
7.
29
What can lithium do to your calcium levels?
Increase them - they should be monitored yearly
30
How long after a lithium dose should samples be taken?
12 hours post dose
31
What is the optimum dose range of Lithium
0.4 - 1mmol/L
32
In patients with acute mania or who have previously relapsed what is the target lithium level?
0.8-1mmol/L
33
What does abrupt withdrawl of lithium increase the risk of?
Relapse - if lithium is to be discontinued the dose should be reduced gradually over 4 weeks (up to 3 months)
34
What should patients be advised to report when on lithium therapy?
signs of lithium toxicity, hypothyroidism, renal dysfunction (polyuria / polydyspepsia), beign intracranial hypertension (persistant headache and visual disturbance)
35
What should patients be counselled on when starting lithium therapy?
1. maintain hydration
2. avoid dietary changes that lead to increase/decrease in salt
3. lithium booklet / alert card
4. contraception
5. recognising toxicity signs
6. OTC sales
36
Indications of lithium therapy
1. acute management of mania/hypomania
2. prophylaxis against bipolar affective disorder
3. control of aggressive behaviour or intentional self harm
4. Treatment/prophylaxis of recurrent depression
37
Why should lithium be prescribed as brand names?
Different salts have different bioavailbilities (carbonate v citrate)
Brands include; Priadel, Camcolit, Liskonum
38
What drugs can cause an increase in lithium levels?
ACEIs,ARBS, Diuretics, NSAIDS, macrolides, metronidazole, steroids, tetracycline
39
What does an increase sodium level do to Lithium levels?
Decreases lithium levels as you drink more and excrete it out (e.g pt on antacids)
40
What does a decreased sodium level do to lithium levels?
Increases the lithium level as decreased excretion may occur
41
What drugs can decrease lithium levels?
Antacids, theophylline, caffeine
42
What are some of the side effects that can occur during the first few weeks of taking antidepressants?
Increased suicial thoughts, agitation, anxiety
43
What drug class is first line in depression?
SSRI (safer and better tolerated)
44
What SSRI is safe in patients who have had a recent MI or unstable angina?
Sertraline
45
What herbal remedy is popular for treatment of depression?
St John's Wort
46
What can St johns wort do to other medications?
St JW is an enzyme INDUCER, it will reduce levels of other meds
47
At the start of antidepressant treatment, how often should patients be reviewed?
Every 1 - 2 weeks
48
How long should treatment be contined for before consdiering switching to an alternative medication?
4 weeks (6 weeks in eldery)
49
Following remission, how long should antidepressant therapy be continued for?
At least 6 months at the same dose or for 12 months in people wiht GAD
50
If a patient has a history of recurrent depression and is tapered off antidepressants, how long should they continue to receive maintenance therapy for?
2 years due to high risk of relapse
51
What electrolyte imbalance is associated with all antidepressants (particularly SSRIS)
Hyponatraemia
52
What is the risk of adding several serotonergic drugs into a patients regime?
Serotonin syndrome risk (esp if long half life drugs e.g. MAOIs)
53
3 main areas of serotonin syndrome
1. Neuromuscular hyperactivity (tremor/hyperreflexia, clonus, ridgity)
2. Autonomic dysfunction (tacycardia, BP changes, hyperthermia, diaphoresis, shivering)
3. Altered mental state (agitation, confusion, mania)
54
If a patient does not respond to an SSRI, what is the next option?
1. increase dose of SSRI
2. switch to different SSRI or Mirtazapine
3. Other agent e.g Lofepramine, moclobemide, reboxetine
4. severe forms - TCAs, Venlafaxine
55
What medication class can be considered for chronic (>4 weeks) anxiety?
Antidepressants
56
How should GAD be treated?
1. psychological approach (CBT)
| 2. Antidepressant (escitalopram, paroxetine, sertraline, venlafaxine, pregabalin)
57
How are paniac disorders, social anxiety disorder, PTSD, OCD treated?
SSRIs
58
What drugs can be used second line in panic disorder?
Clopiramine and imipramine
59
Moclobemide is licensed for what anxiety disorder?
Social anxiety disorder
60
Sedating TCA examples
Amitriptyline, clomipramine, dosulepin, doxepin, trazodone, trimipramine
61
Less sedating TCA examples
imipramine, nortriptyline, lofepramine
62
What are limiting side effects to TCAs
Cardiotoxic + antimuscarinic effects
63
Lofepramine has a better side effect profile is less toxic but use is limited because...
it is hepatoxic
64
What TCA has the most marked antimuscarinic side effects?
Imipramine
65
What time of the day should TCAS be taken?
night - they have a long half life allowing for OD adminsitration
66
Tranylcypromine is a MAOI that is more likely to cause what side effect compared to othe MAOI?
hypertensive crisis
67
Isocarboxazid and Phenelzine are more likely to cause what side effect compared to Tranylcypromine?
Hepatoxicity
68
How long after starting MAOIs should other antidepressants be started if needed?
at least 2 weeks after MAOIs have been stopped (3 weeks if starting Clomipramine or imipramine)
69
How long after an SSRI has been stopped can a MAOI be started?
After 1 week, unless it is Fluoxetine (long half life) whihc needs at least 5 weeks washout
70
When can Vortioxetine be iniatited?
if a patients condition has not responded to 2 antidepressants
71
What monitoring requirement is needed for Agomelatine?
LFTS at 3, 6, 12, 24 months
| - pt should be counselled on how to recognise hepatoxicity
72
What is a monitoring requirement with MAOIs?
BP - risk of postural hypotension and hypertensive responces
73
What food advice should be given to patients taking MAOIs?
TYRAMINE - hypertensive crisis (first sign = throbbing headache)
Only eat fresh foods (nothing stale or going off), especially important with meat/fish/poultry/ mature cheese; game should be avoided. The danger of the interaction persists for up to 2 weeks after stopping. Alcohol should also be avoided
74
Example of an irreversible MAOI
Phenelzine, Isocarboxazid
75
Example of a reversible MAOa selective
Moclobemide
76
Why cant patients on MAOi have cough medications containing sympathomimetics (pseudoephedrine)?
Hypertensive crisis risk due to inhibition of indirect acting sympathomimetics
77
Example of a nonadrenaline reuptake inhibitor (NARI)
Reboxetine
78
Common side effects of SSRIS
- GI symptoms (common at start)
- Anxiety (common at start)
- insomnia
- sexual side effects
- QT prolongation
- Increase bleed risk
79
Why should SSRIs be avoided in pregnancy?
Risk of congential heart defects and if used in 3rd trimester, risk of neonatal withdrawal
80
How many citalopram drops = 10mg tablet?
4 drops (8mg) = 10mg oral tablet
81
What is the contraindication of citalopram?
QT prolongation
82
Which SSRI has the least drug interactions?
Citalopram
83
What is the only SSRI licensed for use in children?
Fluoxetine
84
Why is paroxetine associated with a higher risk of withdrawl reactions?
Has a short halflife
85
Duloxetine and Venlafaxine are examples of what type of antidepressants?
SNRIs
86
What 2 conditions other than depression can duloxetine be used for?
Diabetic neuropathy and Moder to severe stress urinary incontinence
87
What condition is Venlafaxine contraindicated in?
Uncontrolled hypertension
88
Why does venlafazine require a slow withdrawl period?
Short half life
89
What monitoring does Venlafaxine require?
BP monitoring
90
What are some side effects of TCA overdose?
dry mouth, hypotension, dilated pupils, urinary retention, respiratory failure, hypothermia, cardiac conduction defects
91
The tetracyclic antidepressant, Mianserin can cause agranulocytosis. How often should FBC be measured?
Every 4 weeks during first 3 months
92
Mirtazapine drug class
Presynaptic alpha 2 antagonist (increases central NA and 5HT)
93
Side effects of Mirtazapine
Sedation, oedema, increase appetite, weight gain and blood disorders
94
What should patients be advised to report when taking Mirtazapine?
recognising blood disorders e.g. fever, sore throat, stomatitis
95
Antimuscarinic side effects of TCAS
Constipation, dry mouth, blurred vision, urinary retention, cardiotoxic in overdose
96
What TCA should not be prescribed?
Dosulepin
97
When prescribing an antipsychotic for emergency use, what should the IM dose be compared to the oral equivalent?
Lower - owing to absence of first pass effect. Particulary if the patient is active (increase blood flow to muscles)
98
What symptoms of schizophrenia do antipsychotics work best on?
Positive symptoms e.g .hallucinations, dellusions, though disorders
99
How do the first generation antipsychotics generally work?
Block D2 receptors and are not selective for any of the 4 dopamine pathways therefore cause a range of side effects
100
What 3 main groups can the phenothiazines be split into?
group 1: Chlorpromazine, levomopromazine --> pronounced sedative effects, moderate antimuscarinic/EPS
Group 2:
Pericyazine --> moderate sedative effects, fewer EPS than group 1 or 3
Group 3:
Prochlorperazine, trifluoperazine--> fewer sedative effects/ AM effects, more pronounced EPS
101
Examples of butyrophenone antipsychotics
Benperidol (used in inappropriate sexual behaviour) and Haloperidol
Same clinical properties are Group 3 phenothiazines
102
Thioxanthene examples
Flupentixol and Zuclopenthixol
103
Diphenylbutylpiperidine example
Pimozide
104
Substituted benzamide example
Sulpiride
105
What type of antipsychotics are less likely to cause EPS but have distinct side effect profiles?
second generation (atypical)
106
Examples of second generation (atypical) antpsychotics
Risperidone, olanazapine, quetiapine, clozapine, aripiprazole, paliperidone
107
What antipsychotics are better at treating the negative symptoms of Schizophrenia
Second generation
108
In eldery patients with dementia, what is the risk of prescrbing antipsychotics?
Increased risk of stroke/TIA and mortality
109
Which antipsychotics are most likely to cause EPS?
Group 3 phenthiazines (e.g. prochlorperazine), butyrophenones and 1st generation depots
110
Examples of EPS
1. Parkinsonian symptoms (tremor,)
2. Dystonia (abnormal face/body movement)
3. Akthisia (restlessness(
4. Tardive dyskinesia (involuntary movements of tongue/face/jaw - can be irreversible)
111
How can parkinsonian EPS be treated?
Procyclidine
112
Side effects of second generation antipsychotics (atypical)
1. Hyperprolactinaemia
2. Sexual dysfunction
3. Cardiovascular s/e
4. Hyperglycaemia + weight gain
5. Hypotension / interference with temperature regulation
113
What antipsychotic reduced prolactin levels?
Aripiprazole (dopamine receptor partial agonists)
114
Antipsychotics most lilely to cause hyperprolactinaemia
Risperidone, amisulpride, 1st gens
115
Clinical symptoms of hyperprolactinaemia
Sexual dysfunction, reduced bone mineral density, menstrual disturbance, breast enlargement, galactorrhoea
116
which 2 antipsychotics are most likely to cause sexual dysfunction?
Haloperidol and risperidone
117
What antipsychotics have profound QT prolongation risk?
Haloperidol and Pimozide or any IV antipsychotic / above max dose
118
What antipsychotics are most likely to cause diabetes/weight gain?
Olanzapine, Risperidone, Clozapine, Quetiapine
119
What antipsychotics can cause postural hypotension?
Clozapine, Chlorpromazine, lurasidone, quetiapine
120
What are the symptoms of NMS?
hyperthermia, fluctuating level of consiousness, muscle ridgity, tacycardia, liable BP)
121
There is no treatment for NMS but what 2 agents can potentially be used?
Bromocriptine or Dantrolene
122
How long does NMS usually last for?
5 - 7 days after drug discontinuation
123
Which antipsychotic has negliglble effect on the QT profile?
Arirpiprazole
124
What generation of antipsychotic is less likely to caus diabetes?
First gen - lowest risk Haloperidol and Fluphenazine
125
Of the second generation antipsychotics, which have the lowest risk of diabetics?
amisulpride and aripiprazole
126
Which antipsychotic is less likely to lead to sexual dyfunction?
aripiprazole and quetiapine
127
How long should patients have an antipsychotic drug before it is deemed effective?
4 - 6 weeks
128
What is clozapine licensed for?
Treatment resistant schizophrenia - when 2 or more antipsychotics are tried for at least 6-8 weeks and dont work
129
How long does it take for treatment responce to be seen with clozapine?
8 to 10 weeks
130
Monitoring for clozapine
```
FBC - weekly for first 18 weeks then 2 weekly the monthly
ECG
LFTs
BP + Pulse
Weight/ Lipids/ Glucose
Prolactin
```
131
What is a fatal side effect of Clozapine
Constipation - risk of intestinal obstruction, faecal impaction and paralytic ileus
132
Why is an ECG necessary before starting clozapine
Risk of cardiomyopathy + myocarditis
133
When having weekly FBC, what is the max quantity of clozapine that can be prescribed?
10 days
134
When having fortnightly FBC, what is the max quantity of clozapine that can be prescribed
21 days
135
When having monthly FBC, what is the max quantity of clozapine that can be prescribed
42 days
136
If a dose of clozapine is missed for >48 hours what must be done?
Retitrate dose
137
If a dose of clozapine is missed for >72 hours what must be done?
FBC monitoring, frequency may need altering + retitrate
138
What lifestyle habit can affect clozapine levels?
Smoking - due to enzyme induction. (not affected by NRT)
139
Which antipsychotics do not require BP monitoring?
Sulpride
Trifluoperazine
Amisulpride
Aripiprazole
140
What condition can cause a patient to have naturally a lower WBC?
Beign ethnic neutropenia
141
When is the risk for cardiomyopathy the greatest with clozapine?
first 2 months
142
How can hypersalivation associated wiht clozapine be treated?
hyoscine butylbromide
143
When should blood lipids and weight be monitored with antipsychotics?
baseline, 3 months, then yearly (for clozapine - needs monitoring every 3 months for the first year)
144
When should fasting blood glucose be measured when patients are prescribed antipsychotics?
baseline, 4-6 monthly then yearly (clozapine = baseline, 1 month, 4-6 months)
145
What must the patient. prescbier and pharmacist be registered to if a pateint is taking clozapine?
Patient monitoring service
