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MED 5 > Mental health Lecture week 4 > Flashcards

Mental health Lecture week 4 Flashcards

1
Q

Clozapine side effects-MASS Gain

A

Myocarditis
Agranulocytosis
Seizures
Sialorrhea

G-weight gain

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2
Q

EPS antidote

A

Benztropine

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3
Q

4 EPS

A

Dystonia–> sustained muscular contraction and oculogyric crisis
Akathesia–> restlessness, pacing and tapping
Parkinsonism–> cogwheel rigidity, mask-facies, shuffling gait and resting tremor
TD–> lip-tongue smacking, repetitive and uncontrolled

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4
Q

Which antipsychotic(SGA) will most likely to give galactorrhea

A

Risperidone

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5
Q

Features of NMS

A

FARM

Fever
Autonomic changes
Rigidity
Mental state changes

CK,WBC high high–> rhabdomyolysis

Imagine a FARMER with this condition

occurs within days-weeks

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6
Q

Wernicke’s

A

COA- confusion, ophthalmoplegia and ataxia

Confusion (most common)

Oculomotor dysfunction
Gaze-induced horizontal/vertical nystagmus (most common)
Diplopia
Conjugate gaze palsy

Gait ataxia: wide-based, small step

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7
Q

Korsaoff syndrome

-characterized by 3 features

A

Damage to the mamillary body, memory loss
Irreversible

Korsakoff syndrome, which is characterized

irreversible personality changes
anterograde and retrograde amnesia
confabulation.

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8
Q

How can AN be an emergency situation

A

Yes

Hypokalaemia induced arrythmyias

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9
Q

Which benzo has more potency for people to be dependent on

A

Short half-life ones like

“ATOM” is the acronym for benzodiazepines with a short half-life: Alprazolam, Triazolam, Oxazepam, and Midazolam.

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10
Q

Lorazepam
Diazepam

short or long-acting

A

Long-acting

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11
Q

Treatment of alcohol- which drug can do these
- decrease pleasure
-decrease cravings
Increase SE

A

Naltrexone
Acamprosate
Disulfiram

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12
Q

TCA-3C

A

Coma/confusion
Cardiotoxicty
anti-Cholinergic

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13
Q

SSRI 2 biggest complication

A

1) SS

2) Exacerbation of a mania

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14
Q

SS features-4

A

HARM

Hyperthermia
Autonomic instability
Reflexes
Myoclonus

Diarrhea

Fever, tachycardia and HTN are in both SS and NMS
acute onset

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15
Q

What are the 2 biggest complications of Antipsychotics

A

1) EPS

2) Metabolic syndrome

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16
Q

Features of metabolic syndrome and what can be done about it

A

Start them on prophylactic metformin and switch to newer APS

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17
Q

State some principles of safely prescribing benzo

A

1) Psychoeducation and maintain a good therapeutic alliance with the patient
2) Short term course and low dose
3) Establish an agreed plan with the patient and do not deviate from it- discuss informed consent, dependence,e addiction risk and prevention
4) Discuss with senior colleagues if this is appropriate management
5) Liaison with the pharmacy for benzo dispensation and follow up

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18
Q

Prozac

A

Fluoxetine

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19
Q

Zofolt

A

Sertraline

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20
Q

7S’s of SSRIs

A 
7 S’s:
Stomach upset (GI upset)
Sexual dysfunction
Serotonin syndrome – with other serotonergic agents (i.e. MAOs) – hyperthermia, muscle rigidity, flushing, diarrhea
Sleep difficulties (insomnia)
Suicidal thoughts ( esp. in patients age 24 and under)
Stress (agitation, anxiety)
Size increase / Weight gain
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21
Q

4 components of DBT

A

core mindfulness
distress tolerance
emotion regulation
and interpersonal effectiveness.

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22
Q

State some principles of safely prescribing benzo

A

1) Psychoeducation and maintain a good therapeutic alliance with the patient
2) Short term course and low dose
3) Establish an agreed plan with the patient and do not deviate from it- discuss informed consent, dependence,e addiction risk and prevention
4) Discuss with senior colleagues if this is appropriate management
5) Liaison with the pharmacy for a benzo dispensation and follow up

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23
Q

Sleep hygiene advice you can give to a patient

A

https://www.cci.health.wa.gov.au/~/media/cci/mental%20health%20professionals/sleep/sleep%20-%20information%20sheets/sleep%20information%20sheet%20-%2004%20-%20sleep%20hygiene.pdf

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24
Q

Sleep hygiene advice you can give to a patient

A

https://www.cci.health.wa.gov.au/~/media/cci/mental%20health%20professionals/sleep/sleep%20-%20information%20sheets/sleep%20information%20sheet%20-%2004%20-%20sleep%20hygiene.pdf

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25
Q

Alcohol withdrawal: outline what happens in
0-24
24-48
48

A

Alcoholic hallucinosis–> onset: 12–48 hours after last drink
(Alcohol hallucinosis can be confused with schizophrenia because of both presents with hallucinations!)

Delirium tremens–> Persistent alteration of consciousness and sympathetic hyperactivation due to alcohol withdrawal.

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26
Q

CAGE test

A

C: Cut down drinking: “Have you ever felt you should cut down on your drinking?”
A: Annoyed: “Have people annoyed you by criticizing your drinking?”
G: Guilty: “Have you ever felt guilty about drinking?”
E: Eye-opener: “Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to overcome a hangover?”

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27
Q

Vitamin deficiency with long term alcohol use are: and what is the clinical conseqeunce of this

A

Vitamin B1 deficiency (thiamine deficiency): Wernicke-Korsakoff syndrome
Vitamin B6 deficiency: peripheral neuropathy.
Vitamin B9 deficiency (folate deficiency): megaloblastic anemia
Vitamin B12 deficiency: subacute combined degeneration of spinal cord (funicular myelosis), megaloblastic anemia

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28
Q

Vitamin deficiency with long term alcohol use are: and what is the clinical consequence of this

A

Vitamin B1 deficiency (thiamine deficiency): Wernicke-Korsakoff syndrome
Vitamin B6 deficiency: peripheral neuropathy.
Vitamin B9 deficiency (folate deficiency): megaloblastic anemia
Vitamin B12 deficiency: subacute combined degeneration of spinal cord (funicular myelosis), megaloblastic anemia

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29
Q

Why thiamine first and then glucose

A

Because glucose increases thiamine demand and will worsen encephalopathy, IV glucose infusions must be administered AFTER thiamine!

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30
Q

Which medications should not be used to treat depression in adolescents

A

TCA

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31
Q

Maintenance therapy, attempting monotherapy with(which other drugs can be used) for Bipolar

A

Lithium

1) Valproate
2) Quetiapine
3) Lamotrigine

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32
Q

Patient Health Questionnaire-2 (PHQ-2)

A

Over the last 2 weeks, how often have you been bothered by the following problems?

Little interest or pleasure in doing things
Feeling down, depressed or hopeless

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33
Q

With any management plan in Mental health, what should you be thinking about

A

1) Biopsychosocial model
2) MDT

  • short term
  • medium-term
  • long term
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34
Q

What is so special about Aripiprazole

A

It appears to show:

  • predominantly antagonist activity on postsynaptic D2 receptors
  • partial agonist activity on presynaptic D2 receptors
  • a partial activator of serotonin(5-HT3)

Thus because of its partial nature, it is able to let dopamine in and out at different times

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35
Q

Why do you have to be careful with Olanzapine depot administration

A

Depot–> administration is through the buttock–> Need to monitor very carefully

Monitoring for HYPOTENSION –> can be fatal

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36
Q

What happens to the dopamine receptors in the typical antipsychotics(Halo and zuclopenthixol)

A

They all get blocked and no dopamine gets through unlike action of Aripiprazole

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37
Q

1st atypical presentation or first treatment episode, what special test would you order

A

1) Serum copper and ceruloplasmin–> Wilson’s disease
2) FTA-Abs and neurosyphilis
3) Vitamin b12/folate
4) HIV
5) Neuroimaging
6) if indicated-ECG, CXR, LP, karyotyping and heavy metal testing

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38
Q

Hallucinations are

A

Sensory perceptions in the absence of external stimuli

39
Q

What do you need to ask about auditory hallucination

A

Is it in your head, 1st person, 2nd person

what are they?
telling you to harm anyone?

associated with a rational or explantations( secondary delusions)

40
Q

What do you need to ask about auditory hallucination

A

Is it in your head, 1st person, 2nd person

what are they saying?
telling you to harm anyone?

associated with a rational or explantations( secondary delusions)

41
Q

What are pseudo-hallucinations? why are they important?

A

Considered a non-psychotic experience- occur in personality disorder or normality

Often mood congruent-usually derogatory
(Are they saying mean things about you? can you see them?)

May be command hallucinations, describing person inner wishes or desires

42
Q

spectrum of perception

A

Hallucination—-> pseudo-hallucinations(cluster A and BPD)–> flashback(like in PTSD)–> vivid imaginery(illusions)

43
Q

Thoughtform(some terms)- tell me what each one means

  • tangential
  • flight of ideas
  • loosening of assosication
  • blocking
  • echolalia
  • knight-move thinking/derailment
  • neologisms
  • circumstantiality
  • clang associations
A

circumstantiality–> over incluisve

44
Q

Disorder of affect

-4 reasons for flat affect

A

1) schizophrenia- negative symptoms
2) Increase APS dose
3) Parkinson’s disease
4) Severe depression

45
Q

6 A of negative symptoms of schizophrenia

A 
Affect blunted
Alogia
Anhedonia
Asociality 
Avolitation 
Attention
46
Q

Disorder of affect

-4 reasons for flat affect

A

Restricted/constricted=slightly less

Blunted= ++ reduced
Flat= almost absent 
Inappropriate= does not fit with speech content

1) schizophrenia- negative symptoms
2) Increase APS dose
3) Parkinson’s disease
4) Severe depression

47
Q

Insight-what is it?

Comment on these aspects of insight

A

Ability to understand the true cause and meaning of a situation

Do not say “no sight” describe

Comment on these aspects of insight

  • Awareness of diagnosis
  • Awareness of the need for treatment and options
  • Varies during the course of the illness
48
Q

Risks to consider in psychosis

A

1) Suicide
2) Violence
3) Vulnerability
4) Loss of reaction
5) Self-neglect

49
Q

What does adherence therapy do

A

Adherence therapy (AT) is an intervention that seeks to reduce patients’ psychiatric symptoms by enhancing treatment adherence.

Remove barriers to treatment adherence- improved response rates to medication and transparent communication between prescriber and patient

Motivational interviewing principles

50
Q

What does adherence therapy do

-what is the MOST important factor

A

Adherence therapy (AT) is an intervention that seeks to reduce patients’ psychiatric symptoms by enhancing treatment adherence.

Remove barriers to treatment adherence- improved response rates to medication and transparent
1) communication between prescriber and patient

2) Motivational interviewing principles
3) proactively eliciting problems/ side effects deterring the patient from taking treatment and minimizing this
4) previous medication history and problems taken into account

PSYCHOEDUCATION OF the family and carers are the most important factor–> Adherence therapy

51
Q

Improving compliance/adherence in psychotic patients-5

A

 Good therapeutic alliance
 Limit cost (PBS listed medications, Closing The Gap)
 consider ease of travel / access to medication
 Psychoeducation and informed consent
 Simple regime (once-daily dosing, less tablets, depot /
IMI formulations)
 Actively ask about side effects and minimize
 Reminders- alarm or reminder on phone, post-it on
fridge
 Dosette boxes, blister packing where needed
 Involve family and carers (Direct Observed Treatment
DOT’s)
 Case management / NGO support with prompting

52
Q

How long do you continue taking antipsychotic for after 1st episode

A

2-5 years(else 60-80% relaspe)

53
Q

When to stop Antipsychotics and how should you do it

A

Antipsychotics treat acute relapses of positive symptoms and help to prevent relapses

If you decide to stop do this gradually over 6-12 months with close monitoring( abrupt withdrawal increase risk of relapse)

54
Q

Nigrostriatal pathway, what effects do you see

A

EPS
NMS
TD

55
Q

Tubero-infundibular pathway, what effects do you see

A

1) Hyperprolactinemia
2) Galactorrhea
3) Amenorrhea
4) Osteoporosis
5) Sexua side effects–impiared spermatogenesis, decreased libidio, impotence and anorgasmia
6) Weight gain

56
Q

One big difference between FGA and SGA

A

Most SGAs differ from older medications pharmacologically in that serotonin 5HT2 receptor binding exceeds their affinity for dopamine D2 receptors, whereas in FGAs this is generally not the case

5HT2 activity has been suggested as one basis for the lower overall risk of extrapyramidal side effects (EPS) with the atypical drugs compared with FGAs

57
Q

Anticholinergic side effects are seen in which 2 SGA, other than clozapine

A

Olanzapine and Quetiapine

58
Q

QTc prolongation side effects are seen in which 2 SGA

A

Risperidone and Quetiapine

59
Q

Highest Prolactin elevation in SGA is seen in

A

Risperidone

60
Q

Anticholinergic effect reported by SGA are

A

Mostly reported as dry mouth or constipation and less often as blurred vision or urinary retention.

raised intraocular ocular pressure(weird one)

61
Q

Lowest risk of metabolic syndrome

The highest risk of metabolic syndrome

A

aripiprazole

Olanzapine

62
Q

Orthostatic hypotension - why in SGA?

A

Alpha-adrenergic blockade is the likely mechanism of orthostatic hypotension with SGAs

63
Q

Among the SGAs,__________ carries the highest risk of EPS (KNOW THIS FOR EXAM)

A

Risperidone

64
Q

risperidone is important among the SGA why?

A

Among the SGAs, risperidone carries the highest risk of EPS

65
Q

Clozapine ad seizure disorder why?

A

Lowers threshold

Clozapine should be used with caution and in consultation with a neurologist in patients with known seizure disorders

66
Q

The pathognomonic features of the neuroleptic malignant syndrome (NMS)

A

fever, muscle rigidity, mental status changes, and autonomic instability, generally accompanied by rhabdomyolysis and creatine kinase elevation

FARM

The single strongest predictive factor is a prior episode of NMS.

67
Q

Antipsychotic Monotherapy is the goal. Why?

A

 Lower risk of side-effects / NMS.
 Lower risk of non-compliance / medication errors.
 Little difference in efficacy.
 Cost.

68
Q

But my patient isn’t getting better on this medication one of Antipsychotic

A

 Is the person actually taking the medication
 Have you given it enough time to work?
 Have you tried increasing to the maximum dose?
 Have you tried another antipsychotic? Tried clozapine?
 Have you considered another diagnosis?

69
Q

Mnemonic for SGAs-SHEWOMAN

A 
Sedation 
Hyperprolactinemia
EPS(DAPTD)
Weight gain 
Orthostatic hypotension
Metabolic syndrome 
Anticholinergic
NMS
70
Q

NMS antidote medication

A

Dantrolene and bromocriptine

71
Q

What is a WRAP plan

A

The Wellness Recovery Action Plan

Help with relapse prevention

Bipolar- WRAP–> help identify early warning signs and crisis and post-crisis management

The patient, family, carers and clinicians document and
identify these initial symptoms early and agree what to
do when they are present e.g. see doctor, increase
medication, restore sleep, reduce stressors e.g. Bipolar
WRAP

72
Q

In psychiatric history, what other medical history should you ask for to rule out GMC

A

Allergies

Personal history of:
• Thyroid disease
• Head injuries
• Seizure disorders
• Chronic pain/chronic illness
• Cardiac history
73
Q

Static vs dynamic risk factors- definition

A

Static risk factors are fixed and historical.

Dynamic risk factors are changeable and fluctuate.

74
Q

THE SCOFF QUESTIONNAIRE for eating disorders

A

Do you ever make yourself sick because you feel uncomfortably full?

Do you worry you have lost control over how much you eat?

Have you recently lost more than one stone(7KG) in a three month period?

Do you believe yourself to be fat when others say you are too thin?

Would you say that food dominates your life?

75
Q

sleep benzo is

A

temazepam

76
Q

ACUTE BEHAVIOURAL DISTURBANCE- mild

A

Lorazepam 1-2mg (max effect 1-3 hours) OR

Olanzapine 5-10mg (Max 30 mg / 24 hours) ORAL

77
Q

ACUTE BEHAVIOURAL DISTURBANCE
-moderate

-severe

A 
MODERATE highly aroused, distressed, fearful =
give both(lorazepam and olanzapine)

 SEVERE refusing orals, starting to become
violent to self / others / property =IMI Droperidol
2.5-10mg every 20 minutes (max 20mg / 24
hours)

78
Q

Counselling patients on antidepressant initiation(starting them on SSRI)

A
  • pamphlets
    -Warn of both common and serious potential side-effects, including discontinuation effects
  • do not stop them immediately
  • Adequate trial- at least 3 weeks
  • Maintain at least 6 months to 1 year after first
    episode
  • Tell them about suicide hotlines
    -7S of side effects of SSRIs- tell them they will only last for a week and they will feel much better
    -depression–> will help in a couple of week
  • anxiety–> takes like a month- monthsss

how do they?
they make sure the chemicals in your brain are brought back to normal

79
Q

Treatment of bipolar depression

A

Avoid antidepressants first line for bipolar depression,
as they can precipitate a switch into mania or rapid
cycling (>3 episodes a year).

Lamotrigine, quetiapine, lurasidone, lithium and
Olanzapine are effective for bipolar depression.

80
Q

Lithium has anti_______ what affect

A

suicidal

“Anti-suicide” effect (mechanism also unclear).

81
Q

Lithium+ high dose antipsychotics

A

Increase the risk of neurological damage

82
Q

At which levels of lithium, is dialysis indicated

A

Levels >3.5mmol/L are potentially lethal = haemodialysis
recommended.

Lithium toxicity can progress from confusion and
motor impairment to coma, convulsions, and death

83
Q

ALCOHOL DEPENDENCE – DETOX- 5 steps as per lecture

A

1) Use CIWA

2) Thiamine IM 100mg stat – To prevent Wernicke’s
Encephalopathy/Korsakoff’s Psychosis.
—> Wernicke’s = ataxia, ophthalmoplegia, nystagmus,
confusion – Medical Admission and high-dose IV thiamine.

3) Diazepam PO 10mg Q6H, tapering over the following
3-5 days – To prevent symptoms of alcohol withdrawal,
including seizures

4) Paracetamol for headaches.
5) Metoclopramide for nausea.

84
Q

Three drugs for ALCOHOL DEPENDENCE – LONG-TERM

A

Disulfiram
Acamprosate
Naltrexone

85
Q

NICOTINE USE DISORDER TREATMENT-3 drugs

A

Nicotine replacement therapy – first choice in hospital due to
quick response
Varenicline
Bupropion

86
Q

Opioid addict what is the program

A

OPIOID TREATMENT PROGRAM

Methadone- watch QTc

Buprenorphine (Subutex / Suboxone if combined
with naloxone to prevent diversion, sublingual)-
mu receptor agonist, reduces cravings, decreases
effects of additional opioid use, safer in OD

Naltrexone- long-acting opioid antagonist, nonPBS for opioid dependence due to OD risk (loss of
tolerance and can precipitate withdrawal)

87
Q

What are the HAM side effects? Which meds are they associated with?

A

anti-Histamine = sedation, weight gain
antiAdrenergic = hypotension
antiMuscarinic = dry mouth, blurred vision, urinary retention
Drugs: TCAs and low-potency antipsychotics

  • AntiHisamine: sedation, weight gain
  • Anti-alpha1Adrenergic: orthostatic hypotension, cardiac abnormalities, sexual dysfunction
  • AntiMuscarinic-anticholinergic: dry mouth, tachycardia, urinary retention, blurry vision, constipation, ppt of narrow-angle glaucoma
88
Q

How is TCA OD treated?

A

IV sodium bicarbonate

89
Q

ORTHOSTATIC HYPOTENSION

(ADRENERGIC)- which APS have it most

A

Risperidone, Quetiapine most

Clozapine- if you miss 3 consecutive days
need to retitrate from low dose (you quickly
lose tolerance)

90
Q

Benztropine given for

A

EPS side effects

91
Q

What is unique about risperidone?

A
  • Can increase prolactin

- Some orthostatic hypotension and reflex tachycardia

92
Q

Which drugs(2) commonly can cause delirium

A

Anticholinergic

Benzo as well hence we don’t give them expect for alcohol withdrawal

93
Q

Anticholinergic effect-5

A 
Dry mouth
blurred vision
constipation,
urinary hesitancy,
raised intraocular pressure

MED 5 (23 decks)

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