Mental Health Update Flashcards
What are the common s/e of atypical antipsychotics? (7)
Metabolic effects
Anticholinergic
QT prolongation
Lowered seizure threshold
Antiadrenergics
NMS
Sedation
What the common s/e of typical antipsychotics medicines. (7)
EPSE
Anticholinergics
QT prolongation
Lowers seizure threshold
Antiadrenergic
NMS
Sedation
What are the investigations before starting therapies? (9)
Weight
Waist circumference
Pulse + BP
Fasting BM
HbA1c
Prolactin levels
Movement disorders
Nutritional status, diet and physical activities.
ECG
What are the investigations during therapies? (5)
Tx response
Symptom/behavioural changes.
S/e
Weight
Adherence
Physical health (CV)
What antipsychotic gives the least risk of psychosis? (1)
Aripiprazole
What is GASS? (1)
Glasgow Antipsychotic S/E scale:
- Self reporting questionnaire aims to identify s/e of antipsychotic medication.
- Consists of 22 questions with assigned points based on answers given by the px.
What is NMS? (2)
Life-threatening neurological disorder caused by ADR to neuroleptics/antipsychotics drugs.
Disorder develops within the 1st 2 weeks of tx with the drug but disorder can develop at any time during the tx period. Can occur in people taking anti-Parkinsonism.
What are the symptoms of NMS? (6)
High fever
Sweating
Unstable BP
Stupor
Muscular rigidity
Autonomic dysfunction
What are the main features of anti-psychotic induced hyperprolactinaemia? (4)
Hyperprolactinaemia: Endocrine disorder but can be associated with significant morbidity.
Presents as menstrual problems in women and sexual problems in men.
Persistent asymptomatic hyperprolactinaemia can be linked to long-term physical morbidity e.g. OP and breast cancer.
Hyperprolactinaemia managed asymptomatically.
Give e.g. of an antipsychotic that has the least risk of inducing hyperprolactinaemia. (1)
Aripiprazole
What are the main features of Clozapine? (5)
Used when px is unresponsive to or intolerant of conventional antipsychotic drugs.
If px misses 48 hrs or more of Clozapine dose, the clozapine must be discontinued and slowly re-titrated.
Potentially fatal risk of intestinal obstruction, faecal impact ion and paralytic ileus.
Neutropenia and agranulocytosis reported.
Give e.g. of clinical situations that can increase the risk of Clozapine toxicity. (5)
Px stops smoking or switches or an e-cigarette.
Concomitant medicines may interact to increase clozapine levels
Patient has pneumonia or other serious infection.
Reduced Clozapine metabolism is suspected.
Toxicity is suspected.
What monitoring is considered to manage Clozapine toxicity? (1)
Blood concentration levels carried out in addition to required blood tests to manage risk of agranulocytosis.
What factors are considered for antidepressants? (7)
Choice
Initiation
Adjuvants
Non-drug Tx
Risk in OD
Counselling
S/E
What are the key s/e of SSRI’s? (7)
Insomnia/Anxiety/Agitation
GI bleeding
Sexual dysfunction
5-HT syndrome
Suicidal thoughts
FINISH withdrawal
Physiological symptoms
What are the key s/e of TCA? (4)
Anti-histamine
Anti-adrenergic
Anti-cholinergic
Cardiac
What are the key s/e of MAOIs? (6)
Hypertensive crisis
Postural hypotension
Anti-cholinergic
5-HT syndrome
Hepatotoxicity (phenelzine)
Weight gain
What is FINISH? (6)
Discontinuation syndrome.
Flu-like symptoms
Insomnia
Nausea
Imbalance
Sensory disturbances
Hyperarousal (anxiety/agitation)
What are the key s/e of Venlafaxine? (5)
Cardiac effects
Blood dyscrasias/ Bleed risk
SIADH
Suicidal behaviour
Withdrawal syndrome
What are the key s/e of Reboxetine? (6)
Cardiac effects
Hyponatraemia
Hypokalaemia on prolonged tx
Suicidal behaviour
Urinary retention
Impaired vision (caution in glaucoma)
What are the key s/e of Moclobemide? (3)
Lower risk of hypertensive crisis
Troublesome interactions (< MAOI)
Hyponatraemia
What are the key s/e of Mirtazapine? (6)
Not many antimuscarinic effects.
Sedating
Blood disorders
Withdrawal syndrome
Weight gain
Psychotic symptoms
What are the common s/e of general antidepressants? (5)
Potential for an initial increase in agitation, anxiety on starting tx.
Hyponatraemia
Sexual dysfunction
Withdrawal effects
Bleeding risk
Explain the main features of Hyponatraemia with antidepressants. (9)
SSRI = high risk.
Common in elderly.
Symptoms: LOW SODIUM
Occurs within 30 days of starting antidepressants but can take months.
Can be transient or persistent
If identified, stop antidepressant and sodium levels should normalised within 1-2 weeks.
Urgent care if severe (<125mmol/L)
Withdrawal symptoms can occur (less likely at beginning of tx)
What are the main features of SSRI/SNRI and bleeding risk? (1)
Reducing 5-HT uptake by platelets. SSRI reduces ability of platelets to aggregate and increase risk of haemorrhage, particularly GI bleeding.
What factors can increase the bleeding risk when taking SSRI/SNRI? (4)
Elderly
Px with Hx of peptic ulcers
Alcohol excess
Co-administration with other drugs associated with bleeding risk (NSAIDs, Antiplatelets, CS, Warfarin)
What factors can reduce the risk of bleeding when taking SSRI/SNRI? (4)
Avoid SSRI/SNRI
Avoid concomittant drugs
If no suitable alternative can be found, consider GI protection.
NICE suggests GI protection in older px who are taking NSAIDs/Aspirin.
What are the cautions and c/i of antidepressants? (3)
CVD disease + QT prolongation:
- Antidepressant can cause QT prolongation.
- Medication Hx, Lab monitoring and baseline ECG necessary to identify px at risk for QT prolongation before starting an antidepressant that may prolong QT interval.
- Significant QT prolongation can occur through drug-drug interactions where another medication known to affect QT interval is used concomittantly or when a medication alters the metabolism of another drug which is known to affect the QT interval. Considered when new medications are added, even for short-term use e.g. ABx/Antiemetics.
What are the risk factors of QT interval prolongation? (8)
Cardiac conditions e.g. bradycardia, MI/HF.
Electrolyte disturbances e.g. hypokalaemia/hypomagnesemia/hypocalcaemia.
Female
Genetic Polymorphisms
Age > 65 yrs
Congenital long QT syndrome or other inherited cardiac abnormalities.
Concomittant medication or disease states.that prolong QT interval or affect electrolytes (e.g. diuretics, renal dysfunction.)
Hx of QT prolongation
What does MHRA drug safety state about the use of Citalopram + Escitalopram? (7)
Associated with dose-dependent QT interval prolongation. Avoid use in:
- Congenital long QT syndrome
- Known pre-existing QT interval prolongation
- Combination with other medicines that prolong QT interval.
ECG for px with cardiac disease.
Electrolyte disturbances corrected prior tx.
Citalopram max daily dose: 40mg (adults), 20mg (> 65 yrs), 20mg (hepatic impairment)
Escitalopram max dose: > 65 yrs reduced to 10mg/day.
Dose reduction in first 2 weeks of tx is recommended in px with mild/moderate hepatic impairment or poor metabolisers of CYP2C19 (e.g. Omeprazole). GI protection with SSRI in px at risk of bleeds.
What is the general relationship between antidepressants and # risk? (1)
High risk of # for using TCA / SSRI.
What does MHRA/CHM state about the use of SSRI/SNRI? (1)
SSRI/SNRI antidepressants have a small risk of postpartum haemorrhage when used in the month before delivery.
What are the characteristics of 5-HT syndrome? (3)
Altered mental status
Neuromuscular Hyperactivity
Autonomic Instability
What are the symptoms of 5-HT syndrome? (4)
Agitation
Confusion
Delirium
Hallucinations
What are the neuromuscular features of 5-HT syndrome? (5)
Profound shivering
Tremor
Teeth Grinding
Myoclonus
Hyperreflexia
What are the signs of autonomic instability? (7)
Tachycardia
Fever
Hypertension/Hypotension
Flushing
Diarrhoea
Vomiting
What are the signs of severe 5-HT syndrome? (7)
Drowsiness
Coma
Seizures
Hyperthermia
Rhabdomyolysis
Renal Failure
Coagulopathies
What factors can increase the risk 5-HT syndrome? (2)
Concomittant use of antidepressants with other 5-HT drugs (Tramadol, triptans)
Dopaminergic drugs (selegiline)
Close monitoring is advised if co-Rx, alternative drugs are considered.
What is common s/s of 5-HT syndrome? (7)
SHIVERS:
- Shivering
- Hyperreflexia
- Increased temp
- Vital signs abnormal
- Encephalopathy
- Restlessness
- Sweating
Which antidepressants has an overdose risk? (2)
TCA
Venlafaxine
Explain the process of antidepressant withdrawal. (2)
When stopping an antidepressant, gradually reduce dose over 4 weeks. Some people may need longer periods e.g. drugs with shorter half-life (Paroxetine/Venlafaxine)
Not required for fluoxetine (long half life)
What are the common interactions with antidepressants? (8)
High risk of QT prolongation
CYP45O inhibitors/inducers
5-HT syndrome
High bleeding risk
Warfarin
Anticonvulsants effect
Sedation risk (TCA)
Anticholinergics s/e (TCA)
What are the main features of MAOI? (8)
Used when no response to other antidepressants.
May be useful in px refractory to other tx.
Food/drug interactions
E.g. Phenelzine, Isocarboxacid, Tranylcypromine, Moclobemide (reversible MAOI with less s/e)
Withdrawal symptoms
Can cause hepatic impairment.
May carry a MAOI tx card.
What type of ADR can occur when taking MAOI? (1)
Hypertensive crisis s/e which can be fatal can occur if an MAOI is taken with food or drink that has high tyramine content
