Others

Question 1

Describe the:

• use
• mechanism
• contraindications
• side-effects
• monitoring/safety measures
• complications

of Clozapine.

Answer 1

• Clozapine
o Used in treatment-resistant schizophrenia
o Mechanism:blocks D1 and D4 receptors
o Contraindications: previous or current neutropaenia, previous myocarditis, active or progressive liver disease
o Side-Effects: sedation, weight gain, reduced seizure threshold, myocarditis, metabolic syndrome, hypersalivation, GI (swallowing problems, constipation)
NOTE: smoking cessation can lead to a decrease in CYP450 activity resulting in raised clozapine levels

o Register patient with Clozaril patient monitoring service, Dezapine monitoring system or Zaponex treatment access system

o Ensure normal leucocyte count and ECG before starting treatment

o FBC Monitoring:

• Weekly for 18 weeks
• Fortnightly for 1 year
• Monthly thereafter

Side-Effects

Agranulocytosis, neutropaenia

Reduced seizure threshold

• Constipation
• Myocarditis (baseline ECG should be taken before starting treatment)
• Hypersalivation

Question 2

_____ and ____ are currently the preferred SSRIs

Answer 2

Citalopram and fluoxetine are currently the preferred SSRIs

Question 3

___ is useful post-MI

Answer 3

Sertraline is useful post-MI

Question 4

_____ is the drug of choice in children

Answer 4

Fluoxetine is the drug of choice in children

Question 5

What are side effects of SSRIs?

Answer 5

o GI upset

o GI bleeding (if NSAIDs are being used, it should be given with a PPI)

o Increased anxiety and agitation soon after starting
o Fluoxetine and paroxetine have higher propensity for drug interactions

Question 6

What SSRIs are associated with Increased QT intervals?

Answer 6

o Citalopram and Escitalopram are associated with a dose-dependent increase in QTc and should not be used in those with pre-existing QT prolongation or in combination with other medicines that prolong the QT interval
o Maximum daily dose of citalopram: 40 mg for adults; 20 mg for > 65 years, 20 mg for hepatic impairment

Question 7

What drugs do SSRIs interact with?

Answer 7

o NSAIDs and aspirin: if used, give with a PPI
o Warfarin/heparin: avoid SSRIs and consider mirtazapine
o Triptans: avoid SSRIs
o MAOI: risk of serotonin syndrome when given at the same time as SSRIs

Question 8

How should we decide whether SSRIs should be given during pregnancy? What are the risks of having them?

Answer 8

Weigh up benefits and risks when deciding whether to use SSRIs

1st trimester: increased risk of congenital heart defects

3rd trimester: increased risk of persistent pulmonary hypertension of the newborn

SSRIs that are generally considered safe are sertraline, citalopram and fluoxetine

Paroxetine has an increased risk of congenital malformations, particularly in the 1st trimester

Question 9

What are the SEs of Lithium?

Answer 9

• Side-Effects

o Nausea/vomiting and diarrhoea
o Fine tremor
o Nephrotoxicity: polyuria (secondary to nephrogenic DI)

o Thyroid enlargement (and hypothyroidism)

o ECG: T wave flattening/inversion
o Weight gain
o Idiopathic intracranial hypertension

Question 10

How often should we monitor lithium levels?

Answer 10

• Monitoring
o After starting, lithium levels should be performed weekly and after each dose change until concentrations are stable
o Once established, lithium blood levels should be routinely checked every 3 months (levels should be taken 12 hours post-dose)
o Thyroid and renal function should be checked every 6 months
o Patients should be given an information booklet, alert card and record book

Question 11

Describe the

• MOA
• Use
• Max length of use
• Features of withdrawal

of Benzodiazepines.

Answer 11

Enhances the effect of GABA (increases the frequency of opening of the chloride ion channel)

Used as a sedative, hypnotic, anxiolytic, anticonvulsant and muscle relaxant

Should not be used for longer than 2-4 weeks

Features of Withdrawal

o Insomnia
o Irritability
o Anxiety
o Tremor
o Loss of appetite

o Tinnitus

o Perspiration
o Perceptual disturbance

o Seizures

Note: barbiturates work by increasing the duration of chloride channel opening

Question 12

How should we interpret an MMSE?

Answer 12

Any score > 24/30 is considered normal

Cognitive Impairment

o Mild: 18-23
• May require some supervision, support or assistance

o Moderate: 10-17
• Clear impairment, may require 24-hour supervision

o Severe: 0-9
• Marked impairment, likely to require 24-hour supervision and assistance with ADLs

The raw score may need to be corrected based on educational attainment and age

Note: patients with depression may often answer with ‘I don’t know’ whereas patients with dementia will attempt to answer all questions

Question 13

What domains are tested in the MoCA, what is the max score, what is normal? What should we do if a pt scores low?

Answer 13

Domains tested: visuospatial and executive functioning, animal naming, attention, language, abstraction, delayed recall (short-term memory), orientation, education level (1 point added if < 12 years of formal education)

Maximum: 30 points

Normal: > 26 points

Does not differentiate between mild, moderate and severe cognitive impairment

If a patient score < 25, consider referral for further cognitive assessment

Question 14

What is the AMTS comprised of?

Answer 14

Question 15

What are the depression and anxiety questionnaires?

Answer 15

• PHQ-9
• HADS
• GAD-7

Question 16

How should we conduct a PHQ-9 score? How should it be interpreted?

Answer 16

o Ask the patient ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
o 9 items which are scored 0-3
o Includes items about thoughts of self-harm

o Interpretation

o None: 0-4
o Mild: 5-9
o Moderate: 10-14
o Moderately Severe: 15-19

o Severe: 20-27

Question 17

How should we conduct a HADS? How should it be interpreted?

Answer 17

• Hospital Anxiety and Depression Scale (HAD)
o Consists of 14 questions: 7 anxiety + 7 depression
o Focuses on the last week
o Each item scored from 0-3
o Produces a score out of 21 for both anxiety and depression

o Interpretation

o Normal: 0-7
o Borderline: 8-10
o Anxiety/Depression: 11-14

Question 18

How should a Gad-7 score be conducted? How should it be interpreted?

Answer 18

o Asks about 7 symptoms and their frequency (each is worth a maximum of 3 points)

o Focuses on the last 2 weeks
o Interpretation

o Mild:5-10
o Moderate:10-15

o Severe:15+
o Maximum=21

Question 19

What are the alcohol questionnaires?

Answer 19

CAGE – screening tool

Alcohol Use Disorders Identification Test (AUDIT) – screening tool

Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) – determines the severity

of withdrawal (useful for determining the next stage in treatment)

Question 20

What are the

• indications
• Short term SEs
• Long term SEs

for ECT?

Answer 20

Indications
o Catatonia

o Prolonged or severe manic episode
o Severe depression that is life-threatening

o NOTE: it is effective in pregnant women

Short-Term Side-Effects

o Headache

o Nausea
o Short-term memory impairment
o Memory loss of events prior to ECT

o Cardiac arrhythmia

Long-Term Side-Effects

o Impaired memory

Question 21

Define insomnia.

Answer 21

difficulty initiating or maintaining sleep, or early morning awakening that leads to dissatisfaction with sleep quantity or quality.

Question 22

Define chronic insomnia.

Answer 22

diagnosed if a person has trouble falling asleep or staying asleep at least 3 nights per week for 3 months

Question 23

How do we investigate and manage insomnia?

Answer 23

Investigation: usually based on history, may use sleep diary, rarely use polysomnography

Management

o Identify potential causes (e.g.mental or physical health issues or poor sleep hygiene)

o Advise against driving when sleepy
o Advise good sleep hygiene (no screens before bed, limited caffeine intake, fixed bed times)
o Only consider hypnotics if impairment is severe

o Recommended hypnotics include short-acting benzodiazepines (e.g. temazepam) or non-benzodiazepines (e.g. zopiclone)

o Use lowest effective dose for shortest duration
o Review after 2 weeks and consider referral for CBT
o Side-Effects of Sleeping Pills: daytime sedation, poor motor coordination, cognitive impairment, addiction

Question 24

How should we manage chronic insomnia?

Answer 24

Defined as difficulty getting to sleep or maintaining sleep on 3 or more nights of the week for 3 months

May be investigated using a sleep diary and actigraphy

Identify potential causes (e.g. depression and anxiety)

Advice on sleep hygiene and not to drive when tired

CBT-I for insomnia

Consider hypnotics if major day time impairment
o Short-acting benzodiazepines (e.g.lorazepam) or Z-drugs can be used

o Use lowest possible dose for the shortest possible time
o Review in 2 weeks and consider CBT

Question 25

When is applied relaxation therapy used, what does it consist of?

Answer 25

Used for people with anxiety disorders

Based on the premise that these patients have lost the ability to relax

Consists of a series of exercises that teach the patient how to:

o Spot the signs and feelings of tension
o Relax your muscles and relieve tension
o Use these techniques in stressful situations to prevent you feeling tense and panicky

Consists of 12-15 weekly sessions

Question 26

When is mentalisation-based therapy used, what does it consist of?

Answer 26

Form of therapy that focuses on the patient’s ability to attend to mental states in themselves and in others

This helps them understand their actions and the actions of others

This leads to more successful social interactions and relationships

Mainly used for borderline personality disorder and self-harm

Question 27

Rapid tranquillisation prescription

Answer 27

Lorazepam 2mg PO (max 4mg total) OR

Lorazepam 2mg IM (max 4mg total)

Haloperidol 5mg PO (max 12mg total) OR

Haloperidol 5mg IM (max 20mg total)

Promethazine 50mg PO (max 150mg total) OR

Promethazine 50mg IM (max 150mg total)