Passmedicine Flashcards
Deppression assessment tools
There are many tools to assess the degree of depression including the Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
Hospital Anxiety and Depression (HAD) scale
consists of 14 questions, 7 for anxiety and 7 for depression
each item is scored from 0-3
produces a score out of 21 for both anxiety and depression
severity: 0-7 normal, 8-10 borderline, 11+ case
patients should be encouraged to answer the questions quickly
Patient Health Questionnaire (PHQ-9)
asks patients ‘over the last 2 weeks, how often have you been bothered by any of the following problems?’
9 items which can then be scored 0-3
includes items asking about thoughts of self-harm
depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
Deppresion DSM v
NEED 5 OF:
- Depressed mood most of the day, nearly every day
- Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day
- Significant weight loss or weight gain when not dieting or decrease or increase in appetite nearly every day
- Insomnia or hypersomnia nearly every day
- Psychomotor agitation or retardation nearly every day
- Fatigue or loss of energy nearly every day
- Feelings of worthlessness or excessive or inappropriate guilt nearly every day
- Diminished ability to think or concentrate, or indecisiveness nearly every day
- Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide
Alcohol withdrawl times
Mechanism
- chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors
- alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
Features
- symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety
- peak incidence of seizures at 36 hours
- peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Management
- patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
- first-line: benzodiazepines e.g. chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol
- carbamazepine also effective in treatment of alcohol withdrawal
- phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures
Charles-Bonnet syndrome
Charles-Bonnet syndrome (CBS) is characterised by persistent or recurrent complex hallucinations (usually visual or auditory), occurring in clear consciousness. This is generally against a background of visual impairment (although visual impairment is not mandatory for a diagnosis). Insight is usually preserved. This must occur in the absence of any other significant neuropsychiatric disturbance.
Risk factors include: Advanced age Peripheral visual impairment Social isolation Sensory deprivation Early cognitive impairment
CBS is equally distributed between sexes and does not show any familial predisposition. The most common ophthalmological conditions associated with this syndrome are age-related macular degeneration, followed by glaucoma and cataract.
Well-formed complex visual hallucinations are thought to occur in 10-30 per cent of individuals with severe visual impairment. Prevalence of CBS in visually impaired people is thought to be between 11 and 15 per cent.
Around a third find the hallucinations themselves an unpleasant or disturbing experience. In a large study published in the British Journal of Ophthalmology, 88% had CBS for 2 years or more, resolving in only 25% at 9 years (thus it is not generally a transient experience).
Mania/hypomania differention
hypomania <7 days (usually 3-4)
mania > 7 days
along with the other things you already know
How should SSRIs be stopped?
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression.
citalopram (although see below re: QT interval) and fluoxetine are currently the preferred SSRIs
sertraline is useful post myocardial infarction as there is more evidence for its safe use in this situation than other antidepressants
SSRIs should be used with caution in children and adolescents. Fluoxetine is the drug of choice when an antidepressant is indicated
Adverse effects
gastrointestinal symptoms are the most common side-effect
there is an increased risk of gastrointestinal bleeding in patients taking SSRIs. A proton pump inhibitor should be prescribed if a patient is also taking a NSAID
patients should be counselled to be vigilant for increased anxiety and agitation after starting a SSRI
fluoxetine and paroxetine have a higher propensity for drug interactions
Citalopram and the QT interval
the Medicines and Healthcare products Regulatory Agency (MHRA) released a warning on the use of citalopram in 2011
it advised that citalopram and escitalopram are associated with dose-dependent QT interval prolongation and should not be used in those with: congenital long QT syndrome; known pre-existing QT interval prolongation; or in combination with other medicines that prolong the QT interval
the maximum daily dose is now 40 mg for adults; 20 mg for patients older than 65 years; and 20 mg for those with hepatic impairment
Interactions
NSAIDs: NICE guidelines advise ‘do not normally offer SSRIs’, but if given co-prescribe a proton pump inhibitor
warfarin / heparin: NICE guidelines recommend avoiding SSRIs and considering mirtazapine
aspirin: see above
triptans: avoid SSRIs
monoamine oxidase inhibitors (MAOIs) - risk of serotonin syndrome
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks. For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms increased mood change restlessness difficulty sleeping unsteadiness sweating gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting paraesthesia
SSRIs and pregnancy
- BNF says to weigh up benefits and risk when deciding whether to use in pregnancy.
- Use during the first trimester gives a small increased risk of congenital heart defects
- Use during the third trimester can result in persistent pulmonary hypertension of the newborn
- Paroxetine has an increased risk of congenital malformations, particularly in the first trimester
secong generation antipsychotics
Atypical antipsychotics should now be used first-line in patients with schizophrenia, according to 2005 NICE guidelines. The main advantage of the atypical agents is a significant reduction in extrapyramidal side-effects.
Adverse effects of atypical antipsychotics
weight gain
clozapine is associated with agranulocytosis (see below)
hyperprolactinaemia
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
increased risk of stroke
increased risk of venous thromboembolism
Examples of atypical antipsychotics
clozapine
olanzapine: higher risk of dyslipidemia and obesity
risperidone
quetiapine
amisulpride
aripiprazole: generally good side-effect profile, particularly for prolactin elevation
Clozapine
Clozapine, one of the first atypical agents to be developed, carries a significant risk of agranulocytosis and full blood count monitoring is therefore essential during treatment. For this reason, clozapine should only be used in patients resistant to other antipsychotic medication. The BNF states:
Clozapine should be introduced if schizophrenia is not controlled despite the sequential use of two or more antipsychotic drugs (one of which should be a second-generation antipsychotic drug), each for at least 6–8 weeks.
Adverse effects of clozapine
agranulocytosis (1%), neutropaenia (3%)
reduced seizure threshold - can induce seizures in up to 3% of patients
constipation
myocarditis: a baseline ECG should be taken before starting treatment
hypersalivation
Dose adjustment of clozapine might be necessary if smoking is started or stopped during treatment.
Treating side effects of antipsychotics
This patient is suffering from tardive dyskinesia. The episode has been described as severe and so the most appropriate treatment is tetrabenazine.
Propranolol is useful for akathisia (restlessness).
Procyclidine and benztropine are useful for acute dystonia.
Lorazepam could be used to calm a patient who is having a psychotic episode (among many other indications)
what is mirtazapine?
Mirtazapine is an antidepressant that works by blocking alpha2-adrenergic receptors, which increases the release of neurotransmitters.
Mirtazapine has fewer side effects and interactions than many other antidepressants and so is useful in older people who may be affected more or be taking other medications. Two side effects of mirtazapine, sedation and an increased appetite, can be beneficial in older people that are suffering from insomnia and poor appetite.
It is generally taken in the evening as it can be sedative.
Before diagnosing GAD remember
Symptoms of anxiety and hyperthyroidism often overlap and hyperthyroidism can be a cause and an exacerbating factor.
Although phaeochromocytoma and Wilson’s disease are potential differentials they would not routinely be checked for prior to diagnosing anxiety. Insomnia is a symptom rather than a diagnosis here. Depression is an important differential however her range of physical symptoms and absence of low mood are more suggestive of anxiety.
Always look for a potential physical cause when considering a psychiatric diagnosis. In anxiety disorders, important alternative causes include hyperthyroidism, cardiac disease and medication-induced anxiety (NICE).
examples of acute dystonia
Acute dystonia - sustained muscle contraction such as torticollis or oculogyric crisis
suicide risk factors
The following is a list of suicide risk factors taken from the Preventing suicide in
England paper from the Government:
Gender - males are three times as likely to take their own life as females
Age - people aged 35-49 years now have the highest suicide rate
Mental illness
The treatment and care they receive after making a suicide attempt
Physically disabling or painful illnesses including chronic pain
Alcohol and drug misuse
The loss of a job
Debt
Living alone - becoming socially excluded or isolated;
Bereavement
Family breakdown and conflict including divorce and family mental health problems
Imprisonment
