Pharmacological + non-pharmacological management of mental health conditions Flashcards
What is the principle of action of anti-depressants?
Monoamine hypothesis: enhance activity of monoamine neurotransmitter (NA + 5-HT)
When are antidepressants indicated in depression and what do you do if its not working?
- indicated for moderate-severe depression a/w psychomotor/physiological changes
- most take 2-3w to work and up to 6w for main effect to be seen. first few weeks may have agitation/anxiety/suicidal ideation
- if no effect at a typical dose then switch the drug, if partial benefit then increase the dose
1st line - SSRI
2nd line - another SSRI/mirtazapine
Specialists: venlafaxine, lofepramine (TCA), augmentation with lithium/antipsychotics
How long should you use an antidepressant for?
- at least 6m from remission in depression/12m in GAD
* in recurrent depression maintain for at least 2y
Discontinuation syndrome
Stopping AD may cause this - best to reduce dose slowly esp for venlafaxine which has a short half life
Causes sweating, shakes, agitation, insomnia, headache, irritability, N+V, paraesthesia, clonus
Serotonin syndrome
Uncommon ADR due to excessive serotonergic activity
A/w SSRIs (esp fluoxetine-long half life), SNRI, MAOI, and interactions with other meds like opioids, TCAs, anticonvulsants, lithium, OTC meds, antiemetics – check individual interactions
CF: headache, agitation, hypomania, confusion, coma, autonomic sx (shiver, sweat, hyperthermia, tachycardia, nausea, diarrhoea), somatic sx (myoclonus, clonus, hyperreflexia, tremor)
M: stop drug, fluids, monitor
SSRIs mechanism + side effects
Selective serotonin reuptake inhibitors - increase serotonin activity
Used in depression + anxiety disorders
S/e: GI (nausea, dyspepsia, bloating, diarrhoea/constipation), STRESS (Sweating, Tremor, Rash, Extrapyramidal se(rare), Sexual dysfunction, Somnolence, Stopping (discontinuation syndrome))
Examples of SSRIs
E.g. sertraline (50-200mg, safest in heart disease), citalopram (20-40mg, risk of QTc prolongation), escitalopram (10-20mg, also QTc), fluoxetine (20-60mg, risk of serotonin syndrome when switch, longest half life), paroxetine (20-60mg, risk of discontinuation syndrome)
SNRIs
Serotonin + noradrenaline reuptake inhibitors - also bind to NA reuptake receptors so NA + serotonin retained at nerve junction - more rapid effects than SSRIs so good for 2nd line treatment and sometimes in neuropathic pain
E.g. duloxetine, venlafaxine
S/e similar to SSRI, more chance of dry mouth, headache, dizzy, nausea, HTN (monitor BP at higher doses) + sexual dysfunction
NARI - selective noradrenaline reuptake inhibitor
V specific inhibitor e.g. reboxitine
Similar s/e profile. Avoid abrupt withdrawal. Cautions in many conditions.
Mirtazapine
Recommended after 2 SSRIs not worked or if a prominent feature is not eating/not sleeping, is a unique class with serotonin + histamine activity, some NA activity and an alpha blocker (so increases appetite)
S/e: sedation, weight gain, dry mouth, postural hypotension, oedema, tremor, dizziness, confusion, abnormal dreams, myalgia
Tricyclic antidepressants
Used to be used for depression but not much now cos of s/e, often used at low doses for neuropathic pain or migraine prophylaxis
Inhibits reuptake of NA + serotonin, and binds to cholinergic receptors
E.g. amitriptyline, clomipramine, dosulepin, imipramine, lofepramine
Some have sedative properties. Variety of S/e. CI in recent MI/heart block/mania.
Side effects of TCAs
- anticholinergic: blurred vision, urinary retention, dry mouth, constipation
- CVS: long QT, postural hypotension, tachycardia, syncope
- Hypersensitivity: urticaria, photosensitivity
- Psychiatric: mania, confusion, delirium, drowsiness
- Metabolic: weight gain (increased appetite)
- Endocrine: testicular enlargement, gynaecomastia, galactorrhoea
- Neuro: convulsions, dyskinesias, dysarthria, paraesthesia, taste disturbance, tinnitus, headache, tremor
Signs of TCA toxicity
Pyrexia Blurred vision Pupil dilation (mydriasis) Confusion Seizures Tachycardias Cardiac arrest
M: activated charcoal (within 1h), sodium bicarbonate (if wide QRS), BZD for seizures
MAOIs
Monoamine uptake inhibitors - prevent breakdown of dopamine, NA + 5HT
Not used much now and only be specialists as dangerous interactions. E.g. moclobamide, tranylcypromine
- SE: postural hypotension, arrhythmias, drowsy, insomnia, headache, weight gain, hepatic derangement
- Hypertensive reactions with tyramine - must avoid cheese/pickled meats/wine/alcoholic or low alcohol drinks
- Interactions: opiates, insulin, SSRIs, TCAs, anti-epileptics
- Toxic in OD
Vortioxetine
Newer drug for difficult to treat cognitive sx
Well-tolerated, may cause mild nausea
How do antipsychotics work?
- anti-dopaminergic: all work on D2/3 receptors, typical AP usually have higher affinity
- serotonergic: mostly atypicals, this improves affective + negative sx but causes metabolic s/e
- anti-histaminergic, anti-adrenergic, anti-cholinergic - cause many s/e
What are the types of side effects of antipsychotics?
- Extrapyramidal s/e (esp typical)
- Anti-muscarinic (esp atypical): can’t see (blurred vision), can’t pee, can’t shit, can’t spit
- Anti-histaminergic: sedation, weight gain
- Anti-adrenergic: postural hypotension, tachycardia, ejaculatory failure
- Endocrine: hyperprolactinaemia (esp typical cos of dopamine inhibition so prolactin secretion less inhibited), can cause reduced BMD/menstrual disturbance/galactorrhoea
- Metabolic (Esp atypical): impaired glucose tolerance, hypercholesterolaemia
- Cardiac: QTc prolongation (esp haloperidol)
- Clozapine: hypersalivation, agranulocytosis
- Neuroleptic malignant syndrome: rare, life threatening reaction
Extrapyramidal side effects
- Parkinsonism (w-m): bradykinesia, rigidity, coarse tremor, expressionless face, shuffling gait
- Akathisia (first few months, reduce dose + propranolol): unpleasant restlessness
- Dystonia (days): acute painful muscle spasms in neck/jaw/eyes-oculogyric crisis
- Tardive dyskinesia (years, may be irreversible): choreoathetoid movements usually of jaw
Treatment usually antimuscarinics e.g. procylidine. Tardive dyskinesia doesn’t respond to this and may be worsened
Neuroleptic malignant syndrome
Rare, life-threatening reaction to AP in first 10d after treatment beginning/dose increase
CF: pyrexia, confusion, muscle rigidity, sweating, autonomic instability (tachycardia, fluctuating BP), delirium, rhabdomyolysis, renal failure, PE, seizures
RF: high potency dopamine antagonists (typical LPs) in antipsychotic-naiive pt, high doses, young men
M: stop drug, fluid resuscitation, reduce temp, consider BZD, consider dantrolene (muscle relaxant)
What monitoring is required for pt on antipsychotics?
- FBC, U+E, LFTs: initiation then annually (amisulpiride doesnt need LFT)
- Clozapine - FBC weekly for 18w, then fortnightly for 1y, then monthly
- Fasting blood glucose: baseline, at 4-6m then yearly (olanzapine + clozapine need it every 4-6m)
- Lipids: baseline, 3m, yearly
- Prolactin: baseline, 6m, yearly
- ECG: may need before initiating
- BP: before + frequently during (amisulpiride, aripiprazole don’t affect BP)
- Weight
What route may antipsychotics be given?
- Oral usually
- Short-acitng IM
- Depot injections (long acting) every 1-4w e.g. flupentixol, risperidone, olanzapine. Bypass 1st pass metabolism + increase adherence
Typical antipsychotics
Haloperidol, flupentixol, zuclopenthixol, chlorpromazine, sulpiride
More likely to cause EPSEs, raised prolactin, dizziness, sexual dysfunction
Atypical antipsychotics
More serotonergic activity + specific dopamine blockage. 1st line for schizophrenia
Olanzapine, risperidone, quetiapine, amisulpiride, aripiprazole (fewer S/e), cloazpine
S/e: metabolic syndrome (esp clozapine + olanzapine), higher risk of stroke + VTE
Clozapine
Most efficacious atypical AP. Used in schizophrenia after 2 APs have failed
Oral suspension
S/e:
- common: anorexia, constipation, hyper salivation, malaise, speech disorders, urinary incontinence, metabolic syndrome
- uncommon: agranulocytosis (1%)
- rare: GI hypo motility, myocarditis, pancreatitis
Titrate dose slowly + monitor for autonomic dysregulation. Alter dose if smoking starts/stops
Antipyschotic OD
Coma, seizure, arrhythmia, hypotension
Beta blockers
Reduce ANS activation - biopsycho feedback - reduce somatic sx like palpitations/tachycardia/tremor
Usually propranolol
CI in asthma, COPD, heart block, acute LVF
Benzodiazepines
Bind to GABA receptors to potentiate the effect (positive allosteric modulators) - reduce neurone excitability
Ind: insomnia, anxiety disorders severe, delirium tremens, alcohol detoxification (chlordiazepoxide), acute psychosis, violent behaviour –> all short term use
(also seizures obv )
Types:
- long acting: diazepam, chlordiazepoxide, clonazepam
- short acting: lorazepam, temazepam, midazolam
S/e: drowsy, dizzy, confusion, ataxia, amnesia, dependence, paradoxical increase in aggression, muscle weakness, resp depression
Toxicity: ataxia, dysarthria, nystagmus, coma, respiratory depression –> IV flumazenil if indicated (don’t always need to give it)
Withdrawal syndrome: up to 3w after stopping long acting/within a day from short-acting. Tremor, anxiety, sweating, convulsion, perceptual disturbance, irritable, insomnia, reduced appetite, tinnitus
Pregabalin
Increases GABA in brain so reduces neurone activity
Used in anxiety (?), neuropathic pain, epilepsy. Meant to be short-term but often used for longer, less dependence/tolerance than BZD but still misused
S/e are sedation + weight gain
Z-drugs
Anxiolytic used to induce sleep short-term, not a BZD
Zopiclone, zolpidem, zaleplon
Lithium carbonate mechanism
Effective but mechanism unknown! Used for BPAD + schizoaffective disorder, significant evidence that it reduces self harm/suicide . Can be used in acute episodes or for maintenance
Teratogenic - Ebstein’s anomaly
CI in renal failure, pregnancy, breastfeeding, untreated hypothyroidism
Side effects of lithium treatment
Diarrhoea Impaired renal function Diabetes insipidus Fine tremor Hypothyroidism Weight gain Oedema Metallic taste Leucocytosis Idiopathic intracranial hypertension
Lithium toxicity
Levels 1.5-2mM: N+V, coarse tremor, ataxia, muscle weakness, apathy
Severe >2mM: nystagmus, dysarthria, hyperreflexia, oliguria, hypotension, convulsions, coma
M: stop lithium, high fluids with NaCl to stimulate osmotic diuresis, may need dialysis
What monitoring is needed for lithium therapy?
Has a narrow therapeutic window so need monitoring:
- pre-treatment: U+E, TFT, ECG, pregnancy test
- 6 monthly: U+E (renal impairment usually irreversible)
- 12 monthly: TFT (hypothyroidism-usually reversible)
- Lithium levels: weekly when starting/changing dose (12h post-dose) until stable, then 3m. Dehydration + interactions (NSAIDs, TD, ACEi) cause toxicity
Sodium valproate
Anti-convulsant can be used as a mood stabiliser if lithium + atypical AP not working
Avoid in women of child bearing age - causes neural tube defects
S/e: GI, weight gain, aggression, LFT derangement, thrombocytopenia, peripheral oedema, ataxia, tremor, fatigue, teratogenic
Carbamazepine
An anticonvulsant can be used after 1st line tx for mania or for alcohol withdrawal
s/e: drowsy, leukopenia, diplopia, blurred vision, rash, thrombocytopenia
potent enzyme inducer
Lamotrigine
An anticonvulsant that can be used in BPAD, good in women of child bearing age as can’t have SV. but doesnt prevent/treat manic episodes so only used for the depressive episodes
s/e: GI, rash, headache, tremor. potential for Stevens-Johnson syndrome
What drug types can be used as mood stabilisers?
- lithium
- anticonvulsants
- atypical antipsychotics - rapid onset so good for acute mania, e.g. quetiapine (less chance for interacting with lithium for toxicity)
Cholinesterase inhibitors
- Donepezil, galantamine, rivastigmine
- inhibit breakdown of ACh in brain ( AD a/w lower cholinergic acitivity)
- for mild-mod AD to improve cognitive sx + neuropsychiatric sx like apathy
- s/e: N/V/D, insomnia, muscle cramps, anorexia, bradycardia. EPSE (rivastigmine)
- monitoring: pulse regularly, ECG at initiation
- CI in heart disease + epilepsy
- cautioned in asthma/COPD, PUD, arrhythmias
Memantine
Glutamine (NMDA) receptor antagonist which lowers neuronal excitability
Ind: mod-severe AD, or if cholinesterase inhibitors CI
Used for agitation/challenging behaviour
What drugs are used for ADHD?
- Methylphenidate or dextroamphetamine: CNS stimulant so potential for misuse. Can cause growth failure, CI in suicidal ideation
- Atomoxetine: NA reuptake inhibitor. Can cause suicidal ideation
Electroconvulsive therapy
Small current passed through brain to induce modified epileptic seizure - use GA + muscle relaxant to limit motor effects
Usually need 6-12 sessions, 2x a week
Indicated in prolong/severe mania, catatonia or severe depression (treatment resistant, suicidal ideation/serius risk to others, not eating drinking)
S/e: peripheral nerve palsies, arrhythmias, confusion, risks of GA, myalgia, headaches, short term memory impairment, status epilepticus, amnesia, death
CI: recent MI, unstable #, RICP, cerebral aneurysm, recent stroke, h/o status epilepticus, severe GA risk
Cognitive behavioural therapy
Active treatment self help/group/individually
Need pt motivation
Aims to help people identify + challenge automatic negative thoughts + modify abnormal underlying core beliefs
Psychodynamic psychotherapy
Individual, couple or group
Intense. Explore unconscious by free association, therapist interprets this, client develops insight to change maladaptive behaviours
Family therapy
Family members seen together
Focuses on the family system and its ability to help family problems + individual mental illness
Aims to correct impaired communication and dysfunctional communication
Counselling
Form of relieving distress by active dialogue with the aim to help client find solution to problems. Indicated in adjustment disorder, mild depression, normal and pathological grief, adverse life events, substance misuse, chronic medical conditions, prior to decision-making e.g. genetic counselling.
Behavioural therapies
Based on learning theory, esp operant conditioning (behaviour is reinforced if it has positive consequences for the individual and prevents negative consequences). E.g. relaxation training (stress and anxiety), systemic desensitisation (gradual exposure-phobias), flooding (rapid exposure – not commonly used), exposure and response prevention (repeatedly exposed to situation causing anxiety but prevented from doing the compulsive actions - OCD and phobias), behavioural activation (making realistic plans to carry out activities then gradually increasing this – depressive disorders).
Psychoeducation
Deliver information to help understand and cope with their illness. Name and nature, likely causes, what health services can do to help, what they can do to help themselves.
Supportive psychotherapy
Psychological support given by mental health professionals to people with chronic and disabling mental illness. Aims to help people cope with adversity/unsolved problems, includes active listening, reassurance, explaining illness, providing guidance and possible solutions and allowing patient to express themselves in a safe environment.
Interpersonal therapy
Depression and ED. Focus on interpersonal problem e.g. bereavement, relationship issues or loss, interpersonal deficit – which may be causing difficulties in initiating or maintaining relationships.
Eye movement desensitisation + reprocesing
Helps patients access and process traumatic memories – for PTSD. Recall emotionally traumatic material while focusing on an external stimulus (e.g. following finger). Possibly placebo…
Dialectical behavioural therapy
Used for borderline PD. Uses CBT and group skills training to provide alternative coping strategies to self-harm when faced with emotional instability.
Cognitive analytic therapy
Cognitive therapies + psychoanalytic approaches. Analysing problems, how they began and how they affect every day life + reasons behind symptoms.
What is transference?
- Transference: patient re-experiences strong emotions from earlier events – positive transference when emotions are positive and vv for negative
- Counter-transference – therapist affected by powerful emotions felt by patient during therapy and reflects what patient is feeling
