Psych 5 Flashcards
1
Q
Depot antipsychotics
A
- Long acting formulation, only some anti-psychotics available
- Can be given 1-4 weekly, monthly and 3 monthly
- Advantages: useful in non-compliant patients, useful if struggle to take oral
- Disadvantages: plasma level maintained for long time (ADR, interactions), unable to switch antipsychotics quickly
2
Q
Neuromalignant syndrome
A
- Body temperature rises rapidly and it can be fatal in 1-3 days
- Symptoms: Fever, Diaphoresis (sweating), rigidity, confusion, fluctuating consciousness, fluctuating BP, tachycardia, elevated creatine kinase, altered LFT
- More common in first generation but second generation antipsychotics can also cause, as well as antidepressants (SSRI, lithium)
- Combination of antipsychotic and SSRI increases risk
- Risk factors: drug increase or reduction, abrupt withdrawal of anticholingeric, psychosis, organic brain disease, alcoholism, parkinsons, if agitated and in need of restraint/seclusion
3
Q
Diagnosing and treating Neuroepileptic Malignant syndrome
A
- Diagnostic test: no specific test, CK >1000, AST/ALT
- Withdraw antipsychotics, lithium, antidepressant for at least 5 days. Begin with small dose and increase slowly
- Monitor temp, pulse, BP
- Use benzodiazepine- im lorazepam
- Correct any dehydration and hyperpyrexia
- In hospital: rehydration, Bromocriptine and dantrolene (muscle relaxant)
4
Q
Lithium
A
- Class of drug: mood stabiliser, anti-manic drugs
- Mechanism of action: mimics sodium, modulates dopaminergic and serotonergic transmission
- Licensed indications: acute manic or hypomanic episodes, adjunct in treatment resistant depression, prophylaxis bipolar affective disorder. Control of aggressive behaviour or intentional self harm
5
Q
Antipsychotics: management of sexual side effects
A
- Switch to low risk antidepressant= mirtazapine, vortioxetine, agomelatine
- Dose reduction
- In men sildenafil/tadalafil help
- Other medication: Buspropion, transdermal testosterone
6
Q
Clozapine
A
- An atypical antipsychotic indicated if failure of 2 other antipsychotic medications (treatment resistant)
- Side effects: agranulocytosis, neutropenia, reduced seizure threshold, constipation, slurred speech
- Patients should have weekly FBC for the first 18 weeks of treatment then fortnightly for a year and then monthly
- Blood lipids and weight should be measured at baseline, every 3 months for the first year, and then yearly.
- Fasting blood glucose should be tested at baseline, after one months’ treatment, then every 4–6 months.
7
Q
Depressive disorder: pharmacological management
A
- First line – SSRI eg Sertraline, Escitalopram. explain that antidepressants might take 4-6 weeks to be effective. Increases risk of suicide first 2 weeks – need to follow up weekly if risk is high or support form CPN/with patient’s consent, carer to monitor mental state
- If no response 2-4 weeks, increase dose if tolerated. If not tolerated consider switching to different class of antidepressant
- Second line – different class of antidepressants – SNRI, NaSSA
- If no response, reassess diagnosis & severity of illness. Check compliance & adverse effects
- Augment – Lithium, Antipsychotic
- Duration of treatment: depends on individual. Continue treatment until patient has returned to premorbid level plus 6 months thereafter to prevent relapse.
8
Q
Tricyclic antidepressants (TCA’s)
A
- g. amitriptyline, lofepramine, clomipramine
- Inhibit 5-HT and NA uptake which Produces therapeutic effect
- Block of M1, H1, alpha1 receptors produces side effects= causes sedation, postural hypotension and anticholingeric side effects (dry mouth, constipation, urinary retention, blurred vison), long QT syndrome
- Contraindicated in previous heart disease, BPH
- Poorly tolerated and toxic in overdose
- In depression Lofepramine is second line, Clomipramine second line for OCD
9
Q
Selective Serotonin Reuptake Inhibitor (SSRI)
A
- For example: fluoxetine, paroxetine, sertraline, citalopram
- Inhibits 5-HT uptake: produces therapeutic benefit against depression, OCD, panic, anxiety
- Side effects: nausea, early increased anxiety, sexual dysfunction, QT prolongation, hyponatraemia. GI symptoms most common side effects
- Well tolerated and good first line treatment
10
Q
Serotonin syndrome
A
- Potentially life threatening condition due to increased serotonergic activity in the CNS
- Either starting SSRI or drug interaction i.e. SSRI+Tramadol
- Triad of: mental status changes, autonomic hyperactivity and neuromuscular abnormalities
- Clinical diagnosis and stop SSRI
11
Q
Serotonin and Noradrenaline Reuptake Inhibitor (SNRI)
A
- e.g. venlafaxine, duloxetine
- Inhibit 5-HT and NA uptake: Produces therapeutic effect, Produces side effects similar to SSRI
- Better tolerated than TCAs and probably more effective than SSRIs for severe depression therefore good second/third line treatment
- Side effects: nausea, insomnia, tachycardia, agitation
12
Q
Noradrenaline and Serotonin Selective Antagonist (NaSSA)
A
- e.g. mirtazepine
- Modulate norepinephrine and serotonin levels
- Used if want weight gain or sedative effect
- Possibly more potent than SSRIs plus lacks sexual side effects. Can cause marked weight gain and sedation. Used second line
13
Q
5-HT2 antagonist
A
- e.g. Trazodone
- Similar potency to other antidepressants but often added to SSRI’s or SNRI’s at low doses to provide sedation
- Rare side effect of priapism
14
Q
Monoamine Oxidase inhibitor
A
- Traditional e.g. phenelzine, tranylcypromine
- Food & drug interaction: builds up tyramine, cheese, wine, chocolate, salami
- RIMA (sub class) e.g. moclobemide
- Increase levels of 5-HT, NA (and dopamine - traditionals)
- Third/fourth line treatments for severe and/or atypical depression
15
Q
NICE: antidepressants
A
- SSRI first line: If not effective – an alternate SSRI.
- Reasonable alternatives = mirtazepine, but consider moclobemide, reboxetine, lofepramine. Venlafaxine or an older TCA for severe depression
- Vortioxetine as third line agent
- Esketamine for treatment resistant depression (Decision pending)
16
Q
SSRI and pregnancy
A
- 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
- Avoid paroxetine
17
Q
Types of SSRI’s
A
- Sertraline is used post MI
- Caution with SSRI in children and adolescents. Fluoxetine is the antidepressant of choice
- Citalopram associated with QT elongation
- SSRI and NSAID need a PPI
- Avoid with: warfarin/heparin, aspirin, triptans, MAOI
- When stopping SSRI reduce over 4 weeks
18
Q
When to prescribe antidepressants
A
- Antidepressants are a first line treatment for: moderate and severe MDD in adults, Sub-threshold depression that has persisted for 2 years or more.
- Antidepressants are an option for mild MDD especially if: there is a history of moderate to severe recurrent depression. The depression has persisted for more than 2–3 months
- Antidepressants are not a first line treatment for short duration sub-threshold depression in adults but consider if: there is a prior history of moderate to severe recurrent depression. The depression persists for more than 2–3 months
19
Q
Assessing response
A
- Initiation of antidepressant: review in 2 weeks normally and if <25 at 1 week
- Review response after 4-6 weeks
- After 2-4 weeks there should be at least some response; 4-6 weeks there should be significant response
- If partial response increase dose, if no response switch drug
- Treat for 6-12 months from remission, if risk factors longer
- If multiple risk factors review annually
20
Q
Managing difficult to treat depression
A
Augment if partial response and switching failed previously:
- First line: Lithium, quetiapine, aripiprazole
- Second line: Mirtazepine (with SSRIs or SNRIs), T4, risperidone
- Others: pramipexole, stimulants, esketamine, oestrogen, testosterone, etc etc
21
Q
Hypnotics and anxiolytics
A
- Hypnotics: Benzodiazepines, Z-drugs
- Anxiolytics: Benzodiazepine, Buspirone, Gabapentinoids
Hypnotics and Anxiolytics both increase GABA transmission causing: Anxiolysis, Sedation, Muscle relaxation, Anticonvulsant, Amnesia, Reduction of alcohol withdrawal symptoms.
22
Q
Gabapentinoids
A
- Pregabalin (licensed for GAD), gabapentin
- Act by enhancing GABA function through an effect on ion channels,
- Effective for GAD, including at high doses for difficult to treat anxiety
- Also can help neuropathic pain
- Side effects: drowsiness, fatigue, ataxia, blurred vision, diplopia, dizziness, constipation
- Avoid in patient with history of alcohol or substance misuse
- Been reclassified as controlled drugs
23
Q
Other drugs used to manage anxiety or hypnosis
A
- Any drug that has anti-histamine properties E.g. anti-histamines, TCAs, antipsychotics
- 5-HT2 antagonists= Trazadone, Mirtazepine, second generation antipsychotics
- NB – the first line pharmacological treatments for anxiety disorders are SSRIs
24
Q
First line treatment for anxiety disorder
A
often psychological e.g.
- CBT or relaxation for GAD
- Psychoeducation for panic
- Graded exposure for phobias
25
Pharamcological management of GAD
- First line: SSRIs – follow same doses/duration of treatment trials as per depression
- Second line= SNRIs (venlafaxine and duloxetine), buspirone, pregabalin
- Alternative/additional options= ?gabapentin, Benzodiazepines, Quetiapine (for more difficult to treat anxiety)
26
Benzodiazepine
- Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or causing the patient unacceptable distress
- The use of benzodiazepines to treat short-term ‘mild’ anxiety is inappropriate.
- Benzodiazepines should be used to treat insomnia only when it is severe, disabling or causing the patient extreme distress.
- Can be used in GAD, panic and social anxiety. Can cause sedation, cognitive impairment, tolerance and dependence
- Reserved for patients who haven’t responded to three previous treatments
27
Pharmacological management of panic disorder
- SSRIs first-line treatment; some evidence for SNRIs
- Initially treatment can increase panic attacks
- Minimise by starting with a low dose and slowly increasing (or adding a BZ for a few weeks)
- Response takes longer to assess than depression or GAD - up to 12 weeks to assess efficacy
- BZs “in the pocket/bag” can have a positive psychological benefit
28
Pharmacological management of OCD
- Antidepressants: SRI’s (especially SSRI’s and clomipramine), higher doses required, longer treatment (8-12 weeks)
- Difficult to treat OCD: higher doses of SSRI’s or clomipramine, augment with a second generation antipsychotic
29
The 3 main criteria for detaining and treating patients with psychiatric illness per the mental health act 1983
1. mental disorder of a nature or degree which makes it appropriate for them to receive treatment in hospital
2. risk to self or others
3. appropriate treatment is available
4. note dependence on drugs/alcohol and learning disability are 2 notable exclusion criteria
5. >16 years
30
What sections of the mental health act can be used by the police to hold people with a mental illness who needs care/control
- Section 136 - public place: used to take someone to a place of safety. 24h, can be extended for 12h
- Section 135 - private address: allows access to a private address without permission. Used to take someone to a place of safety, up to 36h
- Place of safety may be home, a friend/relative's home, a hospital, a police station
31
Section 5 of the mental health act
- Used to stop patients from leaving hospital if so far they have been in hospital voluntarily. Only if 2, 3, 4 not possible
- Section 5 (4): nurses holding power, can hold a patient for up to 6h. Only trained mental health or learning disability nurse if no doctor available
- Section 5 (2): doctors holding power, only FY2 and above, up to 72h
32
Section 2 of the mental health act
- Allows for admission for mental health assessment and treatment for up to 28 days, non-renewable.
- allows for time for doctors to determine= type of mental disorder, whether treatment is needed, what treatment this will be and impact on overall health
- 2 doctors (at least one of which must be section 12(2) approved) + AMHP
- treatment can be given against their will on this section
33
Section 3 of the mental health act
- Allows for admission for mental health assessment and treatment for up to 28 days, non-renewable.
- allows for time for doctors to determine= type of mental disorder, whether treatment is needed, what treatment this will be and impact on overall health
- 2 doctors (at least one of which must be section 12(2) approved) + AMHP
- treatment can be given against their will on this section
34
Section 4 of the mental health act
- Designed for emergencies when applying Section 2 would cause an unnecessary delay.
- Requires the recommendation of a single doctor and the involvement of either an AMHP or the nearest relative.
- The patient can be detained for a maximum of 72 hours, typically followed by a transition to Section 2
35
5 principle of the mental capacity act 2005
1. Presumption of capacity: assume a person has the capacity to make a decision themselves, unless it's proved otherwise
2. Individuals being supported to make their own decisions wherever possible
3. Unwise decisions: do not treat a person as lacking the capacity to make a decision just because they make an unwise decision
4. Best interests: if you make a decision for someone who does not have capacity, it must be in their best interests
5. Least restrictive option: treatment and care provided to someone who lacks capacity should be the least restrictive of their basic rights and freedoms
36
2 stage test of capacity
- Does the person have an impairment of the mind or brain, or is there some sort of disturbance affecting the way their mind works? (It doesn’t matter whether the impairment or disturbance is permanent or temporary)
- If yes, does that impairment or disturbance mean that the person is unable to make the decision in question at the time it needs to be made?
When does someone lack capacity to make a decision
- understand the information relevant to the decision
- retain that information
- use or weigh up that information as part of the process of making the decision
- communicate their decision (by talking, sign language, or any other means)
Where appropriate, people should be allowed the time to make a decision themselves. Capacity is time- and decision-specific
37
What is a deprivation of liberty safeguard?
Occurs when:
- a person is under continuous supervision and control in a care home or hospital, and
- is not free to leave, and
- the person lacks capacity to consent to these arrangements
3 main criteria to evaluate someone under the mental health act
- mental disorder of a nature/degree that makes it appropriate for them to receive treatment in hospital
- risk to self/others
- appropriate treatment is available
38
New personality disorder classification (ICD-11)
- Single diagnosis of personality disorder with option to describe predominant traits
- Severity of personality disorder must be described
- Diagnosis can be made at any age
- Symptoms should persist for 2 years at minimum
39
Personality disorder classification
- More than one trait domain can apply to the same person
- Types of trait domain: Negative affectivity, Detachment, Dissocial, Disinhibition, Anankastic, Borderline
- Ranked: mild, moderate or severe based on impairement
40
Trait domain: Negative affectivity
- Intense negative emotions with higher frequencies than the average person
- Emotional lability and poor regulation of this
- Feelings of hopelessness, shame and low self-esteem can lead to over-reliance on others and being sensitive to criticism
- Lack of trust in others may manifest with the tendency to hold grudges
- Easily distressed and can lead to suicidal ideation
41
Trait domain: detachment
- Socially or emotionally distant, displaying behaviours to avoid interactions, intimacy as well as emotional expression
- May not react to negative or positive events or find enjoyment from activities
42
Trait domain: dissocial
- Self-centredness and lack of empathy
- Behaviour is guided by their need to be the centre of attention and can be inappropriate or manipulative in nature
- Disregard of other’s feelings
43
Trait domain: disinhibition
- Act impulsively in response to immediate stimuli without considering the consequences, especially regarding safety
- Easily distracted, preferring to act spontaneously with no clear objective
- Prominent disinhibition can lead to irresponsible and reckless acts
44
Trait domain: Anankastic
- Strongly believe in perfectionism, controlling themselves and situations to ensure standards and rules are met
- Lack flexibility and spontaneity
- Can experience difficulties in making decisions and taking risks
45
Trait domain; Borderline pattern
Consists of at least 5 of following:
- Avoidance of real or imagined abandonment
- Pattern of unstable and intense interpersonal relationships
- Identity disturbance
- Tendency to act rashly and engage in self-damaging behaviours
- Recurrent self-harm episodes
- Emotional instability
- Chronic feelings of emptiness
- Difficulty controlling anger with frequent outbursts
- Transient dissociative symptoms or psychotic-like features
