Psych Flashcards
1
Q
pharm depression
A
eTG first line
- SSRI
- SNRI
- Mirtazapine
Use first line
- some response expected by 2 weeks (may take up to six)
- full recovery takes another 6 weeks
- use for at least 6 months (hopefully 12)
Assess in 2-4 weeks
- 50% respond to initial therapy
- if no or small response increase dose
- 2-4 weeks later, if not response switch drugs
- if small response (increase dose again)
- no evidence for advantage in switching class
- if significant side effects, switch drug
- taper down and cease
Changing drugs
- taper down
- drug free interval
- taper up
- monitor for seritonin syndrome
Failure to respond:
- second line drugs
- > MOA
- > TCA
Treatment resistant
-only 1/3rd achieve remission within 6 weeks
Check:
-dose, diagnosis, compliance, substance use, medical conditions etc
Try:
-ECT (response rate = 50-80%)
-lithium augmentation with TCA and SSRI (50% response)
-Quetiapine augmentation
Recurrent depression:
- 2 or more episodes in 5 years
- 3-5 years prophylactic anti-depressants or lithium
- CBT
2
Q
non pharm depression
A
Social:
- Develop supportive therapeutic relationship
- Address environmental factors
- Address contributing factors such as substance use
Psychological:
CBT
- structured, goal directed
- based on theory that thoughts and feelings guide behaviour in negative cycle
- psychoeducation
- de-arousal techniques
- cognitive therapy (coping skills)
- behavioural therapy (engagement in recovery focused activities)
- problem solving techniques
- graded exposure and response prevention
Interpersonal therapy
- time limited
- focuses on improving problematic interpersonal relationships or circumstances
- interpersonal relationships and depression are thought to affect each other in a reciprocal manner
Family and couples therapy
- two fold aim
- modifying negative interactional patterns
- promoting supportive aspects
Other
- progressive muscle relaxation
- imagery
- exercise
3
Q
pharm schizophrenia
A
First episode
- start low, taper up
- atypical (avoid olanzapine)
- check response after 2-3 weeks, increase if need
- agitation/anxiety/insomnia = benzodiazepines
Inadequate response -at 6-8 weeks of therapeutic dose check -compliance -substance use -environmental stressors -switch to another atypical with different properties -if no response to second, try olanzapine
Switching drugs
-1-2 weeks of crossover taper up/down
Treatment resistant 40% have residual symptoms Check -compliance -substance use -environmental stressors -use depot if compliance was issue At least two other drugs trialed -start clozapine -1/3rd show improvement after 6-12 months also used for -recurrent suicidal ideation -marked aggressive behaviour -EPS -substance abuse
Negative symptoms
- clozapine
- olanzapine
- rispiradone
- atypical + fluoxetine
- clozapine + fluoxetine
- clozapine + lamotragine
4
Q
non pharm schizophrenia
A
Manage side effects!!
- monitor and treat metabolic syndrome
- counsel about diet, exercise, smoking cessation
Assertive community treatment
- collaborative care by a team of mental health professionals
- assistance with medication concordance
- social skills training
- welfare support
- financial planning
- housing and counselling
Psychoeducation
- provision of basic information about mental illness
- the mental health care system (roles of mental health professionals and the relevant mental health legislation)
- principles of management and self-management
- provided to the patient and their family or carers
- frequently in a group format, but also on a one-to-one basis.
Cognitive behavioural therapy
- can be used to control/cope with residual positive symptoms
- examine the evidence for a psychotic belief, and use reasoning, coping and problem-solving skills, challenge their beliefs
- also treatment nonconcordance
- varying degrees of success.
- comorbid anxiety or depression
Substance abuse
- CBT
- Motivational interviewing
Family therapy
-addressing difficulties in caring for someone with psychosis
Social skills training
- self care
- interpersonal functioning
- ADLs
Social worker
-welfare, occupational help etc
5
Q
SSRI’s
A
MOA
- all SSRIs appear to treat depression by increasing serotonergic activity
- > decrease the action of presynaptic reuptake pump
- they have very little affinity for other types of receptors
SE
- nausea
- headache
- diarrhoea
- anxiety/agitation
- insomnia
- sexual dysfunction
- dry mouth
- drowsiness
- sweating/tremor
- rare
- > tardive dyskinesia/dystonias
- > palpitations (prolong QT)
- > tachycardia/hypotension
- > hyponatraemia
- > increased bleeding risk
Precautions
- serotonin syndrome
- > MOAI within 2 weeks
- > SNRI’s
- > St Johns wort
- > opioids
- > MDMA/amphetamines
- use lower dose in severe kidney/liver disease
- use lower dose in elderly
- may provoke manic episode in bipolar
- may increase bleeding risk in those at high risk
- generally safe in pregnancy/breastfeeding
6
Q
mirtazapine
A
MOA:
- antagonises presynaptic alpha 2, increasing norepi and serotonin release
- antagonises post synaptic 5HT2 receptors, increasing 5HT1 receptor activity
- also has high affinity for H1 receptors = sedating
- no muscurinic or cholinergic affinity
SE:
- dry mouth
- drowsiness
- apetite increase
- weight gain
7
Q
first generation antipsychotics
A
chlorpromazine, fluphenazine, thioridazine, haloperidol
MOA
-post synaptic blockade of D2 receptors
SE
- EPS
- > pseudoparkinsonism
- > dyskinesias
- > akathesia
- > tardive dyskinesia
- hyperprolactinaemia
- > gynacomastea
- > galactorrhea
- metabolic syndrome
- anticholinergic effects
- > hypotension
- antimuscurinic
- > dry mouth
- > urinary retention and constipation
- > blurred vision
- > QT prolongation and torsades
- neuroleptic malignant syndrome
- > fever
- > rigidity
- > autonomic instability
- > mental status change
- other
- > dysphoria
- > sedation
8
Q
atypical antipsychotics
A
clozapine, risperidone, olanzapine, aripiprazole
MOA
- block post synaptic D2 receptor
- > clozapine selective for D2c
- > D2c found in mesolimbic, D2a in nigrostriatal
- block presynaptic 5HT2 receptor
- > increase serotonergic signalling
- > improve negative symptoms
SE
- same as typicals
- > less EPS
- > no tardive dyskinesia for clozapine
- WCC
- > neutropenia/leukopenia in 2%
- > agranulocytosis in 1%
- clozapine
- > wet pillow syndrome
- > seizures
9
Q
TCAs
A
Amitriptyline, imipramine
MOA
- increase synaptic concentration of serotonin and/or norepi in CNS
- > by inhibiting their reuptake by the presynaptic neuronal membrane pump
TCAs
- antimuscurinic
- > blurred vision
- > dry mouth, constipation
- > urinary retention, hypotension
- > sexual dysfunction
- cardiac
- > Qt interval
- serious
- > coma
- > convulsions
- interactions
- > serotonin syndrome
- > hypertensive crisis
10
Q
MOAs
A
MOA
- irreversibly block MOA
- > the enzyme responsible for deamination of serotonin, norepi, dopamine
SE
- antimuscurinic
- > blurred vision
- > dry mouth
- > constipation
- > urinary retention
- > sexual dysfunction
- serotonin
- > insomnia
- > agitation
- hypertensive crisis
- > foods (tyramine)
- > SSRIs, TCAs
- > amphetamines
- > ephedrine
- serotonin syndrome
- > SSRI/TCA
11
Q
Depression criteria
A
5 or more present most of the time, most days, for 2 weeks: Dysphoria or Anhedonia + FITGAPS
- Fatigue (anergia)
- Insomnia/hypersomnia
- Thinking (cognitive impairment)
- Guilt or worthlessness
- Anorexia/hyperphagia (weight loss/gain)
- Psychomotor slowing
- Suicidal thoughts
Not better explained by medical condition or substance use
Never been a manic or hypomanic episode
Not better explained by schizoaffective disorder, schizophrenia, schizophreniform disorder
12
Q
Depression ddx
A
Psych
- Manic episode with mixed episode or irritable mood (when depressive episode has prominent irritable mood)
- Mood disorder due to another medical condition
- Substance induced depressive or bipolar disorder
- Adjustment disorder with depressed mood (distinguished by fact that full criteria for MDD is met, which precludes diagnosis of adjustment disorder)
- Sadness (distinguished by duration, severity and clinically significant impairment)
Organic -NEUROLOGICAL ->Epilepsy ->MS ->Alzheimers ->Stroke ->Parkinson's ->Huntingtons ->TBI -INFECTIVE ->Neurosyphilis ->HIV -ENDOCRINE ->Hypothyroidism ->Diabetes ->Parathyroid ->Vitamin deficiency (eg. vit D) CARDIAC ->MI ->CCF ->Cardiomyopathy LUNG DISEASE ->COPD AUTOIMMUNE ->SLE NEOPLASTIC ->Lung cancer ->Pancreatic cancer ->CNS tumors MEDICATIONS ->Steroids ->Interferons
13
Q
Depression aetiology and pathophys
A
AETIOLOGY
Genetic:
- Heritability approx 40%. Much of genetic risk attributed to neurotic personality.
- Risk is 2-4 fold higher for first degree relatives than general population
Environmental:
- Adverse childhood events, particularly when multiple and diverse
- Stressful life events are well known precipitants
PATHOPHYS
- abnormal concentrations of neurotransmitters
- > monoamine hypothesis
- > eg. abnormal dopamine reflected in avolition
- dysregulation of HPA axis
- structural brain changes
- > eg thinning of orbitofrontal and cingulate gyrus
14
Q
Schizophrenia criteria
A
6 months of disturbance with typical symptoms
At least 1 month of 2 or more (Dont Have Scotch Before Noon), with at least one being D, H or S:
- delusions
- hallucinations
- disorganised speech
- markedly disorganised/catatonic behaviour
- negative symptoms (reduced emotional expressivity, avolition)
- Causes clinically significant distress
- Schizoaffective, bipolar and MDD with psychotic features have been ruled out
- > no mood episode
- > present for less than 50% of active or residual illness
- Not attributable to substance use or medical illness
Associated symptoms
- Negative symptoms
- > avolition
- > affective flattening
- Sleep disturbance (daytime sleeping)
- Anorexia
- Depersonalisation/derealisation
- Somatic concerns
- Anxieties and phobias
- Cognitive (memory, attention, processing speed etc)
15
Q
risks for schizophrenia
A
Genetic
- monozygotic concordance = 40-50%
- dizygotic = 10-15%
- SNP (many), mainly related to dopaminergic and glutaminergic function
- MHC locus genes implicated (complement component 4 allele)
- CNV (deletion long arm chromosome 22)
Environmental
- late winter/early spring birth
- perinatal morbidity
- immigration
- urban living
- maternal infection herpes/influenza
- cannabis
