Psych Treatment Pathways Flashcards
Mild depression management
Antidepressants not indicated
Generally gets better by itself
Anorexia management guidance
MARSIPAN
Management of really sick patients with anorexia nervosa
Anorexia psychological management
CBT and other psychological therapies Dietician Medical monitoring Art/drama therapy Family therapy Inpatient for high risk (MHA)
Bulimia management
Guided self-help
CBT
SSRI
How long to continue anti-depressant after first episode of depression?
Continue for at least 6 months after full recovery without reducing dose
How long to continue anti-depressant after second episode of depression or more?
Continue for at least 1-2 years after full recovery without reducing dose
What is the first line antidepressant class you should prescribe?
SSRI
If SSRIs don’t work what should you do?
Check they are taking them Consider other diagnosis or factors Increase dose Swap Combine e.g. SSRI and mirtazapine Augment - antipsychotic or lithium first
How to start a patient on anti-depressants?
Do PHQ-9 rating before and after each trial
Review after 1-2 weeks
Acute mania first line management
Antipsychotics - olanzapine, quetiapine or risperidone
If patient already on maintenance therapy then max dose of this medication
Acute mania second line management
Lithium
Valproate
Carbamazepine
ECT
Acute mania symptom control
Benzos - agitation
Z-drugs - insomnia
When and what antidepressant should you prescribe in bipolar disorder?
Not without antimanic drug
Not in those with recent manic/hypomanic episode or rapid cycling
SSRI (esp fluoxetine)
Bipolar depression management
Antipsychotics first line (quetiapine, olanzapine, lurasidone)
Antidepressants alongside anti-spychotic, lithium or valproate
Lamotrigine
ECT
Lithium
(unsure about this flashcard take with pinch of salt)
Bipolar maintenance management
Lithium gold-standard Other options: Antipsychotics Lamotrigine (if primarily depressive) Valproate (if primarily manic/hypomanic) Psychoeducation Other psychological therapies
ECT absolute contra-indications
MI within last 3 months
Recent CVA
Intracranial mass
Phaeochromocytoma
ECT relative contra-indications
Angina Congestive heart failure Severe pulmonary disease Severe osteoporosis Pregnancy
ECT consent procedure
If capacity to consent is impaired need second opinion doctor
For life saving treatment second opinion approval is not needed
PTSD management (NICE guidelines)
CBT first line
Eye movement desensitisation and reprocessing (EMDR) second line
Medication can be combined with psychological therapies:
Venlafaxine or an SSRI
Antipsychotics e.g. risperidone for severe hyperarousal
Alternatives: prazosin, mood stabiliser
Generalised anxiety disorder management
CBT SSRIs (first line) SNRIs (second line) Pregabalin Benzos (short term only)
Panic disorder management
CBT
SSRIs (first line)
SNRIs/tricyclics (second line)
Benzos (short term only)
Specific phobia management
Behavioural therapy (exposure)
Maybe add in CBT
SSRIs or SNRIs if required
Social phobia management
CBT
SSRI first line
SNRI second line
Benzos (short time only)
OCD management
CBT (including response prevention)
SSRIs/clomipramine
Treatment pathway of depression in young people
Watchful waiting for 2 weeks Then group therapy or digital CBT for 2-3 months If unresponsive then individual CBT Then fluoxetine Then sertraline or citalopram
ICD-10 personality disorder criteria
Characteristic and enduring patterns of inner experience and behaviour deviate markedly from cultural norm
Manifested in more than one of: cognition, affectivity, impulse control, interpersonal functioning
Pervasive behaviour
Personal distress and/or adverse impact on the social environment
Stable
Long duration
Onset in late childhood/adolescence
Cannot be explained as other mental health disorder
What personality disorders have little guidance on treatment?
Shizoid Paranoid Histrionic Dissocial Anankastic/obsessive-compulsive Avoidant
When to use low-dose antipsychotics in personality disorders
Reduce suspiciousness in cluster A (paranoid, schizoid and schizotypal)
Can help with paranoid or hallucinations in borderline
When to use antidepressants in personality disorders
Help with mood and emotional difficulties in cluster B (dissocial, emotionally unstable, histrionic)
SSRI can help impulsivity and aggression in borderline and dissocial
Can reduce anxiety in cluster C (anankastic, avoidant and dependent)
Pharmacological management of difficulties with impulse control in personality disorder
SSRI
Pharmacological management of affective dysregulation in personality disorder
SSRI or mirtazapine
Pharmacological management of cognitive-perceptual symptoms in personality disorder
Low dose antipsychotic
Should you use drugs in management of interpersonal difficulties in personality disorder?
No
Avoidant PD management
Social skills training
Some evidence for antidepressants
Emotionally unstable personality disorder management
Dialectical behavioural therapy (ideal)
Mentilisation based therapy
Systems training for emotional predictability and problem solving (STEPPS) - CBT based
Hazardous drinking assessed using audit tool management
Deliver brief intervention
Harmful drinking assessed using audit tool management
Deliver brief intervention
Deliver motivational enhancement therapy sessions
Consider prescribing options
Possible alcohol dependence assessed using audit tool management
Comprehensive assessment
The 6 elements of brief intervention (FRAMES)
Feedback Responsibility Advice Menu Empathy Self-efficacy
Psychosocial interventions for alcohol relapse prevention
CBT
Motivational enhancement therapy
12 step facilitation therapy (AA)
Family and couple therapy
Drug to prevent alcohol withdrawal
Chlordiazepoxide
What are the 3 licensed to prevent relapse after successful alcohol withdrawal?
Acamprosate (corrects neurotransmitter imbalance)
Naltrexone (blocks opioid receptors)
Disulfiram
Drugs prescribed in opioid detox
Methadone
Buprenorphine
Lofexidine
Benefits of buprenorphine over methadone
Less risk of overdose
Less sedative
More likely to block the effect of using on top
Longer effect (only needs to be taken every other day)
Quicker titration (2-3 days)
Easier to detox from
Less stigma
Drawbacks of buprenorphine over methadone
Not indicated for patients using high doses of opioids (as only partial agonist can cause withdrawal)
Can be misused (injected/snorted)
Risk of induced withdrawal
Less sedative
How do you decide between buprenorphine and methadone treatment?
Guided by preference of patient
Taking risk factors and previous treatments into account
Describe methadone induction and maintenance
Start with 10-30mg First week: increase by max 10mg/day or 30mg/week 5 days to steady state dose Usual effective dose 60-120mg No max dose
Describe buprenorphine induction and maintenance
Start with 4-8mg
Second day up to 16mg
Usual effective dose 12-16mg
Max dose is 32mg/day normally
What is the right maintenance dose for opioid replacement?
Dose at which patient stops using and stops experiencing cravings
Can be much higher than amount needed to suppress withdrawal
What should every patient on >100ml methadone receive?
An ECG to look at QTc
Pharmacological first line management for moderate and severe ADHD
Stimulants:
Methylphenidate
Dexamfetamine
Lisdexamfetmine
Pharmacological second line management for moderate and severe ADHD
SNRI:
Atomoxetine
Pharmacological third line management for moderate and severe ADHD
Alpha agonist:
Clonidine
Guanfacine
Pharmacological 4th line management for moderate and severe ADHD
Antidepressents (imipramine)
Antipsychotics (risperidone)
When would you use drugs in autism?
For co-morbidity
Risperidone if severe aggression and significant self-injury.
Management of mild cognitive impairment
Repeat cognitive testing yearly (annual conversion rate 10-15%)
May benefit from home based memory rehabilitation
When to use cholinesterase inhibitors in dementia
Alzheimers
Lew body/parkinson disease dementia (greater effect)
Pharmacological management of agitation in dementia
Antipsychotics Citalopram Memantine Analgesia Dextromethorphan (cough suppressant)
Trazodone for FTD
Pharmacological management of visual hallucinations in dementia
Cholinesterase inhibitors
