Psychiatric emergencies

Question 1

what is the incidence of clozapine-induced agranulocytosis? When is risk highest?

Answer 1

1-2%

Risk highest 6-18 weeks after start of Tx.

Question 2

how would you manage a pt with clozapine-induced agranulocytosis?

Answer 2

1. stop clozapine and any other potentially marrow-suppressing drugs (e.g. sodium valproate). Avoid other antipsychotics for a couple of weeks where possible (if needed, aripiprazole has lleast potential for BM suppression).
2. urgently contact consultant haematologist.
3. avoid sources of infection.
4. consider lithium (stimulates granulopoiesis), G-CDF or GM-CSF.

Question 3

how would a pt with neuroleptic malignant syndrome present?

Answer 3

Onset usually within 2 weeks of 1st dose.

• fever
• muscle rigidity
• autonomic instability: tachycardia, labile BP, diaphoresis
• confusion

Question 4

which investigations suggest a Dx of NMS?

Answer 4

Bloods

• raised CK
• leucocytosis
• raised transaminases
• +/- electrolyte abnormalities

Urine dip
- myoglobinuria

Question 5

how would you manage a pt with NMS?

Answer 5

1. stop antipsychotic
2. fluid resuscitation (prevent renal failure) +/- sodium bicarbonate if rhabdomyolysis (alkalise urine)
3. give dantrolene: RyR antagonist that prevents release of calcium from sarcoplasmic reticulum of striated muscle - reduced muscle rigidity and hyperthermia).
4. if acute psychomotor agitation, give benzodiaepines (also works as muscle relaxant)

Question 6

Suggest risk factors for suicide.

Answer 6

1. male
2. Hx of deliberate self-harm
3. alcohol or drug misuse
4. Hx of mental illness e.g. depression, schizophrenia (10% of people with schizophrenia complete suicide)
5. Hx of chronic disease
6. advancing age
7. unemployment or social isolation/living alone
8. being unmarried, divorced or widowed