Psychiatric Management Flashcards
Common receptor effects of adrenergic
Sweating Tremor Headaches Nausea Dizziness
Common muscarinic (acetylcholine) receptor effects
Dry mouth, difficulty swallowing, thirst
Difficulty urinating, urinary retention
Hot flushed skin, dry skin
Common histamine receptor effects
Dry mouth
Drowsiness
Dizziness
N+V
Features of antidepressants
Work on serotonin activity - increase activity at post synaptic receptors Most of their effect in 2-3 weeks Most commonly used = SSRIs - SNRIs - Mirtazapine - Tricyclics - MAOIs
Method of action of SSRIs
Selective Serotonin Reuptake Inhibitors
- increase serotonin activity by reducing the presynaptic reuptake of serotonin after release
- more serotonin sits in nerve junction
- leads to down regulation of post-synaptic receptors
Side effects of SSRIs
Sense of restlessness and agitation on induction - countered by use of benzodiazepines
Nausea and GI disturbance
Headache
Weight change
Sexual dysfunction
Uncommon
- bleeding - due to serotonin receptors on GI tract and platelets
- suicidal ideation particularly teenagers and early 20s - due to increased motivation before increased optimism
Examples of SSRIs
Sertraline - safest in cardiac disease
Citalopram/Escitalopram - careful of QTc prolongation
Fluoxetine - watch out for serotonin syndrome when switching
Paroxetine - watch out for discontinuation syndrome
Method of action of SNRIs
Serotonin and Noradrenaline Reuptake Inhibitors
- bind to noradrenaline and serotonin reuptake inhibitors
- leads to down regulation of post-synaptic receptors
Evidence base for use in neuropathic pain also
Side effects for SNRIs
Sedation
Nausea
Sexual dysfunction
Types of SNRIs
Duloxetine - low dose range
Venlafaxine - more efficacious and can go to a higher dose
- caution with higher doses in heart disease
Method of action of Mirtazapine
Acts as 5HT-2 and 5HT-3 serotonin receptor antagonist Strong H1 (histamine) activity -> sedation
Side effects of mirtazapine
Sedation
Weight gain
Features of tricyclic antidepressants
Reasonably effective - useful for those who do not responds to SSRIs Newer tricyclics (lofepramine and nortriptyline) tolerated better than older tricyclics (amitriptyline) Used at low doses for neuropathic pain
Side effects of tricyclic antidepressants
Muscarinic and histamine effects
Can be fatal in overdose - QTc prolongation and arrhythmias
Features of MAOIs
Monoamine Oxidase Inhibitors
- MAOI-A - work more on serotonin
- MAOI-B - work more on dopamine
Possibly more effective for atypical depression
Types of MAOIs
Irreversible = more dangerous - phenelzine - isocarboxazid Reversible = less dangerous - moclobamide - tranylcypromine
Considerations of MAOIs
Significant and dangerous interaction with other drugs
Potential for tyramine reaction leading to hypertensive crisis - avoid chees, pickled meats, wine
If changing to another antidepressant needs a washout period - up to 6 weeks
Features of vortioxetine
Serotonergic activity
Effective
Well tolerated - common side effect is nausea but less severe
Evidence for improvement in difficult to treat cognitive symptoms
Considerations when choosing an antidepressant
What has been used before
Was it effective/tolerated
Are there particular symptoms or co-morbidities to address
- weight loss and insomnia = mirtazapine
- neuropathic pain = SSRIs
In new cases start with an SSRI unless major weight loss and insomnia - consider mirtazapine
Considerations for increasing/switching antidepressant
Don't need to wait 4 weeks to have idea about effectiveness For depression - if no benefit then switch - if partial effect then increase dose For anxiety - consider increasing dose If struggling with side effects - may get better in couple of weeks - switch is cannot stand
Define discontinuation syndrome
Group of symptoms occur when antidepressant stopped
- antidepressants not addictive
Influenced by half life - shorter half life = bigger problem
Features of discontinuation syndrome
Sweating Shakes Agitation Insomnia Headaches Irritability Nausea Vomiting Paraesthesia Clonus
How to prevent discontinuation syndrome
Go slow
- can alternate days of taking or snap tablets in half
Sometimes worth switching to Fluoxetine and reducing
Paroxetine and venlafaxine trickiest
Define serotonin syndrome
Symptoms caused by excess serotonin
- risk when starting another antidepressant after fluoxetine
Features of serotonin syndrome
Cognitive
- headaches, agitation, hypomania, confusions, coma
Autonomic
- shivering, sweating, hyperthermia, tachycardia, nausea and diarrhoea
Somatic
- myoclonus, hyper-reflexia and tremor
Treatment of serotonin syndrome
Supportive
- fluids
- monitoring
Method of action of antipsychotics
Reduce level of dopamine activity as D2 receptors antagonists
- target pathways = mesocortical and mesolimbic
- unwanted pathways = nigrostriatal (movement) and tuberoinfundibular (hypothalamic-pituitary-adrenal axis)
Classes of antipsychotics
Typical
- older
- more likely to cause extra-pyramidal side effects
- bind to more muscarinic and histaminic receptors
Atypical
- more serotonergic activity
- more likely to cause diabetes and dyslipidaemia
Examples of antipsychotics
Typical - haloperidol - flupenthixol - zuclopenthixol - chlorpromazine - sulpride Atypical - clozapine - olanzapine - risperidone - quetiapine - amisulpride - aripirazole - partial D2 agonist
Side effects of antipsychotics
Sedation
Weight gain
QTc prolongation
Typical
- extra-pyramidal
- bradykinesia
- muscle stiffness and tremor
- tardive dyskinesia
- akathisia
- dizziness
- sexual dysfunction
Atypical
- weight gain
- dyslipidaemia and diabetesMonitoring required for antipsychotics
Baseline - FBC, lipids, LFTs, HbA1c, weight, ECG, BP and pulse Weekly - weight Others at 3 months then yearly
Features of clozapine
D2 antagonist and 5HT-2 antagonist
Most efficacious antipsychotic
Improvements can continue for several months
Used in schizophrenia after at least 2 other antipsychotics failed
Dose titrated slowly upward over 2 weeks and vital signs monitored due to potential for autonomic dyregulation
Side effects of clozapine
Agranulocytosis
- close monitoring of FBC - weekly for first 18 weeks then fortnightly then monthly
Gastrointestinal hypomobility
- constipation and potentially fatal bowel obstruction
Hypersalivation
Urinary incontinence
Treatment of clozapine induced agranulocytosis
Stop clozapine
Stop other marrow supressing drugs - sodium valproate
Avoid other antipsychotics for a couple of weeks where possible - if needed aripiprazole
Contact consultant haematologist
Avoid sources of infection - consider broad spec abx
Lithium - increased WCC and neutrophil count
Granulocyte colony-stimulating factor - injection
Define neuroleptic malignant syndrome
Rare, life-threatening reaction to antipsychotics
Features of neuroleptic malignant syndrome
Fever Confusion Muscle rigidity Sweating Autonomic instability Death due to - rhabdomyolysis - renal failure - seizures
Risk factor for neuroleptic malignant syndrome
High potency dopamine antagonists (typical antipsychotics)
Antipsychotic naïve patients
High doses
Young men
Treatment for neuroleptic malignant syndrome
Emergency referral to A&E
Stop antipsychotics
Fluid resuscitation
Reduced temperature
Treatment for extra pyramidal side effects of antipsychotics
Anticholinergics
- Ratio of dopamine: acetylcholine in nigrostriatal pathway more important than absolute quantities
- If too much acetylcholine in relation to dopamine - reduce acetylcholine activity
- not effective for tardive dyskinesia
Examples of anticholinergics
Procyclidine - potential for misuse
Benztropine
Trihexyphenidyl
Define acute dystonia
Sustained, often painful, muscular spasms producing twisted abnormal postures
Features of acute dystonia
Neck, tongue, jaw, oculogyric crisis (neck arched and eyes roles back)
50% cases in first 48 hours, 90% in first 5 days
Treatment of acute dystonia
Stop antipsychotic Administer IM or IV anticholinergics - procyclidine Continue for 1-2 days after dystonia Consider long-term prophylactic
Types of anxiolytics
Reduce anxiety
- beta-blockers
- benzodiazepines
- pregabalin
- antidepressants
Method of action of beta-blockers
Reduce autonomic nervous system activation
- bio-psycho feedback
Consideration for beta-blockers
Most commonly used = propranolol
Contraindicated in asthma
Limited effectiveness for enduring anxiety disorders
Method of action of benzodiazepines
Bind to GABA receptors to potentiate effect of GABA
- reduce excitability of neurones
- positive allosteric modulators of GABA receptors
Features of benzodiazepines
Most commonly used - diazepam - long half-life - lorazepam - short half-life Significant potential for - tolerance - dependence - misuse Use for no more than 6 weeks Occasionally cause paradoxical disinhibition
Method of action of pregabalin
Binds to voltage gated calcium channels in neurones
Increases extra-cellular amounts of enzyme responsible for synthesis of GABA
- increases GABA concentrations in brain
Reduces neuronal activity
Features of pregabalin
Used in anxiety, neuropathic pain and epilepsy
Less potential for misuse and dependence than benzodiazepines
BNF says short term use
Causes sedation and weight gain
Antidepressants for anxiety
Most commonly SSRIs
- similar doses
- doses for OCD higher
Types of hypnotics (sleeping tablets)
Benzodiazepines - temazepam - lormetazepam - nitrazepam Nonbenzodiazepines - act in similar way - positive allosteric modulators - zopiclone - zolpidem
Features of hypnotics
Significant potential for misuse, dependence and rebound insomnia
Use for only 2 weeks and take only 5 out of 7 days each week
Features of mood stabilisers
Used to treat bipolar mood disorder Groups - lithium - anticonvulsants - second generation (atypical) antipsychotics
Features of lithium
Most effective mood stabiliser
MOA unknown
Narrow therapeutic window - 3 monthly serum lithium levels
Excreted by kidneys
Reduces suicide - licence for reduction of self-harm
Side effects of lithium
GI disturbance Metallic taste Dry mouth Fine tremor Polydipsia Polyuria Weight gain Long term effects - hypothyroidism - reversible - renal impairment - irreversible - need annual U&Es and LFTs
Features of lithium toxicity
Confusion Coarse tremor N+V Ataxia Seizures
Treatment for lithium toxicity
Supportive - fluids
Dialysis if needed
Risk factors for lithium toxicity
Dehydration - advise to drink lots of water in hot climates Drug interactions - NSAIDs - Loop diuretics - ACE inhibitors
Use of atypical antipsychotics in bipolar
Quetiapine - 1st line for bipolar
Doses and monitoring same for psychosis
Use of anticonvulsants as mood stabilisers
Various modes of action - GABA receptors, calcium channels and sodium channels
Most common
- Sodium valproate - avoid in women in child bearing age due to teratogenicity, check LFTs before and soon after starting
- Carbamazepine
- Lamotrigine - potential for Stevens Johnson Syndrome
- Pregabalin
Side effects of anticonvulsants
Sedation
Weight gain
Thrombocytopenia - check FBC
Drugs used for cognitive symptoms in dementia
Do not prolong life or slow neurodegenerative changes
- improve cognitive and emotional/behavioural symptoms
Acetylcholinesterase inhibitors
Memantine
Method of action of cholinesterase inhibitors
Inhibit breakdown of acetylcholine
- increase levels of acetylcholine in brain
Alzheimer’s associated with lower levels of activity in cholinergic system
Uses of cholinesterase inhibitors in dementia
Used in Alzheimer’s for cognitive and neuropsychiatric symptoms
Indicated in mild to moderate dementia only
Side effects of cholinesterase inhibitors
Nausea Diarrhoea Vomiting Insomnia Muscle cramps Anorexia Muscle cramps Anorexia Bradaycardia
Monitoring for cholinesterase inhibitors
Pulse check at every appointment
ECG before starting
Examples of chonisterse inhibitors
Donepezil
Galantamine
Rivastigmine - given as patch - good for concordance and less GI side effect
Features of Memantine
Glutamine (NMDA) receptor antagonist -> lower neuronal excitability
Used in moderate to severe Alzheimer’s
- agitated/challenging behaviour
Generally well tolerated if initiated slowly
No specific monitoring needed
Side effects of memantine
Headache
Drowsiness
Insomnia
Nausea
Drugs used in ADD and ADHD
Most treatments are CNS stimulants
- potential for misuse and dependency
- monitor weight, height and pulse in children
- Methylphenidate
- most commonly prescribed
- given as combination of immediate and sustained release
- Dextroamphetamine
Atomoxetine
- noradrenaline re-uptake inhibitor
- used according to patient preference, unable to tolerate stimulants or previous drug dependence
Framework of psychological therapies
Type A - psychological treatment as integral part of mental health care
Type B - eclectic psychological therapy and counselling
Type C - formal psychotherapies
Types of formal psychotherapies available
CBT - cognitive-behaviour therapy
Psychoanalytic/psychodynamic therapies
Systemic and family therapy
Define transference
Unconscious transfer of feeling and attitudes from the past into the therapist
- being seen through eyes of the past
Uses of psychodynamic therapy
Recurrent and chronic inter-personal difficulties Contribute to management of - personality disorders - depression - eating disorders - anxiety
Uses of CBT
Depression Anxiety states - phobias, OCD, GAD, panic, PTSD Eating disorders Sexual dysfunction Insomnia
Features of CBT
Based on learning theory
Thoughts, feelings, actions and physical symptoms all connected - changing one can affect others
Unhelpful thinking leads to unhelpful behaviours
Five areas model of CBT
Life situation, relationships and practical problems Altered thinking Altered emotions Altered physical feelings/symptoms Altered behaviour or activity levels
Features of psychodynamic psychotherapy
Evolution of conscious understanding primarily by interpreting what the patient does and says during a session
Addresses issues of transference and psychological defence mechanisms
What is psychotherapy
Systematic use of a relationship between a patient and therapist to produce changes in feelings, cognition and behaviour
Uses of psychodynamic psychotherapy
Recurrent and chronic inter-personal difficulties
Psychological conflict or alienation
Contribute to management of
- personality disorders, depression, eating disorders
Use of interpersonal therapy
Depression
Features of interpersonal therapy
Uses link between onset of depressive symptoms and current interpersonal problems as a focus for treatment
Features of family/systemic therapeis
Target system that generates problematic behaviour
- suggestion, emphasising positive values
Uses of family therapies
Intervention for children
Eating disorders
Adjunctive treatment in schizophrenia
Aim of CBT
Help individuals to identify and challenge their automatic negative thoughts and then modify any abnormal underlying core beliefs
Define selective abstraction
Focusing on one minor aspect rather than the bigger picture
Define all or nothing
Thinking of things in all or nothing terms
Define magnification/minimization
Over or under estimating the importance of an event
Define catastrophic thinking
Anticipating the worst possible outcome of an event
Define overgeneralisation
Anticipating the worst possible outcome of an event
Define arbitrary interference
Coming to a conclusion in the absence of any evidence to support it
Features of relaxation training
Stress-related and anxiety disorders
Patient is asked to use muscle relaxation during times of stress or anxiety
Patient learns to put themselves in situations where they feel relaxed
Features of systemic desensitisation
Phobic anxiety disorders
Individual gradually exposed to hierarchy of anxiety-producing situations
Features of flooding
Patient rapidly being exposed to phobic object
Exposure and response prevention features
Anxiety disorders - OCD and phobias
Patient repeatedly exposed to the situation that causes them anxiety and prevented from performing their compulsive actions
Features of behavioural activation
Depressive illness
Patient avoid doing certain things as they feel they will not enjoy them or fear of failure
Involves making realistic and achievable plans to carry out activities and then gradually increased amount of activity
Indications of psychodynamic therapy
Dissociative disorders Somatoform disorders Psychosexual disorders Certain personality disorders Chronic dysthymia Recurrent depression
Rationale of psychodynamic therapy
Childhood experiences, past unresolved conflicts and relationships significantly influence individuals current situation
