Psychiatric Symptom Management In Hospital Flashcards

1
Q

Key rules of prescribing for depression

A

Unless patient preference, avoid routinely offering antidepressant as 1st line for less severe depression

1st line for new episode severe depression - SSRI/SNRI

Avoid SSRIs if taking NSAIDS - increased risk of GI bleeds
-if no suitable alternative, add PPI

Avoid SSRI if taking 5HT3 rec agonist - increased risk of seretonin syndrome

Avoid SSRI if taking warfarin/heparin - increased bleed risk
-offer mirtazapine, (INR will increase if coprescribed with AC), however associated with weight gain, sleepiness

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2
Q

Key rules of prescribing for insomnia

A

Short term hypnotics can help but use sleep hygiene techniques for long lasting benefits

If accompanied by depressive symptoms - can offer mirtazapine/agomelatine

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3
Q

Key rules of prescribing for anxiety

A

BZ only used in crisis

If psychological interventions not working/an option, can use SSRI
SSRI can be used alongside psychological therapy

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4
Q

Key rules of prescribing in acute behavioural disturbance

A

PO/IM BZ are the safest - lowest risk of AE

If psychotic - PO/IM antipsychotic to get therapeutic plasma conc as quickly as possible
- contact psych team if possible to optimise treatment

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5
Q

Treatment of more severe depression
-1st line
-if no/minimal response after 3-4 weeks on therapeutic dose and adherence confirmed
-if improvement after 4wks at higher dose
-continuation

A

1st line - CBT + antidepressant
-generally SSRI/SNRI unless increased bleeding risk or seretonin syndrome
-however SSRI/venlafaxine linked to sexual dysfunction

If no/minimal response after 3-4wks on therapeutic dose and adherence confirmed
-increase dose/change antidepressant

If some improvement after 4wks at higher dose
-continue for additional 2-4wks, consider switching if
-response still inadequate/SEs/patient wishes

Switches
-initially from same class, then can change

If inadequate response with 2 med changes, other options
-augument with lithium
-augument with quetiapine
-2 antidepressants

Continue for 6months minimum after remission
If recurrent depressive episode/significant risk factors for relapse => continue for 2 years

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6
Q

SSRI drug interactions and discontinuation symptoms

A

Sertraline - lowest risk of significant drug reactions

SSRIs + warfarin/heparin = increased bleeding risk

Discontinuation symptoms reported for all except agomelatine
-low incidence with fluoxetine
-highest incidence with paroxetine

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7
Q

SSRI CI

A

Citalopram in
-known/congenital QT prolongation syndrome
-with other medicines known to prolong QT interval

Be careful in people at risk of TDP, CCF, recent MI bradycardia, lowK

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8
Q

Discontinuation symptoms in SSRIs

A

Within 72hrs of sudden discontinuation/dose reduction
-not reported when antidepressants have been taken for U5-6pms

Transient for 1-2wks, self limiting

Risk reduced by withdrawing antidepressant slowly and gradually, minimum 1month

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9
Q

Key things to inform the patient about with antidepressants

A

They work :)
Not tranquillisers
No risk of addiction, tolerance, dependence
Must be taken everyday and for 6 months once symptoms resolved

Main AEs
Importance of regular monitoring
-if U25 - review after 1wk (increased risk of SH and suicide)
-monitored for as long as they are at risk
Abrupt withdrawal can cause discontinuation symptoms
Poor adherence => poor outcome

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10
Q

Differentials for anxiety symptoms
-medical
-medication

A

Medical
-alcohol/drug withdrawal
-depression
-hypoglycaemia
-hyperthyroidism
-schizophrenia

-Aant (doxazosin)
-Bag (salbutamol)
-CS
-alcohol
-caffeine
-nicotine

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11
Q

Prescribing and management in anxiety

A

Psychological treatment has longer lasting benefits
Starts low but highest dose higher than SSRIs, used for longer

If psychological treatment alone not enough
1st line - sertraline
2nd line - other SSRI (escitalopram or venlafaxine)
Escitalopram dose may need to be lowered if taken with PPI (due to increase in plasma level)
Venlafaxine more effective at lower doses
Duloxetine dose may need to be higher if a smoker
3rd line - pregabalin
Crisis - short term BZ
Bb can be prescribed to manage physical symptoms

Review within 1wk if U30
-Then weekly for the 1st month

Monitoring for AEs and therapeutic effect - every 2-4wks for the 1st months and 3monthly after

Continue for at least 1 year after effective

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12
Q

Prescribing and managing panic disorder

A

Refer to primary care for further assessment and treatment
-help him understand what happened

Don’t give BZ

Psychological therapy is the most effective

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13
Q

Recognition and treatment of insomnia

A

If insomnia related to depression => address depression first
If no change => sedative antidepressant at night (mirtazapine, trazodone)

Hypnotics are last resort when sleep hygiene has failed
-long term use of Z-hypnotics linked to dependence
-only take in short term when absolutely needed
-higher doses only increase AE

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14
Q

Rapid tranquilisation
-when to use it
-current guidance

A

Immediate reduction in agitation, irritability, hostility
Rapid reduction of risk of harm to all

Last resort when risk is high and when other interventions have failed

Offer PO before considering parenternal route
Lowest effective dose
1st line - BZ
-Rare SE of disinhibition
Only use antipsychotics if clearly psychotic or has a psychiatric diagnosis
-do not give IM BZ within 1hr of olanzapine
Once used, monitor temperature, HR, BP, RR

PO and IM are not bio equivalent - prescribe separately
IM doses may be lower than PO doses
Don’t use 2 meds from the same class
Don’t mix 2 meds in the same syringe
If haloperidol used, recent ECG must be available before use

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15
Q

Section 62 MHA

A

Can give immediately necessary treatment which is not
-irreversible or hazardous

Relates to ECT and medication

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16
Q

Clozapine
-what must be monitored
-how often
-SE
-therapeutic drug monitoring scenarios

A

WCC, absolute neutrophil count, platelets

Baseline
Weekly for 1st 18wks
Every 2nd week for rest of the year
Monthly afterwards

Weight gain - aripiprazole can be coadministered to augument and reduce weight gain
Dislipidemia - statins
glucose intolerance
Sedation - prescribe smaller dose in morning, larger at night
Seizures - prescribe valproate unless of childbearing age, avoid carbemazepine as it reduces plasma conc and can cause agranulocytosis
Hypersalivation - can use special absorbent pillows or Procyclidine unless it causes constipation
Constipation - bulk/stimulant laxatives

Smoking cessation, or use of e-cigarette
Using meds that interact with clozapine, affecting blood clozapine conc
Serious infection
Poor clozapine metabolism suspected from lack of therapeutic effectiveness
Toxicity

Smoking reduces plasma level
Caffeine increases plasma level

Chemotherapy causes bone marrow suppression - decision to continue or stop clozapine is patient specific
Avoid omeprazole and macrolides - can reduce plasma conc
BZ - risk of resp collapse
Fluoxetine - raises plasma conc