Psychiatry Flashcards
What are the 5 criteria needed for detention?
MS THC
Mental health disorder likely
Significantly impaired decision making ability
Treatment is available
Harm to themselves or others
Care on informal/voluntary basis not possible
Compare emergency detention, short-term and compulsory treatment orders based on…
Treatment
Personnel needed
Time limit
Right of appeal
EDO // STDO // CTO
No // Yes // Yes
>=FY2 +/- MHO // AMP + MHO // AMP + MHO
72hrs // 28 days // 6 months
No // Yes // Yes
Can you extend/renew detention orders?
STDO: EXTEND 3 days before OR 5 days after CTO submission
CTO: RENEW at 6 months then yearly
What treatments are not covered by detention orders?
Neurostimulation/surgery
Sex drive blunting
Artificial nutrition
SSRI vs SNRI
Venlafaxine
citalopram
sertraline
duloxetine
fluoxetine
SSRI: blocks reuptake of serotonin from synatpic cleft
Citalopram
Fluoxetine
Sertraline
SNRIs: Blocks reuptake of serotonin + noradrenaline
Venlafaxine
Duloxetine
Categorise the following TCAs into more or less sedative…
Clomipramine
Dosulepin
Lofepramine
trazadone
Amitriptyline
Notriptyline
Imipramine
NIL DCAT
Less: Nortripyline, imipramine, lofepramine
More: Dosulepin, Clomipramine, Amitriptyline, Trazadone
Hyponatraemia, GI upset and QT prolongation can occur with which group of drugs?
SSRIs (-pram prolongs QT)
What psych drug class causes dryness, blurred vision, drowsiness and prolonged QT?
TCAs
‘Dryly, drowsily, blurry + QT’
If someone on a warfarin/heparin asks for an SSRI, what can you give?
Mirtazepine
What is the problem with SSRIs and…
NSAIDs
MAOI, Triptans
NSAIDS: Increased bleeding risk
MAOI, Triptans: serotonin syndrome
What antidepressant drugs should be avoided in the following groups?
IHD
HTN
Enlarged prostate
IHD: SNRIs + TCAs
HTN: SNRI
Enlarged prostate: TCAs
What antenatal side effects can occur with SSRIs?
1er: congenital heart defects
3er: Persistent pulmonary HTN
Compare serotonin syndrome and neuroleptic malignant syndrome in terms of…
Causative drugs
Clinical features
Timescale
Treatment
Serotonin // NMS
Antidepressants, stimulants // antipsychotics
Both: Raised HP, BP, temp, rigidity + sweaty
Hyper-reflexia // hyporeflexia
Hours // days
IV fluids + benzos
Cyproheptadine and chlopromazine // dantrolene
What are the counselling points for SSRIs regarding
Starting
Reducing
Starting: Review in 1 week < 30yrs, 2 weeks otherwise
Step down after 6 months stability,
Reduce dose over 4 weeks
GI upset, irritability common side effects
The following drugs are members of which antipsychotic group? list the members of the other group
Haloperidol
Chlorpromazine
Typical
Atypicals (ORC cos they look atypical):
Olazapine
Risperidone
Clozapine
How do typical and atypical antipsychotics differ in terms of
Receptors
EPSES, hyperprolactinaemia
Typical // Atypical
D2 antagonism // D2-4, 5HT antagonism
More common // Less common
What side effects are more associated with atypical antipsychotics?
Agranulocytosis
Seizure threshold reduction
What is the name of the following extrapyramidal side effects?
Tremor, bradykinesia, rigidity
Sustained muscle contraction
Severe restlessness
Late jerking, writhing movements
Parkinsonism
Acute dystonia (give procyclidine)
Akathisia:(literally ‘can’t sit’)
Tardive dysKINESIA
Regarding lithium, what is the…
Therapeutic range
level checking time after titrating
Level checking time routinely
time to check renal and TFTs
~6.0-1.00 mmol
7 days, 12 hours post dose
3 months, 12 hours post dose
Every 6 months
How do you manage a lithium patient experiencing the following…
Increased tremor, reflexes, urination
+ confusion/seizure/coma
Reverse precipitants: Fluids, diuretics, ACE/ARBs, NSAIDs
+ haemodialysis if severe
How does lithium affect
Kidneys
Thyroid
White cells
ECG
toxicity
hyper or hypothyroidism
raised WCC
T wave flattening/inversion
What advice should be given regarding pregnancy and breastfeeding for lithium?
Pregnancy adjustments needs psych input
breastfeeding is contraindicated
What raises suspicion of a depression diagnosis
What further symptoms do you then ask about?
In past month for at least 2 weeks
Feeling down.depressed hopeless AND/OR little pleasure in doing things
+ RISK: want to hurt yourself or others
+ Biological: fatigue, sleep, appetite
+ Psychological: Guilt, worthless
2-4: mild
Functional impairment: Moderate, severe
What scoring systems aid depression diagnosis?
HAD >11
PHQ-9: 5-9 mild, 10-19 mod, >=20 severe
How is depression managed?
Initial
Mild: CBT +/- group support
mod/severe: SSRI + regular psychotherapy over 3-4 months
Try another SSRI or new gen before TCAs or MAOIs
ECT if acute-severe or resistant
What should you do before administering ECT
Reduce antidepressant dose
Rule out potential ICP
How do manic (I) and hypomanic (II) bipolar disorder compare in terms of
Duration
Psychosis
Function/risk
Mania // Hypomania
>=7 days // < 7 days
Yes // no
Significant impairment and risk // lesser risk or impairment
How do you manage bipolar disorder?
Lithium for mood stability
Antidepressant for low mood (fluoxetine)
If acute: Stop antidepressant, start antipsychotic
How does referral differ between hypomanic and manic bipolar?
hypo: routine
Manic: urgent
How do GAD panic disorder compare in terms of treatment
Both start with therapy and SSRI (sertraline for GAD)
Further
GAD: Another SSRI/SNRI –> pregabalin
PD: imipramine/clomipramine (TCAs) –> specialist
What is obsessive compulsive disorder and how is it managed?
Obsessions: unwanted, obstrusive thoughts
Compulsions: Repetitive behaviours that are either internal or external
Management
Mild: CBT + exposure based prevention
Mod: SSRI 12 months + intensive CBT
How do the following conditions differ in terms of symptom course
Alzheimer’s
Vascular
Lewy body
Frontotemporal
Normal pressure hydrocephalus
Alzheimer’s: Short term then executive memory
Vascular: Step wise +/- focal neuro symptoms
Lewy body: fluctuating cognition, visual hallucinations, parkinsonism
Frontotemporal: Disinhibition, memory + perception relatively preserved
Normal pressure hydrocephalus: dementia + parkinsons gait + incontinence
Which dementias are treated with AChEis
Alzheimer’s: donepezil/galmantine/rivastigmine
Lewy body: donepezil/rivastigmine –> galantamine
How do you treat vascular dementia
Alter cardiovascular risk factors
How do you treat acute stress disorder, how does it compare to PTSD?
Trauma focused CBT +/- benzos for acute symptoms
PTSD only 4 weeks after event
What are the following unexplained symptom disorders
Presence of multiple SYMPTOMS (patient reported) for last 2 years, refusal to accept reassuring negative test results
Loss of FUNCTION without feigning or malingering, Can sometimes appear indifferent to the loss
Persistent belief of underlying serious DISEASE
Fraudulent simulation or exaggeration of symptoms to attain financial or other gain
Symptoms that have been intentionally produced (eg taking medication induce symptoms of illness)
Somatisation (SYMPTOMS)
Conversion
Hypochondriasis/illness anxiety (CANCER)
Malingering
Munchausen’s
