Psychiatry Flashcards
Depression in the postnatal period can occur up to how long after birth
1 year
post natal depression will go away by itself
false and it is not entirely due to hormonal changes
when are antidepressants given for pregnant woman
as they are not licensed for breastfeeding women, If psychological treatment is unavailable or unacceptable or symptoms are severe then it is an option
what are the SSRIs of choice in women who are breast feeding
Sertraline and paroxetine
what are thepreferrd tricyclic antidepressants
Imipramine and nortriptyline
what tricyclic should be avoided in breastfeeding
Doxepin
peripartum depression onset is defined as
during pregnancy or within 4 weeks after delivery. however general agreement that onset can occur any time within the first year
in the first year after birth, around — of women experience depression and anxiety
15-20
the most common mental health problems in pregnancy
depression and anxiety
leading cause of maternal death post partum in the first year
suicide
examples of assessments for antenatal and post natal depression
Edinburgh Postnatal depression scale (EPDS) or the Patient Health Questionnaire (PH!-9)
if a moment has any past or present severe mental illness or a FH of severe perinatal mental illness in a first degreee relative be alert for what in the first 2 weeks after childbirth
postpartum psychosis
the universal criteria for depression are
ICD-10 and DSM 5
when does baby blues happen
presents around the second or 3rd post natal day and resolving by the 5th day.
if women on an antidepressant becomes pregnant what should you not do
stop it abruptly
if mild -moderate depression and on a TCA, SSRI or SNRI want to
discuss gradually stopping antidepressant
when do symptoms typically appear in ADHD
3-7 years old
symptoms of ADHD should be present for at least how long
6 months
symptoms of ADHD should be seen in at least 2
settings such as home,school, work
some of the diagnostic criteria for ADHD
start before 12y/o, occurs in two or more settings, been present for at least 6 months
environmental factors most strongly associated with ADHD are
low birth weight and maternal smoking during pregnancy
what type of ADHD accounts for most cases
the combined
when to suspect ADHD
at least 6 in kids or 5 in adults inattention symptoms and or at lest 6 in kids or 5 in adults hyperactivity-impulsivity symptoms
how should you measure effects of ADHD drug treatments
weight, height, blood pressure and heart rate,
how often should weight be measured in children under 10 with ADHD
every 3 months
how often should weight be measured in children and young people over 10 y/o
in over 10 year olds - 3 and 6 months after treatment and every 6 months thereafter
how often should weight be measured in adults with ADHD
every 6 months
how often should height be measured in children and young people on ADHD medication
every 6 months
how often should blood pressure and heart rate be measured in someone with adhd
before and after each dose change and routinely every 6 months
what advice should be given to adults with adhd on an amphetamine for example dexamfetamine or lisdexamfetamine
advice on driving - they should not drive if feel drowsy, dizzy, unable to concentrate
if weight loss becomes a problem with adhd medications then
take medication either with or after food rather than before meals
first line for adhd in preschool children
adhd focused group parent training programme
what med is usually offered first line for school age children and young people
methylphenidate, with lisdexafetamine, dexamfetamine and atomoxetine as possible alternatives
in young people/ school age children if methylphenidate is contraindicated or not effective what may be prescribed for children and adolescents 6-17 years old with ADHD who have insomnia, where sleep hygiene measures have been insufficient
Melatonin
what is usually offered first line in adults with ADHD
methylphenidate or lisdexafetamine
what adhd medication may affect their ability to drive
methylphenidate
most common side effects of methylphenidate
GI, cardio, CNS
what not to prescribe alongside a person taking atomoxetine
a monoamine oxidase inhibitors (MAOIs) - should have a 14 day gap before having the other one
atomoxetine is associated with
QT interval prolongation
titrate with caution if atomoxetine given with
terbinafine - as CP450 enzyme
effects associated with the amphetamines so deja and lisdex
decreased appetite and weight loss
do not prescribe an amphetamine with
Moclobemide or a MAOI ( due to risk or serotonin syndrome or symptoms similar to neuroleptic malignant syndrome)
avoid amfetamine with
atomoxetine( increases risk of psychosis and movement disorders), tricyclic antidepressants
conditions associated with autism
sensory problems, GI disturbances (inflammatroy bowel, coeliac, diarrhoea and constipation), and epilepsy
maternal use of sodium valproate increases risk of
autism in baby
what are amongst the diagnsotic characteristics of autism
stereotypic movement disorder
what scale can be used if you suspect autism in an adult
(AQ-10) Autism spectrum Quotient -10 items tool. if scores above 6 refer to autism team
an early sign of autism in children
language delay
retts syndrome similar to autism but
mainl affects girls and characterised by motor regression, ataxia, hand wringing (characteristic)
manic episode lasts at least
1 week accompanied by at elast 3 additional symptoms
hypomanic episode lasts
4 days
depressed episode in bipolar lasts
at least 2 weeks
what is rapid cycling bipolar defined as
least 4 depressive, manic, hypomanic, or mixed epsiodes within a 12 month period
difference between bipolar I and bipolar II
bipolar II has hypomania but no evidence of mania
what is known to be one of the most heritable psychiatric disorders
bipolar
3 environmental factors for bipolar
toxoplasma gondii exposure,
cannabis use/cocaine exposure, childhood trauam
psychiatric condition with the highest lifetime riskfor suicide
bipolar
the delusions in bipolar are ussually
grandiose
the hallucinations in bipolar are ususally
voices
what is not required for a diagnosis of bipolar
symptoms of depression
the diagnostic criteria for bipolar in children and young people
mania MUST be present
euphoria MUST be present on most days and for most of the time, for at least 7 days
what are not used to diagnose bipoalr
questionannaires in priamry care
what is cyclothymia
chronic disturbance of mood, consisting of periods of depression and hypomania, where the depressive symptoms do not meet the criteria for a. depressive epidsode
how do you treat mania in bipoalr
oral antipsychotic- haloperidol olanzapine, quetiapine or risperidone. second line is then to choose another one out of those 4. 3rd line is lithium or sodium valproate (but not if pre menopausal woman)
what happens to antidepressant medication during mania in bipolar
usually tapered and discontinued
treatment of depression in bipolar
Quetiapine alone
Olanzapine alone
Lamotrogine alone
Fluoxetine with olanzapine
what may be consdiered for bipolar if lithium is poorly tolerated
valproate alone or olanzapine alone
what blood tests should be done if person is taking long term lithium
thyroid function and calcium
if woman is on valproate for bipolar and becomes pregnant what should be done
dose of valproate should be reduced gradually over at least 4 weeks to minimise the risk of relapse
breastfeeding not advised in woman taking
lithium, carbamazepine, clozapine
what are the most commonly prescribed antipsychotics for bipolar
second geenration antipsychotics such as olanzapine quetiapine and risperidoen
antipsychotics can be prescribed on their own but also with
lithium or valproate
if discontinuing an antipsychtotic and moving on to another antipsychotic the original one the dose should be reduced gradually over how many weeks
at least 4
if discontuning an antipsychotic drug and not starting another one how long should it be gradually reduce over
3 months
monitroing if on antpsychotic
BMI weekly for first 6 weeks then at 3 months. Thereafter every 12 months.
serum electrolystes and urea including creatinine and estimated glomerular filtration rate every 12 monthsm
FBC every 12 months
Blood lipids0 3 months after starting treatment then every 12
plasma glucose of HBa1c at 3 months then every 12 ( hyperglycaemia- polydipsia etc)
Pulse and blood pressure during dose titration and at each dose change
ECG after dose changes
prolactin 6 months after then every 12 ( not required for aripiprazole, cloazapine, quetiapine or olanzapien)
liver function tests every 12 months
clozapine can cause what
neutropenia or agranulocytosis and frequent monitoring of FBC is required. constipation is a very common side effect of it
side effects of antipsychtoics
extrapyramidal symptoms
examples of extrapyrimadal effects
dystonic reactions ( abnormal movemetns of the face an body), Pseudoparkinsonism ( tremor, bradykinesia and rigidity)- these can be alleviated by antimuscarinic drugs such as PROCYCLIDINE
akathisia is
motor restlessness -reduce dose of antipsychotic
tardive dyskinesia can be
rhythmical, involuntary movements usually lip smakcing and tongue rotating although it can affect the limbs and trunk - if this happens should discontinue drug
what has been reported as an an adverse effec of aripiprazole
oculogyric crisis
weight gain is common with all antipsychtotics but more frequent in what generation
second -especially clozapine and olanzapine
effects of antipsychotics
dyslipdiaemia (raised lipids)
hyperprolactinaemia
sedation
anticholinergic effects
postural hypotension
hyperglycaemia
QT interval prolongation
avoid prescribing antipsychotics with other drugs knwon to prolong the QT interval such as
tricyclic antidepressants, erythromycin or antiarrhytmics
rare but fatal side effect of antipsychotics
Neuroleptic malignant syndrome
photosensitivity is common iwth what antipsychotic
chlorpromazine
what drugs increase the level of antipsychtoics
azole antifungals, SSRIs
what things reduce the levels of antipsthotics
carbamazepine
when should not drink grapefruti juice
if taking pimozide
if on lamotrogine and develop rash
drug should be stopped immediately
lithium is available as two salts which are
lithium carbonate and lithium citrate
lithium is contraindicated
cardiac disease associated with rhythm disorders
significant renal impairment
untreated hypothyroidism
brugada syndrome
low sodium levels
addisons
initial affects of lithium
nausea, diarrhoea, vertigo, muscle weakness and a dazed feeling but these often resovle with continued therapy. fine hand tremors, polyuria and polydipsia may persisit
long term effects of lithium
hypo or hyper thyroidism
NSAIDS ANd diuretics effects on lithium
increase lithium levels
how should you monitor someone taking lithium
one week after starting, one week after every dose change and weekly until the levels are stable. then every 3 months
if on lithium what should be measured every 6 months
BMI, u+Es, eGFR, calcium and thyroid function tests
lithium levels should be measured how many hours post dose
12
woman taking lithium should be on
reliable contraception
Diarrhoea dn vomitting are effects of
lithium toxicity
sodium valproate and valproic acid are — for the treatment of bipolar
unlicensed
not prescribe valproate in those wtih
liver dysfunction
effects of valproate
gastric irritation and hyperammonaemia both of which can lead to intense nausea
monitoring for valproate
LFTs, BMI, FBC
warfarin and aspirin can interact with valproate and
precipitate toxicity
drugs that inhibit cytochrome P450 enzymes eg erythromycin, fluoxetine and cimetidine can increase
valproate levels
assessment tool for delirium
Short confusion assessment method (short-CAM) or (DSM-5) Diagnostic and statistical manual of mental disorders
3 subtypes of delirium
Hyperactive, hypoactive and mixed
drugs known to precipitate delirium
opiods, benzodiazepines and anti cholinergics
these are - infection drugs, constipation , urinary retention, dehydration and electrolyte imbalance, pain, sensory impairment
precipitating factors for delirium
what drugs should be avoidied or used with caution in Parkinsons disease or demntia with lewy bodies
ANTIPSYCHOTICS
hypERthermia is a symptoms of
Neuroleptic malignant syndrom
3 drug options for delirium
Haloperidol, Lorazepam (only used for challenging behaviou associated with delirium), Levomepromazine ( usually 2/3rd line antiemetic becuase of its sedative effect)
most frequently reported side effect of benzodiazepines
daytime drowsiness, dizziness, muscle weakness, ataxia
alcohol should not be taken with lorazepam due to
enhanced sedative effects
levomepromazine is what generation
first - acts predominatly by blocking dopamine type 2 receptorrs - it is usually given subcutaenously
what is a rf for dementia
parkinsons
2nd most common dementia
vascular then lewy bdoy then frontotemporal
early onset dementia is defined if before what age
65
what are these the pathological features of: atrophy of the cerebral cortex, formation of amyloid plaques and neurofibrillary tangles
alzheimers
patietns with vascular dementia can also present with – at the time of initial assessment
transient neurological symptoms, history of gait abnormalities and incontinence at the time of initial assessment
what are common in vascular dementia
depression and delusion
dementia with lewy body is similar to alzheimers but with
marked spntaneous fluctuations in cognitive abilities, visual hallucinations and parkinsonism
what are lewy bdoies
abnormal deposits of protein inside nerve cells
differencce between lewy body dementia and parkinsons disease dementia
lewy body - cognitive symptoms start before motor symptoms by at least a year
parkisnons disease dementia- motor symptoms develop within 1 year of cognitive symptoms
frontotemporal dementia is a common cause of dementia in who
younger people
what kind of memory is - memeory loss for recent events, repeated questioning and difficulty learning new information
episodic memory
what dementia increases in a stepwise approach
vascular
drugs that can worsen dementia
anticholinergics - benzodiazepines, anticholinergics, opiods
medication for mild to moderate alzheimers
acetylcholinesterase inhibitors eg donzepil, galantamine, rivastigmine
second line for alzheimers if not tolerate AChE inhibitors
memantine
first line for lewy body dementia
donepezil or rivastigmine
patients with frontotemporal dementia should NOT be offered
AChE inhibitors or memantine
acetylcholinesterase inhinitors and antimuscarinics (tricyclic antidepressants) can cause what side effect
constipation, dry mouth ,urine retention
depression definitions
at least 5 out of 8 symptoms during the same 2 week period where at least one of the symptoms is depressed mood or loss of interest or pleasure
chronic depression defined as having an episode for at least
2 years
what gender is a rf for depression
female
what do PHQ-9 and HADS stand for
Patient Health Questionnaire 9 and Hospital Anxiety and depression scale
what drugs should you avoid in depression due to their risk of death in overdose
Tricylics (except for lofepramine) and venlafaxine
symptoms of what may strat when taking an antidepressant
anxiety ,agitation, hoplessness or suicidal ideas
antidepressatns usually start to work within how many weeks
4 weeks
antidepressants may be needed for how long after symptoms stop to reduce the risk of relapse
6 months
usually after starting an antidepressant you review in 2 weeks when do you review after 1
if 18-25 or particular risk of suicide
if already on NSAID, warfarin or aspirin a good antidepressant is
Mirtazapine
how should antidepressants be prescribed
prescribe the starting dose of an antidepressant and titrate up to the recognzed minimum effective dose
what antidepressants have the highest risk in overdose
tricyclic antidepressants and MAOis
what tricyclic has partiuclar risk in overdose
dosulepin whereas lofepramine has relatively low toxicity
when to not prescribe SSRI
manic phase of bipolar
when to not prescribe SNRI
uncontrolled hypertension
very common side effect od SSRIs
insomnia
scales can use for postnatal depression
EDPS or PHQ-9
if depressed woman becomes pregnant what not to si
stop antidepressants abruptly
what is the most common mental health disorder in children and young people
depression
how often should young person be seen after commencement of fluoxetine for depression
weekly contact for the first 4 weeks
treatment for fluxoetine in children should be continued for how long after remission
at least 6 months
when should fluxoetine not be given to children with depression
if got poorly controlled epilepsy
domestic abuse defined if both people are over what age
16
what kind of eating disorders are the most commmon
atypical- closely resemble then main ones but do not meet diagnostic criteria
bulimia nervosa defined as
at least once per week for 3 months!!! flashcard is wrong
satiety related hormones
adiponectin and ghrelin
low weight in anorexia is typically below
18.5
SCOFF questionnaire can be used for
anorexia or bulimia
raised ESR can indicate what in someone with weight loss
an orgnaic cause as it is usuall normal in anorexia
what is suggestive of vimiting or laxative absue
hypokalaemia
generalised anxiety needs to be present for how long
6 months
what assessmnet tools can be used for GAD
GAd 2 and GAD 7
first line for GAD
SSRI
second line for GAD
SNRI
3rd line for GAD
pregablin
The SSRIs most commonly prescribed in the Uk for GAD are
sertaline, paroxetine and escitalopram (last 2 are licensed)
SNRIs that can be given for GAD are
duloxetine and venlafaxine
most common adverse effect of diazepam relate to
its sedative effect
options for drugs for OCD
SSRI or clomipramine
5 SSRIs licensed for OCD
escitalopram
fluoxetine
fluvoxamine
paroxetine
sertraline
person under 18 with OCD should only be prscribed an SSRI following
assessment and diagnosis by a psychiatrist
what can you not give to those under 18 with OCD
clomipramine
example of an opiod
heroin
symptoms of opiod intoxication
constriction of pupils, itching and stractching, low blood pressure and pulse
acute opiod withdrawl symptoms
watering eyes, rhinorrhoea, dilated pupils
want to vaccinate all drug users against what
hep A and B
what is a drug that is licensed for the symptoms of opiod withdrawl
lofexidine
what out of methadone and buprenorphine is only a partial agonist
buprenorphine
common side effect of buprenorphine is
anxiety
what are not recommened in opiod dependance
methadone tablets
what is the form that methadone is recommended
ORAL SOLUTION
what is the most characterstic symptom of PTSD
re-experiencign symptoms - flashbacks or nightmares
adverse effects with a SSRI or SNRI early in treatment may be
increased anxiety, agitation and sleeping problems
drugs that can give for pTSD
venlaxafine or SSRI
what SSRIs are licensed for PTSD
paroxetine and sertaline
contraindication of SNRI if
uncontrolled hypertesnion, with MAOI
one unit of alchol is defined as
10ml of pure ethanol
one unit of alcohol is roughly equal to half a pint of beer, small measure of spirit, standard measure of wine
what bloods are abnormal in alcholol problem
gamma glutamyl transferase(GGT) and Mean corpuscular volume (MCV)
signs of an alcohol problem
dilated ffacial capillaries, bloodshot eyes, hand tremor
signs of wernickes encephalopathy
ataxia, opthalmoplegia, nystagmus, acute confusion
treatement of wernickes encephalopathy
parenteral thiamine
acamprosate is a drug that can be given for what
alcohol problems
examples of positive symptoms
thought disturbance, delusions, hallucinations
a medical condition that can cause schozophrenia
sepsis
what can cause schizhophrenia
certain medicines, susbstance misuse and some medical conditions
what can precede the development of a psychotic disorder
emotional diturbance
when should an antipsychotic not be given unless under advice from a consultant psychiatrist
not be given to the person while awaiting specialist assessment
what is a delusion of reference
the belief that ordinary evetns, objects or the behaviour of others has a meaning specifically for the person for example that people on the radio are talking to or about them eg refering to them
what is delusion of persecution
belief that other people are plotting against the person
schizhoprehnia symptoms need to be present most fo the time for how long
1 month
prescribed drugs that can cause psychosis
anticonvulsants, high dose corticosteriods, levodopa, dopamine agonists or opiods
what symptoms should you be asking in a psychosis review particularly if they are taking a first generation antipsychotic or risperidone
riased prolactin so low libido, sexual dysfunction, menstrual abnormalities , galactorrhoea
people taking what antipsychotic are managed exclusively in secondary care
clozapine
clozapine can cause
neutropenia or agranulocytosis
what monitoring is needed for those on clozapine
FBC weekly for 18 weeks after treatment then every 2 weeks for the next 18 weeks and then every 4 weeks after
antipsychtocics increase the QT interval what other drugs also do and so makes it even more of something to watch
erythromycin, co-trimoxazole, pregablin
these blood tests are performed at what:
fasting glucose HbA1c, lipid profile, U&Es, FBC, LFTs, Prolactin
psychosis review
breastfeeding is fine on an antipsychotic except for
clozapine
difference in action of first and second gen antipsychotics
first - primarily exert effecting by blocking dopamine 2 receptors in the brain
2nd gen - act on range of recepetors
what gen antipschotics are associated with lower extra pyramidal symptoms
second gen - atypical
even though second gen antipsychotics are associated less so with extra pyramidal symptoms what other important adverse affects are they associated with
weight gain, glucose intolerance and hyperprolactinaemia
these are: Benperidol
Chlorpromazine
Flupentixol
Haloperidol
Levomepromazine
Pericyazine
Perphenazine
Pimozide
Prochlorperazine
Promazine
Sulpiride
Trifluoperazine
Zuclopenthixol
typical
the atypical antipsychotics are
Amisulpride
Aripiprazole
Clozapine
Olanzapine
Paliperidone
Quetiapine
Risperidone
examples of extrapyramidal symptoms caused by antipsychotics
Dystonic reactions (abnormal movements of the face and body), and pseudoparkinsonism (tremor, bradykinesia, and rigidity) — these can be alleviated by antimuscarinic drugs, such as procyclidine (should not be prescribed routinely).
Akathisia (motor restlessness) — can often be relieved by reducing the dose of the antipsychotic.
Tardive dyskinesia — late-onset movement disorder that can occur with prolonged use of antipsychotics. It is characterized by rhythmical, involuntary movements, usually lip-smacking and tongue rotating, although it can affect the limbs and trunk. It may be persistent and can sometimes worsen on treatment withdrawal. The drug should be discontinued on appearance of early signs.
weight gain is common with all antipsychtoics but more frequent in
second gen especailly clozapine and olanzapien
photosensitivity is common with what antipsychotic
chlorpromazine
what antipsychotics are associated with increased risk in eldelry with demntia
olanzapine and risperidone
sedation and dyslipidaemia are side effects of that
antipsychotics
antipsychotics have an an hypotensive effect so what drugs increase thsi
antihypertensives
do not drink grapefruit jucie with what antipsychotic
pimozide
what reduces plasma levels of clozapine, haloperidol and risperidone by half
carbamazepine
some ssris can
increase levels of some antipsychoticsx
how long should a psychotic disorder patient be responsibility of the secondary care team
for first 12 months or unitil their condition is stabilized (whichever is longer)
how often should BMI be measured after antipsychoticc
weekly for first 6 weeks then at 3 motnhs then every 12 motnths
what are gamma-aminobutyric acid (GABA) receptor agonists which have hypnotic, anxiolytic, anticonvulsant, and muscle relaxant properties
benzodiazepines
what are z drugs
non-benzodiazepine hypnotics, developed with the intention of overcoming some of the adverse effects of benzodiazepines
the 2 Z drugs available in the UK
zolpidem and zopiclone
anxiolytics means
alleviating anxiety states
2 approaches for stop benzopdiazepines or z drugs
The two potential approaches for withdrawal are slow dose reduction of the person’s current benzodiazepine or z-drug, or switching to an approximately equivalent dose of diazepam, which is then tapered down.
why is switching to diazepam an option for stopping benzodiazeipines
i think it migght be easier to allow for small reduction in dose - not 100% sure though
do not prescribe diazepam if got
acute porphyria is one example
