Psychiatry Flashcards
Mental state examination: What is involved in the mental state examination?
ASEPTIC mnemonic
A mental state examination is used to assess patients presenting with mental health symptoms and disorders. It is equivalent to performing an abdominal examination for a patient with abdominal pain. It offers a structure for assessing and documenting the essential features of a mental health presentation.
The examination involves observing, assessing and commenting on:
Appearance and behaviour
Speech
Mood and affect
Thought
Perception
Cognition
Insight
Judgement
A risk assessment typically follows a mental state examination, giving an estimate of the risk of self-harm, suicide and harm to others.
The features listed below describe typical exam findings in patients with depression, mania and schizophrenia. In reality, patients vary tremendously. For example, depressed patients may appear and sound normal despite having a very low mood and suicidal intentions.
JUST FOR READING
Mental state examination - components of appearence and behavoir
Depressed patients may show signs of poor self-care, with poor hygiene and old clothes. There may be self-harm scars. They may have weight loss or weight gain. They may have slow movements and speech (psychomotor retardation), reduced eye contact, downward gaze and a stooped posture. Alternatively, they may be fidgety and restless (psychomotor agitation). They may be tearful during the consultation
Manic patients may be dressed in bright colours, extravagant outfits, or inappropriate outfits. Alternatively, they may be dressed chaotically and appear disheveled. Their behaviour is hyperactive, energetic, talkative, and overly familiar. They may display disinhibition and sexually inappropriate behaviour. Eye contact may be intense. They may have psychomotor agitation and appear fidgety and restless.
Patients with schizophrenia may be unkempt, dressed inappropriately for the environment or show signs of self-neglect. They may behave agitated, suspicious or aggressive. Alternatively, they may be withdrawn, quiet and blank. Catatonia may be present, with the patient holding unusual postures, performing odd actions, repeating sounds or words, or remaining blank and unresponsive.
Extrapyramidal side-effects from antipsychotic drugs may be observed, including:
Akathisia (psychomotor restlessness, with an inability to stay still)
Dystonia (abnormal muscle tone, leading to abnormal postures)
Pseudo-parkinsonism (tremor and rigidity, similar to Parkinson’s disease)
Tardive dyskinesia (abnormal movements, particularly affecting the face)
JUST FOR READING
Mental state examination - components of Speech
Depressed patients may have slow, quiet, soft and monotone speech. They may have “poverty of speech” (alogia).
Manic patients have characteristically pressured speech, which is fast, unrelenting, and impossible to interrupt. It is typically loud and confident.
Patients with schizophrenia may have poverty of speech (alogia) or poverty of content (speech without meaning). Due to thought disorder, their speech may be incoherent and impossible to understand. They may use invented words (neologisms). Thought blocking can cause sudden interruptions to the flow of thoughts and speech. Word salad refers to when speech contains a completely random jumble of words and phrases with no meaning.
MSE - Mood and affect info for reading
What is blunted affect vs incongruent affect?
what is euthymia?
Euthymia refers to a normal and neutral mood, not low or elevated.
Depressed patients have a low mood. They may describe their mood using many terms, such as sad, depressed, numb, flat, hopeless, empty, miserable or terrible. Blunted affect refers to a reduced emotional range (the ability to experience positive and negative emotions).
Manic patients have an elevated mood. This may be described as euphoric, elated or excited. They can also be irritable and have a labile mood (their mood quickly flips from elevated to angry or depressed).
Patients with schizophrenia may display affective flattening (reduced emotional reactions), anhedonia (lack of interest in activities) and avolition (lack of motivation). Their mood may seem odd or incongruent (e.g., appearing happy when describing upsetting events).
MSE - thoughts
Define:
- flight of ideas
- grandiose delusions
- delusions
- thought disorder
-somatic passivity
- thought insertion or withdrawal
- through broadcasting
- persecutoru delusion
- ideas of reference
- loosening of associations
- knights move thinking
- tangentiality
Depressed patients have negative thoughts, such as thoughts of guilt, hopelessness, worthlessness, self-harm and suicide, which they may ruminate on. They may have poverty of ideas, with reduced production of thoughts.
Manic patients often have thoughts of increased self-worth, self-confidence, optimism and grandiose plans. The typical feature is flight of ideas, which refers to rapidly flowing thoughts that jump quickly from one idea to another. There is generally some understandable connection to the flow of ideas. Grandiose delusions (e.g., that they have special powers or special importance) may be present.
Patients with schizophrenia may have delusions (beliefs that are strongly held and clearly untrue) and thought disorder (disorganised thoughts causing abnormal speech and behaviour). This makes the things they say difficult or impossible to follow and understand. Specific examples include:
Somatic passivity (believing that an external entity is controlling their sensations and actions)
Thought insertion or thought withdrawal (believing that an external entity is inserting or removing their thoughts)
Thought broadcasting (believing that others are overhearing their thoughts)
Persecutory delusions (a false belief that a person or group is going to harm them)
Ideas of reference (a false belief that unconnected events or details in the world directly relate to them)
Preoccupations (being focused and absorbed with one thought without being able to move to the next)
Loosening of associations (no logical association linking one thought to the next)
Knight’s move thinking (jumping from one thought to another without a logical association or flow)
Tangentiality (goes off on a tangent from the original topic without returning to that topic)
Just for reading - MSE Cognition
Memory, concentration, orientation to person, place and time, cognitive impairment
MSE perception:
Define haluccinations?
Define delusional perception?
Hallucinations (hearing or seeing things (perception) without an external stimulus) may be found in:
Psychotic depression
Mania with psychosis
Schizophrenia (particularly a voice narrating the person’s actions)
Usually third peron auditory hallucinations are seen in psychosis.
A delusional perception (seen in schizophrenia and psychosis) occurs when the patient experiences an ordinary and unremarkable perception (e.g., a cat crossing the road) that triggers a sudden, often self-related delusion (e.g., “and I knew I would be meeting the aliens on behalf of humanity”).
MHA - What is:
- section 2
- section 3
- section 4
- section 5 (2)
- section 5 (4)
- section 136
Section 2
Section 2 involves compulsory admission for assessment following a Mental Health Act assessment, with a maximum period of 28 days.
It cannot be renewed. It ends in either discharge or further detention under Section 3.
Section 3
Section 3 involves compulsory admission for treatment. The maximum period is six months, after which the Responsible Clinician can arrange to renew it for further treatment.
Detention under Section 3 requires a Mental Health Act assessment. Patients that are well-known to mental health services may be detained under Section 3 straight from the community. Alternatively, patients may be detained under Section 3 following assessment under Section 2.
Section 4
Section 4 is used to detain patients for up to 72 hours in urgent scenarios where other procedures cannot be arranged in time. It requires an AMHP and one doctor. It is followed by a Mental Health Act assessment.
Section 5(2)
Section 5(2) is used in an emergency to detain patients who are already in hospital voluntarily. It lasts up to 72 hours and requires only one doctor. It is followed by a Mental Health Act assessment.
Section 5(4)
Section 5(4) is used in an emergency to detain patients who are already in hospital voluntarily. It lasts up to 6 hours and requires only one nurse. It is followed by a Mental Health Act assessment.
Section 136
Section 136 is used by the police to remove someone that appears to have a mental health disorder from a public place and take them to a place of safety where they can be assessed. It lasts up to 24 hours. It is followed by a Mental Health Act assessment.
Mental health hospitals often have 136 suites that act as a place of safety and are used for assessment.
What is a mental helath act assessement?
Who is needed for a mental health act assessement?
A Mental Health Act assessment involves a detailed evaluation to determine whether to detain someone under the Mental Health Act.
The Approved Mental Health Professional (AMHP) is the primary person making the application and organising the admission. The Nearest Relative can also make the application.
The decision needs to be recommended by two registered medical practitioners (doctors):
A Section 12 doctor
Another doctor (e.g., their GP)
A Mental Health Act assessment can result in compulsory admission under Section 2 or Section 3.
Define depression?
Causes of depression?
Depression is a disorder that causes persistent feelings of low mood, low energy and reduced enjoyment of activities. It affects people of all ages and from all backgrounds.
Depression may be triggered by life events (e.g., the loss of a loved one). However, it can occur without any apparent triggers. It is thought to be caused by genetic, psychological, biological and environmental factors. Having an affected relative is a significant risk factor.
Physical health conditions can trigger or exacerbate depression, and it commonly occurs with conditions such as stroke, myocardial infarction, multiple sclerosis and Parkinson’s disease.
Presentation of Depression?
Environmental and Essential factors to explore when taking a history
The core symptoms of depression are:
Low mood
Anhedonia (a lack of pleasure or interest in activities)
Emotional symptoms include:
Anxiety
Irritability
Low self-esteem
Guilt
Hopelessness about the future
Cognitive symptoms include:
Poor concentration
Slow thoughts
Poor memory
Physical symptoms include:
Low energy (tired all the time)
Abnormal sleep (particularly early morning waking)
Poor appetite or overeating
Slow movements
Environmental factors may contribute to the condition, such as:
Potential triggers (e.g. stress, grief or relationship breakdown)
Home environment (e.g., housing situation, who they live with and their neighbourhood)
Relationships with family, friends, partners, colleagues and others
Work (e.g., work-related stress or unemployment)
Financial difficulties (e.g., poverty and debt)
Safeguarding issues (e.g., abuse)
Essential factors to explore when taking a history include:
Caring responsibilities (e.g., children or vulnerable adults)
Social support
Drug use
Alcohol use
Forensic history (e.g., violence or abuse)
Every encounter should include a risk assessment for:
Self-neglect
Self-harm
Harm to others (including neglect)
Suicide
What should be considered in a psychiatric risk assessment?
Every encounter should include a risk assessment for:
Self-neglect
Self-harm
Harm to others (including neglect)
Suicide
What is the purpose of the Mental Health Act
The Mental Health Act (1983) (updated in 2007) provides a legal framework for keeping patients in hospital against their wish for assessment and treatment of a mental health disorder. This is called being detained or sectioned under the Mental Health Act.
When a patient with capacity agrees to be admitted to hospital voluntarily, this is called a voluntary or informal admission. An informal admission does not involve detention under the Mental Health Act. Section 131 of the MHA explains that patients can be admitted without involving the MHA.
Pathophysiology of depression
The monoamine hypothesis:
The pathophysiology is not fully understood and likely involves a combination of complex mechanisms. At least partially, it appears to involve a disturbance in neurotransmitter activity in the central nervous system, particularly serotonin, also called 5-hydroxytryptamine (5-HT). This makes sense, considering that medications that boost serotonin are effective treatments.
The cause is often described as “a chemical imbalance” or “low levels of serotonin”, which may be helpful as a simple explanation but is probably overly simplistic.
Investigations for depression?
The key investigation used to screen for and assess the severity of depression is PHQ-9 (patient health questionnaire). There are nine questions about how often the patient is experiencing symptoms in the past two weeks. The higher the score, the more severe the depression:
5-9 indicates mild depression10-14 indicates moderate depression
15-19 indicates moderately severe depression
20-27 indicates severe depression
Textbook - Run routine bloods to look for an organic cause - hypothyroidsim, anaemia, diabetes
Management options for depression - 4 key points
key Support options for a mental health crisis? - 2
Management of Unresponsive or severe depression? - 3
Management options for depression include:
- Active monitoring and self-help
- Address lifestyle factors (exercise, diet, stress and alcohol) - see below
- Therapy (e.g., cognitive behavioural therapy, counselling or psychotherapy)
- Antidepressants (selective serotonin reuptake inhibitors are first-line)
Basically one point for Bio, pyscho, social
- there is good evidence that exercise efficacy is comparable to antidepressants or therapy
- NICE - do not recommend offering antidepressants first-line to patients with less severe depression (defined as less than 16 on the PHQ-9) unless they have a preference for taking antidepressants
- Patients with severe or psychotic depression require urgent specialist input and management.
Mental Health crisis management:
The crisis resolution and home treatment team offer intensive support and treatment for patients having a mental health crisis without them being admitted to hospital (usually for a short period only).
Admission may be required where there is a high risk of self-harm, suicide or self-neglect or where there may be an immediate safeguarding issue.
Additional specialist treatments for unresponsive or severe depression include:
Antipsychotic medications (e.g., olanzapine or quetiapine)
Lithium
Electroconvulsive therapy
What is psychotic depression?
Management
Psychotic depression involves the symptoms of psychosis. Psychosis involves:
Delusions (beliefs that are strongly held and clearly untrue)
Hallucinations (hearing or seeing things that are not real)
Thought disorder (disorganised thoughts causing abnormal communication and behaviour)
When psychosis accompanies depression, it generally indicates severe depression, although psychosis can occur with mild or moderate depression.
Treatment involves a combination of:
- antipsychotic drugs (e.g., olanzapine or quetiapine)
- antidepressants.
- Electroconvulsive therapy (ECT) is also an option.
What is ECT?
Anaesthesia used?
Indications?
Side effects?
Electroconvulsive therapy is the passage of a small electrical current through the brain with the aim of inducing a generalised bilateral clonic seizure for at least 30 seconds which is therapeutic.
The electical dose whould be sufficiently above the individual seizsure threshold to be clinically effective but not so high that it contributes the cognitive adverse effects of treatment.
The mechanism of action is not fully understood but it is thought to alter the neuroanl membrane permiability and therefore reduce activty in reverberating circuits between the limbic system and pre-frontal cortex. DONT MEMORISE THIS.
The procedure occours under general anaethetic and a muscle relacant (suxamethonium) is given to limit the motor effects of the seizure.
Can be bilateral (one electrode on each side of the head) or unilateral (both of the non-dominant cerebral hemisphere). Bilateral is more effective but with more cognitive side effects.
The patient usually required 6-12 treatment sessions, delivered twice a week.
Indications - ECT - Euphoric, catatonic, tearful
- E - treatment reistant mania
- C- catatonia in schizoprenia
- T - tearful - severe life threatening/ treatment-resistant depression/psychotic depression
SEVERE DEPRESSION IS THE MOST COMMON INDICATION
Side Effects:
- headache and post treatment confusion
- muscle aches
- short term memory loss
- prolongued seizure and status epilcticus
- dental trauma
Post Natal depression:
What is the spectrum of postnatal mental health issues?
When does each occur?
There is a spectrum of postnatal mental health issues:
- Baby blues is seen in the majority of women in the first week or so after birth
- Postnatal depression is seen in about one in ten women, with a peak around three months after birth
-Puerperal psychosis is seen in about one in a thousand women, starting a few weeks after birth
What are baby blues?
Management?
Baby blues affect more than 50% of women in the first week or so after birth, particularly first-time mothers.
It presents with symptoms such as mood swings, low mood, anxiety, irritability and tearfulness.
Baby blues may be the result of a combination of significant hormonal changes, recovery from birth, sleep deprivation, increased responsibility and difficulty with feeding.
Symptoms are usually mild, last only a few days and resolve within two weeks of delivery. No treatment is required.
What is post-natal depression?
Management?
Postnatal depression is similar to depression that occurs outside of pregnancy, with the classic triad of low mood, anhedonia (lack of pleasure in activities) and low energy.
Typically, women are affected around three months after birth. Symptoms should last at least two weeks before postnatal depression is diagnosed (me - usually lasts a few months).
Treatment is similar to depression at other times, depending on the severity:
Mild cases may be managed with additional support, self-help and follow up with their GP
Moderate cases may be managed with antidepressant medications (e.g. SSRIs) and cognitive behavioural therapy
Severe cases may need input from specialist psychiatry services, and rarely inpatient care on the mother and baby unit
Screening test for post natal depression?
Interpretation of results?
The Edinburgh postnatal depression scale can be used to assess how the mother has felt over the past week as a screening tool for postnatal depression. There are ten questions, with a score out of 30 points.
A score of 10 or more suggests postnatal depression.
What is puerperal psychosis?
4 Management?
Puerperal psychosis is a rare (0.2% women) but severe illness that typically has an onset between two to three weeks after delivery. Women experience full psychotic symptoms, such as:
Delusions
Hallucinations
Depression
Mania
Confusion
Thought disorder
Women with puerperal psychosis need urgent assessment and input from specialist mental health services.
Treatment is directed by specialist services, and may involve:
- Admission to the mother and baby unit
- Cognitive behavioural therapy
- Medications (antidepressants, antipsychotics or mood stabilisers)
- Electroconvulsive therapy (ECT)
What are the main types of Antidepressant medication? 3 + 1
What is the mechanism of action of the main 3?
The main types of antidepressants are:
Selective serotonin reuptake inhibitors (SSRIs)
Serotonin and norepinephrine reuptake inhibitors (SNRIs)
Tricyclic antidepressants (TCAs)
Others (e.g., mirtazapine and vortioxetine)
Mechanism of Action
Neurones (nerve cells) communicate with each other at connections called synapses. Each neurone is connected to many other neurones via synapses. The synapse is found at the end of one neurone (the axon terminal) and the start of another (the dendrite). The axon terminal releases chemicals called neurotransmitters, such as dopamine, serotonin, noradrenaline and gamma-aminobutyric acid (GABA). The neurotransmitter crosses the synapse and stimulates receptors on the post-synaptic membrane, creating a response in the neurone. Once this stimulation occurs, the neurotransmitter is returned to the axon terminal of the original neurone (reuptake).
Selective serotonin reuptake inhibitors (SSRIs) work by blocking the reuptake of serotonin by the presynaptic membrane on the axon terminal. This results in more serotonin in the synapses throughout the central nervous system, boosting the communication between neurones.
Serotonin and norepinephrine reuptake inhibitors (SNRIs) work by blocking the reuptake of serotonin and noradrenaline by the presynaptic membrane. This results in more serotonin and noradrenaline in the synapses throughout the central nervous system.
Tricyclic antidepressants have a more complex mechanism. They block the reuptake of serotonin and noradrenaline by the presynaptic membrane. They also have additional actions, including blocking acetylcholine and histamine receptors, which give them anticholinergic and sedative side effects.
SSRIs - Which drugs:
- Can cause weight gain and discontinuation symptoms?
- can cause cardiac arrhythmia?
- has a long half life and is first line in children and adolescents?
- Is safest in patients with heart disease and useful in anxiety disorders as well?
Key side effects of SSRIs? -7 get as many as you can x
Sertraline:
- helpful anti-anxiety effects
- one of the safest in patients with heart disease (MI or heart failure)
- SE - higher rate of diarrhoea
Citalopram and Escitalopram:
- can prolong the QT interval, although this effect is dose-dependent (a higher dose is more likely to cause a prolonged QT). QT prolongation can lead to torsades de pointes. They are considered to be the least safe SSRI in patients with heart disease and arrhythmia (although still a lot safer than TCAs).
Fluoxetine:
- long half life of 4-7 days - remains active in the body long after stopping
- first line in children and adolescents.
Paroxetine:
- may cause weight gain
- is more likely to cause discontinuation (withdrawal) symptoms.
Key side effects of SSRIs include:
Gastrointestinal symptoms (e.g., nausea and diarrhoea)
Headaches
Sexual dysfunction, such as loss of libido, erectile dysfunction and difficulty achieving an organism
Hyponatraemia (due to SIADH)
Anxiety or agitation, typically in the first few weeks of use
Increased suicidal thoughts, suicide risk and self-harm (this applies to all antidepressants)
Increased risk of bleeding (e.g., gastrointestinal bleeding, intracranial haemorrhage and postpartum haemorrhage)- The risk of bleeding is significantly increased when SSRIs are taken alongside anticoagulants or NSAIDs.
SNRIs?
2 Examples?
Contraindicated when?
2 key Indications?
Examples of SNRIs include duloxetine and venlafaxine.
They have similar side effects to SSRIs. They can increase the blood pressure and are contraindicated in uncontrolled hypertension.
Indications:
Venlafaxine is often used when there is an inadequate response to other antidepressants. It is more likely to cause discontinuation symptoms when stopped. It has an increased risk of death from overdose.
Duloxetine is also used to treat neuropathic pain, particularly diabetic neuropathy.
TCAs
- common indication?
- key side effect? - 2 main ones
Examples of tricyclic antidepressants (TCAs) include amitriptyline and nortriptyline. They are commonly used at a low dose to treat neuropathic pain. The neuropathic pain dose is too low to treat depression.
Tricyclic antidepressants are particularly known to cause arrhythmias, including tachycardia, prolonged QT interval and bundle branch block. The effects are dose-dependent. Their effect on the heart makes them very dangerous in overdose, with a high risk of death. For these reasons, they are not generally used to treat depression, especially in patients with heart disease or risk factors for suicide.
They have anticholinergic side effects, such as dry mouth, constipation, urinary retention, blurred vision and cognitive impairment. They also cause sedation and are typically taken at night.
Aaron you know this hun!
What is Mirtazapine?
Key side effects
An anti-depressant medication.
Mirtazapine has key side effects of sedation, increased appetite and weight gain. It is taken at night due to the sedative effect. The sedative effect appears to be greatest at low doses (e.g., 15mg) and less present at higher doses (e.g., 45mg). Mirtazapine is less likely to cause sexual dysfunction compared with SSRIs.
TOM TIP: The side effects of sedation and increased appetite may be beneficial, depending on the patient. In someone with a loss of appetite, weight loss, and poor sleep due to depression, these side effects can be very helpful. For this reason, it is commonly used in older patients. However, in someone else who is overweight and oversleeping already, these side effects would be a big problem.
What is Vortioxetine
Vortioxetine is used as a third-line treatment after an inadequate response to two other antidepressants (NICE TA367 2015). It acts as a serotonin reuptake inhibitor and also acts to stimulate and block various types of serotonin receptors. It has helpful anti-anxiety effects. It has a particularly good side effect profile and is considered safe with heart disease. It has minimal effect on sexual function and almost no risk of discontinuation symptoms. However, it commonly causes nausea for the first few weeks.
Not a key card but good to be aware of.
Key Points for starting, swapping and stopping antidepressants.
Starting Antidepressants:
When starting antidepressants, there can be an initial period of worsened agitation, anxiety, suicidal thoughts and acts of suicide. This is particularly a problem in younger patients.
The NICE clinical knowledge summaries (2024) recommend arranging a review within two weeks of starting an antidepressant (one week in patients aged 18-25 due to the increased risk of suicide).
There is usually a noticeable response within 2-4 weeks of treatment. Where there is an inadequate response, the next step is to consider increasing the dose or switching to an alternative treatment.
Swapping Antidepressants:
Swapping antidepressants depends on the medication involved. Always check the guidelines to ensure the correct regime for swapping.
Some can be directly switched, stopping the previous medication and starting the new one the next day. This is the case for switching between SSRIs and SNRIs (except fluoxetine due to the long half-life).
Others need to be cross-tapered over several weeks (e.g., switching between an SSRI and mirtazapine), gradually reducing the dose of the existing drug while increasing the dose of the new one.
Stopping Antidepressants:
Once antidepressants are started, they should be continued for at least six months before stopping (or two years in recurrent depression). Withdrawing them too early can lead to the depression returning.
Antidepressants should not be stopped suddenly. The dose should be reduced slowly over at least four weeks to minimise discontinuation symptoms (unless there is an urgent need to stop).
Discontinuation symptoms are usually mild but occasionally are more severe. They typically start within 2-3 days of stopping treatment and resolve within 1-2 weeks. Possible symptoms include:
Flu-like symptoms
Electric shock-like sensations
Irritability
Insomnia
Vivid dreams
What is Serotonin Syndrome?
3 key categories of symptoms?
management?
Serotonin syndrome can range from mild symptoms to severe and potentially life-threatening. It is caused by excessive serotonin activity. It usually occurs with higher doses of antidepressants and when multiple antidepressants are used together.
There is a long list of possible symptoms, which fall into three categories:
Altered mental state (e.g., anxiety and agitation)
Autonomic nervous system hyperactivity (e.g., tachycardia, hypertension and hyperthermia)
Neuromuscular hyperactivity (e.g., hyperreflexia, tremor and rigidity)
Severe serotonin syndrome is a medical emergency. Severe cases can cause confusion, seizures, severe hyperthermia (over 40°C) and respiratory failure.
Diagnosis is based on the clinical presentation and excluding other causes of the symptoms. Management involves supportive care (e.g., sedation with benzodiazepines) and withdrawal of the causative medications.
Self Harm vs suicide
Self-harm involves intentional self-injury without suicidal intent.
DSH can take the form of:
Self-poisoning in the form of overdose - 90%
Self-injury in the form of cutting, burning, slashing - 10%
DSH is more common in females and those aged under 25. It is often a response to emotional distress and acts as a way for the person to cope with their emotions. Self-harm is not always associated with depression, anxiety or suicide, although it does increase the risk of these conditions.
Suicide involves a person causing their own death. Death by suicide is around three times more common in men and most common around the age of 50 years. It also increases in older age.
What is the cycle of self harm
The cycle of self-harm involves the following six repeating steps:
Emotional suffering
Emotional overload
Panic
Self-harming
Temporary relief
Shame and guilt -> emotional suffering.
Suicide risk assessment - 3 parts to assessing someone’s suicide risk
Suicidal thoughts range from a passing idea that is quickly dismissed and involves no intention to robust and persistent thoughts with intentions and a plan. They need to be explored in detail to determine the risk and suitable management strategy. They can change over time, so a safety plan and reassessment when required are necessary.
Presenting features that increase the risk of suicide include:
Previous suicidal attempts
Escalating self-harm
Impulsiveness
Hopelessness
Feelings of being a burden
Making plans
Writing a suicide note
Background factors that increase the risk of suicide include:
Mental health conditions
Physical health conditions
History of abuse or trauma
Family history of suicide
Financial difficulties or unemployment
Criminal problems (prisoners have a high rate of suicide)
Lack of social support (e.g., living alone)
Alcohol and drug use
Access to means (e.g., firearms)
Protective factors that may help reduce the risk of suicide include:
Social support and community
Sense of responsibility to others (e.g., children or family)
Resilience, coping and problem-solving skills
Access to mental health support
Me this is different to a general psychiatric risk assessment with risk to self, risk from others, risk to others, neglect
Management of DSH or suicide attempts
There is no easy-to-follow guide on this.
Patients may require immediate referral to A&E after a suicide attempt or for physical injuries, overdoses or safety concerns. Once their physical health problems have been managed, they will be seen by the mental health team to decide on further management. This may result in an informal admission to hospital (meaning the patient agrees to the the admission). The Mental Health Act (1983) provides a legal framework for admitting patients to hospital against their wishes for a mental health disorder when required for treatment or safety.
Management considerations for self-harm include:
Treatment of any physical injuries (separate card) - drug detox and suturing wounds.
Empathy, supportive communication and building rapport
Identifying triggers for episodes
Separating the means of self-harm (e.g., removing blades or medications from the environment)
Discussing strategies for avoiding further episodes (e.g., distractions, alternative coping strategies and getting help)
Providing details for support services in a crisis (e.g., mental health services, Samaritans and Shout)
Treating underlying mental health conditions (e.g., depression and anxiety)
Cognitive behavioural therapy
raising any safeguarding concerns
Treatment of an Overdose
Paracetamol
Opioids
Benzodiazepines
Beta Blockers
Cocaine
Carbon Monoxide
others…
Generally, the first step when a patient presents with an overdose is to check TOXBASE for recommendations about treating an overdose of almost any substance. They also have a contact number for advice.
Activated charcoal may be given within one hour of overdose of various substances to reduce the absorption (e.g., aspirin, SSRIs, tricyclic antidepressants, antipsychotic drugs, benzodiazepines and quinine).
Paracetamol - N-Acetylcysteine
Opioids - Naloxone
Benzodiazepines- Flumazenil
Beta blockers- Glucagon for heart failure or cardiogenic shock, Atropine for symptomatic bradycardia
Calcium channel blockers - Calcium chloride or calcium gluconate
Cocaine- Diazepam
Cyanide- Dicobalt edetate
Methanol (e.g., solvents or fuels); Ethylene glycol (e.g., antifreeze) - Fomepizole or ethanol (alcohol)
Carbon monoxide - 100% oxygen
What is Bipolar Affective disorder?
What is Mania vs Hypomania
Bipolar disorder is characterised by recurrent episodes of depression and mania or hypomania. The symptoms often start at a younger age (under 25 years). It has a particularly high rate of suicide.
Depressive episodes feature low mood, anhedonia and low energy and can be severe.
Manic episodes involve excessively elevated mood and energy, significantly impacting their normal functions (e.g., caring and work responsibilities). Me - I think manic episodes last for several weeks, if just a manic day then could be EUPD.
Hypomanic episodes involve milder symptoms of mania without having a significant impact on their function.
Mixed episodes can involve a mix of symptoms or rapid cycling between mania and depression.
Features of Mania
Potential features of mania include:
Abnormally elevated mood
Significant irritability
Increased energy
Decreased sleep (sometimes going days without sleeping)
Grandiosity, ambitious plans, excessive spending and risk-taking behaviours
Disinhibition and sexually inappropriate behaviour
Flight of ideas (rapidly generating and jumping between ideas)
Pressured speech (rapid and unrelenting speech)
Psychosis (delusions and hallucinations)
Types of Bipolar Disorder? 4
Bipolar I disorder involves at least one episode of mania.
Bipolar II disorder involves at least one episode of major depression and at least one episode of hypomania.
Cyclothymia involves milder symptoms of hypomania and milder low mood. The symptoms are not severe enough to significantly impair their function.
Unipolar depression refers to when the person only has episodes of depression, without hypomania or mania.
Management of an Acute Bipolar Episode - Manic vs Depressive
Secondary care specialists should manage acute episodes of bipolar disorder. Patients require a referral for an urgent mental health assessment or hospital admission.
Treatment of an acute manic episode:
- Antipsychotic medications (e.g., olanzapine, quetiapine, risperidone or haloperidol) are first-line
- Other options are lithium and sodium valproate
- Existing antidepressants are tapered and stopped
Treatment of an acute depressive episode:
- Olanzapine plus fluoxetine
- Antipsychotic medications (e.g., olanzapine or quetiapine)
- Lamotrigine
KEY CARD
Longterm management of bipolar affective disorder?
What monitoring is required?
What are the adverse effects? (key)
Lithium is the usual long-term treatment.
Serum lithium levels (taken 12 hours after the most recent dose) are closely monitored to ensure the dose is correct. The usual initial target range is 0.6–0.8 mmol/L. Lithium toxicity can occur if the dose and levels are too high.
Notable potential adverse effects of lithium include:
Fine tremor
Weight gain
Chronic kidney disease
Hypothyroidism and goitre (it inhibits the production of thyroid hormones)
Hyperparathyroidism and hypercalcaemia
Nephrogenic diabetes insipidus
**^ just remeber toxic to renal, thryoid/parathyroid and tremor
**
Nice cks:
- Vomiting and diarhorae
- tremour
- muscle weakness
- hyper-reflexia
- seizsure and syncope
- polyurea and renal failure
Management is supportive and monitoring lithium levels until they return back down to normal range
Alternatives to lithium for long-term treatment include sodium valproate and olanzapine.
Lasting power of attorney and advanced decisions can be helpful, particularly for future episodes of mania where the person’s judgement and decision-making may be impaired, resulting in harmful outcomes (e.g., excessive spending or gambling).
TOM TIP: Sodium valproate is teratogenic. It can cause neural tube defects and developmental delay if used in pregnancy. There are strict rules for avoiding sodium valproate in females with childbearing potential unless there are no suitable alternatives and strict criteria are met. The Valproate Pregnancy Prevention Programme is in place to ensure this happens, which involves ensuring effective contraception and an annual risk acknowledgement form. This has been given much attention over recent years and may be tested in exams.
Define Generalised Anxiety disorder?
GAD vs Panic disorder
Secondary causes of anxiety
Generalised anxiety disorder (GAD) is a mental health condition that causes excessive and disproportional anxiety and worry that negatively impacts the person’s everyday activity. Symptoms should be persistent, occurring most days for at least six months, and not caused by substance use or another condition.
Panic disorder involves recurrent panic attacks. The panic attacks are unexpected (they appear randomly, often without a trigger) and result in worry about further attacks and maladaptive behaviour changes relating to the attacks (e.g., avoiding activities).
Me - The form of episodic anxiety disorder is phobia disorder, where episodes are caused by specific triggers
Secondary Causes of anxiety:
Substance use (e.g., caffeine, stimulants, bronchodilators and cocaine)
Substance withdrawal (e.g., alcohol or benzodiazepine withdrawal)
Hyperthyroidism
Phaeochromocytoma
Cushing’s disease - cortisol = stress hormone
Presentation of GAD
Emotional and cognitive symptoms of GAD include:
Excessive worrying
Unable to control the worrying
Restlessness
Difficulty relaxing
Easily tired
Difficulty concentrating
Physical symptoms (caused by overactivity of the sympathetic nervous system) include:
Muscle tension
Palpitations (e.g., a feeling of their heart racing)
Sweating
Tremor
Gastrointestinal symptoms (e.g., abdominal pain and diarrhoea)
Headaches
Sleep disturbance
What are panic attacks, Sx?
Panic attacks involve a sudden onset of intense physical and emotional symptoms of anxiety. They come on quickly (within minutes) and last a short time (e.g., 10 minutes) before the symptoms gradually fade. The duration and frequency vary between individuals. Panic attacks are relatively common and do not always indicate a panic disorder.
Physical symptoms include tension, palpitations, tremors, sweating, dry mouth, chest pain, shortness of breath, dizziness and nausea.
Emotional symptoms include feelings of panic, fear, danger, depersonalisation (feeling separated or detached) and loss of control.
What is a phobia?
Phobia involves an extreme fear of certain situations or things, causing symptoms of anxiety and panic. There are many types, including fear of animals, heights, pathogens, flying, injections or environments.
Examples of common specific phobias include:
Claustrophobia (fear of closed spaces)
Acrophobia (fear of heights)
Arachnophobia (fear of spiders)
Glossophobia (fear of public speaking)
Trypanophobia (fear of needles)
Agoraphobia is a fear of situations in which they may be unable to escape if something goes wrong. For example, this could be a fear of busy places, public transport, or anywhere outside their home.
Social phobia involves a fear of social situations (also called social anxiety disorder).
Investigations for GAD
The Generalised Anxiety Disorder Questionnaire (GAD-7) can help assess the severity. It involves seven questions, each scored depending on how often the symptoms are experienced. The total score indicates the severity:
5-9 indicates mild anxiety
10-14 indicates moderate anxiety
15-21 indicates severe anxiety
Me - also do TFTs for hyperthyroidism, FBC
