Psychiatry Flashcards
Which anti-depressant is recommended in patients with myocardial infarctions
Sertraline (SSRIs)
Describe how you would monitor someone after starting them on an anti-depressant
- 2 week review
- 1 week review if patient is suicidal
What risks are increased when using SSRIs in pregnant women
- Congenital heart defects in first trimester
- Persistent Pulmonary Hypertension of Newborn in third trimester
Which particular anti-depressant should be used with caution in pregnant women and why
- Paroxetine
- Increased chance of congenital malformation particularly in first trimester
A patient is diagnosed with depression and is required to start an SSRI. They are currently taking ramipril, simvastatin and aspirin for their ischaemic heart disease. What should you prescribe
- Sertraline and PPI
- Sertaline good for IHD
- PPI as SSRIs have increased risk of GI bleed, on top of NSAID use increases this risk
What two questions can you use to screen for depression
During the last month:
- How many times have you felt low in mood, depressed or hopeless?
- How often have you been bothered by having little interest or pleasure in doing things?
Yes to either would prompt further exploration
What scoring systems are there for depression (and anxiety)
- Hospital Anxiety and Depression
- 7 depression and 7 anxiety qu
- score out of 21 for each component
- severity: 0-7 normal, 8-10 borderline, 11+ case
- Patient Health Questionnaire (PHQ-9)
- 9 questions asking patient how often they’ve been bothered by the following things
- total score of 27
- depression severity: 0-4 none, 5-9 mild, 10-14 moderate, 15-19 moderately severe, 20-27 severe
What are some features of anorexia nervosa
Features
- reduced body mass index
- bradycardia
- hypotension
- enlarged salivary glands
What are some physiological features of anorexia nervosa
- Low:
- Potassium
- FSH, LH, oestrogen, testosterone
- T3
- High
- Cortisol
- Growth hormone
- Cholesterol
- Carotin (yelloq pigmentation of skin, xanthoderma)
- impaired glucose tolerance
What are some drug classes which interact with SSRIs
- Warfarin/HEparin
- NICE = recommends mirtazipine instead of SSRI
- NSAID
- Give PPI
- Triptan
- Serotonin syndrome
- Monoamine oxidase inhibitors
- Serotonin syndrome
How does serotonin syndrome present
- agitation,
- hyperthermia,
- hyperreflexia,
- sweating
- dilated pupils.
Management of GAD (Generalised Anxiety Disorder)
- SSRI anti-depressants
- buspirone (5-HT1A partial agonist)
- beta-blockers
- benzodiazepines: use longer acting preparations e.g. diazepam, clonazepam
- cognitive behaviour therapy
How long should an anti-depressant be continued for to avoid remission
6 months
How long do you have to miss a dose of clozapine for it to be re-iterated slowly again (restart therapy)
- 48 hours
List some parameters which need to be monitored when patients are on anti-psychotics and how often
- FBC, U&E, LFT
- Start of therapy and annually
- Clozapine = more frequent, agranulocytosis
- Lipids, weight (Metabolic)
- AT start of therapy, then at 3 months, then annually
- Fasting blood glucose and prolactin
- At start of therapy, at 6 months, then annualy
- Blood pressure
- Baseline
- During dose titrations
- ECG
- Baseline
- Cardiovascular risk assessment
- annually
What side effect is associated with nitrofurantoin
Haemolytic anaemia
MOA of benzodiazepines and Barbiturates
- BZD: increase frequency of chloride channels
- BRB: increase duration of chloride channels opening
Benzodiazipines has more letters than barbs so it is frequency
Indications of benzodiazepines
- Sedation
- Hypnotic
- Anxiolytic
- Anti-convulsant
- Muscle relaxant
What must be done when stopping a patient on benzodiazepine
- Withdraw in steps (ween off) to avoid withdrawal symptoms (similar to EtOH withdrawal symptoms)
- Insomnia
- Irritability
- Anxiety
- Tremor
- Loss of appetite
- Tinnitus
- Perspitation
- Perceptual disturbances
- Seizures
What is the first line treatment of mild depression
Psychological intervention via IAPT (Improving Access to Psychological Therapies) referral
May consider SSRIs whilst they wait for referral but NICE says IAPT is first line
Features of BPD
How do you differentiate between mania and hypomania
- Mania = funcitonal impairment or psychotic symptoms for 7 days+
- Psychotic symptoms - delusions of grandeur or auditory hallucinations)
- Hypomania = decreased or increased function for 4 days or more
Management of bipolar disorder
- Psychological interventions specific to BPD
- Mood stabiliser - lithium (alternative is sodium valproate)
- Mania:
- Consider stopping anti-depressant if they are on one
- Add anti-psychotic (olanzapine or haloperidol)
- Depression
- Talking therpy
- Fluoxetine
- Address co-morbidities
Which anti-depressant is recommende in BPD
Fluoxetine
When should sodium valproate NOT be prescribed in BPD
- If patient is presenting to primary care even though there are signs of hypomania or deterioration of depressive symptoms
- Liaise or refer to
- Community Mental Health Team (CMHT) - if patient has diagnosis
- Psychiatry in Secondary care - if patient undiagnosed
- Liaise or refer to
- DNOT PRESCRIBE in women of child-bearing age
Should only be used in bipolar disorder in patients who have tried antipsychotic medication before
What are the 5 stages of gried
- Denial
- Numb and pseudohallucinations
- Anger
- Bargaining
- Depression
- Acceptance
Not all patients will go through all of the stages
Difference between typical and atypical grief reaction
Atypical
- More likely in women
- If death is sudden and unexpected
- Problematic relationship before death or lack of social support
- Delayed grief: occur >2 weeks before grieving beings
- Prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months
First line treatment of delirium tremens
Oral chlordiazepoxide
Immediate side effects of ECT
- Drowsiness
- Confusion
- Headache
- Nausea
- Aching muscles
- Loss of appetite
- Retrograde memory loss (prior to ECT)
- Cardiac arrhythmia
Long-term side effects of ECT
- Imparied memory
- Apathy]
- Anhedonie
- Difficulty concentrating
- Loss of emotional responses
- Difficulty learning new information
Treatment for borderline personality disorder
Dialectical behaviour therapy
Features of PTSD
- Re-experiencing
- Avoidance
- Hyperarousal
Side effects of clozapine
- Constipation
- Agranulocytosis (1%), neutropenia (3%)
- Lowers seizure threshold (induce in 3% patients)
- Myocarditis
- ECG baseline
- Hypersalivation
- Tachycardia
- Hypotension
NEEDS DOSE ADJUSTMENT IF SMOKING STATUS CHANGES - smoking induces liver enzymes
What are some lithium side effects
- Fine tremor
- D&V
- Polydipsia
- Polyuria
- Hypothyroid
- Renal impairment
What are some symptoms of lithium toxicity
- Coarse tremor
- Ataxia
- Muscle weakness
- Hyperreflexia
- Myoclonus
- Drowsiness, delirium, coma
What is the usual period of time you can use a BZD like diazepam for?
2 (to 4) weeks
How would you discontinue a BZD like diazepam
- Reduce dose in steps of 1/8th of the daily dose every fortnight
Which BZD would present the largest problem in terms of withdrawal and how would you approach this
- Lorazepam
- Shortest half life and makes it more likely to present as a problem when withdrawing
- Switch patient onto a long acting BZD like diazepam and then discontinue
Which SSRI has a licence for the treatment of GAD
Paroxetine
However other SSRIs are used off-licence and may be associated with less discontinuation problems than paroxetine. Sertraline is 1st line on NICE
What is the second line treatment for GAD
- Offer alternative SSRI if primary SSRI had no efficacy
TCA moa
- Serotonin and noradrenaline re-uptake inhibitors
- 20 - blockade of H1 receptor, alpha-receptors, muscarinic receptos
What are the diagnostic criteria for ADHD (Hyperkinetic disorder) ICD-10 or DSM-V
Demonstrable abnormality of attention, activity and impulsivity at home, for the age and developmental level of the child, as evidenced by (1), (2) and (3):
(1) at least three of the following attention problems:
- (a) short duration of spontaneous activities;
- (b) often leaving play activities unfinished;
- (c) over-frequent changes between activities;
- (d) undue lack of persistence at tasks set by adults;
- (e) unduly high distractibility during study e.g. homework or reading assignment;
(2) plus at least three of the following activity problems:
- (a) very often runs about or climbs excessively in situations where it is inappropriate; seems unable to remain still;
- (b) markedly excessive fidgeting & wriggling during spontaneous activities;
- (c) markedly excessive activity in situations expecting relative stillness (e.g. mealtimes, travel, visiting, church);
- (d) often leaves seat in classroom or other situations when remaining seated is expected;
- (e) often has difficulty playing quietly.
(3) plus at least one of the following impulsivity problems:
- (a) often has difficulty awaiting turns in games or group situations;
- (b) often interrupts or intrudes on others (e.g. butts in to others’ conversations or games);
- (c) often blurts out answers to questions before questions have been completed.
