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
What is third line for GAD treatment
- SNRI: Venlaflaxine
- Extended release formulation has licence to treat GAD
What disease results from thiamine deficiency and what are the classical features
- Wernicke’s Encephalopathy
- Confusion
- Ataxia
- Nystagmus
What is the treatment for Wernicke’s Encephalopathy (as a result of thiamine deficiency)
Parenteral thiamine
Alt: Oral BZD
Define delirium tremens and features?
- Altered mental state 72hrs post alcohol withdrawal. Features:
- Agitation
- Confusion
- Paranoia
- Visual and auditory hallucinations
- Delirium tremens is a medical emergency that requires specialist inpatient care
Management of delirium tremens
Oral BZD (Lorazepam NICE)
Qhat condition frequently follows an episode of Wernicke’s Encephaolopathy
- Korsakoff’s Psychosis
Features of Korsakoff’s Psychosis
- Retrograde and anterograde amnesia
- Confabulation to fill in the gaps
- Apathy
- Loss of insight into difficulties
What would you see on neuro-imaging in patient with Korsakoff’s psychosis
Destruction of mammillary bodies
What psychological therapy would you recommend to a patient wanting to quit substance misuse
- Motivational intervieiwng
- Patient-centred
- Therapist helps identify and evelop own motivation to change behVIOUR
What are some screening tools you can use to assess alcohol use
- AUDIT PC 5
- FAST 4
Detect frequency of risky levels of consumption and hazardous and harmful drinking
What are some symptoms suggestive of alcohol withdrawal
- Tremor
- Sweating
- Nausea and vomiting
- Agitation
- Anxiety
- Insomnia
What are the features of substance dependence
- Primacy of substance seeking behaviour
- Becomes most important thing in life and takes priority over interests
- Withdrawal symptoms
- Substance taking to avoid withdrawal symptoms
- Narrowing of repertoire
- Consuming substance in a stereotyped pattern (same substance and/or route)
- Loss oc control of consumption
- Inability top control consumption once substance is taken
- Rapid reinstatement
- Likely to return to a dependent pattern after a period of abstinence
- Continued use in spite of negative consequences
- Tolerance
Which two neurotransmitters are believed to play a role in CNS effects of alcohol
- GABA-A
- Enhanced (anxiolytic)
- Release dopamine mesolimbic (euphoric)
- NMDA glutaminergic transmission
- Inhibitied (amnesic)
When do withdrawal symptoms of opiates appear
- 6-24 hours after the last dose and typically lasts 5-7 days, peaking on 2nd or 3rd day
What are the symptoms of opiate withdrawal
- Dilated pupils
- Sweating Tachycardia
- Hyperteension
- Piloerection (hair)
- Watering eyers-nose
- Yawning
- Cool Clammy skin
What three drugs are used to manage opiate withdrawal in outpatient settings and MOA
- buprenorphine
- Partial opiate agonist
- Methadone
- Long acting synthetic opiate,ORAL, not IV
- Lofexidine
- Alpha adrenergic agonist
- Symptomatic relief
How long should the following be treated for after remission per NICE guidelines:
- 1st episode depression
- 2nd episode depression
- 1st epidose
- Minimum 6 years
- Some data to suggest older people minimum 1 year
- 2nd episode
- 2 years minimum
In clinical setting what two questions could you ask to screen for depression in a patient?
- During the last month, have you often been bothered by feeling down, depressed or hopeless
- During the last minth, have you been bothered by having little interest or pleasure in doing things
If answered yes to either questions, can use GAD-7 or PHQ-9 for an idea of severity. But the patient must be referred to a practioner who can perform a mental health assessment.
List and briefly describe some general measures to advise patients with persistent subthreshold depressive symptoms or mild-to-moderate depression
- Sleep hygiene - regular sleep-wake times, avoid excess eating, smoking or dirnking before sleep, environment for sleep
- Active monitoring - for people who do not want intervention. Discuss ICE, provide informaion about the nature and course of depression. Arrange further assessment in 2 weeks. Make contact if person does not attend follow-up appointments
-
Low-intensity psychosocial intervneionts
- Individual guided self-help based on the principles of CBT
- Computerised CBT
- Structured group physical activity programme
- Group-based CBT
- Structured Group Physical Activity Programme
- Drug treatment - don’t routinely treat persistent subthreshold or mild depression because risk-benefit ratio is poor.
List and describe some psychosocial interventions/therapies and describe which conditions they are commonly used in
-
Psychodynamic psychotherapy - focuses on the unconscious and the past as evidenced in the present. Aims to give insight and self-understanding thence altered interpersonal behaviour
- Difficulties with relationships, some personality disorders
-
Behaviour Therapy - based on idea that adaptive behaviours can be learnt and maladaptive behaviours can be unlearned. Exposure is key component
- Anxiety disorders, phobis, OCD
-
Cognitive Therapy - aims to correct inaccurate or unhelpful ways of thinking, with aim of improveing mood, reducing anxiety and return to normal behaviour
- Anxiety, depressive disorder
-
Cognitive Behavioural Therapy (CBT) -mix of both therapies above.
- Mild-moderate depressive disorder (as effective as anti-depressant)
- Panic disorder and anxiety (more persistent benefit than with anxiolytics)
- Somatoform disorders, OCD
-
Cognitive Analytical Therapy (CAT) - combines cognitive and psychoanalytic approach. Tries to understand how people cope with emotional distress by looking at how the person thinks and how their cihldhood has affected their behaviour
- Depression
- Anxiety
- Relationship problems
-
Interpersonal Therapy (IPT) - uses cognitive, behavioural and psychodynamic concepts and techniques to focus on patient’s relationships and the problems arising from them. Idea that poor relationships can leave you feeling depressed which in turn makes relaitonships worse
- Severe depression or depression resistant to other talking therapies
-
Guided Self-Help - aims to give patient helpful tools and techniques that are used after course has finished
- Depression, anxiety, panic disorder
-
Counselling - Talking therapy that helps find ways to deal with difficulties in life
- Lobg-term condition
- Chronic pain
- Addiction
- Mild to moderate Depression
-
Dialectical Behavioural therapy (DBT) - Combines psychoeducation with behavioural skills training
- Borderline Personality Disorder
-
Eye Movement Desensitisation and Reprocessing (EMDR) - aims to reprocess memories of traumatic events so you can let go of them. Can be distressing so requires good support network
- Post-Traumatic Stress Disorder (PTSD)
- Mentalisation therapy for Bordeline personality disorder
- Group Therapy - share experiences and feelings to examine the relationships that form in a group
-
Family Therapy - Problem is located in the family rather than in the child. Family system is the target of this therapy. Uses psychodynamic, behavioural and other concepts.
- Children with:
- Conduct disorder
- Substance misuse
- Eating disorders
- Depression
- Schizophrenia
- Bipolar disorder
- Children with:
Why is St John’s Wort not recommended for depression (NICE)
- Active ingredient varies between preparations and it can interact with prescribed anti-depressants potentially resulting in serotonin syndrome
- Thought to act as reuopatke inhibitor of 5-HT, DA, NE
- Advice the patient on the above
What antipsychotic drug also has anti-depressant properties
- Flupentixol (Typical Anti-psychotic)
- Not first line for depression
What are some symptoms of serotonin discontinuation syndrome
- Flu-like symptoms
- Dizziness
- Insomnia
- Nausea
- Vomiting
- Sweating
- Agitation
- Electric Shock sensations
- Tinnitus
- Headache
- Irritability
What are some side effects of SSRIs
- Dyspepsia
- N + V
- Diarrhoea and constipation
- Insomnia
- Suicidal behaviour
- HYPONatraemia
Neuroleptic malignant syndrome is caused by anti-psychotics rather than SSRIs
MOA of reboxetine
Selective Noradernaline reuptake inhibitor
MOA of Lofepramine
TCA
MOA of trazodone
SARIs (serotonin receptor antagonist and reuptake inhibitors)
or tricyclic related antidepressant
MOA moclobemide
Reversible MOAi
What are some drug classes that have been shown to be associated with depression
- Corticosteroids
- Oral contraceptives
- Statins
- Ranitidine
- Anti-hypertensives
NOT NSAIDs
What are some symtoms in serotonin syndrome
- Cognitive
- Confusion
- Headache
- Autonomic
- Sweating
- Hyperthermia
- Tachycardia
- Neurological
- Myoclonus
- Hyper-reflexia
What are some options for treatment resistant depression
- Lithium augmentation
- Antidepressant combinations
- ECT
- Liothyronine augmentation
TCA moa
- Serotonin and noradrenaline re-uptake inhibitors
- 20 - blockade of H1 receptor, alpha-receptors, muscarinic receptos
Side effects of TCA
Common:
- Dry mouth
- Sedation
- Blurred vision
- Constipation
- Postural hypotension
Rare:
- Urinary retention
- Convulsions
- Cardiac arrhythmias
- Weight gain
- Precipitation of glaucoma
- Hyponatraemia
- Hepatic impairment
What are some contraindications to TCA therapy
- Known allergy
- Immediately post myocardial infarction
- Cardiac arrhythmias
- Heart Block
- Severe liver disease
- Acute porphyria
TCAs should never be combined with what other drug class and why
- Not to be used i=with MOAi
- TCA inhibits reuptake of serotonin and noradreneline, both usually broken down by MOA.
- Concurrent use of MOAi will exacerbate effects of TCA (serotonin syndrome)
True or false regarding amitriptyline:
- Alcohol increases the sedative effect of amitriptyline
- MOAi exacerbate all actions of amitriptyline
- Amitriptyline lowers the convulsant threshold in epileptics
- Amitriptyline has a predictable effect on INR in patients taking warfarin
- Beta blockers when combined with amitriptyline decreases the risk of ventricular arrhythmias
- Amitriptyline increases the risks of hypotension and ventricular arrhythmias during general anaesthesia
- Alcohol increases the sedative effect of amitriptyline TRUE
- MOAi exacerbate all actions of amitriptyline TRUE
- Amitriptyline lowers the convulsant threshold in epileptics TRUE
- Amitriptyline has a predictable effect on INR in patients taking warfarin FALSE - it is unpredictable
- Beta blockers when combined with amitriptyline decreases the risk of ventricular arrhythmias FALSE
- Amitriptyline increases the risks of hypotension and ventricular arrhythmias during general anaesthesia TRUE
Symptoms of lithium toxicity
- Diarrhoea
- Nausea
- Anorexia
- Myalgia
- Ataxia
- Blurred vision
- Muscle twitches
- Coarse tremor
When do toxic symptoms begin to appear for lithium
- Toxic symptoms >1.0mmol/L
- > 1.5 mmol/L potentially fatal
- > 2.0 mmol/L require urgent treatment
NTherapeutic range = 0.4 - 0.8 mmol/L
Side effects of sodium valproate
- Diarrhoea, nausea, vomiting, ataxia, tremor
- OD: hypotonia, hyporeflexia
- CNS depression/coma
- Constriciton of pupils
- Impaired respiratory function
- Metabolic acidosis
What drug class can cause lithium toxicity if used together
NSAIDs
How is lithium monitored
- Weekly lithium levels, 12 hours after last dose when initiating or changing dose
- Once stable, check every 3 months
When using lithium, how often do you monitor TFTs and renal function
Every 6 months
What three drugs can be used in the first 24hrs of an acute episode of mania
- Olanzapine
- Clonazepam
- Lorazepam
- Fast onset of action and short half life
- Oral or IM
What drugs are NOT recommended for the treatment of acute mania
- Carbamezapine
- VGNa channel blocker
- Post-synaptic GABA potentiator
- GABApentin
- VGCa channel blocker
- Increase GABA, decrease glutamate
- Topiramate
- Blocks Na and Ca channels and affects GABA
- Lamotrigine
- Blocks presynaptic Na and Ca channels
in a patient with BPD who is stable on mood stabilisers (lithium or valproate), how would you manage a depressive episode
- Optimise mood stbailiser
- Consider SSRI
- Refer for structure psychological therapy
What is the strongest risk factor for developing a psychotic disorder (including shcizophreina)
Family history
- Parent with schizophrenia RR 7.5
Risk of developing schizophrenia
- Monozygotic twin has schizophrenia = 50%
- Parent has schizo = 10-15%
- Sibling has it = 10%
- No relatives with it = 1%
Apart from family history, what are some other risk factors for development of psychotic disorders
- Black Caribbean ethnicity RR 5.4
- Migration RR 2.9
- Urban environment RR 2.4
- Cannabis use RR 1.4
According to ICD-10, how long must depressive symptoms last for it to be classified as a depressive episode
2 weeks
What are the three main symptoms of depressive illness
- Low mood
- Anhedonia
- Anergia
Apart from the three main symptoms of depressive illness, what are some toher symptoms that someone might experience
- Reduced attention and concentration
- Decreased self-esteem and confidence
- Feelings of guilt and unworthiness
- Bleak and pessimistic views of the future
- Ideas or acts of self-harm or suicide
- Disturbed sleep
- Diminished appetite and weight loss
- Psychomotor agitation or retardation
- Marked loss of libido
What are the diganostic criteria for a mild depressive episode
- 2 or more of the 3 main symptoms PLUS 2 or more of other symptoms, for definite diagnosis
- None of the symptoms should be present to an intense degree
- Minimum 2 week duration
- Individual may be distressed by symptoms but should be able to work and socialise
What are the diagtnostic criteria for moderate depressive episode
- 2 or more of the 3 main symptoms PLUS 3 (preferably 4) of the other symptoms
- 2 week minimum duration
- Individuals will have difficulty continuing with normal work and socialising
What are the diagnostic criteria for severe depressive episode
- ALL 3 main symptoms PLUS 4 or more other symptoms
- Some of symptoms should be severe intensity
- Minimum 2 weeks BUT if symptoms are severe, then appropriate to make earl;y diagnosis
- Can experience psychotic episodes with severe depressive episodes
- Individuals show severe distress and/or agitation
What is De Clerambault’s Syndrome
- AKA Erotomania
- Form of paranoid delusion with an amorous quality
- Patietn, often a single woman, believes that a famous person is in love with her
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.
Management of ADHD (Hyperkinetic disorder)
NICE: Holistic approach not reliant on therapeutics
- 10 week watch and wait period after presentation to see if symptoms have resolved
- If persist, refer to secondary care
- Paediatrician with interest in behavioural disorders or to CAMHS
- Patient-tailored management
- If persist, refer to secondary care
- Parent education and training programmes
- Drug therapy last resort and avilable only to OVER 5 yo
What are the pharmacological options for management of ADHD (HKD)
-
Methylphenidate first line in children
- 6 week trial
- CNS stimulant acts as dopamine/NE reuptake inhibitor
- Lisdexamfetamine if inadequate response to methylphenidate
- Dexamfetamine start in those who benefit from lisdexamfetamine but can not tolerate SE
In adults: methylphenidate or lisdexamfetamine are first line
Switch netween these drugs if no benefit seen after trial of the other
What are some side effects of methylphenidate in ADHD
- Abdominal pain
- Nausea
- Dyspepsia
In a child who is taking methylphenidate, what should be momnitored and hor often
- Weight and height
- Every 6 months
- ECG
- Potential cardiotoxicity
- Baseline ECG before treatment and refer to cardioologust if significant PMH or FH or any doubt
