Psychiatry Flashcards
How does SSRI discontinuation syndrome present?
GI side effects - diarrhoea, nausea
What adverse effects do antipsychotics increase the risk of in elderly patients?
VTE & Stroke
What should be given to patients on SSRI and an NSAID?
PPI
How long do symptoms have to persist for an PTSD diagnosis?
4 weeks
What to watch out for with Citalopram
Citalopram is the most likely SSRI to lead to QT prolongation and Torsades de pointes
Contraindicated in LQTS
Conversion disorder
typically involves loss of motor or sensory function. May be caused by stress
How long does a depressive episode have to last to be diagnosed?
2 weeks
Questionnaires for depression
Patient Health Questionnaire 9 (PHQ-9)
Hospital Anxiety and Depression Scale (HADS)
Diagnosis of Dysthymia
2 years of chronic subthreshold depressive symptoms
HPA axis changes in Depression
Low hippocamapal volumes due to damage from excess cortisol release.
Risk of SSRIs in adolescents
Transient increase in suicidality
When is Mirtazapine for depression particularly useful?
Insomnia or low body weight –( as it causes drowsiness and increased appetite)
What is the most potent SNRI?
Duloxetine
Venlafaxine is a less potent blocker
Types and examples of MAO inhibitors
Irreversible –> Phenelzine
Reversible –> Moclobemide
Risks of MAO inhibitors
Cheese reaction - foods high in tyramine may cause hypertensive crisis
Describe ECT treatment
Most effective treatment avaiable for severe depression
75% benefit
General Anaesthetic
Electrical pulse through the temporals
Twice weekly for 3-6 weeks
Side effects: post-ictal confusion, headache, memory loss
Management of depression
Mild -> CBT
Mod/severe (5+ symptoms) -> SSRI + CBT
Advice on stopping depression medication
1 year following remission
Difference between bipolar 1 and 2
1 - mania and depression
2 - hypomania and depression
Features of Rapid-cycling bipolar disorder
4 or more mood episodes in a 12 month period
resistant to pharmacological treatment
may be worsened by traditional antidepressants
Duration of hypomania and mania episode
hypomania - 4 days
mania - 7 days
Questionnaires used for bipolar
Mood disorder questionnaire MDQ
Bipolarity Index Depression - Prime MD (useful in GP)
PHQ-9
Gold standard treatment mood stabiliser for bipolar
Lithium
Which drug should be avoided with lithium?
NSAIDs
Lithium monitoring
7 days after dose adjustment, 12 hours since last dose
Check dose weekly thereafter until dose contant for 4 weeks
then 6 weekly
then 3 monthly if stable
Test U+E and TSH 6 monthly
Side effects of lithium
hypothyroidism
nephrogenic diabetes insipidus
Signs of lithium toxicity
vision loss diarrhoea vomiting hypokalaemia tremor dysarthria coma
Duration for generalised anxiety disorder diagnosis
6 months
Who can apply for an emergency detention under the Mental Health act? Details of detention
FY2 and above
72 hours
Allows for assessment and emergency treatment
Best to get advice from Mental Health Officer (however not absolutely necessary)
Who can apply for a short-term detention under the Mental Health act? Details of detention
Psych ST4 and above with consult from mental health officer
Lasts for 28 days
Allows for condition treatment
May be appealed to Tribunal service
Who can apply for a long-term detention under the Mental Health act? Details of detention
Via tribunal using reports from MHO, consultant and GP
Lasts 6 months
Allows condition treatment
May be hospital or community based
Criteria for detainment under the mental health act
Risk to individual or somebody else Diagnosed mental illness (does not include dependence on drugs or alcohol) SIDMA Available treatment for condition Necessary to detain patient
Common Law
Acting in the best interest of the public or individual using previous rulings e.g. use of restraint in agitated patients
Examples of typical antipsychotics
Chlorpromazine, Haloperidol, Zuplopenthixol, Flupenthixol
How do typical antipsychotics work?
block D2 dopamine receptors
Which dopaminergic pathway is targeted by antipsychotics?
Mesocorticolimbic - specifically mesolimbic
Dopamine pathways and effect of anti-psychotic
Hypothalamospinal pathway blockade -> Akathisia
Nigrostriatal pathway blockade -> Parkinsonism, Acute Dystonia, Tardive Dyskinesia
Tuberoinfundibular pathway blockade -> hyperprolactinaemia
Mesocortical pathway blockade -> reduces negative symptoms
Mesolimbic pathway blockade -> reduces positive symptoms
Which dopamine receptor does clozapine have the highest affinity for?
D4
Which typical antipsychotic lowers seizure threshold?
Chlorpromazine
Side effects of Chlorpromazine
Seizures, Sun burn, stiffness, EPSE (dystonic reaction and neuromalignant syndrome)
Features of neuromalignant syndrome
ANS instability - swinging BP
Malignant pyrexia
Increased skeletal muscle tone
Test CK
Risk of AKI due to rhabdomyolysis
Treatment of dystonic reaction and oculogyric crisis
procyclidine
How can presentation of acute dystonia and neuromalignant syndrome differ?
Acute dystonia comes on over minutes or hours
Neuromalignant syndrome comes on gradually over days , is associated with a fever
Management of Akathisia
Propanolol
Which antipsychotic and antisuicidal properties
Clozapine
Side effects of Clozapine
Seizures - lowers threshold weight gain sedation myocarditis - ecg every 3 months agranulocytosis - weekly for first 6/12, then 2-weekly for next 6/12 and monthly thereafter constipation siallorhoea - hyoscine butylbromide
How should patients be advised in terms of trying antipsychotics
Try each for at least 6-8 weeks at an adequate dose before moving on
if wants stimulating drug then aripiprazole
if wants sedation then olanzapine or quetiapine
IM Depo is option every 3 months - especially if compliance is bad
Difference between hallucinations and pseudohallucination
Pseudohallucination - patients have insight
Misidentification Delusion - Capgras
Someone has been replaced by an imposter
Misidentification Delusion - Fregoli
multiple people are in fact the same person
CAGE - questions for alcohol dependence
Cut down - ever thought about cutting down?
Annoyed - ever been annoyed when someone confronts you about your drinking?
Guilty - do you feel guilty about drinking
Eye-opener - is it the first thing you think about when you wake up
Management of alcohol withdrawal syndrome and relapse prevention
BZDs like diazepam - reduce gradually over 7 days
Thiamine (b1) - pabrinex
Relapse prevention: Remember NDA
Naltrexone (first line) - reduces reward
Disulfiram - causes the asian flush symptoms
Acamprosate - reduces cravings
First-line for ADHD
Methylphenidate
Triad for normal pressure hydrocephalus
abnormal gait
dementia
urinary incontinence
Management of agitation in FT dementia
Trazadone
Max dose of sertraline
200mg
IF CBT or EMDR is unsuccessful in PTSD what is next step in management
If CBT or EMDR therapy are ineffective in PTSD, the first line drug treatments are venlafaxine or a SSRI
What should you so if someone misses two clozapine doses in a row?
retitrate and restart again slowly
What happens if SSRIS are stopped suddenly?
SSRI discontinuation syndrome
Diarrhoea is the main feature as well as abdominal pain and vomiting
EXCEPT Fluoxetine
What tool can be used to assess alcohol withdrawal severity?
Clinical Institute Withdrawal Assessment for Alcohol (CIWA) scale can be used to assess alcohol withdrawal severity
What is the risk of giving zopiclone in the elderly?
Increased risk of falls
Management of TCA overdose
IV bicarbonate
Effect of smoking and alcohol intake of Clozapine levels
Smoking - reduces clozapine levels
Alcohol binges - increases clozapine levels
Non-EPSE side effects of anti-psychotics
antimuscarinic: dry mouth, blurred vision, urinary retention, constipation
sedation, weight gain
raised prolactin - galactorrhoea (inhibition of the dopaminergic tuberoinfundibular pathway)
impaired glucose tolerance
neuroleptic malignant syndrome: pyrexia, muscle stiffness
reduced seizure threshold (clozapine)
prolonged QT interval (particularly haloperidol)
Risk of antipsychotics in the elderly
increased risk of stroke
increased risk of venous thromboembolism
What is the preferred SSRI for use post-MI?
Sertraline
What is the SSRI of choice in children and adolescents ?
Fluoxetine
SSRI interactions
NSAIDs Warfarin/Heparin (use Mirtazapine instead) Aspirin Triptans --> Serotonin Syndrome MAOs --> Serotonin Syndrome St John's Wort --> Serotonin Syndrome Ecstasy --> Serotonin Syndrome Amphetamines --> Serotonin Syndrome
Risks of SSRIs in Pregnancy
1st Trimester - congenital heart defects (especially Paroxetine)
3rd Trimester - persistent pulmonary hypertension
Features of Serotonin Syndrome
Neuromuscular Excitation (e.g. hyperreflexia, myoclonus, rigidity)
Autonomic dysfunction (e.g. hyperthermia)
Altered mental state
Management of Serotonin Syndrome
Supportive with IV fluids
Benzodiazepines
If severe serotonin antagonists e.g. cyproheptadine and chlorpromazine
Differences in the presentation of Serotonin syndrome and Neuroleptic malignant syndrome?
Serotonin Syndrome
- SSRIs, MAOs
- Fast onset (hours)
- Hyperreflexia
- Dilated pupils
- In severe cases manage with serotonin antagonists (Cyproheptadine or Chlorpromazine)
Neuroleptic Malignant Syndrome
- antipsychotics
- Slow onset (days)
- Hyporeflexia
- Normal pupils
- Manage with Dantrolene
