psychiatry Flashcards
When do you use section 2?
Section 2 applications can be made by a GP and require the support of another doctor with expertise in mental health. It is usually used to admit a patient who requires but has refused admission for assessment and/or treatment of a mental disorder, and lasts for up to 28 days. This gentleman does not necessarily need inpatient treatment, however, the CMHT will be able to better assess this, nor has he refused admission.
How do you treat bipolar disorder?
psychological interventions specifically designed for bipolar disorder may be helpful
lithium remains the mood stabilizer of choice. An alternative is valproate
management of mania: consider stopping antidepressant if the patient takes one; antipsychotic therapy e.g. olanzapine or haloperidol
management of depression: talking therapies (see above); fluoxetine is the antidepressant of choice
address co-morbidities - there is a 2-3 times increased risk of diabetes, cardiovascular disease and COPD
When do you urgently refer and when do you routinely refer?
if symptoms suggest hypomania then NICE recommend routine referral to the community mental health team (CMHT)
if there are features of mania or severe depression then an urgent referral to the CMHT should be made
What is lithium?
Lithium is mood stabilising drug used most commonly prophylactically in bipolar disorder but also as an adjunct in refractory depression. It has a very narrow therapeutic range (0.4-1.0 mmol/L) and a long plasma half-life being excreted primarily by the kidneys.
What are the adverse effects of lithium?
nausea/vomiting, diarrhoea
fine tremor
nephrotoxicity: polyuria, secondary to nephrogenic diabetes insipidus
thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/inversion
weight gain
idiopathic intracranial hypertension
leucocytosis
hyperparathyroidism and resultant hypercalcaemia
What is the monitoring like when a patient is on lithium?
inadequate monitoring of patients taking lithium is common - NICE and the National Patient Safety Agency (NPSA) have issued guidance to try and address this. As a result it is often an exam hot topic
when checking lithium levels, the sample should be taken 12 hours post-dose
after starting lithium levels should be performed weekly and after each dose change until concentrations are stable
once established, lithium blood level should ‘normally’ be checked every 3 months
after a change in dose, lithium levels should be taken a week later and weekly until the levels are stable.
thyroid and renal function should be checked every 6 months
patients should be issued with an information booklet, alert card and record book
A 43-year-old male has recently been admitted to a psychiatric ward after suffering a psychotic episode. As part of his management, the patient began taking risperidone. Shortly after starting treatment, the patient developed involuntary contractions of muscles of his neck.
Which of the following is the most appropriate treatment for this side-effect?
Acute dystonia secondary to antipsychotics is usually managed with procyclidine
