Psychiatry - Management + Pharmacology Flashcards

Question 1

Q

a) Therapeutic plasma range of Lithium
b) aim in people being prescribed lithium for the first time
ac) im in people who had a relapse in the past while taking lithium or are taking lithium and have subthreshold symptoms with functional impairment

Answer

A

a) 0.6-1.0 mmol/L
b) 0.6-0.8mmol/L
c) 0.8-1.0mmol/L

Question 2

Q

At which lithium levels do patients start experiencing the symptoms of lithium toxicity

Answer

A

> 1.2mmol/L

Question 3

Q

How often does lithium need monitoring?

When are lithium levels measured?

Answer

A

o	1 week after starting lithium
o	1 week after every dose change
o	Weekly until levels are stable
o	Every 3 months for the first year
o	After first year measure every 6 months

o After first year measure every 3 months in
 Older people
 People taking drugs that interact with lithium
 People at risk of impaired renal/thyroid function/ raised ca levels
 People with poor symptom control, poor adherence
 People whose last plasma lithium level was >0.8mmol/L

Levels taken 12h post dose

Question 4

Q

Why should pregnant women//women planning a pregnancy not take lithium?

Answer

A

Can cause Ebstein’s anomaly in the foetus (tricuspid valve defect)

Question 5

Q

Lithium toxicity

Level
Signs
Triggers
Management

Answer

A

Levels >1.2 mmol/L
Life-threatening

•	Symptoms:
o	GI disturbance – Diarrhoea, N+V
o	Polyuria/Polydipsia
o	Sluggishness
o	Giddiness 
o	Drowsiness
o	Ataxia
o	Slurred speech 
o	Gross tremor
o	Fits
o	Renal failure
https://www.google.com/search?q=lithium+toxicity&source=lnms&tbm=isch&sa=X&sqi=2&ved=2ahUKEwjxz5uA3eT1AhUnzYUKHTQkDQ8Q_AUoAXoECAEQAw&biw=1422&bih=578&dpr=1.35#imgrc=_HloQrnAfNBQKM

• Triggers:
o Electrolyte changes due to low-salt diets, dehydration, D+V
o Drugs interfering with lithium excretion e.g. NSAIDs, thiazide diuretics, ACEi
o Overdose

• Management
o Check lithium level
o Stop lithium
 !stopping lithium abruptly can ppt symptoms of mania/depression
o Transfer for medical care – rehydration, osmotic diuresis
o If overdose is severe, patient may need gastric lavage or dialysis

Question 6

Q

Adverse effects of lithium

Answer

A

Mild tremor
Fatigue
GI upset
N+V
Polyuria/polydypsia - diabetes inspidus
Weight gain
Swollen ankles

Hypothyroidism
Hyperparathyroidism

Teratogenicity (Ebstein’s anomaly –> tricuspid valve defect)

Question 7

Q

Which parameters need monitoring during treatment with lithium?

Why?

How often?

Answer

A

U+Es incl Ca
eGFR
TFTs
FBC

risk of renal impairment (Diabetes insipidus) /hypothyroidism/hyperparatyroidism

At the start + every 6 months

especially important to monitor renal and thyroid function! (U+Es +TFTs every 6 months!)

Question 8

Q

Bipolar disorder in the longer term (secondary care) mx

Answer

A

• Mood stabilizers are the mainstay
Lithium is the mood stabiliser of choice
Alternative: sodium valproate (given as sodium valproate because of reduced side effects)

• Psychological intervention e.g. CBT

• Lithium (first line) [mood stabilizer]
o If lithium is ineffective, add valproate
o If lithium is poorly tolerated or not suitable
 Valproate or olanzapine instead
 or
 Quetiapine (If lithium effective during an episode of mania or bipolar depression)

• other drugs may be added when symptoms arise or when facing stress that could precipitate relapse (e.g. antipsychotics or benzodiazepines)

Question 9

Q

Acute de novo mania mx

Answer

A

Stop antidepressant + start antipsychotic

• Stop exacerbating medications – antidepressants, steroids, DA agonists, drug of abuse
o Offer anti-psychotic regardless of whether anti-depressant has stopped

• monitor food and fluid intake to prevent dehydration

• Second generation antipsychotics (SGA)
or mood stabilizer
or mood stabilizer + SGA for severe symptoms/poor response

• If treatment free –> Antipsychotics - First-line in previously untreated (rapid anti-manic effects)
o Haloperidol, Olanzapine, Quetiapine, Risperidone
o Do not offer lamotrigine
o Aripiprazole in moderate to severe manic episodes in adolescents aged 13 or older with bipolar I disorder for up to 12 weeks

•	If already on treatment 
o	Optimise medication
o	Check compliance
o	Adjust doses
o	Consider adding another agent e.g. antipsychotic + mood stabilizer

• Patients already on lithium
o Check plasma lithium levels to optimize treatment
o Consider adding an antipsychotic

• Adjunctive benzodiazepine
o Short term (<2 weeks) to prevent dependence!
o Clonazepam, lorazepam
o To treat agitation + insomnia

If first antipsychotic doesn’t work –> offer a different antipsychotic from the list
If second antipsychotic doesn’t work —> lithium + anti-psychotic
If lithium doesn’t work/ not suitable –> valproate + anti-psychotic
Valproate should not be given during pregnancy (fetal malformations and adverse neurodevelopmental outcomes, spina bifida)

• ECT if life-threatening overactivity and exhaustion despite medication or if unresponsive to medication

Question 10

Q

Acute manic relapse in a known bipolar patient

Answer

A

• Increase dose of mood stabilizer
o Lithium – check lithium levels, optimise plasma levels, consider establishing a higher serum level if good compliance

• Anti-psychotic augmentation
o Add haloperidol, Olanzapine, Quetiapine, Risperidone to lithium
o Can also be done for patients on valproate

• Antipsychotic for psychosis
o For psychosis during a manic/mixed episode that is not congruent with severe affective symptoms

• ECT
o Severely ill manic patients with life-threatening severity e.g. exhaustion
o Treatment resistant mania
o Severe mania during pregnancy

Question 11

Q

Why should valproate not be given during pregnancy/in young women of childbearing age?

Answer

A

Fetal malformations
Adverse neurodevelopmental outcomes
Spina bifida

Question 12

Q

Bipolar depression (secondary care) mx

Answer

A

• Psychological intervention (CBT, ITP, behavioural couples therapy)

• Moderate or severe bipolar depression
o Fluoxetine + olanzapine
o Or Quetiapine on its own
o If no response to fluoxetine + olanzapine or quetiapine on its own, consider lamotrigine on its own

o If the person is already on lithium
 Check + optimize lithium plasma level
 If lithium is at maximum level – add fluoxetine + olanzapine or quetiapine on its own
 If no response to fluoxetine + olanzapine or quetiapine on its own, consider adding only lamotrigine to lithium

o If a person is already on valproate
 Increase dose of valproate within the therapeutic range
 If maximum tolerated dose or dose at top of therapeutic range –> valproate + fluoxetine + olanzapine or valproate + quetiapine

https://www.nice.org.uk/guidance/cg185/chapter/1-Recommendations

Question 13

Q

Adverse effects of valproate

Answer

A

Tremor
Fatigue
Gi upset
Nausea
Peripheral oedema
Weight gain
Hair loss (with curly regrowth)

Liver failure
Pancreatitis

Teratogenicity (spina bifida)

Question 14

Q

Which parameters need monitoring during treatment with valproate?

Why?

How often?

Answer

A

• Carry out FBC, LFTs

o Stop valproate immediately if abnormal liver function or blood dyscrasia is detected
o Valproate can cause liver failure

o Measure at the start and again after 6 months of treatment, repeat annually

Question 15

Q

How often does valproate need monitoring?

Why?

Answer

A

No need to monitor plasma levels (no agreed therapeutic range dose-related toxicity is not usually an issue)

Question 16

Q

in BPAD and mania what is valproate used for?

Answer

A

Valproate is an anti-convulsant

It treats acute mania and provides prophylaxis in BPAD

Question 17

Q

What are the adverse effects of lamotrigine?

What should the patient be on the lookout for?

Answer

A

Rashes (potentially life-threatening)
Insomnia
Headache
Dizziness
Tiredness
Nausea

• Tell doctor immediately if they develop rash while dose of lamotrigine is being increased (think Stevens-Johnson syndrome)

Steven Johnson syndrome - carefully titrate dose when starting/stopping to avoid this syndrome:
Flu-like symptoms
Rash
Blistering mucous membranes

Question 18

Q

List some mood stabilizers (4)

Which of these are anti-convulsants?

Answer

A

Lithium
Valproate (anticonvulsant)
Carbamazepine (anticonvulsant) - second line
Lamotrigine (anticonvulsant) - second line

Question 19

Q

What are the adverse effects of carbamazepine?

Answer

A

Nausea
Headache
Dizziness
Drowsiness

Diplopoia
Ataxia

Leucopenia
Agranulocytosis

Rash

Teratogenicity

Toxic at high doses
Monitor levels closely
Check drug interactions before prescribing –> induces liver enzymes that metabolise many drugs, including itself

Question 20

Q

Relapse prevention strategies in BPAD

what might be the indicators of relapse in BPAD?

Answer

A

o	Daily routine
o	Sleep hygiene
o	Healthy lifestyle
o	Limiting excessive stimulation/stress
o	Addressing substance misuse 
o	Medication changes

Indicators of relapse in BPAD:
Insomnia
Increased energy

Question 21

Q

Which parameters are really important to monitor during treatment with lithium?

Why?

How often?

Answer

A

especially important to monitor renal and thyroid function! (U+Es +TFTs every 6 months!)

risk of renal impairment/hypothyroidism

At the start + every 6 months

Question 22

Q

2 things to monitor before starting carbamazepine and while the patient is on carbamazepine

why

Answer

A

Induces liver enzymes – check for drug interactions before prescribing
Can cause toxicity at high doses – Close monitoring of carbamazepine levels is essential

Question 23

Q

Where is lamotrigine used in the context of BPAD?

Answer

A

Second line prophylaxis in BPAD II

Question 24

Q

Treating depression in BPAD

Answer

A

• Depression in BPAD can be difficult to treat – antidepressants can switch depression to mania

• Antidepressants ONLY prescribed with a mood stabilizer or antipsychotic
o 1st line: fluoxetine (antidepressant of choice) + olanzapine OR quetiapine (on its own)
o 2nd line: lamotrigine

• Talking therapies

• Monitor patient for signs of mania
o Immediately stop antidepressants if signs are present

• Medication can be cautiously withdrawn if the patient is symptom-free for a sustained period

Question 25

Q

List examples of psychological treatment in BPAD

Answer

A

• CBT
o Identify relapse indicators
o relapse prevention strategies
o help patients to test out their excessively positive thoughts to gain a sense of perspective

• Psychodynamic psychotherapy
o Useful if mood stabilised

Question 26

Q

Social interventions in BPAD

Answer

A

Family support and therapy
Aiding return to education or work
Interpersonal and social rhythm therapy (IPSRT) – incorporates aspects of IPT for depression with attention to circadian rhythms

Question 27

Q

• Primary care referral
o Symptoms of hypomania
o Symptoms of mania or severe depression

Answer

A

• Primary care referral
o Symptoms of hypomania – routine referral to CMHT
o Symptoms of mania or severe depression – urgent referral to CMHT

Question 28

Q

Depression - the stepped care model

Step 1

Answer

A

Step 1: All known and suspected presentations of depression

Assessment
Support 
Psychoeducation
Active monitoring 
Referral for further assessment and interventions

Question 29

Q

Depression - the stepped care model

Step 2

Answer

A

Step 2: Persistent subthreshold depressive symptoms, mild to moderate depression

Low-intensity psychosocial interventions
Psychological interventions
Medication
Referral for further assessment and interventions

Question 30

Q

Depression - the stepped care model

Step 3

Answer

A

Step 3: Persistent subthreshold depressive symptoms or mild to moderate depression with inadequate response to initial interventions; moderate to severe depression

High-intensity psychological interventions
Medication
Combined treatments
Collaborative care*
Referral for further assessment and interventions

• Collaborative care = only for depression where the person has a chronic physical heath problem and associated functional impairment

Question 31

Q

Depression - the stepped care model

Step 4

Answer

A

Step 4: Severe and complex depression; risk to life; severe self-neglect

High-intensity psychological interventions
Medication
Combined treatments
ECT
Crisis service
Multiprofessional and inpatient care

Question 32

Q

Mild to moderate depression or subthreshold depressive symptoms mz

Answer

A

o Active monitoring, asses again normally within 2 weeks
o Sleep hygiene
o Low intensity psychosocial intervention
Individual-guided self-help based on principles of CBT
Computerised CBT
Structured group physical activity programme
Relaxation therapy
o Group CBT - if low-intensity psychological intervention is declined

o Do not use anti-depressants routinely to treat persistent subthreshold depressive symptoms or mild depression but consider them for people with:
 A past hx of moderate or severe depression
 Initial presentation of subthreshold depressive symptoms that have been present for a long period (typically at least 2 years)
 Subthreshold depressive symptoms or mild depression that persists after other interventions

Question 33

Q

Depression management

a) Moderate-to-severe
b) or persistent subthreshold depressive symptoms (usually >2 years) or mild to moderate depression with inadequate response to initial interventions (low intensity psychosocial intervention) mx

Answer

A

a) combination of anti-depressant medication and a high-intensity psychosocial intervention (CBT or IPT)
b) Antidepressant medication (normally SSRI) or High intensity psychological treatment (CBT, IPT, behavioural activation, behavioural couples therapy)

Antidepressants - 1st line --> SSRI
High intensity psychosocial intervention
Individual CBT (16-20 sessions over 3-4 months)
Interpersonal therapy  (16-20 sessions over 3-4 months)

o ECT – fast + short-term improvement of severe symptoms after all other treatment options have failed or when the situation is life-threatening

Question 34

Q

Complex and severe depression mx

Answer

A

o Crisis resolution + home treatment teams to manage crises
o Develop a crisis plan that identified potential triggers and strategies to manage triggers – share with GP and any other people involved in the patient’s care
o Consider inpatient treatment if significant risk of suicide, self-harm or self-neglect
o Consider ECT for acute treatment of severe depression + when rapid response is required

Question 35

Q

Severe depression with psychosis mx

Answer

A

o	Add an antipsychotic  
o	Antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone)

 Augmentation of an antidepressant with buspirone, carbamazepine, lamotrigine, valproate should not be used routinely - insufficient evidence for their use

Question 36

Q

Treatment resistant/Refractory depression

Answer

A

o	Review medication concordance + diagnosis – Check medication adherence, side effects, carefully titrate to an effective dose
o	Consider a higher dose, different medication (initially switch often to alternative SSRI), different class of antidepressants (e.g. Mirtazapine, Venlafaixine, TCAs, MAOIs)

o Augmentation strategies (adding something to the antidepressant)
 Lithium
 Second-generation antipsychotics (SGAs) – lower doses than for psychosis
 Combining 2 anti-depressants e.g. Mirtazapine + SSRI (greater risk of hyponatraemia, serotonin syndrome etc)
 ECT

 Buspirone – anxiolytic drug that acts on 5HT1a (no antidepressant action alone but may have a synergistic effect when combined with SSRIs)

Question 37

Q

Drug to try in depression if there are co-existing chronic physical health problems + why

Answer

A

o Sertaraline preferred (lower risk of drug interactions)

o Can rarely cause hypoglycaemia

Question 38

Q

Over how long should anti-depressants be stopped and why?

Answer

A

Stopping anti-depressants should be done over a period of 4 weeks to prevent discontinuation symptoms

Discontinuation syndrome:
	GI sx
	Flu like sx
	Sweating 
	Restlessness
	Problems sleeping 
	Vivid dreams
	Unsteadiness
	Tinnitus
	Altered sensations (electric shock sensations in the head)
	Altered feelings (irritability, anxiety, confusion)

Question 39

Q

What can antidepressants be augmented with?

Answer

A

• Antidepressants can be combined/augmented with
o Lithium (mood stabilizer)
o Antipsychotics (aripiprazole, olanzapine, quetiapine, risperidone)
o Antidepressants (mirtazapine, mianserin)
o Benzodiazepines

 Augmentation of an antidepressant with buspirone, carbamazepine, lamotrigine, valproate should not be used routinely  insufficient evidence for their use
 Augmentation of an antidepressant with a benzodiazepine for more than 2 weeks should not be used routinely  risk of dependence))

Question 40

Q

Discontinuation syndrome sx

Answer

A

	GI sx
	Flu like sx
	Sweating 
	Restlessness
	Problems sleeping 
	Vivid dreams
	Unsteadiness
	Altered sensations (electric shock sensations in the head)
	Altered feelings (irritability, anxiety, confusion)

Question 41

Q

Serotonin syndrome sx

Answer

A

o	Potentially fatal
o	Restlessness
o	Sweating
o	Myoclonus
o	Confusion
o	Fits

Question 42

Q

What is light therapy being used for?

Answer

A

Seasonal Affective/Depressive disorder (SAD) that occurs in autumn/winter

Typical symptoms of SAD: Hypersomnia and hyperphagia

Question 43

Q

Bio-psycho-social approach for depression

Biological interventions
Psychological interventions
Social interventions

Answer

A

Biological - anti-depressants, ECT, rTMS, light therapy, exercise

Psychological - psychosocial interventions e.g. CBT, psychodynamic psychotherapy, ITP, MBCT

Social interventions - sleep hygiene, exercise, healthy diet, psychoeducation, support groups, social network support

Question 44

Q

Give examples of SSRIs (selective serotonin reuptake inhibitors)

Answer

A

Citalopram
Escitalopram
Fluoxetine
Fluvoxamine
Paroxetine
Sertraline

Fluoxetine, fluvoxamine, paroxetine - associated with a higher propensity for drug interactions than other SSRIs

Paroxetine - associated with a higher propensity for drug interactions than other SSRIs (very short half life, 24h)

Question 45

Q

Give examples of SNRIs (Serotonin and NA reuptake inhibitors)

Answer

A

Venlafaxine

Duloxetine

Question 46

Q

Give examples of tricyclic antidepressants (TCAs)

Answer

A

Amitriptyline
Clomipramine
Imipramine
Lofepramine
Nortriptyline

Question 47

Q

Give examples of MAOIs (monoamine oxidase inhibitors)

Answer

A

Phenelzine
Tranylcypromine
Moclobemide

Question 48

Q

Give examples of RIMAs (reversible inhibitors of monoamine oxidase A)

Answer

A

Moclobemide

Question 49

Q

Give examples of NASSAs (noradrenergic and specific serotonin antidepressant)

Answer

A

Mirtazapine

Question 50

Q

Give examples of SARI (serotonin antagonist and reuptake inhibitor)

Answer

A

Trazodone

Question 51

Q

Give examples of Melatonergics

Answer

A

Agomelatine

Question 52

Q

What might be an issue when taking Paroxetine?

Answer

A

Paroxetine is an SSRI

Has a very short half-life (24h) therefore delaying a tablet can cause discontinuation symptoms

Question 53

Q

What might be an issue when taking venlafaxine?

Answer

A

Avoid venlafaxine if risk of arrhythmia

Slowly withdraw venlafaxine - discontinuation symptoms are common due to its short half-life

Question 54

Q

What is an issue wtih TCAs?

Answer

A

Infrequently used due to cardiotoxicity - even small overdoses can be fatal

QT prolongation (torsades de points, VT, normal QT: 0.44ms-0.47ms, if QT>0.50ms - dangerous), ST elevation, AV block

except lofepramine

Question 55

Q

What is an issue with MAOIs?

Answer

A

Can precipitate a hypertensive crisis “the cheese reaction”

Therefore rarely used as tyramine rich foods can cause NA build-up and hypertensive crisis

Hypertensive crisis:
	Tachycardia
	Flushing
	Severe throbbing headache
	Pallor
	Stroke
	Death

Question 56

Q

What is a side effect of moclobemide that patients should look out for?

Answer

A

Severe headache

Moclobemide is a RIMA

(reversible inhibitor of monoamine oxidase A)

Hypertensive crisis still possible therefore avoid tyramine-rich foods and report severe headache immediately

Question 57

Q

What is a side effect of Trazodone that patients should look out for?

Answer

A

Attend hospital if priapism

Trazodone is a SARI

(serotonin antagonist and reuptake inhibitor)

Question 58

Q

What needs to be monitored during treatment with agomelatine?

Answer

A

Monitor LFTs early in treatment

Can stop abruptly without discontinuation symptoms

Question 59

Q

SE of SSRIs

Answer

A

N+V 
Dyspepsia, diarrhoea, constipation (effect bc of serotonin receptors in the gut)
Anxiety/Agitation
Insomnia
Vivid dreams
   advise to take it in the morning 
Tremor
Headache
Sweating
Sexual dysfunction
   in about 70% of patients
Hyponatraemia
Suicidality
Discontinuation syndrome

GI bleeding
Especially in older people or in people taking other drugs that have the potential to damage the GI mucosa or interfere with clotting
consider prescribing a gastroprotective drug in older people who are taking NSAIDs or aspirin

Question 60

Q

SE of SNRIs

Answer

A

Same as SSRIs
N+V 
Dyspepsia, diarrhoea
Anxiety/Agitation
Insomnia
Vivid dreams
Tremor
Headache
Sweating
Sexual dysfunction

GI bleeding
Hyponatraemia
Suicidality
Discontinuation syndrome

PLUS

Constipation
HTN
Raised cholesterol
Dry mouth 
Dizziness
Drowsiness

Question 61

Q

SE of TCAs

Answer

A

Anticholinergic side effects

Dry mouth
Blurred vision
Constipation 
Urinary retention
Arrhythmia
Postural hypotension
Sedation
Sexual dysfunction

Weight gain

Cardiotoxicity 
QT prolongation (torsades de points, VT, normal QT: 0.44ms-0.47ms, if QT>0.50ms - dangerous), ST elevation, AV block

lethal in overdose - cardiac monitor the patient
potential for postural hypotension and arrhythmias
except lofepramine

Rare side effects include:
Urinary retention
Convulsions
Cardiac dysrhythmias
Weight gain
Precipitation of glaucoma
Hyponatremia
Hepatic impairment

Question 62

Q

SE of MAOIs

Answer

A

Hypertensive crisis - cheese reaction:
	Tachycardia
	Flushing
	Severe throbbing headache
	Pallor
	Stroke
	Death

Nausea
Drowsiness
Postural hypotension
Insomnia
Sexual dysfunction

Question 63

Q

SE of RIMAs

Answer

A

Nausea
Agitation/anxiety
Sleep disturbance
Throbbing headache
Sexual dysfunction

*Hypertensive crisis (cheese reaction) still possible - avoid tyramine-rich foods, report severe headache immediately:
	Tachycardia
	Flushing
	Severe throbbing headache
	Pallor
	Stroke
	Death

Question 64

Q

SE of NASSAs

Answer

A

Sedation
Increased Appetite/weight gain
Oedema
Dry mouth
Headache
Dizziness

Sexual side effects relatively uncommon

Answer 65

A

Sedation 
Dizziness, postural hypotension
Headache 
Tachycardia
Nausea/Vomiting
Tremor

Priapism
Sexual dysfunction

*Attend hospital if priapism

Good sedative effect and used in older adults

Answer 66

A

Nausea
Dizziness
Headache/migraine
Insomnia
Drowsiness

Hepatotoxicity

Answer 67

A

Vortioxetine

Good SE profile
GI SE
dizziness
skin reactions

Answer 68

A

Bupropion

Licensed for smoking cessation in the UK

Answer 69

A

• For people started on antidepressants who are not considered to be at increased risk of suicide
o See them after 2 weeks
o Regularly thereafter e.g. at intervals of 2-4 weeks in the first 3 months
o At longer intervals if response is good

• Person with depression started on antidepressants who is considered to present an increased risk of suicide and <30  seen after 1 week and frequently thereafter

Answer 70

A

• Careful when switching
o From fluoxetine/paroxetine to TCA
 Both of these drugs inhibit the metabolism of TCAs
 Lower starting dose of TCA required, particularly if switching from fluoxetine because of its long half-life

o From fluoxetine to other anti-depressants
 Fluoxetine has a long half-life

o From a non-reversible MAOI – 2 week washout period required, do not prescribe other antidepressants

o To a new serotoninergic antidepressant or MAOI – risk of serotonin syndrome

Answer 71

A

Once well, recommended at the same dose for 6-12 months and for 2 years for those at greatest risk of relapse e.g. multiple recent episodes or significant hx

Answer 72

A

Fluoxetine

SSRis

Answer 73

A

Irreversable - phenelzine, tranylcypromine, isocarboxazid

reversible - moclobemide

Answer 74

A

a)SSRI 
o	Bleeding (esp in elderly, gastric ulcers, hyponatraemia) – NSAIDs should be given with PPI

b) Drug interaction – fluoxetine, fluvoxamine, paroxetine
c) Discontinuation symptoms – paroxetine
d) Death from overdose – venlafaxine, TCAs except lofepramine
e) Stopping treatment due to side-effects – venlafaxine, duloxetine, TCAs
f) BP monitoring needed – venlafaxine
g) Worsening hypertension – venlafaxine, duloxetine
h) Postural hypotension and arrhythmia – TCAs

Answer 75

A

o Severe cases managed in hospital
o Stop offending meds
o Supportive measures (ABCDE) – airway management, renal care, IVF, temp control (paracetamol)
o ?Cyproheptadine – antihistamine + serotonin antagonist

Answer 76

A

A first episode of depression should be treated for a minimum of 6 months after remission per NICE.
There are suggestions that older patients may benefit from a minimum of 1 year’s treatment.
A 2nd episode of depression should be treated for at least 2 years following remission.

Answer 77

A

Response to antidepressant treatments is usually seen within 2-4 weeks.

At least 4 weeks at an effective dose is needed before deciding that the patient has failed to respond.

Answer 78

A

• Contraindications to the presribing of amitryptyline
o Known allergy
o Immediately post MI
o Cardiac arrhythmias
o Complete heart block
o (acute porphyria is not a contraindication but note that amitriptyline is metabolised in the liver and can therefore precipitate an acute crisis in those with porphyria)

Answer 79

A

Alcohol increases the sedative effect of amitriptyline
MOAIs exacerbate all the actions of amitriptyline
Amitriptyline lowers the convulsant threshold in epileptics
Amitriptyline increases the risks of hypotension and ventricular arrhythmias during GA
Amitriptyline increases the risk of ventricular arrhythmias when combined with a beta blocker
Amitriptyline has an unpredictable effect on the INR in patients taking concurrent warfarin
TCAs + SSRIs should never be combined with MAOIs  high risk of serotonin syndrome

Answer 80

A

Long term side effects of lithium therapy
• Hypothyroidism
• Irreversible nephrogenic Diabetes Insipidus

• Other SE: Hyperglycaemia, ?hyperthyroidism, hyperparathyroidism

Answer 81

A

•	Sodium valproate at therapeutic level
o	Diarrhoea
o	N+V
o	Ataxia
o	Tremor
o	Hair loss with curly re-growth
o	Weight gain

•	Sodium valproate at overdose
o	Hypotonia
o	Hyporeflexia
o	CNS depression/coma
o	Constriction of pupils
o	Impaired respiratory function
o	Metabolic acidosis

Answer 82

A

Extrapyramidal symptoms e.g. tremor

Answer 83

A

Carbamazepine

Clozapine

Answer 84

A

o The service aims to engage patients with very early symptoms, from adulthood till 35 years

o Psychosis is toxic  the longer the patient is psychotic, the more it will affect their cognitive abilities, insight and social situation => the sooner effective treatment can be started, the better the prognosis

o DUP – the time from the first clear-cut psychotic symptom until the start of effective treatment

o Patients offered antipsychotics + psychosocial interventions - early intervention in psychosis aims to keep the duration of untreated psychosis (DUP) under 3 months

o Service can be used in children >14 y/o  CAMHS can deal with psychosis in children up to 17 y/o
o If urgent intervention is necessary  crisis resolution team, home treatment team

Answer 85

A

• Atypical (2nd generation antipsychotics)
o Olanzapine, risperidone, quetiapine, aripiprazole, clozapine, amisulpride
• Poor response - switch to another atypical antipsychotic

o Psychological interventions (e.g. family intervention, individual CBT)
o CBT should be offered to all patients

Answer 86

A

• Clozapine
o Atypical antipsychotic
o SE: weight gain, hypersalivation, agranulocytosis (fatal 0.03%), regular WBC monitoring
o Small but significant risk of agranulocytosis
o Weekly blood tests to detect early signs of neutropenia
o Requirement to register with a monitoring service
 CPMS (clozapine monitoring system) – national service in the UK that gives advise on the drug dosage to use, depending on the blood test results you send to them. Compulsory for anyone on clozapine. Only consultant psychiatrists can prescribe clozapine

• If lack of response to clozapine  augmentation with another antipsychotic

Answer 87

A

• Treatment resistance = failure to respond to 2 or more antipsychotics, at least one of which is atypical, each given at a therapeutic dose for at least 6 weeks

Answer 88

A

• CBT – 16 or more one-to-one sessions over 6 months
o Should be offered to all schizophrenic patients
o Offered to anyone experiencing psychosis or at an increased risk of developing psychosis (i.e. ARMS)

o CBT has been shown to help positive symptoms
 Emphasis placed on reality testing
 “here and now” focus on normalization of the psychotic experience (stigma)
 Coping skills for managing voices
 Exploring evidence for unusual or distressing beliefs
 Explore the role that the interpretation + behaviour may have in managing negative emotions
 Also helps improve self-esteem and problem-solving, helps people live their lives productively even if still experiencing some hallucinations and delusions

• Family therapy – at least 10 sessions over 6-12 months
o Educates the family to recognise the early signs of an attack + to be more supportive, + to remove any precipitating factors from the patients direct environment e.g. criticism
o Patient encouraged to talk to their family about what is helpful and unhelpful
o Aims to improve relationships by encouraging people to listen to each other + negotiate potential solutions
o Can reduce the effects of high EE through communication skills training, education about psychosis and problem-solving techniques
o Improves understanding + empathy on both sides  can help reduce conflict
o Can reduce relapse rates

• Arts therapy – alleviation of negative symptoms
o Can help people discover new forms of expression and communication with others
o Provided as group therapies
o Can be effective during an acute episode or for negative symptoms in chronic illness

• Concordance therapy – collaborative approach where the patient is encouraged to consider the pros and cons of the management

Answer 89

A

Care-coordination – monitoring mental and physical health, medication, drug use, identifying and solving social problems
Assertive outreach – maintaining contract with patients who may not want contact with services
Early intervention in Psychosis
Structured weekly activities to reduce negative symptoms
May include admission to hospital for observation, treatment or refuge

• Psychoeducation - vital to reduce relapse
o Collaborative approach where people are encouraged to ask + find out more about their illness
o Important part of the therapeutic alliance  encouraging people to consider the pros + cons of their treatment, improving insight into their needs

• Social skills training – primarily aimed at improving interpersonal skills. Using methods such as role-play people develop improved confidence and skills in their day-to-day functioning

• Rehabilitation psychiatry – focuses on quality of life, over-coming disability where possible and accepting limitations where not. It’s a long-term approach, addressing varied needs incl: (social workers, benefits advisors, occupational therapists)
o Education, training, employment – vocational workers
o Skills (e.g. budgeting, cooking)
o Housing (e.g. supported accommodation, independent flats)
o Accessing social activities
o Developing personal skills and pursuing interests (e.g. creative writing)

• Mental health organizations (e.g. Rethink, Mind)
o Provide patient resources
o Carry out important work in promoting social inclusion + helping tackle stigma at a personal + societal level

Recovery – the process of getting well + finding a way to live with psychosis that allows a person to have a fulfilling and meaningful life
Carer support – all carers should have their needs assessed. Formal support from social services or may benefit from carer’s groups

Answer 90

A

• General advice – continue medication for up to 3 years after the first episode of psychosis

Answer 91

A

o Response to treatment + SE
o Adherence
o Emergence of movement disorders

o Waist circumference
o BMI
o Overall physical health
o FBC, LFT, U&Es, lipid profile, CBG (followed by a glucose tolerance test and HbA1c if abnormal)

o	Weight
	Weekly for 6 weeks
	At 12 weeks
	At 1 year
	Annually thereafter

o Pulse + BP
 At 12 weeks
 1 year
 Annually thereafter

o some people need monitoring of
 prolactin levels – if hyperprolactinaemia is suspected or likely (e.g. risperidone)
 ECGs – important in older people + those on high-dose antipsychotics or clozapine – to monitor the QTc interval;

Answer 92

A

o Healthy eating + physical activity programme

o Interventions for metabolic complications of antipsychotics

o Smoking cessation (nicotine replacement therapy or bupropion or varenicline)
 Bupropion + valenicline - inreased risk of adverse neuropsychiatric symptoms - should be monitored closely for the first 2-3 weeks

o Regularly monitor weight + other CV/metabolic parameters

o Consider peer support (support from someone who has recovered from psychosis)
Aripiprazole can help

Answer 93

A

Chlorpromazine
Haloperidol
Zuclopenthixol
Flupenthixol
Trifluoperazine
Fluphenazine

Answer 94

A

Clozapine
Olanzapine
Quetiapine
Risperidone
Amisulpride
Asenapine
Lurasidone
Ziprasidone
Aripiprazole

Answer 95

A

Extrapyramidal side effects 
Parkinsonism
Dystonias
Dyskinesias
Akathisia

• Parkinsonism
o Tremor
o Rigidity
o Bradykinesia
o Postural instability, mask-like expression, gait abnormalities
Mx:
o Anticholinergic medication – procyclidine PO/IM
 Do not give too late in the evening so that pt can sleep
 Can make pt feel high
o Consider reducing antipsychotic dose
o Consider changing to an atypical antipsychotic

• Dystonias
o Sustained or repetitive muscle contractions resulting in twisting and repetitive movements and posture
o Can present as oculogyric crisis and torticollis (painful muscular contraction affecting the SCM muscle in the neck)
o Occurs shortly after administration of antipsychotic
 Occurs due to DA blockade causing an imbalance between dopaminergic and cholinergic transmission)

o Typically in young/antipsychotic naïve (in SBAs, after depot/rapid tranquilisation etc)
o Can be life threatening e.g. laryngeal dystonia
Mx
o Anticholinergic medication – procyclidine IM
o Consider reducing antipsychotic dose
o Consider changing to an atypical antipsychotic

• Dyskinesias
o Tardive dyskinesias = repetitive and stereotypical jerking movements of the face and mouth
o Lip smacking, tongue protrusion, eye blinking
o Idiosyncratic reaction
o Choreo-athetoid movements
o Can be irreversible
o Made worse by anti-cholinergics
Mx:
o Carefully reduce dose of antipsychotic
o Consider changing to an atypical antipsychotic
Tetrabenazine

• Akathisia
o Subjective feeling of restlessness (mental and/or physical) e.g. constantly crossing and uncrossing legs, pacing up and down, rocking from foot to foot
Mx:
o Short-term benzodiazepines
o Consider reducing antipsychotic dose
o Consider changing to an atypical antipsychotic
Propranolol

Hyperprolactinaemia

Answer 96

A

Weight gain
dyslipidaemia
glucose metabolism

• Metabolic syndrome
o Especially with atypical antipsychotics
o Olanzapine causes central obesity
o Schizophrenia is already an independent CV RF
o Metabolic side effects: HTN, central obesity, raised fasting plasma glucose, hyperTGaemia, low HDL

o	NICE recommends regular monitoring of
	BMI
	Waist circumference
	BP
	Bloods (FBC, U+Es, LFTs (check for fatty liver), HbA1c, lipids)

Management:
o Refer to dietician + to exercise programs
o Counsel on smoking cessation – smoking cessation nurse
o Aripiprazole is an anti-psychotic than can potentially help with the metabolic syndrome + diabetic profile

Answer 97

A

On the mesolimbic pathway

Mesolimbic pathway – hyperactivity (D2 receptors) causes the positive symptoms/psychosis in schizophrenia

Answer 98

A

• QTc prolongation
o <0.44s men, <0.47s women
o Risk with all antipsychotics
o NICE recommends an ECG prior to commencing antipsychotic medication + regular monitoring
o Can develop torsades de pointes, VT, cardiac arrest

• Sedation

• Typical antipsychotics - EPSEs (e.g. Parkinsonism, dystonia, akathisia, tardive dyskinesia)
o Extrapyramidal side-effects (EPSEs) can occur at higher concentrations of ALL antipsychotics, less common with atypical ones

Atypical antipsychotics - Weight gain (esp. olanzapine + clozapine), increased risk of DM (olanzapine)
Hyperprolactinaemia (galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism, sexual dysfunction, infertility increased risk of osteoporosis)
Anticholinergic SE (dry mouth, blurred vision, constipation, urinary retention, tachycardia)
Arrythmias
Seizures (decrease seizure threshold)
Neuroleptic malignant syndrome

Answer 99

A

o Agranulocytosis – rare + potentially fatal idiosyncratic reaction - regular FBC testing
o Weekly blood tests to detect early signs of neutropenia
o Requirement to register with a monitoring service
 CPMS (clozapine monitoring system) – national service in the UK that gives advice on the drug dosage to use, depending on the blood test results you send to them. Compulsory for anyone on clozapine. Only consultant psychiatrists can prescribe clozapine

o Excessive sedation

o Hypersalivation – hyoscine patch

o Postural hypotension (dizziness)

o Weigh gain + metabolic syndrome

o Anti-cholinergic effects – particularly constipation [when you start clozapine, start a prophylactic laxative as well]

o Cardiomyopathy and fatal myocarditis
 [patients usually develop tachycardia after given clozapine – do ECT, Bloods to see CK and troponins to rule out myocarditis]

o Seizures – reduces seizure threshold

Answer 100

A

ABCDE
A+E
Stop all antipsychotics

• Supportive:
o IVF
o Antipyretics/cooling devices
o Dialysis

• Potential treatments:
o Muscle relaxant (Dantrolene)
o DA replacement (e.g. Amantadine, bromocriptine)
o ECT

Answer 101

A

Haloperidol

Answer 102

A

Can be caused by all anti-depressants, particularly in SSRI use
Usually within 30 days
Dizziness, drowsiness. Confusion, nausea, muscle cramps, seizures
Stop anti-depressant + manage symptoms

Answer 103

A

o Usually, most people see an effect after 2 weeks

o If the person’s depression shows no improvement after 2-4 weeks, check that the medication is being taken regularly and at prescribed dose, and ask about side effects (compliance screening)

o If absent/minimal response after 3-4 weeks with therapeutic dose:
 Increase support (weekly face to face or telephone contact)
 Increase dose if no significant side effects
 Consider switching to another antidepressant (SSRI if not on this already, or TCA if on SSRI) if the current drug is causing side effects or if the person would prefer a different drug

o If there is some improvement by 4 weeks, continue for 2-4 weeks and consider switching if:
 Response still not adequate
 Still side effects
 Person prefers to change

Answer 104

A

1st line – Mild functional impairment

• Low-intensity psychological therapies

o Brief individual CBT (incl. exposure and response prevention, RP) using structured self-help materials

o Brief individual CBT (incl. ERP) by telephone

o Group CBT (incl. ERP)

o Should be done for up to 10 therapist hours per patient

Answer 105

A

2nd line – moderate functional impairment OR mild functional impairment but low intensity psychological therapies not effective/inadequate OR BDD with moderate functional impairment

• SSRI OR more intensive CBT (including ERP, more than 10 therapist hours per patient)

o SSRI possible agents: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram
 This is an off-label use of citalopram
o Continue SSRI treatment for at least 12 months after remission of symptoms

Answer 106

A

3rd line – severe functional impairment or if inadequate response with an SSRI alone (within 12 weeks) or CBT (incl. ERP) alone (>10 therapist hours per patient)

• Combined treatment with an SSRI + CBT (incl. ERP)

Answer 107

A

4th line (after 12 weeks) – if inadequate response after 12 weeks of combined treatment with an SSRI + CBT (incl. ERP) OR no response to SSRI alone OR patient has not engaged in CBT

• Different SSRI or Clomipramine

o Clomipramine considered only if: a) at least one SSRI has been ineffective or poorly tolerated or b) the patient prefers clomipramine or has had a previous good response to it

Answer 108

A

• Psychoeducation
o Explain the dx
o Reassure that the physical symptoms are not a sign of any underlying physical problem

Avoid exacerbating lifestyle factors (caffeine, nicotine)
Advise regular exercise (150 mins of moderate intensity exercise per week)

•	Stress reduction techniques
o	Breathing techniques
o	Yoga
o	Mindfulness 
o	Get enough sleep
o	Learn to mediate
o	Listen to music 
o	Make time for things that you enjoy
o	Consider getting a pet

Sleep hygiene
Encourage close interpersonal relationships with trusted family and friends

• Carer education
o Friends and family are often recruited in SSB or may facilitate escape avoidance, believing they are protecting the anxious person from harm and distress (go opposite to the principles in exposure therapy)

Answer 109

A

1st line – low-intensity CBT incl. ERP [mild functional impairment start from here]

2nd line – SSRI or more intensive CBT [moderate functional impairment start from here]

3rd line – SSRI + intensive CBT incl. ERP [severe functional impairment start from here]

4th line – different SSRI or Clomipramine
(very rare but just have it in mind – psychosurgery – anterior cingulotomy)

Answer 110

A

1st line: SSRI
2nd line: Clomipramine (TCA)
Those on medications need to understand that there is a lag time between medication initiation + response (6-8 weeks but can be up to 3 months)
The focus of treatment should be for improvement in symptoms, and not complete remission
Important to set up a patient’s expectations of how much improvement they will have on medications – patients can expect a maximum of 30-35% reduction
An “adequate trial” for one medication is between 12-15 weeks, with at least 6 weeks at the maximum dose
Symptoms should always be monitored via a scale like Y-BOCS

Answer 111

A

• CBT incl. ERP

• ERP – Exposure and Response Prevention
o Compulsions are analogous to escape in phobias
o In ERP patients are exposed to situations that trigger obsessions + are thought strategies to prevent the compulsive response that would temporarily relieve their anxiety
o Patients gradually become desensitized to the fear stimulus - improved OCD symptoms

o Exposure = exposing the patient to the thoughts, images, objects, situations that make them anxious and/or trigger obsessions
o Response Prevention = teaching the patient to not perform those compulsive behaviors once those anxiety or obsessions have been triggered; instead, they are taught to perform an opposite action.
o A hierarchy of feared situations is used
o Effective in well-motivated patients

• Those doing therapy need to understand there is an extensive time commitment involved as well

• Relapse is more likely with discontinuation of SSRI therapy compared to CBT/ERP
o Patients must also be treated longer (at least 3 months) with doses near the maximum recommended doses (resulting in increased rates of adverse effects)

Answer 112

A

Exercise - emerging evidence that exercise is a feasible + clinically impactful treatment for OCD
Psychoeducation through self-help literature and online resources
Carer education – friends + family are often recruited in SSB and may facilitate escape and avoidance, believing they are protecting the anxious person from harm or distress

Answer 113

A

• Support, reassurance, problem solving

Psychological
• CBT, ITP

Supportive therapy
Family/Group therapy – may reinforce positive coping strategies
Individual therapy – must be time limited to prevent dependence
Crisis counselling – is of doubtful benefit except in those with no other supports
Psychodynamic psychotherapy

• Mindfulness based therapy
o Problem solving: analyse stressors, determine if they can be eliminated/minimised
o To clarify and interpret the meaning the patient gives to the stressor
o To reframe the meaning of the stressor
o To illuminate the concerns and conflicts the patient experiences
o To identify a means of reducing the stressor
o To maximize the patient’s coping skills (emotional self-regulation, avoidance of maladaptive coping, especially substance misuse)
o To help patients gain perspective on the stressor, establish relationships, mobilize support, and manage themselves and the stressor

Answer 114

A

• TCA +/- ITP

Answer 115

A

Debriefing is not recommended
Watchful waiting may be used for mild symptoms lasting <1m
Trauma focused CBT or EMDR may be used in more severe cases
Drug treatment not routinely recommended (meded says paroxetine and mirtazapine are recommended if drug treatment is used)

Answer 116

A

1st line – Mild functional impairment
• Low-intensity psychological therapies
o Brief individual CBT (incl. exposure and response prevention, RP) using structured self-help materials
o Brief individual CBT (incl. ERP) by telephone
o Group CBT (incl. ERP)
o Should be done for up to 10 therapist hours per patient

Answer 117

A

2nd line – moderate functional impairment OR mild functional impairment but low intensity psychological therapies not effective/inadequate OR BDD with moderate functional impairment
• SSRI or more intensive CBT (including ERP, more than 10 therapist hours per patient)
o SSRI possible agents: fluoxetine, fluvoxamine, paroxetine, sertraline, citalopram
 This is an off-label use of citalopram
o Continue SSRI treatment for at least 12 months after remission of symptoms

Answer 118

A

3rd line – if inadequate response with an SSRI alone (within 12 weeks) or CBT (incl. ERP) alone (>10 therapist hours per patient)
• Combined treatment with an SSRI + CBT (incl. ERP)

Answer 119

A

4th line (after 12 weeks) – if inadequate response after 12 weeks of combined treatment with an SSRI + CBT (incl. ERP) OR no response to SSRI alone OR patient has not engaged in CBT

• Different SSRI or Clomipramine
o Clomipramine considered only if: a) at least one SSRI has been ineffective or poorly tolerated or b) the patient prefers clomipramine or has had a previous good response to it

Answer 120

A

• Combined treatment with an SSRI + CBT (incl. ERP)

Answer 121

A

1st line – low-intensity CBT incl. ERP [mild functional impairment start from here] [up to 10 h per patient]
2nd line – SSRI or more intensive CBT [moderate functional impairment start from here]
3rd line – SSRI + intensive CBT incl. ERP [severe functional impairment start from here] >=[>10h per patient]
4th line – different SSRI or Clomipramine
(very rare but just have it in mind – psychosurgery – anterior cingulotomy)

Answer 122

A

1st line: SSRI
2nd line: Clomipramine (TCA)
Those on medications need to understand that there is a lag time between medication initiation + response (6-8 weeks but can be up to 3 months)
The focus of treatment should be for improvement in symptoms, and not complete remission
Important to set up a patient’s expectations of how much improvement they will have on medications – patients can expect a maximum of 30-35% reduction
An “adequate trial” for one medication is between 12-15 weeks, with at least 6 weeks at the maximum dose
Symptoms should always be monitored via a scale like Y-BOCS

Answer 123

A

• CBT incl. ERP
• ERP – Exposure and Response Prevention
o Compulsions are analogous to escape in phobias
o In ERP patients are exposed to situations that trigger obsessions + are thought strategies to prevent the compulsive response that would temporarily relieve their anxiety
o Patients gradually become desensitized to the fear stimulus  improved OCD symptoms
o Exposure = exposing the patient to the thoughts, images, objects, situations that make them anxious and/or trigger obsessions
o Response Prevention = teaching the patient to not perform those compulsive behaviors once those anxiety or obsessions have been triggered; instead, they are taught to perform an opposite action.
o A hierarchy of feared situations is used
o Effective in well-motivated patients
• Those doing therapy need to understand there is an extensive time commitment involved as well
• Relapse is more likely with discontinuation of SSRI therapy compared to CBT/ERP
o Patients must also be treated longer (at least 3 months) with doses near the maximum recommended doses (resulting in increased rates of adverse effects)

Answer 124

A

• Exercise  emerging evidence that exercise is a feasible + clinically impactful treatment for OCD
o Increased levels of BDNF, improved cerebral flow, increased volume to the hippocampus, enhanced cognitive + neuropsychological functioning, improved resilience + overall well-being
• Psychoeducation through self-help literature and online resources
• Carer education – friends + family are often recruited in SSB and may facilitate escape and avoidance, believing they are protecting the anxious person from harm or distress

Answer 125

A

• Support, reassurance, problem solving

Psychological
• CBT, ITP
• Supportive therapy
• Family/Group therapy – may reinforce positive coping strategies
• Individual therapy – must be time limited to prevent dependence
• Crisis counselling – is of doubtful benefit except in those with no other supports
• Psychodynamic psychotherapy
• Mindfulness based therapy
o Problem solving: analyse stressors, determine if they can be eliminated/minimised
o To clarify and interpret the meaning the patient gives to the stressor
o To reframe the meaning of the stressor
o To illuminate the concerns and conflicts the patient experiences
o To identify a means of reducing the stressor
o To maximize the patient’s coping skills (emotional self-regulation, avoidance of maladaptive coping, especially substance misuse)
o To help patients gain perspective on the stressor, establish relationships, mobilize support, and manage themselves and the stressor

Pharmacotherapy
• Short courses of medication for brief symptom relief e.g. insomnia, anxiety, dysphoria
o BZD, SSRI/SNRI (only if symptoms last more than a few weeks)
o Sedating antihistamine

Answer 126

A

• TCA +/- ITP

Answer 127

A

• Short courses of medication for brief symptom relief e.g. insomnia, anxiety, dysphoria

o BZD, SSRI/SNRI (only if symptoms last more than a few weeks)

o Sedating antihistamine

Answer 128

A

• Exclude injury
• Support and reassurance
• Trauma focused CBT
o Highly trained therapist exploring the thoughts around he traumatic event and linking them to behaviours or symptoms which are developing because of them
o It aims to give control over thoughts ad behaviours back to the individual
• Benzodiazepines may alleviate short-term distress but do not prevent later PTSD

Answer 129

A

Step 1 – recognition and diagnosis
Step 2 – treatment in primary care (self-help)
Step 3 – review and consideration of alternative treatments
Step 4 – review and referral to specialist MHS
Step 5 – care in specialist MHS

Answer 130

A

Self-help
CBT + SSRI
If no response after 12 weeks – TCA (imipramine or clomipramine)

Answer 131

A

• Low-intensity interventions
o Individual non-facilitated self-help (6 weeks)
o Individual facilitated self help (6 weeks, weekly therapist appointment)

Answer 132

A

High intensity psychological intervention +/- medication
CBT or

• Anti-depressant
o If the disorder is long-standing
o If the person has not benefitted/has declined psychological intervention

Answer 133

A

• Psychoeducation
o Carers and families
o About nature of their condition + treatment options available
o Information on the use and likely side-effect profile of medication

• Support and self-help groups
o Offer information about them, where they are available etc.
o To address the emotional, social and economic costs
o Can also promote understanding and collaboration between people who have panic disorders
o Support groups may provide face-to-face meetings, telephone conference support groups (which can be based on CBT principles) or additional information on all aspects of anxiety disorders plus other sources of help)

• Self-help monitoring
o Individuals receiving self-help interventions should be offered contact with primary health care professionals so that progress can be monitored and alternative interventions can be considered if appropriate
o Between every 4 to 8 weeks
• Exercise

Answer 134

A

• Antidepressants
o Should be the only pharmacological intervention used in the longer-term management of panic disorder

• SSRIs – escitalopram, sertraline, citalopram, paroxetine (1st line)

• SNRIs – venlafaxine (1st line)
o If no improvement after 12 weeks  TCAs

• TCA – imipramine, clomipramine (2nd line)
o TCA – if there is no improvement after a 12 week course and if further medication is appropriate
o Highest risk of deliberate self-harm by overdose or otherwise out of the 3

• Monitoring and follow up
o Review efficacy + side effects
 Within 2 weeks of starting treatment
 Again at 4, 6, 12 weeks
o Assess effectiveness of the treatment at the end of 12 weeks
 Decision should be made as to whether to continue or consider an alternative intervention
o If medication is to be continued beyond 12 weeks, review individual at

Answer 135

A

• Where available, consideration should be given to providing psychotherapies in the person’s own language if this is not English
• CBT should be used
o Should be delivered only by suitably trained and supervised people
o Should be offered in the optimal range of duration  7-14 hours in total
o Weekly sessions of 1-2 hours
o Should be completed within maximum of 4 months of commencement
o Should be supplemented with appropriate focused information and tasks
o Briefer CBT – 7 hours, designed to integrate with structured self-help materials
o For a few people, more intensive CBT over a short period of time might be appropriate

Answer 136

A

• If there have been 2 interventions provided (any combination of psychological intervention, medication or bibliotherapy) and the person still has significant symptoms

• Options in secondary care
o Treatment of co-morbid conditions
o CBT with an experienced therapist if not offered already (incl. home based CBT if attendance at clinic is difficult)
o Full exploration of pharmaco-therapy
o Day support to relieve carers and family members
o Referral for advice, assessment or management to tertiary centres

Answer 137

A

Usually present with chest pain
Do not necessarily constitute a dx of panic disorder

• key management
o ask if they are already receiving treatment for panic disorder
o undergo the minimum investigations necessary to exclude acute physical problems
o be referred to primary care for subsequent care
o be given appropriate written information about panic attacks + why they are being referred to primary care
o be offered appropriate written information about sources of support incl. local and national voluntary and self-help groups

Answer 138

A

Assessment in primary care: PACES
• Current or previous violence (incl. severity, circumstances, precipitants, victims)
• Presence of comorbid metal disorders and/or substance misuse
• Contact with the criminal justice system (incl. convictions, periods of imprisonment)
• Current life stressors, relationships, life events
• Collateral history

Assessment in secondary care
• Antisocial behaviours
• Personality functioning, coping strategies, strengths, vulnerabilities
• Comorbid mental disorders
• The need for psychological treatment, social care, support, occupational rehabilitation or development
• Domestic violence and abuse

Psychological
• Screen for alcohol misuse, depression, anxiety
• Group-based cognitive and behavioural interventions
o To address problems such as impulsivity, interpersonal difficulties and antisocial behaviour
o Programmes to reduce offending
• Other psychological interventions (contingency management programmes) if misuse of drugs, alcohol misuse

Social
• Support groups for families and carers
• YoungMind, Carers UK
• Safeguarding for family members

Answer 139

A

Crisis management in primary care PACES
• Assess risk to others and self
• Ask about previous episodes + effective management in the past
• Enhance coping skills/help to focus on current problems
• Encourage identifying manageable changes that will enable them to deal with current problems
• Offer follow up
• Refer to CAMHS if – a) there is increasing distress/risk to themselves, b)they requires further help, c) risk has not subsided despite attempts to reduce anxiety + improve coping skills

Crisis management in secondary care PACES
• Crisis management plan
o Be calm + non-threatening
o Understand the person’s POV
o Explore reasons for distress
o Empathetic open questioning – onset + course
o Stimulate reflection about solutions
o Avoid minimising reasons for crisis
o Do not offer solutions before receiving full clarification of the problems
o Explore other options vs admission to crisis unit/inpatients
o Offer follow up
• Short term sedatives – no longer than 1 week
o E.g. sedative antihistamine (?promethazine) – low SE profile, low addictive properties, minimum potential for misuse, safe in overdose

Treating a crisis
•	Provide contact numbers for
o	Community mental health nurse
o	Out-of-hours social worker
o	Local crisis resolution team

Follow up after a crisis
• Review
o Crisis + causes (environmental, personal relationship)
o Drug treatment, benefits, SE, safety concern, role
o Psychological treatments incl. their role in the overall treatment strategy and their possible role in precipitating the crisis
• Stop drugs within a week

Insomnia
• Sleep hygiene
• Bedtime routine
• Avoid caffeine
• Reduce activities likely to defer sleep
• Consider sedative antihistamines (promethazine) or z-drugs (z-drugs have potential to be misused)

Answer 140

A

Management of personality disorders
For all consider:
At risk of harming themselves or other
s/unable to attend basic self-needs:
• Partial hospitalisation or inpatient hospitalisation referral
• Referral for substance abuse assessment

Patient communication and relationship management (maintain good relationship with patient)
Refer for substance abuse: treatment with naltrexone, acamprosate, disulfiram may be of benefit to patients attempting to abstain from alcohol use

o Antipsychotics – may reduce impulsivity + aggression (e.g. risperidone)
o Antidepressants – may reduce impulsivity + anxisety
o Mood stabilisers – may reduce labile affect (effects aren’t evidence based)

• Treat comorbid problems
o Substance misuse, affective + anxiety disorders require management

Answer 141

A

Low-dose antipsychotics for schizotypal

* Anti-depressants may help self-injurious behaviour and depressive or psychotic-like symptoms

Answer 142

A

• BPD – DBT, MBT

Antipsychotics -  impulsivity, aggression – BPD, paranoid, schizoid
Anti-depressants – may have general effects at reducing impulsivity + anxiety (BPD, cluster c)
Mood stabilisers – e.g. lithium for lability
Treat comorbid problems e.g. substance misuse, affective and anxiety disorders

Answer 143

A

CBT
DBT
CAT – cognitive analytical therapy
MBT – develop empathy, understand what people think and feel
Psychodynamic and psychoanalytical psychotherapy
Social skills training
Dynamic psychotherapy
Therapeutic community

• Most approaches are related to CBT (focusing on the interaction between thoughts, moods and behaviours right now) + psychoanalysis (explores how the past relates to interpersonal difficulties)
o DBT
 Type of CBT that has been adapted for people who experience emotions very intensely
 Used to treat EUPD/BPD
 Focuses on changing unhelpful behaviours + accepting who you are at the same time
o Cognitive analytical therapy (CAT)
o Mentalisation
 Integrative form of psychotherapy that brings together aspects of psychodynamic, CBT and systemic approaches
o Therapeutic communities
 Group-based approach to long-term mental illness
 Housing placements where the residents make their own rules
o Psychodynamic and psychoanalytical psychotherapy

Answer 144

A

Psychoeducation
Carer education
Therapeutic community – consciously designed social environment + programme within residential/day unit
Challenge/modify interpersonal behaviours

Answer 145

A

Psychotherapy
• NICE – Group based cognitive and behavioural interventions (e.g. group CBT) – To address impulsivity, interpersonal difficulties, challenging/antisocial behaviours
• Peer therapy settings more effective than individual therapy
• Psychodynamic therapy is not recommended
• Contingency management treatment ( a behavioural therapy where adaptive behaviours are rewarded) may be used

General therapy principles

Set firm limits using mentalizing based approaches
Therapist must understand + process their own countertransference

Medications
• NICE – Pharmacological interventions should not be routinely used for the treatment of antisocial PD or associated behaviours of aggression, anger and impulsivity

Answer 146

A

Psychotherapy
•	NICE – DBT – most commonly used, especially in women with recurrent self-harm
•	TFP (transference focused therapy)
•	MBT (mentalization based therapy) 
•	SFT (schema focused therapy)

Medications
• NICE – Drug treatment should not be used specifically for BPD or for the individual symptoms or behaviour associated with the disorder
• NICE – Short-term use of sedative medication can be considered in a crisis (should not be longer than 1 week)
• NICE recommends that antipsychotics should not be used for the medium- and long term treatment of BPD

Crisis
• NICE – Short term treatment – consider a drug e.g. a sedative antihistamine (?promethazine) that has low SE profile, low addictive properties, minimum potential for misuse and relative safety in overdose

Insomnia – NICE
• Advice about sleep hygiene
• Z-drugs (zalepon, zolpidem, zopiclone) (potential for misuse)
• Sedative antihistamines (promethazine (less potential for misuse)

Answer 147

A

Psychotherapy with a particular focus on therapeutic alliance

Answer 148

A

For significant self-destructive behaviours
•	MBT 
•	TFP
•	SFT
•	DBT

Higher functioning narcissistic personalities
• Psychodynamic/psychoanalytic psychotherapy
• Supportive psychotherapy

• Individual psychotherapy

Answer 149

A

Psychotherapy
CBT (similar approach for social phobia)
Psychodynamic therapy

Therapists should encourage gradual exposures into the world, and stay aware of threats to patient’s self-esteem

SSRIs
Venlafaxine

Answer 150

A

CBT – can be used to challenge negative thoughts + encourage independent behaviours

Answer 151

A

CBT – best validated treatment of OCPD
(addressing core beliefs e.g. “If I’m not in control, things will fall apart”)
Psychodynamic therapy – may be appropriate when feelings are more accessible

Answer 152

A

DBT
Focuses on the factors contributing to emotional instability
Being emotionally vulnerable and sensitive to stress
Growing up in a environment where your emotions were dismissed by those around you

Vicious cycle: intense + upsetting emotions  make you feel guilty + worthless  lead to actions that can make you feel upset again

Goal: helps learn to manage difficult emotions by letting yourself experience, recognize and accept them
Aims to introduce 2 important concepts
Validation – accepting that your emotions are acceptable
Dialectics – showing you that things in life are rarely black or white and helping you be open to ideas and opinions that contradict your own

As you learn to accept/regulate emotions  more able to change harmful behaviour
Learn more effective ways of dealing with distress
Replace harmful behaviours with ones that can help you move forward with your life
Mindfulness – set of skills helping you focus your attention and live your life in the present, rather than being distracted by worries about the past or future
Distress tolerance
Interpersonal effectiveness – teaching you how to ask for things + say no to other people, while maintain your self-respect and important relationships
Emotion regulation

Answer 153

A

Mentalisation-Base therapy
• Mentalisation is the ability to think about thinking – examining your own thoughts and assessing them based on reality
• Teaches you how to take a step back and scrutinise your thoughts and impulses
• Teaches you how to recognise other peoples’ thought patterns and accept that your interpretation may not be correct
• Usually lasts around 18 months
• Some places recommend staying as an inpatient

Answer 154

A

Psychological therapy
• 2/7 psychological treatments may be considered

• Women for whom reducing self-harm is a priority – comprehensive DBT

Other psychological therapies: MBT, therapeutic communities, arts therapies
Other options: CBT, CAT

•	Monitor the effect of treatment on a broad range of outcomes
o	Personal functioning
o	Drug + alcohol use
o	Self-harm
o	Depression
o	Symptoms of PTD

DBT
Mentalisation-Base therapy

• Art therapies
o Useful for people who struggle to express their feelings verbally

Answer 155

A

Social
• Psychoeducation

• Carer education

• Therapeutic communities
o Involves teaching social skills to groups of people with complex psychological conditions
o Includes tasks that improve your social skills and self-confidence (e.g. household chores, meal preparation)

Specialties guide SSRIs may be useful to reduce impulsive behaviour

Answer 156

A

• Prescribing anti-depressants
o SE on the initiation of antidepressants may be minimised by starting at a low dose + increasing the dose slowly until a satisfactory therapeutic response is achieved
o If the person is showing improvement with an antidepressant, the medication should be continued for at least 6 months after the optimal dose is reached, after which the dose can be tapered

• When prescribing SSRIs be aware of
o Cocaine use (drug-drug interactions)
o The need to avoid concurrent use of multiple serotonergic drugs

Answer 157

A

• All people who are prescribed antidepressants should be informed at the time that the treatment is initiated of
o Potential SE (incl. transient increase in anxiety at the start of treatment)
o Drugs are not associated with tolerance and craving

o Risk of discontinuation/withdrawal symptoms if treatment is stopped abruptly or in some instances on reducing the dose of the drug
 Most commonly experienced – dizziness, numbness, tingling, GI disturbances (N+V), headache, sweating, anxiety, sleep disturbance
 To minimise this risk, the dose should be reduced gradually over an extended period of time
 Pt should seek advice from their medical practitioner if they experience significant discontinuation/withdrawal symptoms
 Mild – reassurance
 Severe – consider reintroducing the drug or prescribing another from the same class with a longer half-life + gradually reducing the dose while monitoring symptoms

o The delay in onset of effect, time course of treatment, need to take medication as prescribed

Answer 158

A

Physical exercise
Tobacco cessation
Reduce harmful drinking
Lose excess weight in midlife
Adhere to healthy diet (a Mediterranean-style diet)
Cognitive training
Social participation and support throughout life
HTN, DM, depression should be managed

Answer 159

A

o Conduct a physical examination and
o Undertake appropriate blood + urine tests to exclude reversible causes of cognitive decline and
o Use cognitive testing but do not rule out dementia solely because the person has a normal score on a cognitive instrument
 10-point cognitive screener (10-CS)
 6-item cognitive impairment test (6CIT)
 6-item screener
 Memory Impairment Screen (MIS)
 Mini-Cog
 Test your memory (TMT)
o Tests that characterize global impairment
 MMSE
 <10 – severe
 10-20 – moderate
 21-26 – mild
 MoCA

• Assess risk
o ADLs – personal care (bathing, dressing, continence), housework, preparing meals, shopping, managing finances, taking drug treatments as prescribed
o Safety in home + outside
o Social functioning + support
o Driving
• Refer the person to a specialist dementia diagnostic service e.g. memory clinic, community old age psychiatry service if
o Reversible causes of cognitive decline have been investigated and
 Delirium, depression, sensory impairment (e.g. sight or hearing loss), cognitive impairment from medicines associated with  anticholinergic burden)
o Dementia is still suspected
• Refer to a specialist neurological service if
o <65
o Focal neurological signs on examination
o Rapid cognitive decline
o Genetic cause likely
o Learning difficulties

Answer 160

A

Ensure that the pt + family/carers have access to a memory service
Assess for any emerging dementia-related needs during primary care appointments

• Care coordination – provide people living with dementia a single named health or social care professional who is responsible for coordinating their care

offer the person and their families oral + written information that explains
• Dementia subtypes + changes to expect as condition progresses

• Which HCP + social care teams will be involved in their care + how to contact them

• How dementia affects driving + what they need to tell the DVLA + car insurer about their dx
o MCI + no driving impairment – may drive, do not need to notify DVLA
o MCI + possible impairment of driving – must not drive, should notify the DVLA
o Dementia – must inform DVLA

Legal rights + responsibilities
Right to reasonable adjustments if they are working or looking for work

• How the following groups can help and how to contact them
o Local support groups, online forums, national charities
o Financial and legal advice services
o Advocacy services

Advanced care planning
Discuss 
•	The benefits of planning ahead
•	LPA
•	Advance statement about their wishes/preferences/beliefs/values re their future car
•	Advance decisions to refuse treatment 
•	Their preferences for place of care and place of death 
•	Wills

Answer 161

A

Always carry ID, address and contact number in case they get lost
Dossett boxes/blister packs to aid medication compliance
Reality orientation (visible clocks, calendars)
Environmental modifications (e.g. patterned carpets can predispose to hallucinations)
Assistive technology (e.g. door mat buzzers)
Do a home safety assessment and ensure that adaptations are made to home (fires, floods, falls)

Answer 162

A

Discuss dx
Arrange F/U 6/12 + if symptoms worsen re-refer to mental health team
Suggest healthy brain exercises – regular exercise, word games, socialisation

Answer 163

A

Discuss dx + give written information
Commence F/U in primary care
Assessment + treatment – community based unless severely disturbed or complex physical/psychiatric problems
Treat identified RF
Treat sensory impairment – glasses, hearing aids
Treat comorbid psychiatric illness (e.g. depression)
Review medication
Exclude delirium
Consider referral to social services, SALT, OP, physiotherapy

Answer 164

A

Admit if severely disturbed
Might need to section under the MHA
Drug treatments should only be initiate by specialists – cannot be started in primary care
Start low, go slow – older people are very sensitive to drug side-effects

Answer 165

A

• Mild to moderate dementia – 3 anticholinesterase inhibitors (AChE inhibitor)
o Donepezil
o Galantamine
o Rivastigmine
o SE – fatigue, dizziness, muscle craps
• Memantine monotherapy for managing AD for people with
o NMDA receptor antagonist
o Moderate AD who are intolerant / have a contraindication to AChE inhibitors or
o Severe AD
• Established diagnosis of AD
o If people are not taking an AChE inhibitor or memantine
 Only start treatment with these on the advice of a clinician who has the necessary knowledge and skills
 Once a decision has been made to start an AChE inhibitor or memantine, the first prescription may be made in primary care
o If people are already taking an AChE inhibitor
 Moderate/Severe disease – memantine in addition to an AChE inhibitor
 Memantine can be prescribed by primary care prescribers without taking advice frm a specialist clinician
 Do not stop AChE inhibitors in people with AD because of disease severity alone

Answer 166

A

• Only consider AChE inhibitors or memantine for people with vascular dementia if they have suspected comorbid AD, PDD, or LBD

Answer 167

A

• 1st line = AChE inhibitors (to treat hallucinations + agitation)
o Mild moderate dementia
 1st line = Donepezil or rivastigmine
 2nd line = Galantamine

o Severe dementia
 Donepezil or rivastigmine
• 2nd line = memantine
• (for REM sleep disorder – low dose melatonin or clonazepam)

Parkinson’s medications could relieve the tremors but worsen the psychosis
Antipsychotics are dangerous and should not be used (they cause severe reactions – confusion, Parkinsonism, death)

• Other (psychosocial)
o Adaptations for patient (with an occupational therapist)
 Reality orientation, environmental modifications

o Social support/support carers
o Optimising physical health (review medications)
o Psychological therapies (reminiscence therapy)

Answer 168

A

• Do not offer AChE inhibitors or memantine – may exacerbate behavioural symptoms
o This is because unlike AD, cholinergic neurons are relatively preserved in FTD
• Behavioural symptoms may respond to antidepressants
o Trazodone – good evidence for treatment of behavioural symptoms related to FTD
o SSRIs – citalopram, fluoxetine, sertraline
• Antipsychotics + anti-epileptics may be effective in the management of behavioural symptoms but are limited in use due to their SE profile

Answer 169

A

1st line – donepezil, rivastigmine

* Galantamine has less evidence

Answer 170

A

• Encourage and enable people living with dementia to give their own views and opinions about their care
• Care plans for people with dementia should include
o Details on dx + treatment – non-pharmacological + pharmacological methods
o Environmental modifications
o Sources of information, review plans
• Psychoeducation – symptoms, treatment, prognosis
• Mild-moderate dementia
o Offer group cognitive stimulation therapy – for cognitive symptoms and maintaining function e.g. word association, categorization, number games, discussing news
o Consider group reminiscence therapy – encourage someone to talk about their life, often using prompts from the past e.g. music, photographs, objects
o Behavioural approaches – identify + modify triggers for difficult/risky behaviours (e.g. wandering may be due to disorientation, boredom, anxiety)
o Validation therapy – reassure and validate emotion behind what is said
o Multisensory therapy – as dementia progresses + speech is lost  easier to respond to touch, music etc.
o Consider cognitive rehabilitation or occupational therapy

Answer 171

A

• Planning
o MHOA teams explore the person’s wishes for the future, supporting them to formalize theses .e.g. writing an advanced decision (e.g. living will), appointing a LPA to manage financial/health decisions, should they lose capacity to make these
o Discuss driving – independence must be balanced against safety

• Offer a range of activities to promote wellbeing that are tailored to the person’s preferences

• Identify and modify underlying triggers for difficult or risky behaviours
o Wandering due to disorientation/boredom/anxiety/pain/hunger/needing toilet  provide regular food/calm environment

• Mild-moderate dementia
o Consider cognitive rehabilitation or occupational therapy to support functional ability

• Home support – practical interventions
o Dosette boxes/blister packs – aid medication concordance
o Orientation aids – clearly visible clocks, calendars, written reminders
o Environmental modifications – remove patterned rugs (tigger visual illusions), change gas to electric hobs
o Helpcards – essential information people carry in case of getting lost (e.g. their name, that they have memory problems, carer/GP contact details)
o Care packages – help at home e.g. personal care, meal preparation, medication supervision
o Assistive technology – sensor alerts carer if one leaves home overnight, tracker watches with panic alarms can help people who get lost or anxious while out and about

• Day centres – enjoyable day activities + social contact
• Day hospitals – daily psychiatric care and rehabilitation for those with greater needs
• Care homes
o When people cant live safely or comoftably at home
o GPs + MHOA support teams can optimise residential + nursing home care

• Social support
o Personal care, meal preparation, medication prompting
o Day centres provide enjoyable daytime activities and social contact
o Day hospitals enable daily psychiatric care for more complex patients

• Carer support, psychoeducation, skills training, psychological therapy incl. CBT + training in stress reduction, communication and problem solving
o Offer carer’s assessment
o Emotional support
o Educate about dementia
o Train to manage common problems
o Provide respite care = Respite care is designed to give carers a break for a limited period of time. Someone else provides care so the carer can go on holiday, attend to everyday activities or just relax.

•	Dementia support services
o	The Alzheimer’s society
o	NHS choices
o	National institute on ageing
o	Family caregiver alliance, carer’s UK
o	The lewy body society
o	Frontotemporal dementia support group

Answer 172

A

• Before starting non-pharmacological or pharmacological treatment for distress in people living with dementia
o Explore possible reasons for their distress
o Check for and address clinical or environmental causes (pain, delirium, inappropriate care)
• Offer psychological + environmental interventions to reduce distress + while people are taking the antipsychotics + after they have stopped taking them
• Behavioural disturbance may require sedatives as last resort (e.g. trazadone, haloperidol)
• Antipsychotics:
o For people living with dementia only if they are either
 At risk of harming themselves or others or
 Experience agitation, hallucinations or delusions that are causing them severe distress
o LBD, PDD
 High potency antipsychotics are contraindicated in LBD!!
 Can worsen the motor features of the condition, result in cognitive impairment, sedation, increased/irreversible acute onset of parkinsonism, or symptoms resembling neuroleptic malignant syndrome
 Antipsychotics can cause severe antipsychotic sensitivity reactions in some cases – can lead to death
 Symptoms of sensitivity – worsening of extra-pyramidal signs, changes in consciousness (acute and severe physical deterioration)
 If an antipsychotic must be used (severely distressed, immediate risk of harm to the person or others), then low potency atypical antipsychotics like clozapine or quetiapine should be used
o When using antipsychotics
 Use the lowest effective dose + for the shortest possible time
 Reassess the person at least every 6 weeks to check whether they still need medication
o Stop treatment with antipsychotics if
 The person is not getting a clear ongoing benefit from taking them and
 After discussion with the person taking them + their family members/carers
o Do not offer valproate
o Avoid using olanzapine + risperidone – increased risk of stroke
• If at increased risk of harming others/themselves
o Advise moving the person to a safe, low-stimulation environment away from others
o Verbal + non-verbal de-escalation techniques
o Short term use of drugs for behavioural control (haloperidol, lorazepam, olanzapine)
o Oral medication offered before parenteral medication
o IM preferred to IV
o Rapid tranquillisation – IM haloperidol and IM lorazepam
o IM haloperidol (or any other IM conventional antipsychotic) – monitor closely for dystonia and other EPSEs
o If SE become distressing especially in acute dystonic reaction  consider use of anticholinergic agents
o If using anti-cholinergic agents  monitor for deteriorating cognitive function

Answer 173

A

Mild-moderate dementia + mild-moderate depression  psychological treatments
Do not routinely offer antidepressants to manage mild/moderate depression in people living with mild/moderate dementia unless they are indicated for a pre-existing severe mental health problem
LBD – SSRIs – sertraline, citalopram
Note – SSRIs may cause hyponatraemia in the elderly, so remember to check sodium levels

Answer 174

A

Do not offer melatonin in AD
Sleep hygiene education, exposure to daylight, exercise, personalised activities
LBD with REM sleep behavioural disorder – clonazepam, melatonin

Answer 175

A

Key is to prevent further cerebrovascular disease by optimal control of major risk factors in people with a history of stroke or TIA
Anti-platelets (aspirin or aspirin/dipyridamole) + lifestyle modification
If carotid stenosis >70% - carotid endarterectomy/angio + stenting
If concomitant AD – cholinesterase inhibitors or memantine
Hypertension – BP control
Elevated LDL – statins
DM – optimise glycaemic control

Answer 176

A

Encourage people living with dementia to have eye tests every 2 years
Take into account the increased risk of delirium in people with dementia during hospital admission
Consider involving a SALT if there are concerns about a person’s safety when eating and drinking
Beware that carer interventions are likely to be most effective when provided in group sessions
Beware that carers of people living with dementia are at an increased risk of depression
LBD – Extrapyramidal symptoms – levodopa, carbidopa

Answer 177

A

•	Rivastigmine
o	N+V
o	Diarrhoea
o	Weight loss 
o	Anorexia
o	Treatment should be stopped if GI symptoms (dyspepsia  gastric/duodenal ulcers) occur and then reiterated on resolution if necessary

• Donepezil
o All of the above
o Vivid dreams

• Galantamine
o Similar to rivastigmine
o Warn patients of serious skin reactions (SJS, acute generalised exanthematous pustulosis, erythema multiforme) – stop drug immediately if symptoms occur, seek advice

•	Memantine 
o	Headaches
o	Somnolence
o	Dizziness
o	Agitation/confusion 
o	Caution if history of convulsions or epilepsy

Answer 178

A

• Behavioural management
o Frequent reorientation (e.g. clocks, calendars, verbal reminders)
o Good lighting (gloomy conditions increase risk of hallucinations/illusions)
o Address sensory problems (e.g. hearing aids, glasses)
o Avoid over or under stimulation (side-room if the main ward is disruptive)
 Silence unnecessary noises (e.g. bleeping alarms)
o Minimise change
 Don’t keep moving the patient
 People at risk of delirium should be cared for by a team of HCP who are familiar to the person at risk – one staff member to engage the patient each shift
 Establish a routine – regular toileting + sleep hygiene
o Remove things that can be thrown or tipped over
o Allow safe and supervised monitoring
o Facilitate regular visits from family and friends
• Address
o dehydration +/or constipation
o Infection
o Immobility or limited mobility
o Pain
o Poor nutrition
o Sensory impairment
o Urinary retention
• Assess for hypoxia + optimise oxygen saturation
• Promote good sleep patterns and sleep hygiene
• Daily observations for recent changes or fluctuations in usual behaviour

Answer 179

A

• Consider referral
o Geriatrics
o Psychiatry
• If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first
• Reorientation – explain where the person is, who they are, what your role is + reassurance
• Manage the cause of delirium
• First consider the non-medical issues that could be causing an altered level of consciousness – pain, vision deficits, hearing deficits, hunger, constipation, urinary retention
• Then consider the medical aetiologies – DIMS-R
o Drugs – intoxication/withdrawal (alcohol,benzodiazepines), sedatives (benzodiazepines, barbiturates, antihistamines), anticholinergics (oexybutynin, tolterodine, anti-naudeants, promotlity agents, TCA, antipsychotics), anti-convulsant (mysoline, phenobarbitone phenytoin), anti-parkinsonian agents (DA agonsits, levodopa-carbidopa, amantadine, benztropine), alcohol – stop unnecessary medications
o Infections – genitourinary, chest, skin/soft-tissue, blood
o Metabolic – glucose/electrolytes/Cr/LFTs, VBG CO2, TSH, B12
 Clinical evidence of changes in hydration status present – e.g. hx of GI losses, signs of hypovolaemia/dehydration, signs of volume overload
o Structural – intracranial pathologies (stroke, haemorrhage, seizures, neoplasms)
o Sensory/environmental – pre-existing dementia, significant auditory/visual disturbances, environmental changes, night
o Retention – fecal impaction or urinary retention – abdominal x-rays, palpation, DRE, disimpaction

Answer 180

A

• Pharmacological management should only be used if the symptoms of delirium threaten the patient’s own safety, the safety of others or would result in the interruption of essential therapy
• Small night time benzodiazepines could promote sleep
• Distressed pt at risk of harming themselves or others
o Verbal + non verbal descalation techniques
o Short-term low dose haloperidol (<1 week) [NICE] or benzodiazepines (specialties guide)
o Baseline ECG for a QTc prolongation monitoring if pt is on haloperidol
o Other first line antipsychotics (psychdb) – risperidone, olanzapine quetiapine
 PD, LBD – atypical antipsychotics are preferred
o Second line (psychdb) – lorazepam
 Can worsen or prolong delirium
 Should only be used for patients with alcohol withdrawal or patients with antipsychotic sensitivity (e.g. PD, LBD)
• Antipsychotic drugs
o Use with caution
o Not suitable for all pt e.g. pt with PD or LBD

• New delusions or hallucinations, particularly nonauditory, in middle age or later deserve evaluation for delirium or another medical cause

Answer 181

A

• Information and support
o Delirium is common and usually temporary
o Describe people’s experience of delirium
o Encourage people at risk + their families and/or carers to tell their healthcare team about any sudden changes/fluctuations in behaviours
o Encourage pt to share their experience of delirium with the HCP during recovery
o Advise the person of any support groups
o Ensure that the information provided meets the cultural, cognitive and language needs of the person

Answer 182

A

• Biological
o SSRIs (e.g. citalopram)
 SSRIs may cause hyponatraemia in the elderly so remember to check sodium levels
o ECT – sometimes used in psychotic or life-threatening depression
• Psychological
o CBT
o Psychodynamic therapy
o Group therapy
o Family therapy
o Couple therapy
• Social
o Age UK
o Consider social workers, community nurses, carers
o Problem solving, increasing socialisation and day-time activities
• F/U people who suffer pseudodementia – at higher risk of developing actual dementia

Answer 183

A

• Management is usually psychological (CBT) although SSRIs can be useful

exercise etc

Answer 184

A

Reduction of sensory impairment
Exclusion of organic cause or LBD
Low-dose antipsychotics

Answer 185

A

• Early intervention in psychosis services
o The service aims to engage patients with very early symptoms, from adulthood till 35 years
o Psychosis is toxic  the longer the patient is psychotic, the more it will affect their cognitive abilities, insight and social situation => the sooner effective treatment can be started, the better the prognosis
o DUP – the time from the first clear-cut psychotic symptom until the start of effective treatment
o Patients offered antipsychotics + psychosocial interventions  aim of keeping the duration of untreated psychosis (DUP) under 3 months
o Service can be used in children >14 y/o  CAMHS can deal with psychosis in children up to 17 y/o
o If urgent intervention is necessary  crisis resolution team, home treatment team

• Offer crisis resolution + home treatment teams
o Consider acute community treatment within crisis resolution and home treatment teams before admission to an inpatient unit

• Primary care  do not start antipsychotic medication for a first presentation of sustained psychotic symptoms in primary care unless it is done in consultation with a consultant psychiatrist
• Treatment options
o Oral antipsychotic +
o Psychological interventions (e.g. family intervention, individual CBT)
• Baseline investigations before starting antipsychotics – weight, waist circumference, pulse, BP, fasting blood glucose, HBA1c, blood lipid profile, prolactin levels, assessment of any movement disorders, assessment of nutritional status, diet and level of physical activity

Answer 186

A

• Treat comorbid psychiatric illness – depression, OCD, substance misuse ]
• Nutritional management + weight restoration
o Realistic weekly weight gain target (usually 0.5-1kg/week)
o Set eating plan
• Ultimate goal of increasing person’s confidence in making positive decisions when coping with stress that do not include food or eating
o Disentangle the emotional factors from the eating behaviour
o That emotional problems no longer affect the eating behaviour
o i.e. still depressed and anxious but no link with eating therefore no eating disorder

Answer 187

A

Medication
• Do not offer medication as the sole treatment for anorexia nervosa
• Encourage people with anorexia nervosa to take age-appropriate oral multi-vitamin + multi-mineral supplement until their diet includes enough to meet their dietary reference values
• If they need SSRI – give one with a long half life (fluoxetine has the longest half life) – less likely to be affected/get withdrawal symptoms by purging behaviours

Bone health
• Incremental physiological doses of oestrogen – women 13-17 with AN who have delayed puberty, long-term low body weight and low BMD with a bone age under 15
• Transdermal 17-β oestradiol (with cyclic progesterone) – women 13-17 with AN who have long-term low body weight + low bone mineral density with a bone age over 15
• Bisphosphonates – women 18 and over with AN who have long-term low body wright and low BMD. Teratogenic
• Avoid high impact physical activity that increases the change of falls or fractures

Answer 188

A

First line
o Individual CBT-ED
 40 sessions over 40 weeks – biweekly sessions in the first 2-3 weeks
 A type of talking therapy to help you manage your feelings about food and eating so that you are able to eat enough to be healthy
 It aims to enhance self-efficacy
 Addresses control, low self-esteem, perfectionism
 Encourages healthy eating + reaching a healthy body weight
 Creates a personalised treatment plan based on the processes that appear to be maintaining the eating problem
o MANTRA – Maudsley AN treatment for adults
 20 sessions
 Helps pt understand the cause of their anorexia
 Encourages the person to develop a non-anorexic identity
 Can involve family members
o SSCM – specialist supportive clinical management
 >20 weekly sessions
 Aims to assess, identify and regularly review key problems
 Help people recognise the link between their symptoms + their abnormal eating behaviour
 Encourage reaching a healthy body weight + healthy eating

Second line
• Consider one of these 3 treatments that the person has not had before or
o FPT – ED focused psychodynamic therapy
 40 sessions over 40 weeks
 Patient centred focal hypothesis that is specific to the individual + addresses
• What the symptoms mean to the person
• How the symptoms affect the person
• How the symptoms influence the person’s relationships with others and with the therapist
o Motivational interviewing
 For patients who lack insight into their disorders or who think that their illness is a good thing
o ITP
 Aims at improving social functioning + interpersonal skills
 Better for patients with alter onset/longer duration of illness

Answer 189

A

o FT- AN – AN focused family therapy
 18-20 sessions over 1 year
 Psychoeducation
 Emphasise role of family in helping person to recover – support carers to take a central role in helping the person manage their eating (temporary role)
 Offer option to children for some sessions to be w/o carers
o Individual CBT-ED
 40 sessions over 40 weeks – biweekly sessions in the first 2-3 weeks – 8-12 additional family sessions
 Family sessions – identify anything in the person’s home life that could make it difficult for the to change their behaviour, discuss meal plans
o AFP-AN – adolescent focused psychotherapy for AN
 32-40 sessions over 12-18 months – 8-12 additional family sessions
 Focus on the person’s self-image, emotions and interpersonal processes + how these affect their eating disorder
 Develop a formulation of the person’s psychological issues + how they use anorexic behaviour as a coping strategy
 Address fears about weight gain + emphasise that weight gain + healthy eating is a critical part of therapy
 Find alternative strategies for the person to manage stress

Answer 190

A

• Psychoeducation
o advice on nutrition and health
o on effects of starvation on the body and mind
o regulating body wright, dieting
o adverse effects of attempting to control weight with self-induced vomiting, laxatives or other compensatory behaviours
• Carer education + support
• SEED support group, beateatingdisorders.org.uk
• BEAT  eating disorder charity

Answer 191

A

o May be necessary if
 BMI <13
 BMI <75% ideal or median for age
 Extremely rapid weight loss >1kg/week
 Serious physical complications
 High suicide risk
o Should occur before the onset of medical instability as manifested by abnormalities in vital signs
 Orthostatic hypotension (<80/50mmHg) with an increase in pulse of 20bpm
 Drop in standing BP of 20mmHg
 Bradycardia <40 bpm or Tachycardia >110 bpm
 Inability to sustain core body temperature
• Cold peripheries
• Core body temperature <34.5
• Hypothermia
 ECG abnormalities – prolonged QT interval
 Electrolyte abnormalities – K+ <2.5, Na+ <130, PO4 <0.5
 Renal failure/significant dehydration
 Hypoglycaemia
 Medical complications e.g. syncope, seizure, pancreatitis, heart failure etc
 Uncontrolled bingeing and/or purging
 Acute food refusal
 Inadequate social support, unreliable or inadequate F/U care
o Other markers of nutritional decompensation requiring urgent medical treatment
 Squat test – inability to stand from squatting without using arms for leverage
 Purpuric rash

Answer 192

A

• Severe – urgent referral to CEDS (community eating disorder service)
o BMI <15, rapid weight loss, evidence of system failure
• Moderate – routine referral to CEDS
o BMI 15-17, no evidence of system failure
• Mild – monitor/advice/support for 8 weeks, recommend support from BEAT, routine referral to CEDS if failure to respond
o BMI >17, no additional co-morbidity

Answer 193

A

Blocks D1 + D4 receptors

* Considered the most effective antipsychotic

Answer 194

A

Previous or current neutropenia
Previous myocarditis
Active or progressive liver disease
Only consultant psychiatrists can prescribe clozapine

Answer 195

A

Agranulocytosis, neutropenia
Myocarditis
Reduced seizure threshold
Sedation
Metabolic syndrome
Weight gain
Hypersalivation GI (swallowing problems, constipation)

Answer 196

A

Nicotine is an enzyme inducer

* Smoking cessation can lead to a decrease in CYP450 resulting in  clozapine levels

Answer 197

A

• Risk of Agranulocytosis
• FBC to detect early signs of neutropenia
o Weekly for the first 18 weeks
o Every 2 weeks for weeks 18-52
o Monthly thereafter
o Monitoring must continue throughout treatment and for at least 4 weeks after discontinuation
• Clozaril patient monitoring service (CPMS)
o Provides for centralised monitoring of leukocyte + neutrophil counts which is a mandatory requirement for all patients in the UK who are treated with clozapine
o National service in the UK that gives advice on the drug dosage to use, depending on the blood test results you send to them
o Compulsory for anyone on clozapine
o Also maintains a database which includes all patients who have developed abnormal leucocyte or neutrophil findings and who should not be re-exposed to Clozapine

Answer 198

A

Response to treatment + SE
Adherence
Emergence of movement disorders

•	Waist circumference 
•	BMI
•	FBC, LFT (?fatty liver), U&Es, lipid profile, CBG (followed by a glucose tolerance test and HbA1c if abnormal) 
•	Weight
o	Weekly for 6 weeks
o	At 12 weeks
o	At 1 year
o	Annually thereafter
•	Pulse + BP
o	At 12 weeks
o	1 year 
o	Annually thereafter
•	some people need monitoring of 
o	prolactin levels – if hyperprolactinaemia is suspected or likely (e.g. risperidone)
o	ECGs – important in older people + those on high-dose antipsychotics or clozapine – to monitor the QTc interval; 
o	Children – height every 6m

Answer 199

A

Procyclidine PO/IM (anti-cholinergic)
Consider  anti-psychotic dose
Consider switching to atypical antipsychotic

Answer 200

A

Tetrabenazine (drug which depletes monoamines – DA, histamine, serotonin
Consider  anti-psychotic dose
Consider switching to atypical antipsychotic

*made worse by anti-cholinergics

Answer 201

A

Procyclidine PO/IM (anti-cholinergic)
Consider  anti-psychotic dose
Consider switching to atypical antipsychotic

Answer 202

A

Short term BZD
Propranolol
Consider  anti-psychotic dose
Consider switching to atypical antipsychotic

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