PT SAFETY IN MENTAL HEALTH

Question 1

switching/cross titration

Answer 1

occurs when no response seen or intolerable side effects

Question 2

discontinuation (withdrawal) effects

Answer 2

electric shocks
flu like symptoms
disturbed sleep
GI issues
ataxia/sensory vasomotor

Question 3

serotonin syndrome

Answer 3

caused by too much serotonin in the synapses of the brain
likely during augmentation, or when treating resistant depression

Question 4

3 main symptoms of serotonin syndrome

Answer 4

neuromuscular hyperactivity/abnormality (tremor, clonus, rigidity)

autonomic dysfunction/instability (tachycardia, hyperthermia, cold sweats)

altered mental state (agitation, confusion)

Question 5

drugs that increase likeliness of developing serotonin syndrome

Answer 5

triptans
synthetic cannabinoids
tramadol
hallucinogens

Question 6

safety issues with lithium

Answer 6

• lithium has a narrow therapeutic index, with a high potential for toxicity and therefore careful monitoring is required
• can interchange with sodium and potassium levels in the body, if dehydrated then lithium ions can get reabsorbed instead of the sodium (toxicity)

Question 7

NSAIDs and lithium

Answer 7

NSAIDs reduce the renal excretion of lithium via their action on renal prostaglandins, resulting in increased plasma lithium levels

Question 8

safety issues with antipsychotics

Answer 8

• metabolic syndrome
• thromboemoblism
• myocarditis/cardiomyopathy
• QTC elongation (arrhythmias, sudden death)
• higher risk of seizures
• neuroleptic malignant syndrome

Question 9

high dose antipsychotic therapy (HDAT)

Answer 9

defined as either a total daily dose of a single antipsychotic which exceeds the max limit stated in the BNF or a total daily dose of two ore more antipsychotics which exceed the BNF max

Question 10

when/why does HDAT happen?

Answer 10

1. acute psychotic episode (switching)
2. relapse prevention/poor concordance
3. acute disturbance/emergency tranquillisation
4. treatment resistance/refractory

Question 11

why are some patients on both the depot and oral

Answer 11

poor concordance
ensures some of the drug is taken

Question 12

monitoring parameters in antipsychotics

Answer 12

baseline tests and every 3 months
- ECG
- pulse/HR
- BP
- Temp.
- FBC
- LFTs/U and Es
- electrolytes associated with homeostasis (Ca, Mg etc.)

Question 13

dangerous side effects of clozapine

Answer 13

agranulocytosis
neutropenia

Question 14

when to prescribe clozapine

Answer 14

trial of 2 other antipsychotics for 6-8 weeks before clozapine

Question 15

clozapine dispensing arrangements

Answer 15

• pt must have valid blood test before supply
• NO BLOOD = NO DRUG
• regular monitoring of WBCs, esp. neutrophils
• neutrophil count coded red, amber and green
• medication supplied when green, discontinue on red
• more likely to be neutropenic at the beginning of treatment

Question 16

clozapine blood testing intervals

Answer 16

0-18 weeks = weekly bloods
next 18 weeks = fortnightly
thereafter = monthly

Question 17

titrating clozapine

Answer 17

gradual titration of dose starting from 25mg daily up to 900mg (max), however break in treatment >48 hours, must re-titrate from starting dose (25mg)

Question 18

clozapine specific safety issues

Answer 18

• red/amber result (no supply)
• management of leukopenia/agranulocytosis
• missed doses (>48 hrs)
• CYP induction/inhibition
• co-prescribing (esp. other neutropenic drugs)
• other medicines via GP10 Rx or depot (diff. supply routes)

Question 19

how to withdraw or stop BZs

Answer 19

need to convert BZ dose to ‘diazepam dose equivalents’

gradual reduction by 1/8th or 1/6th of total daily dose every fortnight - over 6 months (depending on symptoms)

Question 20

inappropriate use of psychotropic drugs

Answer 20

1. incorrect diagnosis/co-morbidity of personality disorder
2. to provide relief or sedation in heightened state
3. high doses/combination therapy (adverse effects)
4. patient group/status (elderly, pregnant/breast feeding)