Random MH Concepts

Question 1

Suicide risk factors (dynamic and static)

Answer 1

Dynamic:

• Thoughts/intent/plan
• Current attempt (severity)
• Employment
• Active alcohol use
• Drugs
• Access to means/methods
• Hopelessness
• Social isolation
• Recent stressors
• Relationship disturbance

Static:

• Male
• Age 19-24/>45
• Widowed/divorced
• Past self-harm
• Past suicide attempt
• Past substance abuse
• Major mental illness diagnosis
• Recent MH admission
• Chronic illness
• Family Hx
• LGBTQI
• Hx of abuse/trauma

Question 2

Clinical interview - suicide risk assessment

Answer 2

1) Assess 5 components of suicide:
- Ideation (passive vs active)
- Intent + seriousness+ perceived seriousness
- Plan (existing? how many? preparation?)
- Access to lethal means
- Hx of past suicidal attempts + substance use + mental health
2) Assess factors around suicidal ideation (predisposing, precipitating, perpetuating, protective, prognostic)
3) Assess static + dynamic factors
4) Assess the suicide attempt

Question 3

SADPERSONS scale

Answer 3

Sex (male)
Age <19 or >45
Depression or hopelessness
Previous suicide attempts or psychiatric care
Excessive alcohol or drug use
Rational thinking loss
Seperated, divorced or widowed
Organised or serious attempt
No social supports
Stated future intent

Score: 6-8 = full emergency psychiatric evaluation
Score >9 = admission

Question 4

Develop a short-term suicide risk management plan

Answer 4

1) Assess the patient’s risk profile –> intent, lethality, access, plan, precipitant, risk to others, risks to the patient
2) Assess patient’s mental state
3) Involve immediate family/friends if appropriate, consented and possible
4) Offer psychoeducation about suicide risk and underlying psychological condition
5) Consider the need for hospitalisation (emergency)
6) Involvement of other health professionals and services
7) Develop a safety plan or refer to mental health clinician who can do this (what was helpful in previous crisis situations, triggers to avoid, noticeable warning signs, social supports who can be contacted)
8) Consider psychotropic medication or psychosocial intervention to treat underlying mental illness
9) Document the risk assessment, mental state, safety plan and people contacted
10) Arrange for review/follow up

Question 5

First-line investigations for presentation of psychosis

Answer 5

Bloods:

• FBC
• UEC + eGF
• CMP
• LFTs
• TFTs
• Vit B12 and folate
• Consider ANA + ESR

Samples:

• Urinalysis
• Urine MCS
• Urine drug screen

Imaging:
- CXR

As required - blood cultures, ECG, troponins, coags, blood drug screen, head imaging if cranial pathology is suspected

Question 6

Management plan for Schizophrenia

Answer 6

Co-existing conditions (Biological):

• Screen for and manage co-existing conditions –> anxiety and depression, substance use and addiction, personality disorders
• Organic conditions

Psychosocial:

• Address significant emotional, psychological and social stressors
• Housing assistance
• Social skills training
• Employment programs
• Disability support benefits
• Community based management

Psychological:

• Suicide prevention
• Individual psychotherapy and CBT –> improve coping strategies, learn how to manage stressful situations, group activities, social rehabilitation
• Family psychotherapy –> information about schizophrenia and its management, support groups for family, learn communication and problem solving skills

Medications:
Acute episodes:
- Second-gen antipsychotics are first line (olanzapine). Take 2-4 weeks to relieve psychotic symptoms. No effect by 2 weeks = change SGA
- Benzodiazepines (e.g. lorazepam) used to relieve acute distress while waiting for effect of SGA

Maintenance therapy:

• Treat for 1 year minimum. Multiple episodes need 2-5 years minimum
• Give minimum dose that controls their symptoms with monitoring for adverse effects
• Depot preps q2-4 weekly to ensure compliance
• No response to 2 adequate trials of 2 different SGAs = give clozapine (should be kept for treatment resistant patients)

Adjunctive treatments:

• Mood stabilisers (valproate, lithium, carbamazepine) if aggression/impulsiveness
• Selected antidepressants (e.g. fluoextine, mirtazapine) to treat negative symptoms of schizophrenia
• Anxiolytics
• PRN benzodiazepines for acute agitation/behaviour disturbance
• ECT

Question 7

Role of neurotransmitters in schizophrenia

Answer 7

Serotonin

• 5HT-2A receptor = excitatory. Antagonism of this receptor is a key activity of SGAs. Drugs that stimulate these produce positive psychotic symptoms.
• 5HT-1A receptor = inhibitory

Glutamate
- Glutamate binds dopamine neurons to produce regional hyper/hypoactivity in dopamine release within the mesocortical and mesolimbic systems respectively

Dopamine

• Positive symptoms of schizophrenia (delusions, hallucinations, disorganisation) are due to increased dopamine in the mesolimbic pathway
• Negative symptoms (anhedonia, poverty of speech) are due to hypoactive dopamine signalling in mesocortical pathway.

Question 8

Neuronal pathways involved in psychosis

Answer 8

Mesolimbic

• Responsible for emotion and reward
• Increased dopamine in this system = positive symptoms of schizophrenia

Mesocortical

• Responsible for cognition and executive functioning
• Hypoactive dopamine in this system = negative symptoms of schizophrenia

Nigrostriatal

• Movement (basal ganglia)
• Decreased dopamine = EPS symptoms

Tuberoinfundibular

• For prolactin regulation
• Decreased dopamine = increased prolactin (side effecti of medications which inhibit dopamine = hyperprolactinemia)