Psychiatric Symptom Management In Hospital Flashcards
Key rules of prescribing for depression
Unless patient preference, avoid routinely offering antidepressant as 1st line for less severe depression
1st line for new episode severe depression - SSRI/SNRI
Avoid SSRIs if taking NSAIDS - increased risk of GI bleeds
-if no suitable alternative, add PPI
Avoid SSRI if taking 5HT3 rec agonist - increased risk of seretonin syndrome
Avoid SSRI if taking warfarin/heparin - increased bleed risk
-offer mirtazapine, (INR will increase if coprescribed with AC), however associated with weight gain, sleepiness
Key rules of prescribing for insomnia
Short term hypnotics can help but use sleep hygiene techniques for long lasting benefits
If accompanied by depressive symptoms - can offer mirtazapine/agomelatine
Key rules of prescribing for anxiety
BZ only used in crisis
If psychological interventions not working/an option, can use SSRI
SSRI can be used alongside psychological therapy
Key rules of prescribing in acute behavioural disturbance
PO/IM BZ are the safest - lowest risk of AE
If psychotic - PO/IM antipsychotic to get therapeutic plasma conc as quickly as possible
- contact psych team if possible to optimise treatment
Treatment of more severe depression
-1st line
-if no/minimal response after 3-4 weeks on therapeutic dose and adherence confirmed
-if improvement after 4wks at higher dose
-continuation
1st line - CBT + antidepressant
-generally SSRI/SNRI unless increased bleeding risk or seretonin syndrome
-however SSRI/venlafaxine linked to sexual dysfunction
If no/minimal response after 3-4wks on therapeutic dose and adherence confirmed
-increase dose/change antidepressant
If some improvement after 4wks at higher dose
-continue for additional 2-4wks, consider switching if
-response still inadequate/SEs/patient wishes
Switches
-initially from same class, then can change
If inadequate response with 2 med changes, other options
-augument with lithium
-augument with quetiapine
-2 antidepressants
Continue for 6months minimum after remission
If recurrent depressive episode/significant risk factors for relapse => continue for 2 years
SSRI drug interactions and discontinuation symptoms
Sertraline - lowest risk of significant drug reactions
SSRIs + warfarin/heparin = increased bleeding risk
Discontinuation symptoms reported for all except agomelatine
-low incidence with fluoxetine
-highest incidence with paroxetine
SSRI CI
Citalopram in
-known/congenital QT prolongation syndrome
-with other medicines known to prolong QT interval
Be careful in people at risk of TDP, CCF, recent MI bradycardia, lowK
Discontinuation symptoms in SSRIs
Within 72hrs of sudden discontinuation/dose reduction
-not reported when antidepressants have been taken for U5-6pms
Transient for 1-2wks, self limiting
Risk reduced by withdrawing antidepressant slowly and gradually, minimum 1month
Key things to inform the patient about with antidepressants
They work :)
Not tranquillisers
No risk of addiction, tolerance, dependence
Must be taken everyday and for 6 months once symptoms resolved
Main AEs
Importance of regular monitoring
-if U25 - review after 1wk (increased risk of SH and suicide)
-monitored for as long as they are at risk
Abrupt withdrawal can cause discontinuation symptoms
Poor adherence => poor outcome
Differentials for anxiety symptoms
-medical
-medication
Medical
-alcohol/drug withdrawal
-depression
-hypoglycaemia
-hyperthyroidism
-schizophrenia
-Aant (doxazosin)
-Bag (salbutamol)
-CS
-alcohol
-caffeine
-nicotine
Prescribing and management in anxiety
Psychological treatment has longer lasting benefits
Starts low but highest dose higher than SSRIs, used for longer
If psychological treatment alone not enough
1st line - sertraline
2nd line - other SSRI (escitalopram or venlafaxine)
Escitalopram dose may need to be lowered if taken with PPI (due to increase in plasma level)
Venlafaxine more effective at lower doses
Duloxetine dose may need to be higher if a smoker
3rd line - pregabalin
Crisis - short term BZ
Bb can be prescribed to manage physical symptoms
Review within 1wk if U30
-Then weekly for the 1st month
Monitoring for AEs and therapeutic effect - every 2-4wks for the 1st months and 3monthly after
Continue for at least 1 year after effective
Prescribing and managing panic disorder
Refer to primary care for further assessment and treatment
-help him understand what happened
Don’t give BZ
Psychological therapy is the most effective
Recognition and treatment of insomnia
If insomnia related to depression => address depression first
If no change => sedative antidepressant at night (mirtazapine, trazodone)
Hypnotics are last resort when sleep hygiene has failed
-long term use of Z-hypnotics linked to dependence
-only take in short term when absolutely needed
-higher doses only increase AE
Rapid tranquilisation
-when to use it
-current guidance
Immediate reduction in agitation, irritability, hostility
Rapid reduction of risk of harm to all
Last resort when risk is high and when other interventions have failed
Offer PO before considering parenternal route
Lowest effective dose
1st line - BZ
-Rare SE of disinhibition
Only use antipsychotics if clearly psychotic or has a psychiatric diagnosis
-do not give IM BZ within 1hr of olanzapine
Once used, monitor temperature, HR, BP, RR
PO and IM are not bio equivalent - prescribe separately
IM doses may be lower than PO doses
Don’t use 2 meds from the same class
Don’t mix 2 meds in the same syringe
If haloperidol used, recent ECG must be available before use
Section 62 MHA
Can give immediately necessary treatment which is not
-irreversible or hazardous
Relates to ECT and medication
