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Chapter 4 - Nervous System > 3. Mental health disorders > Flashcards

3. Mental health disorders Flashcards

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1
Q

Anxiety symptoms

A

fear
restlessness
irritability
difficulty cocentrating

phyiscal
tremors
palpitations
muscle tension
excessive sweating
shortness of breath
insomnia

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2
Q

Anxiolytic drugs

A

Benzodiazepines

5-HT3 agonist

Antidepressant

Antiepileptic

Antipsychotic

Beta-blockers (help with the physical symptoms of anxiety such as tremors, palpitations and muscle tension)
- propanolol
- oxprenolol

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3
Q

Benzodiazepines mechanism of action

A

Acts on binding sites on GABA-a receptors to enhance binding of GABA.

GABA is an inhibitory neurotransmitter causing widespread CNS depressant effects: reduced axiety, muscle relaxation, anticonvulsant, sedation

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4
Q

Benzodiazepine uses

A
  • severe anxiety (short term)
  • muscle spasm
  • seizures
  • insomnia
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5
Q

Benzodiazepines caution/contraindication

A

Should be avoided in elderely patients, if ESSENTIAL, half the dose and use it for half the required period

Should be avoided in mild liver impairement as their sedative effects, can cause hepatic coma.
if ESSENTIAL, can offer a short-acting benzodiazepine.
Should never be used in severe liver impairement

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6
Q

Benzodiazepine side effects

A

As a CNS depressant it causes:

  • drowsiness
  • reduced alertness
  • confusion
  • Ataxia (affects coordination, balance, speech)
  • Muscle weakness
  • May also have a paradoxical effect: increasing anxiety, hostility and aggression
  • Must avoid alcohol as it is also a CNS depressant
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7
Q

Benzodiazepine side effects

A
  • Respiratory depression
    This effect is enhanced if co-prescribed with opioid, can be fatal.
    Patients must report signs and symptoms of slow breathing, sedation, blueish lips and skin

Patients taking methadone must be monitored for ~ 2 weeks

  • Dependence and tolerance
    Must be gradually withdawn to prevent benzodiazepine withdrawal syndrome
    Increased risk with shorter-acting benzodiazepines
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8
Q

Benzodiazepine interactions

A

Interacts with other CNS depressants:

alcohol, opioids, antihistamines, antipsychotics, barbiturates, Z drugs

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9
Q

Attention deficit hyperactivity disorder

A

Symptoms:

Inattention: short attention spam, easily distracted

Hyperactive and Impulsiveness: unable to sit still, acting without thinking

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10
Q

ADHD treatment

A

First line: Methylphenidate OR lisdexamfetamine (or dexamfetamine if patient cannot tolerate long effect profile)

Alternative: Atomoxetine - non stimulant

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11
Q

Methylphenidate and amfetamines mechanism of action

A

stimulate CNS and increase dopamine levels in the brain

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12
Q

How is methylphenidate prescribed

A

Methylphenidate modified release preparations must be prescribed by brand.

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13
Q

Methylphenidate and amfetamines side effects

A
  • growth restriction - can stunt growth so treatment breaks over school holidays can be had
  • psychiatric disorders. Monitor psychiatric symptoms
  • CVS effects, like tachycardia, increased BP. So contraindicated in CVD, severe hypertension, hyperthyroidism.
  • insomnia
  • tics and tourette’s syndrome (vocal and motor tics that last longer than a year)
  • reduced apetite AND weight loss
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14
Q

Methylphenidate and amfetamines interactions

A

Methylphenidate and amfetamines are serotonergic drugs.

So increased serotonin syndrome with:
SSRI’s, TCA’s, MAOI’s, Lithium, MAO-B inhibitors, methadone, St John’s Wort, 5-HT1 agonists, 5-HT3 receptor antagonist e.g ondanestron

Serotonin drugs increases serotonin (5-HT) or act on serotonin 5-HT receptors

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15
Q

What is bipolar disorder

A

extreme mood swings varying from extremely happy to extremely sad, and can last for several weeks or months

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16
Q

Bipolar disorder symptoms

A
  1. Mania - high mood:

high energy
risky, harmful acts
overly ambitious acts

  1. Depression: low mood
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17
Q

Bipolar disorder treatment

A

For acute episodes and maintenance:
* Lithium
* Valproate
* 2nd generation Antipsychotic (olanzapine OR quetiapine, risperidone for acute episodes only)

Antidepressants should not be given in acute episodes, as they elevate moood and can worsen mania

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18
Q

Lithium prescribing

A

Patients must carry their alert card at all times

Patients must be maintained on the same brand, different brands have different bioavailabilities

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19
Q

Lithium and NSAIDS

A

Use of NSAIDs and lithium should be avoided together if possible. As NSAIDs reduce lithium excretion leading to lithium toxicity

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20
Q

Lithium therapeutic index and monitoring

A

0.4-1 mmol/L

treat patient and not level

Blood samples are taken 12 hours after dose. In the first year, blood levels are taken every 3 months and every 6 months thereafter, UNLESS the patient’s blood lithium has been affected.

Usually affected by sodium and water intake.

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21
Q

Lithium toxicity signs

A

G: gastro-intestinal effects, V+D
R: renal effects - polyuria and hypOnatraemia
E: eyes blurred vision
E: extrapyramidal symptoms, e.g tremor
N: nervous sytem, e.g confusion, drowsiness

Lithium is nephrotoxic and can cause nephrogenic diabetes insipidus where much water is lost

Lithium is renally cleared, HypOnatraemia, diuretics, intercurrent illness, diarrhoea, vomiting, predisposes to lithium toxicity due to loss of electrolytes.
High fluid intake dilutes blood sodium levels = psuedo hypOnatraemia

Low fluid intake predisposes to lithium toxicity

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22
Q

Lithium counselling

A

hyPERnatraemia can also cause lithium levels to fall so patients must maintain their salt and fluid inake

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23
Q

Lithium side effects

A
  • Hypothryroidism: patients must report signs such as weight gain, cold intolerance
    MONITOR: TFT
  • Nephrotoxicty: patients must report signs of polyuria, polydipsia
    MONITOR: RFT
  • Prolong QT interval
    MONITOR: cardiac function, ECG,
  • Benign intracranial hypertension
    patient must report signs of: persistent headaches, visual disturbances
  • Lowers seizure threshold
    caution: epilepsy
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24
Q

Lithium and pregnancy/breastfeeding

Study These Flashcards
A

Lithium is teratogenic
Females of childbearing potential must take effective contraception

It is also present in breastmilk

25
Lithium interactions
HypOnatraemia predisposes to lithium toxicity. 1. **Therefore lithium interacts with hypOnatraemic drugs:** : diuretics, lithium is renally cleared, so taking a drug that reduces renal excretion, lithium accummulates, increasing risk of toxicity. 2. **Therefore lithium interacts with nephrotoxic drugs:** ACE inhibitors/ARBS, NSAIDs 1. **hyponatraemia also causes lithium levels to fall as lithium excretion increases= therapuetic failure.** So interacts with common otc products with high sodium content, like effervescents, sodium antacids, like gaviscon 1. **Lithium is a serotonergic drug. Interacts with drugs that increase serotonin = incressing risk of serotonin syndrome**. Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John's wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist 1. **QT prolongation** Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline. Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes 1. **Increased risk of Neurotoxicity when taking with antipsychotics and TCA**
26
Depression symptoms
helpless pessimistic low-self esteem suicidal thoughts Insomnia Weight gain or weight loss fatigue
27
Depression treatment
**Mild:** 1st line: CBT **Moderate - severe depression** 1st line: SSRI and CBT Other antidepressants: SNRI (Duloxetine, Venlafaxine) Antidepressants should be taken for at least 6 months. They take a few weeks to work, depression may become worse before it gets better. If a patient is at risk of suicide, patient must be reviewed after 1 week **Severe depression and rapid response:** Electroconvulsive therapy
28
types of antidepressants
**Selective Serotonin Reuptake Inhibitors** paroxetine sertraline flovaxmine **Tricyclic antidepressants** amitryptiline clomipramine doselupin doxepin **Monoamine oxidase inhibitor:** phenelzine isocarboxazid tranylcypromine
29
Antidepressant side effects
1. Drowsiness caution: Driving 1. Suicidal ideation and behaiviour 1. HypOnatraemia, especially elderly patients 1. Withdrawal reactions (high risk with paroxetine, venlafaxine as they have shorter half lives)
30
Serotonin syndrome
Trio of symptoms 1. neuromuscular hyperactivity: tremeor, muscle rigidity 2. altered mental state: confusion, agitation, mania 3. dysregulated autonomic dysfunction: tachycardia, labile blood pressure, urination, hyperthermia
31
Switching antidepressants
Must have washout period, to prevent serotonin syndrome Switching from MAOI to another antidepressant: Wait 2 weeks No washout period for moclobemide Switching from SSRI to another antidepressant: Wait 1 week Wait 2 weeks from sertraline Wait 5 weeks from fluoxetine Switching from TCA to another antidepressant: Wait 1 - 2 weeks Wiat 3 weeks from clomipramine, imipramine
32
Selectivee Serotonin Reuptake Inhibitor mechanism of action
Selectively blocks the reuptake of 5-HT (serotonin) form the synaptic cleft, to increase concentration of serotonin
33
SSRI's in children
Fluoxetine is the only SSRI that can be given safely to children under the age of 12
34
SSRI's side effects
SIGHSQA S- serotonin syndrome I-increased risk of bleeding G - gastrointestinal upset, N V D H - hypersensitivity (skin rash) S - seizure threshold reduced Q - QT interval prolongation A - apetite and weight gain or loss
35
Sertraline and CVD
Sertraline is safe in MI and unstable angina
36
SSRI's interactions
1. **Fluoxetine, Fluvoxamine and sertraline are enzyme inhibitors, increasing drug levels and increasing risk of toxicity** 1. **Fluoxetine, Fluvoxamine and sertraline Interacts with grapefruit juice as it is an enzyme inhibitor = sertraline levels** 1. **HypONatraemia risk increased when interacting with hyponatraemic drugs** antidepressants, carbamamzepine, desmopressin, diuretics, NSAIDs 1. **Increased risk of bleeding when taken with other drugs that also have this side effect** alcohol anticoagulants, warfarin, DOACs, corticosteroid, venlafaxine 1. **Interacts with drugs that increase serotonin = incressing risk of serotonin syndrome**. Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John's wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist 1. **QT prolongation** Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline. Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes
37
Tricycline and related antidepressants mechanism of action
Blocks the reuptake of serotonin (5-HT) and noradrenaline from synaptic cleft Also block muscarinic receptors, leading to antimuscarinic effects
38
TCA side effects
Typically taken once at night as they are sedating TCAS T - TCAs> SSRI's in overdose, as they are more sedating, antimuscarinic, cardiotoxic C - Cardiac effects, e.g arrhythmias. Should not be used in arrhythmias, or heart block. A - Antimuscarinic effects: (cant see, cant pee, cant spit, cant shxt) S - seizures
39
TCA's interactions
1. **Interacts with hypOnatraemic drugs, increasing risk of hyponatraemia:** antidepressants, carbamazepine, desmopressin, diuretics, NSAIDs 1. **Interacts with antimuscarinic drugs, to increase antimuscarinic effects:** antihistamine, antimuscarinic e.g hyoscrine, antipsychotic 1. **Interacts with other CNS depressants, to increase risk of CNS depressant effects like sedation** alcohol, antihistamine, benzodiazepines, barbiturates, opioids, z-drugs, 1. **Interacts with other hyPOtensive drugs, to increase risk of hypotension** ACE inhibitor, arbs, alpha-blockers, CCBS, levodopa, MAO-B inhibitor, dopamine-receptor antagonist, antipsychotic, diuretic, nitrate, PPDIEtype 5 inhibitor, SGLT2 inhibitor 1. **Interacts with drugs that increase serotonin = increasing risk of serotonin syndrome**. Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John's wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist 1. **QT prolongation with clomipramine** Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline. Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes
40
Monoamine oxidase inhibitors mechanism of action
Block the enzyme monoamine oxidase, therefore monoamines accumulate (serotonin, noradrenaline and dopamine)
41
Monoamine oxidase inhibitors side effects
Rarely used * hypertensive crises: due to increase of sympathomimetics = raise in blood pressure Also associated with intracranial bleeding Should not be used in cerebrovascular disease, e.g strokes, severe CVD * Hepatotoxic * Postural hypotension Should be stopped if palpitations, or headaches become frequent
42
Monamine oxidase interactions
6. **Interacts with drugs that increase blood pressure, to increase the risk of hypertensive crises** ephedrine, pseudoephedrine, phenyephrine, oxymetazoline, xylometazoline, OTC decongestants, adrenalone, noradrenalone, amfetamines, methylphenidate, beta2 agonists 1. **Interacts with drugs that increase serotonin = increasing risk of serotonin syndrome**. Examples include: antidepressants, Lithium, MAO-B inhibitor, methadone, st John's wort, tramadol, 5-HT1 agonist, 5-HT3 receptor antagonist
43
MAOI counselling
Patients should avoid tyramine rich foods or dopa-rich foods, such as cheese. Must avoid stale food and alochol and eat fresh food
44
What is Schizophrenia
a type of psychosis, there is no disctinction between thoughts and reality
45
Schizophrenia symptoms
**Positive symptoms: - antipsychotic drugs better target them** Hallucinations Delusions Disturbed thoughts and speech **Negative symptoms:** apathy social withdrawal poor hygiene catatonia
46
Schizophrenia treatment
**1st line:** Oral antipsychotic monotherapy **For resistant schizophrenia (where 2+ antipsychotic drugs have been tried inl 2nd gen):** Offer clozapine AND oral antipsychotic **For non-adherence:** Offer depot injections **For acute episodes:** Offer IM antipsychotic - must be lower than oral dose. Repeat dose and review daily
47
Prescribing antipsychotic in elderly
In dementia: there is an increased risk of stroke and death Associated with postural hypotension, hyperthermia, hypothermia
48
Prescribing antipsychotic in learning disability
If no psychotic symptoms: reduce dose or discontinue antipsychotic and review
49
Prescribing antipsychotic in unlicensed high doses
First try alternatives such as clozepine Monitoring: ECG, pulse, blood pressure, temp Increase gradually Stop if no improvement
50
Antipsychotic drugs mechanism of action
1st generation: block dopamine-2 receptors in the mesolimbic pathway. This treats the positive symptoms in schizophrenia 2nd generation: blocks dopamine-2 receptors and other receptors. Can cause a wider range of side effects
51
Types of antipsychotic drugs
**1st generation:** **Phenothiazines** Composed of Group 1 (most sedating, ending in -promazine e.g chlorpromazine), Group 2 and Group 3 **Butyophenone** Haloperidol **Thioxanthene** Flupentixol **2nd generation:** Amisulpride Aripiprazole Clozapine (most effective) Olanzapine Quetiapine risperidone)
52
Antipsychotic side effects
1. **Extrapyramidal symptoms:** Dystonia, Akathisia, tardive dyskinesia More commonly caused by 1st generation antipsychotics: group 3 phenothiazines, haloperidol and depot injections 1. **Hyperprolactinaemia (except aripiprazole), as they Inadvertently block regulation of prolactin secretion** breast enlargement or pain, breast milk secretion, reduces bone density menstrual disturbance - more commonly caused by 1st gen antipsychotics and 2nd gen amisulpride, sulpride and risperidone monitoring: prolactin levels 1. **Metabolic effects - more commonly caused by 2nd generation antipsychotics** Hyperglycaemia, Weight gain (common with clozapine and olanzapine), Abnormal lipids monitor: fasting blood glucose, weight, lipids 1. **Cardiovascular effects:** Tachycardia, arrhythmias, prolonged QT interval (pimozide), postural hypotension (clozapine, quetiapine) 1. **Neuroleptic malignant syndrome:** If this occurs, drug must be STOPPED muscle rigidity, fluctuating consciousness, hyperthermia, automic dysfunction
53
More antipsychotic drug side effects
**Antimuscarinic effects** **Seizures** **Sedation** **Sexual dysfunction** **Photosensitivity**, avoid direct sunlight
54
Clozapine side effects
Clozapine can cause fatal toxicity, blood levels should be monitored when a patient has signs of toxicity or there are interactions B M I B -**blood disorders** (neutropenia, agrunlocytosis) Patients must report signs and symptoms of an infection: fever, sore throat, mouth ulcer monitoring: leucocyte, WBC M - **mycocarditis** - inflammation of heart muscle signs include tachycardia I - **intestinal obstruction** As clozapine can impair persistalisis and cause constipation and fecal impaction. Patient must report constipation, before taking another dose
55
Chlorpromazine side effect
Contact sensitisation Must avoid direct contact, do not crush tablets. Handle solutions with care
56
Phenothiazines side effect
1. Hepatoxicity 1. Acute dystonic reactions
57
Antipsychotic drugs interactions
* **QT prolongation - pimozide** Interacts with drugs that also prolong QT interval: antipsychotic, anti-arrhythmic drug, citalopram, escitalopram, Clarithromycin and erythromycin, domperdone, methadone, hydroxyzine, quinolone, onadestron Hypokalaemia is a risk factor for prolonged QT interval. Drugs which cause hypokalaemia: B-agonist, corticosteroid. loop and thiazide diuretics, theophylline. Hypokalaemic drugs and drugs which prolong QT interval increase risk of torsades de pointes * **Interacts with antimuscarinic drugs, to increase antimuscarinic effects:** antihistamine, antimuscarinic e.g hyoscrine, antipsychotic, TCAs * **Interacts with other CNS depressants, to increase risk of CNS depressant effects like sedation** alcohol, antihistamine, benzodiazepines, barbiturates, opioids, z-drugs, * **Interacts with other hyPOtensive drugs, to increase risk of hypotension** ACE inhibitor, arbs, alpha-blockers, CCBS, levodopa, MAO-B inhibitor, dopamine-receptor antagonist, antipsychotic, diuretic, nitrate, PPDIEtype 5 inhibitor, SGLT2 inhibitor
58
Drug given for inapropriate sexual behaiviour
Benperidol
59
TCA risk of fatality in overdose
Lofepramine has the lowest risk of fatality on overdose compared to other TCA's. Amitriptyline and Dosulepin have a high risk of fatality in overdose

Chapter 4 - Nervous System (8 decks)

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