Chapter 4: Mental health disorders

Question 1

Name and explain the 4 dopamine pathways in the brain.

Answer 1

1. Mesocortical pathway: regulates cognition, memory, decision making
2. Mesolimbic pathway: regulates pleasure, addiction, reward
3. Nigrostriatal pathway:
   regulates sensory, movement
4. Tuberoinfundibular pathway: regulates prolactin levels.

Question 2

Describe dopamine activity levels in a schizophrenic patient

Answer 2

1. Underactivity in the mesocortical pathway –> Negative symptoms (Social withdrawal, apathy, poor hygiene).
2. Overactivity of the mesolimbic pathway –> Positive symptoms (hallucinations, delusions, dis organised speech and thoughts).
3. D2 antagonism in nigrostriatal pathway –> extrpyramidal symptoms (Parkinsonism, tremor, tardive dyskinesia, akathesia, dystonia).
4. D2 antagonism in tuberoinfundibular pathway –> hyperprolactinaemia (menstrual disturbances, galactorrhoea, breast enlargement, sexual dysfunction).

Question 3

List the symptoms of schizophrenia

Answer 3

Positive symptoms:
• Hallucinations
• Delusions
• Dis-organised speech and thoughts

Negative symptoms:
• Social Withdrawal
• Apathy
• Loss of motivation in activities

Question 4

What route are antispsychotics often given in an emergency situation?

Answer 4

Intramuscular injections

Question 5

Are normal intramuscular anti psychotic injections the same as intramuscular anti-psychotic depot preparations?

Answer 5

NO (this is very important to note).

Intramuscular anti-psychotic depot preparations are long acting and are administered every 1-4 weeks by intramuscular injection to aid compliance when compliance with oral therapy is unreliable. other normal anti-psychotic IM injections are short acting and used for emergencies

Question 6

Why should a prescription specify a certain dose for both IM and oral route? Why should IM route be lower than the oral route?

When else should you consider lowering an IM dose?

Answer 6

The IM route avoids the first pass effect Oral route dose does not. Hence oral doses should be higher.

If the patient is very active. This is because there is increased blood flow to the muscles which considerably increases rate of absorption.

Question 7

How often should the dose of anti-psychotics for emergency use be reviewed?

Answer 7

Every day

Question 8

What is the time frame that a patient should receive an anti-psychotic drug at optimum dose for before it is deemed ineffective?

Answer 8

4-6 weeks

Question 9

Why should prescribing more than one anti-psychotic at a time be avoided except in certain circumstances for e.g. clozapine augmentation or when changing medication during titration?

Answer 9

Due to risks of ADRs such as extra pyramidal symptoms, QT prolongation and sudden cardiac death.

Question 10

What drug should be offered if schizophrenia is not controlled despite the sequential use of at-least 2 different anti-psychotic (one of which including a 2nd generation drug).

Answer 10

Clozapine.

Question 11

How long must you wait before the addition of a second anti psychotic to augment clozapine?

Answer 11

8-10 weeks.

Question 12

Describe the 1st generation typical antipsychotics

Answer 12

• Acts predominantly by blocking dopamine D2 receptors in the brain.
• Not selective for any of the 4 dopamine pathways in the brain hence causes a range of s.es particularly extrapyramidal symptoms and elevated prolactin than 2nd generation.

Question 13

Which generation antipsychotics have more occurrences of extra-pyramidal symptoms and prolatinaemia ?

Answer 13

1 st generation

Question 14

List all 1st generation anti-psychotics

Answer 14

Phenothiazines
• Chlorpromazine
• Levomepromazine
• Promazine

• Pericyazine

• Fluphenazine
• Perphenazine
• Prochlorperazine
• Trifluoperazine

Butyrophenones
• Benperidol
• Haloperidol

Thioxanthene
• Flupentixol
• Zuclopenthixol

Question 15

Which antipsychotics are the MOST sedating?

Answer 15

chlorpromazine
levopromazine
promazine

Question 16

Which antipsychotics are least sedating?

Answer 16

fluphenazine 
perphenzine 
trifluoperazine 
Prochlorperazine 
haloperidol 
benperidol 
pimozide ? 
sulpiride ?

Question 17

Which antipsychotics is associated with the most extrapyramidal side effects?

Answer 17

fluphenazine 
perphenzine 
trifluoperazine 
Prochlorperazine 
haloperidol 
benperidol

Question 18

Which anti-psychotics are associated with the least amount of extra-pyramidal side effects?

Answer 18

pericyazine
pimozide?
sulpiride ?

Question 19

Which antipsychotic causes QT prolongation?

Answer 19

Haloperidol

Question 20

Describe the 2nd generation atypical anti-psychotics

Answer 20

blocks dopamine 1-4 receptors
Has a more distinct clinical profile in regards to s.es
Has more metabolic s.es (weight gain, diabetes, dyslipidaemia).
May be more effective at treating negative symptoms.

Question 21

List 2nd generation antipsychotic drugs

Answer 21

COAARQ
clozapine 
olanzapine 
risperidone 
amisulpiride 
aripripazole 
quetiapine

Question 22

What is the most effective antipsychotic ?

Answer 22

Clozapine

Question 23

When is clozapine prescribed?

Answer 23

When 2 or more antipsychotics have been tried (inlc 2nd gen) for at least 6-8 weeks each.

Question 24

Can a patient continue taking the next dose of clozapine as normal if 2 days have been missed?

Answer 24

No patient must SPEAK to the doctor/specialist and they will need to re-initiate it.

Question 25

Clozapine causes an increased risk of agranulocytosis. which other drugs cause agranulocytosis?

Answer 25

``` Antipsychotics (clozapine) Cytotoxic drugs (methotrexate) Antimalarials (quinine) Aminosalicylates (sulfasalazine) Any other drugs that cause bone marrow suppresion ```

Question 26

What are the top Side effects of clozapine?

Answer 26

1. Myocarditis and cardiomyopathy Persistent tachycardia in the first 2 months Stop clozapine permanently if it occurs. (rapid heart rate, abnormal rhthyms, sob, ankle swelling) 2. Agranulocytosis and neutropenia monitoring for leucocyte blood count every week for 18 weeks, then every 2 weeks for a year, then monthly onwards. (chills, fever, weakness, sore throat). 3. Gastro-intestinal obstruction Intestinal peristalsis impaired = constipation, paralytic ileus. Advice patient to report constipation immediately before taking next dose.

Question 27

What patient counselling needs to be offered to those on chlorpromazine

Answer 27

``` Very sedating (can cause drowsiness esp drivers). contact sensitization: avoid direct sunlight ```

Question 28

Which anti psychotics cause QT prolongation?

Answer 28

``` Haloperidol Clozapine Pimozide Risperidone Fluphenazine thioridiazine (not licensed in uk?) ```

Question 29

Hyper salivation associated with clozapine can be treated with what?

Answer 29

Hyoscine hydrobromide

Question 30

What monitoring is required for patients on antipsychotics?

Answer 30

Weight: Measure at the start of therapy, then weekly for the first 6 weeks, at 12 weeks, at 1 year, and then yearly. Fasting blood glucose, HbA1c, and blood lipid concentrations: measure at baseline, at 12 weeks, at 1 year, and then yearly. Prolactin concentrations measure at baseline, 6 months and then yearly. Before initiating antipsychotic drugs, an ECG may be required, particularly if physical examination identifies cardiovascular risk factors (e.g., high blood pressure), if there is a personal history of CVD, or if the patient is being admitted as an inpatient. Blood pressure monitoring is advised before starting therapy, at 12 weeks, at 1 year and then yearly during treatment and dose titration of antipsychotic drugs. Expert sources advise to monitor full blood count, urea and electrolytes, and liver function tests at the start of therapy with antipsychotic drugs, and then yearly thereafter.

Question 31

What are the side effects of anti-psychotics?

Answer 31

1. Extrapyramidal symptoms 2. Hyperprolactinaemia 3. Sexual dysfunction 4. Cardiovascular side effects 5. Hyperglycaemia 6. Weight gain 7. Hypotension 8. Neuroleptic malignant syndrome 9. Blood dyscarsias 10. Antimuscarinic s/es 11. Photosensitivity 12. Jaundice (including cholestatic)

Question 32

Most depot preparations often end in 'decanoate' true or false?

Answer 32

True

Question 33

Can a patient with hepatic impairment take chlorpromazine?

Answer 33

Manufacturer advises caution in severe hepatic failure (increased risk of accumulation).

Question 34

Can a patient with renal impairment take chlorpromazine what are the dose adjustments that need to be done?

Answer 34

Start with small doses in severe renal impairment because of increased cerebral sensitivity.

Question 35

When chlorpromazine is injected intramuscularly what are the monitoring requirements?

Answer 35

Patients should be supine; BP should be monitored for 30mins after injection

Question 36

2. Can chlorpromazine tablets be crushed?

Answer 36

NO

Question 37

3. What are the handling and storage recommendations of chlorpromazine?

Answer 37

HCPs should avoid direct contact with chlorpromazine and solutions should be handled with care, tablets cannot be crushed.

Question 38

What formulations are chlorpromazine available as?

Answer 38

Tablets, Sol for inj, Oral sol

Question 39

Can flupentixol be used by pregnant women?

Answer 39

Avoid unless benefits outweighs the risk

Question 40

Can flupentixol be used during breast-feeding?

Answer 40

Avoid- Flupentixol is present in breast milk

Question 41

Can a patient with hepatic impairment take flupentixol?

Answer 41

Manufacturer advises caution- monitor serum drug concentration.

Question 42

Can a patient with renal impairment take flupentixol?

Answer 42

Manufacturer advises caution. Dose adjustments will need to be carried out. Start will small doses of antipsychotic drugs in severe renal impairment because of increased cerebral sensitivity.

Question 43

What time of day should flupentixol not be taken and why?

Answer 43

Although drowsiness may occur, it can also have an alerting effect so should not be taken in the evening

Question 44

What formulations is flupentixol available as?

Answer 44

Tablets

Question 45

Prochlorperazine is used for the treatment of acute migraine but is not licensed for it. Which formulations of prochlorperazine is not licensed for use in children?

Answer 45

* Injections * Buccastem MR tabs * Avoid oral route in children under 10kg --> CNS depression, comatose states, phaeochromocytoma

Question 46

2. What formulations are available for prochlorperazine?

Answer 46

Tablets Sol for inj Buccal tabs Oral solution

Question 47

3. Which antipsychotic is recommended to be avoided in hepatic impairment?

Answer 47

Prochlorperazine

Question 48

4. How would you advice a patient taking buccal tablets to use the medication?

Answer 48

The tablets should be placed high between upper lip and gum and be left to dissolve.

Question 49

Which antipsychotic does not affect blood pressure to the same extent as the others do hence BP monitoring is not mandatory for?

Answer 49

Amisulpride, aripiprazole | • Formulations: Tabs, Oral sol

Question 50

What is the first line of treatment for depression?

Answer 50

SSRIs

Question 51

List the main groups of antidepressants

Answer 51

SSRIs Tricyclic antidepressants Monoamine oxidase

Question 52

Give examples of SSRIs

Answer 52

``` Sertraline escitalopram citalopram paroxetine fluoxetine fluvoxamine ```

Question 53

Give examples of tricyclic antidepressants

Answer 53

``` amitriptyline clomipramine dosulepin doxepin mianserin trazodone trimipramine imipramine lofepramine nortriptyline ```

Question 54

give examples of monoamine oxidase inhibitors

Answer 54

* Tranylcypromine * Phenelzine * Selegiline * Isocarboxazid * Moclobemide

Question 55

Why are SSRIs the recommended first line of treatment for depression?

Answer 55

• Well tolerated • Safer in overdose • Less sedating • Fewer antimuscuranic and cardiotoxic effects than tricyclic antidepressants. • Patients with unstable angina or recent MI --> sertraline

Question 56

What are the symptoms of overdose of SSRIs?

Answer 56

N&V, Agitation , nystagmus, drowsiness, sinus tachcardia

Question 57

Is it safe for pregnant women to take SSRIs?

Answer 57

Avoid if possible unless benefits outweighs the risk. There is a risk of congenital heart defects when taken during early pregnancy (1st trimester). if used during the 3rd trimester there is a risk of neonatal withdrawal symptom symptoms and persistent pulmonary hypertension in the new borns.

Question 58

Patients on antidepressants should not stop medication abruptly. If they do what could be the possible side effects of abrupt treatment cessation?

Answer 58

``` GI disturbances Headache, fatigue, Anxiety Tinnitus electric shock sensation in the head Sleep distubances. ```

Question 59

How should SSRIs be withdrawed?

Answer 59

dose should be tapered gradually over about 4 weeks or longer if withdrawal symptoms emerge (6 months in people who have been on long term maintenance treatment).

Question 60

Which SSRI should be avoided during prengnacy ?

Answer 60

Paroxetine

Question 61

Which SSRI should be avoided during breastfeeding?

Answer 61

Escitalopram, fluoxetine, fluvoxamine, sertraline

Question 62

Which SSRI dose should be reduced if the patinet has an eGFR of <30ml/min/1.73m2

Answer 62

paroxetine