Management Flashcards
(112 cards)
1
Q
What is IAPT?
A
Improving access to psychological therapies - initiative to increase evidence based treatments for anxiety and depression by primary care organisations
2
Q
What is CBT?
A
Treatment based on idea that disorder isnt based on life events but how these are viewed - short term therapy - focussed on here and now - to help with symptom relief
Challenges automatic and negative thoughts
Can be individual / groups / self-help via books or computer
8-12 sessions
3
Q
Give some examples of behavioural therapies?
A
Relaxation training
Systemic desensitization
Flooding
Exposure and response prevention
Behavioural activation
4
Q
What are behavioural therapies based on?
A
Operant conditioning - behaviour is reinforced if it has positive consequences for the individual, and prevents negative consequences
5
Q
What is relaxation training ?
A
Use techniques to cause muscle relaxation during times of stress or anxiety
6
Q
What is systemic desensitization?
A
For phobic anxiety disorders - individual is greatly exposed to a hierarchy of anxiety-producing situations
7
Q
What is flooding therapy?
A
Patient is rapidly exposed to phobic object without any attempt to reduce anxiety beforehand (unlike systemic desensitization) - continuing exposure until anxiety diminishes - not commonly used
8
Q
What is exposure and response prevention?
A
Used in OCD - exposed to situations which cause them anxiety and prevented from performing compulsive action
9
Q
What is behavioural activation?
A
Patients avoid doing certain things as they feel they will not enjoy them or fear of failure in completing them - instead make realistic plans to carry out enjoyable activites - used in depressive illness
10
Q
When is psychodynamic therapy used?
A
Dissociative disorders, psychosexual disorders, PDs, chronic dysthymia, recurrent depression
11
Q
What is psychodynamic therapy based on?
A
Childhood experiences, past relationships and unresolved conflicts influence someones current situation
12
Q
How does psychodynamic therapy work?
A
Unconcious is explored using free association - client says whatever comes to their mind and this is interpreted.
Conflicts and defences are explored - client develops insight to change
1-5 sessions per week for up to years
13
Q
What is psychoeducation?
A
Delivery of information to people in order to help them understand and cope with their mental illness
14
Q
What is counselling?
A
Less technically complicated than other therapies - done by active dialogue between counsellor and client
Can be sympathetic listening or active advice on problem solving
15
Q
What is supportive psychotherapy?
A
Psychological support given by mental health professionals to patients with chronic and disabling mental illnesses - active listening, providing reassurance, explaining illness, providing guidance to difficulties
16
Q
What is problem solving therapy?
A
Mix of counselling and CBT for mild anxiety and depressive disorders
17
Q
What is interpersonal therapy?
A
Used to treat depression and eating disorders - focus on interpersonal problems - bereavement, relationship difficulties, interpersonal deficit
18
Q
What is eye movement desensitization and reprocessing?
A
For PTSD
Client recalls emotionally traumatic materia whilst focusing on external stimulus (e.g. following a moving finger)
19
Q
What is dialectical behavioural therapy?
A
20
Q
Which therapies are recommended for:
Adverse life events
Depression
PTSD
Schizophrenia
Eating disorders
Anxiety disorders
Substance misuse
Borderline personality disorder?
A
21
Q
What are antidepressants used for?
A
- Moderate to severe depressive episodes
- Anxiety / panic attacks
- OCD
- Chronic pain
- Eating disorders
- PTSD
22
Q
Give some examples of SSRIs
A
Citalopram
Escitalopram
Fluoxetine
Paroxetine
Sertraline
23
Q
What SSRI is given for panic disorder?
A
Citalopram
Escitalopram
Paroxetine
24
Q
What SSRI is given for social phobia?
A
Escitalopram
Paroxetine
25
What SSRI is given for bulimia nervosa?
Fluoxetine
26
What SSRI is given for OCD?
Most
27
What SSRI is given for PTSD?
Paroxetine and sertraline
28
What SSRI is given for GAD?
Paroxetine
29
How do SSRIs work?
Increase the concentration of serotonin in the synaptic cleft by inhibiting reuptake from the synaptic cleft into pre-synaptic neurones
30
What are the side effects of SSRIs?
Nausea
Dyspepsia
Bloating
flatulence
Diarrhoea / constipation
Sweating
Tremors
Rashes
Sexual dysfunction
Somnolence
31
What are the symptoms of SSRI discontinuation syndrome?
GI symptoms
Chills
Insomnia
Hypomania
Anxiety
Restlessness
32
What drugs are contraindicated with SSRIs?
Warfarin
Heparin
NOACs
NSAIDs
33
What is **serotonin syndrome**?
Life-threatening complication of increased serotonin activity, usually **within minutes of taking medication**
**Cognitive features** - headache, agitation, hypomania, confusion
**Autonomic effects** - shivering, sweating, hyperthermia, confusion
**Somatic effects** - myoclonus (muscle twitching), hyperreflexia and tremor
MANAGE by stopping offending drug
34
Give 2 examples of SNRIs?
Venlafaxine
Duloxetine
(used after SSRIs)
35
Give an example of a NASSA?
Mirtazapine
36
When to review patients after initiating antidepressants?
2 weeks after
If **\<30** or at increased risk then after 1 week
37
What should be co-prescribed with NSAID and SSRI (if you have to prescribe together)?
PPI
38
Does fluoxetine dose need to be gradually titrated down when stopping like other SSRIs (over 4 weeks)?
No
39
Should citalopram / escitalopram be prescribed in patients with congential long QT?
No
40
Name some TCAs?
Amitriptyline
Clomipramine
Imipramine
Lofepramine
Dosulepin
41
What are the indications for TCAs?
Depression
Nocturnal enuresis
Neuropathic pain
Migraine prophylaxis
42
Give some examples of MAOI?
Phenelzine
Isocarboxide
Moclobemide
43
When are MAOI used?
Side effects?
Third line for depression
Postural hypotension, arrhythmias
Drowsiness / insomnia, headache
Increased appetite, weight gain
44
What foods should be avoided when on MAOIs? Why?
Foods with **tyramine** e.g. cheese, pickled herring, liver, bovril, marmite and red wine
Causes **hypertensive crisis**
45
What are the clinical features of a hypertensive crisis?
Headache
Palpitations
Fever
Convulsions
46
What are antipsychotics also known as?
47
**Neuroleptics**
48
What are the difference between 1st gen and 2nd gen antipsychotics?
Extent to which they cause **extrapyramidal side effects**
49
Give some examples of 1st gen antipsychotics?
**Haloperidol**
**Chlorpromazine**
**Flupentixol**
**Fluphenazine**
**Sulpiride**
50
Name some **atypical antipsychotics**?
Olanzapine
Risperidone
Quetiapine
Amisulpride
Aripriprazole
Clozapine
51
What is used **first line** in **schizophrenia** according to NICE?
**Atypical antipsychotics**
52
What is the advantage of using **clozapine**?
Only antipsychotic found to be **superior** in efficacy to other antipsychotics (used in **treatment-resistant** schizophrenia)
53
When are **antipsychotics** used?
Patients with **delusions** and **hallucinations** (psychotic symptoms)
**Schizophrenia**
**Depression**, **mania**, **delusional disorder**, acute and transient psychotic disorders, delerium and dementia (if present with **psychotic symptoms**)
54
When should **clozapine** be prescribed for schizophrenia?
**Third line** (after trying 2 different antipsychotics)
55
What is the **mechanism of action** of typical antipsychotics?
**Block dopamine receptors** in brain
56
What is the **mechanism** of **action** of **atypical antipsychotics**?
Block **specific** dopaminergic receptors (D2 receptors)
## Footnote
**Serotonergic effects**
57
What are the **side effects** of **antipsychotics**?
58
**EPSE**
**Anti-muscarinic** (can't see - blurred vision, can't wee - urinary retention, can't spit - dry mouth, can't shit - constipation)
**Anti-histaminergic** (sedation and weight gain)
**Anti-adrenergic** (postural hypotension, tachycardia and ejactulatory failure)
**Increased prolactin:** sexual dysfunction, reduced bone mineral density, menstrual disturbances, breast enlargement, galactorrhoea)
**Hypercholesterolaemia**
**Neuroleptic malignant syndrome**
**Prolonged QT**: concern in haloperidol and pimozide - torsades de pointes causing sudden death
59
What are the **specific side effects** of **clozapine**?
**Hypersalivation** (pillow soaking with saliva)
**Agranulocytosis**
60
Which side effects are more common with atypical/ typical antipsychotics?
**Typical antipsychotics** = EPSE and hyperprolactinaemia
**Atypical antipsychotics** = anti-cholinergic, metabolic side effects
61
What are the **EPSE** seen with **typical antipsychotics**?
**PAD****-T**
**Parkinsonism**: bradykinesia, increased rigidity, coarse tremor, masked fancies (expressionless face), shuffling gait (takes weeks /months to occur)
**Akathisia**: unpleasant feeling of restlessness (in first months, treatment = reduce dose and give temporary propanolol)
**Dystonia** = acute painful contractions of muscles (spasms) off muscles in neck, jaw and eyes (oculogyric crisis) occurs in **days**
**Tardive dyskinesia** = late onset (**years**) of choreoathetoid movement (abnormal, involuntary movements) - may be **irreversible** - chewing and pouting of jaw
62
When is **neuroleptic malignant syndrome** seen?
Pts on **antipsychotic medication**
When **dopaminergic drugs** (e.g. levodopa) is stopped suddenly
63
How does **neuroleptic malignant syndrome** (NMS) present?
RAAH!
**Rigidity**
**Altered mental state** (confusion)
**Autonomic instability** (tachycardia, fluctuating BM)
**Hyperthermia**
64
What are the **investigations** for **NMS**?
**CK** (usually raised)
**FBC** (leucocytosis)
**LFTs** (deranged)
65
What is the **management** of NMS?
**Stop antipsychotics**
Monitor **vital signs**
**IV fluids** to prevent renal failure
**Cooling**
Medications = dantrolene (muscle relaxant), bromocriptine (dopamine agonist), benzodiazepines
66
What are some **complications** of **NMS**?
**PE**
**Renal failure**
**Shock**
67
When should **antipsychotics** be used with **caution**?
**CVD** (take ECG)
**Parkinson's** disease (may be exacerbated)
**Epilepsy**
**Depression**
**Myasthenia gravis**
**Prostatic hypertrophy**
**Susceptibility to closed angle glaucoma**
Blood **dyscrasias**
68
Name some **contraindications** to **antipsychotics**?
**Comatose** state
**CNS depression**
**Phaeochromocytoma**
69
What should be **monitored** when on **antipsychotics**?
**FBC, U&E, LFTS** (at start and annually)
**Amisulpride** and **sulpiride** do not require LFT monitoring
**Clozapine** = differential WBC testing weekly for 18 weeks, fortnightly for a year, then monthly
**Fasting blood glucose** (baseline, 4-6 months then yearly)
**Clozapine** and **olanzapine** = baseline after 1 month then every 4-6 months
**Blood lipids** (baseline, 3 months, yearly)
**ECG** (before initiation then monitoring if on **haloperidol** and **pimozide**)
**BP** (before initiation)
**Prolactin** (baseline, 6 months, yearly)
**Weight** (waist size and BMI - baseline, 3 months, yearly)
**Creatine phosphokinase** (baseline CK then if NMS is suspected)
70
What is the **general advice** when **stopping antipsychotics**?
**Continue for 1-2 years** following episode (some up to 5 years)
If stopping then **taper over 3 weeks** rather than abruptly
71
How are antipsychotics administered?
Usually **oral**
Some **IM injection**
Some **depot injection**
Started on lowest dose and titration to lowest dose to be effective
72
How often are depot injections given?
Give some examples of **typical** and **atypical** depot injections?
**1-4 weekly**
**Typical** = flupentixol, fluphenazine
**Atypical** = risperidone, olanzapine, aripiprazole
73
What should be **avoided** when **prescribing antipsychotics**?
**Use a loading dose** of antipsychotics
**Routinely initiate regular combined antipsychotic meciation** (except when changing medication)
**Stop abruptly**
74
What are **mood stabilizers**?
Drugs used to **prevent depression** and **mania** in **bipolar affective disorder** and **schizoaffective disorder**
75
What can be given in **acute severe manic episodes**?
**Stop antidepressant**
Give **antipsychotic** (if not on or check compliance and dose) or **mood stabiliser** (if not on - or check levels - valproate if not childbearing or lithium if adherence likely) consider **short term benzos**
76
When is **lithium indicated**?
**Bipolar affective disorder** (first line prophylaxis)
**Acute manic episode** (if atypical antipsychotic ineffective)
**Depression** (prevents antidepressant-induced hypomania)
77
What are some **side effects** of **lithium**?
"**GI & LITHIUM**"
GI disturbances
**L**eucocytosis
**I**mpaired renal function
**T**remor (fine) / teratogenic / thirst (polydipsia)
**H**ypothyroidism / **h**air loss
**I**ncreased weight / fluid retention
**U**rine increase
**M**etallic taste
78
What are some signs of **lithium toxicity**?
**T**remor (coarse)
**O**liguric renal failure
ata**X**ia
**I**ncreased reflexes
**C**onvulsions / **c**oma / **c**onsciousness decreased
79
What is the **therapeutic window** for **lithium**?
0.4 - 1.0 mmol / L
**Toxic** is \>1.5 mmol / L
80
When to **avoid** **lithium** prescription?
**Renal failure**
**Pregnancy** (teratogenic)
**Breast feeding**
81
When to prescribe **lithium** with **caution**?
QT prolongation
Epilepsy (decreased seizure threshold)
Diuretic therapy
82
When is **lithium contraindicated**?
**Untreated hypothyroidism**
**Addison's disease**
**Brugada syndrome** (heart disease with increased risk of sudden cardiac death)
83
What **monitoring** is required with **lithium**?
**Before treatment** = U&Es, eGFR (lithium has renal excretion and is nephrotoxic), TFTs, pregnancy, baseline ECG
**Lithium levels** = 12 hours, then weekly until therapeutic (0.4-1) stable for 4 weeks, then **3 monthly** (and during illness)
**U&Es** = every 6 months
**TFTs** = every 12 months (ask about symptoms)
84
What is the **dosage** of **lithium**?
**Lithium carbonate** (given for 18 months) start at 400mg at night - titrate between **400-1200mg/day** to keep plasma between 0.5 and 1.0
ORALLY
85
When should lithium **not be prescribed**?
Never in **child bearing age** = teratogenic - congenital heart defects
Never in **severe renal failure**
Never prescribe NSAIDS, diuretics (particularly thiazides) or ACE inhibitors without **careful thought**
Not if **adherence is a problem**
Never **withdraw abruptly** (can precipitate relapse)
86
When can **lithium toxicity occur**?
What is the **management**?
Dehydration, drugs, diuretics (thiazide)
Managment = high intake of fluid (osmotic diuresis)
87
What is sodium valproate used for?
What are some **side effects**?
Mood stabiliser
Side effects = weight gain, aggression, thrombocytopaenia, teratogenic (**neural tube defects** and spina bifida)
88
What to check before initiating **sodium valporate**?
**FBC**
Monitor **LFTs** and PT (for first 6 months)
**Pregnancy test**
Weight / BMI
89
What are the indications of **carbamazepine**?
Mania (not first line)
Prophylaxis of bipolar affective disorder
Alcohol withdrawal
90
What are some **side effects** of **carbamazepine**?
GI disturbances
Dermatitis
Dizziness
Leucopaenia, thrombocytopaenia
91
What are some **contraindications** to **carbamazepine**?
Contraindication = cardiac disease and blood disorder, pregnancy
92
What are the indications of **lamotrigine**?
What are some **side effects**?
**Bipolar depression** (less teratogenic than other mood stabilisers)
GI disturbances, rash, headache and tremor, don't use with carbamazepine (neurotoxicity)
93
What drugs are first line in **anxiety**?
SSRIs
94
What drugs can be used as **hypnotics**?
**Benzodiazepines**
Low dose **amitriptyline**
**Z drugs** (zopiclone, zolpidem, zaleplon)
95
What are the **indications** for **benzodiazepines**?
Give some **examples**?
96
How does **benzo** overdose appear and what is the **management**?
How to wean patients off benzos?
Ataxia, dysarthria, nystagmus, coma, respiratory depression
IV **flumazenil**
Wean off
97
What are the **indications** for **ECT**?
Euphoric (persistent mania)
Catatonic
Tearful (treatment resistant depression)
98
What are some **side effects** of **ECT**?
What are some **contraindications**?
Short term = peripheral nerve palsy, arrhythmia, headaches
Long term = amnesia
**Contraindications** = MI (\< 3 months ago), cerebral aneurysm, raised ICP, stroke (\< 1 month ago)
99
What is the **difference** between **advanced statements** and **advanced directives**?
**Statement** = not legally binding - express wishes
**Directive** = legally binding - only refuse treatment (but not food / drink by mouth or basic hygiene)
100
What is a **section 2** used for? How long does it last? Can it be renewed? When can it be appealed? Can treatment be refused?
Admission for assessment and response to treatment
28 days
Non-renewable
Appealed up to 14 days
Treatment cant be refused
Signed by 2 doctors and ASW (1 doctor must be known to pt)
101
When is **section 3** used? How long does it last? Can it be renewed? Can treament be refused?
**Admission** for treatment (known to services) - requires formal diagnosis
Lasts **6 months**
**Renewable**
**Treatment can be given against will until end of 3 months**
Appealed within 6 months
102
What is the **mental capacity act** (2005)?
**Identifies** those who **lack capacity** to consent / reduce treatment
* Best **interests**
* **Try and get patient to decide themselves** (e.g. interpreters, multiplie times)
* **Eccentric** decisions are allowed
* **Least restrictive intervention**
* **Presumption of capacity**
103
What are the **two types** of **lasting power of attorney**?
Property and affairs (financial)
Personal welfare
104
What are the components of **advanced care planning**?
**Advanced statement** = verbally or written allowing patient to make **general statements for wishes** if they were to lose capacity
**Advanced decision** = legal document with specific refusal of treatment (cant refuse drink / food by mouth) - signed by patient and witnessed
**Lasting power of attorney**
105
Where can deprivation of Liberty safeguard be used and why?
Care homes, hospitals and supported living
DoL must be applied for
106
Who is an **independent mental capacity advocate**? IMCA
Appointed to person who lacks capacity but has no one to speak on their behalf
107
What is the **mental health act** used for?
In **England and Wales** allows people with a **mental disorder** to be **sectioned** (those who do not consent / lack capacity)
Under the **influence of drugs** / **alcohol** are specifically excluded
Pts under section are called **formal** / **involuntary**
108
What is a section 4? Who can enforce it? How long does it last?
Used in **emergency** when **section 2 would involve unacceptable delay**
Enfored by **GP** or **AMHP** or **nearest relative**
Lasts 72 hours
109
What are the **other emergency sections**? How long do they each last? Who can enforce them?
Section 5.2 = holding order for inpatients on any ward (not A&E), no right to appeal, lasts 72 hours, doctor - must then be assessed for S2/S3/discharge/informal
Section 5.4 = holding order for inpatients on MH ward, no right to appeal, lasts 6 hours, nurse
Section 135 = police officer appeals for court order to break into property to remove person to place of safety, lasts 72 hours
Section 136 = police officer can take someone who appears to have a mental disorder from a public place to a place of safety, lasts 72 hours
110
What is a **community treatment order**?
Allows pts who are on S3 and well enough to leave hospital for treatment in community (decision made by responsible clinician)
111
What is a section 117?
Deals with **aftercare** responsibilities after a patient has been detained on **section 3**
112
What is **forensic pathology**?
**Assessment** and **treatment** of **mentally disordered individuals**
