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Management of Mental Health Flashcards

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1
Q

What are the principles of psychotherapy?

A 
Develop therapeutic relationship
Listen to patient's concerns
Empathetic approach
Provide info, support, advice
Allow expression of emotion
Encourage self-help
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2
Q

What are the most commonly used forms of psychotherapy?

A

CBT

Psychodynamic psychotherapy

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3
Q

What are the types of psychological therapies?

A

Type A - psychological treatment as an integral part of mental health care

Type B - eclectic psychological therapy and counseling

Type C - formal psychotherapies e.g. CBT, psychoanalytic/psychodynamic therapies, systemic and family therapy

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4
Q

What is transference?

A

Unconscious transfer of feelings and attitudes from the past into the therapist

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5
Q

What is psychotherapy?

A

The systematic use of a relationship between a patient and a therapist, as opposed to physical and social methods, to produce changes in feelings, cognition and behaviour.

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6
Q

What are common characteristics of all psychotherapies?

A

Intense confiding relationship with a helpful person
Rationale containing explanation of the patient’s distress
Provision of new information about the nature and origins of the patient’s problems and ways of dealing with them
Development of hope in the patient that they will be helped
Opportunities to experience success during treatment, enabling increased sense of mastery
Facilitation of emotional arousal

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7
Q

What are the principles of psychodynamic psychotherapy?

A

Less freq treatment - once or twice weekly sessions, may be brief from 4 months to a year.

Focuses of unconscious and past experience to determine current behaviour. Talk about childhood relationships, reveal unconscious psych.

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8
Q

What are the principles of psychoanalytic psychotherapy?

A

Regular sessions
Unconscious patterns brought into awareness, view of changing these
Verbalise thoughts through free association, fantasy and dreams.

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9
Q

What are the basic principles of CBT?

A

Based on learning theory, exposure to reduce avoidance and permit habituation.
Behavioural techniques for anxiety, OCD, PTSD.

Addresses role of dysfunctional thoughts and beliefs, very structured, problem orientated and time limited therapy.

Very active, homework to complete e.g. experimenting with new behaviours, identifying negative thoughts

Between 5-20 weekly sessions, last 1 hour

Can be individual, group, self help via books or computers

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10
Q

What are examples of behavioural therapies?

A

Relaxation training - for stress related and anxiety disorders

Systemic desensitisation - for phobic anxiety disorders, gradually exposed to hierarchy of anxiety-producing situations

Flooding - rapid exposure to phobic object without any attempt to reduce anxiety prior, continue exposure until diminishes

Exposure and response prevention - for OCD and phobias, repeatedly exposed but prevented from performing compulsive actions.

Behavioural activation - for depressive illness, making realistic and achievable plans to carry out activities, then gradually increasing amount of activity

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11
Q

What is the rationale for psychodynamic therapy?

A

Based upon the idea that childhood experiences, past unresolved conflicts and previous relationships influence individuals current situation

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12
Q

What is psychoeducation?

A

Delivery of information to help cope with mental illness
Inform of causes, health services to help them, self help
May be in groups or individually

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13
Q

What is counselling?

A

Relief of distress
Active dialogue between councillor and client
For e.g. adjustment disorder, mild depression, grief, trauma, prior to decision making
Helps client find own solutions to problems, whilst being supported to do so and being guided by appropriate advice

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14
Q

What is supportive psychotherapy?

A

Psychological support for those with chronic or disabling mental illness
Helps people cope
Listening, reassurance, providing explanation, guidance

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15
Q

What is problem solving therapy?

A

Structured combination of counselling and CBT

Learn to actively deal with life problems, select a solution and review its effect.

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16
Q

What is interpersonal therapy?

A

Used to treat depression and eating disorders.
Focus is on interpersonal problems e.g. bereavement, relationship difficulties
Overlap with CBT and psychodynamic therapy

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17
Q

What is EMDR?

A

Eye movement desensitisation and reprocessing
Recalling emotionally traumatic material whilst focusing on an external stimulus, stimulates both sides of the brain e.g. following finger side to side

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18
Q

What is DBT?

A

Dialect behavioural therapy
For those with borderline PD
CBT and group skills training for alternative coping strategies rather than self harm when faced with emotional instability

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19
Q

What is CAT?

A

Cognitive analytic therapy

Combines cognitive theories and psychoanalytic approaches to an integrated therapy

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20
Q

What are the forms of psychotherapies?

A

Individual
Couples
Family
Group - offers support network for those with similar difficulties

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21
Q

What is the rationale for antidepressants?

A 
Moderate to severe depressive episodes and dysthymia
Anxiety, panic attacks
OCD
Chronic pain
EDs
PTSD
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22
Q

What is the basis of the function of antidepressants?

A

The monoamine hypothesis

Enhances the activity of monoamine neurotransmitters noradrenaline and serotonin

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23
Q

What are the classes of antidepressants?

A

SSRIs
SNRIs - serotonin and noradrenaline reuptake inhibitor
TCA - tricyclic antidepressant
MAOI - monoamine oxidase inhibitor
NARI - noradrenaline reuptake inhibitor
SARI - serotonin antagonist and reuptake inhibitor
NASSA - noradrenaline serotonin specific antidepressant

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24
Q

What is the action of MAOIs?

A

Prevent breakdown of dopamine, noradrenaline and serotonin.

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25
What do TCAs do?
Block reuptake of serotonin and noradrenaline in synaptic cleft?
26
What are examples of SSRIs?
Citalopram, fluoxetine, sertraline
27
What are the indications for SSRIs?
``` Depression Panic disorder - citalopram Social phobia - paroxetine BN - fluoxetine GAD - paroxetine ```
28
What is the mechanism of action of SSRIs?
Inhibit reuptake of serotonin from the synaptic cleft into the pre-synaptic neurones SSRIs increase concentration of serotonin in the synaptic cleft
29
What are the side effects of SSRIs?
``` Nausea, dyspepsia, bloating STRESS Sweating, tremor, rashes Extrapyramidal side effects Sexual dysfunction Somnolence Stopping SSRIs - chills, insomnia, anxiety, restless ```
30
What are the cautions of SSRIs?
History of mania, epilepsy Cardiac disease, glaucoma Diabetes GI bleeding, hepatic impairment, renal impairment
31
What are the contraindications of SSRIs?
Mania
32
What are some common doses of SSRIs?
Sertraline - 50-200mg/day | Fluoxetine - 20-60mg/day
33
What is the route for SSRIs?
Oral
34
What are examples of SNRIs?
Venlafaxine 75mg a day | Duloxetine 60-120mg/day
35
What is the indication for SNRIs?
Second or third line in treatment of depression and anxiety disorders More rapid onset and more effective
36
What is the mechanism of action of SNRIs?
Prevent reuptake of NA and serotonin but do not block cholinergic receptors and therefore many anti-cholinergic side effects
37
What are the side effects of SNRIs?
``` Nausea Dry mouth Headache Dizziness Sexual dysfunction Hypertension ```
38
What are the cautions to SNRIs?
Similar to SSRIs
39
What are the contraindications of SNRIs?
Conditions associated with high risk of cardiac arrhythmias, uncontrolled hypertension
40
What are NASSAs?
Noradrenaline-serotonin specific antidepressants e.g. Mirtazapine
41
What are the indications for NASSAs?
Second line depressed patients Who would benefit from weight gain Suffer from insomnia
42
What is the mechanism of action of mirtazapine?
Weak noradrenaline reuptake inhibiting effect Anti-histaminergic properties and is an alpha 1 and 2 blocker Therefore increases appetite and is a sedative
43
What are the side effects of mirtazapine?
``` Increase in appetite Weight gain, dry mouth Postural hypotension Oedema, drowsiness, fatigue Tremor, dizziness, abnormal dreams Anxiety, arthralgia, myalgia ```
44
Who is mirtazapine cautioned in?
``` Elderly, cardiac disorders Hypotension, urinary retention Susceptibility to glaucoma History of seizures, blood disorders Pregnancy and breast feeding ```
45
What are NARIs?
Noradrenaline reuptake inhibitors | Reboxetine
46
What is the indication for NARIs?
Second or third line for major depression
47
What is the mechanism of action for NARIs?
Highly specific noradrenaline reuptake inhibitor
48
What are the side effects of NARIs?
``` Nausea, dry mouth Constipation Anorexia, tachycardia Palpitations Vasodilatation Postural hypotension Headache, dizziness, chills ```
49
Who are NARIs cautioned in?
``` Cardiovascular disease Epilepsy Bipolar disorder Urinary retention Pregnancy Avoid abrupt withdrawal ```
50
What are SARIs?
Trazodone
51
What are the indications for trazodone?
Depressive illness Particularly where sedation is required Anxiety, dementia with agitation, insomnia
52
What are important warning for prescribing SSRIs?
Do not co-prescribe NSAIDs, but if you have to give a PPI as well. Do not co-prescribe SSRIs and heparin/warfarin Do not stop SSRIs suddenly, dose gradually reduced over 4 week period - but not necessary with fluoextine Do not prescribe citalopram in congenital long QT syndrome/
53
Who should SNRIs not be used in?
Those with cardiac disease and uncontrolled hypertension | BP measurement should be taken before starting venlafaxine, and monitored regularly after.
54
What are some examples of tricyclic antidepressants?
Amitriptyline, clomipramine | Nortiptyline
55
What are the indications for TCA?
Depressive illness Nocturnal enuresis Neuropathic pain Migraine prophylaxis
56
What is the mechanism of action of TCAs?
Inhibit reuptake of adrenaline and serotonin in the synaptic clef Also have affinity for cholinergic receptors and serotonin receptors - contributes to side effects.
57
What are the side effects of TCAs?
Anticholinergic - dry mouth, constipation, urinary retention, blurred vision CV - arrhythmias, postural hypotension, tachycardia, syncope, sweating Hypersensitivity reactions - urticarial, photosensitivity Psychiatric - hypomania, mania, confusion Metabolic - appetite, weight gain Endocrine Neurological - convulsions, movement disorders Headache, sexual dysfunction, tremor
58
When are TCAs cautioned?
``` Cardiac disease History of epilepsy Breastfeeding, pregnancy Elderly Hepatic impairment Thyroid disease Phaeochromocytoma Hx mania Concurrent ECT ```
59
When are TCAs contraindicated?
``` Recent MI Arrhythmias, heart block Mania Severe liver disease Agranulocytosis ```
60
What is an example of TCA dosage?
Amitriptyline 50-200mg/day
61
What is the route of TCAs?
Oral - tablet or solution
62
What are examples of MAOIs?
Irreversible - phenelzine | Reversible - moclobemide
63
What are the indications for MAOIs?
Third line depression Atypical or treatment resistant Social phobia
64
What is the mechanism of action?
Inactive monoamine oxidase enzymes that oxidise monoamine neurotransmitters
65
What are the side effects of MAOIs?
``` CV - postural HTN, arrhythmias Neuro - drowsy, insomnia GI - appetite, weight gain Sexual - anorgasmia Hepatic Hypertensive reactions with tyramine containing foods ```
66
When are MAOIs cautioned?
Avoid in agitated or excited patients, or give with a sedative for up to 2-3 wks Thyrotoxicosis Hepatic impairment Pregnancy, breast feeding If changing to another antidepressant, need a washout period of up to 6 weeks
67
What foods should be avoided with MAOIs?
Tyramine rich foods as MAOIs also metabolise tyramine. Cheese, pickled herring, liver, Bovril, Oxo, marmite, some red wine. Can cause hypertensive crisis - headache, palpations, fever, convulsions, risk of coma.
68
What are examples of typical antipsychotics?
Haloperidol Chlorpromazine Zuclopenthixol
69
What are examples of atypical antipsychotics?
``` Olanzapine Risperidone Quetiapine Aripiprazole Clozapine ```
70
What is the indication for antipsychotics?
Mainstay of treatment for schizophrenia, for delusions and hallucinations.
71
What are the indications for clozapine?
Third line treatment for schizophrenia | Should only be prescribed after failing to respond to two other antipsychotics - treatment resistant schizophrenia
72
What is the mechanism of action of antipsychotics?
Reduce abnormal transmission of dopamine through blocking dopamine receptors Atypicals have a specific dopaminergic action blocking D2 receptors and serotonergic effects
73
How is a first-episode schizophrenia treated with antipsychotics?
Agree on choice Titrate to minimum effective dose, adjust Assess over 2-3 weeks Continue if working Change if not, consider depot if not compliant Not effective - clozapine
74
What are some of the additional side effects of antipsychotics?
Have an affinity for muscarinic, 5HT, histaminergic and adrenergic receptors Have extrapyramidal side effects 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, ejaculatory failure Increase in prolactin Neuroleptic malignant syndrome Prolonged QT interval
75
What are the specific side effects of clozapine?
Hypersalivation - patients may wake up with their pillows soaking with saliva Agranulocytosis
76
What are the EPSEs?
Parkinsonism - bradykinesia, rigidity, coarse tremor, masked facies, shuffling gait Akathisia - unpleasant feeling of restlessness - reduce dose and give propranolol Dystonia - acute painful spasms of neck, jaw and eye muscles, occurs within days Tardive dyskinesia - late onset, choreoathetoid abnormal involuntary movements, chewing and pouting of the jaw
77
What are the cautions of antipsychotics?
``` CV disease - ecg Parkinson's - exacerbated Epilepsy Depression Myasthenia gravis ```
78
What are the contraindications of antipsychotics?
Comatose states CNS depression Phaeochromocytoma
79
What needs to be monitored whilst taking antipsychotics?
FBC, U&Es, LFTs - at start then annually Clozapine needs WBC weekly for 18 weeks Fasting blood glucose Blood lipids - baseline, 3 months then yearly ECG before initiating Advised for haloperidol Mandatory for pimozide Check for long QT BP Prolactin Weight Physical health Creatine phosphokinase - baseline CK, then measure if neuroleptic malignant syndrome is suspected
80
How should antipsychotics be stopped?
Continue for 1-2 years following an episode of psychosis, even up to 5 years to prevent relapse Taper medication over period of approx 3 weeks, relapse rate in first 6 months after abrupt withdrawal is double
81
What is the route of antipsychotics?
Oral Short acting IM injection Depot injection every 1-4 weeks Dose increases only take place after 1-2 weeks of assessment if poor/no response
82
What is the difference between typical and atypical antipsychotics?
Typical - more extrapyramidal side effects, metabolic syndrome less likely, weight gain less likely Less likely to cause Type 2 diabetes, stroke in elderly, tardive dyskinesia, high prolactin levels.
83
What is it important not to do when prescribing antipsychotics?
Do not use loading dose Do not routinely initiate regular combined antipsychotics Do not prescribe without significant cardiovascular hx Do not stop abruptly
84
What are mood stabilisers?
Prevent depression and mania in bipolar affective disorder and schizoaffective disorder. Atypical antipsychotics have a rapid onset of action compared to mood stabilisers so can be used in acute severe manic episodes.
85
What is the treatment guideline of acute mania or hypomania?
Stop antidepressant Is the patient taking antimanic medication? No - consider an antipsychotic if symptoms severe or mood stabiliser - valproate if not childbearing. If taking antipsychotic, check compliance and dose, consider increasing dose, add mood stabiliser.
86
What are the indications for lithium?
First line bipolar affective | Also effective in acute manic episode and as an adjunctive treatment for depression.
87
What is the mechanism of action of lithium?
Some evidence bipolar patients have a raised intracellular conc of sodium and calcium, and lithium can decrease these, as lithium handled in similar way to sodium. Decreased activity of sodium dependent messenger systems.
88
What are the side effects of taking lithium?
GI disturbances ``` LITHIUM Leucocytosis Impaired renal function Tremor - fine Teratogenic Thirst - polydipsia Hypothyroidism Increased weight, fluid retent Urine increase Metalic taste ```
89
What are the signs of lithium toxicity?
``` TOXIC Tremor - coarse Oliguric renal failure AtaXia Increased reflexes Convulsions/coma ``` Toxic levels >1.5mmol/L Therapeutic levels - 0.4-1.0
90
What are the contraindications and cautions of lithium?
Avoid in renal failure Avoid in preg, breastfeeding as teratogenic Caution with QT prolongation, epilepsy and diuretic therapy Contraindicated in untreated hypothyroidism, Addison's, Brugada syndrome
91
When should lithium levels be monitored?
Before treatment started - U&Es, eGFR, TFT, pregnancy status, baseline ECG. Levels monitored 12 hours following first dose, then weekly until therapeutic level stable for 4 weeks. Then check every 3 months. U&Es checked every 6 months. TFTs every 12 months.
92
What should you not do when prescribing lithium?
Do not prescribe unless specialist. Do not give to women of childbearing age. Do not give in severe renal failure. Do not prescribe NSAIDs, diuretics, ACEi without careful thought. Do not withdraw lithium abruptly as can precipitate relapse
93
How can lithium toxicity be enhanced?
4Ds Dehydration Drugs - ACEi, NSAIDs, diuretics Depletion of sodium
94
What is the management of lithium toxicity?
Stop immediately High intake of fluid provided, including IV NaCl therapy to stimulate osmotic diuresis In most severe cases, renal dialysis may be needed
95
What are the indications for sodium valproate?
Comparable efficacy to lithium as a mood stabiliser If lithium is ineffective or unsuitable Can be used with lithium for rapid cycling
96
What is the mechanism of sodium valproate?
Inhibits catabolism of GABA | Decreases turnover of arachidonic acid and activates extracellular signal-regulated kinase
97
What are the side effects of sodium valproate?
GI disturbances VALPROATE ``` Very fat - weight gain Aggression LFTs rise Platelets low Reversible hair loss Oedema Ataxia Tremor/tiredness/teratogenic Emesis ```
98
What are the contraindications for sodium valproate?
Avoid in pregnancy - can cause neural tube defects Hepatic dysfunction Porphyria
99
What is the route and dosage of sodium valproate?
250-500mg, titrated upwards | Oral, IV only used for epilepsy
100
What is the indication for carbamazepine?
Mania not first line Prophylaxis of bipolar affective disorder if unresponsive to lithium Alcohol withdrawal
101
What is the mechanism of action of carbamezapine?
Blocks voltage dependent sodium channels, inhibits repetitive neuronal firing Decreases glutamate release and turnover of dopamine and noradrenaline
102
What are the side effects of carbamezapine?
GI disturbances, dermatitis, dizziness, hyponatraemia, blood disorders e.g. leucopenia, thrombocytopenia
103
What are the contraindications of carbamezapine?
Caution in cardiac disease and blood disorders Contraindicated in AV conduction abnormalities and acute porphyria (metabolic disorder causes nervous symptoms) Avoid in pregnancy Potent enzyme inducer so e.g. COCP metabolised faster
104
What are the indications for lamotrigine?
Used to treat bipolar depression | Does not treat or prevent manic episodes
105
What is the mechanism of action of lamotrigine?
Inhibition of sodium and calcium channels in presynaptic neurones and subsequent stabilisation of neuronal membrane
106
What are the SEs of lamotrigine?
GI disturbances, rash, headache, tremor
107
What are the contraindications of lamotrigine?
Combination of lamotrigine and carbamezapine may cause neurotoxicity
108
What monitoring is required on lamotrigine?
LFTs, FBC and U&Es prior to starting | Do not routinely measure plasma levels unless evidence of ineffectiveness, poor adherence or toxicity.
109
What is the dosage of lamotrigine?
Must be initiated very gradually beginning at 25mg daily. Avoid abrupt withdrawal unless serious stevens johnson rash
110
What drugs can be used as hypnotics?
Benzodiazepines Low dose amitriptyline Zopiclone, Zolpidem, Zaleplon
111
What are examples of benzos?
Long acting >24 hours - diazepam, nitrazepam, clonazepam | Short acting <12 hours - lorazepam, midazolam
112
What are the indications for benzos?
Insomnia, short term use Anxiety disorders - panic disorder, phobic anxiety disorder, short term relief Delirium tremens and alcohol detoxification Acute psychosis Violent behaviour
113
What is the mechanism of action of benzos?
Enhance effect of inhibitory neurotransmitters, increase frequency of Cl channels
114
What are the SEs of benzos?
``` Drowsiness Light headedness Confusion and ataxia Amnesia Paradoxical inc in agitation Muscle weakness Respiratory depression ```
115
What are the cautions and contraindications of benzos?
Respiratory depression and hepatic impairment
116
What are the common routes for benzos?
PO | IM, IV and PR if non compliant and status epilepticus
117
What are the clinical features of a benzo overdose?
``` Ataxia Dysarthria Nystagmus Coma Respiratory depression A-E approach, IV flumazenil ```
118
What is benzodiazepine withdrawal syndrome?
May develop at any time up to 3 weeks after stopping a long acting benzodiazepine May occur within a day in the case of a short acting one Effects include insomnia, anxiety, loss of appetite, tremor, muscle twitching, sweating, tinnitus, perceptual disturbances Seizures - rare
119
What is discontinuation syndrome?
Antidepressants are not addictive but they can be difficult to stop Syndrome characterised by sweating, shakes, agitation, insomnia, headaches, irritability, nausea, vomiting, paraesthesia, clonus
120
What can be used to treat extra pyramidal side effects?
If too much acetylcholine in relation to dopamine and cannot increase dopamine activity - use acetylcholine receptor antagonists e.g. procyclidine, benzatropine, trihexphenidyl
121
What beta blockers are used as an anxiolytic?
Act by reducing autonomic nervous sytem activation Propranolol Dangerous in overdose, contraindicated in asthma
122
What is pregabalin?
Binds to voltage gated calcium channels, reduces neuronal activity - CNS depressant Used in anxiety, neuropathic pain and epilepsy Causes sedation and weight gain
123
What is buspirone?
Non sedating anxiolytic that can be used for GAD Does not cause dependence, but its anxiolytic effect develops more slowly Side effects include nausea, headache, light headedness, dizziness
124
What are the Z drugs?
Zopiclone, zolpidem, zaleplon | Work like benzos, enhance GABA transmission, mainly used as hypnotics as have shorter half lives.
125
What should you not do when prescribing anxiolytics and hypnotics?
Use readily Prescribe benzos long term - should not be prescribed for more than 2-4 weeks Withdraw anxiolytics abruptly Do not forget alternatives - antidepressants have secondary anxiolytic effects and are safer for long term use
126
What is ECT?
Passage of small electrical current through the brain to induce a therapeutic modified epileptic seizure GA given, muscle relaxant e.g. suzamethonium give Bilateral with electrodes on each side, or non dominant cerebral hemisphere - unilateral ECT 6-12 treatment sessions delivered twice a week
127
What basic observational changes are noticed in ECT?
EEG changes - seizure Pulse and BP rise Cerebral blood flow increases by 200%
128
What is the seizure threshold?
The minimum electrical stimulus required to induce a seizure, used in calculating the electrical current dose.
129
What drugs raise the seizure threshold?
Anaesthetic drugs, anticonvulsants, benzodiazepines, barbiturates
130
What drugs decrease the seizure threshold?
Antipsychotics Antidepressants Lithium
131
What are the main indications for ECT?
Euphoric, Catatonic, Tearful Prolonged or severe mania Catatonia Severe depression - treatment resistant, suicidal ideation or serious risk to others, life threatening e.g. will not eat or drink
132
How is consent given for ECT?
Written informed consent | For patients detained under MHA - requires independent second opinion
133
What are the short term side effects of ECT?
PC DAMS Peripheral nerve palsies Cardiac arrhythmias, confusion Dental and oral trauma Anaesthetic risks - laryngospasm, sore throat, N+V Muscular aches, headaches Short term memory impairment, status epilepticus
134
What are the long term side effects of ECT?
Anterograde and retrograde amnesia Deficit is greater in those who receive bilateral ECT vs unilateral
135
What can ECT precipitate in bipolar?
A manic episode
136
What are the contraindications to ECT?
``` MI < 3 months Major unstable fracture Aneurysm - cerebral Raised ICP e.g. intracranial bleed, SOL - the only absolute contraindication Stroke <1 month ago, history of status epilepticus Severe anaesthetic risk ```

Mental Health (15 decks)

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