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Flashcards in Mental Health 2 Deck (123):

What is Bipolar disorder?

Characterised by periods of high mood (mania) and low moods (depression)


What is Bipolar I?

at least one manic episode with or without history of major depressive episodes


What is bipolar II?

one or more major depressive episodes, and at least one hypomanic episode, but no evidence of mania


DSM criteria for mania?

- abnormally and persistently elevated, expansive or irritable mood lasting 1 week
- accompanied by at least 3 of: increased energy/activity, pressure of/incomprehensible speech, flight of ideas, poor concentration, disinhibition, extravagant/impractical plans, delusions or hallucinations
- severe enough to cause marked impairment in social/occupational funcitoning or require hospitalisation or includes psychotic features


WHat is hypomania?

similar to mania, but symptoms only need to have lasted for 4 days, not severe enough to cause marked impairment/hospitalisation, and no psychotic features


How to treat mania?

- consider stopping any antidepressants
- if on mood stabiliser, maximise dose
- use antipsychotics - Haloperidol, Risperidone, Olanzapine, Quetiapine (if ineffective or not tolerated switch)
- if only on antipsychotic and still insufficient response, consider adding lithium or valproate
- do not use lamotrigine for mania


Why is suddenly stopping antidepressants in mania recommended by NICE?

Discontinuation symptoms are better than antidepressants adding to mania


How to treat bipolar depression?

- maximise mood stabiliser dose if on one
- Fluoxetine and Olanzapine, or Quetiapine
- Can also consider – Olanzapine on its own, or Lamotrigine
- If no response to Fluoxetine and Olanzapine, or Quetiapine, use Lamotrigine


What are the treatments for maintenance of bipolar disorder?

- lithium is the gold standard
- other options: add/switch to valproate or olanzapine, or quetiapine if used in acute phases
- some patients can go without medication if they are willing to seek help asap when episodes occur


Important to note when prescribing/dispensing lithium?

Brand specific, not interchangeable


Biological effects of lithium?

- 4-7 days to reach steady state, narrow therapeutic range
- levels should be 0.4-0.8mmol/l 12 hours post dose


Monitoring requirements for lithium?

- check lithium levels weekly until stable, then every three months
- Baseline and regular monitoring of U&Es, eGFR, TFTs, Bone, FBC, ECG, BMI


Main side effects/risks with lithium?

- toxicity. signs: vomiting and diarrhoea, coarse tremor, CNS disturbances
- side effects: fine tremor, acneiform eruptions
- nephrotoxicity, hypothyroidism, hypercalcaemia
- hydration important


Drug interactions with lithium?

NSAIDs, diuretics, ACE inhibitors


What are the counselling points for patients taking lithium?

- Indication, dose, time of dose, frequency
- Brand, MR formulation
- Duration of treatment
- Physical and lithium monitoring
- Why we do monitoring, when we do levels, frequency
- Side effects
- Causes of toxicity – dehydration, changes to salt, other medicines
- Signs of toxicity
- What to do if toxicity occurs
- Drug interactions – only buy OTC medicines from a pharmacy, tell pharmacist that you are taking Lithium.
- Pregnancy


Forms of valproate available?

Sodium valproate or semisodium valproate


Monitoring requirements for valproate?

Baseline and regular BMI, FBC, LFTs – after 6 months, then annually


Purpose of monitoring for valproate?

Check adherence, effect and toxicity


Who is valproate not suitable for and why?

Females of child bearing potential

Huge risk of teratogenic effects - malformations, developmental disorders, autism, ADHD


What is the treatment pathway for BPAD?

- treat acute episodes
- review medication once there is improvement
- back to baseline
- maintenance treatment
- minimum amount and dose of medication


Role of the pharmacist in bipolar treatment?

- medicines reconciliation
- medication options
- counselling and discussion with patient
- monitoring compliance
- Advcie: interactions, pregnancy, complications of treatment
- Side effect and monitoring advice
- recognising toxicity
- reviewing treatment
- recognising relapse


When does anxiety become a disorder?

When it has an impact on the individual's day to day life


Examples of anxiety disorders?

GAD, social anxiety disorder, panic disorders, PTSD, OCD


What therapy can be used to treat anxiety disorders?

CBT - change thinking patterns


Most effective treatment for anxiety disorders?

pharmacological therapy combined with behavioural therapy


What are the three classes of benzodiazepines?

Long acting: >24 hours e.g. diazepam
Short-Intermediate: 5-24 hours e.g. lorazepam
Ultra short acting: <5 hours e.g. midazolam


Five classified uses of benzos?

Anxiolytic (relief of anxiety)
Hypnotic (promotion of sleep)
Myorelaxant (muscle relaxant)
Amnesia (e.g. premedication for surgery)


In which part of the brain does anxiolytic activity occur?

Limbic system - hippocampus and amygdala


Suggested effect of benzos on the brain?

impair discharges from the amygdala & amygdalo-hippocampal transmission


WHich ionotropic receptor do benzos act on?



What is the GABAa receptor?

- most prevalent of the known GABA receptor subtypes
- ubiquitious distribution throughout the brain


Structure of the GABAa receptor?

five subunits comprising an integral transmembrane ion channel (typically two alpha two beta but this varies)
gated by the binding of two agonist (GABA) molecules
- when opened, the channel conducts mostly chloride ions, leading to inhibition in the nerve cell


What other receptor sites do GABAa receptors have?

Those that bind several clinically relevant molecules, all at different sites


What are molecules that can bind to GABA receptors known as?

GABA modulators (increase or decrease the effect of GABA)
some have no effect in the absence of GABA


Where do benzos bind on the GABA receptor, and what effect do they have?

BDZ site
increases affinity for GABA, so channel more likely to open and increase hyperpolarisation (inhibition) of the cell


What is BDZ potency limited by?

availability of GABA


How do different GABAa receptor subtypes arise?

Different subunit compositions, have different regional and cellular locations


Difference in effect of benzos at alpha 1 and alpha 2 subunits?

Those with high activity at alpha 1 are more associated with sedation and amnesia
Those with high activity at alpha 2 have more anxiolytic effect


How is the difference in effect at different alpha subunits clinically useful?

Can select for the right therapeutic effect


Definition of mental capacity?

The ability to make own decisions


What does the mental capacity say about when someone may lack capacity?

If a person is unable to make or communicate a particular decision at a particular time, because of an impairment (or disturbance) in the mind or brain


Important point about mental capacity assessments?

Time and context specific


What is the mental capacity act focused around?

Empowering independent decision making, and protecting those who cannot make decisions for themselves


How does someone act if they want to make decisions on someone else's behalf?

must arrange or conduct a mental capacity assessment


What kinds of people can assess for mental capacity?

Must have training

One person can be assessed for different decisions


What are the criteria for mental capacity?

1. understand the information related to the particular decision
2. remember the information long enough to make a decision
3. weigh up or use the information as part of the decision making process, including consequences of not receiving it
4. communicate the decision in any form


How many criteria must you meet to be deemed to not have capacity?



What are the key principles for making decisions son behalf of others?

1. person must be assumed to have capacity to make a decision unless established otherwise
2. must not be assumed to be unable to make the decision unless all practical steps have been taken to help them make the decision without success
3. person must not be treated as unable because they made an unwise decision
4. any decision made on someone's behalf must be made in their best interests
5. consideration must be given for whether the purpose the decision is needed for can be achieved in any way which is less restrictive on the person


What is 'best interests'?

- must be a definite need to make the decision in question at that time


Mental capacity act best interest checklist?

- consider al circumstances, make sure age/appearance/behaviour etc is not influencing
- consider delaying decision until person regains capacity
- involve person as much as possible in decision making
- do not be motivated to bring about the persons death
- consider past and present wishes and feelings, incl any advance statement/decision
- consider beliefs and values
- take into account views of family/carers
- use the least restrictive option


What does DoLs stand for?

Deprivation of Liberty Safeguards


What are DoLS

- amendment to the MCA 2005
- only concerns patients in hospitals or care homes

for those assessed as lacking capacity, DoLS protects them if caregivers determine they mustt deprives them of their liberty to keep them safe. DoLS is a process whereby arrangements are checked to determine they are necessary and in the patients best interests


What is advance care planning?

- voluntary conversation between patient and HCP
- future decisions and priorities if mental capacity affected in future
- concerns patient beliefs, treatment goals, wishes, values to be taken into account
- covers patient understanding of their condition and its time course
- informs best interest decision making
- plan is recorded and communicated with relevant people/organisations
- can include options relating to power of attorney and advance decisions/statements

must be documented, shared (with permission) and regularly reviewed


What is IMCA?

Independent Mental Capacity Advocates
- there to provide safeguards for those lacking capacity and without family support
- access to medical/social records of the person affected and can represent them at best interest meetings


What is lasting power of attorney?

- Can relate to financial, health, and general welfare
- the person affected nominates a trusted family member/friend to make decisions on their behalf
- person must be registered with the public guardian
- can't involve life sustaining treatment unless specifically mentioned in paperwork


What is an advance decision?

- enables those 18+ with mental capacity to refuse specified medical treatment in future when they may lack capacity
- HCPs should do all they can to find out if advance decisions have been made and if still valid
- can be over-ridden if evidence that the person did or could have changed their mind
- cannot be used to demand treatment or for general decision making


What are advance statements?

Similar to advanced decisions but not legally binding
- used for general decisions like washing or eating
- must still be respected


Important points on crossover between MHA and MCA?

- those with mental illness not assumed to lack capacity
- MCA does allow for restraint proportional to level of risk


Which act do you use if patient is under MHA but has capacity and refuses treatment?

treat under MHA


Which act do you use if someone is under MHA but lacks capacity?

MCA (appoint the necessary people, follow the principles)


Physical illness when a patient is under MHA?

MHA does not cover physical illness, use MCA


MHA and advance decisions?

MHA can override advance decisions
DoLS does not apply in hospitals under MHA


General principles of covert administration?

- last resort
- can only be used when a patient refuses their medicines and doesn't have the capacity to understand this decision
- must be considered essential for health and wellbeing
- administered in the least restrictive way
- patient must be supported in making their own decision as much as possible


Three symptoms groups for schizophrenia?

Positive, negative, cognitive


What do schizophrenia treatments achieve?

- Do not cure the disease, only alleviate symptoms
- high response rate in first episode
- don't prevent relapse


Consequences of non-adherence for schizophrenia treatments?

work best when taken regularly, non adherence increase risk of relapse by 5x


What is the prodromal phase of schizophrenia?

symptoms that occur prior to hte first episode, including mood and behaviour changes


Treatments offered in the prodromal phase of schizophrenia?

CBT and/or family intervention
NOT antipsychotics


Treatments offered in the first episode of schizophrenia?

- Rule out other causes for symptoms
- Full social, physical, psychiatric, occupational and economical assessment
- Offer antipsychotic therapy in conjunction with psychological interventions (individual CBT & family). - Consider arts therapy for –ve symptoms


Maintenance treatments for schizophrenia?

continue for 1-2years if effective
- high relapse risk if stopped
- can withdraw but careful monitoring required


Considerations when choosing antipsychotic therapy?

- Partnership between patients and Dr
- Views of patients’ carer also welcome if patient agrees
- Consider metabolic, EPSE, cardiovascular, hormonal and other side effects
- The patient can decide which treatment they might tolerate more
- Discuss alcohol/smoking/illicit/OTC use
- Dependent on baseline investigations


How to treat subsequent episodes of schizophrenia?

- treat as first episode
- review diagnosis, medication (dose, adherence etc)
- consider influence of illegal drugs
- may need to switch
- switch to atypical if typical tried first


How to treat treatment resistant schizophrenia?

if tried two antipsychotics (at least 1 atypical) - try clozapine


General points when starting antipsychotic therapy?

- Therapy should be prescribed on a trial basis, for 4-6 weeks at optimum dosage
- Record expected benefits and risks of treatment
- Inform patient that treatment may take 2-3 weeks to work
- Start at lower doses and titrate up according to tolerance/efficacy
- Record the rationale for continuing, changing or stopping medication
- Record the reason if high doses are used


Non-pharmacological treatments for schizophrenia?

CBT, art therapy (for negative symptoms)


Role fo CBT in schizphrenia?

- as effective as antipsychotic treatment, combintation is synergistic
- can be used for positive, negative and cognitive symptoms unlike drug treatments
- with or without antipsychotics, but careful review after 1 month


Examples of first generation (typical) antipsychotics?

sulpiride, flupenthixol, haloperidol, chlorpromazine, zuclopenthixol, trifluoperazine, perphenazine


Examples of second generation (atypical) antipsychotics?

amisulpride, quetiapine, risperidone, olanzapine, clozapine, aripiprazole, paliperidone, lurasidone, asenapine


Which of the antipsychotic classes is more effective?

little to no difference


Difference in side effect profiles of the antipsychotic classes?

less EPSEs and hyperprolactinaemia with second gen

atypicals have higher chance of metabolic syndrome (weight gain)


Which of the symptom groups do antipsychotics work on?

positivie - effects on the otgers fairly limited


What are the 4 types of EPSEs?

- Dystonia
- Pseudo-Parkinsonism
- Akathisia
- Tardive dyskinesia


What is dystonia and how can you treat it?

muscle spasms in any part of the body e.g. eye rolling, head/neck twisting

treat with anticholinergic or switch to atypical drug


What is pseudo-parkinsonism and how can you treat it?

tremor, rigidity, bradykinesia
try reducing dose of antipsychotic, switch to atypical
trial anticholinergic for 3 months


What is Akathisia and how can you treat it?

Inner restlessness and desire/compulsion to move – shifting feet, pacing, crossing/uncrossing legs

reduce dose or swtich to atypical


What is tardive dyskinesia and how can you treat it?

Lip smacking/chewing, tongue protrusion
Approximately 50% of cases are not reversible

Anticholinergics make it worse - so stop them, reduce antipsychotic dose, withdraw and swtich to atypical


What is metabolic syndrome?

side effect of antipsychotics, increased weight, blood glucose and lipid profile

thought to contribute to death in schizophrenia, as leads to obesity and all its complications


How to address metabolic syndrome in antipsychotic treatment?

Treat as normal - orlistat, treat diabetes and hyperlipidaemia with relevant drugs


Which antipsychotics have least chance of metabolic syndrome?

most typicals


Which atypical antipsychotics have least chance of metabolic syndorme?

risperidone, quetiapine, paliperidone


Effects of hyperprolactinaemia in antipsychotic treatment?

effects on sexual function, breast growth/milk, amenorrhoea, cancer and BMD


How to treat antipsychotic induced hyperprolactinaemia?

switch to alternative or add aripiprazole


Which antipsychotics have least chance of hyperprolactinaemia?

clozapine, olanzapine, quetiapine, aripiprazole


What is QT prolongation?

QT interval involves de and re-polarising of the heart for pumping action
QT interval prolongation is a risk factor for ventricular arrhythmias and TdP
Some people have QT prolongation syndromes from birth
Drugs can also cause it:
Can be dose related and additive when >1 drug used
Other psychotropic/non-psychotropics implicated
ECGs essential, limits 440ms (men), 470ms (women)


What to do if antipsychotic patient experiences QT prolongation?

switch/reduce dose and refer to cardiology


Which antipsychotics have least chance of QT prolongation?

Aripiprazole least

then olanzapine, clozapine, risperidone/paliperidonE


Which antipsychotics have highest chance of QT prolongation?



What other side effects occur from antipsychotics?

Sedation, anticholinergic effects, lowered seizure threshold, neutropaenia, hyponatraemia, photosensitivity (esp chlorpromazine), postural hypotension and tachycardia


What is neuroleptic malignant syndrome?

Another antipsychotic side effect
Due to rapid changes in dopamine blockade
Watch out for rigidity, hyperthermia, tachycardia, sweating, fluctuating consciousness, raised CK
STOP antipsychotic and initiate specialist treatment


What monitoring is required for antipsychotic treatment?

- response to treatment
- management of side effects
Investigations: waist circumference, pulse and BP, HbA1c, lipids, prolactin levels, baseline ECG


When to use depot antipsychotics?

- useful in non-adherence
- patient preference


WHich antipsychotics are available as depot?

Zuclopenthixol, flupentixol, haloperidol, fluphenazine (typicals – all decanoate)
Olanzapine embonate, paliperidone palmitate, aripiprazole, risperidone (atypicals)


When do we need a test dose for depot antipsychotics and why?

for typicals
test for adverse effects as there will be long lived


Role of antipsychotic polypharmacy?

Approximately 40% of adult inpatients are exposed to combination prescribing
50% of schizophrenics prescribed long acting depot injections and oral antipsychotics


What does NICE say about combined antipsychotic therapy?

not recommended - limited evidence of beneift

only should be considered in treatment resistant alongside clozapine


Efficacy of clozapine?

superior efficacy than many other antipsychotics when patients are poor responders (in treatment resistant schizophrenia)
Between 30-60% of patients with treatment resistant schizophrenia will respond


Adverse effects of clozapine: Myocarditis and cardiomyopathy

- most common in first two months, can be fatal
- fever, fatigue, chest pain, palpitations, low BP, SOB, high pulse
- related to speed of titration - Low and SLow
- can be asymptomatic
- require baseline then daily BP/RR/temp/pulse, weekly Trop/ECG/CRP/FBC
- if suspected, stop and refer


Adverse effects of clozapine: neutropenia and agranulocytosis

- Risk of occurrence actually low (<1%), low death risk
- See directed reading for peak incidence
- Generally reversible, not dose related
- Watch out for any sore throat, flu-like symptoms or others indicative of infection
- If infection suspected get blood test immediately, STOP treatment until test result back


Adverse effects of clozapine: VTE

- Rare (1 in 2000-6000) but risk many times higher than rest of the population
- High risk in first few months, ?dose related
- Assess risk factors and use VTE prophylaxis accordingly


Adverse effects of clozapine: sedation

- Could be useful but may also affect adherence
- Most common clozapine ADR
- Common in early weeks, tolerance may develop
- Review other medications/comorbidities
- Watchful waiting
- Reduce clozapine dose or move to night time dosing if persistent/troublesome


Adverse effects of clozapine: constipation

- Whole system can be affected, rapid fatality possible
- Affects 60% of patients
- Risk factors are higher doses and other traditional risk factors for constipation
- Active screening and assertive treatment essential
- Do not delay using laxatives


Adverse effects of clozapine: Hypersalivation

- Common early on in treatment, and source of much social isolation
- Affects 30-80% of patients
- Hyoscine hydrobromide (Kwells) – TRIAL
- Non-drug treatments include chewing sugar free gum during the day and using pillows at night to raise head
- Reducing clozapine dose a later option


Effect of smoking on antipsychotics?

- Induction of CYP1A2
- Clozapine, olanzapine, duloxetine, TCAs and benzodiazepine (BZD) levels fall by as much as 50% if smoking (haloperidol 20%)
- On stopping smoking clozapine serum levels can increase by 50-72%
- Levels take time to rise
- Monitor levels and/or adjust dose accordingly


Effects of caffiene on antipsychotics?

- Caffeine also competes with clozapine at CYP1A2, causing clozapine levels to rise by 14-47% (lots of variability between individuals)
- Excessive caffeine intake can cause restlessness, insomnia and may worsen psychosis
- Caffeine also antagonises the effects of BZDs and ‘Z drug’ hypnotics


What should a pharmacist do when receiving clozapine prescription?

- check brand of clozapine
- frequency and when most recent FBC
- dose of clozapine
- adherence (if dose has been missed more than 48 hours beforehand)
- who currently supplies the clozapine


Importance of knowing the brand of clozapine

Each has their own monitoring requirements


What are the brands of clozapine?



For how long do we need weekly FBC after starting clozapine? How long do we need fortnihgtly and what happens after?

18 weeks - highest risk in this period
fortnihgtly weeks 19-52
then monthly


How is supply of clozapine related to stage of monitoring/

First 18 weeks - no more than 10 days supply
18-52 weeks - max 21 days supply
53 weeks onwards - 42 days supply


Traffic light system ofr WBC and neutrophils on clozapine?

green: WCC >3.5, neutrophils >2
amber: WCC 3-3.5, neutrophils 1.5-2
red: WCC <3, neutrophils <1.5


What to do if patient is in amber or red of WCC on clozapine?

Amber: dispense but FBC twice a week
Red: do not supply. monitor FBC until back to normal


What happens if patients are not adhering to their clozapine?

If not taken for over 48 hours, need to be retitrated

if more than three days missed, monitoring frequency may need to change


When is it likely that community pharmacy will be dispensing clozapine?

Once patient is on monthly monitoring