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Patient Semester 2 > Mental Health > Flashcards

Flashcards in Mental Health Deck (127):
1

Incidence of schizophrenia?

approx 1% develop it at some point
affects men and women in equal proportions, men tend to have an earlier onset, and women have a second incidence peak in mid-late 40s

2

Biological basis of schizophreia?

MRI scans show sufferers have enlarged ventricles

3

Genetic risk factors for schizophrenia?

there are multiple genes in creating a predisposition to schizophrenia. higher rates between families

4

Environmental risk factors for schizophrenia?

Prenatal problems, obstetric complications, urban/city birth, stressful life events, drug abuse
- related to dopamine production

5

How to genetic and environmental risk factors combine to turn into schizophrenia?

cause gene expression impairments, leading to neurochemical and metabolic changes. altered connectivity leads to impaired information processes and then the symptoms: altered behaviour, altered cognition and altered emotion

6

Positive symptoms of schizophrenia?

Delusions, hallucinations, disorganised speech

7

Negative symptoms of schizophrenia?

reduced emotion, motivation, interests, thought/speech and pleasure

8

Cognitive deficits from schizophrenia?

Problems with attention, memory (working and verbal), executive function

9

Mood symptoms of schizophrenia?

depression/anxiety, hostility/aggression, suicide

10

Which brain circuits/areas cause the positive symptoms of schizophrenia?

mesolimbic and striatal

11

Which brain circuits/areas cause the negative symptoms of schizophrenia?

mesocortical and prefrontal cortex, nucleus accumbens reward circuits

12

Which brain circuits/areas cause the cognitive symptoms of schizophrenia?

dorsolateral prefrontal cortex

13

Which brain circuits/areas cause the aggressive symptoms of schizophrenia?

orbitofrontal cortex

14

Which brain circuits/areas cause the affective symptoms of schizophrenia?

ventromedial prefrontal cortex

15

DSM-V criteria for schizophrenia?

A: at least two of: delusions, hallucinations, disorganised speech, grossly disorganised or catatonic behaviour, negative symptoms for at least one month. certain delusions or hallucinations mean no other symptoms from A need to be present.

B: social/occupational dysfunction

C: duration of at least 6 months

16

Impact of increased dopamine in subcortical pathways?

psychotic symptoms

17

What do agonists of dopamine do, and exmaple?

induce psychotic symptoms e.g. amphetamines

18

What do antipsychotics do?

dopamine antagonists D2

19

How does too much dopamine at the D2 receptors relate to the symptoms?

D2 receptors are inhibitory - so increased dopamine leads to too much inhibition, causing symptoms

20

Consequences of NMDA receptor hypofunction?

- can be genetic or non-genetic, triggers psychosis in early adulthood
- important in the balance of GABA (inhibitory) and glutamate (excitatory)
- hypo NMDA leads to less GABA, which leads to more glutamate. this activates cell bodies to increase dopamine, which can cause psychosis.

21

Examples of typical antipsychotics

haloperidol, chlorpromazine

22

How do typical antipsychotics work?

high affinity for dopamine D2 receptors
- only effective against positive symptoms, not negative ones
- blockade of D2 receptors can lead to motor control impairments

23

Examples of atypical antipsychotics

Clozapine, olanzapine, risperidone

24

How do atypical antipsychotics work?

higher affinity for 5HT2 (serotonin) receptors over D2
- effective against positive symptoms, and more effective than typicals against negative symptoms
- significant side effects of weight gain etc
- less motor impairments than typicals

25

What does evidence suggest about the difference in efficacy vs side effects between antipsychotic types?

differences in efficacy were small, and smaller than the differences in side effects

26

What is EPS?

Extrapyramidal symtpoms

27

What is the balance between receptor occupancy and dose for antipsychotics?

certain receptor occupancy percentage needed to treat psychosis, but too much causes EPS. different drugs require different doses to reach the threshold

28

What is the % D2 occupancy required for antipsychotic efficacy?

65%

29

At what % D2 occupancy does hyperprolactinaemia begin to occur?

70%

30

At what % D2 occupancy do EPS start to occur?

78%

31

Which antipsychotic has least risk of EPS?

Clozapine

32

Which antipsychotic has most risk of EPS?

Haloperidol

33

What are some of the theories about antipsychotic induced weight gain?

- antagonism of histamine H1 receptors, serotonin 5HT2c receptors, dopamine D2
- affecting hormonally controlled systems e.g. leptin
- significant individual variation implies genetic involvement

34

Ways to manage antipsychotic induced weight gain?

- warn patients before starting high risk drugs
- early hunger, snacking and early weight gain are all indicators
- standard weight management
- consider swapping or stopping

35

Which other psychotropic drugs have a greater risk of weight gain?

- TCAs
- Mirtazapine
- Lithium
- Valproate
- Carbemazepine

36

Which other psychotropic drugs have a lower risk of weight gain?

- SSRIs
- Duloxetine
- Agomelatine
- Lamotrigine

37

Which antipsychotics have the highest risk of prolactin increase?

Haloperidol, risperidone, paliperidone

38

When was the Mental Health Act 1983 amdended?

2007

39

Examples of disorders of mood?

Depression, anxiety, elation, anger

40

Examples of disorders of perception?

Hallucinations, sensory perceptions, illusions

41

Examples of disorders of thinking?

Delusions, obsessions, abnormal thought streams

42

Diagnostic process for mental illness?

- Patient interview/observation essential
- May speak to family/carers
- Blood tests/scans used to rule out a physical cause
- Two main diagnostic criteria, DSM-V and ICD-10

43

What countries does the Mental Health Act apply to?

England and Wales

44

What does the mental health act outline?

When people with a mental disorder might be admitted to hospital, assessed and treated against their own will for their own health and safety, and/or the protection of others
Also specifies rights of those with mental health disorders, enshrining respect, communication, participation and least restriction principles

45

What must decisions taken under the Mental Health Act minimise?

undesirable of metnal disorder, by maximising safety and wellbeing, and promoting recover of the patient and protecting others from harm

46

What is an informal mental health patient?

One who comes into hospital voluntarily

47

What does a Section 2 cover?

hospital admission of patients against their will, considered to have a disorder requiring inpatient care for the patients or others' safety

mainly used for assessment and treatment - usually for people not known to services

48

How long does Section 2 last?

28 days

49

How is a Section 2 carried out?

Application for admission made by an Approved Mental Health Professional (AMHP) within 14 days of interviewing the patient (including views of the relatives). Nearest relatives can also apply for admission.

Two doctors must assess the patient to confirm sectioning, one of which is an approved doctor

50

Who manages patient care once the patient is admission?

The responsible clinician

51

What is a Section 3 for?

Appropriate treatment for a mental health disorder

52

How long does a Section 3 last?

Up to 6 months, can be renewed

53

Who is a Section 3 for?

- patients in the community who are known to services/have a previous section
- already in hospital having undergone assessment/treatment under section 2 (apply for section 3 before the section 2 expires)

54

What professions can AMHP be?

Social worker, mental health nurses, psychologists, occupational therapists

55

Who can block a sectioning?

Nearest relative (though this too can be appealed in court)

56

How long can medication be given to sectioned patients with capacity against their will?

Up to 3 months

57

What happens if a sectioned patient continues to refuse medication after 3 months, with or without capacity?

Responsible clinician must get a recommendation that treatment must continue - from a Second Opinion Appointed Doctor (SOAD).

completion of a T3 form

58

What happens if a sectioned patient with capacity consents to medication after 3 months?

T2 form is filled out and proceed

59

Who else must a SOAD consult to continue giving a sectioned patient drugs against their will?

Two other non-doctor professionals involved in the patients care, e.g. nurse and pharmacist

60

What treatment cannot be given without consent under any circumstances?

ECT

61

What must be done every time a dose is administered to a T3 patient?

Consent sought - even if it's not given

62

What is vital with all T2 and T3 forms?

- all individual medicines that are likely to be used to treat the disorder in question are listed (including PRN), according to BNF classification
- if a class is specified, the number included and which are excluded should be specified
- RoA and max dose should be specified for all medicines
- should be kept with prescription charts

63

What is a CTO?

Community treatment order

Can impose certain conditions when they are discharged following section 3

64

Who organises CTOs and how?

Responsible clinician
Must apply to the NHS trust, and gain AMHP approval

65

How long do CTOs last?

6 months, can be renewed

66

Consequences of breaching a CTO?

That or their health deteriorates again, can be brought back into hospital

67

Role of the Medicines Management in mental health hospitals?

- medicines reconciliation completed by pharmacists/technicians (24-72 hour goal)
- Ward rounds/daily patient reviews and make interventions
- Counsel patients on medicines
- Prescribing roles and non-medical prescribing
- Audits and research
- Discharge prescriptions (often handled by external pharmacy)

68

Key differences of mental health pharmacists compared to general hospital?

- Different nature - more professionals, longer
- Legal activity surrounding mental health
- Holistic patient care, tailored treatment choices
- Nature of mental illness - insight and stigma

no one size fits all approach

69

What physical health problems can increase the risk of someone developing a mental health problem?

- obesity and T2D (irrespective of weight)
- positive correlation between number of physical health problems and risk of developing mood disorder
- smoking associated with anxiety and schizophrenia
- adoption of the smoking habit likely in affective and alcohol misuse disorders

70

Which mental health problems increase the risk of someone developing a physical health problem?

- psychoses, bipolar and major depression increase the risk of obesity, diabetes, COPD and CVD
- depression is an independent risk factor for stroke
- patients with depression have less favourable outcomes after cardiac events (perhaps mediated by adherence)
- people with schizophrenia may have higher rates of:
epilepsy, obesity, eczema, hypothyroidism, dermatitis, viral hepatitis, diabetes, hypertension, COPD, fluid/electrolyte disorders

71

Why are people with mental health conditions at higher risk of physical health issues?

- more likely to live unhealthy lifestyles before diagnosis
- result of mental health medications (esp. antipsychotics)
- more likely to experience disparities in care compared to those without mental illness
- less likely to access appropriate services to identify and address problems with physical health

72

What behaviours are mental health patients more at risk of that increases likelihood of physical health problems?

- smoking
- substance misuse
- unsafe sexual acitivty
- poor dental health
- consume less fruit and veg
- consume only one deal per day
- little physical activity
- consume high fats/salt/sugar

73

What disparities in care arise in physical care for mental health patients?

- less likely to be prescribed ACEi/AT2, BBs, antihypertensives and statins
- lower than average cardiac care of schizophrenia and SMI patients (weak link to mortality)
- preventative care often inferior for schizophrenics compared to general population
- only 36% of schizophrenic patients with evidence of IGT have intervention. 59% intervention for smoking and 25% for hypertension
- lithium patients have inadequate renal monitoring

74

What are the four pathways that norardrenaline controls?

Alertness, arousal, sensory perception, motor tone

75

What happens at a noradrenaline synapse?

- Tyrosine -> DOPA -> dopamine -> noradrenaline
- activation of receptors on postsynaptic membrane
- reuptake into presynaptic neurone (MAO breaks it down to inactivate)

76

What happens at a serotonin synapse?

- Tryptophan -> 5-hydroxytryptophan -> 5-hydroxytryptamine -> serotonin
- activation of postsynaptic receptors
- reuptake into presynaptic neurone
- inactivation

77

What effect does noradrenaline have on the postsynaptic receptors?

Protein kinase activation, protein phosphorylation

78

What effect does serotonin have on the postsynaptic receptors?

Opens ion channels

79

What are the 6 pathways that serotonin regulates?

Sleep, food intake, thermoregulation, sexual behaviour, pain, motor tone

80

Difference between unipolar and bipolar depression?

Unipolar is only depressive (either episodes or persistent)

81

Examples of unipolar depression

Major depressive disorder
Dysthymia (persistent mild depression)
Seasonal affective disorder
Postnatal depression

82

What is bipolar depression?

Alternating periods of depresion and mania

83

Causes of depression?

Life events, childhood experience, genetics, chemical imbalance, medication side effects, physical conditions, diet

84

Neurotransmitters involved in depression?

Serotonin, noradrenaline, Ach, Glutamate

85

Treatments for depression?

CBT
Antidepressants
Exercise
ECT

86

Which part of the brain and neurotransmitter gives rise to loss of pleasure, interest and motivation?

Dorso-lateral PFC
Dopamine

87

Which part of the brain and neurotransmitter gives rise to sadness and suicide?

Ventro-medial PFC
serotonin, noradrenaline, dopamine

88

Which part of the brain and neurotransmitter gives rise to fatigue and loss of energy?

Dopamine, noradrenaline and serotonin

89

Which part of the brain and neurotransmitter gives rise to problems with sleep, appetite and libido?

Nucleus accumbens and hypothalamus
Serotonin, noradrenaline and dopamine

90

Which part of the brain and neurotransmitter gives rise to problems with attention, concentration and problem solving?

Dorso-lateral PFC

Dopamine (D1), Ach, Serotonin, noradrenaline, GABA, histamine

91

What are the classes of antidepressant drugs?

- TCAs
- SSRIs
- NaRIs
- SNRIs
- MAOIs
- Atypical
- Ketamine

92

What types of psychotherapy can help with depression?

Talking therapy
Counselling
CBT

93

What kinds of physical interventions can help with depression?

ECT
Electromagnetic therapy
Deep brain stimulation
Vagal stimulation

94

What is the main issue with MAOIs as depression treatment?

A lot of interactions with both foods and drugs - some quite severe

Can't consume tyramine - found in cheese etc. Very dangerous response (precursor for MAO synthesis). Large hypertensive response, often enough to cause haemorrhages

95

How long do antidepressant drugs take to have an effect?

2-4 weeks

96

How long does psychotherapy take to have an effect on depression?

weeks, months, years

97

How long do physical interventions take to have an effect on depression?

Immediate

98

What is the monoamine hypothesis?

Antidepressants correct the depletion of neurotransmitters in the brain, immediately. The effect of the antidepressant on the depression takes several weeks.

Important to consider secondary changes that the corrected monoamine levels have, as these may be what causes the changes in behaviour

99

Reasons why antidepressants take time to work other than the monoamine hypothesis?

1. Some antidepressants initiate neurogenesis, which takes time

2. initiation of SSRI can initially cause autoreceptor activation, which reduces cell firing, so less serotonin released at all. after a while, autoreceptor gets down regulated so normal cell firing is restored and the SSRI can prevent reuptake of a normal amount of serotonin

100

What are the DSM symptoms of depression?

Core (must have at least one of these):
- low mood
- loss of pleasure

Other (must have at least 4):
- Loss of energy
- Worthlessness, guilt
- Recurrent thoughts of death or suicide
- Reduced ability to think or concentrate
- Psychomotor agitation or retardation
- Insomnia/hypersomnia
- Weight changes

101

When to start pharmacological treatment for depression?

- moderate or severe depression
- a past history of moderate or severe depression
- subthreshold depressive symptoms present for at least 2 years
- subthreshold depressive symptoms or mild depression persisting after other interventions

102

What is a big reason for patients stopping their antidepressant treatment?

not being warned properly of the side effects

103

Which class of antidepressants is first line?

SSRI

104

Examples of SSRIs?

Fluoxetine, Sertraline, Citalopram, Escitalopram, Paroxetine

105

Main side effects of SSRIs?

GI effects, hyponatraemia (low sodium)
Can have increased bleeding risk (DDIs)

106

Examples of SNRIs?

Venlafaxine (more common), duloxetine

107

When is venlafaxine contra-indicated?

uncontrolled hypertension

108

Benefits of mirtazapine?

Considered quite well tolerated

109

Main side effects of mirtazapine?

Sedation and weight gain
can also cause blood disorders

110

Examples of TCAs?

Amitriptyline, Clomipramine, Nortriptyline, Lofepramine, Dosulepin

111

Main side effects of TCAs?

Antimuscarinic side effects.
Cardiotoxicity
Shouldn't be used in high suicide risk

112

When should reboxetine not be used?

In the elderly (rarely used anyway)

113

What is Agomelatine?

Melatonergic agonist (also 5HT2C antagonist)

114

Main risks with agomelatine?

Hepatotoxicity - cases of liver injury incl fatal liver failure reported

115

What monitoring needs to be done to agomelatine?

LFTs baseline, 3 weeks, 6 weeks, 3 months, 6 months

116

What is Vortioxetine?

Serotonin based drug

117

When is Vortioxetine recommended for use?

By NICE for adults who have not responded to 2 antidepressants in the current episode

118

First step when initiating antidepressant therapy?

Monotherapy - SSRI first or better tolerated other, can switch if needed (incl between classes)

then try older, less well tolerated antidepressants

119

What to do if inital antidepressant monotherpy doesn't worK?

combinations/augmentation

120

Things to consider before changing antidepressant due to lack of effect?

- how long has the patient been taking it
- have they been taking it properly
- try increasing dose
- 4-6 weeks for full effect

121

Things to consider before changing antidepressant due to side effects?

- which options would be better tolerated?

122

Why is specialist input required for combinations of antidepressants?

- interactions
- serotonin syndrome
- increased risk of or combined side effects

123

What is augmentation with antidepressants?

addition of something else e.g. lithium or antipsychotic

124

Place of St Johns Wort in depression therapy?

- while it is effective, it is not recommended
- causes lots of drug interactions
- different potencies

125

How to stop antidepressant treatment?

- should continue for 6 months after remission (may need to be longer, up to 2 years)
- reduce dose slowly

126

Role of the pharmacist in depression therapeutics?

- advice on choice of medication
- review patient history
- counselling for side effects and adherence
- monitoring for efficacy and side effects

127

What are the main counselling points for antidepressants?

- Patient choice
- Doses – vary for adult and elderly – check appropriate
- Timing of doses
- Increased agitation, anxiety at start – feeling worse before feeling better
- Suicide risk? History, younger patients (under 30)
- Time to benefit
- Duration of treatment
- Not addictive, but can get discontinuation symptoms
- Not to stop abruptly. Discuss with prescriber first.
- Side effects
- Take regularly