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BNF CNS > Mental health disorders > Flashcards

Mental health disorders Flashcards

1
Q

What condition is the serotonin receptor agonist Buspirone contra-indicated in?

A

Epilepsy

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2
Q

What is the MHRA alert regarding Benzodiazepines?

A

risk of potentially fatal respiratory depression - should only co-prescribe opioids + benzos if no other alternative option

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3
Q

How long do benzos have to have been taken for in order to be weaned off?

A

> 2 weeks - risk of benzodiazepine withdrawal

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4
Q

What is an associated risk of an elderly person taking benzos?

A

Increased risk of falls

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5
Q

What CD schedule are Benzos?

A

CD4 - 1

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6
Q

What are the indications of use of Chlordiazepoxide?

A

Short term use in anxiety

Treatment of alcohol withdrawal

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7
Q

What are some of the licensed indications for Diazepam?

A
  • muscle spasicity
  • tetanus
  • status epilepticus
  • premedication
  • anxiety
  • sedation in dental procedures
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8
Q

Intravenous Diazepam holds a risk of what?

A

Severe thrombophlebitis (reduced by using emulsion form)

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9
Q

What drugs can be used to treat anxiety?

A

Benzos or Buspiron (serotin agonist)

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10
Q

What age and gender is ADHD most commonly diagnosed in?

A

3-7 years most common in men

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11
Q

What are the 2 first line drug treatments for ADHD?

A

Lisdexamfetamine mesilate and methylphenidate hydrochloride

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12
Q

If a patient does not respond to Lisdexameftamine or Methylphenidate, what other non stimulant drug can be trialled?

A

Atomoxetine (centrally acting sympathomimetic)

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13
Q

What are the monitoring requirements associated with Methylphendiate?

A

BP, pulse, psychiatric symptoms, appetite, weight, height at initiation ad following dose adjustment then every 6 months thereafter

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14
Q

What CD schedule is methyphenidate?

A

CD2

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15
Q

What drug class is useful in the acute stages of mania?

A

Antipscychotics e.g. Olanzapine, risperidone, qutiapine

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16
Q

What drug class is Asenapine and when is it used?

A

Second generation antipsychotics, used for moderate - severe manic episodes associated with bipolar disorders

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17
Q

How many weeks should antipsychotics be discontinued over?

A

4 weeks if continuing on the antimania drugs or up to 3 months otherwise

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18
Q

What anti-epileptic drug(s) can also be used to prevent bipolar disorder?

A

Carbamazepine

Valporate - treats manic episodes associated with bipolar + prophylaxis

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19
Q

what is the indication for lithium in bipolar disorder?

A

treatment and prevention of mania, hypomania and depression

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20
Q

How long after initiation of lithium therapy can it take for the full prophylactic responce to be seen?

A

6 - 12 months

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21
Q

What 2 side effects of valporate lead to immediate withdrawal of the drug?

A

Pancreatitis and hepatic dysfunction

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22
Q

What false positive on laboratory tests can valporate cause?

A

Ketones

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23
Q

Contra-indications to lithium therapy

A

dehydration, low sodium diet, cardiac disease, untreated hypothyroidism, addisons

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24
Q

Long term lithium therapy is associated with what endocrine disorder?

A

Thyroid disorders - monitor TFTs every 6 months

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25
Q

Side effects of lithium

A
  1. GI disturbances ( particularly at initiation)
  2. Metlic teaste
  3. Weight gain
  4. Ankle oedema
  5. Polyuria and polydipsia (due to ADH inhibition)
  6. Neurotoxicity {paeaesthesia, ataxia, tremor, cognitive impairment}
  7. QT prolongation
  8. hypersalivation
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26
Q

Signs of litium toxicity

A

-Early signs: non-specfic, restlessness, apathy, confusion, drowsiness
-Following signs: Vomiting, diarrhoea. ataxia, weakness, dysarthria,muscle twitching,trmor,visual disturbance
Severe signs: Convulsion, coma, renal failure, hypotension, cardiac arrhythmia

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27
Q

Causes of Lithium toxicity

A

reduced renal function, dehydration, interacting medications (diuretics/NSAIDS), infection

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28
Q

Monitoring requirements for lithium therapy

A
  1. Lithium levels weekly at initation, 3 monthly for 1 year then 6 monthly or after doses changes thereafter
  2. U&Es ( 3 monthly)
  3. Cardiac / ECG (annual)
  4. TFT ( 6 monthly)
  5. Body weight (annual)
  6. Calcium (annual)
  7. FBC (annual)
    7.
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29
Q

What can lithium do to your calcium levels?

A

Increase them - they should be monitored yearly

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30
Q

How long after a lithium dose should samples be taken?

A

12 hours post dose

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31
Q

What is the optimum dose range of Lithium

A

0.4 - 1mmol/L

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32
Q

In patients with acute mania or who have previously relapsed what is the target lithium level?

A

0.8-1mmol/L

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33
Q

What does abrupt withdrawl of lithium increase the risk of?

A

Relapse - if lithium is to be discontinued the dose should be reduced gradually over 4 weeks (up to 3 months)

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34
Q

What should patients be advised to report when on lithium therapy?

A

signs of lithium toxicity, hypothyroidism, renal dysfunction (polyuria / polydyspepsia), beign intracranial hypertension (persistant headache and visual disturbance)

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35
Q

What should patients be counselled on when starting lithium therapy?

A
  1. maintain hydration
  2. avoid dietary changes that lead to increase/decrease in salt
  3. lithium booklet / alert card
  4. contraception
  5. recognising toxicity signs
  6. OTC sales
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36
Q

Indications of lithium therapy

A
  1. acute management of mania/hypomania
  2. prophylaxis against bipolar affective disorder
  3. control of aggressive behaviour or intentional self harm
  4. Treatment/prophylaxis of recurrent depression
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37
Q

Why should lithium be prescribed as brand names?

A

Different salts have different bioavailbilities (carbonate v citrate)
Brands include; Priadel, Camcolit, Liskonum

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38
Q

What drugs can cause an increase in lithium levels?

A

ACEIs,ARBS, Diuretics, NSAIDS, macrolides, metronidazole, steroids, tetracycline

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39
Q

What does an increase sodium level do to Lithium levels?

A

Decreases lithium levels as you drink more and excrete it out (e.g pt on antacids)

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40
Q

What does a decreased sodium level do to lithium levels?

A

Increases the lithium level as decreased excretion may occur

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41
Q

What drugs can decrease lithium levels?

A

Antacids, theophylline, caffeine

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42
Q

What are some of the side effects that can occur during the first few weeks of taking antidepressants?

A

Increased suicial thoughts, agitation, anxiety

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43
Q

What drug class is first line in depression?

A

SSRI (safer and better tolerated)

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44
Q

What SSRI is safe in patients who have had a recent MI or unstable angina?

A

Sertraline

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45
Q

What herbal remedy is popular for treatment of depression?

A

St John’s Wort

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46
Q

What can St johns wort do to other medications?

A

St JW is an enzyme INDUCER, it will reduce levels of other meds

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47
Q

At the start of antidepressant treatment, how often should patients be reviewed?

A

Every 1 - 2 weeks

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48
Q

How long should treatment be contined for before consdiering switching to an alternative medication?

A

4 weeks (6 weeks in eldery)

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49
Q

Following remission, how long should antidepressant therapy be continued for?

A

At least 6 months at the same dose or for 12 months in people wiht GAD

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50
Q

If a patient has a history of recurrent depression and is tapered off antidepressants, how long should they continue to receive maintenance therapy for?

A

2 years due to high risk of relapse

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51
Q

What electrolyte imbalance is associated with all antidepressants (particularly SSRIS)

A

Hyponatraemia

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52
Q

What is the risk of adding several serotonergic drugs into a patients regime?

A

Serotonin syndrome risk (esp if long half life drugs e.g. MAOIs)

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53
Q

3 main areas of serotonin syndrome

A
  1. Neuromuscular hyperactivity (tremor/hyperreflexia, clonus, ridgity)
  2. Autonomic dysfunction (tacycardia, BP changes, hyperthermia, diaphoresis, shivering)
  3. Altered mental state (agitation, confusion, mania)
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54
Q

If a patient does not respond to an SSRI, what is the next option?

A
  1. increase dose of SSRI
  2. switch to different SSRI or Mirtazapine
  3. Other agent e.g Lofepramine, moclobemide, reboxetine
  4. severe forms - TCAs, Venlafaxine
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55
Q

What medication class can be considered for chronic (>4 weeks) anxiety?

A

Antidepressants

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56
Q

How should GAD be treated?

A
  1. psychological approach (CBT)

2. Antidepressant (escitalopram, paroxetine, sertraline, venlafaxine, pregabalin)

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57
Q

How are paniac disorders, social anxiety disorder, PTSD, OCD treated?

A

SSRIs

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58
Q

What drugs can be used second line in panic disorder?

A

Clopiramine and imipramine

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59
Q

Moclobemide is licensed for what anxiety disorder?

A

Social anxiety disorder

60
Q

Sedating TCA examples

A

Amitriptyline, clomipramine, dosulepin, doxepin, trazodone, trimipramine

61
Q

Less sedating TCA examples

A

imipramine, nortriptyline, lofepramine

62
Q

What are limiting side effects to TCAs

A

Cardiotoxic + antimuscarinic effects

63
Q

Lofepramine has a better side effect profile is less toxic but use is limited because…

A

it is hepatoxic

64
Q

What TCA has the most marked antimuscarinic side effects?

A

Imipramine

65
Q

What time of the day should TCAS be taken?

A

night - they have a long half life allowing for OD adminsitration

66
Q

Tranylcypromine is a MAOI that is more likely to cause what side effect compared to othe MAOI?

A

hypertensive crisis

67
Q

Isocarboxazid and Phenelzine are more likely to cause what side effect compared to Tranylcypromine?

A

Hepatoxicity

68
Q

How long after starting MAOIs should other antidepressants be started if needed?

A

at least 2 weeks after MAOIs have been stopped (3 weeks if starting Clomipramine or imipramine)

69
Q

How long after an SSRI has been stopped can a MAOI be started?

A

After 1 week, unless it is Fluoxetine (long half life) whihc needs at least 5 weeks washout

70
Q

When can Vortioxetine be iniatited?

A

if a patients condition has not responded to 2 antidepressants

71
Q

What monitoring requirement is needed for Agomelatine?

A

LFTS at 3, 6, 12, 24 months

- pt should be counselled on how to recognise hepatoxicity

72
Q

What is a monitoring requirement with MAOIs?

A

BP - risk of postural hypotension and hypertensive responces

73
Q

What food advice should be given to patients taking MAOIs?

A

TYRAMINE - hypertensive crisis (first sign = throbbing headache)
Only eat fresh foods (nothing stale or going off), especially important with meat/fish/poultry/ mature cheese; game should be avoided. The danger of the interaction persists for up to 2 weeks after stopping. Alcohol should also be avoided

74
Q

Example of an irreversible MAOI

A

Phenelzine, Isocarboxazid

75
Q

Example of a reversible MAOa selective

A

Moclobemide

76
Q

Why cant patients on MAOi have cough medications containing sympathomimetics (pseudoephedrine)?

A

Hypertensive crisis risk due to inhibition of indirect acting sympathomimetics

77
Q

Example of a nonadrenaline reuptake inhibitor (NARI)

A

Reboxetine

78
Q

Common side effects of SSRIS

A
  • GI symptoms (common at start)
  • Anxiety (common at start)
  • insomnia
  • sexual side effects
  • QT prolongation
  • Increase bleed risk
79
Q

Why should SSRIs be avoided in pregnancy?

A

Risk of congential heart defects and if used in 3rd trimester, risk of neonatal withdrawal

80
Q

How many citalopram drops = 10mg tablet?

A

4 drops (8mg) = 10mg oral tablet

81
Q

What is the contraindication of citalopram?

A

QT prolongation

82
Q

Which SSRI has the least drug interactions?

A

Citalopram

83
Q

What is the only SSRI licensed for use in children?

A

Fluoxetine

84
Q

Why is paroxetine associated with a higher risk of withdrawl reactions?

A

Has a short halflife

85
Q

Duloxetine and Venlafaxine are examples of what type of antidepressants?

A

SNRIs

86
Q

What 2 conditions other than depression can duloxetine be used for?

A

Diabetic neuropathy and Moder to severe stress urinary incontinence

87
Q

What condition is Venlafaxine contraindicated in?

A

Uncontrolled hypertension

88
Q

Why does venlafazine require a slow withdrawl period?

A

Short half life

89
Q

What monitoring does Venlafaxine require?

A

BP monitoring

90
Q

What are some side effects of TCA overdose?

A

dry mouth, hypotension, dilated pupils, urinary retention, respiratory failure, hypothermia, cardiac conduction defects

91
Q

The tetracyclic antidepressant, Mianserin can cause agranulocytosis. How often should FBC be measured?

A

Every 4 weeks during first 3 months

92
Q

Mirtazapine drug class

A

Presynaptic alpha 2 antagonist (increases central NA and 5HT)

93
Q

Side effects of Mirtazapine

A

Sedation, oedema, increase appetite, weight gain and blood disorders

94
Q

What should patients be advised to report when taking Mirtazapine?

A

recognising blood disorders e.g. fever, sore throat, stomatitis

95
Q

Antimuscarinic side effects of TCAS

A

Constipation, dry mouth, blurred vision, urinary retention, cardiotoxic in overdose

96
Q

What TCA should not be prescribed?

A

Dosulepin

97
Q

When prescribing an antipsychotic for emergency use, what should the IM dose be compared to the oral equivalent?

A

Lower - owing to absence of first pass effect. Particulary if the patient is active (increase blood flow to muscles)

98
Q

What symptoms of schizophrenia do antipsychotics work best on?

A

Positive symptoms e.g .hallucinations, dellusions, though disorders

99
Q

How do the first generation antipsychotics generally work?

A

Block D2 receptors and are not selective for any of the 4 dopamine pathways therefore cause a range of side effects

100
Q

What 3 main groups can the phenothiazines be split into?

A

group 1: Chlorpromazine, levomopromazine –> pronounced sedative effects, moderate antimuscarinic/EPS
Group 2:
Pericyazine –> moderate sedative effects, fewer EPS than group 1 or 3
Group 3:
Prochlorperazine, trifluoperazine–> fewer sedative effects/ AM effects, more pronounced EPS

101
Q

Examples of butyrophenone antipsychotics

A

Benperidol (used in inappropriate sexual behaviour) and Haloperidol
Same clinical properties are Group 3 phenothiazines

102
Q

Thioxanthene examples

A

Flupentixol and Zuclopenthixol

103
Q

Diphenylbutylpiperidine example

A

Pimozide

104
Q

Substituted benzamide example

A

Sulpiride

105
Q

What type of antipsychotics are less likely to cause EPS but have distinct side effect profiles?

A

second generation (atypical)

106
Q

Examples of second generation (atypical) antpsychotics

A

Risperidone, olanazapine, quetiapine, clozapine, aripiprazole, paliperidone

107
Q

What antipsychotics are better at treating the negative symptoms of Schizophrenia

A

Second generation

108
Q

In eldery patients with dementia, what is the risk of prescrbing antipsychotics?

A

Increased risk of stroke/TIA and mortality

109
Q

Which antipsychotics are most likely to cause EPS?

A

Group 3 phenthiazines (e.g. prochlorperazine), butyrophenones and 1st generation depots

110
Q

Examples of EPS

A
  1. Parkinsonian symptoms (tremor,)
  2. Dystonia (abnormal face/body movement)
  3. Akthisia (restlessness(
  4. Tardive dyskinesia (involuntary movements of tongue/face/jaw - can be irreversible)
111
Q

How can parkinsonian EPS be treated?

A

Procyclidine

112
Q

Side effects of second generation antipsychotics (atypical)

A
  1. Hyperprolactinaemia
  2. Sexual dysfunction
  3. Cardiovascular s/e
  4. Hyperglycaemia + weight gain
  5. Hypotension / interference with temperature regulation
113
Q

What antipsychotic reduced prolactin levels?

A

Aripiprazole (dopamine receptor partial agonists)

114
Q

Antipsychotics most lilely to cause hyperprolactinaemia

A

Risperidone, amisulpride, 1st gens

115
Q

Clinical symptoms of hyperprolactinaemia

A

Sexual dysfunction, reduced bone mineral density, menstrual disturbance, breast enlargement, galactorrhoea

116
Q

which 2 antipsychotics are most likely to cause sexual dysfunction?

A

Haloperidol and risperidone

117
Q

What antipsychotics have profound QT prolongation risk?

A

Haloperidol and Pimozide or any IV antipsychotic / above max dose

118
Q

What antipsychotics are most likely to cause diabetes/weight gain?

A

Olanzapine, Risperidone, Clozapine, Quetiapine

119
Q

What antipsychotics can cause postural hypotension?

A

Clozapine, Chlorpromazine, lurasidone, quetiapine

120
Q

What are the symptoms of NMS?

A

hyperthermia, fluctuating level of consiousness, muscle ridgity, tacycardia, liable BP)

121
Q

There is no treatment for NMS but what 2 agents can potentially be used?

A

Bromocriptine or Dantrolene

122
Q

How long does NMS usually last for?

A

5 - 7 days after drug discontinuation

123
Q

Which antipsychotic has negliglble effect on the QT profile?

A

Arirpiprazole

124
Q

What generation of antipsychotic is less likely to caus diabetes?

A

First gen - lowest risk Haloperidol and Fluphenazine

125
Q

Of the second generation antipsychotics, which have the lowest risk of diabetics?

A

amisulpride and aripiprazole

126
Q

Which antipsychotic is less likely to lead to sexual dyfunction?

A

aripiprazole and quetiapine

127
Q

How long should patients have an antipsychotic drug before it is deemed effective?

A

4 - 6 weeks

128
Q

What is clozapine licensed for?

A

Treatment resistant schizophrenia - when 2 or more antipsychotics are tried for at least 6-8 weeks and dont work

129
Q

How long does it take for treatment responce to be seen with clozapine?

A

8 to 10 weeks

130
Q

Monitoring for clozapine

A 
FBC - weekly for first 18 weeks then 2 weekly the monthly 
ECG
LFTs
BP + Pulse 
Weight/ Lipids/ Glucose
Prolactin
131
Q

What is a fatal side effect of Clozapine

A

Constipation - risk of intestinal obstruction, faecal impaction and paralytic ileus

132
Q

Why is an ECG necessary before starting clozapine

A

Risk of cardiomyopathy + myocarditis

133
Q

When having weekly FBC, what is the max quantity of clozapine that can be prescribed?

A

10 days

134
Q

When having fortnightly FBC, what is the max quantity of clozapine that can be prescribed

A

21 days

135
Q

When having monthly FBC, what is the max quantity of clozapine that can be prescribed

A

42 days

136
Q

If a dose of clozapine is missed for >48 hours what must be done?

A

Retitrate dose

137
Q

If a dose of clozapine is missed for >72 hours what must be done?

A

FBC monitoring, frequency may need altering + retitrate

138
Q

What lifestyle habit can affect clozapine levels?

A

Smoking - due to enzyme induction. (not affected by NRT)

139
Q

Which antipsychotics do not require BP monitoring?

A

Sulpride
Trifluoperazine
Amisulpride
Aripiprazole

140
Q

What condition can cause a patient to have naturally a lower WBC?

A

Beign ethnic neutropenia

141
Q

When is the risk for cardiomyopathy the greatest with clozapine?

A

first 2 months

142
Q

How can hypersalivation associated wiht clozapine be treated?

A

hyoscine butylbromide

143
Q

When should blood lipids and weight be monitored with antipsychotics?

A

baseline, 3 months, then yearly (for clozapine - needs monitoring every 3 months for the first year)

144
Q

When should fasting blood glucose be measured when patients are prescribed antipsychotics?

A

baseline, 4-6 monthly then yearly (clozapine = baseline, 1 month, 4-6 months)

145
Q

What must the patient. prescbier and pharmacist be registered to if a pateint is taking clozapine?

A

Patient monitoring service

BNF CNS (9 decks)

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