Mental health Lecture week 4 Flashcards
(93 cards)
1
Q
Clozapine side effects-MASS Gain
A
Myocarditis
Agranulocytosis
Seizures
Sialorrhea
G-weight gain
2
Q
EPS antidote
A
Benztropine
3
Q
4 EPS
A
Dystonia–> sustained muscular contraction and oculogyric crisis
Akathesia–> restlessness, pacing and tapping
Parkinsonism–> cogwheel rigidity, mask-facies, shuffling gait and resting tremor
TD–> lip-tongue smacking, repetitive and uncontrolled
4
Q
Which antipsychotic(SGA) will most likely to give galactorrhea
A
Risperidone
5
Q
Features of NMS
A
FARM
Fever
Autonomic changes
Rigidity
Mental state changes
CK,WBC high high–> rhabdomyolysis
Imagine a FARMER with this condition
occurs within days-weeks
6
Q
Wernicke’s
A
COA- confusion, ophthalmoplegia and ataxia
Confusion (most common)
Oculomotor dysfunction
Gaze-induced horizontal/vertical nystagmus (most common)
Diplopia
Conjugate gaze palsy
Gait ataxia: wide-based, small step
7
Q
Korsaoff syndrome
-characterized by 3 features
A
Damage to the mamillary body, memory loss
Irreversible
Korsakoff syndrome, which is characterized
irreversible personality changes
anterograde and retrograde amnesia
confabulation.
8
Q
How can AN be an emergency situation
A
Yes
Hypokalaemia induced arrythmyias
9
Q
Which benzo has more potency for people to be dependent on
A
Short half-life ones like
“ATOM” is the acronym for benzodiazepines with a short half-life: Alprazolam, Triazolam, Oxazepam, and Midazolam.
10
Q
Lorazepam
Diazepam
short or long-acting
A
Long-acting
11
Q
Treatment of alcohol- which drug can do these
- decrease pleasure
-decrease cravings
Increase SE
A
Naltrexone
Acamprosate
Disulfiram
12
Q
TCA-3C
A
Coma/confusion
Cardiotoxicty
anti-Cholinergic
13
Q
SSRI 2 biggest complication
A
1) SS
2) Exacerbation of a mania
14
Q
SS features-4
A
HARM
Hyperthermia
Autonomic instability
Reflexes
Myoclonus
Diarrhea
Fever, tachycardia and HTN are in both SS and NMS
acute onset
15
Q
What are the 2 biggest complications of Antipsychotics
A
1) EPS
2) Metabolic syndrome
16
Q
Features of metabolic syndrome and what can be done about it
A
Start them on prophylactic metformin and switch to newer APS
17
Q
State some principles of safely prescribing benzo
A
1) Psychoeducation and maintain a good therapeutic alliance with the patient
2) Short term course and low dose
3) Establish an agreed plan with the patient and do not deviate from it- discuss informed consent, dependence,e addiction risk and prevention
4) Discuss with senior colleagues if this is appropriate management
5) Liaison with the pharmacy for benzo dispensation and follow up
18
Q
Prozac
A
Fluoxetine
19
Q
Zofolt
A
Sertraline
20
Q
7S’s of SSRIs
A
7 S’s: Stomach upset (GI upset) Sexual dysfunction Serotonin syndrome – with other serotonergic agents (i.e. MAOs) – hyperthermia, muscle rigidity, flushing, diarrhea Sleep difficulties (insomnia) Suicidal thoughts ( esp. in patients age 24 and under) Stress (agitation, anxiety) Size increase / Weight gain
21
Q
4 components of DBT
A
core mindfulness
distress tolerance
emotion regulation
and interpersonal effectiveness.
22
Q
State some principles of safely prescribing benzo
A
1) Psychoeducation and maintain a good therapeutic alliance with the patient
2) Short term course and low dose
3) Establish an agreed plan with the patient and do not deviate from it- discuss informed consent, dependence,e addiction risk and prevention
4) Discuss with senior colleagues if this is appropriate management
5) Liaison with the pharmacy for a benzo dispensation and follow up
23
Q
Sleep hygiene advice you can give to a patient
A
https://www.cci.health.wa.gov.au/~/media/cci/mental%20health%20professionals/sleep/sleep%20-%20information%20sheets/sleep%20information%20sheet%20-%2004%20-%20sleep%20hygiene.pdf
24
Q
Sleep hygiene advice you can give to a patient
A
https://www.cci.health.wa.gov.au/~/media/cci/mental%20health%20professionals/sleep/sleep%20-%20information%20sheets/sleep%20information%20sheet%20-%2004%20-%20sleep%20hygiene.pdf
25
Alcohol withdrawal: outline what happens in
0-24
24-48
48
Alcoholic hallucinosis--> onset: 12–48 hours after last drink
(Alcohol hallucinosis can be confused with schizophrenia because of both presents with hallucinations!)
Delirium tremens--> Persistent alteration of consciousness and sympathetic hyperactivation due to alcohol withdrawal.
26
CAGE test
C: Cut down drinking: “Have you ever felt you should cut down on your drinking?”
A: Annoyed: “Have people annoyed you by criticizing your drinking?”
G: Guilty: “Have you ever felt guilty about drinking?”
E: Eye-opener: “Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to overcome a hangover?”
27
Vitamin deficiency with long term alcohol use are: and what is the clinical conseqeunce of this
Vitamin B1 deficiency (thiamine deficiency): Wernicke-Korsakoff syndrome
Vitamin B6 deficiency: peripheral neuropathy.
Vitamin B9 deficiency (folate deficiency): megaloblastic anemia
Vitamin B12 deficiency: subacute combined degeneration of spinal cord (funicular myelosis), megaloblastic anemia
28
Vitamin deficiency with long term alcohol use are: and what is the clinical consequence of this
Vitamin B1 deficiency (thiamine deficiency): Wernicke-Korsakoff syndrome
Vitamin B6 deficiency: peripheral neuropathy.
Vitamin B9 deficiency (folate deficiency): megaloblastic anemia
Vitamin B12 deficiency: subacute combined degeneration of spinal cord (funicular myelosis), megaloblastic anemia
29
Why thiamine first and then glucose
Because glucose increases thiamine demand and will worsen encephalopathy, IV glucose infusions must be administered AFTER thiamine!
30
Which medications should not be used to treat depression in adolescents
TCA
31
Maintenance therapy, attempting monotherapy with(which other drugs can be used) for Bipolar
Lithium
1) Valproate
2) Quetiapine
3) Lamotrigine
32
Patient Health Questionnaire-2 (PHQ-2)
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things
Feeling down, depressed or hopeless
33
With any management plan in Mental health, what should you be thinking about
1) Biopsychosocial model
2) MDT
- short term
- medium-term
- long term
34
What is so special about Aripiprazole
It appears to show:
- predominantly antagonist activity on postsynaptic D2 receptors
- partial agonist activity on presynaptic D2 receptors
- a partial activator of serotonin(5-HT3)
Thus because of its partial nature, it is able to let dopamine in and out at different times
35
Why do you have to be careful with Olanzapine depot administration
Depot--> administration is through the buttock--> Need to monitor very carefully
Monitoring for HYPOTENSION --> can be fatal
36
What happens to the dopamine receptors in the typical antipsychotics(Halo and zuclopenthixol)
They all get blocked and no dopamine gets through unlike action of Aripiprazole
37
1st atypical presentation or first treatment episode, what special test would you order
1) Serum copper and ceruloplasmin--> Wilson's disease
2) FTA-Abs and neurosyphilis
3) Vitamin b12/folate
4) HIV
5) Neuroimaging
6) if indicated-ECG, CXR, LP, karyotyping and heavy metal testing
38
Hallucinations are
Sensory perceptions in the absence of external stimuli
39
What do you need to ask about auditory hallucination
Is it in your head, 1st person, 2nd person
what are they?
telling you to harm anyone?
associated with a rational or explantations( secondary delusions)
40
What do you need to ask about auditory hallucination
Is it in your head, 1st person, 2nd person
what are they saying?
telling you to harm anyone?
associated with a rational or explantations( secondary delusions)
41
What are pseudo-hallucinations? why are they important?
Considered a non-psychotic experience- occur in personality disorder or normality
Often mood congruent-usually derogatory
(Are they saying mean things about you? can you see them?)
May be command hallucinations, describing person inner wishes or desires
42
spectrum of perception
Hallucination----> pseudo-hallucinations(cluster A and BPD)--> flashback(like in PTSD)--> vivid imaginery(illusions)
43
Thoughtform(some terms)- tell me what each one means
- tangential
- flight of ideas
- loosening of assosication
- blocking
- echolalia
- knight-move thinking/derailment
- neologisms
- circumstantiality
- clang associations
circumstantiality--> over incluisve
44
Disorder of affect
-4 reasons for flat affect
1) schizophrenia- negative symptoms
2) Increase APS dose
3) Parkinson's disease
4) Severe depression
45
6 A of negative symptoms of schizophrenia
```
Affect blunted
Alogia
Anhedonia
Asociality
Avolitation
Attention
```
46
Disorder of affect
-4 reasons for flat affect
Restricted/constricted=slightly less
```
Blunted= ++ reduced
Flat= almost absent
Inappropriate= does not fit with speech content
```
1) schizophrenia- negative symptoms
2) Increase APS dose
3) Parkinson's disease
4) Severe depression
47
Insight-what is it?
| Comment on these aspects of insight
Ability to understand the true cause and meaning of a situation
Do not say "no sight" describe
Comment on these aspects of insight
- Awareness of diagnosis
- Awareness of the need for treatment and options
- Varies during the course of the illness
48
Risks to consider in psychosis
1) Suicide
2) Violence
3) Vulnerability
4) Loss of reaction
5) Self-neglect
49
What does adherence therapy do
Adherence therapy (AT) is an intervention that seeks to reduce patients' psychiatric symptoms by enhancing treatment adherence.
Remove barriers to treatment adherence- improved response rates to medication and transparent communication between prescriber and patient
Motivational interviewing principles
50
What does adherence therapy do
| -what is the MOST important factor
Adherence therapy (AT) is an intervention that seeks to reduce patients' psychiatric symptoms by enhancing treatment adherence.
Remove barriers to treatment adherence- improved response rates to medication and transparent
1) communication between prescriber and patient
2) Motivational interviewing principles
3) proactively eliciting problems/ side effects deterring the patient from taking treatment and minimizing this
4) previous medication history and problems taken into account
PSYCHOEDUCATION OF the family and carers are the most important factor--> Adherence therapy
51
Improving compliance/adherence in psychotic patients-5
Good therapeutic alliance
Limit cost (PBS listed medications, Closing The Gap)
consider ease of travel / access to medication
Psychoeducation and informed consent
Simple regime (once-daily dosing, less tablets, depot /
IMI formulations)
Actively ask about side effects and minimize
Reminders- alarm or reminder on phone, post-it on
fridge
Dosette boxes, blister packing where needed
Involve family and carers (Direct Observed Treatment
DOT’s)
Case management / NGO support with prompting
52
How long do you continue taking antipsychotic for after 1st episode
2-5 years(else 60-80% relaspe)
53
When to stop Antipsychotics and how should you do it
Antipsychotics treat acute relapses of positive symptoms and help to prevent relapses
If you decide to stop do this gradually over 6-12 months with close monitoring( abrupt withdrawal increase risk of relapse)
54
Nigrostriatal pathway, what effects do you see
EPS
NMS
TD
55
Tubero-infundibular pathway, what effects do you see
1) Hyperprolactinemia
2) Galactorrhea
3) Amenorrhea
4) Osteoporosis
5) Sexua side effects--impiared spermatogenesis, decreased libidio, impotence and anorgasmia
6) Weight gain
56
One big difference between FGA and SGA
Most SGAs differ from older medications pharmacologically in that serotonin 5HT2 receptor binding exceeds their affinity for dopamine D2 receptors, whereas in FGAs this is generally not the case
5HT2 activity has been suggested as one basis for the lower overall risk of extrapyramidal side effects (EPS) with the atypical drugs compared with FGAs
57
Anticholinergic side effects are seen in which 2 SGA, other than clozapine
Olanzapine and Quetiapine
58
QTc prolongation side effects are seen in which 2 SGA
Risperidone and Quetiapine
59
Highest Prolactin elevation in SGA is seen in
Risperidone
60
Anticholinergic effect reported by SGA are
Mostly reported as dry mouth or constipation and less often as blurred vision or urinary retention.
raised intraocular ocular pressure(weird one)
61
Lowest risk of metabolic syndrome
The highest risk of metabolic syndrome
aripiprazole
Olanzapine
62
Orthostatic hypotension - why in SGA?
Alpha-adrenergic blockade is the likely mechanism of orthostatic hypotension with SGAs
63
Among the SGAs,__________ carries the highest risk of EPS (KNOW THIS FOR EXAM)
Risperidone
64
risperidone is important among the SGA why?
Among the SGAs, risperidone carries the highest risk of EPS
65
Clozapine ad seizure disorder why?
Lowers threshold
Clozapine should be used with caution and in consultation with a neurologist in patients with known seizure disorders
66
The pathognomonic features of the neuroleptic malignant syndrome (NMS)
fever, muscle rigidity, mental status changes, and autonomic instability, generally accompanied by rhabdomyolysis and creatine kinase elevation
FARM
The single strongest predictive factor is a prior episode of NMS.
67
Antipsychotic Monotherapy is the goal. Why?
Lower risk of side-effects / NMS.
Lower risk of non-compliance / medication errors.
Little difference in efficacy.
Cost.
68
But my patient isn’t getting better on this medication one of Antipsychotic
Is the person actually taking the medication
Have you given it enough time to work?
Have you tried increasing to the maximum dose?
Have you tried another antipsychotic? Tried clozapine?
Have you considered another diagnosis?
69
Mnemonic for SGAs-SHEWOMAN
```
Sedation
Hyperprolactinemia
EPS(DAPTD)
Weight gain
Orthostatic hypotension
Metabolic syndrome
Anticholinergic
NMS
```
70
NMS antidote medication
Dantrolene and bromocriptine
71
What is a WRAP plan
The Wellness Recovery Action Plan
Help with relapse prevention
Bipolar- WRAP--> help identify early warning signs and crisis and post-crisis management
The patient, family, carers and clinicians document and
identify these initial symptoms early and agree what to
do when they are present e.g. see doctor, increase
medication, restore sleep, reduce stressors e.g. Bipolar
WRAP
72
In psychiatric history, what other medical history should you ask for to rule out GMC
Allergies
```
Personal history of:
• Thyroid disease
• Head injuries
• Seizure disorders
• Chronic pain/chronic illness
• Cardiac history
```
73
Static vs dynamic risk factors- definition
Static risk factors are fixed and historical.
Dynamic risk factors are changeable and fluctuate.
74
THE SCOFF QUESTIONNAIRE for eating disorders
Do you ever make yourself sick because you feel uncomfortably full?
Do you worry you have lost control over how much you eat?
Have you recently lost more than one stone(7KG) in a three month period?
Do you believe yourself to be fat when others say you are too thin?
Would you say that food dominates your life?
75
sleep benzo is
temazepam
76
ACUTE BEHAVIOURAL DISTURBANCE- mild
Lorazepam 1-2mg (max effect 1-3 hours) OR
| Olanzapine 5-10mg (Max 30 mg / 24 hours) ORAL
77
ACUTE BEHAVIOURAL DISTURBANCE
-moderate
-severe
```
MODERATE highly aroused, distressed, fearful =
give both(lorazepam and olanzapine)
```
SEVERE refusing orals, starting to become
violent to self / others / property =IMI Droperidol
2.5-10mg every 20 minutes (max 20mg / 24
hours)
78
Counselling patients on antidepressant initiation(starting them on SSRI)
- pamphlets
-Warn of both common and serious potential side-effects, including discontinuation effects
- do not stop them immediately
- Adequate trial- at least 3 weeks
- Maintain at least 6 months to 1 year after first
episode
- Tell them about suicide hotlines
-7S of side effects of SSRIs- tell them they will only last for a week and they will feel much better
-depression--> will help in a couple of week
- anxiety--> takes like a month- monthsss
how do they?
they make sure the chemicals in your brain are brought back to normal
79
Treatment of bipolar depression
Avoid antidepressants first line for bipolar depression,
as they can precipitate a switch into mania or rapid
cycling (>3 episodes a year).
Lamotrigine, quetiapine, lurasidone, lithium and
Olanzapine are effective for bipolar depression.
80
Lithium has anti_______ what affect
suicidal
“Anti-suicide” effect (mechanism also unclear).
81
Lithium+ high dose antipsychotics
Increase the risk of neurological damage
82
At which levels of lithium, is dialysis indicated
Levels >3.5mmol/L are potentially lethal = haemodialysis
recommended.
Lithium toxicity can progress from confusion and
motor impairment to coma, convulsions, and death
83
ALCOHOL DEPENDENCE – DETOX- 5 steps as per lecture
1) Use CIWA
2) Thiamine IM 100mg stat – To prevent Wernicke’s
Encephalopathy/Korsakoff’s Psychosis.
---> Wernicke’s = ataxia, ophthalmoplegia, nystagmus,
confusion – Medical Admission and high-dose IV thiamine.
3) Diazepam PO 10mg Q6H, tapering over the following
3-5 days – To prevent symptoms of alcohol withdrawal,
including seizures
4) Paracetamol for headaches.
5) Metoclopramide for nausea.
84
Three drugs for ALCOHOL DEPENDENCE – LONG-TERM
Disulfiram
Acamprosate
Naltrexone
85
NICOTINE USE DISORDER TREATMENT-3 drugs
Nicotine replacement therapy – first choice in hospital due to
quick response
Varenicline
Bupropion
86
Opioid addict what is the program
OPIOID TREATMENT PROGRAM
Methadone- watch QTc
Buprenorphine (Subutex / Suboxone if combined
with naloxone to prevent diversion, sublingual)-
mu receptor agonist, reduces cravings, decreases
effects of additional opioid use, safer in OD
Naltrexone- long-acting opioid antagonist, nonPBS for opioid dependence due to OD risk (loss of
tolerance and can precipitate withdrawal)
87
What are the HAM side effects? Which meds are they associated with?
anti-Histamine = sedation, weight gain
antiAdrenergic = hypotension
antiMuscarinic = dry mouth, blurred vision, urinary retention
Drugs: TCAs and low-potency antipsychotics
- AntiHisamine: sedation, weight gain
- Anti-alpha1Adrenergic: orthostatic hypotension, cardiac abnormalities, sexual dysfunction
- AntiMuscarinic-anticholinergic: dry mouth, tachycardia, urinary retention, blurry vision, constipation, ppt of narrow-angle glaucoma
88
How is TCA OD treated?
IV sodium bicarbonate
89
ORTHOSTATIC HYPOTENSION
| (ADRENERGIC)- which APS have it most
Risperidone, Quetiapine most
Clozapine- if you miss 3 consecutive days
need to retitrate from low dose (you quickly
lose tolerance)
90
Benztropine given for
EPS side effects
91
What is unique about risperidone?
- Can increase prolactin
| - Some orthostatic hypotension and reflex tachycardia
92
Which drugs(2) commonly can cause delirium
Anticholinergic
Benzo as well hence we don't give them expect for alcohol withdrawal
93
Anticholinergic effect-5
```
Dry mouth
blurred vision
constipation,
urinary hesitancy,
raised intraocular pressure
```
