PSA Specialties- Psych

Question 1

1st line drug depression

Answer 1

SSRIs:
Citalopram + Fluoxetine preferred
Sertraline useful post=MI
Fluoxetine for <16s

Question 2

Most common SE of SSRIs

Answer 2

GI Sx
(+increased risk of bleeding, prescribe PPI if use of NSAID)

Question 3

Most important counselling point for SSRIs

Answer 3

Be vigilant for increased anxiety, suicidal ideation, DSH + agitation after starting a SSRI

Question 4

Which SSRI is associated with dose dependent prolongation of QT interval? What is the maximum daily dose?

Answer 4

Citalopram (+escitalopram)
Max: 40mg (20 for >65s/ hepatic Impairment)

Question 5

Name 2 drugs that increase risk of serotonin syndrome in patents taking SSRIs

Answer 5

Triptans
Monoamine oxidase inhibitors

Question 6

Which SSRI has increased risk of congenital malformation in pregnancy?

Answer 6

Paroxetine

Question 7

When should SSRIs be reviewed?

Answer 7

<25y: 1w after initiation
>25y: 2w after initiation
Continue for at least 6 months after remission

Question 8

First line drug for generalised anxiety disorder

Answer 8

Sertraline

Question 9

First line drug for panic disorder

Answer 9

SSRIs

Question 10

How should SSRIs be stopped?

Answer 10

Gradually reduce over 4w
Not necessary with fluoxetine

Question 11

7 discontinuation symptoms of SSRIs

Answer 11

Increased mood change
Restlessness
Difficulty sleeping
Unsteadiness
Sweating
GI Sx: pain, cramping, D+V
Paraesthesia

Question 12

Therapeutic range of lithium. At what concentrations does toxicity typically occur?

Answer 12

0.4-1.0 mmol/L
Toxicity: >1.5mmol/L

Question 13

Excretion of Lithium

Answer 13

Long plasma half-life
Primarily excreted by kidneys

Question 14

3 precipitants to lithium toxicity

Answer 14

dehydration
renal failure
drugs

Question 15

4 drugs that can precipitate lithium toxicity

Answer 15

Diuretics (esp. thiazides)
ACE inhibitors/ ARBs
NSAIDs
Metronidazole.

Question 16

6 features of Lithium toxicity

Answer 16

Coarse tremor (a fine tremor is seen in therapeutic levels)
Hyperreflexia
Acute confusion
Polyuria
Seizure
Coma

Question 17

Management of Lithium toxicity

Answer 17

Mild-mod: volume resus with normal saline
Severe: Haemodialysis

+/- Sodium bicarbonate (limited evidence)- increases alkalinity of urine, promotes lithium excretion

Question 19

10 Adverse effects of Lithium use

Answer 19

N+V
Diarrhoea
Fine tremor
Nephrotoxicity: polyuria, secondary to nephrogenic DI
Thyroid enlargement, may lead to hypothyroidism
ECG: T wave flattening/ inversion
Weight gain
Idiopathic intracranial HTN
Leucocytosis
Hyperparathyroidism + hypercalcaemia

Question 20

What is Lithium most commonly used for?

Answer 20

Mood stabilising in bipolar disorder

Question 21

When should samples be taken to measure Lithium level?

Answer 21

12h post-dose

Question 22

Describe monitoring requirements for lithium

Answer 22

Weekly + after each dose change until concentrations are stable
Once established, lithium blood level should ‘normally’ be checked every 3 months
Thyroid + renal function: every 6 months

Question 23

2 examples of typical antipsychotics

Answer 23

Haloperidol
Chlorpromazine

Question 24

3 examples of atypical antipsychotics

Answer 24

Clozapine
Risperidone
Olanzapine

Question 25

List 4 extrapyramidal side effects associated with typical antipsychotics

Answer 25

Parkinsonism Acute dystonia (Torticollis, Oculogyric crisis) Akathisia (restlessness) Tardive dyskinesia

Question 26

List 4 antimuscarinic side effects associated with antipsychotics

Answer 26

Dry mouth Blurred vision Urinary retention Constipation

Question 27

Which class of antipsychotics has greater association with hyperprolactinaemia? What is a possible complication of this?

Answer 27

Typical Galactorrhoea

Question 28

List 3 antipsychotics that rarely cause hyperprolactinaemia

Answer 28

Aripiprazole Clozapine Quetiapine

Question 29

Management of acute dystonia caused by antipsychotics

Answer 29

Procyclidine

Question 30

Which antipsychotic is particularly associated with prolonged QT?

Answer 30

Haloperidol

Question 31

Which class of antipsychotics has greater association to reduced seizure threshold?

Answer 31

Atypical

Question 32

4 features of neuroleptic malignant syndrome

Answer 32

Pyrexia Muscle rigidity Autonomic lability: HTN, tachycardia + tachypnoea Agitated delirium with confusion

Question 33

Investigations for neuroleptic malignant syndrome

Answer 33

High CK AKI (secondary to rhabdomyolysis) in severe cases +/- leukocytosis

Question 34

Management of neuroleptic malignant syndrome

Answer 34

STOP antipsychotic Transferr to a medical ward IV fluids to prevent renal failure Dantrolene or Bromocriptine

Question 35

For what period should benzodiazepines be prescribed for?

Answer 35

2-4w Patients commonly develop a tolerance + dependence

Question 36

What may happen if a patient withdraws too quickly from benzos?

Answer 36

Benzodiazepine withdrawal syndrome very similar to alcohol withdrawal syndrome may occur up to 3w after stopping a long-acting drug

Question 37

List 9 features of benzodiazepine withdrawal syndrome

Answer 37

Insomnia Irritability Anxiety Tremor Loss of appetite Tinnitus Perspiration Perceptual disturbances Seizures

Question 38

Describe monitoring of FBC, U&Es, LFTs when on antipsychotics

Answer 38

at the start of therapy Annually cCozapine requires much more frequent monitoring of FBC (initially weekly)

Question 39

Describe monitoring of lipids and weight on antipsychotics

Answer 39

at the start of therapy at 3 months Annually

Question 40

Name 2 antipsychotics that commonly cause weight gain

Answer 40

Clozapine Olanzapine

Question 41

Describe monitoring of fasting blood glucose and prolactin on antipsychotics

Answer 41

at the start of therapy at 6 months Annually

Question 42

Describe monitoring of BP on antipsychotics

Answer 42

Baseline Frequently during dose titration

Question 43

Describe ECG monitoring on antipsychotics

Answer 43

Baseline

Question 44

Describe cardiovascular risk assessment on antipsychotics

Answer 44

Annually

Question 45

Why is frequent FBC monitoring essential during treatment with Clozapine?

Answer 45

Significant risk of Agranulocytosis

Question 46

When is clozapine indicated?

Answer 46

If schizophrenia is not controlled despite the sequential use of >,2 antipsychotics (one of which should be a 2nd-gen antipsychotic), each for at least 6–8w

Question 47

List 6 adverse effects of Clozapine

Answer 47

Agranulocytosis (1%) Neutropaenia (3%) Reduced seizure threshold Constipation Myocarditis: baseline ECG should be taken before starting Tx Hypersalivation

Question 48

Describe the effect of smoking on Clozapine concentration

Answer 48

Smoking (inc. cannabis) reduces amount of clozapine High dose of Clozapine required if smokes

Question 49

Describe initial management of delirium

Answer 49

Tx of underlying cause Modification of the environment

Question 50

What is the first line sedative used in delirium?

Answer 50

Haloperidol 0.5mg

Question 51

How should delirium in Parkinson's patients be managed?

Answer 51

AVOID antipsychotics (worsen Sx) If urgent Tx required: Quetiapine/ Clozapine

Question 52

When should Mirtazapine be taken?

Answer 52

Evening as can be sedative

Question 53

2 side effects of Mirtazapine

Answer 53

Increased appetite Sedation