Psychiatry Explanation

Question 1

Depression and SSRIs - Explanation

Answer 1

Depression / SSRI

• Serotonin is a chemical in the brain that helps lift mood
• It is thought that people with depression release only small amounts of serotonin
• SSRIs boost the amount of serotonin in the brain, help lifts mood

Side effects

• Side effects improve as body gets used to medication
  
  • GI upset most common
  • Increased risk of GI bleeding, so offer PPI if also taking NSAIDs
  • Suicidal thoughts (< 25 years old most at risk) - contact GP/hospital immediately

Dosage

• Lowest effective dose to minimise side effects
• May take 2-4 weeks before you notice improvement in mood. Symptoms may get worse before they get better
  
  • Important to continue despite this!
• Recommended course - 6 months
• Shouldn’t discontinue abruptly due to withdrawal symptoms

Review

• 1-2 weeks to check on SE or suicidal ideation

Other

• Avoid alcohol - reduce efficacy

Drugs

• Citalopram / Sertraline
• Fluoxetine (young patients)

Question 2

Benzodiazepines (Anxiety) - Explanation

Answer 2

Benzodiazepines

• Type of sedative prescribed for short periods to ease symptoms of anxiety + sleeping difficulty
  
  • Ease symptoms within 30-90 mins
• Do not treat underlying cause, but help patient cope better with problems

Side effects

• Drowsiness - AVOID DRIVING / OPERATING MACHINERY

Dosage

• No longer than 2-4 weeks as they can become addictive. Also lose efficacy with time
• Reduce gradually over 1-2 weeks
• Withdrawal symptoms if stopped abruptly

Drugs

• Diazepam
  
  • TOLERANCE
  • DEPENDENCE

Question 3

Lithium

Answer 3

What does it do?

• Lithium is a mood stabiliser
• Mechanism of action unknown - thought to correct chemical imbalanc

Before taking lithium

• Baseline kidney and thryoid function

How to take

• Usually prescribed a low dose (200-400 mg) at night
  
  • Allows time to reach therapeutic levels
• Drink plenty of water!

Side effects

• Narrow therapeutic window - blood tests, tailored dose
  
  • Not addictive
• Common
  
  • Dry mouth, polydipsia, polyuria
  • Metallic taste, nausea & vomiting
  • Tremor
  • Weight gain
• Toxicity (seek immediate medical attention)
  
  • Blurred vision
  • Drowsiness
  • Muscle weakness
  • Abnormal muscle movements or twitches
    
    • Carry lithium card - show to healthcare professionals
    • Keep well hydrated
    • Be mindful of drug interactions

Complications

• Renal / Thyroid dysfunction
• Pregnancy
  
  • Doesn’t affect chances of getting pregnant, but does increase risk of anomalies - heart defect (avoid in first trimester)

Monitoring

• Weekly bloods until steady state reached
• 3 monthly thereafter
• 6 monthly kidney and thyroid checks

Question 4

Olanzapine

Answer 4

What is olanzapine?

• Schizophrenia associated with imbalance of chemicals in the brain
• Olanzapine helps to normalise levels, thus improving symptoms

How to take?

• Orally - with glass of water same time everyday
• Depot injection

Side effects

• Weigth gain (increased appetite)
  
  • Increased risk of DM
• Drowsy - do not drive or operate machinery
• Anti-muscarinic - Dry mouth, Constipation
• EPSE (unusual movements)
  
  • Tardive dyskinesia
• Neuroleptic malignant syndrome
  
  • High fever, muscle ridity

Important

• Do not stop abruptly
  
  • Relapse
  • Withdrawal symptoms
• Safety in pregnancy unknown - best avoided

Monitoring

• Baseline
  
  • FBC, U&E, LFT
  • Blood glucose, lipids
  • Weight
  • ECG (if CVD)

Clozapine

• Better
• Indicated in refractory schizophrenia
• Risk of agranulocytosis
  
  • WCC measured weekly for 18 weeks, 2 weekly thereafter

Question 5

Dementia & Alzheimer’s

Answer 5

What is Dementia?

• Dementia is a condition that affects the brain, causing a gradual decline in mental function
• People with dementia often have problems with their memory, and may become confused as a result of this.
• It can also affect a person’s ability to understand and use language, so a person with dementia may have difficulty following conversations, or they might muddle their words.
• As the condition progresses, dementia may affect a person’s mood and personality, and their ability to perform everyday tasks.

​What causes dementia?

• Not a normal part of aging, but more common in older people
• A number of illnesses cause dementia, the most common of which is Alzheimer’s disease
  
  • In Alzheimer’s disease, nerves within the brain become damaged and die. As a result the brain gradually loses it’s ability to perform its normal functions including memory, understanding and language skills. People with Alzheimer’s also have reduced amounts of a chemical involved in sending messages within the brain. This can be exploited by treatment

Management

• Multidisciplinary support (promote independence)
  
  • District/specialist nurses, OT, physio (mobility)
• Other
  
  • Simplify daily routine
    
    • Write down routine / reminders
    • Place keys/glasses/clothes in prominent places
  • Cognitive stimulation
    
    • Activities to improve memory (recreational/problem-solving)
• No cure, but treatments can improve symptoms and quality of life.
  
  • Acetylcholinesterase inhibitors
    
    • Rivastigmine, Donepezil
      
      • SE: GI disturbance
  • NMDA antagonist (reduces glutamate)
    
    • Memantine

Driving

• Must inform DVLA
• Annual driving test / medical assessment

Question 6

Sodium Valproate

Answer 6

What does it do?

• Epilepsy is caused by an uncontrolled electrical overactivity in the brain, causing seizures
• Valproate dampens down this electrical activity

Course

• One or two tablets daily
• Treatment ‘holiday’ after 2 years

Side effects

• Hair loss (grows back curly)
• GI disturbance
• Drowsy

Cautions

• Hepatotoxic
  
  • Unexplained bleeding/bruising
  • Dark urine
• Pancreatitis
  
  • Abdo pain
• Pregnancy
  
  • Risk of neural tube defects
    
    • Take folic acid (5mg)

Monitoring

• FBC and LFT before
• LFT monthly for first 6 months