Therapeutics in mental health Flashcards
(51 cards)
Mental illness causes:
- biological, genetic, physical, chemical
- social, psychological
4D’s +1
Significant Deviation from normal (“their normal” e.g. must include cultural features)
Patient has significant Dysfunction
Patient/others have significant Distress,
Patient presents a Danger to themselves or others… [Symptoms have been present for a significant Duration]
Therapeutics
- Environmental
Social services
Family - Psychological
General/supportive psychotherapy
Psychodynamic/interpretative psychotherapy
Interpersonal therapy
3. Behavioural Cognitive therapy Cognitive behavioural therapy Dialectic behavioural therapy Problem-solving therapy Meta-cognitive therapy
4. Physical
Psychotropic drugs
Electroconvulsive therapy
Transcranial methods
direct current stimulation
magnetic stimulation
Goals of psychopharmacology
Control immediate threat of harm to self and others Prevention of relapse - minimise - reduce suicidality Minimise symptoms - manage Minimise side effects - manage Improve quality of life - restore/improve functioning - improve social integration To integrate with other therapies contributing to the management of the patient with a mental health disorder
Main medication groups: 4A’s
Antidepressants
Anxiolytics
Mood stabilisers ́(“Antimanics”)
Antipsychotics
Collectively referred to as “psychotropics”
Side Effects of psychotropics
Dry mouth Constipation Nausea Sedation Insomnia Sexual dysfunction Tremor Weight gain
Depression
Cyclical & chronic disorder
Periods of illness separated by periods of good health
Onset: 20-40 years, Sx develop over time (days-weeks) Episode duration varies widely: 3-13 months
Most patients experience a 2nd episode (50-80%)
As patients get older, episodes last longer, have more Sx Over 20 year period – typically 5-6 episodes
Antidepressants primarily used for depressive symptoms of
1) Major depression
2) Depressed phase of bipolar disorder
The choice of antidepressant is determined by the following:
Anti-depressant adverse effect profile
Patients response or lack of response to previous treatment
Adverse effects of previous treatment
Family history of response to treatment
Risk of drug interaction with concurrently administered drugs
Antidepressant safety in overdose
Patient comorbidities
Finding Tx that ‘works’ can include lots of Tx trials, error, and juggling for any individual patient requiring pharmacological Tx
Tricyclic antidepressants (TCAs)
Heterogenous group, multiple pharmacological actions
• Tricyclic chemical structure à name
• Low therapeutic ratio, not 1st choice any longer
• Imipramine (earliest) has been around for 60+ years
ADRs
• Potentially lethal in overdose (seizures, arrhythmias)
• Similar receptor affinity profile as antipsychotics
- H1: Weight gain, drowsiness (can be ‘felt as sedation’)
- Alpha 1-adrenergic blockade: Postural hypotension
- Antimuscarinic: Blurred vision, dry mouth, urinary retention, constipation
- Sodium channel blockade: Arrhythmias, Seizures
• Hyponatraemia: SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
Monoamine oxidase inhibitors (MAOIs)
Tranylcypromine & phenelzine
- Irreversible inhibitors – (up to 2 weeks)
- Non-selective – inhibit both A & B forms
- Interaction with dietary amines limits their use (!)
E.g. Tyramine, normally destroyed by GIT MAO-A
ADRs
Long lasting effects
Postural hypotension, dry mouth, blurred vision, urinary retention, weight gain, agitation, insomnia
Reversible inhibitors of MAO (RIMAs)
Moclobemide: Selective for MAO-A, reversible, dietary amines metabolised
- May lose selectivity at higher doses
ADRs
Transient… Postural hypotension, dry mouth, blurred vision, urinary retention; Weight gain, agitation, insomnia
Serotonin & noradrenaline reuptake inhibitors (SNRIs)
Venlafaxine, Duloxetine
-“dual action antidepressant”
-Minimal dopamine, anticholinergic & antihistamine effects at standard doses
-May increase BP
-Considered even more toxic in overdose than TCAs –
high risk of arrhythmia
NRIs – noradrenaline reuptake inhibitors:
• Reboxetine
SSRI ADRs
Irritability, agitation, anxiety, confusion, tremor ́Insomnia, disturbed sleep, sedation (yes!) ́Nausea, vomiting, GI upset, diarrhoea, anorexia ́Sexual dysfunction
Increased bleeding, vasodilation, hypertension ́ Headache
Dizziness
Hyponatraemia (10% of elderly patients affected)
-SIADH (Syndrome of Inappropriate Antidiuretic Hormone)
Serotonin syndrome
Noradrenergic & specific serotonergic antidepressants (NaSSA)
Mirtazapine
- Comparatively more sedation
- More weight gain
Antidepressant discontinuation
Withdrawal syndrome
́ sleep disturbances (insomnia, abnormal dreams)
́ GIT symptoms (N&V, diarrhoea, cramps)
́ ‘flu-like symptoms (lethargy, myalgia, chills)
́ agitation
́ disequilibrium (dizziness, vertigo, ataxia)
́ sensory disturbances (paraesthesias, electric shock)
Time frame
́ appear 1-3 days after cessation ́ last 7-14 days
Management:
́ taper doses, especially with short acting drugs – paroxetine
discontinuation syndrome
Clinical features: dizziness, anxiety, nausea, headache
Adverse effects: fatigue, diarrhoea, insomnia, tremor
Generalised Anxiety Disorder (GAD)
Onset gradual
Typical Sx include:
- Excessive anxiety for most days for at least 6 months
- Anxiety is not restricted to specific situations (is “general”)
- Palpitations, sweating, trembling, dry mouth, SOB, uncomfortable feeling in chest/abdomen, derealisation, chills
One other psychiatric symptom in 62% e.g. depression ́
EtOH dependence common (self medication)
High level of non-pharmacological Tx
-E.g. Psychotherapy, CBT, relaxation
Panic attacks can also occur in several anxiety disorders
Medications - anxiety
Sedative/hypnotics, benzodiazepines
- Potentiate GABA (Gamma Amino Butyric Acid)
- Bind to benzodiazepine GABAA receptor Antidepressants
- First line – SSRIs, SNRIs
- Second line – TCAs ́Mirtazapine ́MAOIs
- Partial 5HT1a agonist
Buspirone
Antipsychotics
b-blockers
Benzodiazepines (“benzos”)
Sedatives, hypnotics, provide rapid symptomatic relief from anxiety states
Examples include:
Diazepam, oxazepam, alprazolam, nitrazepam, temazepam, clonazepam, etc.
Lipid soluble drugs
Length of time in system greatly extended in
age due to lipophillic nature (liver metabolised)
Can lead to confusion, delirium, falls in elderly
Preference in elderly = use short acting drugs with no metabolites, e.g. oxazepam
For short-term use only
Benzos - tolerance, dependence, withdrawals
Tolerance
- Develops rapidly for hypnotic effects
- Takes longer to develop for anxiolytic effects
- Limited anxiolytic efficacy after 4 months (or less)
Dependence
-Physical (4weeks of daily use may be all that is required!)
Repeated withdrawals from BZEs can increase severity of withdrawal symptoms
Withdrawal Sx
-Agitation, hostility, dysphoria, insomnia, sweating, tachycardia, tremors, muscular tension, derealisation, depersonalisation
At worst
-Psychosis (hallucinations), seizures, increased sensitivity to excitatory amino acid neurotransmitter, glutamate
People taking Benzos - what to look out for on the ward
Memory impairment
Wakes up at night, “Forgot tablet” takes another! (at
home, or in rehab if they are self-medicating)
Daytime sleepiness
Respiratory depression
Other meds with synergistic effect
The elderly
More sensitive to SEs
Not eliminating as well, can accumulate BZEs, signs =
Dizziness, disorientation, vertigo, ↑ risk of falls (!)
More signs: Confusion, decreased reflexes, drowsiness, muscle weakness, shakiness, shortness of breath or trouble breathing, slow heartbeat, slurred speech, staggering, weakness
Psychosis
Symptom-based presentation, not a disease in itself ́ Characterised by a lost sense of reality
- Delusions: Fixed, false beliefs, E.g. grandiose (e.g. special powers), persecutory, etc.
- Hallucinations: False perceptions, Usually auditory, but can be tactile, olfactory, visual
Associated with schizophrenia, not exclusive to it
[Vs. Neurosis – associated with anxiety disorder (e.g.
obsession, phobic, compulsive) but intact reality sense]
Organic psychosis
Direct or indirect insult to brain, e.g. trauma, degenerative, infective, metabolic Functional psychosis Schizophrenic psychosis Affective psychosis Bipolar disorder Psychotic depression
Schizophrenia
It is a “split mind” (not split personality/dissociative disorder)
A major psychotic disorder with variable presenting profiles that reflects a disturbance of:
- Thought
- Perception
- Affect
- Behaviour
