Mental health disorders

Question 1

Anxiety treatment

Answer 1

• Benzodiazepines are indicated for short-term relief of anxiety that is causing unacceptable distress (for 2-4 weeks only). An example is Diazepam
• They can slow down the grieving process and are used in children only for acute anxiety in situations involving fear (e.g. fear of surgery).

Question 2

Symptoms of diazepam overdose

Answer 2

drowsiness, ataxia, dysarthria, nystagmus + coma

Question 3

For chronic anxiety

Answer 3

Chronic - (longer than 4 weeks) it may be appropriate to use an antidepressant.

• Patients with generalised anxiety disorder (a form of chronic anxiety), should be offered psychological treatment followed by an SSRI (sertraline).
• Duloxetine and Venlafaxine (serotonin and noradrenaline re-uptake inhibitors) can also be used.
• If a patient cannot tolerate the above/treatment is ineffective, then pregabalin can be considered

Question 4

Attention deficit hyperactivity disorder (ADHD)

Answer 4

If a child has severe and persistent symptoms of ADHD, then CNS stimulants including Atomoxetine + Methylphenidate can be prescribed

• If a child has moderate symptoms of ADHD they can be treated with CNS stimulants when psychological interventions have been unsuccessful or are unavailable.
• Treatment for ADHD often needs to continue into adolescence and may need to be continued into adulthood.
• If the patient does not respond to Atomoxetine and Methylphenidate, then Dexamfetamine and Lisdexamfetamine are an alternative for children.

Question 5

ADHD - what can be used in children for whom stimulants are not suitable, not tolerated or ineffective

Answer 5

Guanfacine, a non-stimulant alpha2-adrenoceptor agonist

• Therapeutic response to guanfacine should be evaluated every 3 months for the first year, and then atleast yearly, when prescribed for extended periods.

Question 6

Atomoxetine - monitoring requirements

Answer 6

Monitor for appearance or worsening of anxiety, depression or tics. Pulse, BP, psychiatric symptoms, appetite, weight and height should be recorded at initiation of therapy, following each dose adjustment and 6 months thereafter.

Question 7

Atomoxetine - patient/carer advice

Answer 7

Suicidal ideation: following reports of suicidal thoughts and behaviour, patients and their carers should be informed about the risk and told to report worsening suicidal thoughts/behaviour, irritability, agitation or depression.

Question 8

Atomoxetine - hepatic impairment

Answer 8

Recognise and report symptoms such as abdominal pain, unexplained nausea, malaise, darkening of urine or jaundice

Question 9

Dexamfetamine + Lisdexamfetamine

Cautions:

Answer 9

1. Tics and Tourette syndrome: discontinue use if tics occurs.
2. Growth restriction in children may occur during prolonged therapy, monitor height and weight (drug-free periods may allow catch-up in growth.. withdraw slowly to avoid inducing depression,renewed hyperactivity)

• Overdose: wakefulness, excessive activity, paranoia, hallucinations, HTN, exhaustion, convulsions, coma and hyperthermia

Question 10

Bipolar disorder and Mania

Answer 10

Bipolar disorder is a condition that affects moods, which can swing from one extreme to another. People with bipolar disorder often have periods or episodes of:

• Depression – feeling very low and lethargic
• Mania – feeling very high and overactive

Question 11

used to treat mania or hypomania.

Answer 11

Antimanic drugs

Question 12

Antidepressant drugs are used to treat co-existing depression but should be avoided in patients with

Answer 12

rapid-cycling bipolar disorder, a recent history of hypomania or with rapid mood fluctuations.

Question 13

• Long term treatment of bipolar disorder

Answer 13

should continue for atleast 2 years from the last manic episode and up to 5 years if the patient has risk factors for relapse.

Question 14

Benzodiazepines may be helpful in

Answer 14

• Benzodiazepines (e.g. Lorazepam) may be helpful in initial stages of treatment for behavioural disturbance or agitation. But they should not be used for long-periods due to the risk of dependence

Question 15

Antipsychotic drugs

Answer 15

• Antipsychotic drugs (normally olanzapine, quetiapine or risperidone) are useful to treat acute episodes of mania or hypomania. If they are effective in controlling manic episodes, they can be used for the long-term management of BIPOLAR DISORDER.
• Antipsychotic drugs can be given as monotherapy or in combination with lithium or valproate, if patient has frequent relapses or continuing functional impairment.
• For severe acute mania, an antipsychotic drug may be used concomitantly with lithium or valproate.

Question 16

Carbamazepine

Answer 16

• If patients are unresponsive to a combination of prophylactic drugs, Carbamazepine may be used under specialist supervision for the prophylaxis of bipolar disorder (manic-depressive disorder).
• It is used in patients with rapid-cycling manic-depressive illness (4 or more episodes per year)
- The dose of this drug should not normally be increased if an acute episode of mania occurs.

Question 17

Valproate

Answer 17

• Valproate includes Sodium Valproate and Valproic acid (semi-sodium salt). Valproic acid is available as Depakote and Convulex which are licensed for manic episodes associated with bipolar disorder.
• Sodium Valproate is available as Epilim and Epilim Chrono which are licensed for epilepsy + mania
• If the patient has frequent relapses or continuing functional impairment, consider switching therapy to lithium or olanzapine or adding lithium or olanzapine to valproate.
• If a patient taking valproate experiences an acute episode of mania that is not improved by increasing the valproate dose, consider adding olanzapine, quetiapine or risperidone.

Question 18

Lithium

Answer 18

 Lithium salts are used as a mood-stabiliser in bipolar disorder, but it can take 6-12 months for the effect to be seen.
 Cautions: Long-term use of lithium has been associated with thyroid disorders and mild cognitive and memory impairment… hence long-term treatment should be undertaken with careful assessment of risk and benefit and thyroid function should be monitored every 6 months.
 Driving and skilled tasks: this drug may impair performance of skilled tasks (e.g. driving).
 Renal function should also be monitored every 6 months.
 The bioavailability of preparations vary, therefore lithium should ALWAYS BE PRESCRIBED BY BRAND (e.g. Priadel or Camcolit).
 Dose equivalence and conversion: for Priadel liquid: 520mg of Lithium Citrate Tetrahydrate is equivalent to 204mg of Lithium Carbonate.

 Patients should be issued with a lithium treatment pack and advised to maintain adequate fluid intake and avoid changing the amount of salt in their diet.

Question 19

Depression

Answer 19

• Antidepressants should only be used for moderate to severe illness. However, if psychological therapy is ineffective in patients with mild depression, drug treatment may be considered.

• Alternatively, drug treatment for mild depression may be considered if the patient has a history of moderate-severe depression or if they have social/medical problems.
• Most antidepressant drugs are equally effective, so the choice of antidepressant depends on the patient’s needs, co-morbidities, risk of suicide and previous response to antidepressant therapy.

 Antidepressants take 2 weeks for the full effect to be seen, and during this time there may be an increase in agitation, anxiety and suicidal ideation. When initiating treatment, patients should be assessed every 1-2 weeks.
 Treatment should be continued for atleast 4 weeks (6 weeks in elderly) before considering a change in treatment.
 Following remission, antidepressant treatment should be continued at the same dose for atleast 6 months (12 months in elderly). Therapy should continue for atleast 2 years in patients with a history of recurrent depression.
 SSRIs (e.g. Sertraline) are the first-line treatment option since they are safer in overdose than other antidepressants.
 TCA’s have a similar efficacy to SSRIs but are more likely to be discontinued due to side effects. Furthermore, they are more toxic (harmful to the body) in overdose.
 MAOIs have dangerous interactions with certain foods + drugs and are reserved for specialist use.

Question 20

What drugs should be used in caution in depression

Answer 20

Although anxiety is often present in depressive illness (and may be the presenting symptom), the use of an antipsychotic/anxiolytic may mask the true diagnosis. Hence, these drugs should be used in caution but are sometimes added to manage agitation.

Question 21

St John’s wort

Answer 21

 St John’s wort is a popular herbal remedy available OTC for treating mild depression. It SHOULD NOT be prescribed or recommended for depression because it can induce drug metabolising enzymes and has many interactions with conventional (common) drugs.

Question 22

Side effect of all antidepressants

Answer 22

HYPONATRAEMIA (low sodium levels in the blood) is a side effect of ALL antidepressants, and it has been reported more frequently in SSRIs. Patients should be advised to look out for symptoms: drowsiness, confusion and convulsions.

• Antidepressants are linked with SUICIDAL thoughts and behaviour –> children, young adults and patients with a history of suicidal behaviour are particularly at risk. Thus, patients should be monitored for suicidal behaviour, self-harm or hostility.

Question 23

Failure to respond to antidepressants: Depression

Answer 23

• If a patient fails to respond to initial treatment with an SSRI, consider increasing the dose or switching to a different SSRI or Mirtazapine
• Other Second-line choices include Lofepramine, Moclobemide and Reboxetine. Other TCAs and Venlafaxine should be considered for more severe forms of depression.
• Failure to respond to a second antidepressant may require addition of an augmenting agent (top-up drug) such as Lithium, Olanzapine, Quetiapine or Risperidone or Aripiprazole.
• ECT (electroconvulsive therapy) may be initiated in severe refractory depression.

Question 24

TCAs

Answer 24

• TCAs BLOCK the re-uptake of both serotonin and noradrenaline.
• Examples include Amitriptyline and Nortriptyline. Amitriptyline is more sedative than Nortriptyline.
- Agitated and anxious patients tend to respond best to sedative compounds, whilst withdrawn and apathetic patients tend to respond better to less sedative compounds.
• Amitriptyline can cause antimuscarinic side effects including dry mouth, blurred vision, urinary retention and constipation.
• Furthermore, it may interact with Warfarin, either increasing or decreasing INR level. It may also interact with epileptics.
• Low doses should be used for initial treatment in the elderly. In most patients, the long half-life of TCAs allows ONCE daily dosing usually at night, hence MR preparations are not needed

Question 25

SSRIs

Answer 25

• SSRIs include Citalopram, Escitalopram, Fluoxetine, Paroxetine and Sertraline. Only Fluoxetine has been proven to be effective in children and adolescents.
• Serotonin syndrome (or serotonin toxicity) is an uncommon side effect of SSRIs, caused by high levels of serotonin. Symptoms include neuromuscular hyperactivity (tremor, muscle spasm, rigidity, etc.), autonomic dysfunction (tachycardia, hyper/hypotension, hyperthermia, shivering, diarrhoea etc.) and altered mental state (agitation, confusion and mania).
• Onset of symptoms can occur within hours or days following the initiation, dose escalation, overdose, the addition of a new serotonergic drug or the replacement of one serotonergic drug by another.
• Treatment involves withdrawing the serotonergic medication
• SSRIs may interact with drugs which increase the risk of bleeding including Warfarin, Antiepileptics and other antidepressants/antipsychotics.
• Overdose: symptoms of poisoning by SSRIs include nausea, vomiting, agitation, tremor, nystagmus, sinus tachycardia and drowsiness; convulsions may occur.
• Treatment cessation: GI disturbances, headache, anxiety, dizziness, paraesthesia, electric shock sensation in head/neck/spine, tinnitus, sleep disturbances, fatigue, influenza like symptoms and sweating are the most common features of abrupt withdrawal of an SSRI or marked reduction of dose.
• The risk of withdrawal reactions is higher for Paroxetine and Venlafaxine
• The dose should be tapered over a few weeks to avoid these effects.

Question 26

Monoamine Oxidase Inhibitors (MAOIs)

Answer 26

• Used much less frequently than TCAs and SSRIs due to the dangers of dietary and drug interactions.
• Examples include: Isocarboxazid, Phenelzine, Tranylcypromine, Moclobemide
• Phobic and depressed patients are said to respond best to MAOIs. However, they should be tried in patients who are refractory to other antidepressant treatment as there is occasionally a dramatic response.
• Response to treatment may take >3 weeks, and the full effect may not be seen for an additional 1-2 weeks.
• Risk of postural hypotension and hypertensive responses. If palpitations or frequent headaches occur
• Treatment cessation: if possible, avoid abrupt withdrawal. Withdrawal symptoms on cessation of therapy include agitation, irritability, insomnia, drowsiness, etc. Hence, they should be withdrawn slowly (over about 4 weeks) or longer if withdrawal symptoms emerge.
• Eat only fresh foods and avoid food that is suspected to be stale or going off. Avoid alcohol

Question 27

MAOIs interactions

Answer 27

• Interactions:
 Other antidepressants should not be started for 2 weeks after treatment with an MAOI has stopped (3 weeks if staring clomipramine or imipramine)
 In contrast an MAOI should not be started until:
o Atleast 2 weeks after a previous MAOI has stopped (then started at a reduced dose)
o Atleast 7-14 days after a TCA has been stopped (3 weeks in the case of clomipramine or imipramine)
o Atleast a week after an SSRI has been stopped (atleast 5 weeks in the case of fluoxetine).

Question 28

Agomelatine (melatonin receptor agonist + SSRI, doesn’t affect uptake of serotonin, noradrenaline or dopamine)

Answer 28

• Side effects: suicidal behaviour  Monitor patients
• Hepatoxicity: advise patients how to recognise signs of liver disorder and seek immediate attention if symptoms: dark urine, light coloured stools, jaundice, bruising, fatigue, abdominal pain or Pruritis develop.

Question 29

All antipsychotic drugs can precipitate…. in patients with hepatic impairment

Answer 29

coma

Question 30

Psychoses and related disorders: 1st gen antipsychotic drugs:

Answer 30

First-generation Antipsychotic drugs act mostly by blocking Dopamine D2 receptors in the brain. They are not selective for any of the 4 dopamine pathways in the brain so can cause a range of side effects including Extrapyramidal side effects and raised prolactin (see later).
- Examples include Chlorpromazine, Haloperidol and Flupentixol

Question 31

2. Second-generation

Answer 31

Second-generation Antipsychotics act on a range of receptors in the brain and are more distinct than first-generation antipsychotics, particularly with regard to side effects.
- Examples include Aripiprazole, Clozapine, Olanzapine and Risperidone
Patients should have just 1 Antipsychotic at a time, and treatment should be reviewed after 4-6 weeks

Question 32

Advice of Royal College of Psychiatrists on doses of Antipsychotic drugs above BNF upper limit

Answer 32

Unless otherwise stated, doses in the BNF are licensed doses – any higher dose is therefore unlicensed.

• Consider adjuvant therapy and newer or second-generation antipsychotic drugs such as Clozapine.
• Bear in mind risk factors (e.g. obesity as antipsychotic drugs cause weight gain), particular caution is indicated in older patients – especially those >70
• Consider potential for drug interactions
• Carry out an ECG to exclude abnormalities such as prolonged QT interval. Repeat the ECG periodically and reduce dose if prolonged QT interval or other adverse cardiac abnormality develops
• Increase the dose slowly… and not more often than once weekly
• Carry out regular pulse, BP and temperature checks, ensure that patient maintains adequate fluid intake
• Consider high-dose therapy to be for limited period and review regularly. Abandon if no improvement after 3 months (return to standard dosage).

Question 33

Prescribing for the elderly: antipsychotic drugs

Answer 33

• In elderly patients with dementia, antipsychotic drugs are associated with a small increased risk of mortality + an increased risk of stroke or transient ischaemic attack
• Furthermore, elderly patients are susceptible to postural hypotension and to hyper- and hypothermia in hot or cold weather.

It is recommended that:
• Antipsychotic drugs should not be used in the elderly to treat mild or moderate psychotic symptoms
• Initial doses of antipsychotic drugs in elderly patients should be REDUCED (to HALF the adult dose or LESS).
• Treatment should be reviewed regularly.

Question 34

Side effects of antipsychotic drugs

Answer 34

Extrapyramidal symptoms (most likely with piperazine phenothiazines, butyrophenones + 1st gen. depot preparations)

1. Parkinsonian symptoms: (including tremor) appear gradually + commonly in adults & elderly. Parkinsonian symptoms disappear upon withdrawal of drug and may be supressed by antimuscarinic drugs. However routine administration of antimuscarinics is not advised because they may unmask/worsen tardive dyskinesia.
2. Dystonia: (abnormal face + body movements) and dyskinesia (impaired voluntary movements) which occur more commonly in children + young adults & appear after only a few doses
3. Akathisia: (restlessness) which occurs after large initial doses and may resemble an exacerbation of the condition being treated.
4. Tardive dyskinesia: (rhythmic, involuntary movements of the tongue, face and jaw), which usually develops on long-term therapy or with high dosage. But it may develop on short-term treatment with low doses –> short-lived tardive dyskinesia may occur after withdrawal of drug. This side effect may be irreversible upon withdrawal of therapy and treatment is usually ineffective.

Question 35

piperazine phenothiazines examples

Answer 35

Fluphenazine, Perphenazine, Prochlorperazine, Trifluoperazine

Question 36

butyrophenones examples

Answer 36

Benperidol, Haloperidol

Question 37

Hypotension and interference with temperature regulation: antipsychotics

Answer 37

 Hypotension and interference with temperature regulation are dose related side effects that are liable to cause dangerous falls and either hypo or hyperthermia in the elderly.
 Clozapine and Quetiapine can cause postural hypotension (especially during dose initiation) which may be associated with syncope (temporary loss of consciousness) or reflex tachycardia.

Question 38

Other side effects of antipsychotics.

Answer 38

1. Hyperprolactinaemia: is a side effect of most antipsychotics (most likely risperidone, amisulpride + 1st gen.) which can lead to sexual dysfunction, reduced bone mineral density, menstrual disturbances in women, breast enlargement in men and galactorrhoea (except aripiprazole which reduces prolactin levels)
2. Weight gain: all antipsychotics cause weight gain (commonly clozapine & olanzapine) and some may cause hyperglycaemia leading to diabetes  particularly clozapine, olanzapine, quetiapine and risperidone)
3. Neuroleptic malignant syndrome: is a rare but serious side effect of antipsychotics. It presents as hyperthermia, fluctuating levels of consciousness, muscle rigidity, & autonomic dysfunction with pallor, tachycardia, labile BP, sweating and urinary incontinence

Question 39

Important safety information for drugs: antipsychotics.

Answer 39

• Oral preparations are used in hospital for rapid control of an acute episode
• Depot injections are used for maintenance treatment

Question 40

Clozapine, chlorpromazine lurasidone & quetiapine can cause

Answer 40

postural hypotenstion

Question 41

Haloperidol & pimozide can cause

Answer 41

QT-interval prolongation

Question 42

Monitoring: antipsychotics.

Answer 42

• FBC, urea and electrolytes and Liver function tests should be tested at the start of treatment and annually thereafter.
• Lipids, weight, prolactin, blood pressure and blood glucose should be monitored yearly.

Question 43

Chlorpromazine (1st gen.)

Answer 43

• Side effects: this drug can induce acute dystonic reactions such as facial and skeletal muscle spasms and oculogyric crisis. Children (especially girls, young women) are particularly susceptible. Protect skin from
• Handling and storage: due to the risk of contact sensitisation, HCPs should avoid direct contact with this drug, tablets should not be crushed, and solutions should be handled with care.

Question 44

Pimozide (1st gen.)

Answer 44

• Monitoring requirements: following reports of sudden, unexplained death, an ECG is recommended before treatment. Patients should also have an annual ECG and Pimozide should not be given with other antipsychotics, TCAs or other drugs which prolong QT interval (such as certain antimalarials, antihistamines + antiarrhythmics) and should not be given with drugs that cause electrolyte disturbances (esp. diuretics)

Question 45

Clozapine (2nd gen.)

Answer 45

• Cautions: Agranulocytosis: neutropenia and potentially fatal agranulocytosis reported. Leucocyte and differential blood counts must be normal before starting. Monitor counts every week for 18 weeks then atleast every 2 weeks. If clozapine continued and if blood count stable after 1 year, monitor atleast every 4 weeks (and 4 weeks after discontinuation). If leucocyte count or absolute neutrophil count too low, then discontinue permanently. Avoid drugs which depress leucopoiesis. Patients should report immediately symptoms of infection  especially influenza like illness.
• Cautions: Fatal Myocarditis (most commonly in first 2 months) and cardiomyopathy reported.
• Cautions: Intestinal obstruction: caution in patients on drugs that may cause constipation
• Side effects: Hypersalivation associated with this drug can be treated with hyoscine hydrobromide (unlicensed), provided the patient is not at particular risk from the additive antimuscarinic side effects of hyoscine and clozapine.
• Monitoring requirements: monitor leucocyte and differential blood counts. Patient must be closely supervised during initiation due to risk of collapse because of hypotension and convulsions. Blood lipids and weight should be measured at baseline, every 3 months for the first year, and then yearly. Fasting blood glucose should be measured at baseline, after 1 month, then every 4-6 months

Question 46

Olanzapine (2nd gen.)

Answer 46

• Cautions: CNS and respiratory depression
• With IM: Monitor BP, pulse and respiratory rate for at least 4h after IM injection (leave at least 1h between administering olanzapine IM and parenteral benzodiazepines)

Question 47

Benzodiazepines in pregnancy

Answer 47

• There is a risk of neonatal withdrawal symptoms when used during pregnancy. Hence regular use must be avoided unless there is a clear indication e.g. seizure control. High doses administered during late pregnancy or labour may cause neonatal hypothermia, hypotonia and respiratory depression.

Question 48

The effects of taking Benzodiazepines range from

Answer 48

• talkativeness and excitement to aggressive and anti-social acts. Adjustment of the dose (up or down) sometimes attenuates the impulses.
• Drowsiness may persist the next day, and affect performance of skilled tasks such as driving

Question 49

Asenapine

Answer 49

• (2nd gen) is licensed for moderate to severe manic episodes associated with bipolar disorder

Question 50

When discontinuing Antipsychotics

Answer 50

• the dose should be reduced gradually over atleast 4 weeks if the patient is continuing with other antimanic drugs. If the patient is not continuing with other antimanic drugs or if there is a history of manic relapse, the drug can be withdrawn over a period of up to 3 months.

Question 51

Symptoms of lithium toxicity

Answer 51

• GI disturbances (vomiting, diarrhoea), visual disturbances, polyuria, muscle weakness, fine tremor increasing to coarse tremor, CNS disturbances (confusion and drowsiness), abnormal reflexes, myoclonus, incontinence, hypernatremia.
• With severe overdosage: seizures, cardia arrythmias, BP changes, circulatory failure, renal failure, coma and sudden death

Question 52

Lithium has a NARROW THERAPEUTIC INDEX, so blood samples should be taken (+ target)

Answer 52

 12 hours after a dose (target 0.4-1mmol/L in maintenance therapy, 0.8-1mmol/L in acute episodes). Toxic effects occur above 1.5mmol/l.

Question 53

Lithium toxicity is worsened by

Answer 53

 sodium depletion, so concurrent use with diuretics (especially thiazides) should be avoided.