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Management (SSRIs (Adverse effects (Mania (Patients should be counselled…

- - - - Fluoxetine preferred
      - Should be used with caution
    - - Sertraline
    - - Use during 1st Trimester
        
        Risk of congenital heart defects
        
        Paroxetine has increased risk of congenital malformations
      - Use during 3rd trimester
        
        Persistent pulmonary hypertension of the newborn
  - - - Patients should be counselled to be vigilant for increased anxiety and agitation after starting an SSRI
    - - Dose-dependent QT syndrome
        
        Avoid in:
        
        Known pre-existing QT prolongation
        
        Congenital long QT syndrome
        
        Combination with other medicines that prolong the QT interval
  - - - Co-prescribe PPI
    - - Consider mirtazapine
    - - Avoid SSRI
  - - - 1 week
    - - 2 weeks
        
        If a good response they should continue for at least 6 months after remission #
    - - Gradually reduce over a 4 week period
      - Discontinuation syndrome
        
        Increased mood change
        
        Restlessness
        
        Difficulty sleeping
        
        Unsteadiness
        
        Sweating
        
        GI symptoms
        
        Paraesthesia
  - - - Management of GAD
        
        Education & active monitoring
        
        Low intensity psychological interventions
        
        High intensity psychological interventions (CBT) or drug treatment
        
        High specialist input
      - Risk factors
        
        Aged 35-54
        
        Being divorced or seperated
        
        Living alone
        
        Being a lone parent
      - Protective factors
        
        Aged 16-24
        
        Being married or cohabiting
    - - Recognition and diagnosis
        
        Treatment in primary care - CBT or SSRI
        
        Review and consider alternative
        
        Review and referral to specialist
        
        Care in specialist services
- - - - Dose should be withdrawn in steps of 1/8 of the daily dose every fortnight
      - Switch patients to the equivalent dose of diazepam
        
        Reduce dose of diazepam every 2-3 weeks in steps of 2 or 2.5mg
      - the time needed for withdrawal can vary from 4 weeks to a year or more
    - - Can occur up to 3 weeks after stopping
      - Insomnia
      - Irritability
      - Anxiety
      - Tremor
      - Loss of appetite
      - Tinnitus
      - Perspiration
      - Perceptual disturbances
      - Seizures
  - - - S.E: anterograde amnesia
    - - 1st line for alcohol withdrawal as part of a reducing dose protocol
        
        Chronic alcohol consumption enhances GABA mediated inhibition in the CNS and inhibits NMDA-type glutamate receptors
        
        Alcohol withdrawal is thought to lead to the opposite, thus replacing alcohol with a benzodiazepine and reducing in a stepwise fashion reduces withdrawal symptoms
        
        Alcohol Withdrawal
        
        6-12 Hours
        
        Tremor, sweating, tachycardia, anxiety
        
        36 hours
        
        Peak incidence of seizures
        
        48-72 hours
        
        Delirium tremens
        
        Coarse Tremor
        
        Confusion
        
        Delusions
        
        Auditory & visual hallucinations
        
        Fever
        
        Tachycardia
    - - May be used in troublesome sleep paralysis
        
        Sleep paralysis
        
        Common condition characterised by transient paralysis of skeletal muscles which occurs while falling asleep
        
        Thought to be related to the paralysis that occurs as a natural part of REM sleep
        
        Hypnopompic hallucinations & hypnogogic hallucinations
    - - Nitrazepam & flurazepam
        
        Prolonged action
      - Loprazolam, temezepam
        
        Shorter use, withdrawal phenomena more common
      - Diazepam
        
        ON dose may treat insomnia & daytime anxiety
- - - - May occur in those who normally sleep well
      - due to extraneous factors e.g. noise, shift work, jet lag
    - - Usually related to an emotional problem or serious medical illness
      - May last for a few weeks and may recur
      - Limit hypnotic use to 3 weeks max
    - - Rarely benefited by hypnotics
      - Usually associated with psychatric disorders e.g. anxiety
      - Treat underlying psychiatric complaint
        
        Clomipramine or mirtazapine may promote sleep if taken at night
  - - - Withdrawal can cause rebound insomnia & withdrawal syndrome in long-term use
    - - Range from talkativeness & excitement to aggressive & antisocial
      - Adjustment of dose sometimes attenuates the impulses
  - - - Risk of tolerance & withdrawal symptoms
    - - Increased risk of respiratory depression
- - - - Mild-moderate
        
        Low intensity; 6-8 sessions over 10-12 weeks
      - Severe #
        
        High intensity, 16-20 sessions over 6-9 months in combination with antidepressants
    - - Trauma-focused CBT on regular and continuous basis
  - - - With accompanying exposure & relapse prevention (ERP)
    - - Moderate functional impairment = CBT or medical therapy
      - Severe functional impairment = combination
- - - - Aripriprazole has the most tolerable side effect profile of the atypical antipsychotics #
    - - Parkinsonism
      - Acute dystonia
        
        Torticollis
        
        Abnormal, asymmetrical head or neck position
        
        Oculogyric crisis
        
        Prolonged involuntary upward deviation of the eyes
      - Akathisia
        
        Severe restlessness
      - Tardive dyskinesia
        
        Late onset of choreoathetoid movements
        
        e.g. chewing & pouting of jaw
        
        Abnormal, involuntary
        
        40% of patients
        
        May be irreversible
    - - Antimuscarinic
        
        Dry mouth, blurred vision, urinary retention, constipation
      - Sedation, weight gain
      - Raised prolactin
        
        Breast tenderness, gallactorhoea, impaired glucose tolerance
      - neuroleptic malignant syndrome
        
        Pyrexia, muscle stiffness
      - Reduced seizure threshold
        
        < atypicals
      - Prolonged QT interval
  - - - Significant risk of agranulocytosis
        
        FBC monitoring essential
        
        Only indicated in refractory schizophrenia
        
        Arrange a FBC in any patient with an infection to exclude neutropenia
      - If a patient misses doses for >48 hours, dose needs to be titrated back up again
        
        Due to worsened side effects
        
        If >
        
        72 hours, may require more frequent blood tests for a short period
    - - A patient with poor oral compliance should be considered for once monthly IM antipsychotic depot injections
      - If a patient has stabilised on a particular medication, it is best to maintain them on that medication where possible
- - - - Neuropathic pain
      - Prophylaxis of headache (tension & migraine)
- - - - Abdo pain
      - Aggression
      - Anorexia
        
        contraindicated in anorexia nervosa
      - Depression
  - - - Psychiatric symptoms
        
        *Particularly
        
        Agitation
        
        irritability
        
        Suicidal thinking & self-harming behaviour
        
        Unusual changes in behaviour
    - - abdo pain, unexplained nausea, malaise, darkening of urine, jaundice
    - - Abdo pain
      - Anorexia
      - Anxiety
      - Chills
      - Constipation
      - Depression
      - Dermatitis
    - - Phaeochromocytoma
      - Severe cardiovascular disease
      - Severe cerebrovascular disease
- - - - Involves the client talking freely to the therapist, saying the first things that come to mind
      - No attempt to shape ideas before they are said, or tell things in a linear story structure
    - - Redirection of feelings for a significant person onto the therapist
        
        Especially those unconsciously retained from childhood
      - Can manifest in many forms
        
        Erotic attraction
        
        Hatred
        
        Mistrust
        
        Extreme dependence
        
        Rage
      - Through recognition & exploration of the relationship, the client can begin to understand their feelings and resolve any conflicts with figures from their childhood
    - - Therapist stays relatively quiet throughout the therapy, occasionally interjecting with thoughts or interpretations of the topics the client chooses to discuss
- - - - Headache
      - Nausea
      - Short term memory impairment
      - Retrograde amnesia
      - Cardiac arrythmia
    - - Impaired memory
- - - - Blurred vision
      - Aggression
      - Agitation
      - Arthralgia
      - Ataxia
      - Back pain
      - Diarrhoea, dry mouth, nausea
      - Headache, insomnia
      - Nystagmus, tremor
  - - - Due to high teratogenic potential
      - Consider switching to lithium or olanzapine or adding these to valproate
    - - Severe = hepatic & pancreatic dysfunction; suicidal ideation; hypersensitivity reactions
        
        Monitoring
        
        LFTs before therapy & for first 6 months
        
        FBC before treatment & before any surgical intervention
      - Aggression, anaemia, confusion, convulsion, extra-pyramidal disorders, gastric irritation
      - Patients should be advised about signs and symptoms of blood, hepatic & pancreatic disorders
  - - - Prophylaxis and treatment of recurrent unipolar depression
      - Prophylaxis & treatment of mania, hypomania & depression in bipolar disorder
        
        Concomitant therapy in patients who have had an incomplete response to treatment
    - - Addisons
      - Cardiac insufficiency
      - Dehydration
      - Family/personal history of Brugada syndrome & other arrythmias
      - Untreated hypothyroidism
      - Low sodium diets
      - Avoid use in 1st trimester of pregnancy due to risk of teratogenicity
        
        Dose requirements increase during the 2nd & 3rd trimesters
        
        Present in breast milk
    - - Assess regularly & only maintain on lithium if benefit persists, for max 3-5 years
      - Routine serum lithium monitoring weekly after initiation & each dose change until stable
        Then every 3 months after
      - 6 monthly
        
        Thyroid function
        
        Long term use is associated with thyroid disorders & mild cognitive & memory impairment
        
        Body weight/BMI
        
        Serum electrolytes
        
        eGFR
      - Initiation of treatment
        
        Renal
        
        Cardiac
        
        Thyroid function
        
        ECG if cardiovascular disease or risk factors
        
        Weight/BMI
        
        Serum electrolytes
        
        FBC
    - - Increasing GI disturbances
      - Visual disturbances
      - Polyuria
      - Muscle weakness
      - Fine --> coarse tremor
      - CNS disturbances
      - Severe overdose
        
        Seizures
        
        Cardiac arrythmias
        
        BP changes
        
        Circulatory & renal failure
        
        Coma
        
        Sudden death
- - - - Can develop in people of any age following a traumatic event
      - DSM-IV diagnostic criteria = present for >1 month
      - Features
        
        Re-experiencing: e.g. flashbacks, nightmares
        
        Avoidance: e.g. avoiding people, situations or circumstances resembling or associated with the event
        
        Hyperarousal: e.g. hypervigilance for threat, exaggerated startle response, sleep problems, irritability & difficulty concentrating
        
        Emotional numbing: e.g. lack of ability to experience feelings, feeling detached
      - Watchful waiting may be used for mild symptoms
      - Management
        
        CBT or EMDR
        
        Drug treatment: paroxetine or mirtazapine