An elderly patient in a nursing home is started on quetiapine due to persistent aggressive behaviour that has not responded to non-pharmacological approaches.
Which of the following adverse effects do antipsychotics increase the risk of in elderly patients?
Correct Answer D: Antipsychotics in the elderly - increased risk of stroke and VTE.
Antipsychotics: Antipsychotics act as dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways. Conventional antipsychotics are associated with problematic extrapyramidal side-effects which has led to the development of atypical antipsychotics such as clozapine.
Extrapyramidal side-effects:
The Medicines and Healthcare products Regulatory Agency has issued specific warnings when antipsychotics are used in elderly patients:
Other side-effects:
A 30-year-old man presents to his doctor as he has been feeling generally 'out of sorts' for the past few weeks. He is accompanied by his girlfriend who says he has 'not been himself'. She is worried and feels he may need to see a psychiatrist. There is no history of past mental health problems.
Which one of the following symptoms would be most suggestive of depression?
Correct Answer C: Early morning waking is a classic somatic symptom of depression and often develops earlier than general insomnia.
Palpitations and nausea and more common with anxiety. Excessive gambling may suggest either a simple gambling addiction or be part of a hypomanic/manic disorder. Flash-backs are common in post-traumatic stress disorder.
Depression: screening and assessment
Screening The following two questions can be used to screen for depression:
A 'yes' answer to either of the above should prompt a more in depth assessment.
Assessment: There are many tools to assess the degree of depression including the Hospital Anxiety and Depression (HAD) scale and the Patient Health Questionnaire (PHQ-9).
Hospital Anxiety and Depression (HAD) scale:
Patient Health Questionnaire (PHQ-9):
NICE use the DSM-IV criteria to grade depression:
Depression Severity:
Question 13 of 56 A 23-year-old man asks to be referred to a plastic surgeon. From his records you can see he has been treated for anxiety and depression with fluoxetine previously and has been off work with back pain for the past three months. He is concerned that his ears are too big in proportion to his face. He reports that he now seldom leaves the house because of this. On examination his ears appear to be within normal limits.
What is the most appropriate description of this behaviour?
Correct Answer E:
Body dysmorphic disorder: Body dysmorphic disorder (sometimes referred to as dysmorphophobia) is a mental disorder where patients have a significantly distorted body image.
Diagnostic and Statistical Manual (DSM) IV criteria:
A 68-year-old female is noted to be depressed following a recent admission for an exacerbation of chronic obstructive pulmonary disease.
What would be the most appropriate antidepressant to start?
Correct Answer B: Citalopram and fluoxetine are currently the preferred SSRIs. Citalopram is more appropriate in this scenario as it has a lower propensity for drug interactions.
Depression: selective serotonin reuptake inhibitors:
Selective serotonin reuptake inhibitors (SSRIs) are considered first-line treatment for the majority of patients with depression.
Adverse effects:
Interactions:
Following the initiation of antidepressant therapy patients should normally be reviewed by a doctor after 2 weeks.
For patients under the age of 30 years or at increased risk of suicide they should be reviewed after 1 week. If a patient makes a good response to antidepressant therapy they should continue on treatment for at least 6 months after remission as this reduces the risk of relapse.
When stopping a SSRI the dose should be gradually reduced over a 4 week period (this is not necessary with fluoxetine). Paroxetine has a higher incidence of discontinuation symptoms.
Discontinuation symptoms:
A woman who gave birth 5 days ago presents for review as she is concerned about her mood. She is having difficulty sleeping and feels generally anxious and tearful. Since giving birth she has also found herself snapping at her husband. This is her first pregnancy, she is not breast feeding and there is no history of mental health disorders in the past.
What is the most appropriate management?
Correct Answer A: This woman has the baby-blues which is seen in around two-thirds of women. Whilst poor sleeping can be a sign of depression it is to be expected with a new baby!
Post-partum mental health problems:
Post-partum mental health problems range from the 'baby-blues' to puerperal psychosis:
*paroxetine is recommended by SIGN because of the low milk/plasma ratio
**fluoxetine is best avoided due to a long half-life
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