Mental Health
Bradford VTS Clinical Resources
- by Dr Sabah Malik
- Last modified: 9th January 2024
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DOWNLOADS
path: MENTAL HEALTH/other-self-help-leaflets
- activities that are enjoyable.doc
- activity planning.doc
- anxiety – leaflet.doc
- anxiety – worksheet.doc
- bipolar disorder – lithium toxicity leaflet.doc
- bipolar disorder – worksheet.doc
- chronic fatigue syndrome – leaflet.doc
- chronic fatigue syndrome – worksheet.doc
- coping with psychiatric drug side effects.doc
- depression – coping with it – by aaron beck.pdf
- depression – leaflet.doc
- depression – worksheet.doc
- panic or heart attack leaflet.doc
- phobia leaflet.doc
- phobias – worksheet.doc
- problem solving and achieving goals.doc
- progressive muscle relaxation leaflet.doc
- psychosis recognition – worksheet.doc
- ptsd leaflet.doc
- schizophrenia – coping with difficult behaviour.doc
WEBLINKS
PATIENT LINKS
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Information provided on this medical website is intended for educational purposes only and may contain errors or inaccuracies. We do not assume responsibility for any actions taken based on the information presented here. Users are strongly advised to consult reliable medical sources and healthcare professionals for accurate and personalised guidance – especially with protocols, guidelines and doses.
COME AND WORK WITH ME… If you’d like to contribute or enhance this resource, simply send an email to rameshmehay@googlemail.co.uk. We welcome collaboration to improve GP training on the UK’s leading website, Bradford VTS. If you’re interested in a more active role with www.bradfordvts.co.uk (and get your name published), please feel free to reach out. We love hearing from people who want to give.
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Anxiety & Depression at a Glance
- Most antidepressants take 4-6 weeks to work
- Therefore, do not deem an antidepressant treatment to have failed if used for less than 4 weeks.
- Tell the patient to take it every day roughly at the same time without fail. Say something like “the medicine slowly builds up into your system each day and that is why you must take it every day roughly at the same time without any missed days. Otherwise, if you do miss a dose, it’s back to square one again. But once it builds up to a good level, it kicks in and helps with your mood. That usually happens at the 4-6 week stage. However, I have given this one because you may even notice some early effects as early as 2 weeks in” (PS note the element of sowing a positive mental seed – green text).
- If at the 4 week stage the antidepressant has not worked, worth while increasing the dose of the same antidepressant rather than changing to another one.
- When switching – make sure you follow the Maudsley guidelines on switching. Often you will need to taper one antidepressant down before starting the next and sometimes you may need a 2 week antidepressant free period before starting the new one. The Maudsley table will tell you what to do.
SWITCHING ANTIDEPRESSANTS
- The document “antidepressant switching – maudsley” in the downloads box above should help you. However, please try to refer to the latest version if it is not here.
- Maudsley Antidepressant Switching Guidelines
- The Maudsley Hospital is a British psychiatric hospital in south London. The Maudsley is the largest mental health training institution in the UK. It is part of South London and Maudsley NHS Foundation Trust, and works in partnership with the Institute of Psychiatry, King’s College London. It produces some exceptional guidelines in the field of Psychiatry.
WITHDRAWING ANTIDEPRESSANTS
GP Notebook also has some switching and withdrawing tables. See the link below. Remember, sudden stopping of antidepressants can cause withdrawal symptoms which are very upsetting for the patient.
- https://gpnotebook.com/simplepage.cfm?trip=1&ID=1637482568 (you may need to sign up to an account – free)
Suicidal Thoughts
- In rare cases, some people experience suicidal thoughts and a desire to self-harm when they first take antidepressants.
- Young people under 25 seem particularly at risk.
- Warn patients, but tell them that it is RARE. Otherwise they’ll be scared of taking the tablets which might potentially help them.
Say something like…
- In rare cases, some people experience suicidal thoughts and a desire to self-harm when they first take antidepressants. I must stress that it is rare and it is more likely that these tablets will make you feel happier. But in the rare occaision that you do experience thoughts of killing or harming yourself at any time, then Contact your GP, or go to A&E immediately. It may also be useful to tell a relative or close friend if you’ve started taking antidepressants and ask them to read the leaflet that comes with your medicines. You should then ask them to tell you if they think your symptoms are getting worse, or if they’re worried about changes in your behaviour.
Worsening of symptoms
- Some patients may experience a worsening of symptoms before they get better, especially with Sertaline and Paroxetine. Things like increased anxiety, restlessness, and agitation
- Whilst not uncommon, it is important to remember that the large majority do not experience this and therefore you need to say it in a balanced way that does not put patients off taking them especially if you feel they would be more likely to be beneficial.
Say something like…
- At the start of taking the antidepressant, some people may experience some worsening of symptoms before they get better. Please try and persevere through this if you can by reminding yourself things will get better. And remember, you can always call us or 111 or 999 for advice if this happens. However, most people do not experience this and so, please don’t get too worried about it at this stage”.
Read this article to learn more about the Nocebo Effect that many doctors impart on patients unknowingly…
Serotonin syndrome
- an uncommon, but potentially serious, set of side effects linked to SSRIs and SNRIs.
- usually triggered when you take an SSRI or SNRI in combination with another medicine (or substance) that also raises serotonin levels
- Pathophysiology = too much serotonin!
So it can happen when a patient is given an SSRI or SNRI in combination with…
- another antidepressant (like amitriptyline)
- Lithium
- an overdose of an SSRI or SNRI
- St John’s wort, ginseng, nutmeg
- Buproprion (smoking cessation)
- Antisickness – metoclopropamide, odansetron
- Migraine medicines like the triptans – even the antiepileptics carbemazepine, volproic acid
- Opioids like Fentanyl, oxycodone, even tramadol
- monoamine oxidase inhibitors (MAOIs) – old drugs not used this days
- Ritonavir for HIV
- dextromethorphan (cough medicine)
- Street drugs, such as methamphetamine or other amphetamines, cocaine, opiates, ecstasy, LSD, and others have also been associated with serotonin syndrome.
Symptoms & Signs of serotonin syndrome include: (mnemonic SHIVERS)
- Shivering: Neuromuscular symptom that is unique to serotonin syndrome
- Hyperreflexia and Myoclonus: Seen in mild to moderate cases. Most prominent in the lower extremities. This can help differentiate from neuroleptic malignant syndrome which would present with lead-pipe rigidity.
- Increased Temperature: Not always present, but usually observed in more severe cases. Patient might be shivering because of the fever.
- Vital Sign Abnormalities: Tachycardia, tachypnea, and labile blood pressure
- Encephalopathy: Mental status changes such as agitation, delirium, and confusion. Loss of coordination. Abnormal eye movements.
- Restlessness: Common due to excess serotonin activity
- Sweating: Autonomic response to excess serotonin. This symptom can help differentiate from anticholinergic toxicity in which the patients would present with increased temperature but dry to the touch
Tell patients: If you experience these symptoms, you should stop taking the medicine and get immediate advice from your GP or specialist. If this is not possible, call NHS 111.
Symptoms of severe serotonin syndrome include:
- seizures (fits)
- irregular heartbeat (arrhythmia)
- unconsciousness
Tell patients: If you experience symptoms of severe serotonin syndrome, get emergency medical help immediately by dialling 999 to ask for an ambulance
What will hospital do?
- People with serotonin syndrome will usually stay in the hospital for at least 24 hours for close observation.
- Treatment may include:
- Benzodiazepine medicines, such as diazepam or lorazepam to decrease agitation, seizure-like movements, and muscle stiffness
- Cyproheptadine – a drug that blocks serotonin production
- Intravenous (through the vein) fluids
- Stopping medicines that caused the syndrome
- In life-threatening cases, medicines that keep the muscles still (paralyze them), and a temporary breathing tube and breathing machine will be needed to prevent further muscle damage.
Outlook (Prognosis)
- People may get slowly worse and can become severely ill if not quickly treated.
- Untreated, serotonin syndrome can be deadly.
- With treatment, symptoms usually go away in less than 24 hours.
- Permanent organ damage may result, even with treatment.
- Possible Complications
- Uncontrolled muscle spasms can cause severe muscle breakdown. The products produced when the muscles break down are released into the blood and eventually go through the kidneys. This can cause severe kidney damage if not recognized and treated properly.
Examples of SSRIs – Selective serotonin reuptake inhibitors
- sertraline
- paroxetine
- citalopram
- escitalopram
- fluoxetine
Examples of SNRIs – Serotonin and norepinephrine reuptake inhibitors
- duloxetine
- venlafaxine
- desvenlafazine
- Neuroleptic malignant syndrome (NMS) is similar to serotonin syndrome.
- Both conditions are rare but very serious.
- Both – If it’s not treated quickly, it can lead to death.
- Both – most people recover fully after early treatment
- Serotonin Syndrome happens because of prescribing an SSRI or SNRI with another drug known to cause Serotonin levels to spike.
- But NMS can happen due to neuroleptics or antipsychotics when given alone to treat disorders such as schizophrenia and other similar conditions.
How to tell the difference
- NMS happens from usually starting the one drug – an antipsychotic/neuroleptic. Serotonin Syndrome is usually the result of two drugs. Although it’s possible that taking just one drug that increases serotonin levels can cause serotonin syndrome in some people, this condition occurs most often when people combine certain medications. For example, serotonin syndrome may occur if you take an antidepressant with a migraine medication. It may also occur if you take an antidepressant with an opioid pain medication. Another cause of serotonin syndrome is intentional overdose of antidepressant medications.
- NMS is characterised by ‘lead-pipe’ rigidity, whilst serotonin syndrome is characterised by hyperreflexia and clonus.
Dementia at a Glance
See under Elderly Medicine: https://www.bradfordvts.co.uk/clinical-knowledge/elderly/
SMI at a Glance (Severe Mental Illness)
Did you know…
Did you know that patients with SMI die 15-20 years EARLIER than their peers in the general population. Mainly due to CVD problems. Hence ,the annual health check is important in this vulnerable group. Don’t just screen – intervene! Do something about these if present…
- Alcohol and illicit/non-prescribed drug use
- Obesity management & Obesity prevention
- Physical inactivity – brief advice, referral to exercise programmes and activities.social prescribing.
- Hypertension
- Type 2 diabetes – prevention and treatment
- Lipid modification
- Current smokers: facilitate smoking cessation through pharmacotherapies,
intensive behavioural support, and methods such as carbon monoxide
monitoring
And follow them up! See how they are getting on.
Some figures…
Compared to the general population, people aged under-75 in contact with mental health services in England have death rates that are :
- 5 times higher for liver disease
- 5 times higher for respiratory disease
- 3 times higher for cardiovascular disease
- 2 times higher for cancer
Suicide is also an important cause of death in the SMI population. Suicide risk in people with SMI is high following acute psychotic episodes and psychiatric hospitalisation.
SMI type | Which gender more common | Age of onset (MEN) | Age of onset (WOMEN) |
Schizophrenia | Men | 16 – 25 | similar across all ages |
Bipolar disorder | Women | 35 – 45 | 25-35 |
Other Psychosis | Men | 16 – 25 | >75 years old |
DISCUSSION OF WELL-BEING
- Assess mood
- Check clinical letters – any updates from mental health team?
- History – ask how have their moods have been.
- Document suicide risk:
- Thoughts that they would be better off dead
- thoughts of hurting themselves in some way?
- hopelessness about the future
- Examination – Do they look depressed?
- Stable – managed by nurse
- Variable or any concerns regarding mood
- Several weeks history and no upcoming appointment with mental health team – task admin to book telephone appointment within 1-2 weeks with any GP if no follow-up with mental health team in the next month.
- Recent/acute changes – GP appointment within the week
- Use your clinical judgement – if unsure ask on-call GP to assess on the day if seriously unwell.
- Ask about any physical symptoms
- None – managed by GP
- New symptoms depending on severity
- Pre-book appointment with GP
- Walk in or on the day with GP
- On-call appointment with on-call GP
- Discuss sexual health
- Sexual dysfunction?
- Contraception if appropriate
CARDIOVASCULAR RISK
- Document smoking – offer smoking cessation
- Record BP
- Record BMI – offer weight loss/lifestyle advice if overweight (look at weight management protocol
- Dietary advice – Dietician referral/Weight management clinic
- Exercise advice – consider BEEP
- Document QRISK
SMOKING , ALCOHOL & DRUGS
- Document smoking – offer smoking cessation
- Alcohol screening (audit C) and referral as needed
- Document illicit drug use/solvent abuse (consider OTC drugs esp opioids) – refer to GP to review and refer as needed if not already attending Bridge or Community Drugs and Alcohol Team (CDAT)
CANCER SCREENING
Both Male & Female
- Lungs – new breathlessness/cough/haemoptysis/chest pain
- Upper GI/ENT – hoarseness, swallowing difficulties, new onset indigestion
- Lower GI – new onset abdominal pain or bloating, change in bowels
- Genito-urinary – prostate in men (frequency, poor stream, terminal dribbling of urine), blood in urine, repeated UTIs
- Blood cancers – B-symptoms – (i) high fever (38°C or higher), (ii)weight loss of a tenth or more of your previous weight over the past 6 months, when you haven’t been trying to lose weight, (iii) night sweats which drench your nightclothes and bedding.
- Other – any lumps/swellings
Females
- Cervical screening
- Breast screening – mammography attendance, self breast examinations, any family history of breast cancer?
Nurse/HCA staff – any concerns book appointment with on-call Dr – same day
Summary of SMI Physical Health Check
- Measurement of weight (BMI)
- BP/pulse check
- Lipid and Qrisk
- Hba1c
- Assessment of alcohol consumption
- Smoking status
- Assessment of nutritional status/diet/physical activities
- Assessment of illicit sustances/non prescribed drugs
- Access to relevant national screenings
- Medication review
- General physical health query including sexual and oral health
- Indicated follow up
INVESTIGATIONS
- BLOODS
- Basically do bloods for (i) CVD risk assessment and (ii) checking levels of psychotropic drugs
- All patients: FBC, u+es, LFT, HbA1c, Total chol:HDL, Prolactin, TFTs
- Patients on Lithium: above bloods and Lithium
- Other psychotropics – see specific instructions
- ECG
- In all patients
- Looking for prolonged QT interval and/or CVD changes
Neuroleptic malignant syndrome (NMS)
- is a rare but potentially fatal adverse effect of all antipsychotics.
- Signs and symptoms of NMS include fever, increased sweating, rigidity, confusion, fluctuating consciousness, fluctuating blood pressure, tachycardia, raised creatine kinase, leucocytosis, and raise liver function tests.
- Urgent admission required
Examples of antipsychotics: chlorpromazine, clozapine, olanzapine, promazine, zotepine, Amisulpride, aripiprazole, sertindole, risperidone, quetiapine and sulpiride
Antipsychotics can cause a wide range of adverse effects including…
GENERAL SIDE EFFECTS
- Weight gain
- Sedation
- Warn those who do skilled tasks with machinery.
- Also warn about driving.
- Tolerance to sedation usually develops.
- But alcohol will worsen it.
BLOOD DYSFUNCTION
- Dyslipidaemia
- dietary advice +/- statin
- Impaired glucose tolerance
- Hyperglycaemia, and sometimes diabetes (including ketoacidosis and coma)
- Neutropenia
- Stop the suspected drug if neutrophils fall below 1.5 x 109/L and
- seek urgent advice from a secondary care specialist.
- Abnormal liver function tests (LFTs)
- Stop the suspected drug if LFTs suggest hepatitis (transaminases rise to 3 x normal) or prothrombin time or albumin are abnormal.
- Seek advice from a secondary care specialist.
- Hyperprolactinaemia
- most antipsychotics can cause hyperprolactinaemia
- signs/symptoms include: galactorrhoea, amenorrhoea, gynaecomastia, hypogonadism, sexual dysfunction
- increases the risk of osteoporosis.
- Clozapine, olanzapine, quetiapine, and aripiprazole do not increase prolactin above the normal range in standard doses.
CARDIOVASCULAR PROBLEMS
- Postural hypotension
- especially with clozapine, chlorpromazine, quetiapine, and risperidone.
- Hypertension
- commonly reported with clozapine but there are also reports with aripiprazole, olanzapine, quetiapine, and risperidone.
- QT interval prolongation
- considered to be a class effect
- Avoid co-prescribing other drugs that prolong the QT interval (for example tricyclic antidepressants, erythromycin, or antiarrhythmics)
- Monitor potassium levels at least annually.
- People taking antipsychotics who experience palpitations or any other symptoms that suggest cardiac disease should undergo electrocardiography.
- Stroke risk
- olanzapine and risperidone are associated with an increased risk of stroke in elderly people with dementia.
- For acute psychotic conditions in elderly people with dementia: risperidone should be limited to short-term use under specialist advice.
- Olanzapine is not licensed for acute psychosis.
- The possibility of cerebrovascular events should be considered carefully before treating people with a history of stroke or transient ischaemic attack risk factors for cerebrovascular disease (for example hypertension, diabetes, smoking, and atrial fibrillation) should also be considered.
- Venous thromboembolism (VTE)
- review risk factors for VTE before and during antipsychotic treatment and preventive measures undertaken.
OTHER SYSTEMS
- Extrapyramidal symptoms — more common with first-generation antipsychotics.
- Dystonic reactions (abnormal movements of the face and body)
- Pseudoparkinsonism (tremor, bradykinesia, and rigidity) — can be alleviated by antimuscarinic drugs, such as procyclidine (BUT should not be prescribed routinely).
- Akathisia (motor restlessness) — often be relieved by reducing the dose of the antipsychotic.
- Tardive dyskinesia
- late-onset movement disorder with prolonged use of antipsychotics
- Rhythmical, involuntary movements, usually lip-smacking and tongue rotating, although it can affect the limbs and trunk.
- can sometimes worsen on treatment withdrawal.
- The offending drug should be discontinued on appearance of early signs.
- Anticholinergic effects
- dry mouth, blurred vision, urinary retention, constipation, and cutaneous flushing
- Tolerance may develop, but it is very variable, and these adverse effects are often poorly tolerated.
- Quetiapine should be used with caution in people with anticholinergic effects from other drugs.
- Reduced seizure threshold
- the higher the dose, the greater the risk
- Clozapine carries the greatest risk
- Pneumonia
- all antipsychotics are associated with an increased risk of pneumonia.
- The mechanism by which this occurs is unclear.
RARE BUT IMPORTANT
- Neuroleptic malignant syndrome (NMS)
- rare but potentially fatal adverse effect of all antipsychotics.
- Signs and symptoms of NMS include fever, increased sweating, rigidity, confusion, fluctuating consciousness, fluctuating blood pressure, tachycardia, raised creatine kinase, leucocytosis, and raise liver function tests.
Quetiapine
- Sleep apnoea syndrome. Caution in people receiving concomitant central nervous system depressants, who already have or are at risk of sleep apnoea (overweight/obese, males)
- Skin and subcutaneous tissue disorders — can cause an extensive rash, exfoliative dermatitis, fever, lymphadenopathy, and eosinophilia. If any of these – treatment should be withdrawn immediately as it may be suggestive of a severe cutaneous severe reaction, such as Stevens-Johnson syndrome
- Potential of misuse and abuse – care in prescribing with people with drug/alcohol abuse
Chlorpromazine
- Photosensitivity Advise use of sunscreen yo prevent sunburn. SPF 30+ If prescribing – the prescription should be endorsed with ACBS. The Advisory Committee on Borderline Substances (ACBS) is responsible for approving the prescribing and use of borderline substances in NHS primary care and the community.
Olanzapine
- Skin and subcutaneous tissue disorders — olanzapine has been associated with Drug Reaction with Eosinophilia and Systemic Symptoms (DRESS), frequency unknown.
