REvise NEU > Mx revamp > Flashcards

Mx revamp Flashcards

(119 cards)

Study These Flashcards
1
Q

Rapid tranquillisation (adult/older adult/LD): outline management (dose; first - line; monitor)?

A
  • Start with de‑escalation and offer oral meds.
  • When IM needed (adults): lorazepam 1–2 mg IM; repeat after 30–60 min (usual max 4 mg). Alternative: haloperidol 5 mg IM + promethazine 25–50 mg IM. Avoid IM olanzapine within 1 hour of a benzodiazepine.
  • Monitoring: observe every 5–10 min incl. pulse, BP, RR, O2 sat, temperature and level of consciousness; be ready for airway support. ECG if antipsychotics used/QT risk.
  • Older adults/LD: use half doses; prefer lorazepam 0.5–1 mg IM; avoid antipsychotics in Parkinson’s/LBD.
  • Address causes (pain, withdrawal, delirium) and review need for ongoing Rx within 1 hour. Document capacity, rationale and legal framework.
  • [NICE NG10]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Malignant catatonia?

Differentials
Investigations
Initial Management
Avoid in Mx

A
  • Key differentials: NMS, serotonin toxicity, malignant hyperthermia, non‑convulsive status, sepsis, thyroid/adrenal crisis, dissociative stuppor.
  • Investigations: FBC, U&E, CK, CRP, LFTs, TFTs, troponin if indicated; urine tox; consider EEG/CT if atypical.
  • Initial management: lorazepam 1–2 mg PO/IV; repeat and titrate—robust response supports catatonia. Early ECT if poor response/severity (malignant features, autonomic instability).
  • Avoid or use extreme caution with antipsychotics; if needed, low‑dose atypical with benzodiazepine cover. Supportive care (fluids, nutrition, DVT prophylaxis).
  • Monitor vitals and CK; treat complications (rhabdomyolysis).
  • [Catatonia consensus 2023]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

Delirium (incl. dementia/Parkinson’s/Lewy body): outline management (avoid; risk)?

A
  • Identify & treat causes (sepsis, hypoxia, pain, drugs, retention/constipation, dehydration; check glucose, U&E, calcium). Orientation, sensory aids, sleep, hydration, mobilisation, family at bedside.
  • Avoid routine antipsychotics. If severe distress/risk: short course haloperidol 0.5–1 mg PO/IM (max 2–3 mg/24 h), unless Parkinson’s/LBD—use lorazepam 0.5 mg PO/IM or quetiapine low‑dose. Avoid benzodiazepines generally (except alcohol withdrawal).
  • Stop anticholinergics; minimise restraints; prevent falls/pressure areas.
  • Communicate course, expect fluctuation; daily review and deprescribe as able.
  • [NICE Delirium guideline]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Severe akathisia: outline management (avoid; risk)?

A
  • Confirm (inner restlessness + urge to move) and grade (e.g., BARS).
  • Reduce/switch antipsychotic (to quetiapine/aripiprazole) if possible.
  • First‑line: propranolol 20–40 mg TDS (contraindications: asthma, bradycardia).
  • Alternatives/adjuncts: mirtazapine 15 mg nocte, clonazepam 0.25–0.5 mg BD PRN short‑term, or benztropine only if prominent parkinsonism.
  • Check iron and correct deficiency; avoid increasing anticholinergic burden. Educate that it is iatrogenic and reversible.
  • [Evidence reviews/Pringsheim 2018]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

Acute dystonia / oculogyric crisis: outline management (avoid)?

A
  • Recognise sudden sustained muscle spasm (oculogyric crisis, torticollis, trismus), usually after D2 blockers.
  • Give procyclidine 5–10 mg IM/IV (or benztropine if available). Repeat once after 20 mins if needed. Then continue oral procyclidine 5 mg TDS for 48–72 h to prevent relapse.
  • Stop/reduce culprit; consider switching to lower D2‑affinity agent. Warn about anticholinergic adverse effects, especially in older adults.
  • [BNF]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Lithium toxicity & chronic monitoring: outline management (monitor; red flag; risk)?

A
  • Suspect toxicity (GI upset, coarse tremor, ataxia, confusion). Stop lithium; check level, U&E, eGFR; IV fluids; seek nephrology if severe (levels >2.5 mmol/L, or symptoms). Avoid NSAIDs, ACEi/ARBs, thiazides.
  • Therapeutic: 0.6–0.8 mmol/L (0.4–1.0 individualised). Levels: 12 h post‑dose; weekly until stable, then every 3 months; extra if illness, interacting drugs or dose change.
  • Routine 6‑monthly: U&E/eGFR, TSH, calcium; weight/BMI. ECG if cardiac risk.
  • Sick‑day rules: hold lithium during dehydration, febrile illness or if unable to maintain intake; restart only when well and after a level.
  • [BNF; NICE CG185]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Clozapine complications : outline management (dose; risk)?

A
  • Constipation/CIGH: proactively prescribe stimulant + softener; stool chart; red flags (no stool, pain, distension, vomiting): urgent ED. Avoid anticholinergics/opioids.
  • Myocarditis (first 6–8 wks): watch for fever, tachycardia, chest pain; check CRP/troponin; stop and refer if suspected.
  • Infection/smoking: inflammation and smoking cessation ↑ levels—halve/adjust dose and check plasma level if available.
  • Other: hypersalivation (atropine drops), tachycardia, seizures (dose‑related), neutropenia (follow CPMS).
  • Baseline/monitoring per service protocol; educate on fever/constipation action plan.
  • [MHRA/SPS; TEWV CIGH]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Hyponatraemia (SSRI/carbamazepine/SIADH): outline management (liaison; risk)?

A
  • Check severity/symptoms; confirm hypo‑osmolar hyponatraemia and SIADH pattern (serum/urine osmolality & sodium).
  • Hold culprit (SSRIs, carbamazepine, oxcarbazepine, thiazides); fluid restrict (e.g., 800–1000 mL/d) if SIADH. Consider salt tablets/loop diuretic under acute team.
  • Avoid rapid correction (>8–10 mmol/L in 24 h).
  • Switch antidepressant to lower‑risk option (e.g., mirtazapine) if needed.
  • Risk: older age, low BMI, concomitant diuretics. Liaise with acute medicine if Na <125, symptoms, or uncertainty.
  • [NICE CKS; SPS]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Anticholinergic toxicity / burden: outline management (risk)?

A
  • Features: delirium (agitated or hypoactive), mydriasis, dry flushed skin, urinary retention, tachycardia, ↓ bowel sounds, hyperthermia.
  • Actions: stop anticholinergics (e.g., TCAs, procyclidine, oxybutynin); cooling, IV fluids, benzodiazepines for agitation; bladder scan/catheter if needed.
  • Physostigmine only with tox specialist and if pure antimuscarinic syndrome (contraindicated in TCA overdose/QRS widening).
  • Long‑term: reduce ACB score; prefer alternatives with minimal anticholinergic burden.
  • [BGS ACB; toxicology guidance]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Tardive dyskinesia: outline management (dose)?

A
  • Confirm TD; exclude acute EPS and other causes (dentures, chorea).
  • Reduce dose if feasible; switch to lower D2‑occupancy agent (clozapine often best).
  • Consider VMAT2 inhibition: tetrabenazine (licensed in UK for moderate–severe TD); deutetrabenazine under evaluation.
  • Avoid anticholinergics (worsen TD). Adjuncts sometimes used: clonazepam or amantadine.
  • Discuss functional impact and prognosis; minimise dopamine blockade exposure.
  • [NICE (UK) TD evidence; BAP/Expert reviews]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Antidepressant - induced mania / rapid cycling: outline management

What risk ax
What meds
What else to balance

A
  • If clear mania/hypomania emerges: stop antidepressant.
  • Treat acute episode: antipsychotic (e.g., haloperidol, olanzapine, quetiapine, risperidone) or mood stabiliser (lithium; valproate if not of child‑bearing potential and PPP in place).
  • Assess risks (suicide, financial/sexual risk, safeguarding); consider admission if needed.
  • Review diagnosis, precipitants (substances, steroids), and long‑term relapse prevention.
  • [NICE CG185]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

MAOI interactions: outline management (risk)?

A
  • Identify MAOI type - Enforce washout after stopping irreversible MAOI - Tyramine restricted diet avoid sympathomimetics pethidine - Hypertensive crisis treat with phentolamine nifedipine - Serotonin syndrome risk avoid SSRIs SNRIs - Emergency ID alert card inform anaesthetics - Plan safe alternatives - Interactions list in BNF check before - If accidental co admin observe closely
    | “BNF MAOI; MHRA DSU; NICE depression (MAOI use). Fluoxetine washout 5 weeks.”
    ## Footnote
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Depot antipsychotic initiation / missed dose: outline management (dose; monitor)?

A
  • Confirm indication consent check previous oral - Choose LAI - Baselines - Initiation - Injection technique site rotation record batch - Missed dose rules - Monitoring - Missed doses
    | “BNF/SPCs for each LAI (accessed 2025); Maudsley dosing tables.”
    ## Footnote
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Clozapine or lithium + infection/COVID: outline management (dose)

General Advice
What meds to avoid
Toxicity signs
Red flags
Investigations

A
  • Fever/infection ↑ clozapine levels: halve or hold dose if systemic infection; check clozapine level if available; monitor for sedation, seizures; avoid strong inhibitors (e.g., ciprofloxacin, erythromycin). Check neutrophils; consider COVID/pneumonia.
  • Lithium: dehydration/AKI risk—hold during febrile illness/poor intake; check level/U&E; avoid NSAIDs, ACEi/ARBs; restart once well with level.
  • Communicate safety‑netting; document plan.
  • [SPS/MHRA; BNF]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Metabolic syndrome?

how to manage risk of / actual metabolic syndrome with SGAs

A
  • Baselines before SGAs - Lifestyle first diet exercise refer to - Choose lower risk AP if feasible - Monitoring - Pharmacology - Screen for NAFLD sleep apnoea if - Document risk discussion shared plan with - Regularly reinforce lifestyle structured programmes improve - Diagnostic criteria not required for action
    | “NICE CG178/CG185; BNF; Maudsley metabolic monitoring schedule. *Ziprasidone not UK‑marketed widely - use aripiprazole as lower‑risk.”
    ## Footnote
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Prolactinaemia & sexual dysfunction?

A

Screen for headaches and changes to vision . Adjunctive aripiprazole often normalises levels within weeks - Refer if high levels or visual field defects (MRI pituitary) - Ask about gynae/sexual function; menstrual history check TSH, ** pregnancy test** - Repeat prolactin fasting morning; exclude macroprolactin - Switching: aripiprazole has lowest prolactin; risperidone/paliperidone highest - Screen symptoms (amenorrhoea, galactorrhoea, low libido); check prolactin - Rule‑outs: pregnancy, hypothyroidism, pituitary disease; repeat morning level; macroprolactin if borderline - Manage AP‑induced: reduce dose or switch to aripiprazole/quetiapine - Consider adjunct aripiprazole 5 - 10 mg to lower prolactin - Monitor bone health (vit D, DEXA if prolonged hypogonadism); treat sexual dysfunction - Endocrine referral if prolactin >2000 mU/L or symptoms persist
| “NICE SGAs adverse effects; BNF; Endocrine Society hyperprolactinaemia guidance.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

ECG/QTc pathway (incl. long QT interactions): outline management (dose;

QTc managment

What thresholds on ECG?
What other drugs noted to

What else to optimise?

A

If QTc 480 - 499 ms: switch to low‑risk agent; if ≥500 ms: stop culprit and urgent review - Obtain electrolytes; replace K >4.0, Mg >0.8 - Haloperidol: avoid IV; monitor if IM/PO in risk - Methadone + APs markedly increases risk - Identify QTc risk factors (age, female, electrolyte loss, CVD, congenital LQTS, methadone, macrolides) - Baseline ECG before high‑risk AP/TCAs; repeat after dose changes - Thresholds: QTc ≥450 ms (men) / ≥470 ms (women) caution; ≥500 ms avoid/stop QT‑prolonging drugs - Prefer low‑risk agents (aripiprazole, lurasidone); avoid haloperidol IV, ziprasidone - Correct K/Mg/Ca; avoid polypharmacy (AP + macrolide/fluoroquinolone) - If syncope/palpitations: urgent ECG/cardiology - Document and communicate plan
| “MHRA haloperidol QT; BNF QT tables; Maudsley. Threshold ≥500 ms for stopping.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

Hepatic or renal impairment dosing: outline management (avoid; dose; liaison; monitor)?

A
  • Review organ function use BNF for - Avoid/adjust - Antipsychotics - Monitor drug levels where available - Liaise with renal hepatic teams consider - Document dosing rationale; review frequently - Lithium contraindicated if eGFR reduce dose - Lamotrigine - Antidepressants sertraline usually safe in renal
    | “BNF/SPCs; NICE bipolar/depression dosing cautions. Involve specialists for advanced CKD/cirrhosis.”
    ## Footnote
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

BPSD generally + parkinsons / LBD

Medications
Workup
Differentials
Polypharmacy
Care bundle
Legal
Follow up

A
  • Rule out pain, infection, constipation, delirium; review meds (anticholinergics, benzos).
  • Non‑pharmacological first line: personalised activities, environmental tweaks, carer support, sleep hygiene.
  • If severe distress/risk: short trial of antipsychotic (lowest dose, time‑limited), with informed consent and regular review. In LBD/Parkinson’s, avoid antipsychotics where possible—quetiapine (or clozapine specialist) if essential. Consider AChE inhibitors (e.g., rivastigmine) in LBD/PDD.
  • Discuss stroke/mortality risks; plan deprescribing and physical health monitoring.
  • [NICE NG97; BNF]
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Opioid use disorder (OST)?

A
  • Confirm dependence check OST suitability urine - Choose buprenorphine or methadone shared decision - Induct carefully - Provide take home naloxone harm reduction - Titrate to block withdrawal craving supervised - Monitor sedation, QTc , interactions - Psychosocial support safeguarding housing benefits DVLA - BBV: test HIV/HBV/HCV; vaccinate HBV - Naloxone kit with training
    | “NICE NG46; BNF; MHRA methadone QTc; PHE/UKHSA naloxone guidance.”
    ## Footnote
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

Stimulant (cocaine/amphetamine) toxicity/psychosis: outline management (avoid; first - line)?

A
  • Triage - Avoid beta blockers in acute cocaine - Treat psychosis - Manage hyperthermia hyponatraemia IV fluids active - Consider NSTEMI liaise cardiology if chest - Disposition observe until vitals ECG normal - Check CK for rhabdomyolysis treat hyponatraemia - Psychosis often resolves within 24 consider
    | “RCEM acute cocaine guidance; BNF; NICE SMI + substance misuse.”
    ## Footnote
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

GHB/GBL withdrawal: outline management (liaison; risk)?

A
  • Recognise rapid onset withdrawal after frequent - Treat with high dose benzodiazepines ICU - Consider baclofen adjunct avoid antipsychotics unless - Monitor vitals electrolytes manage agitation safely - Refer to specialist addiction services safeguarding - Severe delirium may need ICU phenobarbital - Educate on overdose risks provide harm
    | “Public Health England GHB guidance; BNF. Evidence limited - specialist protocols vary.”
    ## Footnote
  • Protocols often use diazepam 10 - 20 mg q1 - 2 h initially with close observation - Severe delirium may need ICU/phenobarbital - Educate on overdose risks; provide harm‑reduction and follow‑up - Recognise rapid‑onset withdrawal (tremor, anxiety, delirium) after frequent dosing - Treat with high‑dose benzodiazepines (diazepam); ICU if refractory - Consider baclofen adjunct; avoid antipsychotics unless severe psychosis (seizure risk) - Monitor vitals/electrolytes; manage agitation safely - Refer to specialist addiction services; safeguarding
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Cannabis - related problems: outline management (risk)?

A
  • Assess pattern potency route screen for - Psychoeducation on psychosis anxiety risk motivational - Acute anxiety/psychosis - Treat comorbid depression anxiety with CBT - Smoking cessation support consider NRT varenicline - Relapse prevention plan early psychosis referral - High potency THC linked to psychosis - Withdrawal
    | “NICE CG120 (psychosis with substance use); PHE cannabis harm reduction.”
    ## Footnote
  • If psychosis persists beyond intoxication/withdrawal, assess for primary psychosis and treat accordingly - High‑potency THC linked to psychosis; advise reduction/cessation - Withdrawal: irritability, insomnia - brief symptomatic meds (e.g., short z‑drug course) + sleep hygiene - Assess pattern, potency (THC%), route; screen for dependence/withdrawal; co‑use (tobacco) - Psychoeducation on psychosis/anxiety risk; motivational interviewing - Acute anxiety/psychosis: short‑term benzodiazepine; antipsychotic if frank psychosis - Treat comorbid depression/anxiety with CBT‑based approaches; avoid heavy sedation - Smoking cessation support; consider NRT/varenicline - Relapse prevention plan; early psychosis referral if persistent psychosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

Benzodiazepine detoxification: outline management (red flag; risk)?

A
  • Example: diazepam 20 mg/day → reduce by 2 mg every 1 - 2 weeks - Use Ashton manual equivalences as guide (BNF also lists) - In hepatic impairment, use lorazepam/oxazepam equivalence - Provide coping strategies and peer support; avoid alcohol - Assess dose/type/duration; convert to diazepam equivalent - Gradual taper: 5 - 10% dose reduction every 1 - 2 weeks; slower at low doses - Avoid PRN top‑ups; fixed schedule; psychological support (CBT‑I/anxiety management) - Consider inpatient if high dose, comorbidity, or polydrug use - Manage insomnia with CBT‑I; avoid Z‑drugs/substituting dependence - Monitor withdrawal (tremor, seizures); safety plan; relapse prevention
    ## Footnote
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
# Postpartum psychosis Management Priorities
- Lithium postpartum is effective for relapse prevention; monitor levels closely (fluid shifts) - **Breastfeeding: olanzapine/quetiapine generally compatible**; lithium usually not recommended while breastfeeding (monitor infant if used under specialist) - Capacity/MHA as needed to ensure safety - **Psychiatric emergency: same‑day admission to MBU if possible**; risk assess (**suicide/infanticide**) - Start antipsychotic (e.g., olanzapine/quetiapine); consider lithium post‑delivery if bipolar history - Avoid valproate (contraindicated in women of child‑bearing potential); consider benzodiazepine short‑term - Safeguarding: **constant supervision of mother** - infant; involve partner/family - Medical screen (thyroid, infection); breastfeeding counselling re meds - Follow‑up: relapse prevention plan; perinatal team | "NICE CG192; RCPsych perinatal guidance; BNF lactation."
26
# Perinatal depression/anxiety: outline management (liaison; risk)?
- Screen ; assess risk - First‑line - Pharmacology - Non‑drug - Refer to perinatal psychiatry if complex - Safety plan follow up within 1 - Psychotherapy CBT 8 12 sessions MBT - Discuss risks benefits relapse risk if | "NICE CG192; BNF lactation; NHS perinatal IAPT." ## Footnote - Sertraline dosing 50 - 200 mg; start 25 - 50 mg; monitor for PPHN risk (rare) - Psychotherapy: CBT 8 - 12 sessions; MBT/parent - infant therapy if bonding issues - Discuss risks/benefits; relapse risk if stopping antidepressant - Screen (Whooley/GAD‑2); assess risk (self‑harm, safeguarding, DV) - First‑line: guided self‑help/CBT; perinatal IAPT; consider antidepressant if moderate - severe - Pharmacology: sertraline first‑line (pregnancy/lactation); avoid paroxetine in pregnancy (1st trimester) - Non‑drug: sleep, support, treat anaemia/thyroid; peer support - Refer to perinatal psychiatry if complex, bipolar risk, or poor response - Safety plan; follow‑up within 1 - 2 weeks
27
# Valproate restrictions & pregnancy prevention?
- Do not initiate valproate in females - Absolute contraindication in pregnancy - If already on - Provide patient guide risk acknowledgement form - Folic acid pre conception pregnancy test - Communicate with GP; document - Alternatives - Breastfeeding - Report pregnancies to MHRA Yellow Card | "MHRA 2018 - 2023 valproate PPP; NICE CG185." ## Footnote - Alternatives: lithium, lamotrigine, quetiapine for bipolar; carbamazepine may also be teratogenic - Breastfeeding: valproate generally compatible but avoid if possible - Report pregnancies to MHRA Yellow Card - Do not initiate valproate in females of child‑bearing potential unless PPP in place - Absolute contraindication in pregnancy (10% malformations; 30 - 40% neurodevelopmental disorders) - If already on: review urgently; switch if possible; ensure highly effective contraception - Provide patient guide, risk acknowledgement form, annual specialist review - Folic acid pre‑conception; pregnancy test before initiation - Communicate with GP; document
28
# ADHD meds in pregnancy/lactation: outline management (monitor)?
- Review need consider non pharm first - Methylphenidate - Lisdexamfetamine/dexamfetamine - Breastfeeding - If stopping slow taper to avoid - Document shared decision liaise obstetrics perinatal - If treatment essential for functioning safety - Monitor maternal BP HR weight fetal - Consider atomoxetine (limited data) only if stimulants unsuitable - If treatment essential for functioning/safety, use lowest effective dose; avoid polypharmacy - Monitor maternal BP/HR/weight; fetal growth scans if concerns - Review need; consider non‑pharm first; risk - benefit discussion - Methylphenidate: limited data - consider continuation if severe impairment; monitor fetal growth - Lisdexamfetamine/dexamfetamine: similar considerations; avoid high doses; monitor BP - Breastfeeding: small amounts in milk; monitor infant irritability/weight - If stopping, slow taper to avoid rebound; plan postpartum review - Document shared decision; liaise obstetrics/perinatal psych | "UKTIS monographs; BNF; NICE ADHD NG87 acknowledges limited evidence - individualised decisions."
29
# Refeeding syndrome: outline management (risk)?
- Identify high‑risk - Baseline ECG U Es Mg PO₄ - Start low calories and increase slowly - Give thiamine and multivitamins replace PO₄ - Monitor electrolytes daily vitals fluid balance - Escalate if arrhythmia oedema heart failure - Safeguard under MHA MCA if capacity - Thiamine - Calories increased over 4 close monitoring | "NICE NG7 (nutrition support); MARSIPAN/MEED for ED; BNF for electrolyte replacement." ## Footnote
30
# Inpatient ED Routine risk management Screening Red flags
- Clear escalation thresholds (e.g., HR <40, K <3.0, PO₄ <0.5 → medical transfer) - Observations at least BD; SUSS test post‑meal; supervised post‑meal period - ECG weekly initially or with electrolyte shifts; correct QTc risks - Family‑based treatment if adolescent; CBT‑ED for adults - Daily risk board: vitals (lying/standing BP/HR), temp, weight trends, fluid balance - Cardiac monitoring if HR <40, QTc prolonged, or electrolyte derangement - Complications screen: oedema, transaminitis, constipation, infection; bone health longer‑term - Psychological: meal support, behavioural contracts, family involvement - Legal: MCA/MHA for treatment/NG feeding if life‑threatening - Liaise MEED/MARSIPAN; criteria for HDU/ICU transfer - Discharge planning: relapse prevention, GP liaison, dietetic/psych follow‑up | "MEED 2022/MARSIPAN; NICE ED NG69."
31
# Capacity to refuse nutrition? Aids, interpreters MCA vs MHA situations
- Best interests: involve family/IMCA; consider past/present wishes; least restrictive option; time‑limited trial - MCA test: understand, retain, weigh, communicate. Decision/time‑specific. Use aids/interpreters - Interface: if refusal due to anorexia nervosa, MHA may be appropriate for NG feeding - Safeguards: DOLS if continuous supervision/restriction in hospital - Check capacity with MCA 4‑stage test specific to decision to refuse nutrition/NG feeding - Optimise communication/support; treat reversible causes (depression, delirium) - If lacks capacity and life‑threatening risk, treat in best interests; consider NG feeding under MCA/DoLS - If capacitous refusal: explore values; ensure fully informed; offer alternatives; risk‑mitigate - Consider MHA if mental disorder driving decision and treatment is for that disorder - Document rationale; consult family/IMCA; legal advice if dispute; regular review | "MCA 2005 Code of Practice; NICE NG69 (EDs) on MHA use; Case law (Aintree)."
32
# Use of the Mental Capacity Act?
- Presume capacity support decision making unwise - Assess capacity for the specific decision - If lacks capacity - Document assessment and rationale involve family - Advance decisions LPA check and honour - Use DoLS Liberty Protection Safeguards if - Support: communication aids, timing, environment - Best interests - Safeguarding report if abuse neglect concerns | "MCA 2005; Code of Practice; LPS reforms pending - follow local interim DoLS." ## Footnote
33
# Use of the Mental Health Act?
- Consider MHA when mental disorder causes - Choose section - Ensure AMHP 2 doctors nearest relative - Rights on detention information advocacy appeal - Consent to treatment - Record rationale alternatives tried review regularly - Section choice based on purpose time | "MHA 1983 (as amended 2007); Code of Practice; CQC guidance." ## Footnote
34
# DVLA fitness to drive?
- Assess condition, medicines and any episodes of loss of consciousness. - Group 1: notify DVLA for psychotic disorders, bipolar disorder, or any seizures/blackouts; stop driving during acute episodes. For epilepsy/first seizure, must stop and notify; relicensing depends on seizure‑free interval (often ≥6–12 months, specific rules apply). - Dissociative (functional) seizures: must not drive and must notify DVLA; relicensing may be possible after seizure‑free period (often ≥3 months) per DVLA. - Advise on medicine effects (sedating benzos/TCAs); document advice and signpost DVLA guidance & M1 form. - [DVLA; Epilepsy charities summaries]
35
# Safeguarding (adults/children)?
Children: duty to safeguard overrides confidentiality; Section 47 referral if significant harm - Consider modern slavery, PREVENT where indicators present - Adults: Care Act 2014; Making Safeguarding Personal - Domestic abuse: DASH‑RIC tool guides MARAC referral - Identify abuse/neglect/domestic violence; take history safely; consider children at risk - Immediate safety plan; emergency services if imminent danger - Consent/capacity to share; if serious risk, share without consent (public interest) - Refer to local safeguarding team/MASH; MARAC for high‑risk DV - Document facts, injuries, statements verbatim; body maps - Ongoing support: IDVA/ISVA, social care, legal options | "Care Act 2014; Working Together to Safeguard Children 2018; NICE NG116 (domestic violence)." ## Footnote
36
# Risk after discharge / self - harm: outline management (liaison)? What risk features? What mitigation steps? What follow up expectations?
| "NICE NG225 (self‑harm 2022); NHS '72‑hour follow‑up' policy." ## Footnote - Prescribe limited quantities; review in 1 week - Discharge letter within 24 h; crisis team number; WRAP plan - High‑risk features: recent ward leave incidents, akathisia, insomnia, command hallucinations - Stratify suicide/self‑harm risk (recent attempt, plans, hopelessness, isolation, substance use) - Safety plan with patient; means restriction; crisis numbers - Arrange 72‑h follow‑up call/visit; GP handover same day - Address drivers: mood/psychosis, pain, housing, benefits; meds supply (7 - 14 days) - Consider HTT/home treatment; carers' involvement (with consent) - Document formulation, protective factors, contingency
37
# High risk to others?
- MAPPA level set via probation/police - Use HCR‑20/RSR‑V where trained; document rationale - Duty to protect may override confidentiality - Immediate risk containment: remove access to victims/weapons; consider police liaison - Assess specific threats, intent, plans, capability, triggers; substance use - Consider MHA detention; MAPPA referral for violent/sexual risk - Treat underlying disorder (psychosis, mania, PD); meds for agitation - Safeguarding for potential victims; information sharing justified - Ongoing plan: relapse signatures, supervision, MDT review | "GMC confidentiality; MAPPA guidance; NICE psychosis violence risk."
38
# Functional neurological attacks (PNES) in ED?
- In ED: protect dignity, ensure ABCs; avoid noxious stimuli; minimise iatrogenic harm (do not load antiepileptics unless coexistent epilepsy). - Explain diagnosis clearly and non‑pejoratively; show typical signs (e.g., eyes closed, variable movements). Provide written resources and arrange follow‑up (neurology/neuropsychiatry; FND services). - Driving: dissociative seizures—must stop driving and notify DVLA; relicensing after seizure‑free period per DVLA. - Address comorbidities (PTSD, anxiety, pain) and safety plan. - [NHS/charity guidance; DVLA]
39
# First seizure / medication - induced seizure? Medication Culprits Withdrawal culprits Investigations Risk Advice
- Stabilise; history incl. precipitants (sleep loss, alcohol, drugs); exam; glucose. - Investigations (per local pathway): U&E, calcium, magnesium; ECG; consider imaging and EEG urgently via neurology clinic. - Advise no driving and notify DVLA; safety advice (heights, water, machinery), alcohol/sleep. - Medication culprits to review/stop: bupropion, tramadol, theophylline, TCAs, clozapine (dose), fluoroquinolones, imipenem; withdrawal from benzos/alcohol. - Urgent referral to epilepsy specialist (≤2 weeks). - [NICE NG217; seizure‑threshold reviews]
40
# BPSD (behavioural & psychological symptoms of dementia): outline management (risk)? Ladder of care? Meds? Options for DLB/PD? What risks incurred?
- Rule out pain, infection, constipation, delirium; review meds (anticholinergics, benzos). - Non‑pharmacological first line: personalised activities, environmental tweaks, carer support, sleep hygiene. - If severe distress/risk: short trial of antipsychotic (lowest dose, time‑limited), with informed consent and regular review. In LBD/Parkinson’s, avoid antipsychotics where possible—quetiapine (or clozapine specialist) if essential. Consider AChE inhibitors (e.g., rivastigmine) in LBD/PDD. - Discuss stroke/mortality risks; plan deprescribing and physical health monitoring. - [NICE NG97; BNF]
41
# Deprescribing in frailty/polypharmacy?
- Falls reduction: cut sedatives/hypotensives; check orthostatic vitals - Use PRN to bridge where appropriate; avoid therapeutic cascades - Communicate with GP to align repeat scripts - Identify PIMs via STOPP/START, ACB; set goals of care - Prioritise high‑risk meds (anticholinergics, benzodiazepines, Z‑drugs, TCAs, antipsychotics) - Taper safely; one change at a time; monitor withdrawal/relapse - Substitute safer options (e.g., mirabegron for oxybutynin; SSRI for TCA) - Engage patient/carers; shared plan; pharmacy review - Review every 4 - 12 weeks; document outcomes | "STOPP/START v3; NICE multimorbidity; ACB guidance."
42
# TRD pathway: outline management (monitor)? Bloods? Meds ladder? Differentials? Atypical Sx + approach?
- Check TSH, B12/folate; meds that worsen depression (beta‑blockers) - Lithium augmentation requires levels and monitoring (TFTs/eGFR) - Consider MAOI in atypical depression (diet/interaction counselling) - Esketamine via controlled pathways; BP monitoring - Confirm diagnosis/adherence; screen bipolar/substance/medical causes - Optimise SSRI/SNRI dose & duration (≥6 - 8 weeks); switch class if non‑response - Augment: mirtazapine, lithium (target 0.6 - 0.8), quetiapine, aripiprazole - Psychological: CBT 12 - 20 sessions; BA; consider IPT - Physical: ECT for severe/psychotic/suicidal; rTMS/esketamine (specialist) - Monitor suicide risk; review every 2 - 4 weeks | "NICE NG222 (depression 2022); BAP 2023; BNF."
43
# Clozapine initiation? Monitoring A Monitoring B When plasma levels What prophylaxis What key interactions
- CRP/troponin weekly ×4 to detect myocarditis - Observe first doses (hypotension/sedation); dose at night when possible - Provide clozapine card/booklet; arrange plasma levels if poor response/adherence query - Confirm TRS (≥2 adequate AP trials); baseline FBC, U&Es, LFTs, CRP, troponin, weight, BP, HbA1c/lipids; ECG - Register with CPMS; patient consent/education - Start 12.5 mg; titrate slowly to 300 - 450 mg/day; monitor orthostatics/temp - Weekly FBC ×18 weeks → fortnightly → monthly - Prophylaxis for constipation from day 1; bowel chart - Smoking status recorded; adjust dose if smoking changes - Plan physical health monitoring/metabolic support | "Maudsley; CPMS; MHRA myocarditis/constipation alerts."
44
# Psychological therapy selection?
- Match therapy to problem severity and - Depression CBT BA IPT couples therapy - Anxiety disorders CBT with exposure PTSD - OCD: ERP ± SSRI; Psychosis: CBTp; Bipolar: FFT/psychoeducation - Personality disorder - Ensure access/thresholds; address barriers - Combine with meds where indicated shared | "NICE disorder‑specific guidelines; IAPT manual." ## Footnote - Dose: CBT 8 - 12+ sessions; ERP 10 - 20; TF‑CBT/EMDR 8 - 12; DBT year‑long skills + individual - Combine with meds where indicated; shared decision making - Match therapy to problem severity and preference: IAPT stepped care - Depression: CBT/BA; IPT; couples therapy if relationship issues - Anxiety disorders: CBT with exposure; PTSD: TF‑CBT/EMDR - OCD: ERP ± SSRI; Psychosis: CBTp; Bipolar: FFT/psychoeducation - Personality disorder: DBT (BPD), MBT; group options - Ensure access/thresholds; address barriers (language, ASD/LD adjustments)
45
# ADHD + substance misuse/diversion What flags for misuse / diversion? What alternatives? What interactions? What monitoring during titration?
- Avoid co‑prescribing sedatives; caution with MAOIs - Start low, go slow; document benefits and misuse checks - Shared‑care with GP once stable - Assess diversion risk; consider long‑acting formulations; supervised titration - Prefer lisdexamfetamine/OROS methylphenidate; avoid IR where diversion risk high - Consider atomoxetine/guanfacine if stimulants contraindicated - Coordinate with substance services; urine screens; treatment contract - Psychoeducation; structure; relapse prevention; driving advice - Review monthly during titration; BP/HR/weight monitoring | "NICE NG87; BNF; NHS England shared‑care protocols."
46
# Crisis in autism/LD Initial Steps + Escalation approach Causal analysis appraoch Caveats to medication When does MHA apply? What follow up?
- PRN time‑limited and reviewed; consider STOMP principles - PBS over medication; carer training; sensory strategies - Crisis plan shared with GP and carers - Adjust environment/communication; involve carers; reasonable adjustments - Identify triggers (sensory overload, pain, change); use PBS plan - Treat physical causes (constipation, infection, pain) - De‑escalation; short‑term meds only if severe risk (lorazepam low dose; avoid antipsychotics long‑term without review) - Safeguarding; legal (MCA/MHA); hospital passport - Plan follow‑up with specialist autism/LD team. Consider circumstances. ABC / PBS approach. | "NICE NG11/NG93; STOMP (NHS England)."
47
# Breaking bad news / explaining risk: outline management (risk)? Preparation Steps Wrap up
- SPIKES approach; check understanding; invite questions - Offer chaperone/family; consider culture/language needs - Provide crisis contacts if risk factors present - Prepare: private space, enough time; check who should be present - Explore what patient knows/wants to know; signpost structure - Deliver information clearly; small chunks; avoid jargon - Acknowledge emotions; empathy; silence; validate - Discuss options/next steps; safety net; written info - Document discussion and plan; arrange follow‑up | "NICE patient experience CG138; SPIKES model."
48
# Medication refusal on the ward Situational Hx Alternatives Legal options
- Offer liquid, ODT, depot where appropriate - Covert via MDT/Best‑Interests with pharmacist and family; record time‑limit and review - Legal frameworks: MCA vs MHA Part 4 (consent to treatment) - Explore reasons (side effects, insight, cultural); address concerns; offer alternatives/forms - Assess capacity for medication decision; document - If lacks capacity and treatment is for physical health under MCA; for mental disorder consider MHA - Consider covert meds only under strict policy and best‑interests meeting - Use de‑escalation/PRN within guidelines; avoid coercion - Review regularly; involve advocate/IMHA | "MCA/MHA Codes; NICE NG10 for RT coercion limits; Covert meds RPS guidance."
49
# Negative symptoms of schizophrenia Rule outs? Meds to try? Meds to remove? Quantification? What lifestyle actions? What therapies?
- BA and goal‑setting improve engagement; link to vocational rehab (IPS) - Cariprazine has evidence for negative symptoms; monitor akathisia - Measure with PANSS‑NS/BNSS to track change - Rule‑out depression, EPS, sedation, substance use, hypothyroidism - Optimise antipsychotic (trial of cariprazine/aripiprazole may help negatives) - Psychosocial: CBTp, social skills, behavioural activation; supported employment - Address cognition (cognitive remediation), sleep, exercise - Treat comorbidities; minimise anticholinergics/benzos - Set functional goals; involve family; regular review | "NICE CG178; Maudsley; evidence for cariprazine in predominant negatives."
50
# Serotonin syndrome How to avoid Hunter criteria for Dx Core care triad Specific Rx
- Cyproheptadine 12 mg load then 8 mg q6 h (off‑label; oral/NG) - Washout periods before switching to MAOI (fluoxetine 5 weeks) - Hunter criteria guide diagnosis; inducible/spontaneous clonus key - Suspect triad: neuromuscular (clonus, hyperreflexia), autonomic (fever, tachy), mental status change - Stop serotonergic drugs (SSRIs, MAOIs, tramadol, linezolid, triptans, MDMA) - Supportive care: IV fluids, cooling, benzodiazepines - Moderate - severe: cyproheptadine via NG; ICU if hyperthermia/rigidity - Avoid antipyretics/dantrolene (not useful); avoid physical restraint alone - Reintroduce meds cautiously after recovery | "TOXBASE/Hunter criteria; BNF; MHRA MAOI washouts."
51
# Neuroleptic malignant syndrome Diagnostic quad Causes Core treatment triad Specific Rx
- Dx: hyperthermia, rigidity, delirium, autonomic instability; ↑CK, leukocytosis; exclude sepsis/serotonin toxicity. - Immediate: stop antipsychotics; ICU‑level supportive care (airway, cooling, IV fluids, electrolytes). - Pharmacological options (specialist): bromocriptine, dantrolene, or amantadine. - Avoid depot/long‑acting agents in early re‑challenge; when restarting, wait until full recovery, use low‑potency agent at low dose and titrate slowly with close monitoring. - [Reviews & BJPSych Advances]
52
# Sexual side effects Drug switches Adjunctive meds Comorbidities Other help
- Sildenafil 25 - 100 mg PRN; contraindicated with nitrates - Bupropion off‑label in UK for SSRI‑sexual dysfunction; discuss risks - Manage prolactin per separate pathway - Ask proactively; identify cause (SSRI/SNRI, prolactin‑raising APs) - Adjust: dose reduction, drug holiday (SSRIs short half‑life) if appropriate - Switch: to bupropion/mirtazapine/ vortioxetine (antidepressants); to aripiprazole/quetiapine (APs) - Add: sildenafil/tadalafil for erectile dysfunction; adjunct aripiprazole for AP‑induced - Address comorbidities (diabetes, CV); psychotherapy/sex therapy if needed - Monitor outcomes; shared decision; document | "BNF; NICE depression adverse‑effects; Maudsley."
53
# Discontinuation syndrome (antidepressants) What symptom acronym Typical taper How to fine grain What if intolerable
- Example: reduce by 10 - 25% every 2 - 4 weeks; pause if symptoms - Use fluoxetine bridge when switching from short half‑life SSRIs if needed - Safety‑netting: emergency plan if suicidality emerges - Recognise FINISH symptoms after stopping/reducing antidepressant (flu‑like, insomnia, nausea, imbalance, sensory, hyperarousal) - Taper slowly (over weeks); slower for paroxetine/venlafaxine; fluoxetine least risk - Reinstate previous dose if severe, then taper more slowly - Educate patients before starting; provide written plan - Distinguish relapse vs discontinuation; schedule follow‑up - Consider liquid formulations for fine‑grained taper | "NICE NG222 (depression) 2022 includes withdrawal management; Royal College position statement."
54
# Gestational diabetes risk and management with antipsychotic use (perinatal)? Which meds preferable? What MDT members?
SGA choice impacts GDM risk; balance relapse risk vs metabolic harm - Monitoring: weight each visit; HbA1c early; OGTT 24 - 28 wks - Coordinate perinatal psychiatry + obstetrics; document shared decision - Baseline metabolic screen before/after starting SGAs in pregnancy (BMI, HbA1c/FBG, lipids, BP) - Prefer lower‑metabolic‑risk AP (aripiprazole) if clinically feasible; Lamotrigine and Lithium possible; avoid/scrutinise olanzapine/clozapine - Diet/exercise + referral to diabetes in pregnancy team if high risk or abnormal glucose - Screening: 75‑g OGTT at 24 - 28 wks; earlier if risk/SGA exposure - Treat GDM per obstetric protocol; review AP choice/dose - Post‑partum: repeat glucose; infant monitoring; breastfeeding advice | "NICE NG3 (diabetes in pregnancy); CG192 (perinatal mental health); BNF SGAs metabolic risks."
55
# Valproate use in pregnancy - risk counselling, switching/withdrawal Rates of: Relapse, Defects, Neurodev disorders. Alternatives. Vitamins.
- Alternatives: lithium, lamotrigine, quetiapine for bipolar; carbamazepine may also be teratogenic - Breastfeeding: valproate generally compatible but avoid if possible - Report pregnancies to MHRA Yellow Card - Do not initiate valproate in females of child‑bearing potential unless PPP in place - Absolute contraindication in pregnancy (10% malformations; 30 - 40% neurodevelopmental disorders) - If already on: review urgently; switch if possible; ensure highly effective contraception - Provide patient guide, risk acknowledgement form, annual specialist review - Folic acid pre‑conception; pregnancy test before initiation - Communicate with GP; document | "MHRA 2018 - 2023 valproate PPP; NICE CG185."
56
# Post - myocardial infarction depression - screening and management in liaison psychiatry?
- Screen with PHQ 9 post MI - First line CBT BA via cardiac - Pharmacology - Check interactions ; monitor Na - Address sleep pain anxiety cardiac lifestyle - Follow up 2 step up if - Liaise CR team for integrated psychosocial - Consider SSRIs bleeding risk PPI cover | "NICE NG185 (ACS); BNF; SIGN; SSRIs post‑MI safety (SADHART)." ## Footnote
57
# Behavioural & psychological symptoms of dementia (BPSD) Management in Lewy body vs Parkinson's disease dementia?
- Rule out pain, infection, constipation, delirium; review meds (anticholinergics, benzos). - Non‑pharmacological first line: personalised activities, environmental tweaks, carer support, sleep hygiene. - If severe distress/risk: short trial of antipsychotic (lowest dose, time‑limited), with informed consent and regular review. In LBD/Parkinson’s, avoid antipsychotics where possible—quetiapine (or clozapine specialist) if essential. Consider AChE inhibitors (e.g., rivastigmine) in LBD/PDD. - Discuss stroke/mortality risks; plan deprescribing and physical health monitoring. - [NICE NG97; BNF]
58
# Lithium in pregnancy and postpartum - continue vs stop, monitoring, breastfeeding? Risks / Benefits MDT members Meds to avoid Monitoring pattern
- Suspect toxicity (GI upset, coarse tremor, ataxia, confusion). Stop lithium; check level, U&E, eGFR; IV fluids; seek nephrology if severe (levels >2.5 mmol/L, or symptoms). Avoid NSAIDs, ACEi/ARBs, thiazides. - Therapeutic: 0.6–0.8 mmol/L (0.4–1.0 individualised). Levels: 12 h post‑dose; weekly until stable, then every 3 months; extra if illness, interacting drugs or dose change. - Routine 6‑monthly: U&E/eGFR, TSH, calcium; weight/BMI. ECG if cardiac risk. - Sick‑day rules: hold lithium during dehydration, febrile illness or if unable to maintain intake; restart only when well and after a level. - [BNF; NICE CG185]
59
# SSRI use in pregnancy Risk vs Benefit Agents preferred Breastfeeding
- Neonatal adaptation: jitteriness, respiratory distress - usually self‑limiting - PPHN absolute risk ~2/1000 vs 1/1000 baseline; discuss in context - Document informed consent; perinatal IAPT referral - Continue if benefits outweigh risks; sertraline preferred; avoid paroxetine 1st trimester if possible - Counsel small risks (PPHN absolute risk low; neonatal adaptation) - Use lowest effective dose; avoid switching late unless essential - Breastfeeding: sertraline/paroxetine compatible; monitor infant - Monitor maternal mood; plan post‑partum review | "NICE CG192; UKTIS SSRIs; BNF."
60
# Antipsychotics in breastfeeding Risks vs benefits Monitoring Preferred agents MDT
- Quetiapine low milk transfer; olanzapine moderate but often well‑tolerated - Clozapine: avoid - requires infant blood monitoring if used exceptionally - Risperidone raises prolactin but generally compatible; monitor infant - Prefer quetiapine/olanzapine; avoid clozapine (neutropenia risk) unless specialist plan - Monitor infant sedation/feeding/weight; consider prolactin effects on lactation - Use lowest effective dose; once‑daily dosing after feed where possible - Coordinate with health visitor/GP; safety‑net | "BNF lactation; UKDILAS; RCPsych breastfeeding factsheets."
61
# Postpartum psychosis Symptoms Emergency assessment Meds MDT Medical Screen
- Lithium postpartum is effective for relapse prevention; monitor levels closely (fluid shifts) - Breastfeeding: olanzapine/quetiapine generally compatible; lithium usually not recommended while breastfeeding (monitor infant if used under specialist) - Capacity/MHA as needed to ensure safety - Psychiatric emergency: same‑day admission to MBU if possible; risk assess (suicide/infanticide) - Start antipsychotic (e.g., olanzapine/quetiapine); consider lithium post‑delivery if bipolar history - Avoid valproate (contraindicated in women of child‑bearing potential); consider benzodiazepine short‑term - Safeguarding: constant supervision of mother - infant; involve partner/family - Medical screen (thyroid, infection); breastfeeding counselling re meds - Follow‑up: relapse prevention plan; perinatal team | "NICE CG192; RCPsych perinatal guidance; BNF lactation."
62
# Perinatal OCD stepped‑care psychological pharmacological Risk signs Risk step up
- Psychoeducation perinatal informed CBT with ERP - Pharmacology if moderate severe or CBT - Safeguarding - Post natal support partner involvement sleep - Refer to perinatal team if severe - ERP 12 20 sessions include baby - Distinguish OCD vs psychosis | "NICE OCD CG31; CG192 perinatal adaptations; BNF." ## Footnote - Sertraline 50 - 200 mg; monitor infant if breastfeeding - ERP 12 - 20 sessions; include baby‑related triggers - Distinguish OCD vs psychosis (insight preserved in OCD) - Psychoeducation; perinatal‑informed CBT with ERP first‑line - Pharmacology if moderate - severe or CBT unavailable: sertraline preferred - Safeguarding: intrusive harm obsessions ≠ risk if ego‑dystonic; assess/plan if intent present - Post‑natal support; partner involvement; sleep strategies - Refer to perinatal team if severe or comorbid depression
63
# QT prolongation and psychotropics Thresholds What to normalise Interactions Red flags
- If QTc 480 - 499 ms: switch to low‑risk agent; if ≥500 ms: stop culprit and urgent review - Obtain electrolytes; replace K >4.0, Mg >0.8 - Haloperidol: avoid IV; monitor if IM/PO in risk - Methadone + APs markedly increases risk - Identify QTc risk factors (age, female, electrolyte loss, CVD, congenital LQTS, methadone, macrolides) - Baseline ECG before high‑risk AP/TCAs; repeat after dose changes - Thresholds: QTc ≥450 ms (men) / ≥470 ms (women) caution; ≥500 ms avoid/stop QT‑prolonging drugs - Prefer low‑risk agents (aripiprazole, lurasidone); avoid haloperidol IV, ziprasidone - Correct K/Mg/Ca; avoid polypharmacy (AP + macrolide/fluoroquinolone) - If syncope/palpitations: urgent ECG/cardiology - Document and communicate plan | "MHRA haloperidol QT; BNF QT tables; Maudsley. Threshold ≥500 ms for stopping."
64
# Serotonin syndrome - recognition and management?
- Suspect triad - Stop serotonergic drugs - Supportive care - Moderate severe cyproheptadine via NG ICU - Avoid antipyretics dantrolene avoid physical restraint - Reintroduce meds cautiously after recovery - Hunter criteria guide diagnosis inducible spontaneous | "TOXBASE/Hunter criteria; BNF; MHRA MAOI washouts." ## Footnote - Cyproheptadine 12 mg load then 8 mg q6 h (off‑label; oral/NG) - Washout periods before switching to MAOI (fluoxetine 5 weeks) - Hunter criteria guide diagnosis; inducible/spontaneous clonus key - Suspect triad: neuromuscular (clonus, hyperreflexia), autonomic (fever, tachy), mental status change - Stop serotonergic drugs (SSRIs, MAOIs, tramadol, linezolid, triptans, MDMA) - Supportive care: IV fluids, cooling, benzodiazepines - Moderate - severe: cyproheptadine via NG; ICU if hyperthermia/rigidity - Avoid antipyretics/dantrolene (not useful); avoid physical restraint alone - Reintroduce meds cautiously after recovery
65
# Neuroleptic malignant syndrome Diagnosis Differentials / Ix Core Supportive Tx triad Specific Tx Follow up
- Dx: hyperthermia, rigidity, delirium, autonomic instability; ↑CK, leukocytosis; exclude sepsis/serotonin toxicity. - Immediate: stop antipsychotics; ICU‑level supportive care (airway, cooling, IV fluids, electrolytes). - Pharmacological options (specialist): bromocriptine, dantrolene, or amantadine. - Avoid depot/long‑acting agents in early re‑challenge; when restarting, wait until full recovery, use low‑potency agent at low dose and titrate slowly with close monitoring. - [Reviews & BJPSych Advances]
66
# Lithium toxicity - acute management in ED?
- Suspect toxicity (GI upset, coarse tremor, ataxia, confusion). Stop lithium; check level, U&E, eGFR; IV fluids; seek nephrology if severe (levels >2.5 mmol/L, or symptoms). Avoid NSAIDs, ACEi/ARBs, thiazides. - Therapeutic: 0.6–0.8 mmol/L (0.4–1.0 individualised). Levels: 12 h post‑dose; weekly until stable, then every 3 months; extra if illness, interacting drugs or dose change. - Routine 6‑monthly: U&E/eGFR, TSH, calcium; weight/BMI. ECG if cardiac risk. - Sick‑day rules: hold lithium during dehydration, febrile illness or if unable to maintain intake; restart only when well and after a level. - [BNF; NICE CG185]
67
# Clozapine myocarditis/cardiomyopathy - Screening Period of most concern? Diagnosis / Ix
- CRP >100 and troponin rise suggest myocarditis in context of titration - Differentiate from infection; consider CXR/viral screen - Cardiomyopathy later - consider echo if persistent tachycardia/fatigue - High vigilance in first 4 weeks: weekly CRP/troponin; check tachycardia, fever, chest pain, dyspnoea - If suspected: stop clozapine immediately; urgent cardiology; echo; troponin/CRP trend - Do not re‑challenge without specialist advice - Educate patient to report symptoms; document plan | "MHRA 2021 alert; Maudsley; CPMS recommendations."
68
# Antidepressants in the perioperative period - stop/continue specific risks
- Serotonergic interactions: avoid tramadol/linezolid where possible - SSRIs ↑ bleeding risk; discuss with surgeon if high‑bleed procedures - Clear handover in peri‑op notes - Continue most SSRIs/SNRIs; avoid abrupt cessation - MAOIs: specialist anaesthetic plan; consider washout; avoid meperidine - TCAs: continue but caution with arrhythmias; ECG if risk - Lithium: stop 24 h before major surgery; check levels/renal; restart when euvolaemic - Document serotonin syndrome risk with linezolid/tramadol; anaesthetic liaison | "UKCPA perioperative handbook; BNF; MHRA."
69
# Deprescribing antipsychotics in dementia - indications and process?
- Review indication target symptoms assess benefit - Plan taper over weeks monitor relapse - Prioritise stopping if no clear benefit - Non‑pharm strategies concurrently - Document capacity best interests discuss stroke - Reduce by 25 every 2 faster - Use ABC charts to manage behaviours - Reinstate only if clear deterioration attributable | "NICE NG97; BNF. Risperidone licence short‑term only." ## Footnote - Reduce by 25 - 50% every 2 - 4 weeks; faster if no benefit - Use ABC charts to manage behaviours during taper - Reinstate only if clear deterioration attributable to withdrawal - Review indication; target symptoms; assess benefit vs harms - Plan taper over weeks; monitor relapse; involve carers - Prioritise stopping if no clear benefit at 6 weeks or adverse effects - Non‑pharm strategies concurrently - Document capacity/best interests; discuss stroke/mortality risk
70
# Cholinesterase inhibitors vs memantine - when to start, switch, or stop? Monitoring? DLB / PD options?
- Donepezil start 5 mg nocte → 10 mg; rivastigmine patches if GI intolerant - Memantine start 5 mg OD → 20 mg; caution in severe renal impairment - PD/DLB: rivastigmine preferred - AChE inhibitors (donepezil, rivastigmine, galantamine) for mild - moderate AD - Memantine for moderate - severe AD or intolerance to AChEIs - Switch if adverse effects or poor response; avoid dual AChEI - Monitor HR, GI effects, weight; check for bradycardia/syncope - Review 6 - 12 weeks after start; continue if worthwhile benefit | "NICE TA217/TA312; BNF."
71
# Delirium - assessment (4AT) and management incl. non‑pharmacological measures?
- Identify & treat causes (sepsis, hypoxia, pain, drugs, retention/constipation, dehydration; check glucose, U&E, calcium). Orientation, sensory aids, sleep, hydration, mobilisation, family at bedside. - Avoid routine antipsychotics. If severe distress/risk: short course haloperidol 0.5–1 mg PO/IM (max 2–3 mg/24 h), unless Parkinson’s/LBD—use lorazepam 0.5 mg PO/IM or quetiapine low‑dose. Avoid benzodiazepines generally (except alcohol withdrawal). - Stop anticholinergics; minimise restraints; prevent falls/pressure areas. - Communicate course, expect fluctuation; daily review and deprescribe as able. - [NICE Delirium guideline]
72
# Depression in dementia - adapted assessment and treatment?
- Differentiate depression vs apathy dementia collateral - First line psychosocial behavioural activation carer - Antidepressants sertraline citalopram may help avoid - Monitor falls, hyponatraemia, QTc - Address pain sensory deficits sleep hygiene - Start low go slow review at - Consider CBT adapted for cognition involve | "NICE NG97; BNF citalopram dose limits in elderly." ## Footnote - Start low/go slow; review at 4 - 6 weeks - Consider CBT adapted for cognition; involve carers - Differentiate depression vs apathy/dementia; collateral; scales (CSDD) - First‑line psychosocial: behavioural activation, carer support, exercise - Antidepressants: sertraline/citalopram may help; avoid anticholinergic agents - Monitor falls, hyponatraemia, QTc (citalopram dose limits in elderly) - Address pain/sensory deficits; sleep hygiene
73
# Treatment‑resistant depression - augmentation and sequencing (NICE)?
- Confirm diagnosis adherence screen bipolar substance - Optimise SSRI SNRI dose duration switch - Augment - Psychological CBT 12 20 sessions BA - Physical ECT for severe psychotic suicidal - Monitor suicide risk review every 2 - Check TSH B12 folate meds that - Lithium augmentation requires levels and monitoring - Consider MAOI in atypical depression | "NICE NG222 (depression 2022); BAP 2023; BNF." ## Footnote
74
# ECT - indications, consent/capacity, anaesthetic risks?
- Indications severe depression with suicidality psychosis - Pre ECT assessment consent capacity anaesthetic - Bilateral vs unilateral choice course 6 - Monitor cognitive side effects maintenance ECT - DVLA advice; meds adjustments - Continue maintenance meds post ECT to - Capacity use MCA SOAD if detained - Risks | "RCPsych ECT Handbook; NICE depression guidance." ## Footnote - Continue maintenance meds post‑ECT to prevent relapse - Capacity: use MCA; SOAD if detained and refusing - Risks: transient memory problems; mortality very low - Indications: severe depression with suicidality/psychosis, catatonia, treatment‑resistant mania - Pre‑ECT assessment: consent/capacity, anaesthetic risk, baseline cognition - Bilateral vs unilateral choice; course 6 - 12 treatments - Monitor cognitive side effects; maintenance ECT if frequent relapse - DVLA advice; meds adjustments (hold benzodiazepines if possible)
75
# Akathisia - recognition and management?
- Confirm (inner restlessness + urge to move) and grade (e.g., BARS). - Reduce/switch antipsychotic (to quetiapine/aripiprazole) if possible. - First‑line: propranolol 20–40 mg TDS (contraindications: asthma, bradycardia). - Alternatives/adjuncts: mirtazapine 15 mg nocte, clonazepam 0.25–0.5 mg BD PRN short‑term, or benztropine only if prominent parkinsonism. - Check iron and correct deficiency; avoid increasing anticholinergic burden. Educate that it is iatrogenic and reversible. - [Evidence reviews/Pringsheim 2018]
76
# Tardive dyskinesia - prevention and management options?
- Confirm TD; exclude acute EPS and other causes (dentures, chorea). - Reduce dose if feasible; switch to lower D2‑occupancy agent (clozapine often best). - Consider VMAT2 inhibition: tetrabenazine (licensed in UK for moderate–severe TD); deutetrabenazine under evaluation. - Avoid anticholinergics (worsen TD). Adjuncts sometimes used: clonazepam or amantadine. - Discuss functional impact and prognosis; minimise dopamine blockade exposure. - [NICE (UK) TD evidence; BAP/Expert reviews]
77
# Hyperprolactinaemia with antipsychotics - workup and management?
- Adjunctive aripiprazole often normalises levels within weeks - Refer if high levels >2500 or visual field defects (MRI pituitary) - Ask about gynae/sexual function; **menstrual history**, check TSH, pregnancy test - Repeat prolactin fasting morning; exclude macroprolactin - Switching: aripiprazole has lowest prolactin; risperidone/paliperidone highest - Screen symptoms (amenorrhoea, galactorrhoea, low libido); check prolactin - Rule‑outs: **pregnancy**, hypothyroidism, pituitary disease; repeat morning level; macroprolactin if borderline - Manage AP‑induced: reduce dose or switch to **aripiprazole/quetiapine** - Consider adjunct aripiprazole 5 - 10 mg to lower prolactin - Monitor bone health (**vit D, DEXA if prolonged hypogonadism**); treat sexual dysfunction - Endocrine referral if prolactin >2000 mU/L or symptoms persist | "NICE SGAs adverse effects; BNF; Endocrine Society hyperprolactinaemia guidance."
78
# Metabolic syndrome in SMI - monitoring and intervention plan?
- Baselines before SGAs - Lifestyle first diet exercise refer to - Choose lower risk AP if feasible - Monitoring - Pharmacology - Screen for NAFLD sleep apnoea if - Document risk discussion shared plan with - Regularly reinforce lifestyle structured programmes improve - Diagnostic criteria not required for action | "NICE CG178/CG185; BNF; Maudsley metabolic monitoring schedule. *Ziprasidone not UK‑marketed widely - use aripiprazole as lower‑risk." ## Footnote
79
# Clozapine initiation and monitoring - titration, bloods, interactions side‑effect prevention
- CRP/troponin weekly ×4 to detect myocarditis - Observe first doses (hypotension/sedation); dose at night when possible - Provide clozapine card/booklet; arrange plasma levels if poor response/adherence query - Confirm TRS (≥2 adequate AP trials); baseline FBC, U&Es, LFTs, CRP, troponin, weight, BP, HbA1c/lipids; ECG - Register with CPMS; patient consent/education - Start 12.5 mg; titrate slowly to 300 - 450 mg/day; monitor orthostatics/temp - Weekly FBC ×18 weeks → fortnightly → monthly - Prophylaxis for constipation from day 1; bowel chart - Smoking status recorded; adjust dose if smoking changes - Plan physical health monitoring/metabolic support | "Maudsley; CPMS; MHRA myocarditis/constipation alerts."
80
# Clozapine‑induced constipation - prevention red‑flags
- Fatal ileus reported; act early and aggressively - Consider prucalopride/lactulose if refractory; MDT with gastro/surgery if concern - Record as critical adverse effect in notes - Prevent from day 1: prescribe macrogol daily + senna nightly; bowel chart - Ask about bowels every contact; red flags (abdo pain, distension, vomiting, absent stool/ flatus) → urgent surgical assessment - Escalate promptly: glycerol suppositories, sodium phosphate enema if needed - Avoid constipating co‑meds (anticholinergics, opioids); hydrate/fibre - Educate patient/carers; 24/7 contact if no BM >48 h | "MHRA 2017 clozapine constipation alert; Maudsley; BNF."
81
# Long‑acting injectable antipsychotics - selection, initiation, and consent?
- Paliperidone: loading 150 mg day 1 deltoid + 100 mg day 8; then monthly maintenance (50 - 150 mg). No oral overlap - Aripiprazole: 400 mg monthly + 14‑day oral overlap (or use 2‑dose LAI regimen) - Risperidone LAI: 25 - 50 mg q2 weeks + 3‑week oral overlap - Flupentixol/zuclopenthixol: titrate q2 - 4 weeks; EPS risk higher - Missed doses: check SPC tables; may need re‑loading beyond grace periods - Confirm indication/consent; check previous oral trial/tolerability - Choose LAI: e.g., paliperidone, risperidone, aripiprazole, flupentixol, zuclopenthixol - Baselines: weight, BP, HbA1c/lipids, prolactin; ECG if QT risk - Initiation: follow product‑specific loading/overlap (e.g., paliperidone loading; aripiprazole 2‑week oral overlap) - Injection technique/site rotation; record batch/expiry - Missed dose rules: follow SPC (window periods differ by product) - Monitoring: side effects (EPS, prolactin), metabolic; review dose 4 - 8 weeks; shared care with GP
82
# Bipolar mania - acute pharmacological strategy and physical health monitoring?
- Assess risks ; admit if needed - First‑line pharmacology - If already on mood stabiliser optimise - Avoid antidepressants stop if currently prescribed - Physical baselines ; metabolic monitoring - Sleep restoration psychoeducation involve family follow - Consider RT for dangerous agitation per | "NICE CG185; BAP 2020; BNF." ## Footnote
83
# Bipolar depression - management incl. antidepressant cautions? Bipolar depression
- Rule out mixed features, rapid cycling, - First‑line Avoid antidepressant monotherapy - Psychological - Monitor metabolic thyroid - consider ECT - Lithium levels 0.6- 0.88 - OlanzFluox combo metabolic risk monitor | "NICE CG185; BAP 2020; Maudsley." ## Footnote - Quetiapine 300 mg HS typical; lamotrigine slow titration (25→50→100→200 mg) to avoid rash - Lithium levels 0.6 - 0.8 for maintenance - OlanzFluox combo increases metabolic risk - monitor - Rule‑out mixed features/rapid cycling/substance; screen suicide risk - First‑line: quetiapine monotherapy, or olanzapine - fluoxetine; consider lamotrigine; lithium augmentation - Avoid antidepressant monotherapy; if used, ensure mood stabiliser cover and close monitoring - Psychological: CBT/BA; relapse prevention plan - Monitor metabolic/thyroid; consider ECT if severe/suicidal
84
# GAD - stepped care and when to add meds?
- Psychoeducation self help first low intensity - If persistent impairment high intensity CBT - First‑line meds - Avoid benzodiazepines long term short course - Monitor response side effects review 2 - Combine CBT meds for severe cases - Address sleep, caffeine, substances | "NICE CG113 (GAD/panic); BNF." ## Footnote - Sertraline start 25 - 50 mg → 100 - 200 mg; duloxetine 30→60 mg; pregabalin 75 mg BD → 150 mg BD (sedation/weight gain) - Combine CBT + meds for severe cases - Address sleep, caffeine, substances - Psychoeducation/self‑help first; low‑intensity CBT; worry management - If persistent impairment: high‑intensity CBT (12 - 20 sessions) or pharmacotherapy - First‑line meds: sertraline; alternatives: escitalopram, duloxetine, pregabalin (controlled), venlafaxine - Avoid benzodiazepines long‑term; short course only for crisis - Monitor response/side effects; review 2 - 4 weeks; taper slowly on recovery
85
# OCD - ERP referral pathway and SSRI/clomipramine use?
- Offer CBT with ERP first line - SSRI choices - Clomipramine if SSRI ineffective tolerability issues - Monitor suicide risk comorbid tics ASD - Consider specialist referral for refractory OCD - ERP typically 10 20 sessions homework | "NICE CG31 (OCD/BDD); BNF." ## Footnote - Doses: fluoxetine 20→60 mg; sertraline 50→200 mg; clomipramine 25→150 - 250 mg; check ECG/QTc and interactions - Augmentation: low‑dose antipsychotic (risperidone) if partial response - ERP typically 10 - 20 sessions; homework essential - Offer CBT with ERP first‑line; moderate - severe: add SSRI - SSRI choices: sertraline/fluoxetine; high end of dose range often needed; trial 12 weeks - Clomipramine if SSRI ineffective/tolerability issues (ECG/QTc, anticholinergic burden) - Monitor suicide risk; comorbid tics/ASD may need adaptations - Consider specialist referral for refractory OCD (augmentation/DBT‑ERP)
86
# PTSD - TF‑CBT/EMDR and pharmacology?
- Trauma focused CBT or EMDR first - Pharmacology adjunct if severe comorbidity sertraline - Manage sleep/nightmares - Risk/safeguarding; address alcohol/drugs - Consider intensive specialist services if complex - Offer early guided self help avoid - Prazosin dosing titrated at night BP | "NICE NG116 (PTSD); BNF." ## Footnote - SSRI trial 8 - 12 weeks; monitor for activation - Offer early guided self‑help; avoid debriefing - Prazosin dosing titrated at night; BP monitoring - Trauma‑focused CBT or EMDR first‑line; avoid routine benzodiazepines - Pharmacology adjunct if severe comorbidity: sertraline, venlafaxine - Manage sleep/nightmares: prazosin (off‑label) may help; sleep hygiene - Risk/safeguarding; address alcohol/drugs - Consider intensive/specialist services if complex PTSD
87
# Insomnia in severe mental illness - CBT‑I and safe prescribing?
- CBT‑I as effective as meds; deliver digitally if needed - Review after 2 weeks; taper hypnotics to avoid dependence - Avoid quetiapine solely as hypnotic (metabolic risk) - **Prioritise CBT‑I (4 - 8 sessions)**; sleep **restriction/stimulus control** - Optimise underlying disorder treatment; **review activating meds** timing - Short‑term hypnotic if severe distress: zopiclone 3.75 - 7.5 mg for ≤2 - 4 weeks; avoid long‑term benzos - Consider melatonin MR (over 55s; off‑label younger) especially in psychosis - Sleep hygiene, caffeine/alcohol reduction; **treat OSA/RLS** - Monitor for **parasomnias**; avoid combining sedatives with clozapine. | "NICE insomnia; BNF; RCPsych sleep guidance."
88
# Functional (dissociative) seizures assessment diagnosis delivery management Driving
- DVLA: group 1 stop driving until attacks under control per DVLA advice - Communication is treatment: clear non‑pejorative explanation - Physiotherapy/OT for functional motor symptoms; psych referral for dissociation - Diagnose PNES positively (semiology, normal EEG in typical attacks); avoid unnecessary AEDs - Explain diagnosis empathetically; validate symptoms; give written info - Safety: driving advice if attacks with loss of awareness - Refer to neurology and specialist FND services; CBT‑informed therapy - Treat comorbidities (anxiety/depression/PTSD); optimise sleep - Crisis plan; avoid ED repeat iatrogenesis | "NICE (epilepsies) 2022 recognises PNES; NHS FND pathways; DVLA guidance."
89
# Post stroke depression Post‑stroke depression - screening and treatment with stroke‑safe options?
- Screen routinely rule out aphasia related - First line SSRI if moderate severe - Non pharm BA CBT adapted stroke - Avoid TCAs consider mirtazapine for insomnia - Liaise with stroke physician review interactions - Psych therapies adjusted for aphasia cognitive | "NICE stroke rehab; BNF; SIGN stroke depression." ## Footnote - **Sertraline** start 25 - 50 mg → 100 - 200 mg; check Na at 2 - 4 weeks in elderly - Psych therapies **adjusted for aphasia/cognitive impairments** - Screen routinely (PHQ‑9); rule‑out aphasia‑related distress/cognitive deficits - First‑line SSRI (sertraline) if moderate - severe; start low; monitor **hyponatraemia** - Non‑pharm: **BA/CBT adapted**; s**troke rehab team involvement** - Avoid TCAs (anticholinergic, arrhythmia); consider **mirtazapine** for insomnia/poor appetite - Liaise with stroke physician; review interactions (**anticoagulants**)
90
# Epilepsy and psychotropics safe antidepressant/antipsychotic choices Drugs to avoid
- Enzyme inducers (carbamazepine, phenytoin) lower antidepressant/AP levels - dose adjust - Clozapine lowers threshold dose‑dependently; monitor closely - Prefer SSRIs (sertraline/citalopram) for depression; avoid bupropion; use mirtazapine if insomnia - Antipsychotics: avoid clozapine if poorly controlled seizures; use quetiapine/risperidone cautiously - Check AED interactions (enzyme inducers ↓ psychotropics; valproate interactions) - Start low/go slow; liaise neurology; maintain seizure diary - Avoid tramadol; limit doses of TCAs | "NICE NG217; BNF interactions; Maudsley."
91
# Alcohol withdrawal - symptom‑triggered regimen - Wernicke's prophylaxis? - Risks?
- Pabrinex IV: typically 1 pair TDS for 3 days if Wernicke's risk, then OD × 5 days orally - Chlordiazepoxide: e.g., 20 - 30 mg q6 h then taper; tailor to CIWA scores - Relapse prevention: acamprosate, naltrexone (check LFTs), disulfiram (motivated, supervised) - DTs present 48 - 72 h: confusion, tremor, hallucinations, autonomic instability; urgent escalation - Assess severity (CIWA‑Ar); rule‑outs (hypoglycaemia, infection, head injury, Wernicke's) - Thiamine before glucose: IV Pabrinex® for at‑risk; then oral thiamine - Symptom‑triggered chlordiazepoxide (or fixed‑dose if unreliable monitoring); oxazepam in severe liver disease - DTs: high‑dose benzodiazepines; ICU/anaesthetics if refractory; consider phenobarbital per protocol - Treat complications (electrolytes, fluids); manage agitation safely - Plan relapse prevention and safeguarding; refer to alcohol team; discharge plan | "NICE CG100 (alcohol); BNF; RCEM guidance on Wernicke's. Thiamine before glucose."
92
# Opioid use disorder Opioid replacement Induction Risk management
- Buprenorphine: start 2 - 4 mg SL; up‑titrate to 8 - 16 mg/day; ceiling effect reduces overdose risk - Methadone: start low; increase by 10 - 20 mg every 3 - 4 days; typical 60 - 120 mg/day; QTc monitoring if high dose or risk - BBV: test HIV/HBV/HCV; **vaccinate HBV **- Naloxone kit with training - Supervision relaxed after stability; continue psychosocial interventions - Confirm dependence; check OST suitability; urine drug screen; assess risk/overdose history - Choose buprenorphine (safer) or methadone (higher retention); shared decision - Induct carefully: buprenorphine when in moderate withdrawal (COWS ≥8 - 12); methadone start 10 - 30 mg with ECG if QT risk - Provide take‑home naloxone; harm‑reduction (**needle exchange**; BBV testing/vaccines) - Titrate to block withdrawal/craving; **supervised consumption initially** - Monitor sedation, QTc (methadone), interactions (benzos, APs) - Psychosocial support; safeguarding; housing/benefits; DVLA advice
93
# Benzodiazepine dependence Taper Supports Monitoring
- Example: diazepam 20 mg/day → reduce by 2 mg every 1 - 2 weeks - Use Ashton manual equivalences as guide (BNF also lists) - In hepatic impairment, use lorazepam/oxazepam equivalence - Provide coping strategies and peer support; avoid alcohol - Assess dose/type/duration; convert to diazepam equivalent - Gradual taper: 5 - 10% dose reduction every 1 - 2 weeks; slower at low doses - **Avoid PRN top‑ups**; fixed schedule; psychological support (CBT‑I/anxiety management) - **Consider inpatient if high dose, comorbidity**, or polydrug use - **Manage insomnia with CBT‑I**; avoid Z‑drugs/substituting dependence - **Monitor withdrawal (tremor, seizures**); safety plan; relapse prevention | "NICE (insomnia/anxiety); BNF; Ashton approach widely used in UK services."
94
# Cannabis‑induced psychosis - acute and relapse prevention plan?
- If psychosis persists beyond intoxication/withdrawal, assess for primary psychosis and treat accordingly - High‑potency THC linked to psychosis; advise reduction/cessation - Withdrawal: irritability, insomnia - brief symptomatic meds (e.g., short z‑drug course) + sleep hygiene - Assess pattern, potency (THC%), route; screen for dependence/withdrawal; co‑use (tobacco) - Psychoeducation on psychosis/anxiety risk; motivational interviewing - Acute anxiety/psychosis: short‑term benzodiazepine; antipsychotic if frank psychosis - Treat comorbid depression/anxiety with CBT‑based approaches; avoid heavy sedation - Smoking cessation support; consider NRT/varenicline - Relapse prevention plan; early psychosis referral if persistent psychosis | "NICE CG120 (psychosis with substance use); PHE cannabis harm reduction."
95
# Stimulant‑induced psychosis - acute management and longer‑term plan?
- Diazepam 10 mg PO/IV titrated; lorazepam alternative - Cocaine + beta‑blockers: avoid non‑selective; consider labetalol if needed under specialist care - Check **CK for rhabdomyolysis**; treat **hyponatraemia** cautiously - Psychosis often resolves within 24 - 72 h; consider **quetiapine/olanzapine short term** - Triage: **ABC, ECG, temp; exclude ACS/arrhythmia**; benzodiazepines first‑line for agitation - Avoid beta‑blockers in acute cocaine toxicity (**unopposed alpha**) - use benzodiazepines/nitrates - Treat psychosis: short‑acting benzodiazepine ± antipsychotic (haloperidol low dose if QT safe; avoid if seizure risk) - Manage **hyperthermia**/hyponatraemia; IV **fluids**; active cooling - Consider NSTEMI; liaise cardiology if chest pain/ECG changes - Disposition: observe until vitals/ECG normal; refer to substance services | "RCEM acute cocaine guidance; BNF; NICE SMI + substance misuse."
96
# Capacity assessment to consent to treatment - MCA principles applied?
- Support: communication aids, timing, environment - Best interests: consider wishes/values; consult those close; proportionality - Safeguarding: report if abuse/neglect concerns coexist - Record: capacity evidence per element; options considered; review plan - Presume capacity; support decision‑making; unwise ≠ incapable - Assess capacity (4‑stage) for the specific decision/time - If lacks capacity: act in best interests; least restrictive option - Document assessment and rationale; involve family/IMCA - Advance decisions/LPA: check and honour - Use DoLS/Liberty Protection Safeguards if deprivation of liberty | "MCA 2005; Code of Practice; LPS reforms pending - follow local interim DoLS."
97
# Refusal of treatment - interface of MCA and MHA and best‑interest decisions? When MCA preferable? When MHA preferable?
- Respect human rights; least restrictive; involve carers; discharge planning from day 1 - Use MCA if primary issue is capacity without need for detention; MHA if need to detain and treat mental disorder - Section choice based on purpose/time limits; emergencies may use s4 - Consider MHA when mental disorder causes risk and treatment cannot be given under consent/MCA - Choose section: 2 (assessment), 3 (treatment), 4 (emergency), 5(2)/(4) holding powers - Ensure AMHP + 2 doctors; nearest relative rights; SOAD for certain treatments - Rights on detention: information, advocacy (IMHA), appeal/tribunal - Consent to treatment: Part 4 rules; capacity not required for treatment under s3 within limits - Record rationale/alternatives tried; review regularly | "MHA 1983 (as amended 2007); Code of Practice; CQC guidance."
98
# Driving (DVLA) advice - psych conditions and psychotropics?
- Assess condition, medicines and any episodes of loss of consciousness. - Group 1: notify DVLA for psychotic disorders, bipolar disorder, or any seizures/blackouts; stop driving during acute episodes. For epilepsy/first seizure, must stop and notify; relicensing depends on seizure‑free interval (often ≥6–12 months, specific rules apply). - Dissociative (functional) seizures: must not drive and must notify DVLA; relicensing may be possible after seizure‑free period (often ≥3 months) per DVLA. - Advise on medicine effects (sedating benzos/TCAs); document advice and signpost DVLA guidance & M1 form. - [DVLA; Epilepsy charities summaries]
99
# Safeguarding adults at risk - thresholds and information‑sharing?
- Identify abuse neglect domestic violence take - Immediate safety plan emergency services if - Consent capacity to share if serious - Refer to local safeguarding team MASH - Document facts injuries statements verbatim body - Ongoing support - Children duty to safeguard overrides confidentiality - Consider modern slavery PREVENT where indicators - Adults Care Act 2014 Making Safeguarding | "Care Act 2014; Working Together to Safeguard Children 2018; NICE NG116 (domestic violence)." ## Footnote
100
# REM sleep behaviour disorder in DLB/PDD - recognition and management?
101
# Challenging behaviour in intellectual disability - PBS and medication use?
- Functional assessment PBS plan address pain - Non drug strategies first carer training - Short term meds only for crisis - Safeguarding capacity best interests STOMP principles - Review frequently plan for reduction cessation - Involve community LD team consider autism - Document target behaviours and measurable outcomes | "NICE NG11; STOMP." ## Footnote - Involve community LD team; consider autism comorbidity support - Document target behaviours and measurable outcomes - Functional assessment/PBS plan; address pain/constipation/sensory triggers - Non‑drug strategies first; carer training; environmental changes - Short‑term meds only for crisis (e.g., lorazepam); avoid long‑term antipsychotics without clear indication - Safeguarding; capacity/best interests; STOMP principles - Review frequently; plan for reduction/cessation
102
# Adult autism - post‑diagnostic support and reasonable adjustments?
- Provide written diagnosis explanation signpost to - Address co‑occurring conditions - Social care needs benefits workplace adjustments - Communication passport sensory assessment crisis plan - Avoid routine antipsychotics for core autism - Carer support consider social stories and - Refer to specialist employment and psychoeducation | "NICE CG142; NHS autism strategy." ## Footnote - Carer support; consider social stories and supportive CBT adaptations - Refer to specialist employment and psychoeducation programmes - Provide written diagnosis explanation; signpost to autism‑specific support and reasonable adjustments - Address co‑occurring conditions (anxiety/depression/ADHD) - Social care needs, benefits, workplace adjustments; occupational therapy - Communication passport; sensory assessment; crisis plan - Avoid routine antipsychotics for core autism
103
# Adult ADHD - titration, monitoring, and shared‑care protocols?
- Adults: baseline BP/HR, weight, cardiac history/family history; consider ECG if risk. - First‑line: methylphenidate or lisdexamfetamine; if one ineffective after adequate 6‑week trial, switch to the other; atomoxetine if stimulants unsuitable. - Titrate every 1–2 weeks; review adverse effects (sleep, appetite, BP/HR). - Shared care: once stable, GP can continue with agreed monitoring (BP/HR and weight at least every 6 months; review misuse/diversion risk). - Provide psychoeducation/CBT; address comorbidities and substance use. - [NICE NG87; shared‑care protocols]
104
# Eating disorders - refeeding risk assessment and early management (medical/psychiatric)?
- Identify high‑risk - Baseline ECG U Es Mg PO₄ - Start low calories and increase slowly - Give thiamine and multivitamins replace PO₄ - Monitor electrolytes daily vitals fluid balance - Escalate if arrhythmia oedema heart failure - Safeguard under MHA MCA if capacity - Thiamine - Calories increased over 4 close monitoring | "NICE NG7 (nutrition support); MARSIPAN/MEED for ED; BNF for electrolyte replacement." ## Footnote
105
# Adolescent depression - SSRI initiation, monitoring, and risk management?
- Assess risk involve family safeguarding psychoeducation - First line psychological therapy add fluoxetine - Fluoxetine first line SSRI start monitor - Shared decision consent assent weekly early - School liaison sleep exercise crisis plan - Fluoxetine has best evidence safety in - Safety net emergent suicidality urgent review | "NICE NG134 (depression in children/young people); BNFc." ## Footnote - Fluoxetine has best evidence/safety in adolescents; sertraline second‑line - Safety‑net: emergent suicidality → urgent review; consider CAMHS crisis team - Assess risk; involve family; safeguarding; psychoeducation - First‑line: psychological therapy (CBT/IPT) 3 months; add fluoxetine if moderate - severe or non‑response - Fluoxetine first‑line SSRI; start 10 mg → 20 mg; monitor suicidality - Shared decision; consent/assent; weekly early follow‑up - School liaison; sleep/exercise; crisis plan
106
DBT. What is it? Who for? What requirements? Any exclusions?
structured therapy for BPD/self-harm combining acceptance + change via individual sessions, group skills, phone coaching, and therapist support. Essence Structured CBT-derived therapy combining skills training, mindfulness, and validation with behavioural change strategies; designed for BPD/self-harm. What it involves Weekly individual therapy (behavioural analysis, goal setting, diary card review). Weekly group skills sessions (mindfulness, distress tolerance, emotion regulation, interpersonal effectiveness). Between-session phone coaching for skills generalisation. Therapist consultation team to support adherence and prevent drift. Inclusion BPD or traits with chronic suicidality/self-harm, emotional dysregulation, able and willing to commit. Exclusion Uncontrolled psychosis/mania, severe LD, unstable dependence, refusal to engage. Key terms Dialectics (acceptance + change), validation, chain analysis, diary cards, life-worth-living goals
107
# Seclusion review What review pattern What core health items Meication nuances Red flags
Seclusion review - adult inpatient (hard-to-remember essentials) * Red flags → escalate to med/ED: airway/respiratory compromise, over-sedation, hyperthermia/rigidity (NMS), head injury, severe intox/withdrawal. * Must-do baselines: NEWS2, capillary glucose; ECG if QT risk; U\&Es ± CK if restraint/IM antipsychotic or NMS suspected. * RT monitoring: after rapid tranquillisation check pulse/BP/RR/temp/O₂ sats/level of consciousness ≥hourly (q15 min if high risk) until stable. * Antipsychotic QT rule: avoid if QTc ≥500 ms. * High-risk drug combo: never give IM olanzapine within 1 hour of an IM benzodiazepine. * Medication hierarchy: oral first (lorazepam 1-2 mg PO; or olanzapine 5-10 mg PO). If IM needed: lorazepam 1-2 mg IM; or haloperidol 2.5-5 mg IM + promethazine 25-50 mg IM. Typical haloperidol max 10-20 mg/24 h (check BNF). * Legal authority: document capacity and treatment power (MHA Part IV or MCA best interests). Offer IMHA.
108
rTMS
Indications: NICE - treatment-resistant depression (≥1-2 failed trials). Occasionally perinatal/older adults. Not routine for OCD, psychosis, pain. Contraindications: Metal/electronic cranial implants (absolute). Caution: epilepsy, intracranial lesions, mania risk, seizure-threshold-lowering meds, substance withdrawal. Procedure: Outpatient, no anaesthesia, daily x 4-6 wks. Localise DLPFC via motor threshold. High-freq left DLPFC (10 Hz), low-freq right (1 Hz) if anxiety prominent, or iTBS (~3 min). Efficacy: Response ~40-60%, remission ~25-35%. May require maintenance. Adverse effects: Common - headache, scalp discomfort, facial twitching. Rare - seizure (<0.5%), mania, hearing change. Safeguards: Written consent, TMS safety checklist, ear protection, seizure/emergency protocol, daily monitoring of mood/suicidality/mania. Review meds for seizure risk.
109
PErinatal lihtium
Personalised risk plan - specigfic early warning signs Lithiyum: Overall risks like miscarriage/prematurity are unclear. Older studies suggested a small rise in certain heart defects; more recent data show if there is a risk, it’s small. Historically Ebstein’s anomaly was quoted as ~1 in 1,000 vs ~1 in 20,000 background; newer work suggests the increase is much smaller. Newborns can be sleepy, feed poorly, or floppy for a short time-so we plan neonatal monitoring.
110
Perinatal Methadone
“Because you’re stable, continuing methadone is safest; it’s not known to be teratogenic.” “Stopping now carries risks-miscarriage if done early, premature birth/stillbirth late. If you still wished to stop, the safest window is the 2nd trimester with specialist supervision.” “After birth, some babies get neonatal abstinence syndrome from day 2 onwards-poor feeding, vomiting/diarrhoea, yawning/sneezing, high-pitched cry, poor sleep; seizures are rare. The neonatal team will monitor and treat.” “Breastfeeding is encouraged and can lessen NAS; we’d only pause if unsafe meds/illicit use.” “As pregnancy progresses, your body clears methadone faster-we may increase the dose in the 3rd trimester.”
111
112
Safety Planning what extra info What process
Characterise the problem: Suicidal thoughts / other How often + Time of day Triggers + Ameliorators DSH / suicide history Ego syntonic/ dystonic - dislike? fear of acting? 5 STEPS 1. identify triggers 2. Identify warning signs 3. early actions to prevent Ask if they know relaxation, breathing, or grounding techniques? If not suggest they learn one. Offer to teach box breathing or physiologic sigh. Help generate ideas with them (avoid putting words in their mouth) 4. late actions if thoughts come on Document people they can speak to Get pre agreement with them Traffic light system with friends Samaritans / Shout / 111 op 2 Crisis Cafe - evenings Emergency Department 5. Risk management explore access to means - do you have meds at home? Want to avoid accidental harm - keep means away
113
MCI DX + Mx | FB
**MCI to Husband - Dx & Mgmt ** **State up front** * MCI = memory below age‑expected; **function intact**. * **ACE‑III 80/100**; normal ≈ **82-88**. * Bloods/HADS normal → reversible causes unlikely. **Risk** * Progression to dementia ≈ **5-15%** over a few years; many **don’t progress**. **Medications** * **No anti‑dementia drugs** in MCI. * **Vitamins B/C/E/multivitamins:** no evidence unless deficiency. **Management (3 levers; 30-40 s)** * **Body:** regular exercise; control BP/diabetes/lipids; prioritise sleep; minimise alcohol/drugs. * **Mind:** learn something **new** (not long‑mastered puzzles). * **Routine:** memory aids, structured day; **check hearing/vision**. **Safety/Practical** * Gas/electrical safety, medication prompts. * **Driving:** notify **DVLA**; follow their guidance. **Follow‑up & safety‑net** * **Review at 6-12 months** to repeat testing and assess functioning. * Seek earlier review if **getting lost**, new **behaviour/personality change**, **safety issues/falls**, or **rapid decline**. **Time trim & pitfalls** * Compress lifestyle counselling to one concise “three‑levers” block.
114
# Older adult BPSD in Alz : Dx Mx | FB
- Rule out pain, infection, constipation, delirium; review meds (anticholinergics, benzos). - Non‑pharmacological first line: personalised activities, environmental tweaks, carer support, sleep hygiene. - If severe distress/risk: short trial of antipsychotic (lowest dose, time‑limited), with informed consent and regular review. In LBD/Parkinson’s, avoid antipsychotics where possible—quetiapine (or clozapine specialist) if essential. Consider AChE inhibitors (e.g., rivastigmine) in LBD/PDD. - Discuss stroke/mortality risks; plan deprescribing and physical health monitoring. - [NICE NG97; BNF]
115
# older adult Violent older person Risk Ax | FB 5.5
**Gaps to plug** * FTD features not screened: apathy/empathy loss; repetitive/rituals; hyperorality/sweet cravings; language; motor; inattention/rigidity. * Differentials not screened: delirium/infection, stroke/TIA, head injury/seizures, mood/psychosis. * Immediate safeguarding omitted: where is he now, safe to go home, who’s with him, weapons/tools access. * Risk detail thin: who/what re sexual risk, frequency/escalation; finances/driving/supervision. **Do this (scripts)** 1. **Safeguarding first:** “Are you safe now? Where is Aubrey? Safe to go home tonight? Any weapons/tools? Need injuries checked?” 2. **30‑sec bvFTD micro‑screen:** loss of empathy/drive? new rituals? eating/sweet changes/hyperorality? language problems? motor slowing/stiffness/balance? attention/rigidity? 3. **Risk scaffold:** **Others** (who/what/how often/escalation) → **Self** → **Vulnerability** (exploitation, finances, driving) → **Forensic** → **Means**. 4. **Close with plan:** immediate safety + injury review; medical work‑up for reversible causes; specialist assessment for suspected FTD; safeguarding referral (consent); safe plan for tonight.
116
# older adult DLB Dx Mx | FB 5.4
**DLB (Lewy Body Dementia): CASC Flashcard (<200 words)** **Diagnosis - say in 25s** “DLB is a dementia where **Lewy bodies (α-synuclein)** damage brain cells. Expect **vivid visual hallucinations**, **good-bad days** of thinking (fluctuations), and possible **parkinsonism**. A **DaT scan supports**-but **doesn’t prove**-DLB.” **Key features to name** Hallucinations * **Fluctuating cognition** * Parkinsonism (rigidity/bradykinesia ± tremor) * **REM sleep behaviour disorder** * Falls/syncope. Dx nuance: **Cognition → motor = DLB**; **Motor → cognition = Parkinson’s disease dementia**. **Management (essentials)** * **No cure**; aim symptom control. * **First-line:** AChE inhibitor (donepezil/rivastigmine/galantamine). * **Second-line:** **Memantine** (esp. behaviour). * **Critical safety:** **Avoid antipsychotics** (neuroleptic sensitivity; can be fatal). If unavoidable: **lowest-risk, tiny dose, close monitoring**. * **Parkinson’s meds** only if disabling motor symptoms emerge. * **Non-drug:** activity, routine, reminiscence; **delirium prevention** (bowels, UTIs, hydration, sleep). **Risk → Action (30-40s checklist)** 1. **Driving:** stop; **DVLA** advice.
117
118
# Older ADult Alzheimer’s explanation & management | FB 5.2
* **Dx frame:** Dementia = umbrella; **Alzheimer’s** = commonest. Protein plaques/tangles → synaptic failure → atrophy (**hippocampal/parietal**; matches MRI). * **Trim to win time:** Compress bloods/HADS/MRI to one line; redirect \~30-40 s to **meds** + **concrete social plan**. * **Meds (≈30 s):** **AChE-Is** (*donepezil, rivastigmine, galantamine*). Not curative; **may modestly slow decline** and improve symptoms. **Start low, go slow.** **SEs:** GI (nausea/diarrhoea), **bradycardia/syncope**, insomnia/vivid dreams. **Interactions:** anticholinergics. **Monitoring:** pulse/BP ± **ECG** if brady/syncope; review **4-8 weeks**. **Alternative:** **memantine** (AChE-I not tolerated/contraindicated; moderate-severe AD). * **Psych:** Cognitive stimulation; reminiscence; music/art; keep routine; avoid isolation. * **Social plan (one-breath ladder):** **OT home-safety**, **care needs assessment**, **compliance aids** (dosette/blister), **risk mitigation** (falls/wandering/gas/**driving**), step-up settings (sheltered → residential → nursing), **carer assessment/support group**, **written info + named contact**, consider **LPA** (health/welfare; property/finance). * **Follow-up:** schedule reviews; revisit risks, meds efficacy/SEs, supports.
119
# older adult Vascular Dementia - Explanation and Management | FB 5.3
1. **Dx summary:** Dementia = progressive impairment; **vascular** = blood-vessel damage; **stepwise** decline. 2. **Rule out delirium (mini-collateral):** rapid onset? day-to-day **fluctuation**? reduced **alertness**? infection red flags (fever/UTI/chest), pain, falls. 3. **Investigations → Dx:** MRI **small-vessel disease** (periventricular/deep WM hyperintensities); ACE-III **68/100**; HADS low; bloods/urine **normal**. 4. **Driving & legal:** **Stop driving now**; inform **DVLA** and **insurer**; arrange formal driving assessment. 5. **Secondary prevention (core):** Tight **BP** & **lipids**; **antiplatelet/statin** if indicated; **smoking cessation**; **diabetes** control; weight, exercise, diet. 6. **Medicines:** **AChE inhibitors not indicated in *pure* VaD** (consider if **mixed**); treat mood/anxiety if present. 7. **Inheritance:** Not directly inherited; **risk factors** (DM, lipids, HTN) can run in families-encourage screening/lifestyle. 8. **Social/functional:** **OT** home safety, wandering/meds prompts, gas safety; home care/adaptations; **carer support**, charities/befriending; help with **finances**. 9. **Prognosis:** Progressive, often **stepwise**; aim to **prevent further events** and maintain independence.
REvise NEU
flashcards
Decks in class (9)
# Cards
Brainscape helps you reach your goals faster, through stronger study habits.
© 2026 Bold Learning Solutions. Terms and Conditions