Psychiatry
Management of moderate depression
1. Prescribe an SSRI
2. If ineffective for at least 2-4 weeks → check adherence
3. Increase the dose
4. Change to a different SSRI
5. Try alternative class of antidepressant (atypical antidepressants → Mirtazapine)
- Antidepressants should usually show effect in 1-2 week, if no effect after 2-4 weeks → check adherence
- With good response to SSRIs → Continue for at least 6 months after remission as this reduces relapse
- Patients who had 2 or more depressive episodes in the recent past and who experienced significant functional
impairment during episodes → Continue for 2 years
- When stopping SSRIs, the dose should be reduced over a 4-week period
- If the patient stopped medications abruptly and experiencing delusions → Neuropsychiatric analysis
Hospital management for depression
1. Admission to the psychiatric ward
2. investigations
3. Treatment with SSRIs or SNRIs
4. Augmentation with lithium with CBT
5. If nothing works → ECT
Reasons for hospital admission
• Serious risk suicide
• Serious risk of harming others
• Significant self-neglect
• Severe depressive or psychotic symptoms
• Lack or breakdown of social support
• Initiation of Electroconvulsive therapy (ECT)
• Treatment-resistant depression (where inpatient monitoring may be helpful)
- High mood alone in the question (no mention of low mode at all) → Hypomania
- Low mode alone in the question (no mention of high mode at all) → Depression
- High mode and low mode (depression) (no matter time in between) → Bipolar
- High mode with hallucinations and delusions → Mania
- Mania and hypomania are distinguished by hallucinations and delusions in Mania
Risk factors for suicide
• Previous suicide attempts
• Previous self-harm
• Depression and other mental health problems
• Alcohol and drug abuse
• Low socio-economic status
PLABverse - 1
, Psychiatry
Bipolar affective disorder (Manic depression)
➢ Classically, periods of prolonged and profound depression alternate with periods of excessively elevated and
irritable mood, known as mania
Features
• Decreased need for sleep Cyclothymic disorder → milder form of bipolar lasting 2 years,
fluctuating from mild depressive and hypomanic symptoms
• Pressured speech
• Increased libido
• Reckless behavior without regard for consequences
• Grandiosity
• More talkative than usual
These symptoms of mania would alternate with depression
Treatment
• Mood stabilizers → Lithium- Despite problems with tolerability, lithium still remains the gold standard in the
treatment of bipolar affective disorder
Mood stabilizers (LCVL): Lithium, Carbamazepine, Valproic acid, Lamotrigine
Points about lithium
- Don NOT offer lithium to women who are planning a pregnancy or currently pregnant, unless antipsychotic
medication has not been effective
- If a woman taking lithium becomes pregnant consider stopping the drug gradually over 4 weeks
- If a woman continues taking lithium during pregnancy, check plasma lithium levels every 4 weeks, then
weekly from the 36th week and adjust the lithium dose to maintain plasma lithium levels at a therapeutic
dose
Tetralogy of lithium
- Ebstein anomaly of the heart
- Floppy baby $
- Thyroid abnormalities
Mania vs Hypomania
PLABverse - 2
, Psychiatry
Schizophrenia
1. Auditory hallucinations
• Third-person auditory hallucinations → voices are heard referring to the patient as ‘he’ or ‘she’, rather
than ‘you’
• Thought echo → an auditory hallucination in which the content is the individual’s current thoughts
- Hearing thoughts after being produced → Echo de la pensée
- Hearing thoughts at the same time or before as thought being produced → Gedankenlautwerden
• Voices commenting on the patient's behavior
2. Thought disorder
• Thought insertion → The delusional belief that thoughts are being placed in the patient’s head from
outside
• Thought withdrawal → The delusional belief that thoughts have been 'taken out' of his/her mind
• Thought broadcasting → The delusional belief that one’s thoughts are accessible directly to others
• Thought blocking → a sudden break in the chain of thought
3. Passivity phenomena
• Bodily sensations being controlled by external influence
4. Delusional perceptions
• A two-stage process where first a normal object is perceived then secondly there is a sudden intense
delusional insight into the object's meaning for the patient e.g. 'The traffic light is green therefore I am the
King'
Management
1. Antipsychotics
- 1st → olanzapine or risperidone
- If rapid tranquillization is needed → Diazepam
Tardive dyskinesia
- Continuous involuntary movements of the tongue and lower face
- Caused by long-term use of antipsychotic drugs
- Often reported by family members as patients are often unaware of these movements
Atypical antipsychotics have lower risk of TD:
1. Risperidone (tabs, injections) → better for incompliant patient (Depot, long-acting injections)
2. Olanzapine (tabs)
Tardive dyskinesia can be treated by → Tetrabenazine
o Drug-induced parkinsonism → 1 week after starting anti-psychotic
o Akathisia → 1 month after starting antipsychotics
o Tardive dyskinesia → months-years after starting antipsychotics
Paranoid personality disorder
• Hypersensitivity and an unforgiving attitude when insulted
• Unwarranted tendency to question the loyalty of friends
• Reluctance to confide in others
• Preoccupation with constitutional beliefs and hidden meaning
• Unwarranted tendency to perceive attacks on their character
PLABverse - 3
Management of moderate depression
1. Prescribe an SSRI
2. If ineffective for at least 2-4 weeks → check adherence
3. Increase the dose
4. Change to a different SSRI
5. Try alternative class of antidepressant (atypical antidepressants → Mirtazapine)
- Antidepressants should usually show effect in 1-2 week, if no effect after 2-4 weeks → check adherence
- With good response to SSRIs → Continue for at least 6 months after remission as this reduces relapse
- Patients who had 2 or more depressive episodes in the recent past and who experienced significant functional
impairment during episodes → Continue for 2 years
- When stopping SSRIs, the dose should be reduced over a 4-week period
- If the patient stopped medications abruptly and experiencing delusions → Neuropsychiatric analysis
Hospital management for depression
1. Admission to the psychiatric ward
2. investigations
3. Treatment with SSRIs or SNRIs
4. Augmentation with lithium with CBT
5. If nothing works → ECT
Reasons for hospital admission
• Serious risk suicide
• Serious risk of harming others
• Significant self-neglect
• Severe depressive or psychotic symptoms
• Lack or breakdown of social support
• Initiation of Electroconvulsive therapy (ECT)
• Treatment-resistant depression (where inpatient monitoring may be helpful)
- High mood alone in the question (no mention of low mode at all) → Hypomania
- Low mode alone in the question (no mention of high mode at all) → Depression
- High mode and low mode (depression) (no matter time in between) → Bipolar
- High mode with hallucinations and delusions → Mania
- Mania and hypomania are distinguished by hallucinations and delusions in Mania
Risk factors for suicide
• Previous suicide attempts
• Previous self-harm
• Depression and other mental health problems
• Alcohol and drug abuse
• Low socio-economic status
PLABverse - 1
, Psychiatry
Bipolar affective disorder (Manic depression)
➢ Classically, periods of prolonged and profound depression alternate with periods of excessively elevated and
irritable mood, known as mania
Features
• Decreased need for sleep Cyclothymic disorder → milder form of bipolar lasting 2 years,
fluctuating from mild depressive and hypomanic symptoms
• Pressured speech
• Increased libido
• Reckless behavior without regard for consequences
• Grandiosity
• More talkative than usual
These symptoms of mania would alternate with depression
Treatment
• Mood stabilizers → Lithium- Despite problems with tolerability, lithium still remains the gold standard in the
treatment of bipolar affective disorder
Mood stabilizers (LCVL): Lithium, Carbamazepine, Valproic acid, Lamotrigine
Points about lithium
- Don NOT offer lithium to women who are planning a pregnancy or currently pregnant, unless antipsychotic
medication has not been effective
- If a woman taking lithium becomes pregnant consider stopping the drug gradually over 4 weeks
- If a woman continues taking lithium during pregnancy, check plasma lithium levels every 4 weeks, then
weekly from the 36th week and adjust the lithium dose to maintain plasma lithium levels at a therapeutic
dose
Tetralogy of lithium
- Ebstein anomaly of the heart
- Floppy baby $
- Thyroid abnormalities
Mania vs Hypomania
PLABverse - 2
, Psychiatry
Schizophrenia
1. Auditory hallucinations
• Third-person auditory hallucinations → voices are heard referring to the patient as ‘he’ or ‘she’, rather
than ‘you’
• Thought echo → an auditory hallucination in which the content is the individual’s current thoughts
- Hearing thoughts after being produced → Echo de la pensée
- Hearing thoughts at the same time or before as thought being produced → Gedankenlautwerden
• Voices commenting on the patient's behavior
2. Thought disorder
• Thought insertion → The delusional belief that thoughts are being placed in the patient’s head from
outside
• Thought withdrawal → The delusional belief that thoughts have been 'taken out' of his/her mind
• Thought broadcasting → The delusional belief that one’s thoughts are accessible directly to others
• Thought blocking → a sudden break in the chain of thought
3. Passivity phenomena
• Bodily sensations being controlled by external influence
4. Delusional perceptions
• A two-stage process where first a normal object is perceived then secondly there is a sudden intense
delusional insight into the object's meaning for the patient e.g. 'The traffic light is green therefore I am the
King'
Management
1. Antipsychotics
- 1st → olanzapine or risperidone
- If rapid tranquillization is needed → Diazepam
Tardive dyskinesia
- Continuous involuntary movements of the tongue and lower face
- Caused by long-term use of antipsychotic drugs
- Often reported by family members as patients are often unaware of these movements
Atypical antipsychotics have lower risk of TD:
1. Risperidone (tabs, injections) → better for incompliant patient (Depot, long-acting injections)
2. Olanzapine (tabs)
Tardive dyskinesia can be treated by → Tetrabenazine
o Drug-induced parkinsonism → 1 week after starting anti-psychotic
o Akathisia → 1 month after starting antipsychotics
o Tardive dyskinesia → months-years after starting antipsychotics
Paranoid personality disorder
• Hypersensitivity and an unforgiving attitude when insulted
• Unwarranted tendency to question the loyalty of friends
• Reluctance to confide in others
• Preoccupation with constitutional beliefs and hidden meaning
• Unwarranted tendency to perceive attacks on their character
PLABverse - 3
