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Drugs Used in the Treatment of Psychiatric and Sleep Disorders

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Sleep disorders and psychiatric illness are common problems in primary care. This module is designed to assess knowledge on the treatment of psychiatric disease and sleep disorders. Composed of 10 questions relating to typical clinical scenarios, completion will provide 1 hour of CPD to include in your annual appraisal.

On completion of this resource the user should be able to increase understanding of:

The treatment approaches to common psychiatric disorders

The approaches to the treatment of sleep disorders

Sleep disorders are a common problem in primary care as is psychiatric disease. This module is designed to assess knowledge on the treatment of psychiatric disease and sleep disorders. Composed of 10 questions relating to typical clinical scenarios, completion will provide 1 hour of CPD to include in your annual appraisal.

On completion of this resource the user should be able to:

Understand the treatment approaches to common psychiatric disorders

Understand the approaches to the treatment of sleep disorders.

A 43 year old woman is diagnosed with depression and seeks treatment. She does not want to commence

There is some evidence to suggest that St John's wort is effective in the treatment of depression, some studies suggesting that is can be as effective as some anti-depressants. However, NICE guidelines state that it should not be prescribed by practitioners due to a lack of certainty about appropriate doses, variation in preparations and serious potential interactions with other common drugs including the oral contraceptive pill, anticoagulants and anticonvulsants. It is important to note that St John's wort should not be taken in combination with other anti-depressants.

Question 1

A 56 year old woman is being treated for acute paranoid delusions associated with a schizophrenia. Which of the following medications would be used to treat this condition?

Haloperidol is an anti-psychotic agent which has frequently been used in the treatment of schizophrenia. The drug is associated with extra-pyramidal side effects as it is a dopamine antagonist, producing Parkinson's like effects with chronic exposure. Haloperidol is part of a group of drugs known as typical antipsychotics which are being used less and less frequently due to the improved side effect profile of the newer 'atypical' antipsychotics.
Oral atypical antipsychotic drugs amisulpride, olanzapine, quetiapine, risperidone and zotepine are considered to be first-line treatments for individuals with newly diagnosed schizophrenia. They have less extra pyramidal side effects but can cause sedating side effects and weight gain.

Question 2

A 44 year old male is diagnosed with bipolar disorder as his family has been concerned about his change in behavior, mood swings, excessive spending and disinhibition. Which of the following drugs would be typically used in the treatment of this condition?

This patient has bipolar disorder as exemplified by dis-inhibition and excessive spending - typical of a manic episode. These patients may also often experience depressive episodes with feelings of intense low mood and despair, along with episodes of extreme happiness and elation at other times. Lithium is a common treatment for this disorder and is used as a mood stabilizer. Lithium is associated with side effects such as ataxia, thirst and polyuria as well as hypothyroidism. Olanzapine is also recommended by NICE, as is sodium valproate. Sodium valproate should be used with care in women of child-bearing age - they should be given adequate contraception and strongly advised against becoming pregnant whilst on the drug. Sodium valproate is a teratogen - it can disturb the development of an embryo or foetus and can cause the baby to have severe birth defects.

Question 3

A 55 year old female is diagnosed with depression after presenting to the practice with low mood, fatigue and frequent episodes of being tearful. Which of the following is an appropriate treatment?

Selective serotonin re-uptake inhibitors (SSRIs) are a commonly used class of drug in the treatment of depression superseding tricyclic antidepressants such as amitriptyline as first line agents. They are generally very effective treatments with few side effects and a good safety profile. SSRIs work by inhibiting the reuptake of the mood lifting chemical serotonin in the synapses between nerves. This allows more serotonin molecules to be in the synaptic space causing more stimulation of the receptors and leading to an increase in mood.

Question 4

A 36 year old female presents with problematic restless legs, particularly at night, which keep her awake. She has an irresistible urge to wriggle her legs. She is diagnosed with restless leg syndrome. Which of the following would be the most appropriate therapy?

Restless legs syndrome is quite a common disorder and is associated with the disturbed sleep and fatigue. The problem should first be approached with advice on reducing coffee, alcohol intake and exercise. Drug treatment with dopamine agonists such as ropinirole can often help.

Question 5

A 62 year old female presents with a 5 month history of poor, disturbed and unrefreshing sleep. She has difficulty getting off to sleep, as well as waking early and has tried a number of lifestyle changes but without success. She asks if there is anything that she might take that could help her get to sleep as she feels exhausted?

The approach to insomnia, which is a particularly common problem in clinical practice, should be one of a careful history, trying to ascertain what the problems might be related to and advice relating to how to change behavior eg cognitive behavioral therapy, exercise, reducing caffeine/alcohol etc. Generally the newer, less sedative benzodiazepines or 'Z drugs' like zopiclone (a non-benzodiazapine hypnotic) are the recommended first line agents if sleeping tablets are considered necessary. Soporifics are usually prescribed only for short periods (i.e. 7 days) or for intermittent use, to avoid the development of dependence or tolerance.

Question 6

A 78 year old male attends clinic with his wife, as both have been concerned regarding his deteriorating memory and changeable mood. It is likely that he has the early stages of dementia. He is being referred to a memory clinic. Which of the following medications would he be likely to be treated with for Alzheimer's disease?

Drugs such as Donepezil (Aricept), which is an anticholinesterase inhibitor, have been shown to improve cognitive ability and attenuate the decline of cognitive function and progression of dementia.Donezepil works by increasing the amount of acetylcholine in the brain, a substance known whose amounts are known to be reduced in patients suffering from Alzheimer's.

Question 7

A 39 year old woman presents with problems with anxiety. She has had an anxiety disorder for some time. Which of the following medications would be appropriate for anxiety disorder?

This woman has an anxiety disorder requiring treatment. The most appropriate drug is venlafaxine, a selective noradrenergic reuptake inhibitor that is particularly useful in the treatment of generalised anxiety disorder. Venlafaxine can cause gut disturbances, dry mouth, difficulty in sleeping or insomnia, and abnormal dreams, amongst other side effects. This drug should not be taken within 2 weeks of taking and monoamine oxidase inhibitors (MAOIs), another group of antidepressants, due to their potentially dangerous interaction.

Question 8

An 82 year old is being treated in a nursing home for dementia. She has associated disruptive behaviour and is extremely agitated. Which of the following would be most appropriate regarding treating the behavioural problem?

In this patient's case with behavioural issues associated with advanced dementia, the most appropriate treatment would be the antipsychotic drug, quetiapine. This drug should be used with care in demented patients, however, only when really necessary. Antipsychotics are used in demented patients to help manage psychological and behavioural disturbances such as aggression, agitation and sleep disturbances.

The over use of antipsychotics in dementia patients

Question 9

A 55 year old man presents with problems with sleep for the last 2 months. He has difficulty getting off to sleep and also wakes early often associated with pressures of work. He finds that it is impacting upon his work. He doesn't want to take any prescribed medication as yet but is keen to try some over the counter treatment. Besides advice, which of the following could you recommend for this man?

In this patient it is important to firstly provide advice on how to improve the quality of sleep and reduce stress - he should be told how to improve his sleep hygiene. There is evidence to show that melatonin is an effective treatment for circadian sleep disturbance. It is should only really be used in periods up to 13 weeks and is licensed for patients 55 years of age and older.

Drugs Used in the Treatment of Psychiatric and Sleep Disorders

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