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Table37.1Parametersforinitiatingandmonitoringpsychiatricmedications

Test Antipsychotics Lithium Valproate Lamotrigine

Pulseandblood pressure

Atinitiationandatevery dosechange

Every6 monthsand thenannually

Atinitiation

Weight/BMI Atinitiation,thenweekly

for6weeks,thenat12 weeks

Atinitiation,thenevery6 months

Atinitiation, after6months, andthen annually

Blood glucose/HbA1c/lipids

Atinitiation,then12 weeksafterstarting

Druglevels Initiation:

1weekafterstarting 1 week after every dose change Weeklyuntillevelsarestable

Monitoring:

Every 3 months for 1 year, then every 6 months Alternatively,every3monthsifhighriskof toxicity, e.g. elderly, taking interacting medications, impaired renal or thyroid function

Onlyif evidenceof toxicityor ineffectiveness

FBC Atinitiation Atinitiation,

after6months, andthen annually

Atinitiation

LFT Atinitiation,

after6months, andthen annually

Atinitiation

U&E/eGFR Atinitiation,thenevery6

months

Atinitiation

TFTandcalcium Atinitiation,thenevery6

months

ECG Atinitiationif

cardiovascularrisk, inpatient,or recommendedby manufacturer

Atinitiationifcardiovascular risk

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Specialconsiderations

Electroconvulsivetreatment

Shouldbeconsideredforseveremaniathathasnotrespondedtoothertreatments.

Youngpeopleundertheageof18

ShouldbemanagedbyaspecialistCAMHSservice.

Furtherreading

1.MedicinesandHealthcareproductsRegulatoryAgency(2018,updated2021).Valproateusebywomen andgirls.Availableat:https://www.gov.uk/guidance/valproate-use-by-women-and-girls

1AmericanPsychiatric Association.(2013).Diagnosticandstatistical manual ofmentaldisorders(5th

ed.).https://doi.org/10.1176/appi.books.9780890425596

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Chapter38

Depression

Guideline: This chapter was based on: NICE CG90 (Depression in adults:

recognitionandmanagement):https://www.nice.org.uk/guidance/cg90.Since thechapterwaswritten,theguidelinehasbeenupdatedandreplacedwithon NICE NG222 (Depression in adults: treatment and management):

https://www.nice.org.uk/guidance/ng222. Please see the approach to

managementinNG222.

OUPdisclaimer:OxfordUniversity Press makesno representation, express or implied, that the drugdosagesarecorrectand thatthe recommendations are an exclusive or mandatory course of care. All health professionals readingthistexthavearesponsibilitytoevaluateitsappropriatenessandtake theindividualneedsofthepatientintoaccount.

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

Depression isthe mostcommon psychiatric disorder. It is frequently managed by nonspecialists,soagoodunderstandingofsymptomsandbasicmanagementisimportantfor allmedicalprofessionals.

Diagnosis

History/diagnosticcriteria

Usethefollowingscreeningquestionstostartanassessment:

Haveyoufeltdepressed,lowinmood,orhopelessinthelastmonth? Haveyouhadlittlepleasureorinterestindoingthingsinthepastmonth?

Iftheanswertoeitherquestionisyes,thepatientshouldbeassessedmorefully.

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Consider using a validated measure such as the PHQ-9 questionnaire (available at

https://www.mdcalc.com/phq-9-patient-health-questionnaire-9).

Historyshouldconsidersymptoms,durationofsymptoms,andtheextentoffunctional

impairmentthatthesymptomsarecausing.

Symptoms:

Persistentlowmood Lossofinterest/pleasure Fatigue Worthlessnessorexcessiveguilt Suicidalthoughts Poorconcentrationorindecision Psychomotorretardationoragitation Insomniaorhypersomnia Changesinappetiteorweight Psychoticsymptoms.

Consider whether the patient has any history of mood elevation, i.e. whether the depressionmayactuallybepartofbipolardisorder(seeChapter37).

Severityofdepression

Subthreshold=fewerthanfivesymptoms,noclearfunctionalimpairment Mild=approximatelyfivesymptoms,onlymildfunctionalimpairment Moderate=symptomsandimpairmentbetweenmildandsevere Severe=mostsymptoms,markedfunctionalimpairment,withorwithoutpsychoticsymptoms.

Thehistoryshouldalsoinclude:

Previoushistoryofdepressionandtreatmentstrialled Psychiatricandmedicalhistory Interpersonalrelationships Socialcircumstances Alcoholanddrugabuse Riskofsuicideandself-harm(seeChapter44).

Ifthepatientisatimmediateriskofsuicideorself-harm,referurgentlytospecialist services.

Examination

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Amentalstateexaminationmayrevealthesymptomslistedpreviously. Ageneralphysicalexaminationshouldalsobeperformedtoconsideralternativeexplanationsfor depression, e.g. hypothyroidism (see Chapter 23), hypoadrenalism (see Chapter 14), hypercalcaemia(seeChapter16).

Investigations

Nospecificinvestigationisrequired,althoughsomeinvestigationsmaybeusefultohelpeliminate differentialdiagnoses,e.g.TFT,calciumlevels.

Management

Managementstages

Stage1:anypresentationofdepression:

Identification,assessment,education,activemonitoring

Stage2:persistentsubthresholdormild–moderatedepression:

Low-intensitypsychologicalinterventions

Stage3:depressionwithpoorresponsetostage2managementORmoderate–severedepression:

High-intensitypsychologicalinterventionsand/orpharmacologicaltreatment

Stage4:severedepressionORhighriskofself-harmorself-neglectORcomplexcomorbidities:

specialisttreatment.

Patienteducation

Givepatientsdetailsofself-helpandsupportgroups Ensurepatientsandcarersarebothawareofhowtoaccesshelpwhenneedede.g.crisisteams StJohn’swortisnotrecommendedduetoariskofseriousinteractions,anda lackofevidence regardingdosing.

Lifestyleandsimpleinterventions

Sleephygiene,e.g.establishingregularsleepandwaketimes,avoidingalcoholbeforesleep.

Stage1

Activemonitoringshouldbeconsideredforpatientswhorefuseintervention,orwhomayrecover withoutintervention Provideinformationandreviewin2weeks Ensurecontactismadeifpatientfailstoattendfollow-up.

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Psychologicalinterventions

Stage2

If no improvement with stage 1, offer one or more of the following low-intensity psychologicalinterventions:

Self-help GrouporcomputerizedCBT Structuredgroupphysicalactivityprogramme.

Stage3

The following high-intensitypsychologicalinterventions should be used in conjunction withmedication.Theyshouldalsobeusedifstage2treatmentswereunsuccessful:

CBT Interpersonaltherapy Behaviouralactivation(aformoffunctionalanalyticpsychotherapy) Behaviouralcouplestherapy.

Pharmacologicalmanagement

Pharmacological management is used for stage 3 patients, in conjunction with a highintensitypsychologicalintervention.Itshouldalsobeconsideredfor:

Stage2patientswithahistoryofmoderate–severedepression Long-term(>2years)subthresholdpatients Stage2patientswhohavenotrespondedtootherinterventions.

Antidepressantprescribing

SSRIs (e.g. fluoxetine, paroxetine, sertraline, citalopram) are first line. Considerations whenpickingandprescribingamedicationincludethefollowing:

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Interactions—fluoxetineandparoxetinearemorelikelytocauseinteractionsthanotherSSRIs Discontinuationsymptoms—morelikelywithparoxetine Sideeffects:

Considerthelikelihoodofthepatientstoppingthedrugduetosideeffects Sometimesitmaybehelpfultoco-prescribeabenzodiazepineforupto2weekstohelpwith theinitialsideeffectsofanxietyandagitation SSRIs increase the risk of GI bleeding, so co-prescribing gastroprotection should be

considered Monitoringrequirements,e.g.monitoringforhypertensionwithvenlafaxineandduloxetine Time to effect—the patient should be made aware that it takes time for the full effect to be achieved,usuallyatleast2weeks Alternative options, e.g. tricyclic antidepressants (TCA). Combinations of medication may be consideredontheadviceofaconsultantpsychiatrist.

Consider toxicity in the event of overdose when prescribing, and whether the quantityof drugsuppliedat anygiven time shouldbe limited inthe interests of patientsafety.

Switchingantidepressants

Ifaswitchisneeded,itispreferabletoswitchtoanotherSSRI.Thesecond-lineoptionis to switch to an antidepressant of a different class, e.g. serotonin and noradrenaline reuptakeinhibitors(SNRIs),TCAs,ormonoamineoxidaseinhibitors(MAOIs).

Thefollowingmedicationsrequireparticularcautionwhenswitchingbetweenthem:

Fluoxetinetoanyotherantidepressant—fluoxetinehasalonghalf-life Fluoxetine/paroxetine to a TCA—both medications inhibitthemetabolismofTCAs, so a lower startingdoseshouldbeused SwitchingtoserotonergicantidepressantsorMAOIs—riskofserotoninsyndrome Switching from non-reversible MAOIs—long washout period. Other antidepressants should be avoidedfor2weeks.

Electroconvulsivetherapy

Indications:

Severeorlife-threateningdepression,wherearapidresponseisrequired,orothertreatmentshave failed Moderate depression which has not responded to multiple drug treatments or psychological therapies Previousgoodresponsetoelectroconvulsivetherapyorpatientchoice.

Importantconsiderations:

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Comorbiditiesandanaestheticrisk Side effects: there is some evidence regarding cognitive impairment as an adverse effect, especiallyintheelderly.Thisshouldbereassessedregularly ConsiderwhetherthepatienthascapacitytogiveinformedconsentundertheMentalCapacityAct andwhethertheMentalHealthActisrelevant(seeChapter112forconsentandcapacity) If the patient responds well, an antidepressant (± a mood stabilizer such as lithium) should be startedforrelapseprevention.

Psychosocialconsiderations

Supportcarersandencouragethemtobealerttomoodchangesandsuicidalideationinthepatient Befriending and rehabilitation programmes may be helpful for patients with long-standing moderateorseveredepression.

Monitoringandfollow-up

Ifnotathighriskofsuicide

Followupafter2weeks Ifresponding,followup2–4-weeklyforthefirst3months After3months,increaseintervalsasappropriate.

Ifathighriskofsuicideorage<30years

Followupafter1week,thenasfrequentlyasisappropriate.

Treatmentmonitoring

Ifnoimprovementat2–4weeks,reviewmedicationcompliance Ifminimalimprovementat3–4weeksofusingatherapeuticdose,considerincreasingthedoseor switchingthemedication,andprovidingadditionalpsychologicalsupport Ifthereissomeimprovementat4weeks,continuethetreatmentforafurther2–4weeks.Consider switchingifinadequateresponseorunabletotoleratesideeffects.

Stoppingmedication

Medicationshouldbeusedforatleast6monthspostremission,oratleast2yearsifhighriskof relapse(usuallyattreatmentdose) Informpatientaboutpossiblediscontinuationsymptoms,e.g.insomnia,sweating,restlessness Graduallystopthemedicationoveratleast4weeks(longerifthemedicationhasalonghalf-life) Ifdiscontinuationsymptomsaresignificant,itmaybenecessarytorestartthemedicationandtitrate itdownevenmoregradually Aimforthepatienttobestableonaslittlemedicationaspossible(whichmaybenoneatall).

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Chapter39

Eatingdisorders

Guideline: NICE NG69 (Eating disorders: recognition and treatment):

https://www.nice.org.uk/guidance/ng69

Localtrustguidelines:pleaserefertoyourlocalguidelinesasnecessary.

Overview

The topic of eating disorders includes anorexia, bulimia, and binge eating. Eating disorders involve the patient developing a set of negative beliefs around food, weight, andbodyshape,leadingtoinappropriatebehaviours.Thesebehavioursmayhaveserious consequences, such as osteoporosis and growth stunting, so early recognition and treatmentisimportant.

Diagnosis

History/diagnosticcriteria

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Eatingdisorderscandevelopatanyage,buttheriskishighestbetween13–17years High-riskgroupsincludefashionmodels,dancers,andprofessionalsportspeople Symptomsmayinclude:

Excessivelyfastweightloss

Restrictiveeatingpatternsoralteredeatingbehaviour,e.g.refusingtoeatcertainfoods/food

groups,binging

Food-relatedsocialwithdrawal

Disproportionateconcernaboutweightorshape

Problemsmanagingachronicillnesswheredietaryalterationispartofthemanagement,e.g.

coeliacdisease,T1DM

Menstrualdisturbance

Dizziness,fainting,orpalpitations

Compensatorybehaviours,e.g.laxativeabuse,forcedvomiting

Unexplainedabdominalpain Afullpsychiatricandmedicalhistoryshouldbetaken Discusssubstanceandalcoholabuseandtheriskofself-harm.

Examination

Examination is intended to investigate the consequences and complications of malnutritionorthecompensatorybehavioursthepatientisdisplaying.

Findingsmayinclude:

Anorexia:

Reducedmusclepower

Poorperipheralcirculation

Pallor

Peripheraloedema

Lanugo

Stuntedgrowthorpuberty Bulimia:

Unexplaineddentalerosion

Russell’ssign(callusesontheknucklesduetorecurrentdamagefromtheteethwhentryingto

inducevomiting)

Swollenparotidglands.

Investigations

Bedside

https://t.me/med1917

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