Workbook

Week 1

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 Week 1: Curriculum Topics
1. Patient Interviewing

2. Psychiatry Case Reports

3. Psychiatric History

4. Mental State Examination

5. Physical Examination, Collateral History and Formulation

6. Differential Diagnosis

7. Investigations

8. Management

9. Prognosis

10. Mood (Affective) Disorders

11. Management of Depression

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 Overview of the curriculum topics for week 1
Psychiatry case report headings =
Psychiatry assessment & management pathway
(RCSI Psychiatry Course Book Chapters 1-9)
Psychiatric history
• Introduction.
• Presenting difficulty.
• History of presenting difficulty.
• Past psychiatric history.
• Family history.
o Parental history.
o Siblings.
o Family psychiatric history.
• Past medical and surgical history.
• Alcohol and substance misuse history.
• Current medications.
• Personal history.
o Birth and development.
o Childhood and adolescence.
o Education and literacy.
o Occupational history.
o Relationship history.
o Psychosocial history.
• Forensic history.
• Premorbid personality.

Mental State Examination

• Appearance and behaviour.
• Speech.
• Mood and affect.
• Thought.
• Perception.
• Cognition.
• Insight.

Physical examination

Collateral history

Formulation
• Predisposing factors.
• Precipitating factors.
• Perpetuating factors.

Differential diagnosis

Investigations
• Biological & psychological & social.

Management
• Biological & psychological & social.

Prognosis
• Short-term & long-term factors.

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 Patient is referred to psychiatry

Psychiatric history Mental state Collateral Physical

• Introduction. examination history examination
• Presenting difficulty. • Appearance and
• History of presenting behaviour.
difficulty. • Speech.
• Past psychiatric history. • Mood and affect.
• Family history. • Thought.
o Parental history. • Perception.
o Siblings. • Cognition.
o Family psychiatric • Insight.
history.
• Past medical and surgical
history.
• Alcohol and substance
misuse history.
• Current medications.
• Personal history.
o Birth and
development.
o Childhood and
adolescence.
o Education and
literacy.
o Occupational history.
o Relationship history.
o Psychosocial history.
• Forensic history.
• Premorbid personality.

Formulation
• Predisposing factors.
• Precipitating factors.
• Perpetuating factors.
•

Differential diagnosis

Investigations
• Biological.
• Psychological.
• Social.

Management
• Biological.
• Psychological.
• Social.

Prognosis
• Short-term. 5
• Long-term.
 Components of a psychiatric history

“Functional Human brain MAPping”

Functional → F2 → Family history

→ Forensic history

Human → H → History of presenting difficulty

MAP → M2 → Medical and surgical history

→ current Medications

→ A → Alcohol and substance misuse history

→ P4 → Presenting difficulty
→ Past Psychiatric history
→ Personal history
→ Premorbid Personality

Components of a mental state examination (MSE)

“mental illness IMPACTS on peoples’ mental state”

I → Insight
M → Mood and affect (note: mood has BOTH objective & subjective components)
P → Perception
A → Appearance and behaviour
C → Cognition
T → Thoughts (note this includes BOTH thought content & thought form)
S → Speech

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 Mood (Affective) Disorders
(RCSI Psychiatry Course Book Chapter 10)

Mood (affective)
disorders

Manic Bipolar affective Depressive Recurrent Persistent mood

episode disorder episode depressive (affective)
disorder disorder

• Hypomania. • Current • Mild. • Current • Cyclothymia.

episode episode mild.
hypomanic.

• Current
• Mania +/- • Current • Moderate. episode • Dysthymia.
psychotic episode manic moderate.
symptoms. +/- psychotic
symptoms.

• Current • Current
episode mild or • Severe. episode severe
moderate +/- psychotic
depression. symptoms.

• Current • Currently in
episode severe remission.
depression
without
psychotic
symptoms.

• Current
episode mixed.

• Currently in
remission.

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 Hypomania It is beneficial to teach patients (and their
• Lesser degree of mania,
Manic episode families) to recognise the early warning signs
(i.e. the symptoms are less of illness relapse (i.e. their relapse signature)
pronounced). so that they can seek early treatment (e.g. ↓
• No psychotic symptoms. sleep, ↑ mood/irritability, etc.).

↑ mood (or
Reckless irritability)
spending +/-
psychotic
Big &/or symptoms (i.e.
impractical delusions &
schemes/plans hallucinations)

↑ self-esteem Manic episode ↑ energy

(ICD-10)
Duration of symptoms
must be AT LEAST
ONE WEEK

↓ attention ↑ rate of speech

& distractibility (i.e. pressure of
speech)

↓ social ↓ need for sleep

inhibitions

“Multiple Sclerosis ARISES when myelin is damaged”

Multiple → M → ↑ Mood
Sclerosis → S → ↑ Self-esteem

ARISES → A → ↓ Attention (and distractibility)

R →
I →
S →
E →
S →
↑ Rate of speech (i.e. pressure of speech)
↓ social Inhibitions
↓ Sleep
↑ Energy
↑ Spending and big/impractical Schemes/plans

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 Depression
Aetiology of depression Sleep changes in depression
Biological factors • ↓rapid eye movement
• Biochemical (monoamine) hypothesis of ↓ mood (often
(REM) sleep latency.
depression = ↓monoamines (e.g. 5-HT, NA & worse in
• ↑REM sleep in the EARLY
DA). mornings)
• Genetics.
part of the night.
• ↓brain derived neurotrophic factor (BDNF). • ↓slow wave sleep (‘deep
• Developmental factors (e.g. ↓birth weight, sleep’) = stages 3 & 4 of
impaired neurodevelopment, low premorbid IQ, non-REM sleep.
childhood abuse/neglect, lack of parental care, • Disturbed sleep continuity
parental alcohol dependency). (middle & late insomnia) &
• Organic (e.g. steroids, hypothyroidism, stroke, latency (initial insomnia).
alcohol, chronic pain.) Depression
Psychological factors core symptoms
• Life events (e.g. death of a spouse/significant (ICD-10)
individual in one’s life, break-up of a relationship, Duration of
loss of one’s job, personal illness/injury). ↓ interest
• Learned helplessness. symptoms must be AT &
• Cognitive theory of development: cognitive triad LEAST TWO WEEKS enjoyment in
= person has a negative view of themselves, the activities normally
world and the future. enjoyed
• Personality factors (e.g. neuroticism).
↓ energy
Social factors →
• Unemployment. ↑ fatigability
• Urban > rural. & ↓ activity
• Prognosis of depression
• Untreated depression may last about 6 months to
several years.
Germanwings Flight 4U9525 • 70-80% of people with depression will have repeated
• What motivated the co-pilot of Germanwings Flight 4U9525 episodes, averaging 4-5 times.
to probably intentionally crash a fully occupied plane in • After 1st episode of depression, there is a 60% chance
March 2015? of 2nd episode.
• The public discussion quickly focussed on the diagnosis of • After 2nd episode = 70% chance of having a 3rd, after
depression, which the co-pilot allegedly suffered from several 3rd episode = 90% chance of having a 4th episode.
years previous. • Recurrence more likely in ♀ than ♂.
• The German Association for Psychiatry, Psychotherapy and • Frequency & length of episodes ↑with age.
Psychosomatics (DGPPN), said “it is inappropriate to discuss • ~ 80% of people respond very well to treatment but a
on the basis of incomplete information the possible role of a significant number remain treatment refractory.
mental illness in the alleged decision of the co-pilot to crash • 5-10% of people will eventually have a manic episode
the plane. Information is missing on his life story, personality and develop bipolar affective disorder
development, medical and treatment history, prevailing • ~ 10-15% of depressed people end their lives by
symptoms and treatment, use of medications, prevailing living suicide.
conditions and the specific details of his actions. Only if this • People with major depression have up to a 5 fold 
information were available would it be possible to make a risk of having an MI.
sound diagnosis and a causal attribution. In the public
discussion the impression is being wrongly conveyed that
mental illnesses, in particular one of the most common,
depression, represent a risk to the general population and that
protective measures need to be taken against them….”
Poor prognostic factors for depression
• Insidious onset.
• Early age of onset.
• Male gender.
• Elderly.
• Lower socio-economic group
Epidemiology of depression
(IV & V).
• Prevalence: 8%.
• Neuroticism.
• Gender: before puberty ♀ = ♂; after puberty ♀ > ♂.
• Poor premorbid self-esteem/self-
• Mean age of onset: 27 years.
confidence.
• Marital status: divorced or separated (married status is protective for
• Co-morbid alcohol/substance
both ♀ and ♂).
misuse, personality disorder,
• Socioeconomic group: ↑in lower socioeconomic group (i.e. IV and V). dysthymia (‘double depression’),
• Employment: ↑rates in the unemployed. physical illness.
• Geographical region: urban > rural. • Poor psychosocial support
(B). Other
• symptoms
Seasonal influence: ↑risk of Suicide in Spring and Summer. network.
• Premorbid personality: ↑anankastic personality traits/neuroticism. • Poor response to treatment.

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 ↓ concentration
↓ self-esteem
↓ libido &
self-confidence

Anhedonia Feeling guilty

Depression &
other common worthless
symptoms
ICD-10
Duration of symptoms is
AT LEAST TWO WEEKS
Psychomotor Bleak &
retardation or pessimistic
agitation view of the
future

↓ appetite (+/-
weight loss) Ideas/acts of
↓ sleep self-harm or
(+/- early suicide
morning waking)

Residual depression
• ~ 1/3 of people who suffer from an acute episode of depression will suffer from residual symptoms.
• People with residual symptoms are at ↑ risk of relapse & of suffering another episode of depression
within one year. They are also more likely to develop long-term chronic depression & are at ↑ risk of
attempting suicide.
• Residual symptoms & chronicity of depression are part of the illness process itself.
• Residual depression can also be the result of inadequate treatment.
• The outcome of depression is very good with ~ 70-75% of people being completely better in 6 months
& ~ 85% in a year.
• It is therefore about months rather than weeks of treatment. It is important not to rush treatment.

“the Central Weather Service reported that beaumont road was IMPASSABLE due to heavy flooding”

Central → C → ↓ Concentration
Weather → W → feeling Worthless and guilty
Service → S → ↓ Self-esteem and Self-confidence

IMPASSABLE → I → ↓ Interest and enjoyment

M → ↓ Mood
P → Psychomotor retardation or agitation
A → ↓ Appetite
S → ↓ Sleep
S → Self-harm and Suicide
A → Anhedonia
B → Bleak and pessimistic view of the future
L → ↓ Libido
E → ↓ interest and Enjoyment
↓ Energy and fatigability

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 Mood (affective)
disorders

Manic Bipolar Depressive Recurrent Persistent

episode affective episode depressive mood
disorder disorder disorder

ONLY ONE REPEATED (i.e. Cyclothymia

AT LEAST TWO ONLY ONE MORE THAN NUMEROUS
occasion during occasion when
episodes of mood ONE) occasion periods of MILD
which symptoms of symptoms of
disturbance occur at when symptoms of depression & MILD
mania (or depression have
different times (i.e. depression have elation, NONE of
hypomania) are been consecutively
mania or been continuously which are severe or
present for AT present for AT
hypomania AND present for AT long enough to
LEAST ONE LEAST TWO
depression). LEAST TWO fulfil the criteria for
WEEK. WEEKS. WEEKS. bipolar affective
disorder or
recurrent depressive
disorder

OR

Dysthymia
CHRONIC low
mood which does
NOT fulfil the
criteria for recurrent
depressive disorder,
either in terms of
severity or duration
of individual
episodes.

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 Management of depression (RCSI Psychiatry Course Book Chapter 11)

• Psychiatric history (including compliance with any currently prescribed psychotropic medication?).
• Mental state examination.
• Risk assessment preferably including appropriate rating scales such as the BDI, HAM-D, S-RAMM, HCR-20, etc. (consider the different types of risks, e.g. to
self, to others, from others, risk of self-neglect, risk of further deterioration in mental state without adequate treatment, risk of alcohol/substance misuse, risk of
absconsion from hospital [if applicable], risk of non-compliance with medication/treatment, risk of falls).
• Collateral history.
• Consider a possible iatrogenic cause (check currently prescribed medication).
• Consider possible alcohol/substance misuse (do random supervised urine drug screen) or organic cause (do blood tests [FBC, RFT. LFT, TFT, fasting glucose,
B12 & folate level]; & if indicated – EEG, CT/MRI brain scan).
• IMPORTANT to consider regarding potential substance misuse:
(a). Illicit substances (e.g. cannabis, cocaine, heroin, etc.), (b). Head Shop Products, (c). Inhaling petrol, glue, aerosols or inhaling nitric oxide from empty aerosol
canisters, (d). Tablets acquired ‘from the streets’ or from friends/family members (e.g. non-prescribed medication such as benzodiazepines, hypnotics, etc.),
(e).Tablets from pharmacies (e.g. antihistamines, medications containing codeine or ones with dextromethorphan such as cough syrup, etc.), (f). Tablets bought on
the internet, (g). Tablets acquired by attending more than one GP for prescriptions (e.g. benzodiazepines, hypnotics, etc.) OR from attending emergency departments
in different hospitals OR from out of hours doctor on-call service (e.g. D-Doc or Care-Doc), (i).’ Legal highs’ (e.g. Pandora's Box, Cherry Bomb, Clockwork Orange,
China White).

Appropriate location at this time? (i.e. inpatient or outpatient treatment).

• MDT approach (i.e. consider required input from MDT

• If admission is needed, decide on level of observation required (i.e. 1:1 nursing, 15
minute observations or general observations), if the person can have leave off the
ward (accompanied or unaccompanied leave?) AND if the person can have their
day clothes (or if they should remain in night clothes).
• A key worker (staff member) should be assigned to the patient.
• Ward nursing staff can monitor the patient’s mental state & medication
compliance.
• In the longer term following discharge, consider day hospital +/- CPN involvement.
members).
• The patient’s care plan should be prepared considering MDT
input (the care plan should be discussed with the patient).
• Consider involving a spouse/partner or a family member of the
patient in their treatment (if appropriate)
• Keep GP updated about treatment.

Biological Psychological Social

Antidepressant (usually an SSRI) for 6-9 months if 1st • Alcohol/substance misuse
episode depression or two years if recurrent depression. • Psychoeducation.
counselling (if needed).
▼
No/minimal response after 3-4 weeks: • Group work (e.g. ward/day
1. Ask about compliance. • Supportive therapy.
hospital occupational groups to
2. If compliant, ↑ dose OR switch to another improve day to day living skills
antidepressant if side effects cannot be tolerated (e.g. such as self-care, basic
try another SSRI before selecting an antidepressant • CBT.
conversation, vocational skills
from another class). and recreation).

Inadequate response to a trial of an antidepressant • Interpersonal therapy.

• Social skills training.
(used at a sufficient dose & for a sufficient duration) –
Antidepressant augmentation with: • Club houses (offer support &
(a). Mood stabiliser (e.g. lithium) OR • Family/couples therapy if
needed. opportunities for people with
(b). Antipsychotic (e.g. aripiprazole, olanzapine, quetiapine severe & persistent mental
or risperidone) OR illness).
(c). A second antidepressant (e.g. mirtazapine).
▼ • Mindfulness.
• Vocational & rehabilitation
ECT (rarely used – only when all other treatments have training (if needed).
failed or life-saving treatment is needed, e.g. person not
drinking &/or eating).
• Befriending (for people with
mental illness who are
NOTE: doctor should discuss with the patient:
isolated/have poor psychosocial
(a). The rationale for prescribing any psychotropics.
support network).
(b). The main side effects associated with that medication.
(c). Importance of good medication compliance.
• Support group.
(d). Use of alcohol/illicit substances while on medication.
(e). Concerns about potential over-sedation with certain
psychotropic medication when initiating & changing • Patient advocacy.
treatment, and that driving & operating machinery should
cease if affected, only resuming when such side effects have
ceased.
(f). Driving MUST cease during acute psychotic (or
hypomanic/manic illness). Return to driving only when stable
and when not suffering from medication side effects which
could impair driving.

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 Advantages of SSRIs over TCAs Main side effects of antidepressants
• Less sedation. • TCAs
• No anticholinergic side effects. o Anticholinergic/antimuscarinic side effects (dry mouth, blurred vision, drowsiness, constipation &
urinary retention).
• Lower cardiotoxicity.
o Antihistaminic side effects (sedation & ↑ weight).
• Safer in overdose (SSRIs are Safer in overdose than TCAs). o Cardiovascular effects (tachycardia, postural hypotension).
• SSRIs
o Gastrointestinal (nausea & vomiting).
o Central nervous system (headache, dizziness, agitation, insomnia & tremor).
o Sexual dysfunction (SSRIs > TCAs).
Mood stabilisers • SNRIs (venlafaxine, duloxetine) + NARI (reboxetine) = nausea, dry mouth, constipation, dizziness,
(RCSI Psychiatry Course Book Chapter 13) Antidepressants •
headache, insomnia.
SARI (trazodone) = sedation, priapism.
• Lithium.
• NaSSA (mirtazapine) = sedation, ↑ weight.
• Valproate. • NDRI (bupropion) = nausea, dry mouth, dizziness, ↓ weight.
• Carbamazepine. • Agomelatine = nausea, dizziness, headache, insomnia, upper abdominal pain, ↑ sweating, ↑LFTs.
• Lamotrigine. • MAOIs = hypertensive crisis (tyramine-reaction) with irreversible MAOIs > reversible.

Tricyclic Selective Serotonin Noradrenaline Serotonin Tetracyclic Noradrenergic Noradrenergic Melatonergic Monoamine
Multimodal activity
antidepressants serotonin noradrenaline reuptake antagonist & antidepressant & specific & dopaminergic antidepressant oxidase inhibitors
(inhibits serotonin
(TCAs) reuptake reuptake inhibitor reuptake (TeCA) serotonergic reuptake (MAOIs)
reuptake &
inhibitors inhibitor (NARI) inhibitor antidepressant inhibitor modulates serotonin
Amitriptyline (SSRIs) (SNRI) (SARI) (NaSSA) (NDRI) receptor activity)
- Nortriptyline
- Imipramine Fluoxetine Venlafaxine Reboxetine Trazodone Mianserin Mirtazapine Bupropion Agomelatine Phenelzine
Vortioxetine
- Trimipramine Paroxetine Duloxetine Isocarboxazid
- Clomipramine Fluvoxamine Tranylcypromine
- Lofepramine Citalopram Moclobemide
- Dothiepin Escitalopram
- (dosulepin) Sertraline

• Most toxic TCA in overdose = Dothiepin (Dosulepin). → Dothiepin (Dosulepin) is the most Dangerous TCA in overdose.
• Safest TCA in overdose = Lofepramine. → Lofepramine is the Lightest TCA in overdose.
• TCA that can be used to treat obsessive compulsive disorder = Clomipramine. → Clomipramine can be used to treat obsessive Compulsive disorder.
• SSRI with the longest half-life (and is the most protein bound) = fluoxetine.
• SSRI with the greatest risk of withdrawal symptoms (i.e. SSRI with shortest half-life) = paroxetine.
• Antidepressant which can also be used to stop smoking = bupropion.
• Venlafaxine at high doses – need to monitor blood pressure due to risk of hypertension.
• Antidepressant contraindicated in people with hepatic failure = agomelatine (LFTs should be monitored while taking agomelatine due to risk of ↑ LFT).
• Difference between phenelzine and moclobemide = phenelzine is an irreversible MAOI but moclobemide is a reversible MAOI. The risk of a tyramine-food reaction is lower
with moclobemide than with irreversible MAOIs such as phenelzine, isocarboxazid or tranylcypromine.

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 Management of mania (RCSI Psychiatry Course Book Chapter 12)

• Psychiatric history (including compliance with any currently prescribed psychotropic medication?).
• Mental state examination.
• Risk assessment preferably including appropriate rating scales such as the Yung Mania Rating Scale, S-RAMM, HCR-20, etc. (consider the different types
of risks, e.g. to self, to others, from others, risk of self-neglect, risk of further deterioration in mental state without adequate treatment, risk of
alcohol/substance misuse, risk of absconsion from hospital [if applicable], risk of non-compliance with medication/treatment, risk of falls).
• Collateral history.
• Consider a possible iatrogenic cause (check currently prescribed medication).
• Consider possible alcohol/substance misuse (do random supervised urine drug tests) or organic cause (do blood tests [FBC, RFT. LFT, TFT. fasting
glucose, B12 & folate level], & if indicated – EEG, CT/MRI brain scan).
• IMPORTANT: Check blood level of currently prescribed mood stabiliser (if appropriate).

IMPORTANT to consider re potential substance misuse:

(a). Illicit substances (e.g. cannabis, cocaine, heroin, etc.).
(b). Head Shop Products.
(c). Inhaling petrol, glue, aerosols or inhaling nitric oxide from empty aerosol canisters.
(d). Tablets acquired ‘from the streets’ or from friends/family members (i.e. non-prescribed medication such as benzodiazepines, hypnotics, etc.). (e). Tablets from
pharmacies (e.g. antihistamines, medications containing codeine or ones with dextromethorphan such as cough syrup, etc.).
(f). Tablets bought on the internet.
(g). Tablets acquired by attending more than one GP for prescriptions (e.g. benzodiazepines, hypnotics, etc.) OR from attending emergency departments in
different hospitals OR from out of hours doctor on-call service (e.g. D-Doc or Care-Doc).
(h). Misuse of currently prescribed medication (e.g. by taking it inappropriately or by ‘topping up’ the dose from other sources).
(i). ’ Legal highs’ (e.g. Pandora's Box, Cherry Bomb, Clockwork Orange, China White).

Appropriate location at this time? (i.e. inpatient or outpatient treatment).

• MDT approach (i.e. consider required input from MDT members).
• The patient’s care plan should be prepared considering MDT input (the
• If admission is needed, decide on level of observation required (i.e. 1:1 care plan should be discussed with the patient).
nursing, 15 minute observations or general observations), if the person can
have leave off the ward (accompanied or unaccompanied leave?) AND if the
person can have their day clothes (or if they should remain in night clothes)..
• A key worker (staff member) should be assigned to the patient.
• Ward nursing staff can monitor the patient’s mental state & medication • Consider involving the spouse/partner or a family member of the
compliance. patient in their treatment (if appropriate).
• In the longer term following discharge, consider day hospital +/- CPN • Keep GP updated about treatment.
involvement.

Biological Psychological Social

• Alcohol/substance misuse
See “Treatment algorithm for acute mania or hypomania” • Psychoeducation. counselling (if needed).
flow diagram in RCSI Psychiatry Course Book. • Group work (e.g. ward/day hospital
• Enhance coping strategies. occupational groups to improve day
to day living skills such as self-care,
NOTE: doctor should discuss with the patient: • Self-monitoring of mood, basic conversation, vocational skills
(a). The rationale for prescribing any psychotropics. detection of early warning signs. and recreation).
(b). The main side effects associated with that medication. • Social skills training.
(c). Importance of good medication compliance. • Focused family intervention (if • Club houses (offer support &
(d). Use of alcohol/illicit substances while on medication. needed). opportunities for people with severe
(e). Concerns about potential over-sedation with certain & persistent mental illness).
psychotropics when initiating & changing treatment, and that
• Vocational & rehabilitation training
driving & operating machinery should cease if affected, only
(if needed).
resuming when such side effects have ceased.
• Befriending (for people with mental
(f). Driving MUST cease during acute psychotic (or
illness who are isolated/have poor
hypomanic/manic illness). Return to driving only when stable
psychosocial support network).
and when not suffering from medication side effects which
could impair driving. • Support group.
• Patient advocacy.

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 Case-based learning for week 1

Vignette A

Emma is a 32 year old lady who has been referred by her GP to the psychiatry outpatient clinic. The GP became concerned about
Emma when he noticed her mood was low and that she was very tearful on the last two occasions he saw her. When the GP spoke to
Emma she described a two month history of low mood, insomnia and reduced appetite associated with the loss of 5kg of weight. She
said that she had lost interest in going for walks, an activity she had previously enjoyed. She also described a pervasive fatigue over
the past two months which has resulted in her having difficulty undertaking regular everyday activities which would normally not
have posed a challenge for her (e.g. driving her eight year old daughter to and from school each day and putting out the bins for the
weekly rubbish collection). Emma has been spending progressively more time at home in bed which has resulted in a reduction in her
attendance at work and in her interaction with her two close friends. She said that she “just can’t focus on (her) work” which Emma
said means she is a “failure”. Emma’s best friend died of terminal breast cancer a number of weeks ago.

Question 1a: What is your differential diagnosis?

Question 2a: Explain your reasoning behind the differential diagnosis that you have given.

Question 3a: Imagine that you assess Emma in the psychiatry outpatient clinic. Describe what you think her mental state might be
like.

Question 4a: Concerning the differential diagnosis you gave in question 1a above, what questions would you ask Emma in order to
enhance your diagnostic knowledge of this case?

Question 5a: If you could only ask Emma one question relating to her current presentation, what question would be essential to ask
her?

Question 6a: What other questions would be particularly important to ask Emma?

Question 7a: You have finished interviewing Emma. Apart from discussing your management plan with her, what else would you do
in relation to this case?

Question 8a: What are the potential risks in this case?

Question 9a: What is your proposed psychopathology of this case?

Question 10a: What is your management plan for this case?

Question 11a: In relation to your management plan you mentioned in question 10a above, did you include medication? If you did,
what medication did you select and why did you make this choice?

Question 12a: If you would prescribe medication, is there any additional information which might influence the particular medication
you would recommend?

Question 13a: What groups of antidepressants do you know?

Question 14a: Give examples of antidepressants from the groups you mentioned in question 13a above.

Question 15a: Which group of antidepressants are regularly used as first line agents in depression?

Question 16a: If Emma asked you if the particular medication you recommended has any side effects, how would you respond to her
question?

Question 17a: If Emma asked you if antidepressants are addictive, what would you say to her?

Question 18a: If Emma asked you for how long she would be taking the antidepressant you recommended, how would you respond?

Question 19a: Imagine that you gave Emma a prescription for the antidepressant you would prescribe. If she came back to the
psychiatry outpatient clinic after one month and told you that she did not feel any better, how would you deal with this situation?
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Question 20a: If she came back to the psychiatry outpatient clinic after six weeks and told you that she did not feel any better, how
would you deal with this situation at that point?

Question 21a: If she came back to you after another three weeks and told you that she felt a slight improvement but was not at her
baseline level, how would you manage this situation?

Question 22a: If Emma asked you if she will definitely be back to her baseline level with the antidepressant you prescribed, what
would you say to her?

Question 23a: Are there any members of your MDT that you might involve in this case? If you would, who might you involve and
why might you involve that person (those people)?

Question 24a: When you meet Emma in the psychiatry outpatient clinic for a review appointment six months later, you make some
observations you had not previously made. She does not provide clear answers to your questions but rather says “I don’t know” or
provides an answer which does not match the question you asked. She does not remain seated on the chair in your office as she did in
the past. She stands up on several occasions and walks around your office. She is also wringing her hands. What are your thoughts on
her current presentation? Would you do anything?

Question 25a: Imagine that Emma came back to you for her first return appointment after you had started her on your choice of
antidepressant when you initially assessed her. You notice that she does not remain seated but rather stands up on a few occasions and
walks around your office. She is talking a lot faster than when you initially met her. At one stage she runs across the room laughing
and gives you a big hug. What are your thoughts on her current presentation? Would you do anything?

Question 26a: When Emma comes back to you for a return appointment you notice she has a two litre bottle of Coca Cola with her.
She drinks most of the contents of the Coca Cola bottle while she is with you in your office. Would you make any reference to this
during your time with Emma in the psychiatry outpatient clinic?

Question 27a: In relation to the description which is provided for this case, if Emma told you that she could not guarantee her safety
at the current time, what would you do?

Question 28a: If Emma would not agree with the recommendation you made in question 27a above, how might you handle this
situation?

Question 29a: Emma has just now been admitted to the psychiatry inpatient unit. What would you say to the nursing staff working in
that unit?

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Vignette A answers

Answer 1a: What is your differential diagnosis?

• Severe depressive episode (if this has been the first episode) or recurrent depressive disorder, current episode severe without
psychotic symptoms (if there is a past history of depression). If there is a past history of a manic episode – bipolar affective
disorder, current episode severe depression without psychotic symptoms.
• Adjustment disorder.
• Substance induced mood disorder.
• Organic mood disorder (e.g. hypothyroidism).
• Schizoaffective disorder.

Answer 2a: Explain your reasoning behind the differential diagnosis that you have given.
• Regarding severe depressive episode – the presentation fulfils the ICD-10 criteria for depression which is present to such a
degree as to be classified as a severe depressive episode, i.e.
o Low mood (“two month history of low mood”).
o Disturbed sleep (“insomnia”).
o Reduced appetite associated with the loss of 5kg of weight.
o Loss of interest and enjoyment in activities that would normally be pleasurable (“she said she had lost interest in going for
walks, an activity she had previously enjoyed”).
o Decreased energy leading to increased fatigability (“She also described a pervasive fatigue over the past two months which
has resulted in her having difficulty undertaking regular everyday activities which would normally not have posed a
challenge for her, e.g. driving her eight year old daughter to and from school each day and putting out the bins for the weekly
rubbish collection”).
o Decreased concentration and attention (“I just can’t focus on my work”).
o Decreased self-esteem and self-confidence (“I am a failure”).
• Regarding adjustment disorder – “Emma’s best friend died of terminal breast cancer a number of weeks ago”. It is assumed that
this was a significant life event for Emma. However, her current presentation is significantly more severe than what is described
for an adjustment disorder in ICD-10, i.e. “a state of subjective distress and emotional disturbance usually interfering with social
functioning and performance, and arising in the period of adaption to a significant life change or to the consequences of a stressful
life event”. Emma’s current presentation is more in line with severe depression.
• Regarding substance induced mood disorder – we do not know Emma’s alcohol and substance misuse history. Even if Emma
reported that she did not misuse alcohol or use illicit substances, it is important to look for signs of intoxication or withdrawal
from alcohol and illicit substances. A collateral history from a reliable source may provide additional useful information.
Furthermore, key investigations might be useful to consider (e.g. MCV, LFT, random supervised urinary drug screen).
• Regarding organic mood disorder – an underlying organic cause for Emma’s current presentation should be outruled (e.g.
hypothyroidism).
• Regarding schizoaffective disorder – according to ICD-10, “both affective and schizophrenic symptoms are prominent within
the same episode of the illness…….the episode of illness does not meet the criteria for either schizophrenia or depressive or manic
episodes”. We have not been informed of any current “schizophrenic symptoms”. Emma’s presentation does meet the criteria for
depression.

Answer 3a: Imagine that you assess Emma in the psychiatry outpatient clinic. Describe what you think her mental state might be like.
• Appearance and behaviour: black blouse and black jeans, dishevelled with unkempt hair. Staining noticeable on the front of her
blouse. Psychomotor retardation. Downcast head, looking at the floor. Poor eye contact. Reasonable rapport established. Co-
operative. Tearful at times during the interview.
• Speech: decreased volume, rate and tone. Poverty of speech.
• Mood: subjectively – “low”, objectively – depressed
• Thoughts: fleeting thoughts of self-harm but no active plan. Negative cognitions (“I am a failure”, “I am useless at everything”).
Preoccupied with the death of her best friend and with the thought that she was not good enough to her friend (delusional
intensity, i.e. delusion of guilt). She denied any passivity of thought including thought insertion, withdrawal, echo or
broadcasting. She denied any concerns regarding the radio or the television.
• Perception: she denied hallucinations in all modalities.
• Cognition: alert. Orientated in place and person. Gave the date today as being one month and ten days earlier than it is in reality.
Reduced concentration measured by serial 7s testing. Long-term memory intact but reduced short-term memory.
• Insight: she said she is suffering from depression and needs to take medication. She said she understood my explanation for why
she should be admitted to hospital, and agreed with same.

Question 4a: Concerning the differential diagnosis you gave in question 1a above, what questions would you ask Emma in order to
enhance your diagnostic knowledge of this case?
• Regarding severe depressive episode versus recurrent depressive disorder: have you ever felt like this in the past? Have you
had any similar experiences such as this in the past? Do you have a past history of any mood disturbance? Do you have a past
history of depression?

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• Depression versus bipolar affective disorder: do you have a past history of any mood disturbance? Have you ever had the
opposite experience in the past to how you feel now in which your mood may have much better than usual and you might have
had lots of energy and you felt you did not need much sleep?
• Regarding adjustment disorder: this diagnosis is unlikely given the current presentation.
• Substance induced mood disorder: do you drink alcohol? How much/how often do you drink? When did you last drink
alcohol? How much alcohol did you take the last time you drank? Why do you drink/take whatever substance? Have you ever
taken any drugs such as cannabis or cocaine/heroin? When did you last take drugs? How much/how often do you take cannabis
(or whatever other drugs)? What effects do you experience when you take X?
• Regarding organic mood disorder: do you have a history of any medical condition?
• Schizoaffective disorder: this diagnosis is unlikely given the current presentation.

Answer 5a: If you could only ask Emma one question relating to her current presentation, what question would be essential to ask
her?
• Do you have any thoughts of harming yourself?

Answer 6a: What other questions would be particularly important to ask Emma?
It would be important to ask Emma about:
• Past psychiatric history?
• Past history of self-harm?
• Presence/absence of psychotic symptoms?
• Her relationship with her daughter and her current thoughts about her daughter?
• How she is coping with looking after her daughter?
• How she is coping herself?
• Presence of sufficient food in her home?
• Availability of any support from a family member, etc.?
• What (if any) medication is she currently taking (establish her compliance)?
• Impact her best friend’s death may have had on her?

Answer 7a: You have finished interviewing Emma. Apart from discussing your management plan with her, what else would you do in
relation to this case?
• Get a collateral history. It would be very important to talk to a family member or someone else who would know Emma well.
Other useful sources of collateral information could include Emma’s GP, any psychiatric service which she may have had contact
with in the past, and if she has a significant medical illness, it might be helpful to contact that specialist (with Emma’s consent).

Answer 8a: What are the potential risks in this case?

• Risk to self
o Self-harm or suicide.
o Limited/lack of insight might cause the person to disengage from their mental health service (and/or not seek help from their
GP or otherwise) which could result in worsening of the person’s mental state.
o Non-payment of household bills (e.g. electricity, heating, mortgage, etc.).
o Work absenteeism could become an issue and might result in job loss and unemployment.
o Non-collection of any payments due to the person (e.g. social welfare).
o If Emma subsequently developed a manic episode, additional risks might include -
✓ Potential damage to her reputation by her sending sexually provocative (or hostile) emails/texts/letters/videos to other
individuals and/or becoming sexually provocative (or hostile) with family/friends/colleagues.
✓ Reckless driving could result in physical injury or death to person themselves.
✓ Taking large amounts of money out of the person’s own bank account (via bank withdrawal and/or credit card use)
and spending it recklessly.
✓ Taking out a loan for a large sum of money (perhaps from a loan shark or other unscrupulous individual) which could
put the person at risk of significant financial difficulty.
✓ Giving away large amounts of money to charities and/or other causes/individuals.
✓ Gambling could result in the loss of large amounts of money (and potentially the person’s house and other assets).
• Risk to others
o Not adequately caring for any children/other vulnerable individual or pets in the household.
o Verbal and/or physical aggression (varying from mild irritability to actual bodily harm/death).
o If Emma subsequently developed a manic episode, additional risks might include –
✓ Spread of sexually transmitted disease if the person themselves is infected.
✓ Reckless driving could result in physical injury or death of other road users and/or to a passenger in the person’s car.
✓ Serious depletion or even loss of money put aside for any purpose (e.g. tuition fees for any children in the household)
due to reckless over-spending.
• Risk from others
o Financial exploitation.
o Getting fired from work which could result in a difficult financial situation.

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 o Any children and/or pets might be removed from the household by the appropriate authorities if they are deemed to be
neglected/abused/not adequately cared for.
o Break-up of an existing relationship with a partner/spouse.
o Loss of friends (and potential psychosocial isolation).
o If Emma subsequently developed a manic episode, additional risks might include -
✓ Sexual exploitation.
✓ Having unprotected sex with a number of different sexual partners could result in the person becoming pregnant and/or
infected with a sexually transmitted disease.
✓ Physical and/or sexual assault (and potentially murder).
• Risk of self-neglect
o Reduction in the intake of food and/or fluids could result in medical difficulties (or in an extreme case, death).
o Not washing one’s self and/or changing their clothes and/or not brushing their hair.
• Risk of further deterioration in mental state without adequate treatment
• Risk of alcohol and/or substance misuse
• Risk of absconsion from hospital
o If the patient left hospital in their nightclothes they could be vulnerable to the effects of the cold which might be fatal.
o If the patient walked out (or ran out) onto the road they could get knocked down by a car/other vehicle which might result in
physical injury or even death.
o Potentially, no access to food/fluid and/or prescribed medication which could result in physical ill-health and a further
deterioration in mental state.
• Risk of non-compliance with prescribed medication
o This could lead to worsening of the patient’s mental state.
• Risk of falls
o If the person is quite sedated (and/or if they are rushing around – if manic) they could fall which might result in a
fracture/other injury or potentially a head injury.

Answer 9a: What is your proposed psychopathology of this case?

Biological Psychological Social
Predisposing factors • Genetics – family • History of parental • Parental separation.
psychiatric history (mother psychiatric illness (mother).
has recurrent depressive
disorder).
Precipitating factors • Acute relapse of depression. • Acute life event (e.g. death • Death of her best friend.
of her best friend).

Perpetuating factors • Ongoing mental illness. • Unresolved grief. • Ongoing preoccupation

with the death of her best
friend.

Answer 10a: What is your management plan for this case?

• See the flow diagram in the week 1 content of this Workbook which is entitled “management of depression”).
• See the RCSI Psychiatry Course Book for additional information.

Answer 11a: In relation to your management plan you mentioned in question 10a above, did you include medication? If you did,
what medication did you select and why did you make this choice?
• SSRI (e.g. fluoxetine) – SSRIs are generally considered to be the first line antidepressants to use for the management of
depression.

Answer 12a: If you would prescribe medication, is there any additional information which might influence the particular medication
you would recommend?
• Is Emma currently taking any medication (it is possible that she is currently prescribed an antidepressant or she may be taking a
non-psychotropic medication or illicit substance which could be associated with her current presentation)?
• Compliance with her currently prescribed medication?
• Has she taken an antidepressant in the past? If so, which one (or ones) and how did she respond to them (i.e. good response or
no/minimal effect or negative response)?

Answer 13a: What groups of antidepressants do you know?

• Selective serotonin reuptake inhibitors (SSRIs).
• Tricyclic antidepressants (TCAs).
• Serotonin noradrenaline reuptake inhibitor (SNRI).
• Noradrenaline reuptake inhibitor (NARI).
• Serotonin antagonist and reuptake inhibitor (SARI).
• Tetracyclic antidepressant (TeCA).
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• Noradrenergic and dopaminergic reuptake inhibitor (NDRI).
• Melatonergic antidepressant.
• Multimodal activity antidepressant (inhibits serotonin reuptake and modulates serotonin receptor activity).
• Monoamine oxidase inhibitors.

Answer 14a: Give examples of antidepressants from the groups you mentioned in question 13a above.
• See the flow diagram in the week 1 content of this Workbook.

Answer 15a: Which group of antidepressants are regularly used as first line agents in depression?
• SSRIs.

Answer 16a: If Emma asked you if the particular medication you recommended has any side effects, how would you respond to her
question?
• SSRIs – most common side effect is nausea however, this is often mild (or not present at all) and if affected, it is in the early stage
of treatment after the medication has been started.

Answer 17a: Emma asked you if antidepressants are addictive. What would you say to her?
• No, antidepressants are not addictive.

Answer 18a: If Emma asked you for how long she would be taking the antidepressant you recommended, how would you respond?
• Duration of antidepressant treatment is decided on a case-by-case basis. However, the average time is for 6-9 months after
remission in the case of a single episode (i.e. first episode) of depression and two years for recurrent depression.

Answer 19a: Imagine that you gave Emma a prescription for the antidepressant you would prescribe. If she came back to the
psychiatry outpatient clinic after one month and told you that she did not feel any better, how would you deal with this situation?
• Firstly, ask her if she has been taking her antidepressant every day as prescribed (i.e. assess compliance). If she has not been fully
compliant it is important to establish the reason (or reasons) for this.
• Secondly, establish if there are any other relevant factors involved (e.g. alcohol misuse, substance misuse, underlying medical
problem, any other medication she might be taking). Methods to establish this information include asking Emma about these
issues, getting a collateral history (if possible) from a family member/other party and GP, and doing relevant investigations (e.g.
routine blood tests including FBC and TFTs). However, ideally the blood investigations would have already been done by this
stage.
• Thirdly, assuming she has been compliant and there are no other relevant factors involved as mentioned above – increase the dose
of the antidepressant.

Answer 20a: If she came back to the psychiatry outpatient clinic after six weeks and told you that she did not feel any better, how
would you deal with this situation at that point?
• Firstly, ask her if she has been taking her antidepressant every day as prescribed (i.e. assess compliance). If she has not been fully
compliant it is important to establish the reason (or reasons) for this.
• Secondly, establish if there are any other relevant factors involved (e.g. alcohol misuse, substance misuse, underlying medical
problem, any other medication she might be taking). Methods to establish this information include asking Emma about these
issues, getting a collateral history (if possible) from a family member/other party and GP, and doing relevant investigations (e.g.
routine blood tests including FBC and TFTs). However, ideally these blood investigations would have already been done by this
stage.
• Titrate the dose of the antidepressant upwards taking into account the maximum BNF dose of that medication. Continue to
monitor Emma’s mental state and ask about any unpleasant side effects she might be experiencing.

Answer 21a: If she came back to you after another three weeks and told you that she felt a slight improvement but was not at her
baseline level, how would you manage this situation?
• Firstly, ask her if she has been taking her antidepressant every day as prescribed (i.e. assess compliance). If she has not been fully
compliant it is important to establish the reason (or reasons) for this.
• Secondly, establish if there are any other relevant factors involved (e.g. alcohol misuse, substance misuse, underlying medical
problem, any other medication she might be taking). Methods to establish this information include asking Emma about these
issues, getting a collateral history (if possible) from a family member/other party and GP, and doing relevant investigations (e.g.
routine blood tests including FBC and TFTs). However, ideally these blood investigations would have already been done by this
stage.
• Continue to titrate the dose of the antidepressant upwards taking into account the maximum BNF dose of the medication.
• If there has been an inadequate response to a sufficient trial of the antidepressant which was prescribed at a therapeutic dose,
consider augmenting the antidepressant with a mood stabiliser (e.g. lithium), or an antipsychotic (e.g. risperidone or aripiprazole)
or another antidepressant (e.g. mirtazapine). Continue to monitor Emma’s mental state and ask about any unpleasant side effects
she might be experiencing.

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 Answer 22a: If Emma asked you if she will definitely be back to her baseline level with the antidepressant you prescribed, what
would you say to her?
• Do not tell Emma that she will definitely return to her baseline with the antidepressant you prescribed. Never give uncertain
assurances to a patient. Tell her that like all medications, one medication might work better for one person while a different
medication might better suit someone else.
• Inform her of the supports available to her within the psychiatric service and that you will continue to monitor her response to the
antidepressant.

Answer 23a: Are there any members of your MDT that you might involve in this case? If you would, who might you involve and why
might you involve that person (those people)?
• Community psychiatric nurse (CPN): home visits and to monitor Emma’s mental state.
• Ward nursing staff (if admitted to hospital): monitoring of her mental state and her compliance with prescribed medication.
• Social worker: assistance with getting social welfare payments while on sick leave from work (and with any other relevant
financial matters if applicable). The social worker would also be helpful to the clinical team if there are any concerns regarding
Emma’s young child (e.g. neglect, abuse, etc.).
• Psychologist: CBT (if available) could be added to the biological management. However, in the case of Emma’s initial
presentation, she may have been too unwell to engage with CBT at that time.

Answer 24a: When you meet Emma in the psychiatry outpatient clinic for a review appointment six months later, you make some
observations you had not previously made. She does not provide clear answers to your questions but rather says “I don’t know” or
provides an answer which does not match the question you asked. She does not remain seated on the chair in your office as she had
done in the past. She stands up on several occasions and walks around your office. She is also wringing her hands. What are your
thoughts on her current presentation? Would you do anything?
• Consider the serotonin syndrome – establish from the patient (and/or via collateral) if she has commenced any new medication
e.g. ‘over the counter’ medication such as tramadol, or any other agents either prescribed or non-prescribed).
• If this is a case of serotonin syndrome –
o Severe symptoms require immediate transfer to the emergency department for supportive treatment and acute management.
o Discontinue any serotonergic agents.
o Benzodiazepines may be helpful to relieve muscular symptoms (if present).
o Consider serotonin receptor antagonist (e.g. cyproheptadine).
o Beta-blockers (e.g. propranolol and pindolol) may be useful in reversing some of the neuromuscular and autonomic
complications and are especially useful if tachycardia and/or hypertension are present.
o Monitor pulse, blood pressure and temperature.
o Most cases resolve without sequelae within 24-36 hours with adequate supportive measures.
o Restart antidepressant treatment slowly and consider using a serotonergic agent from a different class.
o Psychoeducation regarding potential agents that could precipitate another episode of serotonin syndrome (e.g. avoid tramadol
while taking an SSRI!!).

Answer 25a: Imagine that Emma came back to you for her first return appointment after you had started her on your choice of
antidepressant when you initially assessed her. You notice that she does not remain seated but rather stands up on a few occasions
and walks around your office. She is talking a lot faster than when you initially met her. At one stage she runs across the room
laughing and gives you a big hug. What are your thoughts on her current presentation? Would you do anything?
• Consider antidepressant-induced mania.
• Management as per that for acute mania in the flow diagram in the week 1 content of this Workbook.

Answer 26a: When Emma comes back to you for a return appointment you notice she has a two litre bottle of Coca Cola with her.
She drinks most of the contents of the Coca Cola bottle while she is with you in your office. Would you make any reference to this
during your time with Emma in the psychiatry outpatient clinic?
• Establish what volume of fluid she is taking on a daily basis. If that volume is in excess of what might be expected, ask why she
is drinking that quantity of fluid (increased thirst? dry mouth? underlying medication condition such as diabetes insipidus?
Psychological reason, e.g. psychogenic polydipsia?), and for how long she has been consuming this volume of fluid.
• Consider the syndrome of inappropriate secretion of antidiuretic hormone (SIADH) secondary to antidepressant use. Lithium is
another example of a medication that can cause polydipsia.

Answer 27a: In relation to the description which is provided of this case, if Emma told you that she could not guarantee her safety at
the current time, what would you do?
• Ask her if she has any specific plans to end her life.
• Consider inpatient psychiatric admission.

Answer 28a: If Emma would not agree with the recommendation you made in question 27a above, how might you handle this
situation?
• It would be preferable if Emma was in agreement to be admitted to hospital. It would therefore be important to clearly explain to
her the reason for your recommendation of admission and how she might benefit from such intervention.

21
• Establish if she has any particular concerns about being admitted to hospital (e.g. any negative preconceived ideas or fears she
might have about the admission, etc.). Her child would have to be cared for by someone during the admission.
• If she did have negative preconceived ideas or fears about the admission, establish if it might be helpful if she saw the psychiatry
unit (if adjacent to the outpatient clinic) and/or if one of the unit nurses could met with her to talk to her further.
• If following your best efforts the patient is still not agreeable to the admission and it was deemed to be in her best interest (in the
interests of her safety and/or to prevent a further deterioration in her mental state), involuntary admission under the Mental Health
Act 2001, could be considered.

Answer 29a: Emma has just now been admitted to the psychiatry inpatient unit. What would you say to the nursing staff working in
that unit?
• Provide nursing staff with a verbal summary of the main points of the case, including Emma’s current presentation and any
concerns you might have regarding risk.
• Advise staff of the medication you are prescribing.
• Inform staff of the observation level needed (1:1 nursing, 15 minute observation or general observations).
• Advise staff if she can have leave from the ward (accompanied or unaccompanied leave?)
• Advise staff if she can have her day clothes or if she should remain in her nightwear.
• If there are concerns about a possible absconsion risk – consider telling nursing staff that the patient should only wear night attire
for the moment (her day clothes should be taken from her for the time being).

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Vignette B

Laura is a 34 year old lady with long-standing bipolar affective disorder. Her management regimen includes lithium. She has come to
talk to you (the psychiatry registrar) regarding her concerns of taking lithium during pregnancy. Laura informs you that she and her
partner want to have a child.

Question 1b: How would you respond to Laura regarding her concerns of taking lithium during pregnancy?

Question 2b: Four months later, Laura returns home to Ireland following a four week trip to the Middle East where she was visiting a
friend of hers. Laura’s friend became concerned about Laura and arranged for Laura to be accompanied back home on a flight to
Dublin. Her parents are very concerned when they meet her at Dublin Airport. They note Laura to be confused, with rambling and
slurred speech. She is disorientated to time and place, and is staggering rather than walking as she normally would. She is unable to
say what is wrong with her when asked by her parents. What do you think might be the problem?

Question 2c: You receive a letter from Laura’s GP. The GP is concerned about Laura and wants your advice as to if she should
continue taking her prescribed lithium. Laura has been taking lithium for about five years at this stage. No polyuria/polydipsia has
been described. The GP arranged investigations for Laura. The results are as follows:

• Blood pressure: 125/70mmgHg.

• Urine dipstick – no abnormalities detected.
• Urine specific gravity – low.

• Creatinine 160umol/L (normal = 44-80umol/L).

• Sodium = 144mmol/L (normal = 135-145mmol/L).
• eGFR = 41mls
• Parathyroid hormone = 52pg/ml (normal = 10-55pg/ml)
• Corrected calcium = 2.55mmol/L (normal = 2.20-2.70mmol/L)
• Phosphate = 0.82mmol/L (normal = 0.80-1.40mmol/L)
• Urine osmolality = 444mOsm (normal = 500-800mOsm)

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Vignette B answers

Answer 1b: How would you respond to Laura regarding her concerns of taking lithium during pregnancy?
• Firstly, it would be important to establish when Laura would like to have the child (e.g. is it now or in two years’ time?).
• Secondly, it would be important to consider the nature of Laura’s psychiatric illness (e.g. for how long has her mental state been
stable [assuming that is the case]?). How many episodes of illness has she had over the years? How were these episodes managed?
Did they require inpatient admission?
• Consider the risk versus benefit of lithium treatment on a case-by-case basis.
• If Laura has had several relapses which have required inpatient admission and she has responding well to lithium, the risk of
stopping lithium outweighs the benefit. Discontinuing lithium could put her at risk of having another relapse of illness. Such
relapse would not only impact negatively on her but also on a baby during pregnancy. Mental health stability during pregnancy
(and at all other times) is priority.
• If Laura has been stable for the last number of years and has had very few episodes of illness which may not have required
inpatient admission, consider slowly reducing the dose of lithium while monitoring her mental state. If she is not experiencing
negative mental health consequences to the slow reduction in dose, continue to slowly reduce the dose of lithium while gradually
changing her over to an antipsychotic such as olanzapine.
• Any medication has the potential to have some degree of negative impact on a foetus, not only lithium. This should be explained
to Laura as well as the importance of her maintaining mental health stability.
• Use the lowest possible dose of any required psychotropic agent during pregnancy which maintains stability of mental health for
the person concerned.
• Ensure the patient’s obstetrician knows what psychotropic medication the patient is prescribed (collaboration between psychiatry
and obstetrics is essential here).
• Ensure she knows that there is a risk of foetal heart malformations when lithium is taken in the first trimester.
• Ensure she knows that lithium levels may be high in breast milk with a risk of toxicity for the baby.

Answer 2b: Four months later, Laura returns home to Ireland following a four week trip to the Middle East where she was visiting a
friend of hers. Laura’s friend became concerned about Laura and arranged for Laura to be accompanied back home on a flight to
Dublin. Her parents are very concerned when they meet her at Dublin airport. They note Laura to be confused, with rambling and
slurred speech. She is disorientated to time and place, and is staggering rather than walking as she normally would. She is unable to
say what is wrong with her when asked by her parents. What do you think might be the problem?
• Lithium toxicity secondary to increased sweating and reduced fluid intake during her time in the Middle East.
• It is unlikely that Laura is intoxicated with alcohol or an illicit substance. She does not drink alcohol and she does not have any
known history of using illicit substances.

Answer 3b: You receive a letter from Laura’s GP. The GP is concerned about Laura and wants your advice as to if she should
continue taking her prescribed lithium. Laura has been taking lithium for about five years at this stage. No polyuria/polydipsia has
been described. The GP arranged investigations for Laura. The results are as follows:
• Blood pressure: 125/70mmgHg.
• Urine dipstick – no abnormalities detected.
• Urine specific gravity – low.
• Creatinine 160umol/L (normal = 44-80umol/L).
• Sodium = 144mmol/L (normal = 135-145mmol/L).
• eGFR = 41mls
• Parathyroid hormone = 52pg/ml (normal = 10-55pg/ml)
• Corrected calcium = 2.55mmol/L (normal = 2.20-2.70mmol/L)
• Phosphate = 0.82mmol/L (normal = 0.80-1.40mmol/L)
• Urine osmolality = 444mOsm (normal = 500-800mOsm)

• eGFR is roughly equivalent to percent of kidney function.

o eGFR 30mls/min is approximately 30% kidney function.
o eGFR 50mls/min is approximately 50% kidney function.
• Stages of chronic kidney disease:
Stage of chronic kidney disease GFR Description of kidney function

1 >90 Normal unless urine/structural/genetic abnormality

2 60-89 Normal or mildly reduced if above criteria met
3 30-59 Moderately reduced
4 15-29 Severely reduced
5 <15 Very severe/end-stage kidney disease

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• The risk of end-stage kidney disease with lithium use is over-emphasised and in fact is relatively low (0.5% versus 0.2% in the general
population). It is important to balance the needs of the patient against the very low risk of progressive chronic kidney disease. Laura’s
use of lithium can therefore be continued.
• The clinical features of end-stage kidney disease are:
o SLOWLY progressive decline in eGFR.
o Minimal proteinuria.
• Kidney function declines with age:
o 10mls GFR loss per decade from the age of 30 years old.
o 2/3 healthy older adults decline CrCl over time.
• Refer to nephrology if there is a sustained reduction in eGFR to 30-44 (stage 3b chronic kidney disease).

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Week 1 - notes

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