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Perinatal psychiatric disorders are common and can result in significant suffering for women and their families; indeed, suicide is a leading cause of maternal death. The severest form of postpartum mood disorder, postpartum psychosis, follows approximately one in 1000 deliveries. Women with a history of bipolar disorder or who have suffered a previous severe postpartum episode are at a many hundred-fold...
The medical manifestations of alcohol are protean. A drinking history and high index of suspicion for alcohol misuse is part of comprehensive medical assessment. Identification of hazardous and harmful drinking, and provision of brief advice and brief intervention if indicated, should occur in any episode of healthcare. In acute settings, prevention and management of alcohol withdrawal, and of Wernicke's...
Treatment of alcohol dependence generally requires more intensive treatment than brief interventions. This may include a withdrawal programme (detoxification) to enable the dependent subject to stop drinking, and ongoing interventions to remain abstinent such as counselling, pharmacotherapy and self-help programmes. Treatment and maintenance of abstinence from alcohol involves the use of pharmacotherapy...
Medically unexplained physical symptoms (MUPS) are physical symptoms that trigger the sufferer to seek healthcare, but which remain unexplained after appropriate medical assessment. They are very common, and cause significant distress and disability. Relevant aetiological factors can usually be discovered by careful and sympathetic clinical interview. What doctors say and do, and the way in which...
Self-harm is one of the commonest reasons for presentation to hospital. It is a reflection of distress rather than a diagnosis in itself. This article focuses on the management of people who present to hospital with behaviour that they report, or which staff suspect, was related to an intent to harm themselves, usually in relation to suicidal-related impulses. Self-harm is associated with a significantly...
First generation (typical) and second generation (atypical) antipsychotics are the mainstay of psychosis treatment. Most antipsychotics block dopamine D 2 receptors. Greater affinity for serotonin 5-HT 2 receptors over D 2 and fast dissociation from the D 2 receptor are the two competing theories for the activity of atypical antipsychotics. Movement disorders, hyperprolactinaemia,...
Many types of antidepressant are available. They vary in mode of action and adverse effect profile. The groups of antidepressants are presented together with their mode of action, drug interactions, adverse effects and their use in vulnerable patient groups. This article further discusses briefly the issues of suicide risk, antidepressant time to effect, first-line antidepressant choice and treatment...
Psychopharmacology is not the sole province of psychiatrists. General practitioners (GPs) need to be familiar with the management of common psychiatric disorders, especially depressive and anxiety disorders, as most people with these disorders are treated in primary care. Hospital physicians will encounter many patients for whom psychiatric drugs have been prescribed, given the increased prevalence...
Three major families of psychological therapies are briefly described; cognitive behavioural, psychodynamic, and person-centred perspectives. The underpinning theory and therapeutic approach of each form of therapy are briefly described. Key references describing the theories and evidence of effectiveness are also given.
Mood stabilizers vary in their mode of action and commonly include valproate, lithium, lamotrigine and carbamazepine. Some antipsychotics are also used in long-term treatment of bipolar disorder. This chapter gives advice on the appropriate dosing of mood stabilizers, their use in vulnerable groups of patients, and how and when to monitor therapeutic plasma drug concentration. Common adverse effects,...
As every doctor knows, mental and physical health conditions are often linked. This article covers common presentations of psychiatric problems in a general medical setting. In addition, it summarizes the key points of the other articles in the two chapters on Psychiatry. Finally, it explains how psychiatric services work in the community. If you have a liaison psychiatry service, these tips should...
Several drugs are effective in delaying the cognitive decline associated with the illness and in managing the neuropsychiatric symptoms that often accompany dementia. Acetylcholinesterase inhibitors and memantine are the only agents currently available to treat the cognitive symptoms in Alzheimer's disease. Their mode of action, adverse effects and interaction profiles are discussed. Neuropsychiatric...
Chronic physical diseases are the main cause of disability throughout the world. Much of this disability arises from co-morbid mental health complications. The two are likely to co-exist; indeed, over 50% of working age adults with mental ill health also have physical ill health and this rises to 95% in those over 79 years. This co-morbidity adversely influences outcomes by worsening disability, quality...
Chronic fatigue syndrome (CFS) is a debilitating condition that can lead to severe impairment of function in all aspects of patients' lives. It therefore constitutes a considerable burden on the individual, their carers and society. No single cause has yet been found, and it is likely to be a condition of multiple aetiologies. Delays in diagnosis can lead to increased disability and less chance of...
The compulsory detention and treatment of patients is a key ethical issue facing psychiatry. It involves clinicians overriding the apparent autonomy of their patients, with ensuing ethical implications. The legal basis for detention and treatment is equally complex, with two acts – the Mental Health Act and the Mental Capacity Act – both applying to patients with mental illness.
Benzodiazepines and so-called ‘Z’ drugs are used as hypnotics. Their mode of action is to enhance the activity of central γ-aminobutyric acid. Adverse effects include anterograde amnesia and paradoxical reactions. Tolerance, dependence and withdrawal symptoms can develop, which may be minimized by intermittent dosing. Concurrent administration with central nervous system (CNS) depressants is not recommended...
Substances of abuse dysregulate the major pathways underlying aspects of motivation, reward, decision-making and memory. As drug use evolves from an impulsive to compulsive action, the brain undergoes neuro-adaptation, during which there is a shift in the importance of different neurotransmitters. Dopamine plays an important role in addiction, providing initial pleasure to a drug, or a positive reinforcing...
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