Medicine (Abingdon, England : UK ed.)最新文献

Insomnia can result in impaired daytime functioning and reduced quality of life. Effective treatment is important to reduce suffering. Cognitive behavioural therapy for insomnia is efficacious both in-person and digitally and should be the first-line option in either short-term or long-term insomnia. Hypnotics or sedatives can be offered if non-drug treatments are ineffective or unsuitable but should be kept to short-term use because of associated adverse effects. Treatment should be withdrawn gradually to reduce risks of rebound anxiety, other distressing symptoms, confusion and convulsions. Melatonin is an alternative hypnotic for the short-term management of insomnia in individuals aged >55 years. Orexin receptor antagonists are an option in chronic insomnia where cognitive behaviour approaches are not an option.

Depression is common in individuals with chronic physical health conditions and should be assessed and treated. People with serious mental illness including schizophrenia and bipolar disorder die 15–20 years earlier than the general population. Of these deaths 70% result from physical health conditions, particularly cardiovascular and respiratory disease. Multimorbidity is common and occurs earlier in this population. There are higher rates of obesity, diabetes and cardiovascular disease in patients with mental illness, which should be screened for and treated. Antipsychotic agents improve symptoms of psychotic illnesses and reduce all-cause mortality, but cause weight gain and hyperlipidaemia and predispose to diabetes, which should be monitored. Anorexia nervosa carries a high rate of premature mortality; medical emergencies such as hypoglycaemia and refeeding syndrome must also be recognized and treated. Clinicians should be aware of diagnostic overshadowing and system-level factors that contribute to the disparity in treatment of physical health complaints in those with mental illness.

This article outlines current guidelines for the pharmacological treatment of depression, with an update based on recently published information. For the acute treatment of moderate to severe depression in the absence of specific factors, the recommendation is treatment with a selective serotonin reuptake inhibitor or mirtazapine. Recommendations for next-step treatment for patients with an inadequate response include increasing the dose, switching to another antidepressant, augmentation with another agent or using a combination of antidepressants. Recommendations for the treatment of depression in older adults are included. The options for non-pharmacological treatments are briefly explored in regard to symptom severity and other clinical features, and a list of non-pharmacological treatment options is provided.

Electroconvulsive therapy (ECT) is the most effective treatment for depression, with a remission rate of approximately 50% with standard brief-pulse ECT. It is recommended for treatment-resistant depression, where there is patient preference and/or a previous good response, for rapid improvement of life-threatening episodes of severe depression, and for severe or prolonged mania and catatonia. It is a medically safe procedure, and the major risks are related to anaesthesia. Cognitive adverse effects can be minimized by using right unilateral electrode placement and ultra-brief pulse width (<0.5 ms) stimuli. Most adverse effects usually resolve within a few weeks after the course of treatment, although retrograde amnesia can persist with some forms of ECT. Repetitive transcranial magnetic stimulation has been approved by the UK National Institute for Health and Care Excellence for use in depression, but is much less effective than ECT. Other methods of brain stimulation include vagus nerve stimulation, transcranial direct current stimulation and deep brain stimulation. Neurosurgery for mental disorders is only available in specialized centres and under highly regulated conditions, but can benefit some patients.

Antipsychotic medicines are the mainstay of treatment of patients with psychosis. They are also used in the acute and long-term treatment of patients with bipolar disorder, depression and some other conditions. Knowledge of their mechanism of action, adverse effects and dose–response relationships can help to optimize and tailor treatment for individual patients. Antipsychotics vary greatly in their adverse effect profiles, with small differences in their efficacy, except for clozapine, which is unique in its improved efficacy in treatment-resistant schizophrenia. Metabolic adverse effects, seen often with second-generation antipsychotics, should be monitored and promptly managed.

Self-harm is one of the most common reasons for presentation to hospital. It reflects distress rather than a diagnosis in itself. This article focuses on the management of people presenting to hospital with behaviour attributed to intent to harm themselves. Self-harm is associated with a significantly increased risk of future suicide, around 10% dying by suicide within 10 years, with the risk being greatest in the first month. The UK National Institute for Health and Care Excellence quality standards and guidelines for the short-term management of self-harm make recommendations relevant to all healthcare professionals, emphasizing the importance of parallel psychosocial and physical management and assessment of the risk of further self-harm or suicide. Observation levels and discharge plans are also important. Current mental illness is a major risk factor for suicide, as are high intent of suicide at the time of the self-harm, a history of self-harm, current physical illness, poor social support and demographic variables. Risk of further self-harm is also higher in certain groups, including individuals who are middle-aged or elderly, have substance misuse or frequently self-harm. There are several standardized tools to aid risk assessment but none has adequate sensitivity and specificity to replace clinical judgement.

Psychiatric adverse drug reactions (ADRs) have been reported with a diverse range of medicines used to treat physical illness. Whereas some are mild (e.g. transient sleep disturbances), others (e.g. psychosis) are severe and warrant discontinuing the suspected causal agents. Some reactions are predictable, while others are unpredictable. The mechanism by which they are mediated is often unclear. It is essential that serious psychiatric ADRs observed during routine clinical practice in the UK are reported via the Yellow Card reporting scheme as relatively uncommon ADRs may only be detected through post-marketing surveillance in the wider population. Patients have reported finding symptoms of psychiatric ADRs extremely distressing and sometimes frightening, and can be hesitant to mention these to clinicians.

Perinatal psychiatric disorders are common and can result in significant suffering for women and their families: suicide is a leading cause of maternal death. The most severe form of postpartum mood disorder – postpartum psychosis – follows approximately 1 in 1000 deliveries. Women who have a history of bipolar disorder or who have suffered a previous severe postpartum episode have a many-hundred-fold increased risk, and identifying them in the antenatal period is a key aspect of management. Decisions regarding the use of psychotropic medication in pregnancy must be made after a full risk–benefit analysis. The risks of taking many medications remain unknown but include teratogenic effects, withdrawal or toxic symptoms in the newborn and long-term developmental effects. However, these must be balanced against the risks of untreated mental illness and the risk of recurrence from stopping or switching well-established and efficacious medications. More data are needed to inform the difficult choices regarding medication that women with severe mental illness have to make in regard to pregnancy.

There is good evidence for the use of pharmacological treatments to improve outcomes in patients with alcohol dependence. The management of acute withdrawal should include a high risk of suspicion for Wernicke–Korsakoff syndrome, necessitating treatment with parenteral thiamine. Benzodiazepines in reducing doses should be used in conjunction with a continuing treatment plan after medically assisted withdrawal (detoxification). The relapse prevention medications acamprosate and naltrexone should be considered in all patients with moderate to severe alcohol dependence wishing to maintain abstinence. Disulfiram can be considered as a second-line treatment, but should be initiated by a specialist. Nalmefene has been shown to be effective in patients with mild dependence wishing to reduce their alcohol consumption. Baclofen remains off licence in much of the world: it may have a role in patients with co-morbid liver disease and anxiety symptoms.