Adult Psychiatry 1.2 Flashcards
(167 cards)
1
Q
What did Kendell show in his 1996 study?
A
Pregnancy induced hypertension increased the risk of psychosis almost 9 fold
2
Q
What obstetric events are linked to schizophrenia?
A
Low birth weight, small for gestational age
Perinatal factors e.g. PIH
Hypoxic events e.g. PROM
3
Q
What is used to measure obstetric complications during childbirth?
A
Lewis-Murray scale
4
Q
Which study started research into cannabis and schizophrenia?
A
Swedish study in 1960s by Andreassen
5
Q
What did the Dunedin cohort show re cannabis and schizophrenia?
A
Exposure at 15 to cannabis compared to 26 showed there was an association with psychosis
6
Q
What did Bauml et al divide psychosocial interventions into?
A
Obligatory
Voluntary
7
Q
What is basic level competency?
A
Process of empowerment of patients and relatives to understand and accept the illness and cope with it in a successful manner
8
Q
Examples of voluntary psycho-social interventions
A
Individual behavioural therapy
Communication training
Family therapy
9
Q
What is the most basic and important part of psychosocial intervention for schizophrenia?
A
Psychoeducation
10
Q
Who first employed the term psychoeducation?
A
ANderson
11
Q
What did psychoeducation first consist of?
A
Briefing patient about their illness
Problem solving
Communicatino training
Self-assertiveness training
12
Q
What does Cochrane review of psychoeducation for schizophrenia show?
A
Reduction in relapse
Improved compliance
13
Q
Who did studies into high expressed emotion in families of schizophrenia?
A
Brown & Rutter
14
Q
What did Brown & Rutter show in families with schizophrenia?
A
Patients in families with high expressed emotion were more likely to experience a relapse during the following year despite medication
15
Q
Impact of family therapy on schizophrenia?
A
Reduces relapse rate from 64% to 24% when there is high expressed emotion
16
Q
When is family therapy for schizophrenia more effective?
A
If baseline risk of relapse is increased
17
Q
NNT for family therapy for relapse prevention in schizophrenia?
A
6
18
Q
Who created the framework for social skills training?
A
Bellack and Mueser
19
Q
What are the forms of social skills training?
A
Basic Model
Social problem-solving model
Cognitive remediation model
20
Q
What is the basic model of social skills training?
A
Complex social repertoires are broken down into simpler steps, practiced through role playing and applied in natural settings.
21
Q
What is the social problem-solving model?
A
Focuses on improving impairments in information processing that are assumed to be the cause of social skills deficits.
Targets things like medication and sx management, self-care.
22
Q
What is the cognitive remediation model in social skills training?
A
Corrective learning process begins by targeting fundamental cognitive impairments like attention & planning.
23
Q
What did Birchwood say re CBT for schizophrenia?
A
Target is emotional dysfunction that accompanies psychotic experience and not the sx themselves.
24
Q
What did Turkington describe re the elements of CBT for psychosis?
A
Therapeutic alliance - validation
Improving medication adherence
Providing alternate explanations to unusual experiences
Decreasing impact of positive sx
Graded reality testing using peripheral questioning and inference chaining
25
What did a meta-analysis for CBT in psychosis show?
34 trials concluded positive beneficial effects for target sx
No effect on hopelessness
26
Competitive employment rate for those with SMI?
<20%
27
Elements of supported employment?
```
Goal of permanent competitive employment
Minimal screening for employability
Avoidance of preoccupational training
Individualized placement
Time-unlimited support
Consideration of preferences
```
28
Unweighted mean of patients in supported employment programs for obtaining competitive employment?
65% vs 26% in controls
29
Relapse rate of psychosis in one year irrespective of treatment
27%
30
Relapse rate of psychosis in one year if not on treatment
61%
31
Relapse rate of psychosis regardless of treatment if patient has 5 or more episodes in one year?
48%
32
Relapse rate of psychosis if no treatment of patient who has had 5 or more episodes in one year?
87%
33
Relapse rate of psychosis in one year regardless of treatment for patients living in stressful environments?
62%
34
Relapse rate of psychosis in one year if receiving antipsychotics and family education?
19%
35
Relapse rate of psychosis in one year if receiving antipsychotics and social skills training?
20%
36
Definition of recovery for schizophrenia
GAF>60
37
Recovery rate of schizophrenia at 15 years
37% with schizophrenia
| 54% with other psychoses
38
Who did a meta-analysis into schizophrenia and suicide?
Palmer et al
39
Lifetime prevalence of suicide in schizophrenia?
5.6%
40
Self-harm rates in people with schizophrenia
38% had at least one episode in 2-12 year follow up period
41
Median standardised mortality rate for schizophrenia?
2.58
42
Is standardised mortality rate increasing or decreasing for schizophrenia?
Increasing
43
Which subtypes of schizophrenia have the best outcome?
Paranoid
| Catatonic
44
Which subtype of schizophrenia has the worst outcome?
Hebephrenic
45
Which study looked into prognosis of schizophrenia?
187 schizophrenic patient study from Chestnut Loge over 19 years
46
What did Chestnut Lodge study show re prognosis of paranoid schizophrenia?
Paranoid patients had older age of onset, developed rapidly in people with good functioning, was intermittent during first 5 years and associated with good recovery.
47
What did Chestnut Lodge study show re prognosis of hebephrenic schizophrenia?
Earlier age of onset
Poor premorbid functioning
Continuous illness
Poor long-term prognosis
48
What did Chestnut Lodge study show re undifferentiated schizophrenia and its prognosis?
Poorly distinguished from patients premorbid state
Early hx of behavioural difficulties
Continuous but stable disability
49
Factors suggestive of good prognosis for schizophrenia
```
Late onset
Obvious precipitating factors
acute onset
Good premorbid adjustment
Affective sx
Married
FHx of affective disorders
Good social support
Positive sx only
Good initial response to Rx
```
50
What is the best predictor of a good prognosis of schizophrenia?
Good initial response to treatment
51
Poor prognostic factors for schizophrenia
```
Early onset
No precipitating factors
Insidious onset
Poor premorbid adjustment
Social withdrawal
Single/divorced/widowed
FHx of schizophrenia
Poor social network/High EE families
Negative sx
Poor compliance
Neurological sx
Hx of perinatal trauma
No remissions in 3 years
Many relapses
Hx of violence
```
52
Best predictors of poor short-term outcome in acute psychosis
Stressful live events
High EE
Non-compliance
53
Predictors of good medium (2-5 years) outcome in
| psychosis?
Females
Married
Social contacts outside home
Acute onset
54
Best predictor of course of schizophrenia?
Course of illness n first 2 years
55
Which antipsychotics show an effect size difference from first generation antipsychotics?
Clozapine
56
What did CATIE and CUtLASS studies show?
Second generation drugs are no better than first in terms of efficacy and cost
Olanzapine better than other atypicals for attrition
57
Who did a meta-analysis into dose comparison of antipsychotics for psychoses?
Davis & Chen, 2003
58
What did Davis & Chen 2002 find re doses for antipsychotics for psychoses?
Maximal effective dose of Haloperidol ranges from 3.3-10mg/day
No evidence that higher doses more effective
59
Best doses for atypical antipsychotics
Aripiprazole 10mg/day
Clozapine >400mg/day
Olanzapine 5mg/day
Risperidone 2mg/day
60
Guidelines for Chlorpromazine dose/day
100mg.day
61
Guidelines for Quetiapine dose/day
75mg/day
62
Guidelines for Ziprasidone dose/day
60mg/day
63
Guidelines for Aripiprazole dose/day
7.5mg/day
64
What did Essock et al. 2007 do with the CATIE study?
Used data to find out whether switching or staying with same medication was useful
65
What did Essock et al 2002 find?
People who stayed on same medication did better, particularly for Olanzapine.
66
Best medication for aggression?
Clozapine
Olanzapine
Haloperidol
(in that order)
67
What are primary negative sx?
Sx that are intrinsic to schizophrenia
68
What are secondary negative sx?
Sx that occur in association with or are caused by positive sx, affective sx, medication SE, environment, illness-related.
69
What % of schizophrenic patients have primary negative sx?
20-30% (clinical)
| 14-17% (population)
70
First criteria of deficit schizophrenia?
```
At least 2 of 6 of the following present and of clinical severity:
Restricted affect
Diminished emotional range
Poverty of speech
Curing of interest
Diminished sense of purpose
Diminished social drive
```
71
Second criteria of deficit schizophrenia
2 or more of these features present for preceding 12 months and present during periods of clinical stability.
72
Third criteria of deficit schizophrenia
2 or more of these enduring features are idiopathic i.e. not secondary to factors other than the disease.
73
Fourth criteria of deficit schizophrenia
Patient meets DSM V criteria for schizophrenia.
74
Difference between DSM IV and V re schizophrenia
DSM V has no special attribution to bizarre delusions of first-rank auditory hallucinations.
75
Associations with deficit schizophrenia
```
Frontal atrophy
Familial pattern
Summer birth
Increased eye tracking dysfunctions
More tardive dyskinesia
Poor functional outcome
Lower suicide and depression rates
```
76
Best antipsychotic for negative sx?
Amisulpride
77
What augmentation medication can be used for negative sx?
D-cycloserine; partial agonist at glycine modulatory site of glutamatergic N-methyl-d-aspartate receptor.
Selegiline
78
Impact of glycine on negative sx?
30% reduction
79
Which study looked into suicide prevention in schizophrenia?
Intersept study?
80
What did Intersept study show?
Suicidal behaviour significantly less in patients treated with clozapine or olanzapine
81
Which antipsychotics lead to improvement in neurocognition?
Second generation
82
What was Goldberg et al. 2007's RCT?
Risperidone v Olanzapine in patients with first episode schizophrenia
83
Finding of Goldberg et al. 2007?
Effect size for cognitive change in patients exposed to 2nd gen antipsychotic was similar to healthy control group.
84
NICE recommendations for first line Rx of psychosis
PO atypical antipsychotic as per patient choice
85
NICE guidelines if good effect with typical PO antipsychotic but SEs
Consider PO atypical antipsychotic
86
Which antipsychotic to use if more than one atypical antipsychotic is considered appropriate?
Drug with lowest purchase cost should be prescribed
87
Which treatment should be given for psychosis if discussion between patient and clinician is not possible?
PO atypical - lower potential risk of EPSEs
88
How long should monotherapy be trialled for schizophrenia?
4-6 weeks
89
IPAP recommendation for initial monotherapy for schizophrenia?
```
Amisulpride
Aripiprazole
Olanzaine
Quetiapine
Risperidone
Ziprasidone
```
90
IPAP recommendation if initial monotherapy fails for schizophrenia?
4-6 week trial of second atypical
91
IPAP recommendation if 2nd monotherapy fails for schizophrenia?
6 month trial of clozapine up to 900mg.day
92
IPAP recommendation if persistent sx of psychosis despite 6 months of clozapine?
Optimize clozapine and/or augment with ECT or adjuvant medication
Alternate strategies
93
What should the clinician consider each time they review antipsychotics for schizophrenia for a patient?
```
Major suicide risk
Metabolic risk - especially with Olanzapine
Severe agitation/violence
Non-compliance
Depression/mood sx
Substance abuse
Prodromal/first episode
Catatonia
```
94
What does treatment of future episodes of psychosis depend on?
```
Compliance
Therapeutic responde
Side effects
Cause of relapse
Treatment resistant
```
95
What % of patients with psychosis relapse despite on treatment?
20%
96
What % of patients with psychosis relapse if they do not take their medications?
60%
97
Risk of relapse if one stops medication for psychosis
Five fold increase
98
Duration of maintenance treatment recommended for psychosis
1-2 years
99
Duration of maintenance treatment for multiple episodes of psychosis
At least 5 years
100
What medications to change to if EPSEs?
Atypicals; avoid high doses, especially of Risperidone
101
Which medications to avoid for metabolic syndrome?
Clozapine
| Olanzapine
102
Best medications to avoid metabolic syndrome?
Amisulpride
| Aripiprazole
103
Which medications are safe for high prolactin?
Aripiprazole
Olanzapine
Quetiapine
104
Which medications to switch to if problems with sedation?
Haloperidol
Aripiprazole
Amisulpride
105
Which medications have fewer SE of tardive dyskinesia?
Clozapine
| Atypicals
106
Better profile for sexual dysfunction re medications?
Aripiprazole
| Quetiapine
107
Who did a meta-analysis into depot for schizophrenia?
Adams et al.
108
What did Adams et al. find re depot use for schizophrenia?
Global improvement among patients given depot compared to those on PO and similar rate of SEs
109
Who did a survey of OP with depot for schizophrenia?
Pereira & Pinto 1997
110
What did Pereira & Pinto 1997 find re depot and schizophrenia?
Patients who were receiving depots prefered to continue on them.
60% of patients converted to depot and said they felt better on it.
Patients felt when on depot they were able to live normal lives and the depot protected them from relapses
111
Characteristic features of Zuclopenthixol depot
More effective in aggressive patients
Better at relapse prevention
High EPSE burden
112
Characteristic features of Flupentixol
Antidepressant effect
113
Characteristic features of haloperidol depot
Useful in prevention of manic relapse
| May need 3-6 months to reach steady state
114
Characteristic features of Pipotiazine depot
Fewer EPSEs
115
Characteristic features of Fluphenazine depot
May induce depressed mood
116
Characteristic features of Risperidone depot
Needs aqueous suspension before injection.
Needs to be stored in fridge
Test dose not required
117
Risk of NMS with depot vs PO meds?
Same risk
118
Risk of TD for depot vs PO meds>
Same
119
Evidence of high dose prescribing for antipsychotics
No evidence that high dose prescribing provides sx relief in those who have not responded at lower doses
120
Guidelines for high dose prescribing
Consider alternative approaches such as adjuvant therapy, newer antipsychotics such as Clozapine
121
When are risk factors such as metabolic effects more pronounced in high dose prescribing of antipsychotics?
>70 years of age
122
Guidelines of increasing dose for high dose px
Increase dose no more than weekly
ECG
Regular physical examination, obs and hydration status
123
Duration guidance for high dose px
For 3 months only; no use in continuing after 3 months if no response
124
Who provided evidence of Clozapine for treatment-resistant schizophrenia?
Kane et al. 1998
| Wahlbeck et al. 1999 - meta-analysis
125
Describe structure of Kane et al. 1998's study
Multicentre clinical where schizophrenia patients failed to respond to 3 meds, underwent a prospective, single-blind trial of high dose haloperidol for 6 weeks.
Patients who didn't improve on haloperidol where double-blinded and given clozapine or chlorpromazine for 6 weeks.
126
Results of Kane 1998's study?
Out of 268 patients, 30% of clozapine patients responded compared to 4% of chlorpromazine patients.
127
Meltzer's conclusino of clozapine?
30% of clozapine patients would respond in 6 weeks, 20% by 3 months, 10-20% by 6 months.
128
Relationship between clozapine plasma levels and clinical response?
None
129
What plasma level of clozapine should be reached before patient can be considered non-respondent to clozapine?
350-450ng/ml
130
Who reproduced the methodology of Kane 1998 and what did they find?
Conley et al 1998
| Olanzapine no better than chlorpromazine in treatment resistance
131
NICE's definition of treatment resistance of schizophrenia
Lac of satisfactory clinical response to sequential use of at least two antipsychotics for 6-8 weeks; at least one must be atypical.
132
What medications have been used to augment clozapine?
Risperidone
Fluoxetine
Anticonvulsants
Amisupride - high potency D2 blockade
133
Studies of augmentation of clozapine with lamotrigine?
Improvement in positive sx
| No effect on negative sx
134
Studies of augmentation of clozapine with risperidone?
Low risperidone dosage (4.5mg/day) and long duration of trial is associated with good outcome
135
Non-pharmacological adjuvant to clozapine?
Fish omega oil - ethyl-eicoaspentanoate
136
What does CATIE stand for?
Clinical Antipsychotic Trials of Intervention Effectiveness
137
What type of study was CATIE?
Double-blind pragmatic RCT
138
Patients in CATIE?
1493 patients with chronic schizophrenia across 57 sites from 2001-2004
139
Medications used in CATIE?
```
Olanzapine
Quetiapine
Risperidone
Ziprasidone (added later)
Perphanazine
```
140
How many patients discontinued treatment in 18 months in CATIE?
74%
141
Which medication had lowest discontinuation rate in CATIE?
Clozapine - 10 months
| Olanzapine - 64%
142
Which medication had highest SE burden in CATIE?
Olanzapine
143
Which medication caused most anticholinergic sx in CATIE?
Quetiapine
144
Which medication caused most EPSes in CATIE?
Perphenazine
145
What happened in phase 2 of CATIE?
Those who terminated phase 1 due to SEs (444 participants) were tested with Olanzapine, Risperidone, Quetiapine or ZIprasidone.
146
Effectiveness of medications in phase 2 of CATIE?
Olanzapine and Risperidone had equal effectiveness and both better than the others
147
Problems with CATIE
Perphenazine only used in one randomized phase
Double-blind treatment decreased resemblance to clinical case
Mean doses used is controversal
148
What is CUtLASS?
Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study
149
What type of study was CUtLASS?
Unblinded randomised control trial comparing first and second generation antipsychotics
150
Primary outcome of CUtLASS?
QoL at 1 year
151
Secondary outcome of CUtLASS?
Sx measures at 1 year
152
Participants in CUtLASS?
1,227 patients with schizophrenia assessed by their clinical team for medication review because of poor response or adverse effects were randomised
153
Second generation drugs used in CUtLASS?
Amisulpride
Olanzapine
Quetiapine
Risperidone
154
Rate of follow-up at 1 year in CUtLASS?
81%
155
Results of CUtLASS?
No advantage of 2nd generation drugs
Those on 1st generation drugs did relatively better
Patients had no clear preference
156
What was the second phase of CUtLASS?
Compared clozapine with other 2nd gen antipsychotics in 136 patients
157
Results of 2nd phase of CUtLASS?
Significant advantage for clozapine in sx improvement in 1 year
Patients preferred Clozapine
158
Treatment of Delusional Disorders
Fluoxetine 80mg/day; effect at 8-12 weeks
159
Who conducted a systematic review into post schizophrenic depression?
Levinson
160
What did Levinson find re post schizophrenic depression?
Antidepressants are beneficial for patients stable re psychotic sx
161
Which antipsychotics have antisuicidal effects in schizophrenia?
Clozapine
| Olanzapine
162
Main treatment for schizoaffective disorder
Mood stabiliser
163
Which medication is best for depressive type of schizoaffective disorder?
Carbamazepine
164
Who did a meta analysis of 10 RCTs into psychotic depression?
Wijkstra et al.
165
What did Wijkstra et al. find re medication treatment for psychotic depression?
Combination of antidepressant and antipsychotic is no better than antidepressant monotherapy.
166
Which combination is superior for psychotic depression compared to monotherapy?
Antidepressant + antipsychotic compared to antipsychotic alone
167
What do NICE guidelines recommend re treatment for psychotic depression?
Combination strategy
