Canadian Guidelines--Schizophrenia (2017) Flashcards
1
Q
list the first rank symptoms of schizophrenia
A
auditory hallucinations
thought withdrawal, insertion or interruption
thought broadcasting
somatic hallucinations
delusional perception
feelings or actions controlled by external agents
2
Q
how many first rank symptoms of schizophrenia are there
A
6
3
Q
list the four negative symptoms associated with schizophrenia
A
affective flattening
avolition
alogia
anhedonia
4
Q
what are the core negative symptoms of schizophrenia
A
affective flattening
avolition
5
Q
what is the most widely used semi-structured diagnostic interview available for adolescents with regard to schizophrenia
A
Schedule for Affective Disorders and schizophrenia for School Age Children
6
Q
what areas of the MSE should be paid particular attention to when assessing schizophrenia/related disorders
A
symptoms of psychosis
negative symptoms
general psychopathology
insight
competence
risk of suicide and aggression
7
Q
why do we care about the duration of untreated psychosis in a patient presenting with first episode psychosis
A
because this duration has prognostic value –> significant predictor of outcomes
8
Q
what is considered the appropriate standard wait time for a scheduled, non-urgent first episode referral psychosis by the CPA
A
2 weeks
9
Q
in which patients do the guidelines recommend neuropsychological testing in the assessment of schizophrenia/related disorders
A
those presenting with first episode psychosis and those with poor responses to treatment
may be important for documenting cognitive deficits and for treatment and academic planning
10
Q
what are signs and symptoms suggestive of autoimmune encephalitis (that may prompt MRI)
A
new focal CNS findings
seizures not explained by a previously known seizure disorder
rapid progression of working memory deficits over less than 3 months
11
Q
what is the benefit of using the Calgary Depression Scale for Schizophrenia when assessing for depressive symptoms in schizophrenia/related disorders
A
reliable and valid
developed to assess depression in schizophrenia/related disorders INDEPENDENT of negative symptoms
12
Q
do command hallucinations carry higher risk of suicide?
A
yes
13
Q
most of the excessive risk of violence/violent offending in those with schizophrenia/related disorders is associated with what other comorbidity? (rather than with schizophrenia/related disorders alone)
A
substance use comorbidity
14
Q
what are clinical features associated with violence in schizophrenia/related disorders
A
psychotic symptoms, such as persecutory ideation
15
Q
is physical violence toward other people common in those presenting with first episode psychosis
A
no
16
Q
pharmacotherapy treatment recommendations are categories into how many areas in the Canadian guidelines for schizophrenia/related disorders
A
6
first episode schizophrenia
acute exacerbation
relapse prevention and maintenance treatment
treatment resistant schizophrenia
clozapine resistant schizophrenia
specific symptom domains
17
Q
should antipsychotic medication therapy be recommended for patients with first episode psychosis
A
yes
18
Q
how many meta analyses are there that support a relationship between shorter duration of action of untreated psychosis and improved outcomes?
how large is the magnitude of the association
A
3
association is modest
19
Q
is there established clinical superiority for a specific antipsychotic in first episode psychosis? what about antipsychotic class?
A
no establish superiority in either case in terms of clinical outcomes
however, there is differences in terms of side effect profiles (and this is often what guides treatment decision)
20
Q
how long should a first trial of an antipsychotic be in first episode psychosis?
A
at least TWO WEEKS unless there are significant tolerability issues
21
Q
when there is a poor response to medication what should you assess before lack of response can definitively be established
A
medical adherence
substance use
22
Q
how long should you wait after starting a medication in first episode psychosis before considering change in antipsychotic?
A
FOUR weeks
if no response to medication after 4 weeks, despite dose optimization, should consider change in agent
23
Q
what do you do if there is a partial response to initial antipsychotic after 4 weeks but not robust response?
A
in this case, reassess after 8 weeks unless there are significant adverse events
24
Q
what is the objective in acute treatment with antipsychotics for first episode psychosis
A
adequate clinical trial in terms of dose and duration
25
what is an adequate trial of antipsychotic in terms of duration
between 4-6 weeks on adequate therapeutic dose (midpoint or beyond of the licensed dose range)
26
should you target the higher end or the lower end of the therapeutic effective dose range when starting an antipsychotic in first episode psychosis
the lower end
*much of the antipsychotic effect is evident in the first several weeks of treatment
27
how long should someone be treated with antipsychotic agent after first episode of schizophrenia/related disorders
at least 18 months FOLLOWING resolution of positive symptoms
28
does attaining remission and/or stabilization for a period of time on maintenance therapy eliminate the risk of relapse in schizophrenia/related disorders
no
*cumulative risk of first relapse is 82%
29
how much higher is the risk of first or second relapse in those not taking medication compared to those who are in schizophrenia/related disorders
risk of first or second relapse was 5x HIGHER in those not taking medication as compated to those who were
30
does continued antipsychotic use eliminate the risk of relapse in schizophrenia/related disorders
no--> but it does diminish the risk of relapse
31
can exacerbations of psychotic symptoms be selfcontained
yes
but sometimes intervention is required
32
what maintenance dose of antipsychotic therapy should be offered to patients who suffer an acute episode of schizophrenia/related disorders (NOT first episode)
at low or moderate regular dosing of:
300-400mg of chloropromazine equivalents
/
4-6mg risperidone equivalents
33
what is currently the only empiric strategy for establishing dose equivalents
dopamine D2 occupancy as measured using in vivo neuroimaging
*such data are not available on all antipsychotics
*some meds have pharmacology that prevents such comparisons
34
which antipsychotics have pharmacology that prevents comparision with others in terms of "equivalents"
quetiapine
aripiprazole
clozapine
35
how long should maintenance therapy be planned for after acute episode of schizophrenia/related disorders
2 years--> possibly up to 5 years
36
how do LAIs compare to oral agents in terms of relapse rates in early schizophrenia/related disorders
LAIs are superior in reducing relapse rates in early schizophrenia
RCT in first episode schizophrenia--> better symptom control and 6-fold reduction in relapse at 1 year for LAI vs oral
37
how does risk of rehospitalization change for those on LAI vs oral agents
risk of rehospitalization in patients on LAIs is 1/3 of that for patients on oral treatment according to a nation wide registry study
38
what medication should be offered to patients with treatment resistant schizophrenia
clozapine
*it is the only recommended treatment in treatment resistant schizophrenia
39
what % reduction in positive or negative symptoms is required in order to be considered to have responded favorably to a medication trial
at least 20% reduction in symptoms
40
do the canadian guidelines make any specific recommendations with regard to augmentation strategies for those who do not respond adequately to clozapine in the case of treatment resistant schizophrenia
no--> some other guidelines do, but the canadian guidelines specifically do not as there is insufficient evidence to do so
(usually other guidelines suggest addition of other antipsychotics and/or ECT)
41
what agent is preferred for people with psychosis associated with aggression
clozapine
*clinically superior in the treatment of aggression
42
what is one area the guidelines identify requires further clarification/study?
the issue of antipsychotic discontinuation in those who have responded effecrtively to treatment
+
what to do if someone is resistant to clozapine
43
which is more effective for those with schizophrenia in terms of increasing competitive employment, according to the evidence: supported employment or prevocational training
supported employment
44
when can CBT for psychosis be initiated
basically any phase (initial, acute, recovery), even in inpatient settings
45
list some of the benefits observed when employing CBT for psychosis
reduces symptom severity, hospitalization and relapse
also showed significant benefit on level of depression
46
what are the most frequently used substances by people with schizophrenia
alcohol and cannabis
47
what % of those with schizophrenia use cigarettes
60-90%
48
does the presence of psychosis appear to increase the risk of cannabis use?
no
but the presence of cannabis use does increase the risk of psychotic symptoms
49
how much earlier do people seem to develop psychosis if they have used cannabis, compared to those who have not?
symptoms appear approx 2.7 years earlier
50
what is the best model of care for those with both psychosis and substance use
integrated substance use and psychosis treatment, like a concurrent disorders program or unit
(rather than parallel or sequential treatment)
51
what is likely to be the primary modifiable cardiovascular risk factor in those with schizophrenia
cigarette smoking
52
which antipsychotics are particularly sensitive to starting/stopping cigarette smoking
clozapine and olanzapine
53
what pharmacotherapy should be considered to help people with schizophrenia stop smoking
NRT for people with psychosis or schizophrenia
BUPROPRION for those with a diagnosis of schizophrenia
VARENICLINE for those with psychosis or schizophrenia
54
what should you warn patients about if you prescribe buproprion or varenicline for smoking
increased risk of adverse neuropsychiatric symptoms (particularly in first 2-3 weeks)
i.e sleep impairment, suicidality, reemergence of psychotic symptoms
55
which pharmacologic intervention currently has the most evidence for stopping smoking in those with schizophrenia
buproprion
(whereas for those without schizophrenia, varenicline seems to have the best evidence) --> thus buproprion is recommended first then varenicline for those with schizophrenia
56
are there particular preferences for certain antipsychotics in those with both schizophrenia and SUD?
no... ?clozapine but evidence sucks
57
for those who have ?substance induced psychosis that does not resolve rapidly with abstinence, how long do you treat with antipsychotics
not clear--> guidelines suggest following recommendations for first episode psychosis especially if risk factors are present
58
list the 3 medications indicated for use in people with alcohol use disorder
naltrexone
acamprosate
disulfram
59
which medications for the treatment of alcohol use disorder have evidence in those with schizophrenia
naltrexone *most
disulfiram *limited
(no evidence currently for acamprosate)
60
are there currently any indicated pharmacotherapies for cocaine use disorder
no
61
are there currently any indicated pharmacotherapies for those with cannabis use disorder
no
*data has been NEGATIVE for mirtazapine, buproprion, nabilone, dronabinol
*there is also no evidence of specific psychosocial interventions despite well designed studies
62
what is the prevalence of childhood onset schizophrenia
quite rare
1.6-1.9 per 100 000 children
63
what is considered childhood onset schizophrenia
before age 12
64
after what age does the prevalence of schizophrenia increase rapidly
age 14 --> particularly in males
65
psychosis/schizophrenia accounts for what % of all psychiatric admissions in young people between ages 10-18
25%
66
how does age at onset of schizophrenia affect suicide risk
higher risk of suicide in those with earlier onset
67
in children and young people with first presentation psychosis, should antipsychotic medication be started in the primary care setting
no--> unless done in consultation with psychiatrist with CAP training
68
what proportion of all adults with schizophrenia have their onset of symptoms before age 18
1/3
69
is antipsychotic medication treatment as effective in kids as in adults
yes
70
what side effect clusters should be discussed with patients before starting antipsychotic therapy
metabolic
extrapyrimidal
cardiovascular
hormonal
other
71
metabolic side effects of antipsychotics
weight gain
diabetes
72
extrapyramidal side effects of antipsychotics
akathesia
dyskinesia
dystonia
73
cardiovascular risk factors of antipsychotics
prolonged QTc
74
hormonal side effects of antipsychotics
increased plasma prolactin
75
which are the only antipsychotics currently approved in canada for children and adolescents with schizophrenia or bipolar disorder
aripiprazole
lurasidone
76
other than the fact only two antipsychotics are approved for kids and teens in Canada, is there any evidence in the guidelines for clinical superiority of one agent over another
no
77
when is an ECG recommended before starting or changing and antipsychotic for a kid with schizophrenia
1. it is specified in the health canada drug product database
2. physical exam has identified a CV risk (i.e high BP)
3. personal history of CV disease
4. family history of CV disease such as premature cardiac death or prolonged QTc
78
how do you start an antipsychotic in a kid if it is not licensed for kids/teens
give dose BELOW LOWER END of the licensed range for adult (and AT the lower end if it IS licensed)
slowly titrate upwards
target dosing to efficacy rather than weight
79
which 3 risk factors that carry a poor prognosis are MOST strongly associated with poor outcomes (including risk of relapse)
cannabis use
other comorbidities (i.e depression)
medication nonadherence
80
how does using cannabis regularly in adolescence affect the risk of reporting psychotic symptoms of being diagnosed with schizophrenia during adulthood
DOUBLES the risk
81
how long should you monitor for signs and symptoms of relapse after discontinuing antipsychotic therapy
at least 2 years
82
why is it important to prevent relapses of psychotic symptoms, and treat them promptly when they occur
risk of persistent psychotic symptoms increases with repeated relapses
relapses may lead to REDUCTION IN GRAY MATTER which can reduce responses to meds and impair social, emotional and vocational attainment
83
are kids at higher risk of dystonic reactions to antipsychotic medications
yes
*thus, limit use of first generation antipsychotics in this younger age group
84
is there evidence to support the prescription of antihistamines in cases of agitation
no
85
what medications do the guidelines mention for aggression/agitation in youth with schizophrenia
benzos or antipsychotics (ideally one the kid is already on if they are being treated for schizophrenia)
86
which antipsychotic has the greatest risk of weight gain? (and what other 2 are also known to be particularly likely to cause weight gain)
olanzapine
(followed by clozapine and quetiapine)
87
which 3 antipsychotics have the greatest risk of neurological side effects like parkinsonism, akathesia and other EPS
risperidone
olanzapine
aripiprazole
88
can you use clozapine in kids
yes--> same pathway as for adults in terms of treatment resistance
89
is schizophrenia an independent risk factor for diabetes?
yes
(and long term antipsychotic use adds to this risk)
90
list 3 antipsychotics at higher risk of clinically important weight gain
chlorpromazine
clozapine
olanzapine
91
list 3 antipsychotics as lower risk of clinically important weight gain
aripiprazole
asenapine
ziprasidone
92
list 5 antipsychotics at intermediate risk of clinically important weight gain
lurasidone
paliperidone
risperidone
quetiapine
perphenazine
+other FGAs
93
do we know the mechanism by which antipsychotics cause weight gain
no not exactly
94
what is a hypothesis for why antipsychotics cause weight gain
antipsychotic binding affinity for H1 receptors--> associated with change in eating behaviours and decreased sensation of satiety
there may also be genetic susceptibility that affects this
95
what medication can be prescribed to help managed weight gain and other metabolic consequences of antipsychotics
metformin
*its use is recommended by the guidelines for those who are experiencing weight gain on antipsychotic meds
96
what is torsade de pointes
a malignant ventricular arrhythmia associated with syncope and sudden death and is associated with prolonged QTc
97
how does treatment with antipsychotics affect the risk for sudden cardiac death
those on antipsychotics (both FGA and SGA) had DOUBLE the rate of sudden cardiac death as those who were not
relationship was dose dependent
98
what other two factors, other than antipsychotic use, were found to have increased risk of QTc prolongation
female gender
CYP450 34A metabolized drugs
99
APA
what brain imaging is preferred according to these guidelines for working up a patient with schizophrenia
MRI
(but can do CT or MRI if clinically indicated based on neuro exam or history)
100
APA
when should you do diabetes screening for those undergoing treatment for schizophrenia
fasting blood glucose or HbA1C at 4 months after initiating a new treatment and at least annually thereafter
101
APA
when should you lipid panel on those undergoing treatment for schizophrenia
at 4 months after initiating a new antipsychotic and at least annually thereafter
102
APA
when should you order an ECG when initiating treatment for someone with schizophrenia
before treatment with:
chlorpromazine
droperidol
iloperidone
pimozide
thioridazine
ZIPRASIDONE
OR in the presence of cardiac risk factors
103
APA
what is the guidelines/recommendation for determining treatment setting for someone with schizophrenia
patients should be cared for int he least restrictive setting that is likely to be safe and allow for effective treatment
104
APA
list possible indications for hospitalization for those with schizophrenia
patient posing serious threat of harm to self or others
being unable to care for themselves and needing constant supervision or support as a result
other psychiatric or medical problems that make outpatient treatment unsafe or ineffective or new onset psychosis that warrants initial inpatient stabilization
105
APA
in someone with >20% symptom reduction with antipsychotic monotherapy, but with ongoing symtomatology/inadequate response, + those with negative symptoms or depression, what type of agent should you consider for augmentation
antidepressant
106
APA
in someone with >20% symptom reduction with antipsychotic monotherapy, but with ongoing symtomatology/inadequate response, + those with catatonia, what type of agent should you consider for augmentation
benzodiazepine
107
APA
in someone with >20% symptom reduction with antipsychotic monotherapy, but with ongoing symtomatology/inadequate response with ongoing prominent psychotic symptoms, what type of agent should you consider for augmentation
clozapine
can also consider other agents like lithium, anticonvulsants but not alot of available evidence due to study design
can consider combo of two antipsychotic agents --> some data to suggest ER visits and rehospitalization is lower in those on two vs just one antipsychotic + no evidence that combining is any more harmful than the additive risks of the two meds separately
108
APA
what antipsychotic side effects are common early in the course of treatment
sedation
orthostatic changes in BP
anticholinergic side effects
acute dystonia can happen
akathesia, med induced parkinsonism
elevated prolactin
metabolic side effects (can also be delayed)
109
list anticholinergic side effects
dry mouth
constipation
difficulty with urination
110
acute dystonia is associated with blockade of which receptor
D2
111
APA
acute dystonia is particularly common with which antipsychotics
high potency:
i.e haloperidol, fluphenazine
112
APA
when can acute dystonia be life threatening
when associated with laryngospasm
113
why can NMS be life threatening
due to associated hyperthermia and autonomic instability
114
APA
NMS typically occurs in what phase of treatment
within first month of treatment, with resumption of treatment or with an increase in the dose of med
115
hyperprolactinemia is related to blockade of which receptor
D2 blockade in the HPA axis
116
symptoms of hyperprolactinemia
breast enlargement
galactorhhea
sexual dysfunction
menstrual disturbances
117
when do metabolic side effects of antipsychotic occur
can occur early in treatment but also later
118
when is severe neutropenia with clozapine most often seen in course of treatment
most typically early in treatment
119
list side effects of clozapine
neutropenia
seizures (at very high doses, rapid increases or shifts due to other meds etc)
myocarditis (typically within first six weeks)
cardiomyopathy (typically later in treatment)
GI effects--> can lead to fecal impaction or paralytic ileus
sialorrhea
tachycardia
120
dermatological reactions have been observed with which antipsychotics
thioridazine--> hyperpigmentation
hyperpigmentation and other cutaneous reactions--> risperidone, clozapine, olanzapine, quetiapine, haldol
121
which antipsychotics in particular may increase risk of hyperlipidemia
olanzapine
clozapine
122
what is the etiology of myocarditis seen in clozapine
unclear--> ?autoimmune
123
incidence of myocarditis with clozapine
0.015-8.5%
*highest rates in australia--> in other countries, rates much lower. Denmark study showed rate of 0.03% with fatality risk similar to cardiac death risk for other antipsychotics
(rates of cardiomyopathy are even lower)
124
can you get fever with clozapine initiation
yes, even in absence of other worrying features (i.e signs of myocarditis)
125
orthostatic side effects of antipsychotics are due to blockade of which receptor
alpha-receptor blocking
*these risks are dose dependent
