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3. Psychosis > Canadian Guidelines--Schizophrenia (2017) > Flashcards

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

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2
Q

how many first rank symptoms of schizophrenia are there

A

6

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3
Q

list the four negative symptoms associated with schizophrenia

A

affective flattening

avolition

alogia

anhedonia

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4
Q

what are the core negative symptoms of schizophrenia

A

affective flattening

avolition

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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

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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

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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

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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

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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

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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

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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

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12
Q

do command hallucinations carry higher risk of suicide?

A

yes

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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

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14
Q

what are clinical features associated with violence in schizophrenia/related disorders

A

psychotic symptoms, such as persecutory ideation

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15
Q

is physical violence toward other people common in those presenting with first episode psychosis

A

no

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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

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17
Q

should antipsychotic medication therapy be recommended for patients with first episode psychosis

A

yes

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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

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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)

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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

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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

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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

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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

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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

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25
Q

what is an adequate trial of antipsychotic in terms of duration

A

between 4-6 weeks on adequate therapeutic dose (midpoint or beyond of the licensed dose range)

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26
Q

should you target the higher end or the lower end of the therapeutic effective dose range when starting an antipsychotic in first episode psychosis

A

the lower end

*much of the antipsychotic effect is evident in the first several weeks of treatment

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27
Q

how long should someone be treated with antipsychotic agent after first episode of schizophrenia/related disorders

A

at least 18 months FOLLOWING resolution of positive symptoms

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28
Q

does attaining remission and/or stabilization for a period of time on maintenance therapy eliminate the risk of relapse in schizophrenia/related disorders

A

no

*cumulative risk of first relapse is 82%

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29
Q

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

A

risk of first or second relapse was 5x HIGHER in those not taking medication as compated to those who were

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30
Q

does continued antipsychotic use eliminate the risk of relapse in schizophrenia/related disorders

A

no–> but it does diminish the risk of relapse

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31
Q

can exacerbations of psychotic symptoms be selfcontained

A

yes

but sometimes intervention is required

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32
Q

what maintenance dose of antipsychotic therapy should be offered to patients who suffer an acute episode of schizophrenia/related disorders (NOT first episode)

A

at low or moderate regular dosing of:

300-400mg of chloropromazine equivalents
/
4-6mg risperidone equivalents

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33
Q

what is currently the only empiric strategy for establishing dose equivalents

A

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

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34
Q

which antipsychotics have pharmacology that prevents comparision with others in terms of “equivalents”

A

quetiapine

aripiprazole

clozapine

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35
Q

how long should maintenance therapy be planned for after acute episode of schizophrenia/related disorders

A

2 years–> possibly up to 5 years

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36
Q

how do LAIs compare to oral agents in terms of relapse rates in early schizophrenia/related disorders

A

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

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37
Q

how does risk of rehospitalization change for those on LAI vs oral agents

A

risk of rehospitalization in patients on LAIs is 1/3 of that for patients on oral treatment according to a nation wide registry study

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38
Q

what medication should be offered to patients with treatment resistant schizophrenia

A

clozapine

*it is the only recommended treatment in treatment resistant schizophrenia

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39
Q

what % reduction in positive or negative symptoms is required in order to be considered to have responded favorably to a medication trial

A

at least 20% reduction in symptoms

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40
Q

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

A

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)

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41
Q

what agent is preferred for people with psychosis associated with aggression

A

clozapine

*clinically superior in the treatment of aggression

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42
Q

what is one area the guidelines identify requires further clarification/study?

A

the issue of antipsychotic discontinuation in those who have responded effecrtively to treatment

+

what to do if someone is resistant to clozapine

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43
Q

which is more effective for those with schizophrenia in terms of increasing competitive employment, according to the evidence: supported employment or prevocational training

A

supported employment

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44
Q

when can CBT for psychosis be initiated

A

basically any phase (initial, acute, recovery), even in inpatient settings

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45
Q

list some of the benefits observed when employing CBT for psychosis

A

reduces symptom severity, hospitalization and relapse

also showed significant benefit on level of depression

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46
Q

what are the most frequently used substances by people with schizophrenia

A

alcohol and cannabis

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47
Q

what % of those with schizophrenia use cigarettes

A

60-90%

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48
Q

does the presence of psychosis appear to increase the risk of cannabis use?

A

no

but the presence of cannabis use does increase the risk of psychotic symptoms

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49
Q

how much earlier do people seem to develop psychosis if they have used cannabis, compared to those who have not?

A

symptoms appear approx 2.7 years earlier

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50
Q

what is the best model of care for those with both psychosis and substance use

A

integrated substance use and psychosis treatment, like a concurrent disorders program or unit

(rather than parallel or sequential treatment)

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51
Q

what is likely to be the primary modifiable cardiovascular risk factor in those with schizophrenia

A

cigarette smoking

52
Q

which antipsychotics are particularly sensitive to starting/stopping cigarette smoking

A

clozapine and olanzapine

53
Q

what pharmacotherapy should be considered to help people with schizophrenia stop smoking

A

NRT for people with psychosis or schizophrenia

BUPROPRION for those with a diagnosis of schizophrenia

VARENICLINE for those with psychosis or schizophrenia

54
Q

what should you warn patients about if you prescribe buproprion or varenicline for smoking

A

increased risk of adverse neuropsychiatric symptoms (particularly in first 2-3 weeks)

i.e sleep impairment, suicidality, reemergence of psychotic symptoms

55
Q

which pharmacologic intervention currently has the most evidence for stopping smoking in those with schizophrenia

A

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
Q

are there particular preferences for certain antipsychotics in those with both schizophrenia and SUD?

A

no… ?clozapine but evidence sucks

57
Q

for those who have ?substance induced psychosis that does not resolve rapidly with abstinence, how long do you treat with antipsychotics

A

not clear–> guidelines suggest following recommendations for first episode psychosis especially if risk factors are present

58
Q

list the 3 medications indicated for use in people with alcohol use disorder

A

naltrexone

acamprosate

disulfram

59
Q

which medications for the treatment of alcohol use disorder have evidence in those with schizophrenia

A

naltrexone *most

disulfiram *limited

(no evidence currently for acamprosate)

60
Q

are there currently any indicated pharmacotherapies for cocaine use disorder

A

no

61
Q

are there currently any indicated pharmacotherapies for those with cannabis use disorder

A

no

*data has been NEGATIVE for mirtazapine, buproprion, nabilone, dronabinol

*there is also no evidence of specific psychosocial interventions despite well designed studies

62
Q

what is the prevalence of childhood onset schizophrenia

A

quite rare

1.6-1.9 per 100 000 children

63
Q

what is considered childhood onset schizophrenia

A

before age 12

64
Q

after what age does the prevalence of schizophrenia increase rapidly

A

age 14 –> particularly in males

65
Q

psychosis/schizophrenia accounts for what % of all psychiatric admissions in young people between ages 10-18

A

25%

66
Q

how does age at onset of schizophrenia affect suicide risk

A

higher risk of suicide in those with earlier onset

67
Q

in children and young people with first presentation psychosis, should antipsychotic medication be started in the primary care setting

A

no–> unless done in consultation with psychiatrist with CAP training

68
Q

what proportion of all adults with schizophrenia have their onset of symptoms before age 18

A

1/3

69
Q

is antipsychotic medication treatment as effective in kids as in adults

A

yes

70
Q

what side effect clusters should be discussed with patients before starting antipsychotic therapy

A

metabolic

extrapyrimidal

cardiovascular

hormonal

other

71
Q

metabolic side effects of antipsychotics

A

weight gain

diabetes

72
Q

extrapyramidal side effects of antipsychotics

A

akathesia

dyskinesia

dystonia

73
Q

cardiovascular risk factors of antipsychotics

A

prolonged QTc

74
Q

hormonal side effects of antipsychotics

A

increased plasma prolactin

75
Q

which are the only antipsychotics currently approved in canada for children and adolescents with schizophrenia or bipolar disorder

A

aripiprazole

lurasidone

76
Q

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

A

no

77
Q

when is an ECG recommended before starting or changing and antipsychotic for a kid with schizophrenia

A
  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
Q

how do you start an antipsychotic in a kid if it is not licensed for kids/teens

A

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
Q

which 3 risk factors that carry a poor prognosis are MOST strongly associated with poor outcomes (including risk of relapse)

A

cannabis use

other comorbidities (i.e depression)

medication nonadherence

80
Q

how does using cannabis regularly in adolescence affect the risk of reporting psychotic symptoms of being diagnosed with schizophrenia during adulthood

A

DOUBLES the risk

81
Q

how long should you monitor for signs and symptoms of relapse after discontinuing antipsychotic therapy

A

at least 2 years

82
Q

why is it important to prevent relapses of psychotic symptoms, and treat them promptly when they occur

A

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
Q

are kids at higher risk of dystonic reactions to antipsychotic medications

A

yes

*thus, limit use of first generation antipsychotics in this younger age group

84
Q

is there evidence to support the prescription of antihistamines in cases of agitation

A

no

85
Q

what medications do the guidelines mention for aggression/agitation in youth with schizophrenia

A

benzos or antipsychotics (ideally one the kid is already on if they are being treated for schizophrenia)

86
Q

which antipsychotic has the greatest risk of weight gain? (and what other 2 are also known to be particularly likely to cause weight gain)

A

olanzapine

(followed by clozapine and quetiapine)

87
Q

which 3 antipsychotics have the greatest risk of neurological side effects like parkinsonism, akathesia and other EPS

A

risperidone

olanzapine

aripiprazole

88
Q

can you use clozapine in kids

A

yes–> same pathway as for adults in terms of treatment resistance

89
Q

is schizophrenia an independent risk factor for diabetes?

A

yes

(and long term antipsychotic use adds to this risk)

90
Q

list 3 antipsychotics at higher risk of clinically important weight gain

A

chlorpromazine

clozapine

olanzapine

91
Q

list 3 antipsychotics as lower risk of clinically important weight gain

A

aripiprazole

asenapine

ziprasidone

92
Q

list 5 antipsychotics at intermediate risk of clinically important weight gain

A

lurasidone

paliperidone

risperidone

quetiapine

perphenazine

+other FGAs

93
Q

do we know the mechanism by which antipsychotics cause weight gain

A

no not exactly

94
Q

what is a hypothesis for why antipsychotics cause weight gain

A

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
Q

what medication can be prescribed to help managed weight gain and other metabolic consequences of antipsychotics

A

metformin

*its use is recommended by the guidelines for those who are experiencing weight gain on antipsychotic meds

96
Q

what is torsade de pointes

A

a malignant ventricular arrhythmia associated with syncope and sudden death and is associated with prolonged QTc

97
Q

how does treatment with antipsychotics affect the risk for sudden cardiac death

A

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
Q

what other two factors, other than antipsychotic use, were found to have increased risk of QTc prolongation

A

female gender

CYP450 34A metabolized drugs

99
Q

APA

what brain imaging is preferred according to these guidelines for working up a patient with schizophrenia

A

MRI

(but can do CT or MRI if clinically indicated based on neuro exam or history)

100
Q

APA

when should you do diabetes screening for those undergoing treatment for schizophrenia

A

fasting blood glucose or HbA1C at 4 months after initiating a new treatment and at least annually thereafter

101
Q

APA

when should you lipid panel on those undergoing treatment for schizophrenia

A

at 4 months after initiating a new antipsychotic and at least annually thereafter

102
Q

APA

when should you order an ECG when initiating treatment for someone with schizophrenia

A

before treatment with:
chlorpromazine
droperidol
iloperidone
pimozide
thioridazine
ZIPRASIDONE

OR in the presence of cardiac risk factors

103
Q

APA

what is the guidelines/recommendation for determining treatment setting for someone with schizophrenia

A

patients should be cared for int he least restrictive setting that is likely to be safe and allow for effective treatment

104
Q

APA

list possible indications for hospitalization for those with schizophrenia

A

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
Q

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

A

antidepressant

106
Q

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

A

benzodiazepine

107
Q

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

A

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
Q

APA

what antipsychotic side effects are common early in the course of treatment

A

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
Q

list anticholinergic side effects

A

dry mouth

constipation

difficulty with urination

110
Q

acute dystonia is associated with blockade of which receptor

A

D2

111
Q

APA

acute dystonia is particularly common with which antipsychotics

A

high potency:

i.e haloperidol, fluphenazine

112
Q

APA

when can acute dystonia be life threatening

A

when associated with laryngospasm

113
Q

why can NMS be life threatening

A

due to associated hyperthermia and autonomic instability

114
Q

APA

NMS typically occurs in what phase of treatment

A

within first month of treatment, with resumption of treatment or with an increase in the dose of med

115
Q

hyperprolactinemia is related to blockade of which receptor

A

D2 blockade in the HPA axis

116
Q

symptoms of hyperprolactinemia

A

breast enlargement

galactorhhea

sexual dysfunction

menstrual disturbances

117
Q

when do metabolic side effects of antipsychotic occur

A

can occur early in treatment but also later

118
Q

when is severe neutropenia with clozapine most often seen in course of treatment

A

most typically early in treatment

119
Q

list side effects of clozapine

A

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
Q

dermatological reactions have been observed with which antipsychotics

A

thioridazine–> hyperpigmentation

hyperpigmentation and other cutaneous reactions–> risperidone, clozapine, olanzapine, quetiapine, haldol

121
Q

which antipsychotics in particular may increase risk of hyperlipidemia

A

olanzapine
clozapine

122
Q

what is the etiology of myocarditis seen in clozapine

A

unclear–> ?autoimmune

123
Q

incidence of myocarditis with clozapine

A

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
Q

can you get fever with clozapine initiation

A

yes, even in absence of other worrying features (i.e signs of myocarditis)

125
Q

orthostatic side effects of antipsychotics are due to blockade of which receptor

A

alpha-receptor blocking

*these risks are dose dependent

3. Psychosis (10 decks)

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