CPTP 3.2 Case 38 Launch

Question 1

What are the symptoms of paranoid schizophrenia?

Answer 1

Auditory hallucinations (which discuss the patient in a derogatory way)

Disorders of thought:
• Delusional perception (e.g. “I’m king of the world because that red car drove past me”)
• Idea that thoughts are being controlled or broadcast
• Persecutory delusions

Catatonic behaviour (stupor):
• Apathy
• Social withdrawal
• Blunted emotions

Question 2

What makes prescribing difficult with paranoid schizophrenic patients?

Answer 2

Lack of insight (knowledge or understanding that a disease is present)

Compliance

Question 3

How is dose decided with treatment for paranoid schizophrenics?

Answer 3

Start with minimum effective dose for 4-6 weeks then titrate up.

Use a single antipsychotic

Question 4

What is monitored during antipsychotic treatment?

Answer 4

Response

Adherence

Side effects:
• Extrapyrimidal side effects (EPSEs)
• Weight, pulse, BP
• Glucose and lipid levels

Question 5

When are glucose and lipid levels tested for patients undergoing antipsychotic treatment?

Answer 5

at 12 weeks and then annually

Question 6

Which antipsychotic has the most evidence for effective use against schizophrenia?

Answer 6

Haloperidol

Question 7

What are the extrapyrimidal side effects?

Answer 7

Parkinson-like symptoms:

Tremor at rest
Bradykinesia
Rigidity

Question 8

What are the non-extrapyrimidal (normal) side effects of antipsychotics?

Answer 8

Weight gain & diabetes

Cardiovascular (Prolonging QT interval)

Hormonal

Question 9

What are the causes of non response to antipsychotics?

Answer 9

Inadequate dose

Incorrect diagnosis

Noncompliance

Need to switch antipsychotic

Question 10

What is depot medication and why is it used?

Answer 10

Injectable forms of slow release medication (that is usually also available as a tablet).

The idea is that in an injectable form, it only needs to be administered fortnightly (due to the slow release), so it can be used for antipsychotics to combat noncompliance long enough for the patient to gain insight into their condition.

Question 11

List the antipsychotics in the student formulary

What are the routes of administration for these, and which are available in depot form?

Answer 11

Oral Route Allows Calm And Quiet Humans

• HALOPERIDOL
• OLANZAPINE
• Risperidone
• Quetiapine
• Clozapine

Alternatives:
• Aripiprazole
• Amisulpiride

All oral, the following are available as DEPOTS:
• Haloperidol
• Risperidone

Question 12

When is drug treatment considered for depression?

Answer 12

When moderate to severe

Subthreshold for more than 2 years

Subthreshold that persists after other interventions

When subthreshold depression complicated care of physical health problem

Question 13

What is the greatest risk with prescribing TCAs for depression?

Answer 13

Overdose, causing death through cardiotoxicity

Question 14

Which antidepressive class of drugs has the least side-effects?

Answer 14

SSRIs

Question 15

Name the SSRIs in the student formulary

Answer 15

FLUOXETINE
Sertraline
Citalopram

Question 16

Name the classes of antidepressants

Answer 16

TCAs
SSRIs
Monoamine oxidase inhibitors
Noradrenergic/Serotonin-related ones

Question 17

Name the TCAs

Answer 17

AMITRIPTYLINE

Trazodone

Question 18

Name a monoamine oxidase inhibitor

Answer 18

Phenelzine

Question 19

Name the NaSSA & SNRI (ATYPICAL) antidepressants (which affect norepinephrine and serotonin)

Answer 19

Mirtazapine NaSSA

Venlafaxine SNRI

Question 20

Outline how you would review antidepressant treatment

Answer 20

Review after 4 weeks

If there is no response, change antidepressant

If there is minimal response, increase dose

If there is improvement continue treatment for another 4 weeks

Question 21

How long must antipsychotic treatment be continued for and what is the risk if this isn’t met?

Answer 21

2 years otherwise there is a risk of relapse

Question 22

How long must antidepressant treatment be continued for?

Answer 22

Stay on antidepressants for 6 months after patient is well, to avoid relapse. After this, reduce dose over a period of 4 weeks to avoid withdrawal effects.

Question 23

How long must antidepressant treatment be continued for if the patient is experiences recurrent depression or is at high risk?

Answer 23

2 years

Question 24

What proportion of paranoid schizophrenics recover after their first episode?

Answer 24

80%

Question 25

What proportion of recovered paranoid schizophrenics never experience another episode?

Answer 25

20%