Ips Flashcards
Basic investigations:
haemogram, blood sugars and lipid levels, liver functions, renal functions, electrocardiogram (focus on QTc)
Assessment basic
- Pt And caregiver
- History
- Physical exam including BO, WEIGHT, BMI, WAIST CIRCUMFERENCE
- MSE
- DIAGNOSIS
- D/d
- Basic investigation
- Assessments of caregivers: knowledge and understanding of the illness, attitudes and beliefs regarding treatment, impact of the illness on them, personal and social resources
- Ongoing assessments: response to treatment, side effects, treatment adherence, the impact of patient’s immediate environment, disability assessments, other health‐care needs, ease of access and
relationship with the treatment tea - Scales
11 cognitive function assessment
Indications for IPD
Presence of suicidal behaviour which puts the life of the patient at risk
• Presence of severe agitation or violence which puts the life of others at risk • Refusal to eat which puts the life of patient at risk
• Severe malnutrition
• Patient unable to care for self to the extent that she/he requires constant
supervision or support
• Catatonia
• Presence of general medical or comorbid psychiatric conditions which
make management unsafe and ineffective in the outpatient setting
Options for management for schizophrenia
- Antipsychotic medications
First‐generation antipsychotic medications (Oral/parenteral/depot or long acting‐ preparations)
Second‐generation antipsychotic medications (Oral/parenteral/depot or long acting‐ preparations) - Somatic treatments
Electroconvulsive therapy (ECT) - Adjunctive medications
Anticholinergics, antidepressants, benzodiazepines, hypnotic‐sedatives, anticonvulsants, lithium carbonate - Psychosocial interventions
Family intervention, cognitive behavioural therapy, social skills training, cognitive remediation, individual therapy, group therapy, vocational rehabilitation, early‐intervention programmes, case management, community mental‐health teams, crisis resolution teams
Factors that influence selection of antipsychotics
• Past treatment response
• Cost of treatment, affordability
• Psychiatric comorbidity
• Medical comorbidity
• Side effects
• Patient or family preference
• Preferred route of administration • Concomitant medications
• Non‐adherence
• Treatment resistance
Olanz max dose a/to IPS
30
LAI PRESENT IN INDOA
Zuclopenthixol decanoate
Paliperidone palmitate( 234 initially followed by 117 monthly)
Fluphenazine decanoate ( 12.5‐50
)
Haloperidol decanoate
Risperidone depot (RisperidalConsta)
Olanzapine pamoate
Adequate antipsychotic trial
highest tolerable dose for 6-8 weeks, with the exception of clozapine, where the minimum period of treatment is at least 3-6 months.
Possible indications of use of ECT in patients of schizophrenia
• Catatonic symptoms
• Affective symptoms
• Need for rapid control of symptoms
• Presence of suicidal behaviour which puts the life of the patient at risk
• Presence of severe agitation or violence which puts the life of others at risk
• Refusal to eat which puts the life of patient at risk
• History of good response in the past
• Patients not responding to adequate trial of an antipsychotic medication
• Augmentation of partial response to antipsychotic medication
• Clozapine resistant schizophrenia
• Not able to tolerate antipsychotic medications
Basic components of Psychoeducation
- Assessing the knowledge of the patient and caregivers about aetiology, treatment and prognosis
- Introducing the diagnosis of schizophrenia into discussion
- Providing information about aetiology, treatment options,
- Discussing about importance of medication and treatment compliance
5.Providing information about possible course and long term outcome - Discussing about problems of substance abuse, marriage! Communication patterns, problem solving, disability benefits
- Discussing about relapse and how to identify the early signs of relapse
- Dealing with day today stress
- Improving insight into illness
- Handling expressed emotions and improving communication
- Enhancing adaptive coping to deal with persistent/residual symptoms
Adherence is defined as “
the extent to which the patients’ behaviour, in terms of regular clinic visit, taking medications, following diets, executing lifestyle changes, coincide with the clinical prescription”.
Factors associated with poor medication compliance
- Demographic risk factors
• Younger age, male gender, unemployment, lower socioeconomic status - Patient related factors
• Knowledge about illness and treatment, perceived need for
treatment (insight), motivation, beliefs about treatment risks and benefits, past experiences/“transference”, past history of adherence, self‐stigma - Social risk factors
• Living independently, poor social support, poor financial support - Clinical risk factors
• Poorer premorbid functioning, earlier age of onset, prior history of non‐adherence - Symptom‐related risk factors
• Lack of insight, paranoia, grandiose delusions, conceptual disorganization, impaired cognition, substance abuse, comorbidities, depression, refractoriness, spontaneous remissions - Treatment‐related risk factors
• Medication side effects, poor treatment alliance, complex dosing, negative experience of medication, route of administration, length of treatment, cost of treatment, number of medications - Service‐related risk factors
• High cost of medication, poor accessibility of treatment services - Family/caregivers‐related risk factors
• Lack of supervision, negative attitudes towards treatment, lack of knowledge about medicines, nature of relationship with patient, perceived need for treatment, beliefs about benefits and risks with continued treatment, involvement in treatment, stigma, financial constraints, support from other sources - Clinician/provider related factors
• Therapeutic alliance, frequency and nature of contact with clinicians, expected duration of treatment, duration of past treatment, accessibility to clinicians and services, reimbursement, psychoeducation and psychosocial treatment, complexity of administration
PHASES OF ILLNESS/TREATMENT
Management of schizophrenia can be broadly divided into three phases, i.e., acute phase, continuation treatment or stabilization phase, maintenance or stable phase.
CONTINUATION TREATMENT PHASE
This phase begins once the acute symptoms reduce in severity or remit and conventionally lasts for about 6-12 months.
MANAGEMENT IN THE MAINTENANCE OR STABLE PHASE
- Goals of treatment:: to maintain or improve functioning, improve quality of life and facilitate personal recovery. Psychotic exacerbations need to be effectively treated. Adverse effects are to be noted and managed.
- Dose: Stable patients who do not have positive symptoms may be candidates for reduction in doses. Doses need to be reduced gradually at the rate of about 20% every 6 months till a minimum effective dose is reached.
- Duration of treatment:
• First-episode patients ought to receive 1-2 years of
maintenance treatment
• Patients with several episodes or exacerbations are to
receive maintenance treatment for 5 years or longer
after the last episode
• Patients with history of aggression or suicide attempts
should receive treatment for longer period or lifelong.
