Schizophrenia

Question 1

What are the key clinical features of schizophrenia?

Answer 1

Positive symptoms, negative symptoms, functional impairment.

Question 2

What non-pharmacological therapy do we use for schizophrenia?

Answer 2

• supportive counselling
• social skills therapies
• rehab
• vocational training

Question 3

What is something to note about the relapse of schizophrenia?

Answer 3

Relapse is often delayed for several weeks after cessation of treatment. Adipose tissues act as depot reservoirs after chronic regular usage of antipsychotics.

Question 4

What are some methods to overcome poor treatment adherence?

Answer 4

• IM long acting injections
• community psychiatric nurse
• patient and family education

Question 5

Is long term treatment necessary for schizophrenia?

Answer 5

Yes, long term treatment is often necessary after the first episode of psychosis.

Question 6

What are the 4 tracts the central dopamine system is composed of?

Answer 6

1. Mesolimbic tract:
   - blockade of dopamine receptors in this tract is the common mechanism of action for all antipsychotics, bc overactivity in this region is responsible for positive symptoms of schizophrenia.
2. Mesocortical tract:
   - dopamine blockade results in this region results in negative symtoms.
3. Nigrostriatal tract:
   - dopamine blockade in this region can cause extrapyrimidal side effects (EPSE).
4. Tuberoinfundibular tract:
   - dopamine blockade in this region leads to hyperprolactinemia.

2, 3 and 4 lead to adverse effects.

Question 7

What antagonism does SGA have?

Answer 7

5HT2A antagonism -> may improve mood symptoms and also possibly help with negative symptoms

Question 8

What treatment strategy do we use for schizophrenia?

Answer 8

• initiate a suitable non-clozapine FGA or SGA and titrate
• adequate antipsychotic trial of at least 2-6 weeks at the recommended therapeutic dosing range
• clozapine trial may require 3 months
• if first agent fails, try using another non-clozapine FGA or SGA
• DO NOT use polypharmacy for antipsychotics

Question 9

What is treatment resistant schizophrenia (TRS)?

Answer 9

Not responsive to at least 2 adequate trials of antipsychotics, of which one is a SGA

Question 10

What do we use for TRS?

Answer 10

Clozapine

Question 11

What do we need to monitor for clozapine?

Answer 11

Monitor baseline and periodic FBC with ANC due to risk for agranulocytosis (reduced absolute neutrophil count)
Discontinue if severe.

Question 12

When is antipsychotic use contraindicated?

Answer 12

QTC prolongation

Question 13

What important precaution do we need to consider for elderly with dementia?

Answer 13

With antipsychotic treatment, there can be increased risk for mortality and stroke.

Question 14

How do we treat a patient who is acutely agitated or aggressive?

Answer 14

1. De-escalate
2. Consider oral antipsychotic e.g. risperidone +/- benzodiazepine e.g. oral lorazepam
3. If patient refuses or not possible to administer oral medications, consider fast-acting IM injection:
   - IM haloperidol with pre-treatment ECG
   - IM lorazepam

Question 15

Which SGAs need to be administered with food?

Answer 15

Lurasidone and ziprasidone

Question 16

What are the FGAs and SGAs?

Answer 16

FGAs:

• chlorpromazine
• haloperidol

SGA:

• amisulpride
• aripiprazole
• brexipiprazole
• clozapine
• lurasidone
• olanzapine
• quetiapine
• risperidone
• ziprasidone

Question 17

What long acting IM antipsychotic can we give in poor adherence?

Answer 17

IM long acting haloperidol decanoate

Question 18

What are the toxicities of FGA and SGA?

Answer 18

FGAs:

• more muscle side effects (EPSE)
• more hyperprolactinemia

SGA:

• lesser EPSE
• more metabolic side effects, except aripiprazole, brexipiprazole, lurasidone and ziprasidone
• the -ines like clozapine, olanzapine and quetiapine are relatively more sedating and have more weight gain
• the -ones and -piprazoles like risperidone, lurasidone, ziprasidone and aripiprazole are relatively less sedating and less weight gain

Question 19

How to manage side effects of antipsychotics?

Answer 19

EPSE:

• dystonia, tremors/rigidity -> give anticholinergics e.g. benztropine or switch to lower potency antipsychotics like quetiapine
• akathisia -> give clonazepam and or propranolol OR switch to SGA or lower potency antipsychotic
• tardive dyskinesia (can be irreversible if detected late) -> discontinue any anticholinergics, switch to low potency SGA and treat with valbenazine

Metabolic side effects:

• treat diabetes with metformin
• treat HLD with statins
• lifestyle change for weight gain OR
• switch to aripiprazole, brexipiprazole, lurasidone or ziprasidone or haloperidol

Hyperprolactinemia: switch to aripiprazole

Question 20

What is neuroleptic malignant syndrome (NMS)?

Answer 20

• lead-pipe muscle rigidity
• fever
• labile BP
• diaphoresis
• altered consciousness
• increased CK

potentially lethal. occurs with high potency antipsychotics.

Question 21

How to treat NMS?

Answer 21

IV dantrolene
Oral dopamine agonist

After recovery, do not give haloperidol, switch to SGA

Question 22

What happens when you take dopamine-augmenting agents like levodopa with antipsychotics?

Answer 22

Mutual antagonism

Question 23

What should carbamazepine not be combined with?

Answer 23

Clozapine -> agranulocytosis