Schizophrenia Flashcards
Life expectancy of a patient with schizophrenia:
Schizophrenic patients die on average 15-20 years earlier than the rest of the population
- Very poor awareness and monitoring of physical health
- Risk of death 2.5x rest of population, and increasing over time
- Less likely to seek health care assistance
- More patients smoke etc
SYMPTOMS:
Symptoms of active illness clustered into 3 main areas Positive - Delusions - Hallucinations - Thoughts (interruption/withdrawal)
Negative
- Poverty of speech
- Lack of motivation
- Emotional flattening
Cognitive
- Memory difficulties
- Attention deficit
- Executive functioning
Diagnosis:
Differential diagnosis important:
- The role of family, criminal justice system, educational institutions, employers and friends is vital
- Prognosis variable, poor for some i.e. male
- There are different types of schizophrenia [not examinable]
- ICD-10 and DSM-V diagnostic criteria – see Mike Harte’s lecture
Treating schizophrenia:
Antipsychotics…–>
- Do not CURE schizophrenia, they only ALLEVIATE symptoms
- Have a high response rate in first episode schizophrenia, but may not prompt symptom recovery
- Do not prevent relapse of illness in everyone, as after first episode schizophrenia, only 20-30% are relapse free after 5 years despite treatment
- Work best when taken regularly, poor adherence increases the risk of relapse by 5 times
- -> Non-adherence associated with lots of other problems. 9/10 patients partially adherent to medication. Associated with various problems i.e. poor QoL, self harm, relationship problems etc.
Treating schizophrenia in adults – NICE pathway:
Prodromal phase:
- Offer CBT +/- family intervention
- DO NOT offer antipsychotics
First episode schizophrenia:
- Rule out other causes for symptoms
- Full social, physical, psychiatric, occupational and economical assessment
- Offer antipsychotic therapy in conjunction with psychological interventions (individual CBT & family
Maintenance treatment:
- May continue on treatment for 1-2 years if effective
- Relapse risk high if stopped
- Can withdraw but careful monitoring needed
Considerations when choosing an antipsychotic:
- Partnership between patients and Dr
- Views of patients’ carer also welcome if patient agrees
- Consider metabolic, EPSE, cardiovascular, hormonal and other side effects
- The patient can decide which treatment they might tolerate more
Discuss alcohol/smoking/illicit/OTC use - Dependent on baseline investigations
When using antipsychotic therapy:
- Therapy should be prescribed on a trial basis, for 4-6 weeks at optimum dosage
- Record expected benefits and risks of treatment
- Inform patient that treatment may take 2-3 weeks to work
- Start at lower doses and titrate up according to tolerance/efficacy
- Record the rationale for continuing, changing or stopping medication
- Record the reason if high doses are used
Pathway for treatment resistant schizophrenia and clozapine
Offer clozapine If not responded adequately to treatment deposits the sequential use of adequate doses of at least 2 different antipsychotics one of which is a second generation atypical.
Non-pharmacological options for schizophrenia:
Individual cognitive behavioural therapy (CBT)
- CBT is as effective as antipsychotic treatment, and the combination is synergistic
- Unlike antipsychotics, CBT can be effective for positive, negative & cognitive symptoms of schizophrenia
- Involves multiple sessions with a therapist
- Focus on changing behaviour and ways of thinking, particularly when faced with problems and challenges
- Can be administered with or without family interventions
- Can be used without antipsychotic therapy, but careful review required after 1 month
Arts therapies can be particularly useful for negative symptoms
Pharmacological options for schizophrenia:
First generation ‘typical’ antipsychotics versus second generation ‘atypicals’
- First generation: sulpiride, flupenthixol, haloperidol, chlorpromazine, zuclopenthixol, trifluoperazine, perphenazine
- Second generation: amisulpride, quetiapine, risperidone, olanzapine, clozapine, aripiprazole, paliperidone, lurasidone, asenapine
- LITTLE OR NO DIFFERENCE in efficacy between first and second generation antipsychotics when used appropriately
- Generally less extra-pyramidal side effects (EPSEs) and hyperprolactinaemia for second generation drugs – with notable exceptions
- Metabolic side effects with second generation drugs – ‘metabolic syndrome’
- Antipsychotics have limited effects on negative and cognitive symptoms of schizophrenia
This is important as these symptoms are correlated more closely with impairments in social/occupational functioning than positive symptoms
Extra-pyramidal side effects (EPSEs) to antipsychotics:
- EPSE’s are dose related and more likely to occur with typical antipsychotics
- However, higher doses of risperidone and amisulpride (second gen) can also cause EPSEs
- Generally speaking, there are 3 main treatments depending on the type of EPSE
Dystonia
Muscle spasms in any part of the body, e.g. eye rolling, head/neck twisting swallowing problems
Treat with anticholinergic or switch to atypical antipsychotic drug
Akathisia
Inner restlessness and desire/compulsion to move – shifting feet, pacing, crossing/uncrossing legs
Treat by reducing the antipsychotic dose, or switching to an atypical drug
Anticholinergics are not useful here
Pseudo-Parkinsonism
Characterised by tremor, rigidity, bradykinesia
Treat by reducing the dose of antipsychotic, or by switching to an atypical drug
Can use anticholinergics short term, review 3/12 as pseudo parkinsonism only lasts around 1 month.
Tardive dyskinesia
Lip smacking/chewing, tongue protrusion
Approximately 50% of cases are not reversible
Anti-cholinergic drugs make it worse
Stop anticholinergics, reduce antipsychotic dose, withdraw antipsychotic and switch to atypical drug
What is metabolic syndrome?
- ‘Metabolic syndrome’ describes a collection of side effects to antipsychotics causing increased weight, blood glucose and lipid profile
- If not addressed, these side effects can lead to obesity, diabetes, hyperlipidaemia and associated complications including macro/microvascular diseases and death
Thought to be important contributor to early deaths in population with serious mental illness - Hard to show cause and effect, but all antipsychotics implicated though some present much higher risks than others (see below)
- Must monitor/screen carefully, use education/behavioural change, switch drugs if needed.
- Use statins and treatments for T2DM as required, orlistat and metformin useful for obesity
What is hyperprolactinaemia?
- All antipsychotics increase prolactin
- Some asymptomatic, but should treat regardless due to effects on sexual function, breast growth/milk, amenorrhoea, cancer and BMD
- Treat: switch to alternative or add aripiprazole
- Some evidence for dopamine agonists
QT prolongation as a side effect of antipsychotics:
- QT interval involves de and re-polarising of the heart for pumping action
- QT interval prolongation is a risk factor for ventricular arrhythmias and TdP
Causes
- Some people have QT prolongation syndromes from birth
- Drugs can also cause it:
- -> Can be dose related and additive when >1 drug used
- -> Other psychotropic/non-psychotropics implicated
- ECGs essential, limits 440ms (men), 470ms (women)
- If QT interval prolonged: switch/reduce dose and refer to cardiology
Other side effects to antipsychotics:
- Sedation
- Anticholinergic effects, particularly clozapine and some typicals
- Lowering seizure threshold
- Neutropenia
- Hyponatremia
- Photosensitivity, especially chlorpromazine (use sunscreen)
- Postural hypotension and tachycardia
- Neuroleptic malignant syndrome – rare but could be fatal
Due to rapid changes in dopamine blockade
Watch out for rigidity, hyperthermia, tachycardia, sweating, fluctuating consciousness, raised CK
STOP antipsychotic and initiate specialist treatment
