Schizophrenia

Question 1

what are the death rates of schizophrenia like?

Answer 1

• Schizophrenic patients die on average 15-20 years earlier than the rest of the population
o Very poor awareness and monitoring of physical health
o Risk of death 2.5x rest of population, and increasing over time
o 12x risk of suicide
o Other mortality is due to lifestyle such as smoking and alcohol
o Less likely to seek health care assistance

Question 2

what are the positive symptoms of schizophrenia?

Answer 2

delusions
hallucinations
thoughts

Question 3

what are the negative symptoms?

Answer 3

poverty of speech
lack of motivation
emotional flattening

Question 4

what are the cognitive symptoms?

Answer 4

memory difficulties
attention deficit
executive functioning

Question 5

what is prodromal state?

Answer 5

before you have the full blown schizophrenia. This usually happens in the younger population
o Less able to think, agitated, fixated on certain things
o Not all these people will have full blown schizophrenia usually only a third
o The earlier we treat the better it is

Question 6

how do you diagnose schizophrenia?

Answer 6

• there is usually overlapping with other mental illnesses
• role of family, empolyers, friends is crucial
• ICD-10 and DSM-V diagnostic criteria

Question 7

what is the role of antipsychotics?

Answer 7

• 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 – but they are much better then not taking them at all. After 2 years if you have stopped treatment people 100% would relapse
• Work best when taken regularly, poor adherence increases the risk of relapse by 5 times

Question 8

what is the NICE guideline pathway?

Answer 8

• predromal phase you would offer CBT
• first episode you would need to rule out other causes, give a full assessment, offer antipsychotics along side CBT
• Maintenance treatment you need to continue for 1-2 years as a risk of relapse if you suddenly stop
• subsequent acute episodes treat as if it was the first episode, review diagnossis, may need to switch to other medication
• treatment resistnace you need to offer clozapine if not responded

Question 9

how should you use antipsychotics?

Answer 9

• 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

Question 10

what is CBT?

Answer 10

• can be as effective as any antipsychotic treatment
• can be used for positive, negative and cognitice symptoms
• multiple sessions needed with a therapist
• focuses on changing behaviour

Question 11

what are first generation antipsychotics?

Answer 11

sulpiride
flupenthixol
haloperidol
chlorpromazine
zuclopenthixol
trifluoperazine
perphenazine

Question 12

what are second generations?

Answer 12

amisulpride
quetiapine
risperidone
olanzapine
clozapine
aripiprazole
paliperidone
lurasidone
asenapine

Question 13

which have less effects first or second generations?

Answer 13

• 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

Question 14

what are EPSE side effects?

Answer 14

• EPSE’s are dose related and more likely to occur with typical antipsychotics
• However, higher doses of risperidone and amisulpride can also cause EPSEs (second generations)
• Generally speaking, there are 3 main treatments depending on the type of EPSE
o Anticholinergic
o Switch – sometimes the actual drug, sometimes the route of admin
o Swap

Question 15

what is dystonia?

Answer 15

muscle spasms in any part of the body eg eye rolling, head or neck twisting

Question 16

how do you treat dystonia?

Answer 16

treat with anticholingeric or switch to an atypical antipsychotic drug

Question 17

what are pseudo-parkinsonism symtpoms?

Answer 17

tremor, ridigity, bradykinesia

Question 18

how do you treat pseudo parkinsonism?

Answer 18

reduce the dose of antipsychotic drug or switch to an atypical

also could add anticholingeric short term

Question 19

what is akathisia?

Answer 19

inner restlessness and desire/ compulsion to move shifting feet, pacing or crossing legs

Question 20

how do you treat akathisia?

Answer 20

treat by reducing the dose of the antipsychotic or swithc to an atypical

anticholingeric would NOT help

Question 21

what is tardive dyskinesia?

Answer 21

lip smacking/chewing, tongue protrusion. sometimes this is NON reversible

Question 22

how do you treat tardvie dyskinesia?

Answer 22

anticholingeric drugs make it WORSE

stop any of these and reduce the antipsychotic drug dose and need to switch to an atypical

Question 23

what is metabolic syndrome?

Answer 23

describes a collection of side effects to antipsychotics causing increased weight, blood glucose and lipid profile
• Hard to show cause and effect, but all antipsychotics implicated though some present much higher risks than others (see below)
• Have effects of micro and macro vascular

Question 24

how can you treat metabolic syndromes?

Answer 24

need to monitor and screen carefully, switch drugs if needed

use statins and treatments for type 2 diabetes (orlistate and metformin)

Question 25

how would you treat hyperprolactinaemia?

Answer 25

* Treat: switch to alternative or add aripiprazole (prolactin sparing) * Some evidence for dopamine agonists – need to be mindful of psychosis worsening with this

Question 26

what is QT prolongation?

Answer 26

* 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

Question 27

what causes QT prolongattion?

Answer 27

* 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

Question 28

what are other side effects of antipsychotics?

Answer 28

* 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

Question 29

how do you monitor therapy?

Answer 29

• Regularly record response to treatment including changes in symptoms/behaviour • Regularly screen for and record management of side effects to antipsychotic treatment • Investigations for antipsychotic treatment (see also individual drug SmPCs) – usually taken at baseline and then periodically throughout treatment o Weight o Waist circumference o Pulse and BP o Fasting BMs and HbA1c o Lipids o Prolactin levels o Assessment of movement disorders, adherence nutrition and exercise

Question 30

when would you use a depot?

Answer 30

* May be useful in cases where avoiding covert non-adherence is a priority * If the patient is refusing to take oral medication, explore preventable reasons first * Some patients may prefer to use depots * BUT we must stress need to visit clinics or have home visits for injections this doesn’t always increase adherence as they still need to show up to appointments * Better rate of adherence and less likely to be admitted to hospital

Question 31

which drugs can be used as a depot?

Answer 31

Zuclopenthixol, flupentixol, haloperidol, fluphenazine (typicals – all decanoate). Olanzapine embonate, paliperidone palmitate, aripiprazole, risperidone (atypicals)

Question 32

what is combined antipsychotic treatment/

Answer 32

* Antipsychotic polypharmacy – more than one agent prescribed * Approximately 40% of adult inpatients are exposed to combination prescribing * 50% of schizophrenics prescribed long acting depot injections and oral antipsychotics * NICE 2014: Do not initiate combined antipsychotic medication, except for short periods (for example, when changing medication)

Question 33

what is clozapine?

Answer 33

‘Offer clozapine to people with schizophrenia whose illness has not responded adequately to treatment despite the sequential use of adequate doses of at least 2 different antipsychotic drugs. At least 1 of the drugs should be a non-clozapine second-generation antipsychoti

Question 34

how do you manage the adverse effects of clozapine?

Answer 34

Myocarditis and cardiomyopathy • Most common in the first two months of treatment, can be fatal • Symptoms/signs include fever, fatigue, chest pain, palpitations, low BP, SOB, high pulse • Related to speed of titration – START LOW GO SLOW • Can be asymptomatic • MUST take baseline tests then daily BP/RR/temp/pulse, weekly Trop/ECG/CRP/FBC • Always ask if symptoms present; if suspected STOP treatment and REFER Neutropenia and agranulocytosis • Risk of occurrence actually low (<1%), low death risk • See directed reading for peak incidence • Generally reversible, not dose related • Watch out for any sore throat, flu-like symptoms or others indicative of infection • If infection suspected get blood test immediately, STOP treatment until test result back

Question 35

what is venous thromboembolism?

Answer 35

rate but risk manu times higher than the rest of the population. higher risk in the first few months of using clozapine

Question 36

what is sedation?

Answer 36

could be useful but could affect adherence most common as a ADR of clozapine common in the first early week and tolerance may develop

Question 37

how is constipation caused by clozapine?

Answer 37

whole system can be affects, rapid fatality rate affects 60% of population greater risk at higher doses

Question 38

what is hypersalivation?

Answer 38

common early on in treatment and source of much social isolation

Question 39

how do you treat hypersalivation?

Answer 39

hyoscine hydrobromide TRIAL Non drug treatments include chewing gum, and using pillows to prop head up at night reducing the dose if needed