Schizophrenia Flashcards
what are the death rates of schizophrenia like?
• 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
what are the positive symptoms of schizophrenia?
delusions
hallucinations
thoughts
what are the negative symptoms?
poverty of speech
lack of motivation
emotional flattening
what are the cognitive symptoms?
memory difficulties
attention deficit
executive functioning
what is prodromal state?
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
how do you diagnose schizophrenia?
- there is usually overlapping with other mental illnesses
- role of family, empolyers, friends is crucial
- ICD-10 and DSM-V diagnostic criteria
what is the role of 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 – 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
what is the NICE guideline pathway?
- 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
how should you use antipsychotics?
- 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
what is CBT?
- 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
what are first generation antipsychotics?
sulpiride flupenthixol haloperidol chlorpromazine zuclopenthixol trifluoperazine perphenazine
what are second generations?
amisulpride quetiapine risperidone olanzapine clozapine aripiprazole paliperidone lurasidone asenapine
which have less effects first or second generations?
- 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
what are EPSE side effects?
• 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
what is dystonia?
muscle spasms in any part of the body eg eye rolling, head or neck twisting
how do you treat dystonia?
treat with anticholingeric or switch to an atypical antipsychotic drug
what are pseudo-parkinsonism symtpoms?
tremor, ridigity, bradykinesia
how do you treat pseudo parkinsonism?
reduce the dose of antipsychotic drug or switch to an atypical
also could add anticholingeric short term
what is akathisia?
inner restlessness and desire/ compulsion to move shifting feet, pacing or crossing legs
how do you treat akathisia?
treat by reducing the dose of the antipsychotic or swithc to an atypical
anticholingeric would NOT help
what is tardive dyskinesia?
lip smacking/chewing, tongue protrusion. sometimes this is NON reversible
how do you treat tardvie dyskinesia?
anticholingeric drugs make it WORSE
stop any of these and reduce the antipsychotic drug dose and need to switch to an atypical
what is metabolic syndrome?
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
how can you treat metabolic syndromes?
need to monitor and screen carefully, switch drugs if needed
use statins and treatments for type 2 diabetes (orlistate and metformin)
how would you treat hyperprolactinaemia?
- Treat: switch to alternative or add aripiprazole (prolactin sparing)
- Some evidence for dopamine agonists – need to be mindful of psychosis worsening with this
what is QT prolongation?
- 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
what causes QT prolongattion?
- 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
what are other side effects of 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
how do you monitor therapy?
• 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
when would you use a depot?
- 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
which drugs can be used as a depot?
Zuclopenthixol, flupentixol, haloperidol, fluphenazine (typicals – all decanoate).
Olanzapine embonate, paliperidone palmitate, aripiprazole, risperidone (atypicals)
what is combined antipsychotic treatment/
- 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)
what is clozapine?
‘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
how do you manage the adverse effects of clozapine?
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
what is venous thromboembolism?
rate but risk manu times higher than the rest of the population. higher risk in the first few months of using clozapine
what is sedation?
could be useful but could affect adherence
most common as a ADR of clozapine
common in the first early week and tolerance may develop
how is constipation caused by clozapine?
whole system can be affects, rapid fatality rate affects 60% of population
greater risk at higher doses
what is hypersalivation?
common early on in treatment and source of much social isolation
how do you treat hypersalivation?
hyoscine hydrobromide TRIAL
Non drug treatments include chewing gum, and using pillows to prop head up at night
reducing the dose if needed
