Schizophrenia-therapies- biological

Question 1

File drawer problem

Answer 1

studies are often not published especially those funded by drug companies

there is no compulsion to publish trials, so much data goes unpublished

(so data that is published is likely to exaggerate effect of some drugs over others- e.g. ones that the drug company are producing)

Question 2

cochrane reviews

Answer 2

indepdent medical organisation who conduct reviews and MA of medical treatments

generally accepted as less likely to be biased than individual research parties

Question 3

NICE

Answer 3

national institute for clinical excellence provide guideline for clinical practice in the UK

they currently state that patients should be offered drug treatment, CBT and where possible family intervention

ECT should only be used for catatonic and suicidal patients

Question 4

ECT who for

Answer 4

rarely used for SZ except for catatonic or suicidal sz patients

more commonly used for major depression
tends to be used for those who have been sectioned i.e.hospitalised without their consent due to danger to themselves or others

Question 5

URAP

Answer 5

uses- who for

rationale- theory behind it

aim- what it do

-procedure

then evaluate with effectiveness and appropriateness

Question 6

ECT- use

Answer 6

originally developed to treat SZ, now for depression, often for those with catatonic sz or if patients are suicidal or pregnant

Question 7

ECT ratioanle

Answer 7

there is abnormal activity of neurotransmitters and or hormones

the shock is supposed to disrupt the abnormality

but it’s not certain how it works

Question 8

ECT process

Answer 8

anaethestic and muscle relaxants admissistered before shock

current given bilaterally or more commonly unilaterally (electrodes) done to the non-dominant cerebral hemisphere to minimise memory loss

small electric current (70-130 mv)

for 0.5 seconds to 5 seconds

induces mini seizure by producing electrival convulsions in brain

several sessions over a number of weeks

Question 9

ECT- effectiveness

Answer 9

initially believed to be very effective but soon to be placed by drug treatments

good evidence- for suicidal and catatonics

ineffective in treating negative symptoms od depression and less effective in the long term than short term

mechanism is unclear

reporting of research is unclear as well as there being big gaps in the research

Question 10

ECT- effectiveness tharyan and adams

Answer 10

review of 26 RCTs found that ECT led to fewer relapses (than sham ECT) in the short term- but no evidence that it is maintained in the medium/longer term

etc compared to antipsychotic drug treatments- drug treatments were favoured

limited evidence that ex and drug treatments results in greater improvement than drugs alone

leading to it’s reduction in use for treating SZ

overall effective in the short term for some people. the combo of drugs and ECt may be considered an option for some ppl especially where global reduction and improvement is required

this evidence is strong due to the organisation it was conducted by, the use of randomised control trials and ma demonstrating reliable un biased evidence

Question 11

ECT - effectiveness J Greenhalgh et al

Answer 11

clinical and cost effectiveness

found no randomised evidence for it’s effectiveness in catatonic sz, older ppl and adolescents and even less evidence for effectiveness in sz and mania despite NICE recommending it for such patients

there is need for further high quality RCTS of the use of ECT in specific sub groups

little good-quality quantitative evidence for short term and long term cognitive side effects of ECT
cognitive functioning should be measured using well validated instruments

more research into the mechanism of action as well )despite 50 years of research it’s still unclear

improvements in quality of reporting by strict adherence to the CONSOLDIATED STANDARDS of REPORTING TRIAls (CONSORT) RECOMMENDATIONS

Question 12

ECT- appropriateness

Answer 12

major short term effect- memory loss, though it is unclear due to lack of research whether this continues in the longer term
- arguably justifiable if patients know the side effects and are willing to take the risk and most justifiable for those who are suicidal

improvements in procdure have meant that fractures have been eliminated

the remaining issue is that of consent- patients given ECT are often serious cases who due to the illness are unable to give such consent and are often treated without

2 doctors, social worker and an independent psychiatrist must agree that the treatment is necessary

Judging the need for treatment or not is difficult for example with the suicidal sub group- measures of suicidal intent may be unreliable.

I think the treatment should only be used in most severe cases and when other treatment forms have even ineffective, if the patient or allocated decision maker of the patient (e.g relative) is able to make an informed decision with full knowledge of the side effects and it’s mechanism, only then should it be considered. The process and the side effects are highly risky and in some cases it’s not worth these.

Question 13

drug treatments- conventional typical antipsychotics e.g chlorpromazine

Answer 13

developed in the 1950s it was previously used to post- operatively reduce stress until Delay and Deinker found therapeutic benefits and revolutionised schizophrenia treatment

use: reduces positive symptoms
rationale: sz results from an excess of dopamine activity at synapses
aim: to reduce dopamine activty at receptor sites
process:
they are taken orally or injected (if patients are unreliable at taking medication)
typical antipsychotics are antagonists - they bind to dopamine receptors e.g D2 and block their action so the action of dopamine passing along neurones is diminished in turn reducing the positive symptoms

the success of the treatment lead to the dopamine hypothesis

Question 14

typical anti-psychotics- effectiveness

Answer 14

Adams et al - cochrane review
chlorpromazine versus placebo

Effective for 60% of patients

299 trials were excluded from consideration due to flawed research method/reporting of data leaving only 50 high quality control trials

1) these trials found that chlorpromazine to be more effective than placebo across symptoms
2) reduction in relapse rates from the short to medium term (but data is heterogeneous) for the longer term C was also favoured and results were homogeneous.
3) fewer people allocated to C left trials early!

meta analyses show that findings in support for the effectiveness of the drugs are consistent

trials should be well controlled experiments, with blind procedures and random allocation and a control condition

Question 15

3 differences between typical and atypical anti-psychotics

Answer 15

1) atypical have fewer side effects

2) Typical based on the theory of excess dopamine int he brain so targets only DRD2 receptors
whereas atypical also acts on serotonin receptors due to belief these play a role in negative symptoms

3)so atypical reduce both positive and negative symptoms
typical is j postive

Question 16

appropriateness of antipsychotics typical

Answer 16

the drug is sedating so there are some major side effects

movement and coordination disorders: tariff dyskinesia- involuntary movements of the tongue and jaw (20%) and parkinsonianism e.g stiffness

also lower blood pressure leading to dizziness and weight gain and sexual dysfunction (50%)

these often put patients off taking the drugs so lower rates of compliance

Question 17

atypical antipsychotics e.g clozapine

Answer 17

introduced in last 15 years

many people are resistant to typical AP, and they fail to treat negative symptoms

USE: to treat SZ without previous problems of side effects

Rationale: based on theory that SZ results from an excess dopamine activity and the imbalance in neurotransmitters such as serotonin (producing negative symptoms) so is able to reduce these symptoms

AIM to target dopamine and serotonin receptors in post synaptic membranes of neurones

PROCESS: the precise biochemical mechanisms are unknown but they combine the blocking of both serotonin and dopamine receptor sires

Question 18

atypical antipsychotics e.g clozapine effectiveness

Answer 18

in trials comparing clozapine to typical APs

Essali et al

review of RCT found fewer relapses, more improvement in functioning and negative symptoms with clozapine than typical form the BPRS scores

improvements in those who did not improve on anti-psychotics
34% fof treatment resistant patients had clinical improvement with clozapine

clozapine found to be more effective in longer term treatment of sz than typicals

Question 19

evaluation of Adams et al and Essali et al

Answer 19

both cochrane reviews so can trust data to be of high quality
however major issues in publication bis due to drug companies burying unfavourable data so results may exaggerate benefits

Question 20

overall evaluation of drug treatments

Answer 20

It remains a concern is cherry picking and burying data: a study by davis et al found that in head to head comparison trials 90% of reports were in favour the sponsers drug… this bias limits validity of these kind of trials
NICE
APs remain the primary treatment for sz, due to their well established evidence and efficacy in both acute psychotic episodes and reducing relapses over time.

but nonetheless considerable problems remain: 40% of the drugs users have poor response and continue to show moderate to severe symptoms.

Question 21

atypical- appropriateness

Answer 21

a small % of those on clozapine have reduced white blood cell count which should be monitored
fewer side effects than typical which is why they’re often favoured
although possible: drowsiness, hyper salivation and temperature increase