Summary

Question 1

Key clinical features of Schizophrenia

(a.k.a. “Thought Disorder”):

Answer 1

– Positive Sxs, Negative Sxs, Functional Impairment

– Accurate diagnosis necessary to guide treatment and subsequent monitoring

Question 2

MOA of Antipsychotics (a.k.a. “Thought Organizers”)

Answer 2

– FGA, SGA:
• D2 antagonism (in mesolimbic dopamine tract) improves (+)ve Sxs

– SGA:
• 5HT2A antagonism may improves mood Sxs, ?and possibly also (–)ve Sxs.

Question 3

Clinical differences between SGA and FGA:

Efficacy
Toxicity
The “-pines” versus the “-ones”

Answer 3

– Efficacy:
• SGA effective for both (+)ve Sx and mood Sx
• FGA only useful for +ve Sxs

– Toxicity:
• FGA generally has more “muscle side effects”
• SGA (except Aripiprazole, Ziprazidone) generally has more “metabolic side effects”

– The “-pines” versus the “-ones”
• The “-pines” (e.g. Clozapine, Olanzapine, Quetiapine)
– Relatively more sedating, more weight gain

• The “-ones” or (e.g. Risperidone, Paliperidone, Ziprasidone, Aripiprazole)
– Relatively less sedating, less weight gain

Question 4

Non-Pharmacological Management (psychosis)

Answer 4

Non-Pharmacological Management

– Supportive counseling, social skills therapies, rehab, vocational training, etc

Question 5

Pharmacological Treatment

psychosis

Answer 5

Pharmacological Treatment
– Initiate a suitable non-clozapine SGA (or FGA), titrated to effect.
– Choose the Antipsychotic Formulation:
• Oral:
– Immediate release, Oral Dispersible, Oral solution
– Oral extended release

• Intramuscular:
– IM rapid-acting (e.g. IM haloperidol)
– IM long-acting (e.g. IM Haloperidol decanoate)

– Adequate Antipsychotic Trial
• At least 4-6 weeks at recommended therapeutic dosing range
• clozapine trial may require 3 months.

– Adjunctive Treatments:
Antidepressants; Benzodiazepines; Mood Stabilizers.

Question 6

Treatment Resistant Schizophrenia tx

Answer 6

Treatment Resistant Schizophrenia
– Not responsive to at least 2 adequate trials of antipsychotics, of which one is a SGA.
– Consider Clozapine
• Monitor baseline and periodic FBC with ANC due to risks for agranulocytosis

Question 7

psychosis goal

Answer 7

Acute Stabilization Phase
– Goal: DECREASE agitation, aggression, hostility; improve sleep

– If acutely agitated/aggressive:
• 1st: De-escalate
• 2nd: Consider oral antipsychotic +/- benzodiazepine

• 3rd: If refuse or not possible to administer oral medications,
– consider fast-acting IM alternatives with monitoring:
– e.g. IM Haloperidol 5mg (for psychosis) + IM Lorazepam 2mg STAT

– Monitor for Treatment-Emergent Adverse Effects:
• E.g. dystonia, pseudo-parkinsonian side effects and treat accordingly (e.g. oral or IM benztropine 2mg) • monitor vitals (BP/ HR/ RR/ Temp/ pain)

Stabilization and Maintenance Phase
– Goal: Minimize/ prevent relapse; maintain baseline functioning
– Monitor and manage adverse effects.
– If poor adherence to oral medications, consider:
• Long-acting IM Antipsychotic Injection (e.g. IM Haloperidol Decanoate)
• Community Psychiatric Nurse Referal