SZ- Treatments

Question 1

What is the diagnostic process for SZ?

Answer 1

• Ideally GP is first point of contact
  – GP will refer to mental health team
• A&E is also an option in more serious/urgent cases
• In severe cases, a person can be detained under the mental
  health act
• Medical assessment to determine whether psychosis may be
  drug induced or organic
• Psychiatric assessment of symptoms
  – Hallucinations
  – Delusions
  – Thought disorders
  – How they have been functioning in their daily life
• Formal diagnosis is made following specialist assessment

Question 2

What does the healthcare team do?

Answer 2

• First episode should be referred to early intervention in psychosis team
  – Specialist type of Community Mental Health Teams (CMHTs)
  – Referred by GP, hospital, mental health services
  – Team includes psychiatrists, psychologists, psychiatric nurses, social workers, support workers
  – Organised by a Care Coordinator
• This person may be a nurse, social worker, community psychiatric nurse, or occupational therapist

Question 3

Managing SZ

Answer 3

• NICE guidance (CG 178) lists a number of recommendations. The key aims relating to medication and physical health are:
• Oral antipsychotic medication should be offered in conjunction with psychological interventions
• The choice of antipsychotic should be made by the individual and health professional together
• The physical health of individuals with psychosis or schizophrenia should be monitored before starting an antipsychotic
• A combined healthy eating/physical activity programme and stop smoking support should be offered. If there is rapid or excessive weight gain, abnormal lipid levels or problems with blood glucose management

Question 4

Choice of antipsychotic

Answer 4

• There is no first-line antipsychotic drug suitable for all people with psychosis/schizophrenia
• Choice depends on several factors:
  – the person’s personal choice
  – medication history
  – degree of sedation required
  – risk of particular adverse effects
  – degree of negative symptoms (second-generation antipsychotics may be more likely to improve negative symptoms)
• Clozapine generally offered to people who do not respond adequately to two other antipsychotics and is always initiated and monitored in secondary care
• Individual responses to antipsychotics are variable. Dosage and dosage interval will, therefore, be adjusted specifically according to the person’s response

Question 5

What is the algorithm/ flowchart used for treatment?

Answer 5

Check slide 8 for flowchart

Question 6

What are the 3 psychosocial treatments?

Answer 6

1. Psycho-education
2. Cognitive Behavioural Therapy
3. Cognitive Remediation Therapy

Question 7

What are the advantages and disadvantages of each of the 3 psychosocial treatments?

Answer 7

1. Psycho-education
   Advantages:
   Increases awareness and insight of patient family.
   May be useful adjunct.
   Disadvantages:
   Few studies; must be combined withdrug Rx. Limited to problem-oriented and supportive therapies; must be combined with drug Rx.
2. Cognitive Behavioural Therapy
   Advantages:
   May reduce positive symptoms.
   Disadvantages:
   Few studies; must be combined withdrug Rx.
3. Cognitive Remediation Therapy
   Advantages:
   Treat cognitive symptoms
   Disadvantages:
   Long term benefits? Limited studies; must be combined with drug Rx.

Question 8

What are Depot injections for antipsychotics

Answer 8

• ‘long acting injectables’
• Long-lasting intramuscular injection
• Administered every 2-4 weeks (varies depending on drug)
• Useful for patients who
  – Have difficulty swallowing medication
  – Frequently forget to take their medication
  – Would prefer not to take medications everyday
• Patient should be stabilised on short acting form of the antipsychotic to confirm effectiveness of treatment and absence of severe adverse effects

Question 9

Treatment resistance

Answer 9

• At least 30% of patients do not respond to antipsychotics, or are intolerant of them
• Clozapine is effective in about 1/3 of these cases (Leucht et al., 2009)
• Limited evidence to support strategies other than clozapine (Miyamoto et al, 2014)
• This is the only situation where it might be appropriate to prescribe two antipsychotics at once
• Amisulpride? High D2 affinity
• Aripiprazole?
• Lamotrigine? Mood stabiliser

Question 10

Clozapine

Answer 10

• BNF indicates clozapine should be used in patients who are unresponsive or intolerant of other antipsychotics
• Best option in patients who do not respond to other antipsychotics
  – Usually at least two other medications tried before clozapine
• Main risks are
  – Neutropenia (low neutrophil count)
  – Agranulocytosis (low granulocyte count – neutrophils, basophils, & eosinophils)
• Neutropenia occurs in ≈3%, agranulocytosis in ≈1%
• Fatal agranulocytosis in ≈0.03%
• Blood counts must be normal before starting clozapine, and monitored during treatment. Blood tests should be:
  – Weekly for the first 18 weeks (highest risk period)
  – Every two weeks from 18 weeks to 12 months
  – Monthly for the remainder of treatment
• Discontinue and refer to haematologist if leucocyte count below 3000/mm3 or if absolute neutrophil count below 1500/mm3

Question 11

Comorbidities

Answer 11

People with schizophrenia are more likely to:
* Die by suicide
* Be a victim of violent crime
* Shortened life expectancy
* Anxiety
* Depression
* Substance abuse