Treating psychosis

Question 1

What are the main objectives of treatment?

Answer 1

Reduction of symptoms

Prevention of relapse

Prevention of onset of psychosis altogether –> Meds similar to treating psychosis =patients don’t like and stop = induce episode

More social improvement, helping people to get back to uni, work etc

Question 2

Dopamine in treatment

Answer 2

• All antipsychotics act on D2 receptors
• Pre-synaptic dopamine dysfunction
  -Main effect reduce psotivie symtpoms (when you look at PAANS)
• All antipsychotics have similar efficacy which vary between one to one slightly except for clozapine = Main difference in side effects

Question 3

What treatment is used for psychosis?

Answer 3

Antipsychotic medication is the only effective treatment (has the strongest evidence vs. CBT or FI BUT could be due to nature of the studies)
Around 2/3rds of patients show a good response
Selection of drug driven by side effect profile
Patients prefer drugs with fewest side effects
1/3 will be non-responders (could be identified with biomarker)

Question 4

Relapse

Answer 4

Once symptoms are controlled, main aim of treatment is to prevent subsequent relapse
Most patients will relapse, but it is unpredictable
Main factor influencing risk of relapse is adherence to antipsychotic treatment- 75% of people do not take meds as prescribed

Question 5

How to measure and ensure drug adherence?

Answer 5

1. Blood level drug concentration
   - disliked by patients and doctors
   - cost a lot
   - take a lot of time
2. New finger pricking methods (fast in taking sample and results)
   - allows fast dose adjustment
3. LAI (DEPO shots)

Question 6

Why is clozpaine under prescribed by clinicians?

Answer 6

Risk of neutropenia (3%), cardiac problems, constipation
Treatment entails regular blood testing of white cell count

Misperceptions:
Initiating treatment requires hospital admission
Can only be prescribed by specialists
Treatment requires intensive blood monitoring = Patients won’t tolerate it

Question 7

What is not being addressed by antipsychotics?

Answer 7

Negative symptoms
Cognitive impairments
Non-response to clozapine
Pressing need for new types of treatment

Question 8

What is Cariprazine?

Answer 8

It is a partial agonist at D2/D3 receptors
Approved treatment for mania
Potential novel treatment for psychosis for negative symptoms

Cariprazine has a good side effect profile it does not tend to cause too much sedation, or weight gain and does not have a great effect on cardiometabolic measures like glucose or lipids.
Possible early side effect of akathisia but this usually is tolerable and goes away after a week or 10 days.

Question 9

How does cannabidiol do?

Answer 9

CBD modulates function in hippocampus and striatum

Molecular target still unclear, but it may reduce activity at cannabinoid receptors as well as having effects at some serotonin receptors

Does not directly act on dopamine

Some evidence to improve CAARMS in URH