Treatment of Psychosis Flashcards
1
Q
Key clinical features/symptoms of Schizophrenia (3)
A
- Positive symptoms
- Negative symptoms
- Functional symptoms
2
Q
5 domains of Schizophrenia
A
- Positive symptoms
- Negative symptoms
- Depression/anxiety
- Aggression
- Cognitive impairment
3
Q
Pathway for +ve symptoms
A
Mesolimbic pathway
4
Q
Pathway for -ve symptoms
A
Mesocortical pathway
5
Q
Pathway for EPSE
A
Nigrostriatum pathway
6
Q
MOA of antipsychotics (2)
A
- D2 antagonism
- all antipsychotics - 5-HT2A antagonism
- SGA (improve mood & negative symptoms)
7
Q
SGA
A
Second Generation Antipsychotics
8
Q
FGA
A
First Generation Antipsychotics
9
Q
Clinical efficacy of FGA vs SGA
A
FGA :
- more effective for +ve symptoms
SGA :
- more effective for +ve symptoms, mood & ?-ve symptoms
10
Q
Clinical toxicity of FGA vs SGA
A
FGA :
- more muscle side effects (EPSE)
- more hyperprolactinemia
SGA :
- more metabolic side effects
- except (5)
1. Lurasidone
2. Ziprasidone
3. Aripiprazole
4. Brexpiprazole
5. Risperidone
LZABR
11
Q
SGA -ines vs -ones/-piprazoles
A
-ines :
more sedation and weight gain
eg clozapine, olanzapine & quetiapine
-ones/-piprazoles :
less sedation and weight gain
12
Q
Non-pharmacological management (4)
A
- Cognitive Behavioural Therapy (CBT)
- Electroconvulsant Therapy (ECT)
- Repetitive Transcranial Magnetic Stimuation (rTMS) (less invasive)
- Psychosocial Rehabilitation Program (individual, group & cognitive behavioural)
13
Q
Psychosocial Rehabilitation Program
A
- Individual
- supportive counselling
- personal therapy
- social skills therapy
- vocational sheltered (employment and rehabilitation) - Group
- interactive/social - Cognitive Behavioural
- CBT
- compliance therapy
14
Q
Pharmacological treatment algorithm
A
1st line : FGA/SGA
- 2-6 weeks
- PO/IM
2nd line : FGA/SGA
- 2-6 weeks
- PO/IM
3rd line : Clozapine
- 3months trial
- agranulocytosis
- monitor FBC with Absolute Neutrophil Count (ANC) weekly for 18 weeks then monthly
- long term treatment often necessary
15
Q
Adjunctive treatment (2)
A
- Benzodiazepines
- lorazepam - Antidepressants
- for depression
16
Q
Treatment Resistant Schizophrenia (TRS)
A
- not responsive to 2 adequate trials of antipsychotics (at least 1 is SGA)
- Clozapine for at least 3 months
17
Q
Acute Stabilisation Phase treatment
A
If acutely agitated/aggressive
- PO antipsychotics +/- Benzodiazepines
If refuse or not possible to administer PO
- IM fast acting antipsychotics +/- IM Lorazepam
eg IM Haloperidol / Olanzapine
18
Q
EPSE types (4)
A
- Dystonia
- Pseudo-parkinsonian SE
- Akathisia
- Tardive dyskinesia
19
Q
Dystonia management
A
Anticholinergics PRN
eg Benztropine
20
Q
Pseudo-parkinsonian SE management (3)
A
- Reduce dose
- Switch to SGA
- Anticholinergics PRN
21
Q
Akathisia management (4)
A
- Reduce dose
- Switch to SGA
- Clonazepam
- anticholinergics generally unhelpful
22
Q
Tardive dyskinesia (5)
A
- Discontinue anticholinergics (dyskinesia worsened by anticholinergics)
- Reduce dose
- Switch to SGA
- Clonazepam
- Valbenazine
23
Q
Neuroleptic Malignant Syndrome (NMS) treatment (3)
A
- Switch to SGA
- IV Dantrolene
- PO dopamine agonists
24
Q
Acute stabilisation phase goals (2)
A
- Minimise threat to others and self
2. Minimise acute symptoms
25
Stabilisation phase goals (3)
1. Prevent/minimise relapse
2. Optimise dose
3. Promote medication adherence
26
Stable/Maintenance phase goal
Improve functioning & quality of life
27
Poor adherence to PO medications management (3)
1. IM long acting antipsychotics +/- benzodiazepines
- eg IM Haloperidol Decanoate
2. Community Psychiatric Nurse
3. Patient & Family Education (social support)
28
Metabolic side effects management
- maintain on current antipsychotics (to prevent relapse)
- treat emergent diabetes/dyslipidemia with lifestyle modification or meds
- switch to antipsychotics with less metabolic side effects
eg Aripiprazole, Brexpiprazole, Lurasidone, Ziprasidone & Risperidone
29
Daytime sedation
- administer dose in early evening for sedation to wear off
eg 7pm
- consolidate to once-nightly dosing
30
Dizziness (orthostatic hypotension)
- rise up slowly from lying position
31
Schizophrenia definition
- one of the more common forms of psychosis
- disorganised or bizarre thoughts
- delusions and hallucinations
32
Onset of schizophrenia
Late adolescents and early adulthood
33
Organic factors of psychotic symptoms (4)
- iatrogenic causes
- psychosis related to alcohol & substance misuse
- parkinson's disease
- dementia
34
Predisposing factors of Schizophrenia (2)
1. Genetics
| 2. Neurodevelopmental effects
35
Precipitating factors of Schizophrenia (2)
1. Drugs
eg benzodiazepines, barbiturates & antidepressants
2. Alcohol
36
Perpetuating factors of Schizophrenia (2)
1. Lack of social support
| 2. Poor adherence to antipsychotic medications
37
Important assessment for patients with Schizophrenia
Mental State Assessment (MSE)
- assess for suicidal/homicidal ideations & risks
- reassess MSE on every interview to evaluate risks & efficacy
38
Risks of relapse if non-compliant to antipsychotic medications
- medications reduce risk of relapse in stable illness to <30%/year
- 60-70% risk of relapse within 1 year
- 90% risk of relapse within 2 year
39
Antipsychotic agents vs Benzodiazepines
- generally tranquillise patients without impairing consciousness
- without causing paradoxical excitement
- can be used to calm disturbed patients regardless of the underlying psychopathology
40
Purpose of antipsychotics in patients with Schizophrenia
- Relieve symptoms of psychosis (thought disorder, hallucinations & delusions)
- Prevent relapse
41
Reason for delay in relapse episodes for several weeks after cessation of treatment
- adipose tissues act as depot reservoir after chronic regular use
- longer time for relapse for those w chronic use
42
Tuberoinfundibular pathway leads to __
Hyperprolactinemia
43
Less potent SGA
1. Quetiapine
| 2. Clozapine (but agranulocytosis)
44
Haematological side effects management
- Agranulocytosis
- reduce ANC
- reduce WBC
Discontinue antipsychotic agent (Clozapine) if severe
- WBC <3x10^9/L
- ANC <1.5^10^9/L
45
Parameters to monitor side effects (6)
1. BMI
2. Fasting Blood Glucose level
3. Lipid panel
4. Blood pressure
5. EPSE
6. FBC & ANC
46
CYP1A2 DDI with antipsychotics
CYP1A2 inhibitors
- Fluvoxamine
- Quinolones
- Macrolides
Victim antipsychotic
- Clozapine (increase serum conc)
47
(DDI) Carbamazepine(anti-epileptic) & Clozapine
Agranulocytosis
48
Time course of treatment response
Early improvements :
1 week (reduce agitation)
2-4 weeks (reduce hallucinations & paranoia)
Late improvements :
6-12 weeks (reduce delusions)
3-6 months (improve cognitive)
49
(DDI) Antipsychotics & drugs with CNS depressants effect
| potential DDI effect
Additive CNS depressant effect
50
(DDI) Antipsychotics & drugs with :
- anticholinergic effect
- antihistamine effect
- alpha1 adrenoceptor blockage
- dopamine blockage
Additive effects
- anticholinergic
- antihistamine
- postural hypotension (alpha1 adrenoceptor blockage)
- parkinsonism (dopamine blockage)
51
(DDI) Antipsychotics & dopamine enhancing drugs
| eg anti-parkinson drugs
Mutual antagonism
52
(DDI) Antipsychotics & antihypertensive agents
Additive hypotension effect
53
Which dopaminergic pathway does antipsychotics act on?
Mesolimbic dopaminergic pathway
| +ve symptoms
54
Neuroleptic Malignant Syndrome (NMS) symptoms (4)
1. Lead-pipe rigidity
2. Fever
3. Elevated creatine kinase
4. Altered consciousness
