treatment of schizophrenia

Question 1

Definition of psychosis

Answer 1

Being out of touch with reality

! Lack of insight

Question 2

Schizophrenia onset

Answer 2

Commonly adolescence or early adulthood

Question 3

Schizophrenia symptoms

Answer 3

Disorganised and bizarre thoughts 
Delusions 
Hallucinations 
Inappropriate affect 
Impaired psychosocial functioning

Question 4

Schizophrenia prevalence

Answer 4

~1%

Question 5

Organic disorder diagnoses associated with psychotic symptoms

Answer 5

Iatrogenic causes
Psychosis related to alcohol (hallucinosis) and psychoactive substance abuse
Epilepsy
Cerebral lesions

Question 6

Affective disorder diagnoses associated with psychotic symptoms

Answer 6

Mania
Psychotic Depression
Post-partum psychosis

Question 7

Predisposing etiological factors

Answer 7

Genetics 
Environment in utero 
Neurodevelopmental effects
Personality 
Physical, psychological and social factors in infancy and early childhood

Question 8

Precipitating etiological factors

Answer 8

Cerebral tumours or injury
Drugs
Personal misfortune
Environment of high expressed emotion

Question 9

Perpetuating etiological factors

Answer 9

Secondary demoralisation
Social withdrawal
Lack of support/poor socio-economic status or environment
Poor adherence with antipsychotic medications

Question 10

Clinical presentation of schizophrenia

Answer 10

Two or more, persisting for at least 1m
- Delusions
- Hallucinations
- Disorganised speech
- Grossly disorganised or catatonic behaviour
- Negative symptoms (effective flattening, avolition)
Social/occupational dysfunction
Continuous signs of the disorder for at least 6m
Schizoaffective or mood disorders excluded
Not due to medical disorder or substance abuse

Question 11

General assessments

Answer 11

History of presenting illness
Psychiatric history
Substance use history
Complete medical history and medication history
Family, social, forensic, developmental and occupational history
Physical and neurological exam
Mental State Exam (MSE) for accurate diagnosis
- Assess for suicidal/homicidal ideations and risks
Labs and other investigations

Question 12

Non-pharmacological treatment

Answer 12

Individual Cognitive Behavioural Therapy (CBT)
Electroconvulsive Therapy (ECT)
Psychosocial rehabilitation

Question 13

Therapeutic goals of pharmacological treatment

Answer 13

Acute stabilisation 
- Minimise threat to self and others
- Minimise acute symptoms
Stabilisation 
- Prevent relapse 
- Medication adherence
- Optimisation of dose 
Stable/maintenance phase 
- Improve functioning and quality of life

Question 14

Antipsychotics for schizophrenia

Answer 14

Used short term to calm disturbed patients whatever underlying psychopathology
Relieve symptoms of psychosis, prevent relapse
Long term treatment often necessary
Relapse often delayed for several weeks after cessation

Question 15

Methods to overcome poor treatment adherence

Answer 15

IM long-acting injections
Community psychiatric nurse
Patient and family/caregiver education

Question 16

Antipsychotics MOA

Answer 16

Blockage of dopamine receptors in mesolimbic tract

Question 17

AE

Answer 17

Mesocortical tract -- symptoms 
Nigrostriatal tract -- extrapyramidal side effects (parkinson's symptoms) 
Tuberoinfundibular tract -- hyperprolactinemia
Weight gain 
Sedation 
Orthostasis
Anticholinergic effects 
QTc interval prolongation

Question 18

Treatment algorithm

Answer 18

1. Single FGA or SGA (except clozapine)
2. Another single FGA/SGA not previously tried
3. Clozapine
4. 1. Clozapine + augmenting agent (FGA/SGA/ECT)
5. 2./5. Combination therapy

Question 19

Choice of therapy

Answer 19

Medication selection is individualised
Compliance to adequate trial of at least 2-6w at optimal therapeutic doses before being considered non-responders
Management of intolerable side effects
Clozapine only in those who are treatment resistant (failed ≥ 2 adequate trials) w routine haematological monitoring

Question 20

Precautions to antipsychotics use

Answer 20

CI in QTc prolongation 
CV diseases 
Parkinson's disease 
Prostatic hypertrophy 
Angle-closure glaucoma 
Severe respiratory disease 
Blood dyscrasias 
Elderly with dementia (higher risk of stroke and death)

Question 21

Adjunctive treatments

Answer 21

Acute Agitation 
- Oral/IM Lorazepam 
- Oral/IM antipsychotics(haloperidol, olanzapine, PO risperidone)
Catatonia 
- Benzodiazepines (PO/IM lorazepam) 
Negative/depression Sx
- Antidepressants

Question 22

Antipsychotics to be administered with food

Answer 22

Lurasidone

Ziprasidone

Question 23

FGA

Answer 23

Haloperidol 5-15mg/day, max 20mg/day
Chlorpromazine
Sulpiride
Trifluoperazine

Question 24

SGA

Answer 24

Clozapine, 200-450mg/day, max 900mg/day 
Olanzapine 5-20mg/day, max 20mg 
Quetiapine 150-500mg/day, max 800mg/day
Risperidone 2-6mg/day, max 16mg/day 
Aripiprazole 
Amisulpride

Question 25

Management of EPSE

Answer 25

Dystonia: IM anticholinergics
Pseudo-parkinsonism: decrease dose/switch to SGA, anticholinergic PRN
Akathisia: decrease dose/switch to SGA, clonazepam PRN, propanolol PRN
Tardive dyskinesia: decrease dose/switch to SGA, discontinue anticholinergics, , valbenazine 40-80mg/day, clonazepam PRN

Question 26

Hyperprolactinemia Management

Answer 26

Decrease FGA dose
Dopamine agonists
Switch to apiprazole

Question 27

Metabolic SE management

Answer 27

High risk: Olanzapine, Clozapine 
Low risk: Aripiprazole, Lurasidone 
Lifestyle modification 
Treat T2DM and HDL 
Switch to lower risk agents

Question 28

Neuroleptic malignant syndrome management

Answer 28

IV dantrolene 50mg TDS
PO dopamine agonists
Switch to SGA

Question 29

Hematological SE management

Answer 29

Discontinue clozapine if WBC < 3x10^9/ANC < 1.5x10^9

Question 30

Monitoring parameters

Answer 30

BMI
Fasting blood sugar
Lipid panel 
Blood pressure 
EPSE exam