Treatments for Pychosis Flashcards
1
Q
what is DUP ?
A
- duration of untreated psychosis
- predictor of poor outcome in psychotic illnesses
2
Q
what is EIP ?
(EIiP)
A
- early intervention in psychosis
- NHS service aimed to get people treated quickly
- mostly for younger adults
3
Q
what can EIP typically offer someone experiencing their first episode of psychosis ?
A
- antipsychotic drug, CBT, and family therapy
- then taken antipsychotics for 1-2 years to minimise chance of relapse
- people with multiple episodes may need to continue for life
4
Q
what do we know about drug potenency and efficacy of average antipsychotics ?
A
- wide variation in doses (potencies)
- but very little difference in clinical effect, apart from clozapine
5
Q
what was the first antipsychotic in clinical use ?
A
chlorpromazine (thorazine)
6
Q
why is clozpaine so expensive ?
A
- it has specialised perscribing procedures
- needs monitoring, can cost up to £12 a day
7
Q
what are 3 common antipsychotics and why are these chosen ?
A
- olanzapine, risperidone, quetiapine
- low cost and manageable side effects
8
Q
what is chlorpromazine ?
antipsychotic
A
- first effective antipsychotic
- ‘largactil’ or ‘thorazine’
- not commonly used now
- forms the standardization of other antipsychotic drugs
can also be used to treat huntingtons disease
9
Q
what are the side effects of chlorpromazine ?
antipsychotic
A
- sedating effects
- moderate extrapyramidal (movement disorders)
- moderate muscarinic
- moderate galactorrhea
- neuroleptic malignant syndrome
10
Q
what happened as a result of chlorpromazine being a successful drug ?
A
companies made lots of derivatives which have similar efficacies but different side effects
11
Q
what are the two groups used to classify antipsychotics ?
A
- typical (1st gen)
- atypical (2nd gen)
- (3rd gen)
atypical can be an umbrella term for 2nd and 3rd gen antipsychotics
12
Q
how are antipsychotics classfiied as atypical drugs ?
A
- lower rate extrapyramidal effects (movement disorders)
- good efficacy against negative symptoms of schizophrenia
13
Q
what are the primary mechanisms of action for 1st gen and 2nd gen antipsychotics ?
A
competitive antagonists as dopamine D2 receptors
14
Q
what are the mechanisms of 3rd gen antipsychotics and an example ?
A
- D2 partial agonist
- aripiprazole
still dampens down activity
15
Q
what type of drug is clorpromazine ?
A
group 1 phenothiazine
16
Q
what generation are phenzothiazines ?
A
1st gen/ typical
17
Q
what is an example of a third gen antipsychotic ?
A
aripiprazole
18
Q
what is an example of a 2nd gen drug ?
A
clozapine (1st atypical introduce)
19
Q
what are the mechanisms of action of atypical drugs ?
A
on many receptors:
- (higher) affinity 5HT2A/C compared to D2
- rapid dissociation from D2
(- D2, D3, 5HT2A, GlyT, M1, M4, H1 etc)
20
Q
what is the least atypical drug and where does its activity target?
A
risperidone
- D2, D3, 5HT2A
21
Q
what is the most atypical drug ?
A
clozapine
22
Q
What is haloperidol ?
A
- most common typical antispychotic (1st gen)
- can be used for tourettes and antiemetic
- fewer sedative and cholinergic effects compared to chlorpromazine
- high risk of EPS, restlessness and neuroleptic malignant syndrome
EPS (extrapyramidal side effects)
23
Q
what is risperidone ?
A
- atypical (2nd gen) antipsychotic
- moderate risk of EPS
- can cause sedation, weight gain, galactorrhea
24
Q
what is olanzapine ?
A
- atypical (2nd gen) antipsychotic
- low risk EPS
- very sedating, weight gain
- high risk hyperglycaemia + high level of muscarnic side effects
brand name ‘zypreza’
25
what is quentiapine ?
- atypical (2nd gen) antipsychotic
- low risk EPS
- moderate weight gain, very sedating
- high risk hyperglycaemia
- moderate anticholinergic action
## Footnote
'seroquel' - brand name
26
what is aripiprazole ?
- atypical (3rd gen)
- dopamine D2 partial agonist
- benign side effects
- lower risk of weight gain and EPS
27
what did NICE recommend for adjunct medications for antipsychotic induced weight gain ?
use of medications used to treat type 2 diabetes e.g. metformin, liraflutide
28
what are the characteristics of neuroleptic malignant syndrome ?
## Footnote
NMS
- characterised by muscle contractions, tremors, high body temp, autonomic dysfunction, loss of consciousness/confusion
29
what is NMS caused by ?
antagonism of dopamine receptors (with polymorphisms in D2 as a genetic risk factor)
30
who is clozapine useful for?
cases of treatment resistant or treatment-refractory schizophrenia
| TRS
31
why was clozapine withdrawn from the market origionally?
- caused deaths due to agranulocytosis (loss of WBCs)
## Footnote
rare- only in 1-2% of patients
32
why was clozapine re-introduced onto the market ?
- could be done with blood testing to monitor WBC levels
- most effective treatment for TRS
33
when can cloapine be perscribed ?
after failure of two other drugs, one of which must have been atypical
## Footnote
used as a last resort
34
cardiac side effects of clozapine ?
- rare: heart failure, myocarditis
- 1/4 of patients: hypotension, tachycardia
## Footnote
can be avoided by starting on low dose and slowly increasing
35
what are some muscarinic side effects of clozapine and why do these occur?
- constipation (fatal): M3 anatagonistic actions
- hypersalivation: agonistic action at M4, or metabolite as M1
36
why is clozapine highly sedating ?
H1 histamine receptor antagonist
37
what is the summary of side effects for clozapine ?
- agranulocytosis
- cardiac effects
- muscarinic effects
- highly sedating
- weight gain/ diabetes
38
how can clozapine-induced agranulocytosis be fatal?
- loss of white blood cells (only in 1-2% of px)
- weakened immune system
- normally can be treated with antibiotics, but between 4-16% can die
39
what is involved in clozapine monitoring ?
- often initiated as in-patient
- ramped slowly
- health check up
- white blood cell count
mointor:
- 3rd day
- weekly (18 weeks)
- biweekly (34 weeks)
- 4 weekly therafter
| if miss >2 days: start over monitoring
## Footnote
only get given enough to last you till next test date, unless red result you don't get it
40
what role can antipsychotics play in bipolar ?
antipsychotics in combination with classic mood stabilizers like lithium, valproate, lamotrignine
41
why are mood stabilizers sometimes given in schizophrenia ?
to augment the effects of antipsychotics, can be useful in TRS
42
why do people with schizophrenia or schizoaffective disorder sometimes have low compliance ?
- lack of belief in illness
- side effects (even if believe ill may be too much)
- cogntive probelems, disorganized life-style
## Footnote
noncomplicance rates may be as high as 76%
43
what are the most common formulations of antipsychotics ?
- oral (voluntary)
- some available in sustained release (only have to take medication once a day)
44
what are the less frequently used formulations of antipsychotics ?
- intramuscular injection
- intramuscular depot injection
45
what is acepromazine ?
a component of a large animal immobilon (tranquilizer)
## Footnote
used in tranquilizer darts / not for humans
46
when are intramuscular injections used ?
- in psychiatric emergency situations
- involuntary
47
when are intramuscular depot injections used ?
- involuntary
- disorganised patient (forget to take medication)
- only 2-4 weeks
48
what are some advantages of a depot injection ?
- can eliminate covert non-compliance (when they tell them they are taking medication, but they are not)
- sometime effect is delayed
## Footnote
especially useful in young patients
49
what is a limitation of depot injections ?
not all drugs are available as a depot
50
what is an example of a depot only antipsychotic ?
pipotiazine
## Footnote
but withdrawn due to manufacturing difficulties
51
what depot medication would be good to give to someone who struggles with taking their medication ?
palliperidone as it lasts up to 3 months
52
why and how do people with alzheimer's disease and other forms of dementia use antipsychotics ?
- can sufffer from psychosis, agitation, aggression and this can be potentially dangerous
- so use antipsychotics for a short period at a low dose
- sedative effect
53
what are the two antipsychotics licensed for treating psychosis in AD ?
- risperidone
- haloperidol
54
what are the risks of antipsychotics in AD patients ?
- increased mortality
- cardiovascular issues e.g. stroke
55
what are non-pharmacological treatments for psychosis ?
talking therapies as an early intervention e.g. CBT with medication can improve symptoms further
56
when may talking-therapies be useful in patients with psychosis or schizophrenia ?
if they are refusing to take their antipsychotics
57
what are the benefits of talking therapies for psychosis and schizophrenia ?
- patients only recieving cognitive therpy had a significant reduction in positive and negative schizophrenic symptoms
- viable and safe for patients not on medication
58
How can lamotrigine be used in schizophrenia ?
an adjunct medication to increase effects of antipsychotic
59
what is a comon antipsychotic that can be done in depot injection ?
risperidone
60
what hisotrical treatment is still used for schizophrenia, although not frequently used ?
electroconvulsive therapy
61
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