Transcript PSYCHIATRIC REHABILITATION

Managing treatment
resistant Schizophrenia
Case 1: PL
• 40 year old man
• Paranoid Schizophrenia diagnosed 15 years ago
Admissions 20 Apr 2007 – 15 Oct 2007, Sect 3
9 Dec 2004 – 14 Jan 2007
28 July 1992 – 20 Aug 1992 - Schizophrenia
19 July 1991 – 16 Sept 1991 - Psychosis
Residual Symptoms - Poor insight, grandiose ideas,
voices, negative Symptoms
Risks - Self neglect, aggression, poor compliance
Case 1:PL – General history
• Med Hx:
•
•
•
•
•
•
Type 2 DM diagnosed 2003
Hypertension
Obesity
Family Hx: Maternal aunt suffers with a mental illness
Social Hx: Lives with retired father, mother in nursing
home, brother lives nearby
Personal:
Minor head injury at 2 yrs of age
1 GCSE, left school at 16, did odd jobs
Premorbid: ‘Personable young man’ with friends, had girlfriends
Forensic:
Nil
Substance Use: Smokes, has drunk alcohol to excess in the past
Case 2 : MR
•
•
34 year old man
Paranoid Schizophrenia 1994, Depression 1992
Chronic Psychotic Choreoathetosis 1994
Admissions
28 Aug 2007 – Current – Section 3
29 Jan 2007 – 13 Aug 2007 – Section 3
27 Aug 2004 – 27 Nov 2006 – Section 3
7 Apr 2004 – 29 June 2004 – Informal
31 May 2002 – 17 Oct 2002 ‘Toxic Psychiatry’
16 Jan 1997 – 13 Mar 1997 – Informal
7 July 1995 – 12 Feb 1996 – Section 3
Feb 1995 – Schizophrenia – Informal
19 Feb 1994 – 4 July 1994 – Psychosis
1992 – Depression, Informal
•
•
Residual Symptoms – Tics, mannerisms, persecutory delusions, negative
symptoms
Risks – Derogatory comments when disinhibited, aggression,
noncompliance, self neglect
Case 2: MR - General History
• Med Hx:
Nil of note
• Family Hx:
Father also had tics and mannerisms
• Social Hx:
Close contact with parents and girlfriend
No sibs
• Personal:
HTN in pregnancy, Low birth weight,
young offender, some trouble in teens,
experimented with illicit drugs
6 GCSEs, 1 Art and Design A level
• Forensic:
Young offenders institute 1992
• Substance Use: 20 rollups/day, Past hx illicit drug use
Case 3: EW
•
29 yr old man
•
Schizo-affective Disorder diagnosis at 19 yrs of age
Admissions
14/7/2002 – present; Informal/Section 3
7/2002 – Informal/Section 3
1/2002 – Informal
1998 – Schizoaffective disorder - Section 3
1997 – Psychosis; ongoing drug use - Informal
1992 – Drug induced psychosis – Section 2
Persistent Symptoms - Poor insight, fluctuating mood, negative symptoms
Risks - Self harm, self neglect, aggression, poor compliance
Case 3: EW General History
Med Hx:
Nil significant
Family Hx:
Maternal cousin - chronic psychosis
Paternal grandmother - probable schizophrenia
Maternal aunt - depression
Paternal uncle – epilepsy
Social Hx:
In hospital for ~10 years, Close to mother in
France, father lives nearby,
brother & sisters in
touch
Personal:
No problems at birth or in childhood; Drugs++ teens
Left 6th form 16 yrs of age; went back obtained 6 A levels.
Began University philosophy degree, not completed
Forensic:
Nil
Substance Use: Cigarettes, frequent alcohol. Past cannabis, cocaine, heroin,
LSD, speed and ecstasy. Denies IV drugs.
Treatment-resistant
Schizophrenia
• ‘ The presence of poor psychosocial and
community functioning which persists
despite trials of medication that have been
adequate in terms of dose duration and
adherence. ’
– NICE 2002
What is treatment-resistant
schizophrenia?
• A substantial minority of patients show a
poor response to antipsychotics
• Identifiable during the first episode
• More often identified within the first two
years
• Effect on functioning due to positive and
negative symptoms
Clinical characteristics
•
•
•
•
•
Negative symptoms
Neurocognitive function
Depressive features
Substance misuse
Physical illness
Negative symptoms
• Deficit Syndrome - Smaller frontal lobes,
lower frontal metabolism, executive
performance deficits etc.
• Type I/Type II model (Crow 1980)
• Fluctuating nature of symptoms
• Atypicals more effective but mostly in
acute schizophrenia
Neurocognitive function
• Cognitive impairment key predictor of
overall treatment response
• Can appear in the first episode
• Some improvement with atypical
antipsychotics
• However, continues to have lower
cognitive performance than expected
Findings in Neuroimaging
• Structural abnormalities very common
• Literature inconsistent on association
between structural abnormalities and
treatment response
• Progressive brain changes seen
• Differential cerebral blood flow seen in
patients receiving risperidone (Honey et al.
1999)
Demographic variables
• Earlier age of onset associated with poor
outcome (approx.5 years earlier)
• Duration of untreated psychosis (DUP)
• Gender (a robust predictor)
• Poor pre-morbid function
• Neurological soft signs
• Cognitive impairment
Nonresponsiveness and
Intolerance
Treatment Resistance / Non-responsiveness
– ‘ a lack of satisfactory clinical improvement despite the use of
adequate doses of at least two marketed neuroleptics prescribed
for adequate durations.’
Intolerance
– ‘the impossibility to achieve adequate benefit with conventional
neuroleptics drugs because of severe and untreatable neurological
adverse reactions (extra pyramidal symptoms or tardive
dyskinesia)’
- BNF Summary of Product Characteristics
Schizophrenia Epidemiology
•
NICE estimates 210,000 individuals in the UK and Wales (0.4 - 1.4% of
the population) have schizophrenia and are eligible for antipsychotic
treatment
•
63,000 (30%) will be treatment resistant and eligible for treatment with
Clozapine.
•
25,200 (40%) of those who are treatment resistant will not adequately
respond to Clozapine alone.
(NICE 2002)
Management
• Pharmacological treatment
• Psychological and social approaches
• Rehabilitation and Recovery
NICE Meta-analyses –
‘Talking therapies’
CBT
Family interventions
Cognitive remediation
Counselling
Psychoanalytic/psychodynamic
therapy
Psycho education
Social skills training
*
Psychosocial approaches
• CBT
• Cognitive rehabilitation and compensation
strategies
• Family therapy
• Psychosocial programmes
Pharmacological treatment
• High doses of typical antipsychotics seen
to be ineffective in most cases
• Atypical antipsychotics and Clozapine
• Combining antipsychotics
• Adjunctive pharmacological treatments
• Treatment of co-morbid conditions
Maudsley Recommendations
Attempt augmentation if there is no clear benefit after an
adequate trial of Clozapine
Carefully monitor for
– Symptom improvement
– Worsening side effects
– Improvement in side effects
Stop after 3-6 months if not useful
Adjunctive treatments
•
•
•
•
•
Clozapine and Sulpiride
Mood stabilisers
Benzodiazepines
Antidepressants
ECT
Conclusion
• NICE estimates up to 30% of patients with
schizophrenia will be treatment resistant
• Clozapine therapy will fail in 40% of treatment
resistant cases
• If there is an affective component, use
antidepressants or mood stabilisers
• Clozapine augmentation is recommended in partial
response
• 2 alternative anti-psychotics recommended if
Clozapine not tolerated
Working towards recovery
• Psychiatric rehabilitation
• Assertive Community treatment
• Specific interventions (such as for
substance use)
• Community support
• Addressing forensic issues
Rehabilitation
•
•
•
•
•
•
Social learning programmes
Enhancing skills
Cognitive remediation
Modifying environments
Compensating for deficits
Family psycho-education