Transcript Following Frank

Following Frank
Patients with Chronic Mental Illness
John R. Hall MD
Te Roopu Whitiora
Maori Mental Health Service
Being Frank
• Ian Rankin
• Included in A Good Hanging
General Follow Up
• Monitor symptoms
• Monitor for side effects and toxicity
• Monitor for concurrent medical problems
Schizophrenia
• A—2+
– Delusions
– Hallucinations
– Disorganized speech
– Disorganized or catatonic behaviour
– Negative symptoms
• B—socio-occupational dysfunction
• C—duration 6 months
Schizophrenia
• D—exclusion
– No mood episode concurrent with active
phase symptoms
– Mood episode is brief relative to active phase
symptoms
Symptom management
• Auditory hallucinations
– Nature of voices
– Risk of response to voices
• Delusions
• General Function
• Negative Symptoms
– Affective flattening
– Alogia
– Avolition
Compliance
• Deficits of insight
• Denial or disagreement with provider
• Side effects of treatment
• Make treatment as tolerable as possible
• Utilize Depot intramuscular preparations
Typical Antipsychotics
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Haloperidol
Zuclopenthixol
Chlorpromazine
Trifluoperazine
Extra-Pyramidal Symptoms
• Dystonia
– Muscle spasm
• Oculogyric crisis
• torticollis
• Parkinsonism
– Bradykinesia
– Tremour, rigidity
• Akathisia
Tardive Dyskinesia
• Lip smacking, tongue protrusion
• Choreiform hand movements
• Documented prior to introduction of
antipsychotic medications
• Relative advantage to atypical
antipsychotics—especially clozapine
Atypical Antipsychotics
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Risperidone
Olanzapine
Quetiapine
Ziprasidone
Aripiprazole
Amisulpride
Prolactinaemia
• Elevated prolactin levels are related to
dopamine blockade
• Worst offenders; Risperidone
• Relative advantage; Quetiapine, Clozapine
• Risks; menstrual disturbances,
gynecomastia, galactorrhoea, sexual
dysfunction
Weight Gain
• Increased food intake/ reduced energy
expenditure
• Worst offenders; Clozapine, Olanzapine
• Relative advantage; Ziprasidone,
Aripiprazole, Amisulpride
• Switching medications and/or behavioural
interventions
ECG changes
• QT prolongation
• An estimation of risk of torsade de pointes
and related arrhythymia (QTc>470,500ms)
• Offenders; Ziprasidone, Pimozide, tricyclic
antidepressants
• Relative advantage; Aripiprazole, SSRIs
Clozapine
• First two weeks—daily sighting for BP,
temp, pulse, adverse effects
• First 18 weeks—weekly haematology
• After that monthly haematology
• Weight and lipids 3-6monthly
Clozapine
• Haematology—
– White cells/ neutrophils
– Agranulocytosis 1/10,000
– Neutropenia 2.7%
• Serum Levels—
– To monitor compliance
– To establish a baseline
– When considering reducing dosage
Clozapine
• Other risks
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Hypersalivation
Seizure risk
Weight gain and dyslipidemias
Pulmonary embolism
Myocarditis
Cardiomyopathy
Constipation
Advantages of IMI treatment
• Compliance
• Contact with a nurse
• Patient preference?
IMI management
• Haloperidol
– 25-200mg
– 4 weekly injections
• Flupenthixol
– 20-400mg
– 2-4 weekly injections
• Fluphenazine
– 12.5-50mg
– 2-4 weeks
IMI management
• Zuclopenthixol
– 100-600mg
– 2-4 weekly injections
• Pipothiazine
– 25-200mg
– 4 weekly injections
SGA IMIs
• Risperdal Consta
– 25mg, 37.5mg, 50mg
– 2 weekly injections
– Gluteal or deltoid now
• Olanzapine
Bipolar Disorder
• Distinct Episodes
– Mania
– Depression
– “Mixed”
• Interepisodic recovery
• Treatment is essentially prophylactic
Symptom management
• Depression
– Motivation/interests, energy
– Feelings of hopelessness
– Suicidal ideation
• Mood Elevation
– Flightiness, distractibility, excessive energy
– grandiosity
• Sleep
• Activity level
• Psychotic symptoms
Lithium
• Serum levels (0.4-1.0mmol/L)
– 3-6months
– Physiological changes, medication changes
• Toxic symptoms
– Gastrointestinal symptoms
• Anorexia, nausea, diarrhea
– Ataxia, disorientations, seizures
Sodium Valproate
• Serum levels (300-700 micromol/L)
– 3-6 months
• Toxic Symptoms
– Gastric irritation, hyperammonaemia
– Lethargy, confusion
– Thrombocytopenia
– Hepatic changes
Teratogenicity
• Lithium
– Cardiac anomaly
• Sodium Valproate
– Neural tube defects
Other Mood Stabilizers
• Carbamazepine
• Lamotrigine
• Antipsychotics
Lithium
• Other things to monitor
– Thyroid
– Renal function
Depression in Bipolar Disorder
• Addition of an antidepressant
• Optimization of mood stabilizer
• Addition of an atypical antipsychotic
Antidepressants-Long term
• No peculiar guidelines to long term use
• General follow up for depression
guidelines
– 1yr following single episode
– 3-5 yr after two or three episodes
–?
• Be aware of discontinuation syndrome
John R. Hall
• Consultant Psychiatrist
• Te Roopu Whitiora
– Maori Mental Health Services
• 1/25 Rathbone Street
• 430-4101 3537
• [email protected]