Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Following Frank
Document related concepts
no text concepts found
Transcript
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 • • • • 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 • • • • • • 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 • • • • • • • 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]
