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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]