following frank patients with chronic mental illness john r. hall md te roopu whitiora maori mental...
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Following FrankFollowing FrankPatients with Chronic Mental IllnessPatients with Chronic Mental Illness
John R. Hall MDJohn R. Hall MDTe Roopu WhitioraTe Roopu Whitiora
Maori Mental Health ServiceMaori Mental Health Service
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Being FrankBeing Frank
• Ian Rankin
• Included in A Good Hanging
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General Follow UpGeneral Follow Up
• Monitor symptoms
• Monitor for side effects and toxicity
• Monitor for concurrent medical problems
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SchizophreniaSchizophrenia
• A—2+– Delusions– Hallucinations– Disorganized speech– Disorganized or catatonic behaviour– Negative symptoms
• B—socio-occupational dysfunction
• C—duration 6 months
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SchizophreniaSchizophrenia
• D—exclusion– No mood episode concurrent with active
phase symptoms– Mood episode is brief relative to active phase
symptoms
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Symptom managementSymptom management
• Auditory hallucinations– Nature of voices– Risk of response to voices
• Delusions• General Function• Negative Symptoms
– Affective flattening– Alogia– Avolition
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ComplianceCompliance
• Deficits of insight
• Denial or disagreement with provider
• Side effects of treatment
• Make treatment as tolerable as possible
• Utilize Depot intramuscular preparations
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Typical AntipsychoticsTypical Antipsychotics
• Haloperidol
• Zuclopenthixol
• Chlorpromazine
• Trifluoperazine
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Extra-Pyramidal SymptomsExtra-Pyramidal Symptoms
• Dystonia– Muscle spasm
• Oculogyric crisis• torticollis
• Parkinsonism– Bradykinesia– Tremour, rigidity
• Akathisia
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Tardive DyskinesiaTardive Dyskinesia
• Lip smacking, tongue protrusion
• Choreiform hand movements
• Documented prior to introduction of antipsychotic medications
• Relative advantage to atypical antipsychotics—especially clozapine
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Atypical AntipsychoticsAtypical Antipsychotics
• Risperidone
• Olanzapine
• Quetiapine
• Ziprasidone
• Aripiprazole
• Amisulpride
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ProlactinaemiaProlactinaemia
• Elevated prolactin levels are related to dopamine blockade
• Worst offenders; Risperidone
• Relative advantage; Quetiapine, Clozapine
• Risks; menstrual disturbances, gynecomastia, galactorrhoea, sexual dysfunction
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Weight GainWeight Gain
• Increased food intake/ reduced energy expenditure
• Worst offenders; Clozapine, Olanzapine
• Relative advantage; Ziprasidone, Aripiprazole, Amisulpride
• Switching medications and/or behavioural interventions
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ECG changesECG 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
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ClozapineClozapine
• 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
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ClozapineClozapine
• Haematology—– White cells/ neutrophils– Agranulocytosis 1/10,000– Neutropenia 2.7%
• Serum Levels—– To monitor compliance– To establish a baseline– When considering reducing dosage
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ClozapineClozapine• Other risks
• Hypersalivation
• Seizure risk
• Weight gain and dyslipidemias
• Pulmonary embolism
• Myocarditis
• Cardiomyopathy
• Constipation
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Advantages of IMI treatmentAdvantages of IMI treatment
• Compliance
• Contact with a nurse
• Patient preference?
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IMI managementIMI management
• Haloperidol– 25-200mg– 4 weekly injections
• Flupenthixol– 20-400mg– 2-4 weekly injections
• Fluphenazine– 12.5-50mg– 2-4 weeks
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IMI managementIMI management
• Zuclopenthixol– 100-600mg– 2-4 weekly injections
• Pipothiazine – 25-200mg– 4 weekly injections
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SGA IMIsSGA IMIs
• Risperdal Consta– 25mg, 37.5mg, 50mg– 2 weekly injections– Gluteal or deltoid now
• Olanzapine
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Bipolar DisorderBipolar Disorder
• Distinct Episodes– Mania– Depression– “Mixed”
• Interepisodic recovery
• Treatment is essentially prophylactic
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Symptom managementSymptom management
• Depression– Motivation/interests, energy– Feelings of hopelessness– Suicidal ideation
• Mood Elevation– Flightiness, distractibility, excessive energy– grandiosity
• Sleep• Activity level• Psychotic symptoms
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LithiumLithium
• Serum levels (0.4-1.0mmol/L)– 3-6months– Physiological changes, medication changes
• Toxic symptoms– Gastrointestinal symptoms
• Anorexia, nausea, diarrhea
– Ataxia, disorientations, seizures
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Sodium ValproateSodium Valproate
• Serum levels (300-700 micromol/L)– 3-6 months
• Toxic Symptoms– Gastric irritation, hyperammonaemia– Lethargy, confusion– Thrombocytopenia– Hepatic changes
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TeratogenicityTeratogenicity
• Lithium– Cardiac anomaly
• Sodium Valproate– Neural tube defects
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Other Mood StabilizersOther Mood Stabilizers
• Carbamazepine
• Lamotrigine
• Antipsychotics
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LithiumLithium
• Other things to monitor– Thyroid– Renal function
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Depression in Bipolar DisorderDepression in Bipolar Disorder
• Addition of an antidepressant
• Optimization of mood stabilizer
• Addition of an atypical antipsychotic
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Antidepressants-Long termAntidepressants-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
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John R. Hall John R. Hall
• Consultant Psychiatrist
• Te Roopu Whitiora– Maori Mental Health Services
• 1/25 Rathbone Street
• 430-4101 3537