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

Being FrankBeing Frank

• Ian Rankin

• Included in A Good Hanging

General Follow UpGeneral Follow Up

• Monitor symptoms

• Monitor for side effects and toxicity

• Monitor for concurrent medical problems

SchizophreniaSchizophrenia

• A—2+– Delusions– Hallucinations– Disorganized speech– Disorganized or catatonic behaviour– Negative symptoms

• B—socio-occupational dysfunction

• C—duration 6 months

SchizophreniaSchizophrenia

• D—exclusion– No mood episode concurrent with active

phase symptoms– Mood episode is brief relative to active phase

symptoms

Symptom managementSymptom management

• Auditory hallucinations– Nature of voices– Risk of response to voices

• Delusions• General Function• Negative Symptoms

– Affective flattening– Alogia– Avolition

ComplianceCompliance

• Deficits of insight

• Denial or disagreement with provider

• Side effects of treatment

• Make treatment as tolerable as possible

• Utilize Depot intramuscular preparations

Typical AntipsychoticsTypical Antipsychotics

• Haloperidol

• Zuclopenthixol

• Chlorpromazine

• Trifluoperazine

Extra-Pyramidal SymptomsExtra-Pyramidal Symptoms

• Dystonia– Muscle spasm

• Oculogyric crisis• torticollis

• Parkinsonism– Bradykinesia– Tremour, rigidity

• Akathisia

Tardive DyskinesiaTardive Dyskinesia

• Lip smacking, tongue protrusion

• Choreiform hand movements

• Documented prior to introduction of antipsychotic medications

• Relative advantage to atypical antipsychotics—especially clozapine

Atypical AntipsychoticsAtypical Antipsychotics

• Risperidone

• Olanzapine

• Quetiapine

• Ziprasidone

• Aripiprazole

• Amisulpride

ProlactinaemiaProlactinaemia

• Elevated prolactin levels are related to dopamine blockade

• Worst offenders; Risperidone

• Relative advantage; Quetiapine, Clozapine

• Risks; menstrual disturbances, gynecomastia, galactorrhoea, sexual dysfunction

Weight GainWeight Gain

• Increased food intake/ reduced energy expenditure

• Worst offenders; Clozapine, Olanzapine

• Relative advantage; Ziprasidone, Aripiprazole, Amisulpride

• Switching medications and/or behavioural interventions

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

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

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

ClozapineClozapine• Other risks

• Hypersalivation

• Seizure risk

• Weight gain and dyslipidemias

• Pulmonary embolism

• Myocarditis

• Cardiomyopathy

• Constipation

Advantages of IMI treatmentAdvantages of IMI treatment

• Compliance

• Contact with a nurse

• Patient preference?

IMI managementIMI management

• Haloperidol– 25-200mg– 4 weekly injections

• Flupenthixol– 20-400mg– 2-4 weekly injections

• Fluphenazine– 12.5-50mg– 2-4 weeks

IMI managementIMI management

• Zuclopenthixol– 100-600mg– 2-4 weekly injections

• Pipothiazine – 25-200mg– 4 weekly injections

SGA IMIsSGA IMIs

• Risperdal Consta– 25mg, 37.5mg, 50mg– 2 weekly injections– Gluteal or deltoid now

• Olanzapine

Bipolar DisorderBipolar Disorder

• Distinct Episodes– Mania– Depression– “Mixed”

• Interepisodic recovery

• Treatment is essentially prophylactic

Symptom managementSymptom management

• Depression– Motivation/interests, energy– Feelings of hopelessness– Suicidal ideation

• Mood Elevation– Flightiness, distractibility, excessive energy– grandiosity

• Sleep• Activity level• Psychotic symptoms

LithiumLithium

• Serum levels (0.4-1.0mmol/L)– 3-6months– Physiological changes, medication changes

• Toxic symptoms– Gastrointestinal symptoms

• Anorexia, nausea, diarrhea

– Ataxia, disorientations, seizures

Sodium ValproateSodium Valproate

• Serum levels (300-700 micromol/L)– 3-6 months

• Toxic Symptoms– Gastric irritation, hyperammonaemia– Lethargy, confusion– Thrombocytopenia– Hepatic changes

TeratogenicityTeratogenicity

• Lithium– Cardiac anomaly

• Sodium Valproate– Neural tube defects

Other Mood StabilizersOther Mood Stabilizers

• Carbamazepine

• Lamotrigine

• Antipsychotics

LithiumLithium

• Other things to monitor– Thyroid– Renal function

Depression in Bipolar DisorderDepression in Bipolar Disorder

• Addition of an antidepressant

• Optimization of mood stabilizer

• Addition of an atypical antipsychotic

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

John R. Hall John R. Hall

• Consultant Psychiatrist

• Te Roopu Whitiora– Maori Mental Health Services

• 1/25 Rathbone Street

• 430-4101 3537

• John.Hall@northlanddhb.co.org