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OPEN Ad Security Guru Online 4 $ 3 of 59 % & Management of schizophrenia Download Now Oct. 26, 2015 • 96 likes • 49,971 views Recommended Download to read o!line Psychosis Health & Medicine HI HI 52.9K views • 16 slides dr.swati arora junior resident(psychiatry) Swati Arora Schizophrenia Follow Richard Asare Resident, Psychiatry 32K views • 77 slides PRICE DROP Schizophrenia THUSHARA MOHAN 58.7K views • 28 slides Psychotic disorders Ahmed Almumtin 25.9K views • 31 slides Big save on Temu Temu Mania roshni-kiran 113.4K views • 21 slides Personality disorders KVM COLLEGE OF NURSING 106K views • 96 slides More Related Content Slideshows for you (20) MOOD DISORDERS Bipolar disorder Obsessive compulsive di… Organic mental disorder an hanisahwarrior • 75.9K views Chandan N • 90.1K views Soumya Ran… • 139.9K views Priyanka Ku… Nan • 36.6K views Similar to Management of schizophrenia (20) GROUP NO 6 PPT.pptx PHARMACOTHERAPY POI… psy schizo syahida.ppt Treatment of schizophre… Ha ShumailaQadir2 • 5 views samthamby79 • 4 views Siti Syahida • 3 views Dr. Sunil Suthar • 16.3K views Han Advertisement Recently uploaded (20) ORAL ANTIDIABETIC DRU… TRANSRADIAL ACCESS.pdf Cranial nerves.pptx Heart Failure Prediction … An Dipti Chand • 17 views Thieu Minh Son • 34 views Sai Sailesh Kum… • 13 views JatinSinghSagoi • 13 views Anu Related Books Free with a 30 day trial from Scribd View All Ebook Ebook Ebook Ebook Ebook Ebook Psychopharma… for Medical… Arash Ansari Students Second and Third Generation… Ryan S. 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MANAGEMENT OF SCHIZOPHRENIA BY: DR.SWATI ARORA JR2 2. WHAT IS SCHIZOPHRENIA ? • The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted a!ect. • Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits may evolve in the course of time. 3. WHAT IS SCHIZOPHRENIA ? • Schizophrenia encompasses: Positive Symptoms – Hallucinations & Delusions Negative Symptoms – Lack of motivation , poverty of speech Cognitive Deficits – Impairment in attention , memory and problem solving Psychosocial obstacles – Poor or lacking social relationships , unemployment , high risk of substance abuse , increased risk of homelessness , strain in family relations 4. MANAGEMENT DIAGNOSTIC EVALUATION TREATMENT HISTORY EXAMINATION MSE INVESTIGATION PHARMACO- LOGICAL NON- PHARMACOLOGICAL COMBINATION 5. PHASES OF TREATMENT IN SCHIZOPHRENIA • ACUTE PHASE - characterized by psychotic symptoms that require immediate clinical attention. Treatment during this phase focuses on alleviating the most severe psychotic symptoms. Usually last from 4 to 8 weeks. Acute schizophrenia is typically associated with severe agitation, which can result from such symptoms as frightening delusions ,hallucinations or suspiciousness or from other causes ,including stimulant abuse. 6. • STABLIZATION PHASE: In which acute symptoms have been controlled ,but patients remain at risk for relapse if treatment is interrupted or if the patients are exposed to stress. During this phase, treatment focuses on consolidating therapeutic gains, with similar treatments as those used in the acute stage. This phase last as long as 6 months following recovery from acute symptoms. • STABLE OR MAINTANENCE PHASE- When illness is either in a relative stage of remission or symptomatically stable. Goals during this phase are to prevent psychotic relapse or exacerbations and to assist patients in improving their level of functioning. 7. REASON FOR HOSPITALIZATION INDICATED FOR: • For Diagnostic purposes • For Stabilization of medications • For patients /relatives safety(suicidal and homicidal ideation) • For grossly disorganized or inappropriate behaviour (including the inability to take care of basic needs such as food , clothing and shelter) Hospital treatment plans should be oriented towards practical issues of self –care , quality of life ,employment and social relationships 8. ASSESSMENT • Before starting medication patients should receive a physical examination with neurological examination ,a mental status examination, and a laboratory evaluation. • Blood tests for complete blood count (CBC),electrolytes , fasting glucose , lipid profile , liver , renal , and thyroid function should be ordered. • Other evaluations that should be considered are pregnancy test in women, and hiv test. • Individuals with schizophrenia are at a higher risk for cardiovascular disease than the population at large. 9. • RATING SCALES USED FOR ASSESMENT OF SYMPTOMS OF SCIZOPHRENIA: Should be applied at baseline. • Following scales can be used: PANSS (Positive and negative symptoms scale) SANS(Scale for the assessment of negative symptoms) SAPS(scale for assessment of positive symptoms) BPRS(brief psychiatric rating scale) 10. • Treatment of schizophrenia: Pharmacological Non pharmacological Combined 11. • Antipsychotic medications-the mainstay of pharmacological treatment –are e!ective for reducing the impact of psychotic symptoms such as hallucinations, delusions and suspiciousness. • In many symptoms can be completely eliminated , once these symptoms are minimized , medications can decrease the likelihood that symptoms will recur. 12. SELECTION OF AN ANTIPSYCHOTIC DRUG Antipsychotics are categorized into two main groups 1st generation (FGAs) 2nd generation(SGAs)or dopamine receptor antagonists(DAs) serotonin dopamine antagonist (SDAs) • FGAs are further categorized as being low, mid or high potency. • Higher potency drugs – more specificity and greater a!inity for D2 receptor and greater tendency to cause EPS. • Lower potency drugs are less likely to cause EPS, but likely to cause hypotension, sedation, and anticholinergic e!ects. • Basically selection of drug is based on individual patient profile. 13. • SELECTION OF DRUGS DEPENDS ON: Availability Side e!ect profile Symptoms Specifics contraindications Familiarity Cost 14. COMPARISONS OF ANTIPSYCHOTICS • CUtLASS (cost utility of latest antipsychotic drugs in schizophrenia) and • CATIE ( clinical antipsychotic trial of intervention e!ectiveness) both studies did not found substantial advantages in overall tolerability , acceptability, and e!ectiveness for SGAs over FGAs. 15. DRUG MINIMUM EFFECTIVE DOSE 1ST EPISODE MINIMUM EFFECTIVE DOSE MULTIPLE EPISODE MAXIMUM EFFECTIVE DOSE FGAs Chlorpromazine 200 mg 300 mg 1000 mg /day Haloperidol 2 mg 4 mg 20 mg /day Sulpiride 400 mg 800 mg 2400 mg /day Trifluoperazine 10 mg 15 mg 30 mg /day SGAs Amisulpride 400 mg Unclear ? 400mg 1200 mg /day Aripiprazole 10 mg 10 mg 30 mg/day Asenapine 10 mg 10 mg 20 mg (sublingual) Olanzapine 5 mg 7.5 mg 20 mg/day Quetiapine 150 mg 300 mg 750 mg /day Risperidone 2 mg 3 mg 16 mg/day Ziprasidone 40 mg 80 mg 160 mg/day 16. EQUIVALENT DOSES DRUG EQUIVALENT DOSE chlorpromazine 100 mg/kg Haloperidol 2 mg/kg Trifluoperazine 5 mg/kg Olanzapine 7.5 -10 mg Risperidone 3 mg Queitiapine 300 mg Aripiprazole 10 mg 17. TREATMENT OF FIRST EPISODE SCHIZOPHRENIA 18. Either ; Agree choice of antipsychotic with patient Or, If not possible; Start 2nd generation antipsychotic Titrate , if necessary , to minimum a!ective dose Adjust dose according to response and tolerability Assess over 2-3 weeks 19. Change drug and follow above process consider use of either a SGAs or a FGAs If poor compliance related to poor tolerability, discuss with pt and change the drug. If poor compliance related to other factors, consider early use of depot. Continue at dose established as e!ective Clozapine (THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12TH EDITION) 20. TREATMENT OF RELAPSE OR ACUTE EXACERBATIONS (Full adherence to medication confirmed) 21. Investigate social or psychological precipitants Provide appropriate support and or therapy. Continue usual drug treatment Add-short term sedative Or Switch to di!erent, acceptable discuss choice with pts and assess over at least 6 weeks Switch to clozapine (THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12TH EDITION) 22. TREATMENT OF RELAPSE OR ACUTE EXACERBATIONS (ADHERENCE DOUBTFUL OR KNOWN TO BE POOR) 23. • Confused or • disorganised Lack of insight poorly tolerated t/t Or support Investigate reasons for poor adherence Simply drug regimen Reduce anticholinergic load Consider depot Discuss with the patient consider depot antipsychotics Discuss with patient switch to acceptable drug 24. • First generation drugs may be slightly less e!icacious than some SGAs. FGAs should be probably be reserved for 2nd line use because of the possibility of poorer outcome compared with FGAs and higher risk of movement disorder ,particularly tardive dyskinesia. • Choice is, however, based largely on comparative adverse e!ect profile and relative toxicity. patients seem able to make informed choices based on these factors, although in practice they may only very rarely be involved in drug choice. • Where there is prior treatment failure olanzapine or risperidone may be better options than quetiapine. • Olanzapine because of the wealth of evidence suggesting slight superiority over other antipsychotics , should always be tried before clozapine unless contraindicated. • Where there is confirmed treatment resistance evidence supporting the use of clozapine is overwhelming. 25. MANAGING AGITATIONIN ACUTEPSYCHOSIS • Agitation in acute schizophrenia can result from disturbing psychotic symptoms such as frightening delusions or suspiciousness or from other including stimulants abuse or EPS, particularly akathisia. • If pts are receiving agent associated with EPS, usually a first generation , a trial with anticholinergic antiparkinsonism medication or propranolol may be helpful in making the discrimination. • An advantage of an antipsychotic is that a single i.m injection of haloperidol, fluphenazine ,olanzapine , aripiprazole or ziprasidone will o"en result in calming without an excess of sedation. 26. • Intramuscular ziprasidone, aripiprazole , and olanzapine are similar to their counterparts in not causing substantial EPS during acute treatment. • Rapidly dissolving oral olanzapine, risperidone or aripiprazole may also be helpful as an alternative to an intramuscular injection. • Benzodiazapines are also e!ective for agitation during psychosis. • Lorazepam has the advantage of reliable absorption when administered either orally or intramuscularly. • The combination of lorazepam + antipsychotic found safer and more e!ective than large doses of DAs in controlling excitement and motor agitation. 27. ACUTEMANGEMENTOFPSYCHOTICEPISODE • With exception of Canadian guidelines ,all other recommend the use of either SGAs (1st line) or FGAs (2nd line) as standard drugs. • The Canadian guidelines only recommend the use of SGAs such as olanzapine , risperidone or quetiapine. • Based on recent evidence, the unified guidelines recommends the use of either 1st or 2nd generation antipsychotics based on clinical and economic needs at a dosage of 300-1000 chlorpromazine equivalents. 28. PROPHYLAXIS OF SCHIZOPHRENIA • All guidelines recommend the continued use of the same antipsychotic used to manage the acute episode for prophylaxis. • In longer term a balance needs to be made between e!ectiveness and adverse-e!ects. • Very low doses increase the risk of psychotic relapse. 29. HOW AND WHEN TO STOP? • Decision to stop antipsychotic drugs require a through risk- benefit analysis for each pt. • Withdrawal of drug a"er long term t/t should be gradual and closely monitored. • The relapse rate in 1st 6months a"er abrupt withdrawal is double that seen a"er gradual withdrawal (slow taper down over at least 3wks for oral antipsychotics or abrupt stopping of depot preparation) 30. DURATION OF PHARMACOTHERAPY • The APA and Canadian guidelines recommended similar duration of acute( , stabilization ,and stable phase treatment. • The NICE and Maudsley guidelines recommend acute treatment to last 2 years and give no specific recommendation on duration of prophylaxis. • The unified guidelines recommends: The acute phase treatment : last at least 12 weeks, The stabilization phase :last at least 12 months, The stable phase : last at least 2 years for a first episode and 5 years to lifetime for multiple episodes. 31. NON-PHARMACOLOGICALTREATMENT • O!en pharmacotherapy alone is not enough to address the devastating functional consequences of this condition and most individuals with schizophrenia continue to experience significant social, functional, and vocational disability leading to a poor quality of life. • This highlights the critical importance of the use of psychosocial interventions to help further the recovery of people with schizophrenia. 32. The Schizophrenia Patient Outcomes Research Team (PORT) provide recommendations on current evidence-based psychosocial treatment interventions for persons with schizophrenia. 2009 PORT review produced psychosocial treatment recommendations: 1. Family-based services, 2. Token economy, 3. Skills training 4. Assertive community treatment, 5. Supported employment, 6. Cognitive behavioural therapy, 33. SOCIAL SKILL TRAINING • Persons with schizophrenia who have skill deficits such as problems with social skills or activities of daily living should be o!ered skills training. • In addition to psychotic symptoms seen in patient with schizophrenia , other noticeable symptoms involve: The way person relate to others Including poor eye contact Unusual delay in response Odd facial expressions Lack of spontaneity in social situations etc. 34. • Behavioural skills training addresses these behaviours through the use of video tapes of others and of the pt, role playing, home work assignments for specific skills being practiced. • Social skill training has been shown to reduce relapse rates as measured by the need for hospitalization. 35. TOKEN ECONOMY INTERVENTIONS • A token economy is a system of behavior modification based on the principles of operant conditioning. • Emphasis is on reinforcing positive behaviour by awarding "tokens" for meeting positive behavioural goals. • Patients earn tokens, which they can exchange for privileges, such as time watching television or walks on the hospital grounds, by completing assigned duties (such as making their beds) or even just by engaging in appropriate conversations with others 36. • Advantages of token economy • tokens are flexible • tokens can be used for several needs and therefore saturation is improbable • there is no delay giving tokens a"er the desired behavior has been shown • mostly the token economy is well-regulated thus it is easy for therapists to decide whether they have to give a token or not 37. FAMILY INTERVENTIONS • PORT Recommendation. Persons with schizophrenia who have on- going contact with their families, including relatives and significant others, should be o!ered a family intervention that lasts at least 6–9 months. • ‘Family’ includes people who have a significant emotional connection to the service user, such as parents, siblings and partners. • The goals of family-based services are to increase understanding of the disorder, reduce levels of expressed emotion, reduce feelings of isolation, stress, and burden of family members, foster development of coping skills, and develop an ongoing collaborative relationship between family and clinicians. 38. AIMS OF FAMILY INTERVENTIONS: To help families cope with their relatives’ problems more e!ectively. Collaboration with relatives who care for the person with schizophrenia. Reducing the emotional stress and burden on relatives and within the family unit. Enhancement of relatives' ability to anticipate and solve problems. Reducing expressions of anger and guilt by the family . Maintenance of reasonable expectations for patient performance Attainment of desirable change in relatives' behavior and belief system 39. FAMILY INTERVENTIONS This can be started either during the acute phase or later, including in inpatient settings. Family intervention should: • include the person with schizophrenia if practical. • be carried out for between 3 months and 1 year • include at least ten planned sessions • take account of the whole family’s preference for either single-family intervention or multi-family group intervention • take account of the relationship between the main carer and the person with schizophrenia • have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work. 40. FAMILY INTERVENTIONS • For whom a longer intervention is not feasible or acceptable a shorter intervention that is at least 4 sessions in length should be o!ered to persons with schizophrenia. • Characteristics of the briefer interventions include education, training, and support. • Proposed as adjuncts rather than alternatives to drug treatments • The selection of a family intervention should be guided by collaborative decision making among the patient, family, and clinician. 41. Family interventions have been found to significantly reduce rates of relapse and re-hospitalization Possible benefits for patients include : • reduced psychiatric symptoms, • improved treatment adherence, • improved functional and vocational status, and • greater satisfaction with treatment. Positive family outcomes include : • reduced family burden and • increased satisfaction with family relationships. 42. PSYCHOEDUCATION Implies provision of information and education to a service user with a severe and enduring mental illness, including schizophrenia, about the diagnosis, its treatment, appropriate resources, prognosis, common coping strategies and rights. Psychoeducation involves quite lengthy treatment and runs into management strategies, coping techniques and role-playing skills. It is commonly o!ered in a group format. Psychoeducational interventions were defined as: • any programme involving interaction between an information provider and service users or their carers, which has the primary aim of o!ering information about the condition; and • the provision of support and management strategies to service users and carers. To be considered as well defined, the educational strategy should be tailored to the need of individuals or carers. 43. ASSERTIVECOMMUNITYTREATMENT PORT Recommendation: Systems of care serving persons with schizophrenia should include a program of assertive community treatment (ACT). It should be provided to individuals who are at risk for repeated hospitalizations or have recent homelessness. The key elements of ACT include • A multidisciplinary team including a medication prescriber, • A shared caseload among team members, • Direct service provision by team members, • A high frequency of patient contact, • Low patient-to-sta! ratios (usually 10–15 patients per member), and • Outreach to patients in the community. 44. • In ACT patients are diverted to the care of a community-based, multidisciplinary team including psychiatrists, nurses, and social workers. • The team carries small case loads and sees patients frequently in their own homes or in the workplace and deliver all services when and where needed by the pateint,24hrs a day,7 days a week. • This mobile and intensive intervention that provides treatment , rehabilitation and support activities. • These include home delivery of medications, monitoring of mental and physical health, in vivo social skills and frequent contact with the family members. • There is high sta!-to-patient ratio (1:12) ACT programs can e!ectively decrease the risk of hospitalization for persons with schizophrenia , but they are labor-intensive and expensive programs to administer. 45. • Teams care for the full range of acutely ill patients, including those who are suicidal, potentially violent or reluctant service users. • ACT teams also place particular emphasis on medication adherence • ACT has the same aims as case management but whereas under case management great emphasis is placed on individual responsibility of case managers for clients, ACT by contrast emphasizes team-working. • Care is provided at, as far as possible. • ACT has been found to significantly reduce hospitalizations and homelessness among individuals with schizophrenia. 46. COGNITIVE BEHAVIOUR THERAPY • Persons with schizophrenia who have residual psychotic symptoms while receiving adequate pharmacotherapy should be o!ered adjunctive cognitive behaviourally oriented psychotherapy . • The key elements of this intervention include: A shared understanding of the illness between the patient and the therapist. The identification of target symptoms. The development of specific cognitive and behavioural strategies to cope with these symptoms. 47. COGNITIVE BEHAVIOUR INTERVENTIONS • There is evidence for the e!ectiveness of CBT in the treatment of several forms of psychopathology, including anxiety and a!ective disorders. • Controlled studies have shown benefits of CBT in reducing the severity of delusions, hallucinations, positive symptoms, negative symptoms, and overall symptoms and in improving social functioning among individuals with schizophrenia who have persistent psychotic symptoms despite adequate pharmacotherapy 48. COGNITIVE BEHAVIORAL THERAPY CBT focuses on : Helping individuals recognize delusional thoughts and testing of key beliefs that may be supporting delusional thinking Helping in recognizing early signs of relapse and development of problem-solving strategies to reduce relapse. learning and strengthening skills for coping with and reducing symptoms and stress. Identification of factors exacerbating symptoms. development of a collaborative understanding of the nature of the illness, which encourages the patient’s active involvement in treatment 49. VOCATIONAL REHABILITATION • Employment rates among individuals with schizophrenia and related disorders are substantially lower than in the general population. • Employment status appears likely to have substantial impact on the economic circumstances of many patients and influences many aspects of quality of life. • Two main classes of programes have evolved to help people stay in employment: • pre-vocational training • supported employment • There is no evidence that employment obtained with these methods leads to increased stress or exacerbation of symptoms • There is some, evidence that employment status may have positive impacts on self-esteem, on aspects of psychiatric symptoms, and on the likelihood of relapse. 50. • In Prevocational training participants undergo a period of extensive preparation before being encouraged to seek competitive employment. The person is supported in some form of sheltered work before entering real-world employment • In Supported employment the emphasis is on placing individuals in competitive employment sooner and o!ering considerable a"er- placement job-support services from a team of professionals. • There is strong evidence that supported employment is superior to prevocational training, improving employment prospects and hours per week spent in competitive employment significantly more when the two are compared.(NICE 2010) 51. COMPARISION OF GUIDELINES FOR MANAGEMENT OF SCHIZOPHRENIA 52. APA CANADIAN NICE MAUDSLEY ACUTE T/T OF 1ST EPISODE SGAs/FGAs Olanzapine Risperidone Quetiapine SGAs/FGAs SGAs/FGAs PROPHYLAXIS To continue same antipsychotic To continue same antipsychotic To continue same antipsychotic To continue same antipsychotic DURATION ACUTE: 4 TO 8 wks. STABILIZATION: upto 6 months. STABLE :upto 1 to 1.5yrs in 1st episode; 5 to 10 yrs in case of 2 or more episode & indefinite for multiple prior episodes or more than 2 episodes in 5yrs. ACUTE PHASE: 6 to 12 wks STABILIZATION PHASE: 1 Yr STABLE PHASE: upto 2 yrs in 1st episode and upto 5yrs in case of multiple episodes. Acute treatment to last 2yrs . No duration of long term treatment indicated Same as NICE 53. APA CANADIAN NICE MAUDSLEY PSYCHOSOCIAL MANAGEMENT Family psycho- education (>9 months), Assertive community treatment, supported employment, social skills training and CBT ( 16-20 sessions) Supported employment, family psycho- education, skills training, and CBT CBT(16-sessions)/ FFT(10 sessions)/ arts therapy/ supported employment No recommendati ons 54. REFERENCES • Kaplan and Sadock’s Comprehensive textbook of psychiatry,9th edition,Volume 1 Chapter 12,pg 1645-1652 and pg 1693- 1733. • Kaplan and Sadock’s Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry,11th edition,chapter 13,pg.no 488- 497. • The Maudsley prescribing guidelines in psychiatry, 12th edition,chapter 2 ,pg. no 15-77. • American Psychiatric Association. Practice Guideline for the Treatment of Patients With Schizophrenia. 55. • Robert w. buchanan et al,the schizophrenia port psychopharmacological treatment recommendations and summary statements, schizophr bull.2010 jan;36(1):71-93. • S.saddichha and santosh k. chaturvedi,Clinical practice guidelines in psychiatry: more confusion than clarity? A critical review and recommendation of a unified guideline.ISRN psychiatry,vol.2014. 56. APA CANADIAN NICE MAUDSLEY UNIFIED PSYCHOSOCIAL MANAGEMENT Family psycho- education (>9 months), Assertive community treatment, supported employment, social skills training and CBT ( 16-20 sessions) Supported employment , family psycho- education, skills training, and CBT CBT(16- sessions)/ FFT(10 sessions)/ arts therapy/ supported employment No recommen dations Family psycho- education (>9months) Assertive community treatment, supported employment, social skill training and CBT( 16-20 sessions) 57. APA CANADIAN NICE MAUDSLEY UNIFIED ACUTE T/T OF 1ST EPISODE SGAs/FGAs Olanzapine Risperidone Quetiapine SGAs/FGAs SGAs/FGAs SGAs/FGAs PROPHYLAXIS To continue same antipsychotic To continue same antipsychotic To continue same antipsychotic To continue same antipsychotic To continue same antipsychotic DURATION ACUTE: 4 TO 8 wks. STABILIZATION: upto 6 months. STABLE :upto 1 to 1.5yrs in 1st episode; 5 to 10 yrs in case of 2 or more episode & indefinite for multiple prior episodes or more than 2 episodes in 5yrs. ACUTE PHASE:6 to 12 wks STABILIZATIO N PHASE: 1 Yr STABLE PHASE: upto 2 yrs in 1st episode and upto 5yrs in case of multiple episodes. Acute treatment to last 2yrs . No duration of long term treatment indicated Same as NICE ACUTE PHASE: upto 12 wks STABILIZATIO N PHASE:upto 12 months STABLE PHASE: 2yrs for 1st and 5 yrs to life time for subsequent episodes. About Support Terms © 2023 SlideShare from Scribd Privacy Copyright Cookie Preferences Do not sell or share my personal information English ! # "
