Download - Schizophrenia management
Management of SchizophreniaDr. Pavan Kumar KAsst ProfessorDept Of PsychiatryCAIMS
•PHARMACOLOGICAL MANAGEMENT
•PSYCHOSOCIAL MANAGEMENT▫PSYCHOTHERPIES▫REHABILITATION
•Treatment of first episode schizophrenia
Either:Agree choice of antipsychotic with patient &/or carer
Or ,if not possible:Start 2nd generation antipsychotics
Titrate , if necessary to minimum effective dose
Adjust dose according to response & tolerability
Assess over 2-3 weeks
Continue at dose established as effective
Change drug & follow above process. Consider use of either a SGA or a FGA
If poor compliance related to poor
tolerability, discuss with patient & change drug .
If related to other factor,consider depot
prep/compliance therapy/aid.
Repeat above process
CLOZAPINE
Effective
Not effective
Not tolerated / poor compliance
•Treatment of relapse or acute exacerbation with adherence confirmed.
INVESTIGATE SOCIAL / PSYCHOLOGICAL PRECIPITANTS
PROVIDE APPROPRIATE SUPPORT & / THERAPY
CONTINUE USUAL DRUG TREATMENT
ADD SHORT-TERM SEDATIVESOR
SWITCH TO A DIFFERENT , ACCEPTABLE ANTIPSYCHOTIC IF APPROPRIATE
DISCUSS CHOICE WITH PATIENT &/ CARERACCESS OVER ATLEAST 6 WEEKS.
SWITCH TO CLOZAPINE
AC. DRUG TREATMENT REQUIRED
TREATMENT INEFFECTIVE
•Treatment of relapse or acute exacerbation of schizophrenia with adherence doubtful
INVESTIGATE REASONS FOR POOR
ADHERENCE
SIMPLIFY DRUG REGIMENREDUCE
ANTICHOLINERGIC LOAD
CONSIDER COMPLIANCE AIDS*
DISCUSS WITH PATIENT
SWITCH TO ACCEPTABLE DRUG
DISCUSS WITH PATIENT
CONSIDER COMPLIANCE
THERAPYOR DEPOT ANTIPSYCHOTICS
CONFUSED /DISORGANIZED
POORLY TOLERATED TREATMENTLACK OF
INSIGHT OR SUPPORT
Comparison of antipsychotics•In general all antipsychotics are effective.•The makers and marketers of
antipsychotics have sponsored many studies and their drugs have always been found to be superior.
•Independently conducted meta-analysis have found few effectiveness differences between the drugs exception being for clozapine.
•CATIE AND Cut-LASS•These studies are state sponsored and
they have found clozapine to be effective in refractory individuals but no clear important advantages in effectiveness for any other drug for most patients.
•Both studies have found out no changes in tolerability or acceptability for SGA/FGA.
Long acting injectable antipsychotics•These drugs are helpful for continuation
and maintenance treatment.•Some oral supplementation is necessary
while optimum plasma levels are being achieved.
•ACUTE PHASE•MAINATAINANCE PHASE
▫Stabilization phase▫Stable phase
Psychosocial treatment•PSYCHOTHERAPY
▫FAMILY THERAPY▫COGNITIVE BEHAVIOUR THERAPY▫SOCIAL SKILL TRAINING
•REHABILITATION▫TOKEN ECONOMY ▫VOCATIONAL REHABILITATION▫SUBSTANCE ABUSE REHABILITATION▫COGNITIVE REHABILITATION
PATIENT OUTCOME RESEARCH TEAM•Family intervention•Supported employment•Assertive community treatment•Skills training•CBT•Token economy interventions
Family interevention:
Supported employement•Persons with schizophrenia who have the
goal of employment should be offered supported employment, the key elements of which include individualized job development, rapid placement emphasizing competitive employment, ongoing job support, and integration of vocational and mental health services.
Social skills training•Social dysfunction is a defining
characteristic of schizophrenia. People with this illness have difficulty fulfilling social roles.
•Social dysfunction is semi-independent of symptomatology, and it plays an important role in the course and outcome of the illness
Core components:
•Social perception•Social cognition and •Behavioural resoponse
Elements that are to be concentrated include• Expressive behaviours
▫Speech content ▫Paralinguistic features
Voice volume Speech rate Pitch Intonation
• Nonverbal behaviors ▫Eye contact (gaze) ▫Posture ▫ Facial expression
•Receptive Skills (social perception) ▫ Attention to and interpretation of relevant
cues ▫Emotion recognition
•Processing Skills ▫ Analysis of the demands of the situation ▫ Incorporation of relevant contextual
information ▫Social problem solving
•Interactive Behaviors ▫Response timing ▫Use of social reinforcers ▫Turn taking Situational Factors
CBT•findings from the past two decades
suggest that schizophrenia patients can benefit from CBT that directly targets psychotic symptoms.
•CBT is a psychological approach to treatment that is focused on the interrelationship between thoughts, behaviors, and feelings
TOKEN ECONOMY PROGRAM•Token economies are behavioral
reinforcement programs based on the principles of social learning.
• (1) managing patients' behaviors while they are in the hospital or facility, and
• (2) preparing them to be able to function better in other, presumably less restrictive and less structured settings
•(1) identification of “target behaviors” that are considered important/desirable for all patients,
• (2) earning points or tokens for engaging in these behaviors,
• (3) redeeming the points in exchange for material items or privileges, and
•(4) participation by all patients in the treatment setting
SUBSTANCE USE REHABILITATION•Most common and clinically significant
comorbidity with schizophrenia. •Approximately 50 percent of adults with
schizophrenia have at least one co-occurring substance abuse
•complicate their lives, ▫leading to increased symptoms, ▫relapses, ▫hospitalizations, ▫violence, incarceration,▫ unstable housing, homelessness,
victimization, ▫family problems, and ▫serious medical problems such as HIV and
hepatitis
Effectiveness of particular treatment
•Effectiveness = Efficacy + Tolerability+
Compliance+ ease of Use
Recovery •Mental health recovery is in a journey of
healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential
REFERENCES
• Sadock BJ, Sadock VA, Ruiz P. Comprehensive textbook of Psychiatry,Schizophrenia. 9th Edition,VOL1:Lippincott Williams ltd; 2009.
• IPS guidelines for management of schizophrenia.
• NICE guidelines: core interventions in treatment and management of schizophrenia ,2002.
• APA guidelines: practice guidelines for treatment of patients with schizophrenia,2004.
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