following frank
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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