MEDICATIONSINPSYCHOSISPaulaWadell,MD

MedicalDirectorEarlyDiagnosis&PreventaAveTreatmentClinic(EDAPT)

SacEDAPTClinicUCDavisDepartmentofPsychiatry

DISCLOSURES

•  none

OUTLINE

•  Oralmedica-ons•  Injectablemedica-ons•  Nutri-onalsupplements

EarlyInterven-onforPsychosish<ps://raiseetp.org/• TheRAISEEarlyTreatmentProgram(ETP)isaresearchstudythatsupportscoordinatedspecialtycare(CSC).• Dr.JohnKanefromtheFeinsteinIns-tuteforMedicalResearchinManhasset,NYdirectedtheETPstudy.Thestudytookplacein34communitymentalhealthcentersandhospitaloutpa-entmentalhealthfacili-esin21states

Psychopharmacology•  NAVIGATEPsychopharmacologicalTreatmentManual

–  DevelopedbyTheNAVIGATEPsychopharmacologicalTreatmentCommi<ee.•  TheCommi<eeischairedbyDelbertG.Robinson,M.D.ChristophU.Correll,M.D.,BenKurian,M.D.,AlexanderL.Miller,M.D.,RonnyPipes,M.A.andNinaR.Schooler,Ph.D.contributedtothescien-ficcontentoftheManualandtheCOMPASSComputerDecisionSupportSystem.PrestonPark,MCSDledtheprogrammingteamandPatriciaMarcy,R.N.andCris-naGomesGonzalez,CCRPprovidedadministra-vesupport

ORALMEDICATIONS

•  An-psycho-cs:allhavesimilarefficacyexceptclozapine–  Benefits

•  Relieffromposi-vesymptoms•  Improvedmoodstability•  Decreasedanxiety•  Improvedsleep•  Relapsepreven-on:relapseratesare2-6foldhigheroffmedica-on

ORALMEDICATIONS

•  Firstgenera-onan-psycho-cs(FGAs,Typicals)– Higherriskofabnormalmovements

•  Secondgenera-onan-psycho-cs(SGAs,Atypicals)– Higherriskofweightgainandassociatedmetabolicsyndrome

CLOZAPINE•  consideredforpa-entswhohavepersistentposi-ve

symptomsabertrialsoftwoanApsychoAcs•  shouldbethetreatment,unlesscontraindicatedor

refused,forpa-entswithpersistentposi-vesymptomsabertrialsofthreean-psycho-cs.

•  Useislimitedbypoten-alforagranulocytosis–  Requiresweeklyblooddrawsfor6months,thenevery2weeksfor6months,thenevery4weeksaslongasthemedica-onistaken

CLOZAPINE– Earlieruseofclozapineinthemedica-onsequenceshouldbeconsideredforpa-entswithpersistentsuicidalidea-on.

– Priortoini-a-ngclozapinetreatmentforpersistentposi-vesymptoms,trialsofrisperidoneandolanzapine(andlongac-ngan-psycho-csforsuspectednonadherence)shouldbeconsidered.

ANTIDEPRESSANTS•  Depressivesymptomsverycommonlyco-occurwithafirst

episodeofschizophrenia.•  Depressivesymptomsmaybeacorepartoftheacuteillness.•  Thesesymptomsusuallyresolvewithan-psycho-c

monotherapyasthepsychosisremits(seeKoreenetal;AmJPsychiatry1993;150:1643-1648).

LONGACTINGINJECTABLES(LAI)•  Benefits–  Adherence:upto50%ofpa-entsstoptakingoralmedica-on

–  Decreasedratesofhospitaliza-on–  Superiortooralmedica-on

LONGACTINGINJECTABLES(LAI)

•  Op-ons– Allappeartobeequivalentinefficacy– Sideeffectprofilesandfrequencyofinjec-ondriveselec-on

LAIs

•  FirstGenera-onAn-psycho-cs(FGA)– Fluphenazine(Prolixin)givenevery4wks•  FluphenazineDecanoate

– Haloperidol(Haldol)givenevery4weeks•  HaloperiodolDecanoate

LAIs

•  SecondGenera-onAn-psycho-cs(SGA)– Aripiprazole(Abilify)•  Maintenaformula-ongivenevery4weeks•  NewerAristadaformula-oncanbegivenuptoevery6weeks

– Risperidone(Risperdal)•  Givenevery2weeks

LAIs

•  SecondGenera-onAn-psycho-cs(SGA)–  Paliperidone(Invega)

•  Sustennagivenevery4weeks,includesaloadingdosesodoesnotneedoverlapwithoralmedica-on

•  Trinzagivenevery12weeks– Olanzapine(Zyprexa)

•  Relprevv,requires3hoursofmonitoringpostinjec-onduetoriskofpostinjec-onsyndromeincludingconfusion,seda-on,agita-on,EPS

SUBTHRESHOLDPSYCHOSIS•  ApooledmetaanalysisfoundaNNTof7so

far…•  An-psycho-cmedica-onisnoteffec-ve

enoughatpreven-ngtransi-ontopsychosistojus-fyit’suse

•  Anditisnotanymoreeffec-vethantherapyinreducingpsycho-clikesymptoms–  (McGlashan2003,McGorry2002,Phillips2009,McGorry2013)

OmegaFaRyAcids•  Essen-alfa<yacidsneededforbraindevelopment•  Mayhelpreducesideeffectstoan-psycho-cs•  Decreasesriskofcardiovasculardisease

FISHOIL•  Omegafa<yacids– Ammingeretal,2010

•  76individuals,12-weekinterven-onperiodof1.2g/dPUFA(700mgEPA+480mgDHA)orplacebo,followedbya40-weekmonitoringperiod

•  2of41individuals(4.9%)intheomega-3groupand11of40(27.5%)intheplacebogrouptransi-onedtopsychosis

•  Omega-3TreatmentShowsLong-termPsychosisPrevenAon-Medscape-Aug20,2015

FISHOIL•  McGorryetal,2017•  Mul-sitestudyof304adults,840mgEPAand560mgofDHAfor6

months,allreceivedcogni-vebehavioralcasemanagement•  At12months,thetransi-onrateswere11.2%inthecontrolgroup

and11.5%intheω-3PUFAgroup•  FinalWord?Omega-3'sDon'tPreventTransiAontoPsychosis-Medscape-Nov30,2016

FISHOIL,butit’snatural•  “evidencefromanimalstudiesshowthatlargedosesofoxidisedlipidsmaycauseorgantoxicity,growthretarda-on,andacceleratedatherosclerosis.” -Albert, BB et al, Fish oil supplements in New Zealand are highly oxidised and do not meet label content of n-3 PUFA. Scientific Reports, January 2017.

VITAMINS

NMDARECEPTORMODULATORS•  Sarcosine•  N-AcetylCysteine•  D-serine•  Glycine– Allledtosmallimprovementswhenaddedtoan-psycho-csEXCEPTforclozapine

– Glycineworsenedsymptomsinindividualstreatedwithclozapine

BVITAMINS•  Ideaof“megavitamins”introducedinthe1950s•  ThereisnoconsistentevidencetosupporttheuseofBvitaminsinthetreatmentofschizophrenia

VITAMIND•  IndividualswithschizophreniaaremorelikelytobedeficientinVitaminD

•  ThereisnocurrentevidencetosuggestvitaminDsupplementa-onreducessymptomsofschizophrenia

VITAMINSA,CandE•  ThereisnocurrentevidencetosuggestvitaminA,CorEsupplementa-onreducessymptomsofschizophrenia

•  Toxicitycanoccur–  VitaminA:headaches,nausea,blurredvision,hairloss–  VitaminC:nausea,diarrhea,kidneystones–  VitaminE:nausea,diges-veproblems

SUPPLEMENTS•  Thereislimitedevidencetosupporttheuseofvitaminsupplementsinschizophrenia

•  Ahealthy,balanceddietthatlimitsprocessedfoodsisagoodgoalforeveryone

•  NMDAreceptormodulatorssuchassarcosineandNACcanprovidesomebenefitwhenaddedtoanan-psycho-c

QUESTIONS