Recovery in Schizophrenia

8/8/2019 Recovery in Schizophrenia

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R ECOVERY IN

SCHIZOPHRENIA AND

AMISULPRIDE

Dr.Surabhi VermaDr. G. K. Vankar

B.J. Medical college, Ahmdabad



ORGANIZATION

What is recovery?Evolution of recovery movement

Journey to recovery:rehabilitataionEvidence based treatmentsChanging role of psychiatrist

Additional issues



S chizophrenia is one of the mostdevastating and challenging of mentalillnesses.Common disorder with prevalence of 1%S chizophrenia is associated with highlydeleterious effects on social and

occupational functioning, independenceand integrationRisk of suicide is much higher thangeneral population



WHAT I S RECOVERY ?

Mental health recovery is a journeyof healing and transformation

enabling a person with a mentalhealth problem to live a meaningfullife in a community of his or herchoice while striving to achieve hisor her potential



WHAT I S RECOVERY ?

S hifting focus from ´illnessµ alone

to ´personµ Advocating for quality of lifeS ubjective experience

Participation in treatment





F U NDAMENTALCOMPONENT S OF RECOVERY

S elf directionLead ,control ,exercise choiceThemselves define goals

Individualized and person centreredRecovery based of persons strength,

resiliences,needs,preferences,experiences,cultural

backgroundEmpowerment Authority to choose among the options



HolisticEncompasses various aspects:mind ,body,spirit andcommunity

Non linearContinual growth ,occasional setbacks, and learning fromexperience

S trengths basedRecovery based on capabilities,resiliences,talents,copingskills

Peer supportMutual support

Provide each other with supportive relationships



RespectProtecting rights,eliminating

discrimination and stigma

ResponsibiltyPersonal responsibilty for their own

self care and recoveryIdentify coping strategies

HopeMotivating message of a better future



A PPROACHE S TO S CHIZOPHRENIA

Degree to which persons with mentalillness can recover is uncertainNo recoveryS ome recoverF ully recover

Most relaible indicator of long termoutcome is is unremitting psychosis in thefirst 2 years following its onset



VOL U TION O F RECOVERY MOVEMENT

1950·s ² introduction of antipsychotic treatment

1960 and 1970- civil rights movements among

the minoritiesrefused employment and educational

opportunitiesillness was embarssiningreintegration only by not revealing the fact

Anger against the ´psychiatric establishmentµ

Thomas S zasz - Antipsychiatry views



NAMI -1979supportive of psychiatric treatmentnow focus also on issues other than

psychiatric treatment

Greater attention to non psychiatric problems

Consumers and family members as coequalparticipants

Recognise metabolic syndrome





E VIDENCE BA S ED TREATMENT

Emerged in 1990 at McMaster U niversity inCanadaPORT funded to ´develop and disseminate

recommnedations for treatment of schizophrenia based on scientific eveidence...µconformance to psychosocial treatment was

lower than pharmacological recommendations

highlighting facilitators and barriers,including rules and regulationsEBT is integration of best research evidence

with clinical expertise and patient values



E VIDENCE BA S ED TREATMENT (CONT .)

15-20 yrs lag between what we know and whatwe do

Apprehension- interefere with clinical judgement and specific consumerconsiderationChallenge was to facilitate widespread

adoption of research based practicesQuality and accountabilityF inancial issues are biggest obstacles



Tool kits include introductoryvideos,practise demonstration videos, andworkbooks and manuals

Illness managemant and recovery

Assertive community treatmentF amily psychoeducationS upported employmentCo-occuring disorder :integrated dualdiagnosis treatment



ILLNE SS MANAGEMENT AND RECOVERY

Recovery strategiesPractical facts about mental illnessThe stress ²vulnerability model andstrategies for treatmentBuilding social supportU sing medication effectivelyReducing relapses and coping with stressCoping with problems and symptomsGetting needs met in the mental healthsystem



A SS ERTIVE COMM U NITY TREATMENT

S ymptom managementHousingF inances



F AMILY P S YCHOED U CATION

Learn about mental illnessMaster new ways of managing their mentalillnessReduce tension and stress within the familyProvide social support and encouragement toeach other

F ocus on the futureF ind ways for families and supported to helpconsumers in their recovery



S U PPORTED EMPLOYMENT

Eligibilty based on consumer choices andpreferencesS upported employment as an integrated

treatmentContinous follow-along supportsHelp with moving beyond the patient roleand developing new employment relatedroles



CO-OCC U RING DI S ORDER S ;INTEGRATED D U ALDIAGNO S IS TREATMENT

Individualized treatmentEducation about the illness

Case managementHelp with housingMoney management

Relationships and social supportCounseling



THE CHANGING ROLE S OF

P S YCHIATRI S TS

Recovery is possible and everyone has the potential to recover

Change from ´how can I relieve the symptoms ?µ to´How can I help you as a person in the world?µRemove obstacles to help consumer achieve his self-defined goals

Psychiatrist serves as the educatorMulti-disciplinary teamCommunication with primary care physicianPsychiatrist as an advocate



´T ravel companion than a travel agentµ

Listening to recovery storiesMaintaining longterm relationshipEmpatheticlistening,clarification,awareness of changes in subjectsF rom patient to partner

Acknowledge strengths

Doctor in charge modelF lexible boundariesEthical issues



S ide effectsS exual side effetcs

S hared decision making : ´Two experts ina room :The practioner and the clientµS igns of potential relapse



A DDITIONAL I SSU E S

S pirituality and religionS ense of self esteem and coping response

Also contribute to negative affectsanger at god

discouragement with religious attendancedifficulty in making conversation

insults by religious leadersBeliefs of leaders which are anti medication



Recovery

Experts(information)

Veterans(guidance)

Peers(emotionalsupport)



Peer support

Wellness recovery action plan(WRAP)developed by Mary Ellen Copeland

greater sense of control over their dailylivesattention to qualitywritten action plan



A MISULPRIDE



D OPAMINE P ATHWAYS



Dopaminepathways

From - To Controls Blockade of dopamine

receptors in this

pathway by Anti-psychotics

Mesolimbicdopamine pathway

Tegmentum toNAcc

Controls behavioralreactions such as

pleasure

sensations,rewards,

motivation,euphoria

Controls positivesymptoms like

delusions,

hallucinations &bizarre behavior.

Mesocorticaldopamine pathway

Tegmentum tofrontal cortex

Controls cognitionand normal mood

Worsens negativesymptoms,

depression andcognition

NAcc: Nucleus Accumbens ;



Dopamine pathways From - To Controls Blockade of dopamine

receptors in thispathway by Anti-

psychotics

Nigrostriataldopamine pathway

Substantia nigrato dorsal striatum

Controlsmovements

Producesmovement

disorders like EPS-akathisia, tremor,slow movement,

dystonia

Tuberoinfundibulardopamine pathway

Hypothalamus toanterior pituitary

gland

Controls prolactinsecretion

Induces endocrineS/E e.g.

galactorrhoea,amenorrhoea,gynecomastia,

sexual dysfunction

EP S : Extra-pyramidal symptoms



A MI SU LPRIDE - M E SOCORTICAL PATHWAY IMPROVE S NEGATIVE , DEPRE SS IVE AND COGNITIVES YMPTOM S

At low doses Amisulprideblocks the pre-synapticD3/D2 receptors in the mesocortical pathway.This increases the dopaminergic transmission.

Thus, improving the negative symptoms1,depressive 2 and cognitive symptoms.

1. Perrault et al. Encephale 1996 ;229spec issue 2):3-8

2. Gessa et al. Eur Psychiatry 1996 ;11(s3):123s-127s



-PATHWAY

CONTROL S PO S ITIVE S YMPTOM S

At doses of 400-800 mg/d, amisulpride blocksboth the pre- and post-synaptic D3/D2 receptorsin the mesolimbic pathway.

This blocks the dopaminergic transmission.Thus, controlling the positive symptoms.

Peuch A et al. Acta Psychiatr Scand 1998 ;98(1):65-72



RECEPTOR PRO F ILE

Lacks the combined antagonosm of 5HT2/D2receptors which usually defines ¶atypicality·Low doses : presynaptic

High dose : post synapticLittle affinity for other dopamine receptorsubtypesS erotonin

AdrenergicHistaminemuscarine



A MI SU LPRIDE ² N IGRO S TRIATALPATHWAY

M INIMAL EP S

Amisulpride has more affinity for D3 > D2receptors.

D3 receptors are absent in the nigrostriatalpathway.

Doses >1200 mg are required to block the post-synaptic D2 receptors in this pathway.

Therefore, amisulpride at recommended dosages(up to 1200 mg) cause minimal EP S .

Xiberas X et al. J Clin Psychopharmacol 2001 ;21(2):207-214



PHARMACOKINETIC S

Absorptionwithin 8-10 hours of oral administrationMetabolism

Minimal2 inactive metabolitesExcretion

Via urine

Elimination half-life -20 hours



INDICATION S

Acute and chronic schizophrenia

S pecial population:

Hepatic impairement : S tandard doseRenal impairement : dose reduction when

creatinne clearance <60 ml/min

Plasma concentration : 150-250 g/l with minimalEP S



A DVANTAGE S OF AMIL SU LPRIDE

Greater improvement in positive and negativesymptomsTorerabiltiy advantages

Less weight gainLow risk of drug ²drug interactionLess sedative effetcsDoes not increase BMI

F avourable lipid profileLower propensity to cause DM and metabolicsyndromes



S IDE E FF ECT S

Increase in prolactin levelsWeight gain

Acute dystonia

EP STremorsRigidityHypokinesia

Hypersalivation



A MI SU LPRIDE DO S AGE ALGORITHM

Acute episode:S evere and recurrent treated patients

Initial dose 800mg/d(upto 1200 mg/d for in-patients)

Mild-moderateOut-patient

Initial dose 400 mg/d

F irst episodeU ntreated patients

Initial dose 600mg/d



S HORT TERM F OLLOW U P

According to symptom evolution

S evere pts.

Reduce dose by 200mg/d

Mild- moderateContinue patients at same dose

F irst episodeIncrease dose by 200mg/d



M AINTENANCE

Modulation according to symptomsNo positive symptoms

Patients stable

Dose reduce by 100-200mg/d every 2-3 months

MAINTENANCE DO S E :200-400 mg/d(for predominantly negative symptoms: 200 mg/d)



THANK YOU.....

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Recovery in Schizophrenia