Schizophrenia & Related Psychotic Disorders · Schizophrenia & Related Psychotic Disorders Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum

Schizophrenia & Related Psychotic

DisordersAssessment; Differential Diagnosis;

Comorbidity

Heather I. Milliken, MDCM; FRCPC; CSPQ

Associate Professor, Department of Psychiatry, Dalhousie University

Psychiatrist, Nova Scotia Early Psychosis Program

Chair, Canadian Psychiatric Association

Continuing Professional Development Committee

Disclosure: Funding Support

(Past 2 Years)

• Clinical trials

• Janssen; Lundbeck; Otsuka

• Advisory boards:

• Janssen; Lundbeck; Otsuka;

• CME honoraria:

• Janssen

Learning Objectives

At the end of this presentation participants will be able to:

1. Describe the Canadian Schizophrenia Guidelines (2017)

2. Discuss the differential diagnosis for psychotic disorders

3. Describe the signs and symptoms of schizophrenia

4. Discuss the issues related to comorbid substance use disorders and schizophrenia with a focus on the upcoming legalization of cannabis

5. Describe the management of comorbid substance use disorders and schizophrenia with a focus on smoking cessation

Schizophrenia & Related

Psychotic Disorders

Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia

Spectrum and Other Psychotic Disorders

Canadian Journal of Psychiatry, Volume 62, Number 9, September 2017, 594 - 603

Canadian Guidelines: Development

• Goal: To provide evidence-based recommendations for the

assessment and treatment of schizophrenia and schizophrenia

spectrum disorders for use by mental health care professionals

• 9 working groups (child & adolescent and adult psychiatrists

specializing in schizophrenia & related psychotic disorders; general

psychiatrists; family physician; pharmacist; evidence based

medicine methodologist; 4 individuals with lived experience with

schizophrenia; Schizophrenia Society of Canada representative)

• Used the ADAPTE process

– Systematic approach using existing guidelines

– 6 relevant guidelines identified; modified to suit Canadian context

– Recommendations based on level of evidence :1++; High quality meta-

analyses; systematic reviews of RCTS; 2++; High quality systematic

reviews of case control or cohort studies; 3; Nonanalytic studies (case

reports; case series); 4; Expert opinion

– Graded based on level of evidence (A, B, C, D, De Novo)

Canadian Guidelines: Development

• Recommendations finalized at in-person

consensus meeting attended by members of

all working groups

• Recommendations launched at CPA 67th

Annual Conference, Ottawa, September

14th-16th 2017

• Recommendations published Canadian

Journal of Psychiatry, Volume 62, Number 9,

September 2017, 594 - 603


DisordersTerminology & Phases of Illness

Terminology

• Psychosis– Term which is used to refer to disorders in which there is a

loss of contact with reality

– Psychosis affects the ability to think, feel, perceive and act

• “Prodromal Psychosis”

– Onset of non-specific signs and symptoms (sub-threshold

symptoms) but before the onset of clearly identifiable

psychotic signs and symptoms.

– Historically has been a retrospective diagnosis made at

time of presentation with first episode psychosis

– 80-90% of individuals with schizophrenia retrospectively

report a prodromal period

Terminology

• First episode psychosis

– Refers to the initial diagnosis of a psychotic disorder in an individual’s lifetime

• Early psychosis

– Refers to early course of illness after initial diagnosis

• “Critical period”

– 1st 5 years after onset of illness

Pre-morbid

Phase

At risk/

Prodromal

Phase

Duration

of Untreated

PsychosisStable Phase

Diagnosis

Treatment

of First/Acute

Episode

Onset

Psychotic

Symptoms

Functional

Decline/

Subthreshold

Symptoms

Stabilization

Phase

Optimize

Recovery

Relapse

Prevention


DisordersAssessment:

Is it “Prodromal Psychosis”?

Common Prodromal Symptoms

In descending order of frequency

• Reduced concentration, attention

• Reduced drive and motivation, anergia

• Depressed mood

• Sleep disturbance

• Anxiety

• Social withdrawal

• Deterioration of role functioning

• Irritability

Prodromal Symptoms

• Epidemiological evidence of continuum of psychotic symptoms in general population1

• Commonly seen in a number of different psychiatric disorders

• Do not have sufficient specificity or sensitivity to be used as signs of risk of initial onset of psychosis in general population (low predictive validity)2

1 van OJ, Linscott RJ, Myin-Germeys I et al Psychol Med 2009; 39(2): 179-195

2Malla AK, Norman RM. Br J Psychiatry 1994; 164: 487-93

Detection of “At Clinical High

Risk” Individuals• Recent focus on prospectively defining “at clinical high

risk” individuals

• Strategies combine prodromal symptoms with other risk

factors

– Family history

– Transient psychotic symptoms or schizotypal personality

traits

– Decline in functioning

• Measures and criteria have been developed that can

reliably detect “at clinical high risk” individuals

– 25-35% risk of developing diagnosable psychotic illness**Fusi-Poli P, Bonoldi I, Yung AR et al. Arcg Gen Psychiatry 2012;693):

220-229

Assessment: PRIME Screen

• For use with help-seeking individuals

• Easy to administer self-report questionnaire that

can be completed in waiting room prior to

interview

• 12 items rating experiences within the past year

from 0 (definitely disagree) to 6 (definitely agree)

• Purpose is identification of individuals for whom

a more through assessment is indicated

– Score of at least 5 on 3 items or 6 on 1 item

Within the past year Definitely

disagree

Somewhat

disagree

Slightly

disagree

Not sure Slightly

agree

Somewhat

agree

Definitely

agree

I think that I have felt that there are odd or

unusual things going on that I can’t explain. 0 1 2 3 4 5 6

I think that I might be able to predict the

future 0 1 2 3 4 5 6

I may have felt that there could possibly be

something interrupting or controlling my

thoughts, feelings, or actions.

0 1 2 3 4 5 6

I have had the experience of doing

something differently because of my

superstitions.

0 1 2 3 4 5 6

I think that I may get confused at times

whether something I experience or perceive

may be real or may be just part of my

imagination or dreams.

0 1 2 3 4 5 6

I have thought that it might be possible that

other people can read my mind, or that I

can read other’s minds

0 1 2 3 4 5 6

I wonder if people may be planning to hurt

me or even may be about to hurt me 0 1 2 3 4 5 6

I believe that I have special natural or

supernatural gifts beyond my talents and

natural strengths

0 1 2 3 4 5 6

I think I might feel like my mind is “playing

tricks” on me 0 1 2 3 4 5 6

I have had the experience of hearing faint or

clear sounds of people or a person

mumbling or speaking when there is no one

near me

0 1 2 3 4 5 6

I think that I may hear my own thoughts being

said out loud 0 1 2 3 4 5 6

I have been concerned that I might be “going

crazy” 0 1 2 3 4 5 6

Assessment

• Answers to PRIME screen useful to guide

questions to elicit nature, frequency and

severity of symptoms; course of illness;

impact on functioning; substance use;

psychiatric and physical comorbidity

• If suspect prodromal psychosis refer to

NSEPP (ages 19-35) or IWK Youth

Psychosis Program (ages 12- 18)

Canadian Guidelines:

“At Clinical High Risk”

• Recommendation 1: Modified from NICE

Strong)

– If a person is distressed; decline in functioning

and has

• Transient or attenuated psychotic symptoms or other

signs/symptoms suggestive of possible psychosis or

schizophrenia or

• First degree relative with psychosis or schizophrenia

or schizotypy

– Refer ASAP for comprehensive assessment to

specialized EPP program or mental health

service


“At Clinical High Risk”

• Recommendation 2: (NICE Strong)

– A consultant psychiatrist or trained mental health

clinician with experience in “at clinical high risk

states” should carry out assessment

– Use of SIPS/SOPS or CAARMS

– Identify comorbid AXIS 1 conditions

• 73%

• Depression most common


DisordersAssessment:

First Episode Psychosis

Schizophrenia Spectrum Disorders

Canadian Guidelines: Assessment

• Recommendation 1: Assessment and Care

Planning (Level of evidence: C)

– Initial comprehensive multidisciplinary

assessment (including evaluation by a

psychiatrist)

Recommendation 1: Assessment and Care Planning

• Full mental status examination with particular

attention to symptoms of psychosis, negative

symptoms, general psychopathology, insight and

competence

• Risk of suicide and aggression

• Psychiatric history including prior diagnoses and

treatment; prior hospitalizations and emergency

room treatments


• For patients with previous episodes review

and document

– All treatments provided:

• Types; doses

• Duration of treatment

• Response to treatment

• Adherence

• Outcomes (including quantitative measures if

possible)


• History of substance use (tobacco; alcohol;

cannabis; hallucinogens; stimulants; opioids;

other)

• History of any neurodevelopmental or

psychosocial problems

• Current social and occupational (educational)

functioning

• Past and current physical health

– Accessibility to primary care

Recommendation 2: Assessment of First Episode Psychosis (De Novo Recommendation)

• See new patients within 2 weeks of referral

• Assessment as per recommendation 1 with

particular attention to:

– Onset of changes in behaviour and timing and

course of symptoms

– Relationship of substance use to onset of

symptoms

– Onset of decline in function (prognostic value)

– Duration of untreated psychosis (prognostic value)

Recommendation 3: Neuropsychological Assessment (De Novo Recommendation)

• Suggested in:

– First episode psychosis

– Poor response to treatment (treatment

resistance)

– Evidence of cognitive impairment

• MATRICS cognitive battery

• Interpretation of results optimally done by

neuropsychologist

• Predictor of functioning

• Focus of specific interventions

Recommendation 4: Brain Imaging (De Novo Recommendation)

• Not routinely recommended in first episode

psychosis

• Consider on case-by-case basis for first episode

and recurrent acute episodes

– History of signs and symptoms suggestive of

intracranial pathology

– History of head injury with loss of consciousness

Recommendation 5: Genetic Testing (De Novo Recommendation)

• Testing for 22q11.2 deletion syndrome if

characteristic features present


Differential Diagnosis

Types of psychotic disorders

PSYCHOSIS

DELUSIONS HALLUCINATIONS

ODD BEHAVIOUR

THOUGHT DISORDER

BRIEF PSYCHOSIS

SCHIZOPHRENIFORM

PSYCHOSIS

SCHIZOPHRENIAA

SCHIZO-

AFFECTIVE

DISORDER

BIPOLAR

DISORDER

PSYCHOTIC

DEPRESSION

SUBSTANCE

INDUCED

DUE TO A

MEDICAL

CONDITION

DELUSIONAL

DISORDER

PSYCHOSIS *NEC

*Psychosis NEC = Psychosis Not Elsewhere Classified

Differential Diagnosis: DSM 5Disorder Characteristics

Schizophrenia Meets Criteria A for symptoms; Signs of illness for ≥ 6 mo; Criteria A symptoms for ≥ 1 month; social/occupational dysfunction

Schizophreniform psychosis

Similar to schizophrenia except duration of illness of < 6 mo.

Schizoaffective disorder

Uninterrupted period of illness meeting Criteria A for Schizophrenia and criteria for Major Depression or Mania; Lifetime prevalence of > 2 wks. of Criteria A symptoms in absence of mood episode; Mood episode is present for > 50% of total duration of illness

Delusional disorder Delusions for > 1 mo and does not meet the criteria for schizophrenia2013-2014 31

Differential Diagnosis: DSM 5Disorder Characteristics

Brief psychotic disorder

Psychotic symptoms for > 1 day but < 1 mo; May or may not be related to stressor; full return to premorbid level of functioning

Substance-induced psychotic disorder

Delusions or hallucinations develop within 1 mo of substance intoxication or withdrawal; are etiologically related to substance use & are not better accounted for by another psychotic disorder

Psychotic disorder due to another medical condition

Delusions or hallucinations are direct physiologic consequence of another medical condition & develop in absence of delirium

Differential Diagnosis: DSM 5

Disorder Characteristics

Psychotic disorder not elsewhere classified

Psychotic symptoms present but criteria for specific disorder not met or there is insufficient or contradictory information

Major depression with psychotic features

Major depressive episode with mood congruent (most common) or mood incongruent psychotic symptoms

Bipolar disorder Manic episode with mood congruent (most common) or mood incongruent psychotic symptoms

Criteria A: Schizophrenia &

Schizophreniform Psychosis

• At least 2 of the following and at least 1 must

include 1-3:

1. Delusions

2. Hallucinations

3. Disorganized speech

4. Grossly abnormal psychomotor behaviour such

as catatonia

5. Negative symptoms

Signs and Symptoms of

Schizophrenia

1. Crow TJ. Br Med J 1980;280:66–8 2. Andreasen NC. Lancet 1995;346:477–8

It is now accepted

that psychosis

encompasses three

key domains of

disturbance1,2

Classification of Schizophrenia Symptoms

Negative

Positive

Cognitive

Positive Symptoms Include:

1. Hallucinations

2. Delusions

3. Thought Disorder

4. Disorganized or Bizarre behaviour

Positive Symptoms: Hallucinations

• Are sensory perceptions that occur in the absence of any real external stimulus

• Can affect any of the senses. The person may hear, see, smell, feel or taste sensations that are not there.

• The hallucinations are very real to the person and may be very distressing.

Positive Symptoms: Delusions

• Strongly held (fixed) false beliefs not shared by

other people

• Are believed to be very real even when the

person is told they are not.

Persecutory

Grandiose

Religious

Somatic

Delusions of

Reference

Delusions of

Control

Delusions

Positive Symptoms:

Thought Form Disorder

A person with psychosis:

• May think and communicate less logically.

• Have problems organizing their thoughts.

• May have thought that may be confused, sped up or slowed down.

• May have speech that reflects their thought process.

• May jump from one topic to the next.

• Stop in the middle of a sentence.

• Make up words.

• May simply be difficult to understand.

Positive Symptoms: Disorganized

or Bizarre Behaviour

People with psychosis may behave differently

than they usually do.

• May become extremely active or agitated, restless.

• May laugh inappropriately or display inappropriate

appearance, hygiene or conduct.

• May become guarded or untrusting (may stop eating

because of fear their food is poisoned).

• Hold body in strange postures or make odd gestures.

• Behaviours or experiences that have been

reduced or lost because of the illness. Problems getting motivated (avolition)

Problems taking pleasure in things (anhedonia)

Withdrawal from social relationships & activities

(asociality)

Problems getting words out (alogia)

Seeming flat and blunted

Negative Symptoms

• May be misinterpreted by caregivers as “laziness”

• May have greater effect on functioning than positive

symptoms

• More difficult to treat than positive symptoms & may

take longer to respond to treatment

• Have significant effect on caregivers Negative symptoms are one of the main predictors

of the level of burden and distress in a sample of 52 caregivers of

patients with schizophrenia1

More specifically, anhedonia/asociality and blunted affect were

strong predictors of burden in a sample

of 101 caregivers2

1.Dyck et al. Psychosomatic Medicine (1999).

2. Ukpong. Turk J Psychiatry (2012).

Negative Symptoms

Cognitive Symptoms

• Inability to focus and sustain attention. • Find it hard to filter out all the various stimuli in their

environment. (sounds, lights).

• Impaired concentration• Slower speed in focussing on & processing information and

then reacting

• Difficulty with memory especially remembering things they are told (verbal memory)

• Difficulty in organizing and planning activities (executive functions)

• For example to plan and manage the time and tasks of everyday life (i.e. schoolwork, money management).

Mood Symptoms

• Symptoms can include depersonalization; derealization; irritability; anger; anxiety; dysphoria & depression; suicidal ideation; excitement; mood swings

• Can occur at all phases of illness

Substance Use and Schizophrenia

Substance Use: Epidemiology

• ECA Study (Regier et al., 1990)– Lifetime prevalence of substance use

disorders in individuals with schizophrenia was 47% compared to 16.7% in general population

– Odds of having any substance use disorder 4.6 times greater in individuals with schizophrenia compared to general population

• National Comorbidity Study (Kessler et al. 1996)– 58% of persons with non-affective psychosis

had one or more lifetime substance use disorders


• The most common concurrent disorder among

individuals with schizophrenia is a substance use

disorder (SUD)

• Inpatients range from 48 - 72% (lifetime)

– Cantwell et al, 1999 (inpatients, first episode)

• 37% lifetime diagnosis of a SUD

• Outpatients range from 32 - 60% (lifetime)

– Fowler et al, 1998 (outpatients)

• 59.8% lifetime diagnosis of SUD

• Highest rates found in services attending to less

stable, more severe cases (ER; walk-in clinics)


• Prevalence rates in large epidemiological studies

(excluding nicotine and caffeine)

– 44.8% - 47%

• Cigarette smoking reported in 60% - 90%

– Rates declining

• Alcohol and cannabis most frequently used

substances (excluding nicotine and caffeine)

• Substance use is risk factor for developing

psychosis

– Met-analysis: Persons who used cannabis

developed psychosis 2.7 years earlier

• Negative impact on course and outcome

Schizophrenia & Substance Use Disorders

• Binge rather than regular use

– i.e. polymorphous, chaotic, opportunistic use

• Use is highly sensitive to environmental prompting

• Dependence more likely with the more accessible

drugs (nicotine, alcohol, cannabis, Rx drugs)

• Specific vulnerability for DA-agonist substances

(nicotine, cocaine)

– augment positive symptoms

– reduce negative symptoms

– counteract DA-blockade of antipsychotics

Substance Use and First Episode Psychosis

• Substance use is very common in first episode psychosis

• Lifetime use rates of up to 70%1

• Rates of substance use in first episode psychosis are higher than in the age comparable general population2

• Alcohol, cannabinoids and tobacco are the most commonly used substances

1. Power et al; Br J Psychiat 1998: 172:Suppl 33, 71-76

2. Van Mastrigt et al; Soc Psych Psych Epid 2004; 39:69-72

Substance Abuse and


• Substance abuse disorders are also very common in first episode psychosis patients

• Rates of substance abuse disorders in 203 consecutive admissions to the Calgary early psychosis program:*

– Any substance use disorder: 51%

– Alcohol use disorder: 35%

– Cannabis use disorder: 33%

*Addington J, Addington D; Acta Psychiat Scand 2007; 15(4):304-309

Cannabis

• Medical marijuana

– “Cure-all”?

• Upcoming legalization

– Harmless or harmful?

• Risk factor for schizophrenia

Cannabis: Rates of UseCanadian Alcohol & Drug Use Monitoring Survey

2012

– Rates of cannabis abuse/dependence exceeded rates of all

othersubstance abuse/dependence combined (6.8% vs. 4.0%)

55

All

Canadians

Youth

(15-24)

Adults

(25+)

Lifetime 41.5% 34.8% 42.8%

Past Year 10.2% 20.3% 8.4%

Age at

initiation

18.6 16.1 19

Cannabis Use

Canadian Alcohol & Drug Use Monitoring Survey

2012

• Increase in prevalence of cannabis use in

Canada over past 2 decades

– ~ 34% of Canadians (12 million) have used

cannabis in their lifetime

• Rates of cannabis abuse/dependence

exceed rates of all other substance

abuse/dependence combined

• 6.8% vs. 4.0%

Cannabis UseCanadian Alcohol & Drug Use Monitoring Survey

2012

• In Canada 12 month prevalence rate of cannabis use in youth (ages 11 – 15) is highest out of 29 countries1

• Canada: 28%; US: 23% (recreational use legal in Alaska, Colorado, Oregon, Washington, Washington DC); Netherlands: 17%

• 5% of all Canadian adolescents and 10% of Grade 12 students use pot daily

• Younger users (< age 16) smoke more often (~25 times/wk. & smoke more (~15 grams/wk)2

1United Nations Childrens’ Fund Study 20132Psychology of Addictive Behaviors 2012

Cannabis: Chemical Constituents

• 4 main cannabinoids in cannabis

– Delta-9 THC; Cannabidiol (CBD); Cannabinol

(CBN); Delta-8 THC

• Delta-9 THC

– Psychoactive constituent

• “Positive” effects: Euphoria

• Negative effects: Anxiety; panic attacks; paranoia;

acute psychosis

– Potency ↑ from 4.56% 1996 to 11.75% in 2008 (Burdoff et al; 2011)

– Constituted 1% of cannabis in 1960’s vs. 10-30%

today (Health Canada 2014)58

Shatter

• Very potent type of cannabis

• Concentration of THC ~ 80%

Synthetic Cannabinoids

• JWH-0184

– Analgesic compound acts on cannabinoid

receptors

– Effects similar to THC

– Component of various “street drugs” e.g.

“Spice”, “Kronic”, “Incense”

– Can cause psychosis

60

Cannabis: Effect on the Brain

• Cannabis acts on cannabinoid 1 and cannabinoid 2

endogenous brain receptors

• Receptors are widespread in both grey and white matter

– Involved in memory, mood and reward processing

• Endogenous cannabinoid system is still developing

during adolescence

– ↑ sensitivity to effects of cannabis on brain

development

• Effects on cortical development; neural migration;

connectivity; synaptogenesis; white matter development

(brain circuitry)

• Effects on dopamine

Cannabis: Effect on the Brain

• Effects peak at onset of adolescence decreasing

during adulthood

• Neuroimaging and neuropsychological studies have

demonstrated adverse effects of initiation of regular

cannabis use in adolescence

• Evidence of structural and functional brain

abnormalities (Psychopharmacology, 2013; Journal of Neuroscience

2014)

– Cognitive effects (↓ in IQ)

– ↑ risk with earlier age of use (<16 y.o.)

Cannabis: Effects

• Cannabis use disorders

– Addiction

• Cannabis induced psychosis

– Delusions or hallucinations develop within 1 mo. of substance intoxication or withdrawal

– Etiologically related to substance use

• ↑ risk for schizophrenia

Cannabis Use and Risk of Psychosis:

A Systematic Review*

• Included 35 longitudinal population based studies in meta-analysis

• Concluded that:

– Cannabis use increases the relative risk for psychotic disorders by 1.4

– Is a dose-response effect with an increased risk of 50-200% in the most frequent users

– In UK ~14% of psychotic disorders in young adults could be avoided if cannabis was never consumed

*Moore et al; Lancet 2007; 370:319-328

Cannabis Use and Risk of Psychosis

• Study* reviewed the evidence of cannabis as

a causal risk factor for psychosis

• Concluded that:

– Cannabis use in adolescence leads to a 2-3 X

increase in the relative risk for SZ in adulthood

– Cannabis use is not necessary nor sufficient

cause, but forms part of a causal constellation

– ~8% of schizophrenia could be avoided with the

elimination of cannabis use in the population

*Arseneault et al; Br J Psychiat 2004; 184:110-117


• Swedish longitudinal study

• Higher frequency of cannabis use associated

with increased risk of psychosis

• Risk increased 6 fold in heavy users

compared to non-users

– Heavy use defined as greater than 50

occasions by age 18


• Genetic vulnerability

• 3 polymorphisms for COMT gene

– Val/Val, Val/Met, Met/Met

• Individuals homozygous for wild type Val158

polymorphism vs. Met158 have higher activity enzyme resulting in faster dopamine breakdown (thus lower sustained prefrontal cortical synaptic levels of dopamine)

Gene Polymorphism and Cannabis Use:

Risk of Schizophreniform Psychosis

Adapted from Caspi et al, Biol Psychiatry 57:1117-27, 2005

0

2

4

6

8

10

12

14

met/met met/val val/valno yes no yes no yes Adolescent cannabis use

Genotype

Perc

ent

with D

isord

er

Legalization of Cannabis in Canada

Impact?

Cannabis Legalization:

March 19 2018

• The Trudeau government's proposals include:

– Restrictions on the colour of packaging and the depiction of branding

– Requirements for mandatory warning labels

– Ban on packaging designed to appeal to young people.

• Mandatory warning labels

– Require producers to include one of 14 mandatory health warnings on each package.

– Producers and/or cultivators would be required to make sure all messages appear on their products by rotating the various warnings "on each package of each brand name with equal frequency in a calendar year."


Warning Labels: March 19 2018


March 19 2018

XXIX W.O. MCCORMICK

ACADEMIC DAY CONFERENCE

Psychiatric Aspects of Cannabis

Friday, April 27, 2018

Marriott Halifax Harbourfront

www.psych.dal.ca

http://www.psych.dal.ca/

Canadian Schizophrenia Guidelines:Schizophrenia and Other Psychotic

Disorders with Coexisting Substance Use Disorders

David Crockford MD, FRCPC & Donald Addington MD

Canadian Journal of Psychiatry, Volume 62, Number 9, September 2017, 624 - 634


Substance Use Disorders

• 43 recommendations

• Recommendation 1: (NICE STRONG)

– Importance of engagement

– Direct, nonjudgmental approach

– Motivational interviewing techniques

– Awareness of likelihood of denial of psychosis,

substance use or both

• Stigma


Substance Use Disorders• Recommendation 9:

– Adults and young people with psychosis and coexisting

substance use should not be excluded from age appropriate

mental health care because of substance use disorder

• Recommendation 10:

– Adults and young people with psychosis and coexisting

substance use should not be excluded from age appropriate

substance use services because of psychosis

• Recommendation 11: (Modified from NICE STRONG)

– For most adults and young people with psychosis and

substance use disorder treatment for both conditions

should be provided by mental health care professionals


Tobacco Use Disorders• Recommendation 21: (NICE STRONG)

– Offer help to stop smoking even if previous attempts have

been unsuccessful

– Be aware of potentially significant effect of reducing cigarette

smoking on metabolism of other drugs (olanzapine;

clozapine)

• Recommendation 22: Smoking cessation strategies

(NICE STRONG)

– Nicotine replacement therapies (psychosis or schizophrenia)

– Buproprion (schizophrenia)

– Varenicline (psychosis or schizophrenia)

– Increased risk of neuropsychiatric symptoms with buproprion

and varenicline esp. in 1st 2-3 wks.

• Need to warn patients and monitor closely


Smoking Cessation Strategies• Strong evidence to support benefits of smoking cessation

strategies in schizophrenia1

• Most effective when patients stable and motivated

– Precontemplative or contemplative: Motivational interviewing

– Preparatory or action stages: Psychosocial counseling;

Pharmacologic treatments

• NRTs well tolerated but limited evidence of benefit1, 2

• Buproprion:

– Most evidence for benefit in schizophrenia1,2

– Monitor for sleep impairment, suicidality and reemergence of

psychosis

• 1 TsoiDT, Porwai M, Webster AC Cochrane Databse Syst. Rev.

2013;(2):CDOO7253

• 2 Tidley JW, Miller ME BMJ. 2015;351: h4065


Smoking Cessation Strategies• Varenicline

– Greatest efficacy in individuals without schizophrenia

– Recommended as second-line to buproprion in

schizophrenia1,2

– Limited evidence of increased risk of suicidality or

reemergence of psychotic symptoms but need to monitor

closely3

• 1 TsoiDT, Porwai M, Webster AC Cochrane Databse Syst. Rev.

2013;(2):CDOO7253

• 2 Tidley JW, Miller ME BMJ. 2015;351: h4065

• 3 Thomas KH, Martin RM, Knipe DW et al. BMJ 2015;350:h1109

Resources

• PDF copy of today’s slides:

– http://cme.medicine.dal.ca/chp.htm

– Will be available for one month

• Canadian Schizophrenia Guidelines

– The Canadian Journal of Psychiatry September 2017, Volume 62, Number 9

– http://journals.sagepub.com/toc/cpab/62/9

• Milliken H.I. “Psychoses” in Compendium of Therapeutic Choices 2017 Edition

– https://www.pharmacists.ca/products-services/therapeutic-choices/

http://cme.medicine.dal.ca/chp.htm

http://journals.sagepub.com/toc/cpab/62/9

https://www.pharmacists.ca/products-services/therapeutic-choices/

Evaluation

https://surveys.dal.ca.opinio/s?s=40232

https://surveys.dal.ca/opinio/s?s=40232

Suggested Future Topics

• “Management of Schizophrenia with Comorbid Physical Health Conditions”

• “Antipsychotic Polypharmacy: What Are We Treating?”

Documents

Schizophrenia & Related Psychotic Disorders · Schizophrenia & Related Psychotic Disorders Canadian Guidelines for the Assessment and Diagnosis of Patients with Schizophrenia Spectrum