MANAGEMENT OF SCHIZOPHRENIABY: DR.SWATI ARORAJR2

WHAT IS SCHIZOPHRENIA ?

• The schizophrenic disorders are characterized in general by fundamental and characteristic distortions of thinking and perception, and by inappropriate or blunted affect.

• Clear consciousness and intellectual capacity are usually maintained, although certain cognitive deficits may evolve in the course of time.

WHAT IS SCHIZOPHRENIA ?

• Schizophrenia encompasses:

Positive Symptoms – Hallucinations & DelusionsNegative Symptoms – Lack of motivation , poverty of

speechCognitive Deficits – Impairment in attention , memory

and problem solving Psychosocial obstacles – Poor or lacking social

relationships , unemployment , high risk of substance abuse , increased risk of homelessness , strain in family relations

MANAGEMENT

DIAGNOSTIC EVALUATION TREATMENT

HISTORYEXAMINATION

MSEINVESTIGATION

PHARMACO-LOGICAL

NON-PHARMACOLOGICAL

COMBINATION

PHASES OF TREATMENT IN SCHIZOPHRENIA• ACUTE PHASE - characterized by psychotic symptoms that

require immediate clinical attention.

Treatment during this phase focuses on alleviating the most severe psychotic symptoms.

Usually last from 4 to 8 weeks.

Acute schizophrenia is typically associated with severe agitation, which can result from such symptoms as frightening delusions ,hallucinations or suspiciousness or from other causes ,including stimulant abuse.

• STABLIZATION PHASE:In which acute symptoms have been controlled ,but patients

remain at risk for relapse if treatment is interrupted or if the patients are exposed to stress.

During this phase, treatment focuses on consolidating therapeutic gains, with similar treatments as those used in the acute stage.

This phase last as long as 6 months following recovery from acute symptoms.

• STABLE OR MAINTANENCE PHASE-When illness is either in a relative stage of remission or

symptomatically stable.Goals during this phase are to prevent psychotic relapse or

exacerbations and to assist patients in improving their level of functioning.

REASON FOR HOSPITALIZATION

INDICATED FOR:• For Diagnostic purposes• For Stabilization of medications• For patients /relatives safety(suicidal and homicidal ideation)• For grossly disorganized or inappropriate behaviour (including the inability to take care of basic needs such as food , clothing and shelter)

Hospital treatment plans should be oriented towards practical issues of self –care , quality of life ,employment and social relationships

ASSESSMENT• Before starting medication patients should receive a physical

examination with neurological examination ,a mental status examination, and a laboratory evaluation.

• Blood tests for complete blood count (CBC),electrolytes , fasting glucose , lipid profile , liver , renal , and thyroid function should be ordered.

• Other evaluations that should be considered are pregnancy test in women, and hiv test.

• Individuals with schizophrenia are at a higher risk for cardiovascular disease than the population at large.

• RATING SCALES USED FOR ASSESMENT OF SYMPTOMS OF SCIZOPHRENIA: Should be applied at baseline.

• Following scales can be used:

PANSS (Positive and negative symptoms scale) SANS(Scale for the assessment of negative symptoms)SAPS(scale for assessment of positive symptoms)BPRS(brief psychiatric rating scale)

• Treatment of schizophrenia:Pharmacological

Non pharmacological

Combined

• Antipsychotic medications-the mainstay of pharmacological treatment –are effective for reducing the impact of psychotic symptoms such as hallucinations, delusions and suspiciousness.

• In many symptoms can be completely eliminated , once these symptoms are minimized , medications can decrease the likelihood that symptoms will recur.

SELECTION OF AN ANTIPSYCHOTIC DRUG

Antipsychotics are categorized into two main groups

1st generation (FGAs) 2nd generation(SGAs)or dopamine receptor antagonists(DAs) serotonin dopamine antagonist (SDAs)

• FGAs are further categorized as being low, mid or high potency.• Higher potency drugs – more specificity and greater affinity for D2

receptor and greater tendency to cause EPS.• Lower potency drugs are less likely to cause EPS, but likely to cause

hypotension, sedation, and anticholinergic effects.• Basically selection of drug is based on individual patient profile.

• SELECTION OF DRUGS DEPENDS ON:

AvailabilitySide effect profileSymptomsSpecifics contraindicationsFamiliarityCost

COMPARISONS OF ANTIPSYCHOTICS

• CUtLASS (cost utility of latest antipsychotic drugs in schizophrenia) and

• CATIE ( clinical antipsychotic trial of intervention effectiveness) both studies did not found substantial advantages in overall tolerability , acceptability, and effectiveness for SGAs over FGAs.

DRUG MINIMUM EFFECTIVE DOSE1ST EPISODE

MINIMUM EFFECTIVE DOSE MULTIPLE EPISODE

MAXIMUM EFFECTIVE DOSE

FGAs

Chlorpromazine 200 mg 300 mg 1000 mg /day

Haloperidol 2 mg 4 mg 20 mg /day

Sulpiride 400 mg 800 mg 2400 mg /day

Trifluoperazine 10 mg 15 mg 30 mg /day

SGAs

Amisulpride 400 mg Unclear ? 400mg 1200 mg /day

Aripiprazole 10 mg 10 mg 30 mg/day

Asenapine 10 mg 10 mg 20 mg (sublingual)

Olanzapine 5 mg 7.5 mg 20 mg/day

Quetiapine 150 mg 300 mg 750 mg /day

Risperidone 2 mg 3 mg 16 mg/day

Ziprasidone 40 mg 80 mg 160 mg/day

EQUIVALENT DOSESDRUG EQUIVALENT DOSE

chlorpromazine 100 mg/kg

Haloperidol 2 mg/kg

Trifluoperazine 5 mg/kg

Olanzapine 7.5 -10 mg

Risperidone 3 mg

Queitiapine 300 mg

Aripiprazole 10 mg

TREATMENT OF FIRST EPISODE SCHIZOPHRENIA

Either ;Agree choice of antipsychotic with patient

Or, If not possible;Start 2nd generation antipsychotic

Titrate , if necessary , to minimum affective dose

Adjust dose according to response and tolerability

Assess over 2-3 weeks

Change drug and follow above process consider use of either

a SGAs or a FGAs

If poor compliance related to poor tolerability, discuss with

pt and change the drug.If poor compliance related to other factors, consider early

use of depot.

Continue at dose established as effective

Clozapine

(THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12TH EDITION)

effective Not effectiveNot tolerated or

poor compliance

Not effective

TREATMENT OF RELAPSE OR ACUTE EXACERBATIONS

(Full adherence to medication confirmed)

Investigate social or psychological precipitantsProvide appropriate support and or therapy.

Continue usual drug treatment

Add-short term sedative Or

Switch to different, acceptable discuss choice with pts and assess over at least 6 weeks

Switch to clozapine• (THE MAUDSLEY,PRESCRIBING GUIDELINES IN PSYCHIATRY,12TH EDITION)

Acute drug treatment required

Treatment ineffective

TREATMENT OF RELAPSE OR ACUTE EXACERBATIONS

(ADHERENCE DOUBTFUL OR KNOWN TO BE POOR)

• Confused or • disorganised

Lack of insight poorly tolerated t/tOr support

Investigate reasons for poor adherence

Simply drug regimen Reduce anticholinergic load Consider depot

Discuss with the patient consider depot antipsychotics

Discuss with patient switch to acceptable drug

• First generation drugs may be slightly less efficacious than some SGAs. FGAs should be probably be reserved for 2nd line use because of the possibility of poorer outcome compared with FGAs and higher risk of movement disorder ,particularly tardive dyskinesia.

• Choice is, however, based largely on comparative adverse effect profile and relative toxicity. patients seem able to make informed choices based on these factors, although in practice they may only very rarely be involved in drug choice.

• Where there is prior treatment failure olanzapine or risperidone may be better options than quetiapine.

• Olanzapine because of the wealth of evidence suggesting slight superiority over other antipsychotics , should always be tried before clozapine unless contraindicated.

• Where there is confirmed treatment resistance evidence supporting the use of clozapine is overwhelming.

MANAGING AGITATION IN ACUTE PSYCHOSIS

• Agitation in acute schizophrenia can result from disturbing psychotic symptoms such as frightening delusions or suspiciousness or from other including stimulants abuse or EPS, particularly akathisia.

• If pts are receiving agent associated with EPS, usually a first generation , a trial with anticholinergic anti-parkinsonism medication or propranolol may be helpful in making the discrimination.

• An advantage of an antipsychotic is that a single i.m injection of haloperidol, fluphenazine ,olanzapine , aripiprazole or ziprasidone will often result in calming without an excess of sedation.

• Intramuscular ziprasidone, aripiprazole , and olanzapine are similar to their counterparts in not causing substantial EPS during acute treatment.

• Rapidly dissolving oral olanzapine, risperidone or aripiprazole may also be helpful as an alternative to an intramuscular injection.

• Benzodiazapines are also effective for agitation during psychosis.

• Lorazepam has the advantage of reliable absorption when administered either orally or intramuscularly.

• The combination of lorazepam + antipsychotic found safer and more effective than large doses of DAs in controlling excitement and motor agitation.

ACUTE MANGEMENT OF PSYCHOTIC EPISODE

• With exception of Canadian guidelines ,all other recommend the use of either SGAs (1st line) or FGAs (2nd line) as standard drugs.

• The Canadian guidelines only recommend the use of SGAs such as olanzapine , risperidone or quetiapine.

• Based on recent evidence, the unified guidelines recommends the use of either 1st or 2nd generation antipsychotics based on clinical and economic needs at a dosage of 300-1000 chlorpromazine equivalents.

PROPHYLAXIS OF SCHIZOPHRENIA

• All guidelines recommend the continued use of the same antipsychotic used to manage the acute episode for prophylaxis.

• In longer term a balance needs to be made between effectiveness and adverse-effects.

• Very low doses increase the risk of psychotic relapse.

HOW AND WHEN TO STOP?

• Decision to stop antipsychotic drugs require a through risk- benefit analysis for each pt.

• Withdrawal of drug after long term t/t should be gradual and closely monitored.

• The relapse rate in 1st 6months after abrupt withdrawal is double that seen after gradual withdrawal (slow taper down over at least 3wks for oral antipsychotics or abrupt stopping of depot preparation)

DURATION OF PHARMACOTHERAPY

• The APA and Canadian guidelines recommended similar duration of acute( , stabilization ,and stable phase treatment.

• The NICE and Maudsley guidelines recommend acute treatment to last 2 years and give no specific recommendation on duration of prophylaxis.

• The unified guidelines recommends: The acute phase treatment : last at least 12 weeks,The stabilization phase :last at least 12 months,The stable phase : last at least 2 years for a first episode and

5 years to lifetime for multiple episodes.

NON-PHARMACOLOGICAL TREATMENT

• Often pharmacotherapy alone is not enough to address the devastating functional consequences of this condition and most individuals with schizophrenia continue to experience significant social, functional, and vocational disability leading to a poor quality of life.

• This highlights the critical importance of the use of psychosocial interventions to help further the recovery of people with schizophrenia.

The Schizophrenia Patient Outcomes Research Team (PORT) provide recommendations on current evidence-based psychosocial treatment interventions for persons with schizophrenia.

2009 PORT review produced psychosocial treatment recommendations:

1. Family-based services, 2. Token economy, 3. Skills training4. Assertive community treatment, 5. Supported employment, 6. Cognitive behavioural therapy,

SOCIAL SKILL TRAINING

• Persons with schizophrenia who have skill deficits such as problems with social skills or activities of daily living should be offered skills training.

• In addition to psychotic symptoms seen in patient with schizophrenia , other noticeable symptoms involve:

The way person relate to othersIncluding poor eye contactUnusual delay in response Odd facial expressionsLack of spontaneity in social situations etc.

• Behavioural skills training addresses these behaviours through the use of video tapes of others and of the pt, role playing, home work assignments for specific skills being practiced.

• Social skill training has been shown to reduce relapse rates as measured by the need for hospitalization.

TOKEN ECONOMY INTERVENTIONS

• A token economy is a system of behavior modification based on the principles of operant conditioning.

• Emphasis is on reinforcing positive behaviour by awarding "tokens" for meeting positive behavioural goals.

• Patients earn tokens, which they can exchange for privileges, such as time watching television or walks on the hospital grounds, by completing assigned duties (such as making their beds) or even just by engaging in appropriate conversations with others

• Advantages of token economy• tokens are flexible• tokens can be used for several needs and therefore saturation is

improbable• there is no delay giving tokens after the desired behavior has been

shown• mostly the token economy is well-regulated thus it is easy for

therapists to decide whether they have to give a token or not

FAMILY INTERVENTIONS• PORT Recommendation. Persons with schizophrenia who have on-

going contact with their families, including relatives and significant others, should be offered a family intervention that lasts at least 6–9 months.

• ‘Family’ includes people who have a significant emotional connection to the service user, such as parents, siblings and partners.

• The goals of family-based services are to increase understanding of the disorder, reduce levels of expressed emotion, reduce feelings of isolation, stress, and burden of family members, foster development of coping skills, and develop an ongoing collaborative relationship between family and

clinicians.

AIMS OF FAMILY INTERVENTIONS: To help families cope with their relatives’ problems more

effectively. Collaboration with relatives who care for the person with

schizophrenia. Reducing the emotional stress and burden on relatives and

within the family unit. Enhancement of relatives' ability to anticipate and solve

problems. Reducing expressions of anger and guilt by the family . Maintenance of reasonable expectations for patient

performance Attainment of desirable change in relatives' behavior and belief

system

FAMILY INTERVENTIONS

This can be started either during the acute phase or later, including in inpatient settings.Family intervention should:• include the person with schizophrenia if practical.• be carried out for between 3 months and 1 year• include at least ten planned sessions• take account of the whole family’s preference for either single-

family intervention or multi-family group intervention• take account of the relationship between the main carer and

the person with schizophrenia• have a specific supportive, educational or treatment

function and include negotiated problem solving or crisis management work.

FAMILY INTERVENTIONS• For whom a longer intervention is not feasible or acceptable

a shorter intervention that is at least 4 sessions in length should be offered to persons with schizophrenia. • Characteristics of the briefer interventions include education,

training, and support.• Proposed as adjuncts rather than alternatives to drug

treatments• The selection of a family intervention should be guided by

collaborative decision making among the patient, family, and clinician.

Family interventions have been found to significantly reduce rates of relapse and re-hospitalization

Possible benefits for patients include :• reduced psychiatric symptoms, • improved treatment adherence, • improved functional and vocational status, and • greater satisfaction with treatment.

Positive family outcomes include : • reduced family burden and • increased satisfaction with family relationships.

PSYCHOEDUCATION

Implies provision of information and education to a service user with a severe and enduring mental illness, including schizophrenia, about the diagnosis, its treatment, appropriate resources, prognosis, common coping strategies and rights.

Psychoeducation involves quite lengthy treatment and runs into management strategies, coping techniques and role-playing skills. It is commonly offered in a group format. Psychoeducational interventions were defined as:• any programme involving interaction between an information

provider and service users or their carers, which has the primary aim of offering information about the condition; and

• the provision of support and management strategies to service users and carers.

To be considered as well defined, the educational strategy should be tailored to the need of individuals or carers.

ASSERTIVE COMMUNITY TREATMENT

PORT Recommendation: Systems of care serving persons with schizophrenia should include a program of assertive community treatment (ACT).

It should be provided to individuals who are at risk for repeated hospitalizations or have recent homelessness. The key elements of ACT include • A multidisciplinary team including a medication prescriber, • A shared caseload among team members, • Direct service provision by team members, • A high frequency of patient contact, • Low patient-to-staff ratios (usually 10–15 patients per member), and • Outreach to patients in the community.

• In ACT patients are diverted to the care of a community-based, multidisciplinary team including psychiatrists, nurses, and social workers.

• The team carries small case loads and sees patients frequently in their own homes or in the workplace and deliver all services when and where needed by the pateint,24hrs a day,7 days a week.

• This mobile and intensive intervention that provides treatment , rehabilitation and support activities.

• These include home delivery of medications, monitoring of mental and physical health, in vivo social skills and frequent contact with the family members.

• There is high staff-to-patient ratio (1:12) ACT programs can effectively decrease the risk of hospitalization for persons with schizophrenia , but they are labor-intensive and expensive programs to administer.

• Teams care for the full range of acutely ill patients, including those who are suicidal, potentially violent or reluctant service users.

• ACT teams also place particular emphasis on medication adherence

• ACT has the same aims as case management but whereas under case management great emphasis is placed on individual responsibility of case managers for clients, ACT by contrast emphasizes team-working.

• Care is provided at, as far as possible.

• ACT has been found to significantly reduce hospitalizations and homelessness among individuals with schizophrenia.

COGNITIVE BEHAVIOUR THERAPY

• Persons with schizophrenia who have residual psychotic symptoms while receiving adequate pharmacotherapy should be offered adjunctive cognitive behaviourally oriented psychotherapy .

• The key elements of this intervention include:A shared understanding of the illness between the patient and

the therapist.The identification of target symptoms.The development of specific cognitive and behavioural

strategies to cope with these symptoms.

COGNITIVE BEHAVIOUR INTERVENTIONS

• There is evidence for the effectiveness of CBT in the treatment of several forms of psychopathology, including anxiety and affective disorders. • Controlled studies have shown benefits of CBT in reducing the

severity of delusions, hallucinations, positive symptoms, negative symptoms, and overall symptoms and in improving social functioning among individuals with schizophrenia who have persistent psychotic symptoms despite adequate pharmacotherapy

COGNITIVE BEHAVIORAL THERAPY

CBT focuses on : Helping individuals recognize delusional thoughts and

testing of key beliefs that may be supporting delusional thinking

Helping in recognizing early signs of relapse and development of problem-solving strategies to reduce relapse.

learning and strengthening skills for coping with and reducing symptoms and stress.

Identification of factors exacerbating symptoms. development of a collaborative understanding of the

nature of the illness, which encourages the patient’s active involvement in treatment

VOCATIONAL REHABILITATION• Employment rates among individuals with schizophrenia and

related disorders are substantially lower than in the general population. • Employment status appears likely to have substantial impact on

the economic circumstances of many patients and influences many aspects of quality of life.• Two main classes of programes have evolved to help people stay in

employment:• pre-vocational training • supported employment

• There is no evidence that employment obtained with these methods leads to increased stress or exacerbation of symptoms • There is some, evidence that employment status may have positive

impacts on self-esteem, on aspects of psychiatric symptoms, and on the likelihood of relapse.

• In Prevocational training participants undergo a period of extensive preparation before being encouraged to seek competitive employment. The person is supported in some form of sheltered work before entering real-world employment

• In Supported employment the emphasis is on placing individuals in competitive employment sooner and offering considerable after-placement job-support services from a team of professionals.

• There is strong evidence that supported employment is superior to prevocational training, improving employment prospects and hours per week spent in competitive employment significantly more when the two are compared.(NICE 2010)

COMPARISION OF GUIDELINES FOR MANAGEMENT OF SCHIZOPHRENIA

APA CANADIAN NICE MAUDSLEY

ACUTE T/T OF 1ST EPISODE

SGAs/FGAs OlanzapineRisperidoneQuetiapine

SGAs/FGAs SGAs/FGAs

PROPHYLAXIS To continue same antipsychotic

To continue same antipsychotic

To continue same antipsychotic

To continue same antipsychotic

DURATION ACUTE:4 TO 8 wks.STABILIZATION: upto 6 months.STABLE :upto 1 to 1.5yrs in 1st episode;5 to 10 yrs in case of 2 or more episode & indefinite for multiple prior episodes or more than 2 episodes in 5yrs.

ACUTE PHASE:6 to 12 wksSTABILIZATION PHASE:1 YrSTABLE PHASE: upto 2 yrs in 1st episode and upto 5yrs in case of multiple episodes.

Acute treatment to last 2yrs .No duration of long term treatment indicated

Same as NICE

APA CANADIAN NICE MAUDSLEY

PSYCHOSOCIAL MANAGEMENT

Family psycho-education (>9 months),Assertive community treatment,supported employment,social skills training and CBT ( 16-20 sessions)

Supported employment, family psycho-education,skills training, and CBT

CBT(16-sessions)/FFT(10 sessions)/arts therapy/supported employment

No recommendations

REFERENCES• Kaplan and Sadock’s Comprehensive textbook of psychiatry,9th

edition,Volume 1 Chapter 12,pg 1645-1652 and pg 1693-1733.

• Kaplan and Sadock’s Synopsis of Psychiatry Behavioral Sciences/Clinical Psychiatry,11th edition,chapter 13,pg.no 488-497.

• The Maudsley prescribing guidelines in psychiatry, 12th edition,chapter 2 ,pg. no 15-77.

• American Psychiatric Association. Practice Guideline for the Treatment of Patients With Schizophrenia.

• Robert w. buchanan et al,the schizophrenia port psychopharmacological treatment recommendations and summary statements, schizophr bull.2010 jan;36(1):71-93.

• S.saddichha and santosh k. chaturvedi,Clinical practice guidelines in psychiatry: more confusion than clarity? A critical review and recommendation of a unified guideline.ISRN psychiatry,vol.2014.

THANK YOU

APA CANADIAN NICE MAUDSLEY UNIFIED

PSYCHOSOCIAL MANAGEMENT

Family psycho-education (>9 months),Assertive community treatment,supported employment,social skills training and CBT ( 16-20 sessions)

Supported employment, family psycho-education,skills training, and CBT

CBT(16-sessions)/FFT(10 sessions)/arts therapy/supported employment

No recommendations

Family psycho-education (>9months)Assertive community treatment,supported employment,social skill training and CBT( 16-20 sessions)

APA CANADIAN NICE MAUDSLEY UNIFIED

ACUTE T/T OF 1ST EPISODE

SGAs/FGAs OlanzapineRisperidoneQuetiapine

SGAs/FGAs SGAs/FGAs SGAs/FGAs

PROPHYLAXIS To continue same antipsychotic

To continue same antipsychotic

To continue same antipsychotic

To continue same antipsychotic

To continue same antipsychotic

DURATION ACUTE:4 TO 8 wks.STABILIZATION: upto 6 months.STABLE :upto 1 to 1.5yrs in 1st episode;5 to 10 yrs in case of 2 or more episode & indefinite for multiple prior episodes or more than 2 episodes in 5yrs.

ACUTE PHASE:6 to 12 wksSTABILIZATION PHASE:1 YrSTABLE PHASE: upto 2 yrs in 1st episode and upto 5yrs in case of multiple episodes.

Acute treatment to last 2yrs .No duration of long term treatment indicated

Same as NICE ACUTE PHASE: upto 12 wks STABILIZATION PHASE:upto 12 monthsSTABLE PHASE:2yrs for 1st and 5 yrs to life time for subsequent episodes.