Antipsychotic Prescribing Erin Turner 2/3/16

Aims To increase confidence in prescribing antipsychotic medication To improve understanding of choice of medication Consider monitoring requirements- and who should do this.

History and Benefits of AP medication Mode of action FGA vs SGA Side effects FGA vs SGA Choice of medication Goals of Treatment Maintenance vs targeted therapy Monitoring requirements Questions

Why are Antipsychotics so misunderstood? CPZ discovered 1952 Strong Anti Psychiatry movement Historically high doses used with resulting stigmatising side effects

Benefits of Antipsychotics Instils hope of recovery Reduction in intensity of hallucinations, delusions, thought disorder Improvement in sleep, appetite and concentration Minimisation of distress (for sufferer and families) Harm reduction- self harm, suicide, homicide Reduction in rates of hospital admission Reduction in number of MHA assessments and detention rates Asylum closure

Classification AP FGA Chlorpromazine Haloperidol Flupenthixol Zuclopenthixol SGA Risperidone Olanzapine Quetiapine Amisulpiride Aripiprazole Clozapine

FGA Mechanism Action D2 Blockade

SGA Mechanism Action D2/5HT2A antagonism

Side effect profile FGA EPSEs- Parkinsonism - Akathesia - Dystonias Tardive Dyskinesia Hyperprolactinaemia SGA Metabolic Syndrome -Central Obesity -Hypertension -Dyslipideaemia -Insulin Resistance

EPSEs

Which Antipsychotic? FGA vs SGA Meta analysis- FGAs and SGAs equally effective - varied tolerability - Clozapine most effective However FEP increased sensitivity EPSEs therefore SGA first line

Try to match AP to desired Side Effect eg Olanzapine- wt gain and sedation/hypnotic Risperidone- less wt gain/more EPSEs Quetiapine- Affective Psychosis Aripiprazole-less wt gain/non sedative Clozapine- Rx Res Consider IM vs Oral

Treatment Goals Reduce DUP (Duration Untreated Psychosis) Rapidly reduce distress Symptomatic resolution Relapse prevention Side effect minimisation AP treatment part of a wider holistic biopsychosocial management plan

Reduction of distress Benzodiazepines effective- may allow slower titration AP Sedative effect of AP helpful- effects seen in days Reassurance essential Offer hope

Symptom Resolution FEP > 80% effective Positive symptoms- delusions, hallucinations, thought disorder Time to effect usually within 2-4 weeks; may be months Complete symptom resolution not always possible (or desirable)

Relapse Prevention 12- 24 months recommended continuation therapy after FEP 2 or more episodes with Risk- longterm Rx likely However long term AP prescribing risks Compliance very poor in FEP at 12 months (>50%) Is there a place for targeted treatment? Relapse prevention/staying well plan essential

Monitoring physical health 15- 20 years reduced life expectancy CVS risk Smoking Lifestyle Schizophrenia predisposition to metabolic syndrome Poorer access to healthcare for SMI Suicide

Baseline Screening (TFTs, LFTs, Us and Es etc) to exclude organic cause BMI/abdo circumference. BP Lipids, HBA1c/Fasting glucose, prolactin Repeat at 3 months ECG

CQUIN interventions required Smoking Substance misuse Alcohol Weight BP Lipids Glucose control

GP Questions

“ Young person with withdrawal , poor sleep, reduced concentration in surgery. What would make me suspect Psychosis?” SCREENING Anything odd happening to you at the moment? How do your thoughts feel? Do you feel they are being tampered with? Hearing/Seeing/experiencing anything unusual and others cant?

What if I suspect FEP? Assess risk Single point Access Mention EIS, psychosis on referral form Support family- offer reassurance Hope and optimism

Should I commence AP? Consider BZDs If second episode and they responded well and there is a delay to Appt and you feel confident then reasonable to do so. Physical check!

Can I commence antidepressant? Common prescribing combination SSRI and SGA

Who is Responsible for Monitoring? BOTH Psych and GP - but don’t assume the other is doing so therefore communication KEY Psychiatrist- initially and first year GP long term

Thank you