1. 1 THE PHILIPPINE COLLEGE OF PSYCHOPHARMACOLOGY 2010 PSYCHOSIS (Featuring the HDL method) TEACHING MODULE FOR THE PRIMARY CARE PHYSICIANS

2. 2 OBJECTIVES At the end of the module, the family physician is expected to: 1.identify the core psychotic symptoms, specifically that of schizophrenia using the HDL method. 2.prescribe the appropriate antipsychotic medications using the STEPS approach. 3.refer to a psychiatrist, if needed.

3. 3 FORMAT OF ACTIVITIES Case presentation Lecturettes Interactive sessions Summary

4. 4 WHY PSYCHIATRY FOR GPs? Most psychiatric patients first seen by GPs GPs need updated skills and knowledge to help psychiatric patients better More easy, quick, diagnostic tools for GPs now available Presence of new drugs which are safe, tolerable, effective, priced right, and simple to use by GPs

5. 5 INTERACTIVE SESSION 1 “What is your most unusual experience?” (Unusual vs Usual) “What makes you different from others? (Unique vs Common) “Do you hear voices?” (Abnormal vs Normal)

6. 6 CASE PRESENTATION A 21-year old male, single, college student, suddenly runs out of his classroom. He shouts, ‘ back off ’ at a friend who follows him. He is convinced that his teachers and classmates intend to kill him. He hears the mocking voices of his teachers coming from the electric fan and on the classroom walls, talking about him and calling him nasty names.

7. 7 CASE PRESENTATION The patient is brought to a GP. PE and lab tests for illegal drugs are normal. He looks blankly at the walls. He is inattentive and responds irrelevantly to questions. He mumbles incoherently, “A,B, (ZTE) F,G”. He accuses his parents and the doctor to be in a plot to kill him. He cannot be convinced otherwise. Judgement, impulse control, and insight are poor. Sensorium is intact. t

8. 8 CASE PRESENTATION Background: socially withdrawn and avoids group activities; with few friends and lacks initiative. An only child who relates poorly to parents who are very busy. Father is very critical and mother is overprotective. Mother had a history of similar difficulties. The current episode is his second in two years. No meds for three months

9. 9 Case Summary A young man’s second episode of behavioural changes like blank stares, hearing voices, fixed ideas of being harmed, and irrelevant speech. These occur in the background of poor family bonding and lack of social interactions. There is a positive family history of psychiatric illness. No maintenance meds.

10. 10 LECTURETTE Identifying Core Symptoms of Psychosis Positive Symptoms: HDL method * Hallucinations – most important ; usually auditory, multiple voices talking about the patient Delusions - persecutory, bizarre, systematized Looseness of associations – irrelevant speech, hard to understand * hallucinations and delusions should be present

11. 11 LECTURETTE Negative Symptoms: 4 As * Alogia - limited speech ; tendency to mutism Affective blunting – flat; blank stares; no emotion Avolition – unexplained lack of initiative Anhedonia – pervasive lack of interest / pleasure unrelated to depression * 2 or more enhance the diagnosis

12. 12 LECTURETTE Other Features: (exclusion criteria) * At least six months duration Social/occupational dysfunction No mood disorder * No substance abuse / medical condition *

13. 13 INTERACTIVE SESSION 2 Positive symptoms of our patient: What is the H? What is the D? What is the L?

14. 14 INTERACTIVE SESSION 3 Negative symptoms of the patient: Name at least 2 As: A?

15. 15 LECTURETTE Other features present in our patient: Poor functioning: school, parents, peers Positive family history (mother) Second episode in two years High emotional expressivity (or ‘High EE’)- overcritical and overprotective parents

16. 16 PSYCHOTIC? Positive and negative symptoms plus impaired functioning but no mood symptoms Due to substance ←↓→ Due to medical illness? abuse? If no ↓ Ask duration < 1month← ↓ →< 6 months Brief Psychotic Schizophreniform Disorder Disorder > 6 months Schizophrenia

17. 17 LECTURETTE Some Aetiologic Considerations: (Multifactorial) Genetics- family, twin, and adoption studies Biological- neurodevelopmental defects due to subtle birth injuries: sulcal and ventricular enlargements, hypo- frontality; hyperactivity of dopamines

18. 18 LECTURETTE Treatment Strategies: (including the STEPS approach) 1. Antipsychotic Drugs: Typicals Atypicals 2. Day-to-Day Management: family cooperation/involvement approach of physician

19. 19 THE STEPS APPROACH IN PSYCHOSIS Typical Antipsychotics: Examples chlorpromazine (Thorazine), haloperidol (Haldol) fluphenazine decanoate (Modezine) Safe in short-term; TD a problem in long-term Tolerable, but EPS a concern Effective, but less with (-) symptoms Price inexpensive (P20-30/day) Simple, not very (2-3x a day, except depots)

20. 20 Average Doses of Typicals Chlorpromazine (Thorazine) 100-400 mg/day Haloperidol (Serenace, Haldol) 2-4 mg/day Fluphenazine Decanoate (Modezine) 12.5 – 25 mg/month (0.5 -1.0 cc) IM (long-acting)

21. 21 Treatment for EPS Biperiden (Akineton) One ampoule (1 cc or 5 mg) IM or slow IV then 1 tablet/day ( 2 mg) as maintenance (‘Cabuquit’s cocktail’) Diphenhydramine (Benadryl) One ampoule ( 1cc or 50 mg) IM or slow IV then 1 capsule/day (50 mg); sedating

22. 22 USING THE STEPS APPROACH Atypical Antipsychotics : Examples aripiprazole (Abilify), clozapine (Ziproc), olanzapine (Zyprexa), quetiapine (Seroquel), risperidone (Aspidon) Safe in short-term and long-term Tolerable, except for weight gain and DM; less EPS Effective, for both (+) and (-) symptoms Price expensive ; generics more affordable Simple (usual OD dosing)

23. 23 Recent Data on Typicals vs Atypicals Studies comparing typicals vs atypicals Efficacy is comparable ( Lieberman et al Catie 1 & 2, 2004, 2005) Quality of life is comparable (Jones, et al CUtLASS, 2006) Typicals much more affordable (Jones, et al CUtLASS, 2006) Tolerability still a concern for typicals (Lieberman 2004, 2005; Jones 2006)

24. 24 Considering the safety profiles of OLZ, QTP, and RIS (Based on CAFÉ Study 2005) For Patients With AVOIDGIVE weight problemsOLZQTP or RIS menstrual problems RISQTP or OLZ orthostatic BP changes QTPOLZ or RIS EPS tendenciesRIS/OLZQTP insomnia / night awakenings RIS/OLZQTP

25. 25 Prices of Atypical Antipsychotics- Mercury Drug ( Feb 2008) AtypicalsUsual dose (mg/day) Daily expense (pesos) Monthly expense (pesos/30 days) CLZ2001444,320 OLZ103089,240 QUE3002206,600 RIS21123,360 ARI102467,380

26. 26 USING THE STEPS APPROACH The fine art of choosing the best drugs (PCPsych) (5 – finest ; 1- not so fine) Drugs S T E P S CLZ 3 3 5 4 3 OLZ 3 2 4 2 4 QUE 4 3 4 3 3 RIS 4 3 4 4 4 ARI 4 3 4 3 4

27. 27 LECTURETTE When to refer? Diagnosis is vague or confusing Psychiatric emergency Need for psychotherapy Poor response to treatment GP feels “burnt out”/overwhelmed

28. 28 LECTURETTE What to say to the patient? Do you acknowledge failure? Should you imply referral is a “last resort?” Is the referral a rejection of the patient? Is the psychiatrist the more appropriate doctor to deal with the problem? (suggest it is a team approach)

29. 29 SUMMARY Core features of psychosis are HDL: hallucinations, delusions, and looseness of associations Except for their price, atypicals can be first line drugs for psychosis; typicals remain good choices, inexpensive but with tolerability issues Primary care physicians can be effective partners of psychiatrists in treating patients with psychosis

30. 30 THANK YOU FOR LISTENING Do you hear the gears talking to you?