1. Antipsychotic Prescribing
Erin Turner
2/3/16

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

3. 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

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

5. 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

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

7. FGA Mechanism Action
D2 Blockade

8. SGA Mechanism Action
D2/5HT2A antagonism

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

10. EPSEs

11. 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

12. Try to match AP to desired Side Effecteg
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

13. 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

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

15. 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)

16. Relapse Prevention
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

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

18. 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

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

20. GP Questions

21. “ 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?

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

23. 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!

24. Can I commence antidepressant?
Common prescribing combination SSRI and SGA

25. 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

26. Thank you