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Following Frank Patients with Chronic Mental Illness John R. Hall MD Te Roopu Whitiora Maori Mental Health Service
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Being Frank Ian Rankin Included in A Good Hanging
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General Follow Up Monitor symptoms Monitor for side effects and toxicity Monitor for concurrent medical problems
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Schizophrenia A—2+ –Delusions –Hallucinations –Disorganized speech –Disorganized or catatonic behaviour –Negative symptoms B—socio-occupational dysfunction C—duration 6 months
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Schizophrenia D—exclusion –No mood episode concurrent with active phase symptoms –Mood episode is brief relative to active phase symptoms
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Symptom management Auditory hallucinations –Nature of voices –Risk of response to voices Delusions General Function Negative Symptoms –Affective flattening –Alogia –Avolition
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Compliance Deficits of insight Denial or disagreement with provider Side effects of treatment Make treatment as tolerable as possible Utilize Depot intramuscular preparations
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Typical Antipsychotics Haloperidol Zuclopenthixol Chlorpromazine Trifluoperazine
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Extra-Pyramidal Symptoms Dystonia –Muscle spasm Oculogyric crisis torticollis Parkinsonism –Bradykinesia –Tremour, rigidity Akathisia
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Tardive Dyskinesia Lip smacking, tongue protrusion Choreiform hand movements Documented prior to introduction of antipsychotic medications Relative advantage to atypical antipsychotics—especially clozapine
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Atypical Antipsychotics Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Amisulpride
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Prolactinaemia Elevated prolactin levels are related to dopamine blockade Worst offenders; Risperidone Relative advantage; Quetiapine, Clozapine Risks; menstrual disturbances, gynecomastia, galactorrhoea, sexual dysfunction
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Weight Gain Increased food intake/ reduced energy expenditure Worst offenders; Clozapine, Olanzapine Relative advantage; Ziprasidone, Aripiprazole, Amisulpride Switching medications and/or behavioural interventions
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ECG changes QT prolongation An estimation of risk of torsade de pointes and related arrhythymia (QTc>470,500ms) Offenders; Ziprasidone, Pimozide, tricyclic antidepressants Relative advantage; Aripiprazole, SSRIs
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Clozapine First two weeks—daily sighting for BP, temp, pulse, adverse effects First 18 weeks—weekly haematology After that monthly haematology Weight and lipids 3-6monthly
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Clozapine Haematology— –White cells/ neutrophils –Agranulocytosis 1/10,000 –Neutropenia 2.7% Serum Levels— –To monitor compliance –To establish a baseline –When considering reducing dosage
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Clozapine Other risks Hypersalivation Seizure risk Weight gain and dyslipidemias Pulmonary embolism Myocarditis Cardiomyopathy Constipation
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Advantages of IMI treatment Compliance Contact with a nurse Patient preference?
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IMI management Haloperidol –25-200mg –4 weekly injections Flupenthixol –20-400mg –2-4 weekly injections Fluphenazine –12.5-50mg –2-4 weeks
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IMI management Zuclopenthixol –100-600mg –2-4 weekly injections Pipothiazine –25-200mg –4 weekly injections
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SGA IMIs Risperdal Consta –25mg, 37.5mg, 50mg –2 weekly injections –Gluteal or deltoid now Olanzapine
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Bipolar Disorder Distinct Episodes –Mania –Depression –“Mixed” Interepisodic recovery Treatment is essentially prophylactic
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Symptom management Depression –Motivation/interests, energy –Feelings of hopelessness –Suicidal ideation Mood Elevation –Flightiness, distractibility, excessive energy –grandiosity Sleep Activity level Psychotic symptoms
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Lithium Serum levels (0.4-1.0mmol/L) –3-6months –Physiological changes, medication changes Toxic symptoms –Gastrointestinal symptoms Anorexia, nausea, diarrhea –Ataxia, disorientations, seizures
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Sodium Valproate Serum levels (300-700 micromol/L) –3-6 months Toxic Symptoms –Gastric irritation, hyperammonaemia –Lethargy, confusion –Thrombocytopenia –Hepatic changes
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Teratogenicity Lithium –Cardiac anomaly Sodium Valproate –Neural tube defects
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Other Mood Stabilizers Carbamazepine Lamotrigine Antipsychotics
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Lithium Other things to monitor –Thyroid –Renal function
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Depression in Bipolar Disorder Addition of an antidepressant Optimization of mood stabilizer Addition of an atypical antipsychotic
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Antidepressants-Long term No peculiar guidelines to long term use General follow up for depression guidelines –1yr following single episode –3-5 yr after two or three episodes –? Be aware of discontinuation syndrome
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John R. Hall Consultant Psychiatrist Te Roopu Whitiora –Maori Mental Health Services 1/25 Rathbone Street 430-4101 3537 John.Hall@northlanddhb.co.org
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