1. Managing Psychosis (NICE Guidelines 2014)
Dr. Azlan Luk
Consultant Psychiatrist
Guildford CMHRS

2. Disclosure
I have received speaker fees/honorary payments from Lilly, Astra Zenica, Bristol-Myers Squibb, Pfizer and Lundbeck.
Employed in partnership with Richmond Pharmacology for a Phase 1 Drug Trial
Investment in pharmaceutical companies – None

3. Outline Recap on Schizophrenia Psychosis Physical Health Carers
Prodromal
Prevention
First Episode
Subsequent Episodes
Promoting recovery
Treatment Resistant
Physical Health
Carers
Peer Support
Referral pathways

4. Reminders Lifetime incidence – 1% Young adulthood Most people recover
Patient centred care
(cost to society – England 2004/5 – 6.7 billion)
Most people recover although some will have persisting difficulties orremain vulnerable to future episodes
Significant stigma

5. Reproduced from Prince et al. Lancet. 2007;370: 859-877
Reproduced from Prince et al. Lancet. 2007;370: © 2007, Elsevier Ltd.

6. World Wide Causes of Disability

7. Symptoms
Prodromal - ↓ Functioning, unusual ideas, disturbed communication & affect, social withdrawal, transient psychosis
Positive – hallucinations, delusions
Negative – emotional apathy, lack of drive, poverty of speech, social withdrawal, self neglect
A few days to 18/12

8. Prodromal CBT Treat other conditions Anxiety Depression Emerging PD
Substance Misuse

9. Preventing Psychosis (2014)
If distressed, functioning decline and has
Transient or attenuated psychotic symptoms
Other experiences or behaviour suggestive of possible psychosis
First degree relative with psychosis / schizophrenia
Refer to secondary care
Trained specialist to carry out assessment
Offer CBT
No antipsychotics
If unsure – monitor for up 3 years
Freq and duration of monitoring – severity of symptoms, level of impairment / distress and degreee of family disruption of concern

10. First Episode Psychosis
Higher risk of suicide
Early Intervention in psychosis services
Assess for PTSD (2014)
CBT (16 sessions) & Family intervention (10 sessions)
Antipsychotics (4-6 weeks trial) – choice
Metabolic , cardiovascular, hormonal, extrapyramidal, other
Not combined
Primary care - only in consultation with Consultant Psychiatrist
(SIGN – amisulpiride, olanzapine, risperidone)
PTSD in 1/3 with psychosis and schizophrenia
2/3 relate to psychosis and the management
Little evidence for family interventions or CBT alone without antipsychotic medications (if wanting just psychotherapy – agree a time limit - ? 1 month

11. Monitoring Monitor Weight (weekly for 6/52, 12/52, 1 year, Annually)
Waist circumference (annually)
Pulse & BP (12/52, 1 year, Annually)
Fasting Glucose, HbA1c, lipids, prolactin (12/52, 1 year, Annually)
Movement disorders
Nutritional status
ECG if CVS risk, inpatient
Adherence
Overall physical health
(Copies of results shared between primary /secondary care)
(secondary care until stabilised)

12. Fasting BG, HbA1c, lipids, Prolactin
6 weeks
12 weeks
1 year
Annually
Weight ✔
Waist
Pulse BP
Fasting BG, HbA1c, lipids, Prolactin 12

13. Physical health (2014)
Offer combined healthy eating and physical activity programme
Lipid modification, preventing type 2 diabetes
Stop smoking
Nicotine replacement
Bupropion
Varenicline
Watch for neuropsychiatric symptoms first 2-3 weeks
Weight, cardiovascular and metabolic indicatora – audited in annual team reporet
Compliance with monitoring cardiovascular and metabolic disease – board level performance indicators
Smoking : offer despite failed attempts previously. Effect on antipsychotics – clozapine and olanzapine

14. Early Post-acute period
Write account of experiences
Medication for 1-2 years
If withdraw medication – monitor for up to 2 years
Long term health risks, increased mortality and cortical grey matter loss linked to antipsychotic exposure.
Dutch trial 20% successful stopping after 7 years f/u
High risk of relapse if stop within 1 -2 years

15. Promoting recovery Primary care Clozapine Review medication annually
Physical healthcare at least annually
Copy of results to secondary care (2014)
Clozapine
Review medication annually
Supported employment programmes / occupational or educational activities offered (2014)
Return to primary care when stable

16. Treatment resistant
Review, adherence, psychological therapies, comobidities
Clozapine
Augmentation - trial of 8-10 weeks

17. Relapse and re-referral
Re-refer when
- relapse
- poor response to treatment
- non-adherence
- side effects
- co-morbid substance misuse
- risks
- patient request

18. Subsequent Episodes
Medications - not intermittent dosage strategies routinely
(single point of entry)
CBT
Family intervention
Art therapies
Not counselling or supportive psychotherapies / adherence therapy / social skills training
CBT – acute phase or later including inpatient stay

19. Carers (2014) Needs assessment (secondary care) – reviewed annually
Social services formal carer’s assessment
Information
Diagnosis & Mx
+ve outcomes & recovery
Types of support for carers
Role of teams and services
Help in crisis

20. Carers – cont. Carer focused education & support programme
Availability
+ve message

21. Peer Support & Self Management (2014)
Peer support worker – trained
Face to face - Manualised self management programme
Psychosis, medication, symptom management, access, coping with stress, crisis, social support network, preventing relapse
Evidence is not strong - low quality

24. Outline Recap on Schizophrenia Psychosis Physical Health Carers
Prodromal
Prevention
First Episode
Subsequent Episodes
Promoting recovery
Treatment Resistant
Physical Health
Carers
Peer Support
Referral pathways

25. Questions ? 25