Transcript No Slide Title

Medication in Early
Onset Psychosis
Manchester Mental Health &
Social Care Trust
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Aims & Objectives of
Session
To increase the awareness of the major
issues in the use of anti-psychotic medication
For participants to understand the processes
involved in the prescribing of medication.
To present the advantages and side effects of
medication and the issues of compliance.
To provide an understanding of how and why
this medication works.
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Medication and Psychosis
Medication is one of the first treatments
offered to people who are struggling to cope
with confused thinking and strange
experiences
The most often used types of drugs are called
“anti-psychotic” medication
The choice of anti-psychotic should be a joint
decision between clinician and individual
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Anti- Psychotic Medication
Anti- psychotic medication is used to control psychosis
Psychological treatments are more effective when
medication is taken as well
Medication is only ONE PART of a comprehensive
package of care that aims to help keep a person stable
and to live as normal a life as possible
Anti- psychotic medications are MOST EFFECTIVE at
controlling POSITIVE SYMPTOMS (hallucinations,
delusions) - less effective at treating negative ones
(apathy, withdrawal etc)
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Prescribing Medication
When taking anti-psychotic medication it is
advisable to start on a dose at the lower end
of the standard dose range (NICE 2002)
‘Continuous’ rather than ‘intermittent’ dosing
should be used to avoid relapse and
deterioration of mental state.
Only one type of anti-psychotic medication
should be prescribed at a time, unless this is
for a short period to facilitate a change of
medication.
If there is no improvement after 6-8 weeks of
a therapeutic dose, a change to alternative
medication should be considered.
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How is the medication taken?
Anti -psychotic medication can be taken in
several ways: tablets, dissolvable capsules,
liquid ‘syrups’ or injections
The method of taking the medication is
personal choice as each has advantages
and disadvantages
Medication should be continued for at least 6
months. It should never be stopped suddenly
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How do clients receive their
medication?
Most people receive medication as a
prescription from their G.P., often following a
consultation with a psychiatrist
A repeat prescription can be organised
through the local chemist who might deliver it
to the persons’ home
Medication can be packaged as a ‘dossette
box’ with a separate compartment for each
daily dose of medication or a ‘blister-pack’
Injections or “depots” are given by a nurse at
a ‘depot’ clinic, at a GP’s surgery or, in some
cases, at home
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Medication - Group exercise
In two large groups 1. Consider your own history in taking
prescribed medications
2. As a group, with one person acting as the
‘scribe’, write on flip chart paper all the
reasons you can remember for why you
DIDN’T take the full course of medication as
prescribed
3. Consider what rationales you would need
to take all future medication as prescribed?
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Helping people to make informed
choices about medication
Some people don’t like to take medication
(this is true of ANY type of medication)
Forcing people or using heavy-handed
methods doesn’t usually work
The best way is to provide information about
the drugs that they need
Encourage the consideration of the
advantages and disadvantages – this way the
person makes an INFORMED choice
Never disguise medication in food or drinks
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Interventions to enhance
concordance
Depot injections are often offered if the person is not
able to cope with, or reluctant to take oral medication.
If medication is refused as a result of intolerable side
effects, alternative medication should be considered
– although this might mean substituting one side
effect for another
‘Motivational interviewing’ techniques may be used to
enhance compliance through collaboration, education
and empowerment
When two different anti-psychotic medications have
been tried over a period of 6-8 weeks, the person
might be considered ‘treatment resistant’ and as a
result offered clozapine (NICE 2002)
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What about side effects?
At one time anti-psychotic medication had a
reputation for causing serious side effects
More recently types of medication have been
developed which have fewer side effects
All medications have potential adverse
reactions yet it is important that they are
noticed as early as possible so that the drug
can be reduced or changed, or another drug
can be added to help to cope with it
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Maintenance Regimes
Antipsychotics are generally continued for 1 - 2 years
to prevent further relapse
About 20% of people will still experience a relapse
despite maintenance treatment of medication
It is not possible to tell in advance if relapse will
occur. Therefore everyone should be offered
maintenance treatment.
Withdrawal from antipsychotics should be undertaken
gradually, whilst monitoring for relapse for up to 2
years
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Medication management for a
first episode of psychosis?
Generally, antipsychotics are started only by
specialist mental health services, following an initial
assessment
Antipsychotic medication may be initiated by the GP
in the first instance if the person is awaiting and initial
meeting with a psyciatrist
Where possible, treatment should be discussed with
specialist mental health services before it is started
If ‘acute’ symptoms persist or if the client is at risk an
URGENT appointment should be sought with
specialist services ( NICE 2002)
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Choice of medication for a first
episode of psychosis
Clozapine or sertindole must ONLY be prescribed by
specialist mental health services
Atypical antipsychotics, prescribed at the lower dose
range, are the preferred treatment for first episode
psychosis, due to reduced risk of ‘extra-pyramidal’
side effects
Avoid Clozapine or Respiridone with clients with a
history of any CEREBROVASCULAR DISEASE ,
TIAs, hypertension
CARDIOVASCULAR DISEASE - Avoid zotepine,
respiridone & quetiapine; these drug reduce BP,
resulting in reflex tachycardia that may exacerbate
angina
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Medication Management antipsychotic for first episode
CARDIOVASCULAR DISEASE/ Arrhythmias:
Most antipsychotic drugs have the potential to
affect the QT interval. Amisulpride is probably
safe in people with arrhythmias. Zotepine
(and sertindole) should NOT be used
Phenothiazines, higher doses of haloperidol
and prescribing ABOVE BNF limits should
also be avoided
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Medication Management - Choice
of oral ‘atypical’ antipsychotic
EPILEPSY - All antipsychotic drugs can lower the
seizure threshold. Incidence of seizures was low in
trials of olanzapine, respiridone and quetiapine.
Whichever drug is chosen, start at a low dose and
increase dose gradually in a person with epilepsy.
If prescribing antipsychotic medication it important to
be aware of those factors that increase the risk of
seizures, such as head injuries, previous history of
seizures, being on drugs that reduce the seizure
threshold and withdrawal from drugs of the central
nervous system (alcohol, barbiturates etc)
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Medication Management
Diabetes
The incidence of Type II diabetes is more
common in people with schizophrenia than
the general population. Antipsychotics MAY
increase this risk, though no causal link has
been established.
Both ‘typical’ and ‘atypical’ antipsychotics
have been associated with an increased risk
of diabetes especially with olanzapine &
clozapine (Sernyak et al 2002; Lean and
Pajonk 2003)
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Medication Management Adverse effects of antipsychotics
Antipsychotics cause a wide range of side
effects, including sedation, weight gain and
sexual dysfunction.
Tardive dyskinesia (TD) is a late-onset
movement disorder that can occur with
prolonged use of antipsychotics. It can be
irreversible and may get worse when
treatment stops
Around 20% of people on antipsychotics
eventually experience TD - older people are
more at risk
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Medication Management Switching antipsychotics
Changing medication needs to be done with
care and is preferably done under medical
guidance
Stopping antipsychotics abruptly can lead to
relapse or cause withdrawal reactions such
as cholinergic rebound (nausea,
restlessness, anxiety, insomnia) and
withdrawal dyskinesias (extrapyramidal
symptoms etc)
The dose of the original drug should be
tapered down slowly (over about 8 weeks)
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Medication Management minimising effects
GPs need to know how to manage side effects
as 25% of people with psychosis are managed
within primary care teams
Weight gain - occurs mainly in first 6-9
months. Advice and support on healthy eating
and exercise is essential
Sedation - Lowering the dose may help
Postural hypotension - Should be carefully
monitored - change medication if necessary,
though tolerance develops
Maudsley (2001) Prescribing Guidelines
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Medication Management Minimising adverse effects
Tardive Dyskinesia - Emergence of Extra
Pyramidal Symptoms (EPS) is a strong predictor
for later TD. Withdrawal of antimuscarinic drugs
can help, as can a switch to clozapine or
olanzapine
Neuroleptic malignant syndrome – This is a very
rare, idiosyncratic but life-threatening adverse
effect. Symptoms include hyperthermia, muscle
rigidity, autonomic instability, fluctuating
consciousness. URGENT medical treatment is
essential
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Changing from a typical antipsychotic to an atypical?
Do not change medication unless it is necessary
(NICE 2002)
‘Atypical’ antipsychotics should be considered for
people taking typical antipsychotics who are
experiencing unacceptable side effects, despite
adequate symptom control
Might also be considered if client has relapsed and
failed to achieve adequate symptom control with
typical antipsychotics, or experienced unacceptable
adverse effects
This should be a decision by clinician and patient
(NICE 2002)
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Medication - Group Exercise
In two large groups 1. List all of the different types of medication that you
have heard of to help with the symptoms of any
mental illness
2. When you have exhausted this list, attempt to put
the drugs into their broad groups (e.g. those for
voices ,antidepressants, those for anxiety)
3. Try and link these drugs with the types of mental
health problems they are designed to treat (e.g.
antidepressants to treat low mood etc)
4. Which of these medications have more than one
purpose?
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The Origins of Anti- Psychotic
Medication
Anti-psychotic drugs, also called ‘neuroleptic’
drugs - the mainstay treatment for people
with psychosis.
They are used to control acute symptoms
(hallucinations, delusions, ‘thought disorder’)
and assist in relapse prevention.
The first of these drugs was discovered by
accident in France when people noticed that
it made patients who took it more tired. The
drug was called chlorpromazine and it was
being investigated as an anti-hay fever drug,
not as an antipsychotic!
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The Central Nervous System
Messages are sent to different parts of the brain by
bundles of nerve cells (‘neurons’). These neurons
are not connected physically , there is a gap
between them called the ‘synaptic cleft’.
Information is sent across this gap by a chemical
messenger called a ‘neurotransmitter’.
There are lots of different types of neurotransmitters
in the nervous system.
The end of the neuron which receives this chemical
message has specialist ‘receptors’ to accept
delivery of the message.
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The Role of Dopamine
 One of these chemical messengers or
‘neurotransmitters’ is called ‘dopamine’. It is
thought that an over activity of dopamine might
be one reason why some people experience
psychotic symptoms
 This is known as the ‘dopamine hypothesis’
 It could be either that there is an overproduction of dopamine from nerve endings or
the receiving receptor sites might be too
sensitive
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The Role of Dopamine?
It is thought that dopamine is connected with
the way we interpret the world around us
Hallucinations, strange beliefs and
disturbances in the way we think can all
seem to result from over-activity of dopamine
Anti- psychotic medication controls the
amount of dopamine received by the
receptor sites. They do this by binding on
these sites and blockading them
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Antipsychotic medication & first
onset psychosis
One of the strongest predictors of outcome in
psychosis is the length of the duration of untreated
psychosis (DUP) (Johnstone et al 1986; Loebel et al
1992)
Use of low-dose anti -psychotics to avoid treatment
delay has been advocated by some clinicians,along
with CBT (e.g. EPPIC in Melbourne (McGorry et al
2002)
However, other researchers have avoided its early
use, opting for psychological management strategies
instead (e.g. Morrison et al 2004)
So, which approach is best?
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To conclude .. the drawbacks of
medication
 Medication can have stigmatising side effects
 The effects on the developing adolescent
brain is as yet unknown
 If symptoms are not causing distress, should
medication be offered?
 People often stop taking medication after a
short period
 There is a risk of medicating ‘false-positive’
patients with potentially high risk drugs
(Bentall and Morrison 2002)
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To conclude – the advantages of
medication
It is known to be effective in managing
symptoms if carefully prescribed
Careful prescribing can minimise side effects
by up to 85%
People with first episode who were given low
dose medication managed to become
symptom free after a few weeks of treatment
(McGorry & Singh 1995)
Families and clients often want rapid relief
from difficult and burdensome situations
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