schizophrenia management

Management of SchizophreniaDr. Pavan Kumar KAsst ProfessorDept Of PsychiatryCAIMS

•PHARMACOLOGICAL MANAGEMENT

•PSYCHOSOCIAL MANAGEMENT▫PSYCHOTHERPIES▫REHABILITATION

•Treatment of first episode schizophrenia

Either:Agree choice of antipsychotic with patient &/or carer

Or ,if not possible:Start 2nd generation antipsychotics

Titrate , if necessary to minimum effective dose

Adjust dose according to response & tolerability

Assess over 2-3 weeks

Continue at dose established as effective

Change drug & follow above process. Consider use of either a SGA or a FGA

If poor compliance related to poor

tolerability, discuss with patient & change drug .

If related to other factor,consider depot

prep/compliance therapy/aid.

Repeat above process

CLOZAPINE

Effective

Not effective

Not tolerated / poor compliance

•Treatment of relapse or acute exacerbation with adherence confirmed.

INVESTIGATE SOCIAL / PSYCHOLOGICAL PRECIPITANTS

PROVIDE APPROPRIATE SUPPORT & / THERAPY

CONTINUE USUAL DRUG TREATMENT

ADD SHORT-TERM SEDATIVESOR

SWITCH TO A DIFFERENT , ACCEPTABLE ANTIPSYCHOTIC IF APPROPRIATE

DISCUSS CHOICE WITH PATIENT &/ CARERACCESS OVER ATLEAST 6 WEEKS.

SWITCH TO CLOZAPINE

AC. DRUG TREATMENT REQUIRED

TREATMENT INEFFECTIVE

•Treatment of relapse or acute exacerbation of schizophrenia with adherence doubtful

INVESTIGATE REASONS FOR POOR

ADHERENCE

SIMPLIFY DRUG REGIMENREDUCE

ANTICHOLINERGIC LOAD

CONSIDER COMPLIANCE AIDS*

DISCUSS WITH PATIENT

SWITCH TO ACCEPTABLE DRUG

DISCUSS WITH PATIENT

CONSIDER COMPLIANCE

THERAPYOR DEPOT ANTIPSYCHOTICS

CONFUSED /DISORGANIZED

POORLY TOLERATED TREATMENTLACK OF

INSIGHT OR SUPPORT

Comparison of antipsychotics•In general all antipsychotics are effective.•The makers and marketers of

antipsychotics have sponsored many studies and their drugs have always been found to be superior.

•Independently conducted meta-analysis have found few effectiveness differences between the drugs exception being for clozapine.

•CATIE AND Cut-LASS•These studies are state sponsored and

they have found clozapine to be effective in refractory individuals but no clear important advantages in effectiveness for any other drug for most patients.

•Both studies have found out no changes in tolerability or acceptability for SGA/FGA.

Long acting injectable antipsychotics•These drugs are helpful for continuation

and maintenance treatment.•Some oral supplementation is necessary

while optimum plasma levels are being achieved.

•ACUTE PHASE•MAINATAINANCE PHASE

▫Stabilization phase▫Stable phase

Psychosocial treatment•PSYCHOTHERAPY

▫FAMILY THERAPY▫COGNITIVE BEHAVIOUR THERAPY▫SOCIAL SKILL TRAINING

•REHABILITATION▫TOKEN ECONOMY ▫VOCATIONAL REHABILITATION▫SUBSTANCE ABUSE REHABILITATION▫COGNITIVE REHABILITATION

PATIENT OUTCOME RESEARCH TEAM•Family intervention•Supported employment•Assertive community treatment•Skills training•CBT•Token economy interventions

Family interevention:

Supported employement•Persons with schizophrenia who have the

goal of employment should be offered supported employment, the key elements of which include individualized job development, rapid placement emphasizing competitive employment, ongoing job support, and integration of vocational and mental health services.

Social skills training•Social dysfunction is a defining

characteristic of schizophrenia. People with this illness have difficulty fulfilling social roles.

•Social dysfunction is semi-independent of symptomatology, and it plays an important role in the course and outcome of the illness

Core components:

•Social perception•Social cognition and •Behavioural resoponse

Elements that are to be concentrated include• Expressive behaviours

▫Speech content    ▫Paralinguistic features    

 Voice volume        Speech rate        Pitch        Intonation

• Nonverbal behaviors     ▫Eye contact (gaze)       ▫Posture      ▫  Facial expression

•Receptive Skills (social perception) ▫ Attention to and interpretation of relevant

cues    ▫Emotion recognition

•Processing Skills   ▫ Analysis of the demands of the situation   ▫ Incorporation of relevant contextual

information    ▫Social problem solving

•Interactive Behaviors    ▫Response timing    ▫Use of social reinforcers    ▫Turn taking Situational Factors

CBT•findings from the past two decades

suggest that schizophrenia patients can benefit from CBT that directly targets psychotic symptoms.

•CBT is a psychological approach to treatment that is focused on the interrelationship between thoughts, behaviors, and feelings

TOKEN ECONOMY PROGRAM•Token economies are behavioral

reinforcement programs based on the principles of social learning.

• (1) managing patients' behaviors while they are in the hospital or facility, and

• (2) preparing them to be able to function better in other, presumably less restrictive and less structured settings

•(1) identification of “target behaviors” that are considered important/desirable for all patients,

• (2) earning points or tokens for engaging in these behaviors,

• (3) redeeming the points in exchange for material items or privileges, and

•(4) participation by all patients in the treatment setting

SUBSTANCE USE REHABILITATION•Most common and clinically significant

comorbidity with schizophrenia. •Approximately 50 percent of adults with

schizophrenia have at least one co-occurring substance abuse

•complicate their lives, ▫leading to increased symptoms, ▫relapses, ▫hospitalizations, ▫violence, incarceration,▫ unstable housing, homelessness,

victimization, ▫family problems, and ▫serious medical problems such as HIV and

hepatitis

Effectiveness of particular treatment

•Effectiveness = Efficacy + Tolerability+

Compliance+ ease of Use

Recovery •Mental health recovery is in a journey of

healing and transformation enabling a person with a mental health problem to live a meaningful life in a community of his or her choice while striving to achieve his or her full potential

REFERENCES

• Sadock BJ, Sadock VA, Ruiz P. Comprehensive textbook of Psychiatry,Schizophrenia. 9th Edition,VOL1:Lippincott Williams ltd; 2009.

• IPS guidelines for management of schizophrenia.

• NICE guidelines: core interventions in treatment and management of schizophrenia ,2002.

• APA guidelines: practice guidelines for treatment of patients with schizophrenia,2004.

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