Managing Psychosis(NICE Guidelines 2014)

Dr. Azlan Luk

Consultant Psychiatrist

Guildford CMHRS

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

OutlineOutline

• Recap on Schizophrenia

• Psychosis• Prodromal

• Prevention

• First Episode

• Subsequent Episodes

• Promoting recovery

• Treatment Resistant

Physical Health

Carers

Peer Support

• Referral pathways

RemindersReminders

Lifetime incidence – 1%

Young adulthood

Most people recover

Patient centred care

(cost to society – England 2004/5 – 6.7 billion)

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

World Wide Causes of Disability

SymptomsSymptoms

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

ProdromalProdromal

CBT

Treat other conditions

• Anxiety

• Depression

• Emerging PD

• Substance Misuse

Preventing Psychosis (2014)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

First Episode PsychosisFirst 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)

MonitoringMonitoring

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)

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Physical health (2014)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

Early Post-acute periodEarly Post-acute period

Write account of experiences

Medication for 1-2 years

If withdraw medication – monitor for up to 2 years

Promoting recoveryPromoting recovery

Primary care

• 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

Treatment resistantTreatment resistant

Review, adherence, psychological therapies, comobidities

Clozapine

Augmentation - trial of 8-10 weeks

Relapse and re-referralRelapse and re-referral

Re-refer when

- relapse

- poor response to treatment

- non-adherence

- side effects

- co-morbid substance misuse

- risks

- patient request

Subsequent EpisodesSubsequent 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

Carers (2014)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

Carers – cont.Carers – cont.

Carer focused education & support programme

• Availability

• +ve message

Peer Support & Self Management (2014)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

OutlineOutline

• Recap on Schizophrenia

• Psychosis• Prodromal

• Prevention

• First Episode

• Subsequent Episodes

• Promoting recovery

• Treatment Resistant

Physical Health

Carers

Peer Support

• Referral pathways

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Questions ?