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Mental Health Care Challenges in Management of Schizophrenia and other non affective psychosis presented by Chief Dr H.T.O. LADAPO, MD (Ukraine) FMC Psych..,

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Presentation on theme: "Mental Health Care Challenges in Management of Schizophrenia and other non affective psychosis presented by Chief Dr H.T.O. LADAPO, MD (Ukraine) FMC Psych..,"— Presentation transcript:

1 Mental Health Care Challenges in Management of Schizophrenia and other non affective psychosis presented by Chief Dr H.T.O. LADAPO, MD (Ukraine) FMC Psych.., FWACP, FHAN, MPH (Unilag)

2 Introduction (1) Early Greek physicians described delusions of grandeur, paranoia, and deterioration in cognitive functions and personality. Early Greek physicians described delusions of grandeur, paranoia, and deterioration in cognitive functions and personality. Schizophrenia did not emerge as a medical condition worthy of study and treatment until the eighteenth century. Schizophrenia did not emerge as a medical condition worthy of study and treatment until the eighteenth century.

3 Intoduction (2) Emil Kraepelin delineated insanity: manic-depressive psychosis and dementia praecox (or dementia of the young) Emil Kraepelin delineated insanity: manic-depressive psychosis and dementia praecox (or dementia of the young) In 1911 Eugen Bleuler suggested the term schizophrenia (splitting of the mind) for the disorder. In 1911 Eugen Bleuler suggested the term schizophrenia (splitting of the mind) for the disorder.

4 Intoduction (3) He also described four primary symptoms (the four As): abnormal associations, autistic behavior and thinking, abnormal affect, and ambivalence. He also described four primary symptoms (the four As): abnormal associations, autistic behavior and thinking, abnormal affect, and ambivalence.

5 Intoduction (4) Nondisease models: Nondisease models: -The societal reaction theory ("a sane reaction to an insane world") -Thomas Szasz's theory which states that schizophrenia is a myth enabling society to manage deviant behavior

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7 Epidemiology (1) Schizophrenia is a leading public health problem that exacts enormous personal and economic costs worldwide. Schizophrenia is a leading public health problem that exacts enormous personal and economic costs worldwide. Schizophrenia affects just under 1 percent of the world's population (approximately 0.85 percent). Schizophrenia affects just under 1 percent of the world's population (approximately 0.85 percent).

8 Epidemiology (2) NIMH’s Epidemiologic Catchment Area (ECA) study – lifetime prevalence 1.5% NIMH’s Epidemiologic Catchment Area (ECA) study – lifetime prevalence 1.5% International Pilot Study of schizophrenia (IPSS) International Pilot Study of schizophrenia (IPSS) Determinant of Outcome studies by WHO (12 countries) Determinant of Outcome studies by WHO (12 countries)

9 Epidemiology (3) A 1987 review of over 70 prevalence studies of schizophrenia published since 1948 identified point prevalence in various population groups ranging from 0.06 percent to 1.7 percent, with lower rates in developing countries. A 1987 review of over 70 prevalence studies of schizophrenia published since 1948 identified point prevalence in various population groups ranging from 0.06 percent to 1.7 percent, with lower rates in developing countries.

10 Epidemiology (4) Life time risk ranges from 0.7% to 1.3% Life time risk ranges from 0.7% to 1.3% The prevalence rate is similar in different cultures when assessed using similar instrument ( Jablensky et al 1992) The prevalence rate is similar in different cultures when assessed using similar instrument ( Jablensky et al 1992) Exceptions include Slovenia, Western Ireland, Catholics in Canada and Tamils of Southern India Exceptions include Slovenia, Western Ireland, Catholics in Canada and Tamils of Southern India

11 Epidemiology (5) Low rates have been reported in the Hutterrites and the Anabaptist sects in the USA Low rates have been reported in the Hutterrites and the Anabaptist sects in the USA Onset usually between the ages of 15 and 45 Onset usually between the ages of 15 and 45 Peak age in men 15 - 25years Peak age in men 15 - 25years Peak age in women 25 – 35 years Peak age in women 25 – 35 years

12 Risk factors Genetic Factors Genetic Factors Ethnicity and Racial Factors Ethnicity and Racial Factors Age Age Sex Sex Season and Birth Order Season and Birth Order Birth and Fetal Complications Birth and Fetal Complications Social Class: ”downward drift” and “social causation” theories Social Class: ”downward drift” and “social causation” theories

13 Risk factors Marital Status Marital Status Immigration Immigration Urbanization and Industrialization Urbanization and Industrialization Life Stressors Life Stressors Infections Infections Suicide Risk Suicide Risk

14 Aetilogy (1) Cause is unknown Cause is unknown Results from a complex interplay of genetic, environmental and social factors Results from a complex interplay of genetic, environmental and social factors

15 Aetiology (2) Neurobiological model Structural abnormalities include: enlarged lateral ventricles enlarged lateral ventricles enlarged third ventricle, and enlarged third ventricle, and reduced volume of a number of structures, including hippocampus, amygdala, and frontal and temporal cortices. reduced volume of a number of structures, including hippocampus, amygdala, and frontal and temporal cortices.

16 Aetiology (3) Genetic factors Family studies Family studies Twin studies Twin studies Adoption studies Adoption studies

17 Population Prevalence (%) Gen pop. 1.0 Non twin sibling 8.0 Child with one parent with schizophrenia 12.0 Dizygotic twin of schizophrenia patient 12.0 Child of two parents with schizophrenia 40.0 Monozygotic twin of a schizophrenia patient 47

18 Aetiology (4) Genetic factors Putative schizophrenia susceptibility loci yielding some evidence of confirmation include loci on chromosomes 6, 8, and 22. Putative schizophrenia susceptibility loci yielding some evidence of confirmation include loci on chromosomes 6, 8, and 22.

19 Aetiology (5) Neurobiology blood flow to several brain regions, including prefrontal and temporal areas, is altered in schizophrenia. These changes may be related to or may underlie positive and negative symptoms as well as some cognitive deficits. blood flow to several brain regions, including prefrontal and temporal areas, is altered in schizophrenia. These changes may be related to or may underlie positive and negative symptoms as well as some cognitive deficits.

20 Aetiology (6) Neurobiology Biochemical basis of schizophrenia Dopamine Dopamine Serotonin Serotonin glutamate glutamate

21 Aetiology (7) Dopamine hypothesis: It postulates a hyperactivity of dopamine transmission at the D2 receptors in the mensecephalic projection to the limbic striatum (Synder et al. 1974) It postulates a hyperactivity of dopamine transmission at the D2 receptors in the mensecephalic projection to the limbic striatum (Synder et al. 1974)

22 Aetiology (8) Evidence in support of dopamine hyp. There is a tight correlation between the therapeutic doses of conventional antipsychotic drugs and their affinities for D2 receptors (Seeman, 1987) There is a tight correlation between the therapeutic doses of conventional antipsychotic drugs and their affinities for D2 receptors (Seeman, 1987) Indirect dopamine agonists can induced psychosis in healthy subjects and at very low doses provoke psychotic symptoms in schizophrenia (Carlsson 1988) Indirect dopamine agonists can induced psychosis in healthy subjects and at very low doses provoke psychotic symptoms in schizophrenia (Carlsson 1988)

23 Postmortem and PET studies have shown increased dopamine D2 receptor level in the brain of schizophrenic patients (Wing et al, 1986) Postmortem and PET studies have shown increased dopamine D2 receptor level in the brain of schizophrenic patients (Wing et al, 1986) There is also emerging evidence for a presynaptic dopaminergic abnormality in schizophrenia (Laruelle et al 1999). There is also emerging evidence for a presynaptic dopaminergic abnormality in schizophrenia (Laruelle et al 1999). Existing literature suggested heritable abnormalities of prefrontal dopamine function are prominent features of schizophrenia (Egan et al, 2001) Existing literature suggested heritable abnormalities of prefrontal dopamine function are prominent features of schizophrenia (Egan et al, 2001)

24 Serotonin Serotonin receptors are involved in the psychotomimetic and psychotogenic properties of hallucinogens [e.g (LSD)]; Serotonin receptors are involved in the psychotomimetic and psychotogenic properties of hallucinogens [e.g (LSD)]; the number of cortical 5-HT 2A and 5- HT 1A receptors is altered in schizophrenic brains; the number of cortical 5-HT 2A and 5- HT 1A receptors is altered in schizophrenic brains;

25 5-HT 2A and 5-HT 1A receptors play a role in the therapeutic and/or side­ effect profiles of atypical antipsychotics (e.g., Clozapine); 5-HT 2A and 5-HT 1A receptors play a role in the therapeutic and/or side­ effect profiles of atypical antipsychotics (e.g., Clozapine); certain polymorphisms of the 5-HT 2A receptor gene are associated with schizophrenia; certain polymorphisms of the 5-HT 2A receptor gene are associated with schizophrenia; the trophic role of serotonin in neurodevelopment may be usurped in schizophrenia; the trophic role of serotonin in neurodevelopment may be usurped in schizophrenia;

26 5-HT 2A receptor-mediated activation of the prefrontal cortex may be impaired in some schizophrenics; 5-HT 2A receptor-mediated activation of the prefrontal cortex may be impaired in some schizophrenics; serotoninergic and dopaminergic systems are interdependent and may be simultaneously affected in schizophrenia (Liebermann et al. 1998, Harrison 1999). serotoninergic and dopaminergic systems are interdependent and may be simultaneously affected in schizophrenia (Liebermann et al. 1998, Harrison 1999).

27 Glutamate Potent non-competitive antagonist of the NMDA subtype of glutamate receptor (NMDA-R), induce schizophrenia-like symptoms in healthy individuals and worsen some symptoms in Schizophrenia (Hirayasu et al. 2001; Andreasen 1997). Potent non-competitive antagonist of the NMDA subtype of glutamate receptor (NMDA-R), induce schizophrenia-like symptoms in healthy individuals and worsen some symptoms in Schizophrenia (Hirayasu et al. 2001; Andreasen 1997). Postmortem studies of schizophrenic brains additionally indicate abnormalities in pre and postsynaptic glutamatergic indices. Postmortem studies of schizophrenic brains additionally indicate abnormalities in pre and postsynaptic glutamatergic indices.

28 NMDA-R hypofunction in the cortical association pathways could be responsible for a variety of cognitive and other negative symptoms (Carlsson et al 2000). NMDA-R hypofunction in the cortical association pathways could be responsible for a variety of cognitive and other negative symptoms (Carlsson et al 2000). It has been proposed that NMDA-R antagonist can cause excess compensatory release of glutamate that can over activate unoccupied non- NMDA glutamate receptors. This might in part be responsible for their behavioural effects. It has been proposed that NMDA-R antagonist can cause excess compensatory release of glutamate that can over activate unoccupied non- NMDA glutamate receptors. This might in part be responsible for their behavioural effects.

29 The effects of inhibiting NMDA-R may manifest through dopamine neurotransmission as dopamine and glutamate systems in the central nervous system have both anatomical and functional inter relationship. The effects of inhibiting NMDA-R may manifest through dopamine neurotransmission as dopamine and glutamate systems in the central nervous system have both anatomical and functional inter relationship. Finally, NMDA-R hypo function may also produce abnormalities in the neuroplasticity of neurons by altering synaptic connectivity. Finally, NMDA-R hypo function may also produce abnormalities in the neuroplasticity of neurons by altering synaptic connectivity.

30 Aetiology (9) Neurodevelopmental hypothesis: posits that insults occuring in-utero or shortly after birth are responsible for the structural abnormalities which manifest in symptoms later in adolescence/adulthood Neurodevelopmental hypothesis: posits that insults occuring in-utero or shortly after birth are responsible for the structural abnormalities which manifest in symptoms later in adolescence/adulthood

31 Evidence in support includes Absence of gliosis despite evidence of neuronal loss Absence of gliosis despite evidence of neuronal loss Evidence of impaired maturation, migration and pruning of neurons in schizophrenic brains Evidence of impaired maturation, migration and pruning of neurons in schizophrenic brains Cytoarchitectural abnormalities in medial temporal lobe Cytoarchitectural abnormalities in medial temporal lobe

32 Aetiology (10) Environmental factors: maternal bonding maternal bonding early rearing early rearing Poverty Poverty immigration status immigration status Stress Stress viruses. viruses.

33 Aetiology (11) Social factors Culture Culture Migration Migration Residence Residence Social isolation Social isolation Occupation and social class Occupation and social class

34 Aetiology (12) Psychosocial stresses: experiencing life event in the preceding six months doubles the risk of developing schizophrenia (Paykel 1978) experiencing life event in the preceding six months doubles the risk of developing schizophrenia (Paykel 1978) There is however, no evidence that schizophrenics experience more life events than the general population There is however, no evidence that schizophrenics experience more life events than the general population

35 Aetiology (13) Family Deviant role relationship: “schizophrenogenic mother” Deviant role relationship: “schizophrenogenic mother” Lidzs & Lidzs (1948) described marital schism and marital skew Lidzs & Lidzs (1948) described marital schism and marital skew Bateston et al, 1956 described Disorder family communications (Double bind theory) Bateston et al, 1956 described Disorder family communications (Double bind theory)

36 Aetiology (14) Psychodynamic factors Mainly of historical interest Freud's theory of schizophrenia Freud's theory of schizophrenia Melanie Klein’s theory Melanie Klein’s theory

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38 CLINCAL FEATURES DIAGNOSTIC CRITERIA Schneider Schneider Langfelt Langfelt New Haven Schizophrenia Index New Haven Schizophrenia Index St. Louis Criteria St. Louis Criteria Research diagnostic Criteria Research diagnostic Criteria Present State Examination (PSE) Present State Examination (PSE) ICD-10 ICD-10 DSM DSM Positive vs. Negative symptoms Positive vs. Negative symptoms

39 SCHNEIDERIAN FIRST RANK SYMPTOMS a) Audible thoughts b) Voices arguing or discussing or both c) Voices commenting d) Somatic passivity experiences e) Thought withdrawal and other experiences of influenced thought f) Thought broadcasting g) Delusional perceptions h) All other experiences involving volition, made affects, and made impulses

40 Second rank symptoms Second rank symptoms a) Other disorders of perception b) Sudden delusional ideas c) Perplexity d) Depressive and euphoric mood changes e) Feelings of emotional impoverishment f) “And several others as well”

41 DSM IV and ICD 10 DSM IV and ICD 10

42 Types Type I schizophrenia was characterized by predominantly positive symptoms, good premorbid functioning, sudden onset, normal brain structures by computed tomography (CT), good response to treatment, and a better long-term course. Type I schizophrenia was characterized by predominantly positive symptoms, good premorbid functioning, sudden onset, normal brain structures by computed tomography (CT), good response to treatment, and a better long-term course.

43 Type II schizophrenia was characterized mainly by negative symptoms, an insidious onset, poor premorbid functioning, abnormalities on CT scans, a tendency to drug resistance, and a poorer long-term course and outcome, often resulting in behavioral deterioration. (Tim Crow) Type II schizophrenia was characterized mainly by negative symptoms, an insidious onset, poor premorbid functioning, abnormalities on CT scans, a tendency to drug resistance, and a poorer long-term course and outcome, often resulting in behavioral deterioration. (Tim Crow)

44 Other types Paranoid Paranoid Hebephrenic/disorganised Hebephrenic/disorganised Catatonic Catatonic Simple Simple Residual Residual undifferentiated undifferentiated

45 TREATMENT Pharmacotherapy Pharmacotherapy Psychosocial intervention Psychosocial intervention

46 Factors Influencing Antipsychotic Drug Selection Factors Influencing Antipsychotic Drug Selection Factors Considerations Subjective response A dyphoric subjective response to a particular drug predicts poor compliance with that drug Sensitivity to extrapyrimidal A serotonin-dopamine antagonist (SDA) adverse effects Tardive dyskinesia Clozapine or (possibly another SDA) Poor medication compliance Injectable form of a long-acting antagonist or high risk of relapse Haloperidol or fluphenazine) Pregnancy Probably haloperidol (most data supporting its safety) Cognitive symptoms Possibly an SDA Negative symptoms Possibly an SDA

47 Psychosocial intervention Individual psychotherapy Individual psychotherapy Group therapy Group therapy Family Therapy Family Therapy Psychiatric Rehabilitation Psychiatric Rehabilitation Social Skills Training Social Skills Training Vocational Rehabilitation Vocational Rehabilitation Residential Treatment And Housing Programs Residential Treatment And Housing Programs

48 Features Weighing Toward Good to Poor Prognosis in Schizophrenia Good Prognosis Poor Prognosis Late onset Young onset Obvious precipitating factors No precipitating factors Acute onset Insidious onset Good premorbid social, sexual, Poor premorbid social, sexual, and work histories and work histories Mood disorder symptoms Withdrawn, autistic behavior (especially depressive disorders) Married Single, divorced, or widowed Family history of mood disorders Family history of schizophrenia Good support systems Poor support systems Positive symptoms Negative symptoms

49 Other features of poor prognosis Neurological signs and symptoms Neurological signs and symptoms History of perinatal trauma History of perinatal trauma No remissions in 3 years No remissions in 3 years Many relapses Many relapses History of assaultiveness History of assaultiveness

50 Other psychotic Disorders Delusional Disorders Delusional Disorders Schizophreniform Psychosis Schizophreniform Psychosis Reactive Psychosis Reactive Psychosis Schizo-Affective Schizo-Affective Atypical-Folie a Deaux, culture bound syndrome, Capgras,Cotard,Fregoli Atypical-Folie a Deaux, culture bound syndrome, Capgras,Cotard,Fregoli Schizotypal personality disorder Schizotypal personality disorder Postpartum psychosis Postpartum psychosis

51 Recent advances Team working in LMU Team working in LMU Found rare genetic variations that have a major influence, but also found frequent genetic variations that have only a minor effect on the disease risk.“ Found rare genetic variations that have a major influence, but also found frequent genetic variations that have only a minor effect on the disease risk.“ identify three so-called microdeletions.” identify three so-called microdeletions.”

52 Challenges Of Management Of Psychiatric Disorders Available service not centralized but concentrated only in the cities within the country. Available service not centralized but concentrated only in the cities within the country. Non inclusion of services in National health Insurance Scheme. Non inclusion of services in National health Insurance Scheme. Problem of stigma and negative perception of mentally ill patients Problem of stigma and negative perception of mentally ill patients Challenges of religious doctrines leading to mis management and chronicity. Challenges of religious doctrines leading to mis management and chronicity.

53 Atypical drugs though available has given hope for treatment of resistant and chronic condition thereby reducing chronicity. Atypical drugs though available has given hope for treatment of resistant and chronic condition thereby reducing chronicity. - cost of drugs is on the high side, many could not afford to purchase. - Infiltration of fake and genuine drugs in drug market. - Need for government subsidy of drugs to reduced burden of family and community.

54 Iloperidone, also known as Fanapta, and previously known as Zomaril, is an investigational atypical antipsychotic. It is being investigated mainly for the treatment of schizophrenia symptoms. Iloperidone, also known as Fanapta, and previously known as Zomaril, is an investigational atypical antipsychotic. It is being investigated mainly for the treatment of schizophrenia symptoms. investigationalatypical antipsychoticschizophrenia investigationalatypical antipsychoticschizophrenia

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56 THANK YOU FOR LISTENING THANK YOU FOR LISTENING


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