1. Following Frank Patients with Chronic Mental Illness John R. Hall MD Te Roopu Whitiora Maori Mental Health Service

2. Being Frank Ian Rankin Included in A Good Hanging

3. General Follow Up Monitor symptoms Monitor for side effects and toxicity Monitor for concurrent medical problems

4. Schizophrenia A—2+ –Delusions –Hallucinations –Disorganized speech –Disorganized or catatonic behaviour –Negative symptoms B—socio-occupational dysfunction C—duration 6 months

5. Schizophrenia D—exclusion –No mood episode concurrent with active phase symptoms –Mood episode is brief relative to active phase symptoms

6. Symptom management Auditory hallucinations –Nature of voices –Risk of response to voices Delusions General Function Negative Symptoms –Affective flattening –Alogia –Avolition

7. Compliance Deficits of insight Denial or disagreement with provider Side effects of treatment Make treatment as tolerable as possible Utilize Depot intramuscular preparations

8. Typical Antipsychotics Haloperidol Zuclopenthixol Chlorpromazine Trifluoperazine

9. Extra-Pyramidal Symptoms Dystonia –Muscle spasm Oculogyric crisis torticollis Parkinsonism –Bradykinesia –Tremour, rigidity Akathisia

10. Tardive Dyskinesia Lip smacking, tongue protrusion Choreiform hand movements Documented prior to introduction of antipsychotic medications Relative advantage to atypical antipsychotics—especially clozapine

11. Atypical Antipsychotics Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Amisulpride

12. Prolactinaemia Elevated prolactin levels are related to dopamine blockade Worst offenders; Risperidone Relative advantage; Quetiapine, Clozapine Risks; menstrual disturbances, gynecomastia, galactorrhoea, sexual dysfunction

13. Weight Gain Increased food intake/ reduced energy expenditure Worst offenders; Clozapine, Olanzapine Relative advantage; Ziprasidone, Aripiprazole, Amisulpride Switching medications and/or behavioural interventions

14. ECG changes QT prolongation An estimation of risk of torsade de pointes and related arrhythymia (QTc>470,500ms) Offenders; Ziprasidone, Pimozide, tricyclic antidepressants Relative advantage; Aripiprazole, SSRIs

15. Clozapine First two weeks—daily sighting for BP, temp, pulse, adverse effects First 18 weeks—weekly haematology After that monthly haematology Weight and lipids 3-6monthly

16. Clozapine Haematology— –White cells/ neutrophils –Agranulocytosis 1/10,000 –Neutropenia 2.7% Serum Levels— –To monitor compliance –To establish a baseline –When considering reducing dosage

17. Clozapine Other risks Hypersalivation Seizure risk Weight gain and dyslipidemias Pulmonary embolism Myocarditis Cardiomyopathy Constipation

18. Advantages of IMI treatment Compliance Contact with a nurse Patient preference?

19. IMI management Haloperidol –25-200mg –4 weekly injections Flupenthixol –20-400mg –2-4 weekly injections Fluphenazine –12.5-50mg –2-4 weeks

20. IMI management Zuclopenthixol –100-600mg –2-4 weekly injections Pipothiazine –25-200mg –4 weekly injections

21. SGA IMIs Risperdal Consta –25mg, 37.5mg, 50mg –2 weekly injections –Gluteal or deltoid now Olanzapine

22. Bipolar Disorder Distinct Episodes –Mania –Depression –“Mixed” Interepisodic recovery Treatment is essentially prophylactic

23. Symptom management Depression –Motivation/interests, energy –Feelings of hopelessness –Suicidal ideation Mood Elevation –Flightiness, distractibility, excessive energy –grandiosity Sleep Activity level Psychotic symptoms

24. Lithium Serum levels (0.4-1.0mmol/L) –3-6months –Physiological changes, medication changes Toxic symptoms –Gastrointestinal symptoms Anorexia, nausea, diarrhea –Ataxia, disorientations, seizures

25. Sodium Valproate Serum levels (300-700 micromol/L) –3-6 months Toxic Symptoms –Gastric irritation, hyperammonaemia –Lethargy, confusion –Thrombocytopenia –Hepatic changes

26. Teratogenicity Lithium –Cardiac anomaly Sodium Valproate –Neural tube defects

27. Other Mood Stabilizers Carbamazepine Lamotrigine Antipsychotics

28. Lithium Other things to monitor –Thyroid –Renal function

29. Depression in Bipolar Disorder Addition of an antidepressant Optimization of mood stabilizer Addition of an atypical antipsychotic

30. Antidepressants-Long term No peculiar guidelines to long term use General follow up for depression guidelines –1yr following single episode –3-5 yr after two or three episodes –? Be aware of discontinuation syndrome

31. John R. Hall Consultant Psychiatrist Te Roopu Whitiora –Maori Mental Health Services 1/25 Rathbone Street 430-4101 3537 John.Hall@northlanddhb.co.org