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

Being Frank Ian Rankin Included in A Good Hanging

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

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

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

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

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

Typical Antipsychotics Haloperidol Zuclopenthixol Chlorpromazine Trifluoperazine

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

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

Atypical Antipsychotics Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Amisulpride

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

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

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

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

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

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

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

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

IMI management Zuclopenthixol – mg –2-4 weekly injections Pipothiazine –25-200mg –4 weekly injections

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

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

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

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

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

Teratogenicity Lithium –Cardiac anomaly Sodium Valproate –Neural tube defects

Other Mood Stabilizers Carbamazepine Lamotrigine Antipsychotics

Lithium Other things to monitor –Thyroid –Renal function

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

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

John R. Hall Consultant Psychiatrist Te Roopu Whitiora –Maori Mental Health Services 1/25 Rathbone Street