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

Outline Recap on Schizophrenia Psychosis Physical Health Carers Prodromal Prevention First Episode Subsequent Episodes Promoting recovery Treatment Resistant Physical Health Carers Peer Support Referral pathways

Reminders Lifetime incidence – 1% Young adulthood Most people recover Patient centred care (cost to society – England 2004/5 – 6.7 billion) Most people recover although some will have persisting difficulties orremain vulnerable to future episodes Significant stigma

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

World Wide Causes of Disability

Symptoms 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 A few days to 18/12

Prodromal CBT Treat other conditions Anxiety Depression Emerging PD Substance Misuse

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 Freq and duration of monitoring – severity of symptoms, level of impairment / distress and degreee of family disruption of concern

First 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) PTSD in 1/3 with psychosis and schizophrenia 2/3 relate to psychosis and the management Little evidence for family interventions or CBT alone without antipsychotic medications (if wanting just psychotherapy – agree a time limit - ? 1 month

Monitoring 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) (secondary care until stabilised)

Fasting BG, HbA1c, lipids, Prolactin 6 weeks 12 weeks 1 year Annually Weight ✔ Waist Pulse BP Fasting BG, HbA1c, lipids, Prolactin 12

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 Weight, cardiovascular and metabolic indicatora – audited in annual team reporet Compliance with monitoring cardiovascular and metabolic disease – board level performance indicators Smoking : offer despite failed attempts previously. Effect on antipsychotics – clozapine and olanzapine

Early Post-acute period Write account of experiences Medication for 1-2 years If withdraw medication – monitor for up to 2 years Long term health risks, increased mortality and cortical grey matter loss linked to antipsychotic exposure. Dutch trial 20% successful stopping after 7 years f/u High risk of relapse if stop within 1 -2 years

Promoting recovery Primary care Clozapine Review medication annually 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 resistant Review, adherence, psychological therapies, comobidities Clozapine Augmentation - trial of 8-10 weeks

Relapse and re-referral Re-refer when - relapse - poor response to treatment - non-adherence - side effects - co-morbid substance misuse - risks - patient request

Subsequent 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 CBT – acute phase or later including inpatient stay

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. Carer focused education & support programme Availability +ve message

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 Evidence is not strong - low quality

Outline Recap on Schizophrenia Psychosis Physical Health Carers Prodromal Prevention First Episode Subsequent Episodes Promoting recovery Treatment Resistant Physical Health Carers Peer Support Referral pathways

Questions ? 25