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Following Frank

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.

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Following Frank

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  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

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