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Comprehensive Management of Schizophrenia and Bipolar Disorder: Insights from Māori Mental Health Services

This document outlines critical strategies for managing patients with schizophrenia and bipolar disorder, emphasizing the importance of monitoring symptoms, side effects, and concurrent medical problems. Key considerations include treatment compliance, utilization of intramuscular injections, and medication management with a focus on antipsychotic and mood stabilizer therapies. It stresses tailored approaches for Māori patients, ensuring cultural sensitivity and individual preferences are prioritized in care. Following best practices can significantly improve clinical outcomes and enhance quality of life for those affected by chronic mental illnesses.

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Comprehensive Management of Schizophrenia and Bipolar Disorder: Insights from Māori Mental Health Services

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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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