Schizo Pharm and other Tx

  1. treatment modalities
    • Acute phase: inpatient, milieu therapy, nurse-pt relationship, medications
    • chronic: residential or day programs, group homes, managed apts, psychosocial rehab for ADL's, assertiveness training, communications, health/nutrition, exercise, medication adherence, vocational/financial training
    • medication: primary form of tx
    • individual therapy: supportive, cognitive behavior therapy
    • group or family therapy
  2. tx modalities 2
    • program of assertive community treatment:
    • a program of case management that takes a team approach in providing comprehensive, community based psychiatric treatment, rehabilitation, and support to persons with serious and persistent mental illness
    • List of services:
    • - substance abuse tx
    • - psycho educational programs
    • - family support and education
    • - mobile crisis intervention
    • - attention to health care needs
    • - psychiatrist and nurses
  3. PACT (also known as MTT mobile treatment teams)
    • services are provided by a multidisciplinary team
    • services are available 24 hours a day, 365 days a yr
    • services are provided where assistance by the client is required
  4. PACT
    the primary goals of pact
    • to meet basic needs and enhance quality of life
    • to improve role functioning
    • to enhance independent living (stay in home)
    • to lessen family burden of providing care
    • to decrease debilitating symptoms of mental illness
    • to minimize recurrent acute episodes of the illness
  5. tx modalities 3 *
    • based on new research, recovery model should be present in all forms of therapy: day tx, family, social, individual, group and behavioral
    • recovery is a concept of healing and transformation enabling a person with mental illness to live a meaningful life in the community while striving to achieve his or her FULL potential
    • in order to work pt has to know access to tx
  6. Psychopharmacology
    • Antipsychotics agents: purpose
    • effectiveness
    • other names
    • actions
    • types:
    • - 1st generations (conventional/typical)
    • - 2nd generation/atypical
    • have varying side effects
  7. Purpose of Antipsychotics
    • decrease as many of the psychotics symptoms as possible--- allows patients to assume more control over their lives, can participate more effectively in other forms of tx, eg group therapy, vocational rehab
    • used to decreased agitation and psychotic symptoms of schizo and other psychotic disorders
    • other names: neuroleptics, psychotropic medications, major tranquilizers
    • can't do the recovery model until they are medically treated
  8. Purpose- action
    • action: block receptors for the NT dopamine, however the therapeutic mechanism of action is only partially understood
    • may show a significant degree of improvement in the first fee days, may take 2-4 weeks for other to show improvements
    • blockage of dopamine receptors thought to be responsible for controlling positive signs of schizo
  9. Clinical Use and Efficacy
    response varies with targeted symptoms
    • positive symptoms most responsive- can take up to 7 days
    • agitation irritability often relieved within hours- sedation
    • affective symptoms may take 2-4 weeks- mood, decision making, thoughts
    • cognitive & perceptive symptoms may take 2-8 weeks
    • see this w/1st generation. 2nd generation more mood
  10. clinical use and efficacy
    negative symptoms
    • negative symptoms respond slowest and least
    • - increased doses do not help here*
    • lowest dose shortest amount of time (start low + go slow)
    • - divided doses: 3-4x/day when pt tolerates/minimal side effects, chx to daily dose, this will increase compliance
    • Atypical or the newer antipsychotics- more effective on negative symptoms*
    • help s/e right away so they remain compliant.
  11. First Generation
    • names: Thorazine (1stst used in 1950), Haldol, Prolixin, Trilafon and Mellaril (rarely used now)
    • Action: blocking postsynaptic dopamine receptors
    • usage lower due to side effects, but newer antipsychotic have other undesirable side effects, so resurgent use here
    • high potency is Haldol, Prolixin- chemical restriants/emergence- calm pt down, 72 hrs in system (sit in fat cells- lives longer)
    • moderate potency is Thorazine, Mellaril
    • - antiemetic effect
    • - tx nausea
  12. First generation s/e (general)
    • 1. Medical contraindications: Prolong the OT interval; contraindications if pt on other drugs that also produces this side effect
    • 2. lower seizure threshold **- if pt has potential to have seizure you may lower it
    • 3. liver impairment
    • 4. diminished libido
    • 5. weight gain
    • 6. EPS this is a serious neurologic symptom... major side effects. there are secondary to the blockage of D2 receptors in the midbrain region of the brain stem. higher incidence with first generation meds
    • EKG prior to start, adults 3months, children 8 weeks
    • becareful with cardiac meds
    • AIMS
  13. EPS
    • are side effects of antipsychotic medicine. EPS can cause movement and muscle control problems through out the body such as:
    • 1. Akathesia- restlessness and nervous energy shown by pacing, marching, shuffling, or foot tapping- "walkie-talkies" can't stop walking and talking
    • 2. Dystonia- acute muscular rigidity and cramping¬† severe, uncontrolled muscle contractionss of your head, neck, trunk- painful, can turn into emergency
    • 3. torticollis dystonia- severe twisted head and neck
    • 4. Oculogyric crisis- eyes rolled back in a locked position- painful
  14. EPS cont
    • 5. pseudoparkinsonism- such as tremors, stiff posture, or no arm movement when you walk, weak voice, drooling, or little or no facial expression
    • 6. tardive dyskinesia- is a difficult to treat and often incurable of dyskinesia. occurs due to long term (usually at least moths duration) or high dose use of antipsychotic drugs. this can lead to uncontrolled movements of your tongue, jaw, lips or face such as pursing, chewing or frequent eye blinking, movements of fingers or toes, head nodding, or pelvic thrusting, fast, irregular breathing w/grunts, gasping or sighing
    • all very frightening to patient
  15. TX
    for oculogyric crisis, dystonia, torticollis
    • immediate tx anticholinergic drugs eg IM cogentin (benzotropine mesylate) or IM benadryl usually brings rapid relief**
    • for ankathesia is change in dose or brand antipsychotic med or concurrent used meds listed as above po dauly and prn
    • for pseudo parkinsonism is change to antipsychotic with lower incidence of EPS, lower dose of med or treat with same med as above congentin po prn, artane (po only) or benadryl po daily and prn
  16. s/e of anticholinergic
    • Congentin, artane, benadryl, vistaril
    • orthostatic hypotension
    • dry mouth
    • urinary retention
    • blurred vision
    • photophobia
    • constipation
    • need to increase fluids, fiber, fruit, tend to lips and skin, increase dental care and use biotene (rinse), offer throat drops and hard candies
  17. NMS neuroleptic malignancy syndrome
    • rare, potentially fatal adverse effect, medical emergency
    • onset can occur within hours or yrs
    • progression rapid, over folllowing 24-72 hours
    • symptoms:
    • - severe muscle rigidity
    • - hyperpyrexia up 107
    • - tachycardia, tachyapenea, fluctuations in bp
    • - diaphoresis
    • - rapid deterioration of mental status to stupor and coma
    • in conjuntion with SSRI
  18. NMS effects
    • effects 1%
    • 10% mortality rate
    • young male pt most often effected
    • leukocytosis (elev WBC 15,000-30,000)
    • greatly elev creatine phosphokinase (CPK)- due to¬† muscle tissue damage
  19. tx of NMS
    • tx: may be admitted to the ICU
    • d/c med immediately
    • monitor VS, LOC, I&O (hydration)
    • cooling blankets, prn
    • management of arrhythimas and htn
    • MD may order:
    • - parlodel-antiparkinsonian
    • - dantrium- muscle relaxant to counteract effectts (muscle ridigity)
    • wait 1-2 weeks to restart any meds
  20. contraindicated
    unless dx with long term chronic disabling psychotic, elderly patients should not be on an antipsych meda
  21. Atypical antipsych 2nd generation
    • less incidence with EPS, NMS
    • dopamine and serotonin antagonists
    • - clozapine (clozaril)-
    • , Olanzepine (zeprexa)- alot of pts on this
    • , risperidone (risperdal),MRI to make sure no tumor, prolactin levels monitor, neuroendo- men boobs
    • Quetiapine (seroquel)- check eye exam q 6 months
    • DA/SSRI system stabilizers-partial agonist
    • (does not completely distrupt the dopamine pathways)
    • - ziprasidone (geodon)- cardiac problem and aripiprazole (abilify)- antidepre/antipsych slowly goes in- for stable pt
  22. 2nd generation atypical
    saphris (asenapine (new and said to rebalances dopamine and serotonin to improve thinking, mood and behavior
  23. general side effects of atypical
    • n/v
    • gi distress
    • mood chx
    • sedation
    • weight gain
    • development of mild eps
  24. specific s/e of atypical
    • geodon- can increase seizure risk, and cardiac consideration, prolonged QT wave, myocardiditis
    • resperdone can increased risk of EPS over other atypical and high neur endocrine effect as the incr prolactin
    • zyprexa- weight gain 50-80% and metabolic syndrome (risk for developing dm)
    • seroquel- can affect mood, catarycts
    • all can induce
    • abdominal obesity
    • incr in trig lebel
    • bp incre 130/85 or higher
    • fasting glucose of 100 or over
  25. other metabolic s/e
    • priapism- not associated with sexual arousal
    • urologic emergency that requires prompt intervention to prevent damage to penis
    • hyperprolactic levels (breast enlargement, galactorrhea, amenorrhea)
  26. s/e atypical
    • Clinical Antipsychotic trials of intervention Effectiveness
    • Study 2005 by NIMH (1000s participated schizo landmark study). 13% had Dm at baseline- 4x more common than the general population, FDA reccommends monitoring glucose levels
    • study states 41% pf all pts had the metabolic syndrome at baseline w/abd obesity waist measurement in men > 40 women > 35 trig >150
  27. other metabolic s/e atypical
    • orthostatic hypotension usually goes away after 3-4 weeks teach to get up slowly
    • hypersalivation (clozaril)- embrassing and risk for aspiration
    • makes them look more ill
  28. Clozaril (atypical chronic unresponsive to other meds)
    • have to register pt on this med
    • most significant s/e increase susceptibility to bacterial and fungal infections
    • so watch for fever, fatigue, sore throat, buccal ulcers, dyspnea, tachycardia
    • usual course- acute-very sedating, blurred vision (may not resolve until med removed, dec bp, incr salivation (tx w/prasosin- also help them sleep)
    • miracle drug
    • all labs go to pharmacy
    • if pt doesn't like needles or immune system problem= dont use meds
  29. clozaril cont check
    • frequent WBC
    • - agranulocytosis can be fatal blood disorder
    • - wbc below 3000 ANC (absolute neutril count) >1500
    • this is reversible only if discovered in early stages
    • used after several other drugs failed
    • check weekly (esp children), then q 2 wks, then monthly
    • pt stops if bottom out then one attempt thats it
    • if ANC <2000 check q 3 days
  30. clozaril- can be fatal
    how to take
    • 40% mortality rate usually from overwhelming infection
    • monitor wkly for the 1st 6 months
    • then every other week for 1 yr
    • then once a monthly to admin med
    • check wbc esp ANC
  31. depo medication long acting injectable
    • prolixin decanoate IM q 7-28 days
    • haldol decanoate IM q 4 weeks
    • risperdal consta mixed results and relatively new IM q2 weeks
    • other depo meds- olanzapine, ablify
    • long acting antipsych if you se/ it will last longer- so they usually start on the po med 1st
  32. benefits depo
    • gradually release overtime
    • better med adherence
    • maintenance of stable drug levels
    • prevention or delay of relapse
    • better monitoring of pt compliance
    • see nurse monthly or bi weekly for assessment
    • people with schizo who difficulty to remember to take meds dauly or those who lack insight to take their meds on regular basis benefit from receiving meds IM
    • prevention of acute hosp/
  33. contraindication to the use of depo
    • known hypersensitivity to meds
    • CNS depression
    • blood dyscrasias
    • parkinson disease
    • liver, renal, cardiac insufficiency
    • - most metabolize in liver
    • - excreted by kidney
  34. reason for non adherence to meds
    patient r/t factors
    • symptoms
    • cognitive function is slower
    • healthcare beliefs
    • previous non adherence
    • hx of co-morbid subtance use
    • cultural or religious abstention
  35. reason for non adherence
    medical r/t factor
    • lack of efficacy
    • distressing s/e
    • high doses w/incr complication
    • medication type
    • medication regimen complexity
    • may not feel that they are working
  36. reason for non med adherence
    environment factos
    • care giver suppor
    • fam and social support
    • financial barrier
    • practical barrier- transportation
    • clinical factor
    • poor therapeutic alliance
    • attitude of staff
  37. other meds co-occuring
    • anxiolytics
    • antidepress
    • mood stab mania- lithium
    • mood stab- anticonvulsants, tegretol, depakote
    • all may help with negative symp of schizo
    • polypharm
  38. other tx
    • ECT- was initially developed for schizo
    • currently ECT is controversal for schizo- catatonia- can be used
    • schizo pt w/catatonia, affective, positive on recent onset- ECt may work
    • also a combo with pharmatherapy and ECT may work well together (clorazil)
  39. relapse prevention
    • etiology
    • denial of illness (insight)
    • noncompliance (past hx)
    • lack of fam support (resources)
    • inability to cope or access health system (practical barries)
    • med failures
    • educate about
    • symptoms
    • meds
    • compliance
    • post d/c services
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Schizo Pharm and other Tx