Presentation Headline

Report
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
•
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)
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
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
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)
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)
Weight
6 weeks
12 weeks
1 year
Annually
✔
✔
✔
✔
✔
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
Early Post-acute period
 Write account of experiences
 Medication for 1-2 years
 If withdraw medication – monitor for up to 2 years
Promoting recovery
 Primary care
• 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
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
Outline
•
Recap on Schizophrenia
•
Psychosis
•
Prodromal
•
Prevention
•
First Episode
•
Subsequent Episodes
•
Promoting recovery
•
Treatment Resistant
Physical Health
Carers
Peer Support
•
Referral pathways
Questions ?
25

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