Managing Psychosis (NICE Guidelines 2014) Dr. Azlan Luk Consultant Psychiatrist Guildford CMHRS.
Transcript of Managing Psychosis (NICE Guidelines 2014) Dr. Azlan Luk Consultant Psychiatrist Guildford CMHRS.
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
OutlineOutline
• Recap on Schizophrenia
• Psychosis• Prodromal
• Prevention
• First Episode
• Subsequent Episodes
• Promoting recovery
• Treatment Resistant
Physical Health
Carers
Peer Support
• Referral pathways
RemindersReminders
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
SymptomsSymptoms
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
ProdromalProdromal
CBT
Treat other conditions
• Anxiety
• Depression
• Emerging PD
• Substance Misuse
Preventing Psychosis (2014)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 PsychosisFirst 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)
MonitoringMonitoring
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)
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Physical health (2014)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 periodEarly Post-acute period
Write account of experiences
Medication for 1-2 years
If withdraw medication – monitor for up to 2 years
Promoting recoveryPromoting 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 resistantTreatment resistant
Review, adherence, psychological therapies, comobidities
Clozapine
Augmentation - trial of 8-10 weeks
Relapse and re-referralRelapse and re-referral
Re-refer when
- relapse
- poor response to treatment
- non-adherence
- side effects
- co-morbid substance misuse
- risks
- patient request
Subsequent EpisodesSubsequent 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)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.Carers – cont.
Carer focused education & support programme
• Availability
• +ve message
Peer Support & Self Management (2014)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
OutlineOutline
• Recap on Schizophrenia
• Psychosis• Prodromal
• Prevention
• First Episode
• Subsequent Episodes
• Promoting recovery
• Treatment Resistant
Physical Health
Carers
Peer Support
• Referral pathways
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Questions ?