Eleni Palazidou MD PhD MRCP FRCPSYCHEast London Foundation Trust

Action ProgrammeScaling up care for mental, neurological, andsubstance use disorders

VisionEffective and humane care for all with mental, neurological, and

substance

GoalClosing the GAP between what is urgently needed and what is currentlyavailable to reduce the burden of mental, neurological, and substance

usedisorders worldwide by:• Reinforcing the commitment of stakeholders to increase the allocation

offinancial and human resources; and• Achieving higher coverage of key interventions especially in countries

with low and lower middle incomes.

Drug/alcohol-induced psychosis Organic psychosis

Schizophrenia

Paraphrenia Other Paranoid psychoses

Schizophrenia is a chronic illness Onset generally occurs during young

adulthood (15-25years) Lifetime prevalence = 0.7% (300-600,000

people at any one time in UK) Economic burden: Can account for up to

1.5% to 3% of healthcare costs

Mental illness is associated with higher mortality rates for physical illness

50% increased risk of death from physical disease in schizophrenia

20% decrease in life span for physical disease in schizophrenia

Cardiovascular mortality increased 1976-1995

Greatest increase in SMR(ratio of observed over expected death rate) from 1991-95

Positive symptoms Negative Positive symptoms Negative symptomssymptomsDelusions

Hallucinations

Grandiosity

Suspiciousness/Persecution

Excitability

1. Kay SR, Fiszbein A, Opler LA. The positive and Negative Syndrome Scale (PANSS).Schizophr Bull 1987;13:261-276.

Somatic concernAnxiety / Guilt feelings

Mannerisms and posturingUncooperativeness

DisorientationPoor impulse control

Preoccupation

General General PsychopathologyPsychopathology

Blunted affect

Emotional withdrawal

Difficulty in abstract thinking

Social withdrawal

Lack of spontaneity

Poor rapport

Primary (?deficit) SecondaryPrimary (?deficit) Secondary

Blunted/flat affect Resulting from +ve s-ms Poor rapport -depression Emotional withdrawal -

demoralisationPassive social withdrawal Poor social skills Rx related side effectsPoor self care -EPSAlogia(poverty of speech)AnergiaApathyAvolition

In-patient care Community care

?Need for using Mental Health Act

Community mental health teams

Care Programme Approach (CPA)

Care coordinator

Care planCare plan

Antipsychotic drugsPsychoeducation

Cognitive behavioural therapyFamily therapy, psychoeducation

Monitoring and supportRehabilitation – social skills, work, training

etc

Guidelines in the treatment of medical disorders

Review the literature on efficacy and tolerability of drugs as well as cost efficiency

1960s-70s First generation – “classical”First generation – “classical”

Phenothiazines - chlorpromazine Butyrophenones - haloperidol Thioxanthines - flupenthixol

From 1980s Second generation – “atypicals”Second generation – “atypicals”

Clozapine, olanzapine, quetiapine, Sulpiride, amisulpride

Risperidone, paliperidone Aripiprazole

ExtrapyramidalExtrapyramidalParkinsonism

DystoniaAkathisia

Tardive dyskinesia

Hyperprolactinaemia Hyperprolactinaemia AmenorrhoeaLow fertility

Sexual dysfunction

Cardiovascular – QT intervalHaematological

Weight gainLower seizure threshold

Drug interactions

Electrolyte imbalance ( ↓K, ↓Mg)

Underlying cardiac abnormalities

Hypothyroidism

Familial QT prolongation Σ

Drugs known to prolong QT

Higher risk of QTc prolongation and Torsades de Pointes – iv administration or high doses

Recent recommendation an ECG to be performed prior to Rx

Great variation in pharmacological profile!

In general they have decreased likelihood of extrapyramidal effects or

hyperprolactinaemia

BUT

Weight gainDiabetes

Metabolic syndrome

First generationFirst generation Second generationSecond generation

Weight gain

Hyperglycaemia, diabetes

Insulin resistance

Cardiovascular dis

Dyslipidaemia

Less EPS

Less QT prolongation

Less hyperprolactinaemia

Neurological side effects

EPS

Tardive dyskinesia

Hyperprolactinaemia

5.1

9.8

7.9

18.0

23.0

29.0

3.7 4.05.0

9.0

6.0

3.00

5

10

15

20

25

30

Aripiprazole** Ziprasidone PALI*** Risperidone Quetiapine Olanzapine

Per

cen

t o

f P

atie

nts

(%

) Drug Placebo

* Based on USPIs** Error bars reflect reporting of w eight gain in PI by baseline BMI*** Based on SCH-303, 304, 305 pooled dataset (all doses)

Drug treatment needs to be tailored to the individual taking into consideration:

clinical presentation potential efficacy potential side effects present/previous physical health family history ethnicity gender, age patient choice