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.
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Managing Psychosis(NICE Guidelines 2014)
Dr. Azlan Luk
Consultant Psychiatrist
Guildford CMHRS
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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
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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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RemindersReminders
Lifetime incidence – 1%
Young adulthood
Most people recover
Patient centred care
(cost to society – England 2004/5 – 6.7 billion)
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Reproduced from Prince et al. Lancet. 2007;370: 859-877. © 2007, Elsevier Ltd.
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World Wide Causes of Disability
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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
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ProdromalProdromal
CBT
Treat other conditions
• Anxiety
• Depression
• Emerging PD
• Substance Misuse
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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
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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)
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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
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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
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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
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Treatment resistantTreatment resistant
Review, adherence, psychological therapies, comobidities
Clozapine
Augmentation - trial of 8-10 weeks
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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
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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
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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
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Carers – cont.Carers – cont.
Carer focused education & support programme
• Availability
• +ve message
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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
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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 ?
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