Podcast Summary
Effective Strategies for Complex Psychosis Cases: This book offers strategies for managing complex psychosis cases involving comorbid conditions, extensive medication reviews, and consultation-style Q&A sections.
The book "Management of Complex Treatment Resistance Psychotic Disorders" offers effective strategies for addressing complex cases of psychosis, which often involve comorbid conditions like traumatic brain injury, substance use disorder, and personality disorders. The authors, Michael Cummings and Stephen Stahl, draw from their experience working with a large population of severe psychosis patients in California's state hospitals. The book is highly readable, featuring succinct information and numerous tables, making it accessible for healthcare professionals. The primary focus is on positive psychotic symptoms in schizophrenia, which are particularly relevant in forensic settings. The book provides an extensive review of the 85 most commonly used medications for treating these symptoms and offers consultation-style Q&A sections for easy reference. Overall, this resource is an invaluable tool for mental health professionals dealing with complex psychosis cases.
Assessing and treating positive psychotic symptoms in schizophrenia: Dopamine antagonists are commonly used to treat schizophrenia's agitation and delusions. Haloperidol, flufenazine, and olanzapine are common options. Careful dosing and frequent administration are crucial to prevent rekindling of agitation and over-sedation.
The treatment for positive psychotic symptoms of schizophrenia, such as agitation and delusions, often involves dopamine antagonism. This means using drugs that decrease dopamine signal transduction in the mesolimbic system. The severity of these symptoms can be assessed by observing physical signs of agitation, such as hyperactivity, aggression, and destructive behavior. Treatment typically involves administering dopamine antagonists like haloperidol, flufenazine, or olanzapine, along with sedating medications. It's important to titrate doses carefully to avoid over-sedation and to administer medications frequently enough to prevent rekindling of agitation. Oral olanzapine may not be the best option for acute treatment due to its long plasma concentration time. The diagnosis of treatment-resistant schizophrenia requires failure of at least two antipsychotics from different classes, given at sufficient doses for an extended period without significant improvement. The odds of responding to any antipsychotic other than clozapine for treatment-resistant schizophrenia are less than 7%.
Measuring plasma levels for accurate treatment of TRS: Effective treatment for TRS requires monitoring plasma levels to ensure adequate medication, as individual differences in absorption and metabolism impact drug availability in the brain. Persist with treatment options, even when initial trials fail, as response likelihood decreases over time.
When dealing with treatment-resistant schizophrenia, it's crucial to ensure adequate medication levels in the patient's body. Psychiatrists often rely on dosages, but plasma concentrations are a more accurate guide due to individual differences in absorption and metabolism. For instance, valproic acid, a commonly used medication, is highly protein-bound and only a small fraction is available as free drug to enter the brain. Measuring plasma levels can help determine if the patient is receiving an effective dose. It's also important to note that some patients may require higher doses to achieve therapeutic effects. The discussion also highlighted the importance of persisting with treatment options, even when initial trials are unsuccessful, as the likelihood of response to certain medications, like clozapine, decreases significantly after a certain period of treatment resistance.
Mood stabilizers for managing psychomotor agitation in schizophrenia spectrum disorders: Mood stabilizers like lithium and valproic acid can effectively manage psychomotor agitation in schizophrenia spectrum disorders beyond just mood stabilization. Valproic acid's rapid onset of action makes it useful at the outset of treating a psychotic disorder, while lithium's longer onset can determine an initial dose and decrease psychomotor agitation.
When it comes to treating refractory seizure disorders with mood stabilizers like valproic acid, a recommended upper limit of 120 mg/dL is suggested due to tolerability issues. However, individual responses may vary, and some patients may manage well with subthreshold levels. For medications like carbamazepine and oxcarbazepine, while they have their uses, they come with significant side effects and interactions with other drugs. In the context of treating psychomotor agitation in schizophrenia spectrum disorders, mood stabilizers like lithium and valproic acid can be effective beyond just mood stabilization. They inhibit the activity of the limbic system and help suppress psychomotor agitation by decreasing limbic responses. Valproic acid, which has a rapid onset of action, can be useful at the outset of treating a psychotic disorder. Lithium, on the other hand, can be loaded to help determine an initial dose, and while it takes longer to reach steady state, it can be effective in decreasing psychomotor agitation. Overall, mood stabilizers play a crucial role in managing psychomotor agitation and other symptoms in schizophrenia spectrum disorders.
Long acting injectables improve patient outcomes and adherence: Long acting injectables lead to better patient outcomes, longer lifespans, and fewer hospitalizations compared to oral antipsychotics. Providers can seek training to administer them and consider storing and dispensing for streamlined process.
Long acting injectable antipsychotics can significantly improve patient outcomes and adherence compared to oral antipsychotics. Adherence to oral antipsychotics is poor, with studies showing rates as low as 30-40%. Long acting injectables, on the other hand, have been shown to result in longer lifespans and fewer hospitalizations for patients in Europe, where usage rates are much higher than in the US. For providers with no experience in administering long acting injectables, it may be helpful to seek training from nursing staff or local nurse trainers. The injection process itself is not difficult, but infrequent practice can lead to inadequate skills. Providers can also consider storing and dispensing medications in their own practices to streamline the process. Clozapine, a medication often used for treatment-resistant schizophrenia, is another topic worth exploring in the context of long acting injectables.
Clozapine's Additional Benefits for Schizophrenia Patients: Clozapine reduces violence and aggression, and decreases suicide attempts and completed suicides in schizophrenia and schizoaffective patients, without requiring high dopamine receptor occupancy or blocking dopamine directly.
The atypical antipsychotic medication, clozapine, not only shows a higher response rate in patients with schizophrenia, but also has additional benefits. These benefits include a decrease in violence and aggression, potentially due to its effect on improving glutamate signaling in the frontal lobe. Additionally, clozapine has been found to decrease the rate of suicide attempts and completed suicides in schizophrenic and schizoaffective patients by about 5-fold. Unlike other antipsychotics, clozapine does not require high dopamine receptor occupancy to exhibit its benefits, and it is not providing its benefits by blocking dopamine directly. Imaging tests like SPECT and PET scans can be useful in certain cases, such as when there are unusual or atypical features to a patient's psychosis, but they cannot diagnose mental illness directly.
Motivational interviewing may have limited benefit for clozapine-treated schizophrenia patients due to side effects: Side effects of clozapine like emotional blunting and sedation can hinder motivational interviewing and make patients less responsive. Cognitive rehab programs, partial dopamine agonist antipsychotics, memantine, acetylcholinesterase inhibitors, and pramipexole show potential for improving symptoms in clozapine-resistant schizophrenia.
For patients with treatment-resistant schizophrenia on clozapine, motivational interviewing may have limited benefit due to the potential side effects of the medication, such as emotional blunting and sedation. These side effects can make patients less responsive to motivational interviewing and more distant. Sedation from clozapine can last from 4 to 12 weeks, depending on the individual's sensitivity to histamine blockade. For negative symptoms and cognitive deficits, it's recommended to dose antipsychotics at bedtime, as giving them in divided doses is unnecessary. Cognitive rehab programs and partial dopamine agonist antipsychotics have shown positive results for improving cognition and negative symptoms. Although the data is slim, there is some evidence suggesting that memantine and acetylcholinesterase inhibitors may also help improve cognition in schizophrenia. Additionally, pramipexole has shown promise in improving mood and other negative symptoms in these patients.
Medications for aggression and violence in mental health disorders: For bipolar depression, pramipexole may help. Antipsychotics can reduce violence risk in schizophrenia if psychosis is controlled. Antidepressants are generally contraindicated for bipolar illness. Cognitive rehab and mood stabilizers can benefit persistent aggression in schizophrenia. Anticholinergics should be avoided for ongoing use due to side effects.
For individuals with bipolar depression, pramipexole is among the medications that may be helpful. For those with schizophrenia, antipsychotics like dopamine antagonists can help reduce the risk of violence if their psychosis is under control. Antidepressants are generally contraindicated for bipolar illness due to the risk of triggering mania or hypomania. For persistent aggression and violence in schizophrenia patients, cognitive rehabilitation and mood stabilizers like valproic acid or lithium can be beneficial. Anticholinergic medications, while effective for acute dystonia, should be avoided for ongoing use due to potential side effects.
Amantadine: The Long-Term Solution for Preventing Parkinsonism and Dystonia: Amantadine, an antiviral agent, is the long-term solution for preventing Parkinsonism and dystonia in people who have experienced extrapyramidal side effects from antipsychotics. It's typically dosed between 100-200 mg per day, and hydroxyzine, despite its anticholinergic reputation, is not anticholinergic.
While about 70% of people who experience extrapyramidal side effects (EPS) from antipsychotics can be taken off the medication after three months without recurrence, the long-term solution to prevent Parkinsonism or dystonia is actually amantadine, an antiviral agent. Amantadine is typically dosed between 100-200 milligrams per day, and extended-release formulations can help mitigate motor side effects. For those who have been on antipsychotics for a long time, gradually reducing the dosage can lead to noticeable improvements. A common misconception is that hydroxyzine, an antihistamine, is anticholinergic. However, studies show that hydroxyzine has a high Ki value for acetylcholine receptors, making it essentially not anticholinergic. Despite this, hydroxyzine's reputation as an anticholinergic persists due to outdated information. The book being discussed includes a section in Part 2 dedicated to anti-Parkinsonian drugs. Each chapter contains tables with essential information, including mechanisms of action, dosing instructions, and potential side effects. The final table in each chapter provides clinical pearls for effective use. It's crucial to be aware of misconceptions, like the one about hydroxyzine being anticholinergic, and to stay informed of the latest research and information. Regularly updating resources and addressing discrepancies can help ensure that accurate information is shared.
Considering insomnia treatment in schizophrenia, Soporxlonal is common but sleep hygiene, melatonin, and circadian rhythm modulators are also important.: In treating insomnia in schizophrenia, Soporxlonal is often used due to its long half-life. However, sleep hygiene, melatonin, and circadian rhythm modulators should also be considered for sleep phase issues. In childhood onset schizophrenia, a thorough workup is crucial to rule out medical and developmental causes of psychosis or substance use.
When dealing with insomnia in schizophrenic patients, Soporxlonal is the commonly used sedative due to its longer half-life. However, it's important to consider sleep hygiene and potential use of melatonin or circadian rhythm modulators for those with sleep phase problems. In the case of childhood onset schizophrenia, a thorough workup is necessary to rule out medical and developmental issues that may mimic psychosis or be exacerbated by substance use. It's essential to be aware of designer drugs and creative methods children may use to avoid detection in urine drug screens. The comorbidity of substance use disorders in schizophrenia spectrum disorders is prevalent, ranging from 50% to 80%, and can worsen brain deterioration or cause damage leading to schizophrenia-like symptoms. Stimulants like methamphetamine and cannabis use in adolescents, especially for those predisposed to psychotic disorders, can significantly contribute to this comorbidity.
Assessing drug abuse history in new onset schizophrenia: Thoroughly investigating drug use history is essential for new onset schizophrenia patients to improve their prognosis. Amphetamines are commonly linked to schizophrenia cases, but may only be detected for 48 hours on urine drug screens. Always confirm positive results with further testing.
When dealing with new onset schizophrenia, it's crucial to conduct a thorough drug abuse history, not just from the patient, but from any available collateral sources. Failure to address substance use disorders alongside psychosis can negatively impact the patient's prognosis. Amphetamines are commonly linked to schizophrenia cases, especially in areas like Southern California. On urine drug screens, amphetamines may only be detected for 48 hours, and bupropion nasal decongestants can lead to false positives. If a positive result is obtained, reserve a sample for further gas or liquid chromatography mass spectrometry analysis to confirm the presence of the drug. Dr. Cummings' book provides valuable insights and clinical pathways for treating schizophrenia, available in both paperback and electronic formats. Searchable ebooks can be particularly helpful. Remember, your feedback in the form of Amazon reviews can help spread this essential information to future readers.