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Base Course Psychosis

Version-2.00 May 2017 DO NOT UPLOAD ON THE INTERNET. Base Course Psychosis. Contents (Psychosis). Introduction Learning objectives Key actions Establish communication and build trust Conduct assessment Plan and start management Follow up. What is psychosis?. Psychosis

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Base Course Psychosis

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  1. Version-2.00 May 2017 DO NOT UPLOAD ON THE INTERNET Base CoursePsychosis

  2. Contents (Psychosis) • Introduction • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  3. What is psychosis? Psychosis • A syndrome involving the loss of contact with reality Hearing voices or seeing things that are not there Having false beliefs being suspicions Experiencing disorganized thoughts and behavior • The person may not be aware of the psychosis Acute psychosis • The symptoms started within last 3 months or there is a worsening of symptoms • It can be a first episode or a relapse mhGAP-IG base course - field test version 1.00 – May 2012

  4. Natural history of psychosis • Psychosis often begins when a person is in their late teens to mid-twenties. • There are 3 possible clinical courses • the person recovers completely or partially with some symptoms • the person recovers but has a future episode (relapse) • symptoms continue for 3 months or more (chronic psychosis) mhGAP-IG base course - field test version 1.00 – May 2012

  5. Facts about psychosis • Psychosis occurs frequently three out of 100 people will experience psychosis at some time in their lives. • Psychosis can be a symptom of a mental illness or a physical problem. • Psychosis has a dramatic impact on individuals, families and society andsss can be responsible for any of the following: • Loss of relationships and income opportunities • Human rights violations (discrimination, abuse, confinement) • Burden on carers (time, money, stigma) mhGAP-IG base course - field test version 1.00 – May 2012

  6. Facts about psychosis • Psychosis can be managed outside hospitals • e.g., at primary health care clinics • Care can be offered in non-specialized health care • Medical treatment is simple and effective • More accessible than specialist care • Less stigmatized than care in mental hospitals mhGAP-IG base course - field test version 1.00 – May 2012

  7. Contents (Psychosis) • Introduction • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  8. Learning objectives • To be able to assess a person with possible Psychosis • To be able to manage untreated Psychosis utilizing the following: • pharmacological interventions • Psychosocial interventions • To know when to refer clients. • To be able to provide follow-up care. mhGAP-IG base course - field test version 1.00 – May 2012

  9. Contents (Psychosis) • Introduction • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  10. Establish communication and build trust Treat the person with respect and dignity Try to understand the person's perspective Introduce your questions in a respectful way Do not rush; it may take several sessions to build trust Do not challenge false beliefs or mock the person Ask how the person's life has been affected Advocate on the person's behalf mhGAP-IG base course - field test version 1.00 – May 2012

  11. Contents (Psychosis) • Introduction • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  12. ASSESSMENT of PSYCHOSIS. COMMON PRESENTATIONS OF PSYCHOSES Marked behavioral changes (aggression, agitation, decreased or increased activity) neglecting usual responsibilities related to work, school, domestic or social activities. Fixed false beliefs not shared by others in the person’s culture. Hearing voices or seeing things that are not there. Lack of realization that one is having mental health problems. mhGAP-IG base course - field test version 1.00 – May 2012

  13. ASSESSMENT EVALUATE FOR MEDICAL CONDITIONS Is the history, clinical examination, or laboratory findings, suggestive of a delirium due to an acute physical condition? Does he present with signs or symptoms of an acute physical condition?( e.g. cerebral malaria, dehydration, infection or metabolic abnormalities). Is he experiencing side effects to medication? Assess and manage any physical condition and refer the patient to emergency services or to a specialist if required. mhGAP-IG base course - field test version 1.00 – May 2012

  14. ASSESSMENT Explore other explanations for the symptoms Assess for other relevant MNS conditions. Assess for acute manic episode Evaluate if the person has psychosis mhGAP-IG base course - field test version 1.00 – May 2012

  15. Conditions that may cause Psychosis Assess for the following; Dementia - problems with memory and orientation - behavioral problems, apathy or irritability - loss of emotional control, easily upset, irritable or tearful Depression: Does he present with persistent depressed mood -Lack of interest or pleasure in activities once enjoyed. Drug/Alcohol intoxication or withdrawal. If present refer to relevant modules and consult with Mental Health specialist for management of concurrent condition. mhGAP-IG base course - field test version 1.00 – May 2012

  16. Is the person having an acute manic episode Have several of the following symptoms occurred simultaneously, lasting for at least 1 week and interferes with work or social activities? Elevated or irritable mood, inflated self esteem Decreased need for sleep, easily distracted Increased activity and increased energy Impulsive or reckless behavior increased talkativeness or rapid speech Loss of normal social inhibitions (sexual discretion) If a Manic episode is present then suspect Bipolar Disorder Manic Episode. mhGAP-IG base course - field test version 1.00 – May 2012

  17. Does the person have Psychosis? Does the person have at least two of the following: – Delusions, fixed false beliefs not shared by others in the person’s culture Hallucinations, hearing voices or seeing things that are not there. Is his speech disorganized? Is he mumbling or laughing to himself? is his behavior strange? are there signs of self-neglect? If present, Psychosis must be considered. If absent consult with a specialist to review other causes. Is there a risk of suicide? this should be urgently managed. mhGAP-IG base course - field test version 1.00 – May 2012

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  21. Contents (Psychosis) • Introduction • Learning objectives • Key actions • Establish communication and build trust • Conduct assessment • Plan and start management • Link with other services and supports • Follow up mhGAP-IG base course - field test version 1.00 – May 2012

  22. Management Management protocol consist of the following: Psychosocial Intervention. Pharmacological Intervention. Promoting functioning in daily activities. Safety of the person and that of others. Providing regular follow-up. Support rehabilitation in the community. Reduce stress and strengthen social supports. mhGAP-IG base course - field test version 1.00 – May 2012

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  24. MANAGEMENT FOR SPECIAL POPULATIONS Women who are pregnant or breast feeding Adolescents The Elderly Please note that interventions for Psychosis may differ in these populations. mhGAP-IG base course - field test version 1.00 – May 2012

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  26. PSYCHOSOCIAL INTERVENTIONS The following psychosocial interventions are used in the management of Psychosis: 1. Psychoeducation 2. Reduce stress and strengthen social supports 3 . Promote functioning in daily living activities. 4. General advice to carers. mhGAP-IG base course - field test version 1.00 – May 2012

  27. PSYCHOSOCIAL INTERVENTIONS PSYCHOEDUCATION Key messages for the person and their carers: Explain that the symptoms are due to a mental health condition that is treatable, and that the person can recover. Clarify common misconceptions about psychosis . Avoid blaming the person or their family of being the cause of the symptoms. Educate the person and the family on the importance of taking the prescribed medications Explain the importance of regular follow-up care. mhGAP-IG base course - field test version 1.00 – May 2012

  28. PSYCHOEDUCATION Recommend avoiding alcohol, cannabis or other nonprescription drugs. Give advise on maintaining a healthy lifestyle. Encourage the person to resume social activities. Explain that symptoms can reoccur or worsen and the importance of visiting the health facility as soon as possible should this happen. Coordinate with available health and social resources to meet the family’s physical, social, and mental health needs mhGAP-IG base course - field test version 1.00 – May 2012

  29. Reduce stress and strengthen n social support Coordinate with other sectors such as health and social services to assist with the family’s physical, social, and mental health needs. Identify the person’s prior social activities that, if reinitiated, may provide direct or indirect psychological and social support. Encourage the person to resume social activities while seeking support from family members. ss mhGAP-IG base course - field test version 1.00 – May 2012

  30. Promote functioning in daily living activities Continue regular social, educational and occupational activities as much as possible. Facilitate inclusion in economic activities, including culturally appropriate supported employment. Offer life skills training and/or social skills training for people with psychosis and bipolar disorders and for their families and/or carers. Facilitate, if available and needed, independent living and supported housing that is culturally and contextually appropriate in the community. mhGAP-IG base course - field test version 1.00 – May 2012

  31. General advice for carers Do not try to convince the person that his or her beliefs or experiences are false . Try to be neutral and supportive. Avoid constant or severe criticism or hostility towards the person with psychosis. Give the person freedom of movement. Avoid restraining the person, but ensure that their security and that of others is met. Explain that it is better for the person to live with family or within a supportive community environment . Avoid long-term hospitalization. mhGAP-IG base course - field test version 1.00 – May 2012

  32. PHARMACOLOGICAL INTERVENTIONS PSYCHOSIS. Antipsychotics should routinely be offered to a person with psychosis Start antipsychotic medication immediately. Prescribe one antipsychotic at a time start at lowest dose titrate up slowly to reduce risk of side effects. Try the medication at a typically effective dose for at least 4-6 weeks before considering it ineffective. Monitor weight, blood pressure, fasting sugar, cholesterol and ECG for persons on antipsychotics if possible mhGAP-IG base course - field test version 1.00 – May 2012

  33. Side effects to look for: Extrapyramidal side effects (EPS): akathisia, acute dystonic reactions, tremor, cog- wheeling, muscular rigidity, and tardivedyskinesia. Treat with anticholinergic medications when indicated and available. Metabolic changes: weight gain, high blood pressure, increased blood sugar and cholesterol. ECG changes (prolonged QT interval): monitor ECG if possible. Neuroleptic malignant syndrome (NMS): a rare, potentially life-threatening disorder characterized by muscular rigidity, elevated temperature, and high blood pressure mhGAP-IG base course - field test version 1.00 – May 2012

  34. Management of EPS • If extrapyramidal side-effects (EPS) occur, reduce the dose of antipsychotic medication • If dose reduction is ineffective, consider anticholinergics to counteract side effects • Anticholinergics arefor short-term use ifextrapyramidal side-effects are acute, severe or disabling. mhGAP-IG base course - field test version 1.00 – May 2012

  35. Anticholinergic medications mhGAP pg 43 Biperiden Trihexyphenidyl (benzhexol) These medications are used for treatment of extrapyramidal side effects (EPS). They should be avoided in women who are pregnant or breast feeding if possible. They are only used in the short term, and only after dose reduction have failed. mhGAP-IG base course - field test version 1.00 – May 2012

  36. Biperiden DOSING:Start 1 mg twice daily. Increase to 3-12 mg daily. Route: p.o or intravenous (i.v.) SIDE EFFECTS Common: sedation, confusion and memory disturbance (especially in older adults), tachycardia, dry mouth, urinary retention and constipation. Caution in patients with: cardiac, liver, or kidney disease. Drug-drug interactions: Caution when combining with other anticholinergic medications mhGAP-IG base course - field test version 1.00 – May 2012

  37. TRIHEXYPHENIDYL (Benzhexol) Dosing start 1 mg daily. Increase to 4-12 mg per day in 3-4 divided doses (maximum 20 mg daily). Route: p.o Common side effects: sedation, confusion and memory disturbance (especially in older adults), tachycardia, dry mouth, urinary retention and constipation. Rarely, angle-closure glaucoma, myasthenia gravis and gastrointestinal obstruction. mhGAP-IG base course - field test version 1.00 – May 2012

  38. Manic Episode in Bipolar Disorder If patient is on antidepressants: DISCONTINUE ANTIDEPRESSANTS to prevent further risk of mania. Begin treatment with lithium, valproate, carbamazepine, or with antipsychotics (see Table 3). Lithium: consider using lithium as first line treatment of bipolar disorder only if clinical and laboratory monitoring are available, and prescribe only under specialist supervision mhGAP-IG base course - field test version 1.00 – May 2012

  39. Manic Episode in Bipolar Disorder Valproate and Carbamazepine: These can be used if clinical, laboratory or specialist monitoring for lithium is not available. Haloperidol and risperidone: can be considered only if no clinical or laboratory monitoring is available to start lithium or valproate. Risperidone can be used as an alternative to haloperidol in individuals with bipolar mania . mhGAP-IG base course - field test version 1.00 – May 2012

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  44. Review adherence, side effects and dosing based on clinical situation/ presentation CLINICAL SITUATION The person is not tolerating antipsychotic medication, i.e. the person has extrapyramidal symptoms (EPS) or other serious side effects ACTION Reduce the dose of antipsychotic medication. If side-effects persist, consider switching to another antipsychotic medication. Consider adding anticholinergic medication for short-term use to treat EPS if these strategies fail or if symptoms are severe. mhGAP-IG base course - field test version 1.00 – May 2012

  45. Review adherence, side effects and dosing based on clinical situation/ presentation CLINICAL SITUATION: Adherence to treatment is unsatisfactory ACTION Discuss reasons for non-adherence with the person and carers. Provide information regarding importance of medication. Consider depot/long-acting injectable antipsychotic medication as an option after discussing possible side effects of oral versus depot preparations. mhGAP-IG base course - field test version 1.00 – May 2012

  46. Review adherence, side effects and dosing based on clinical situation/ presentation CLINICAL SITUATION Treatment response is inadequate despite adherence to medication ACTION Verify that the person is receiving an effective dose of medication. If the dose is low, increase gradually to lowest effective dose. Askabout alcohol, substance use or stressful event. Rule out physical and/or other priority MNS conditions. Consider risperidone as an alternative to haldol. mhGAP-IG base course - field test version 1.00 – May 2012

  47. Management of Persons with agitated and/or Aggressive Behavior. ASSESSMENT Attempt to communicate with the person. Evaluate for underlying cause: – Check Blood Glucose. If low, give glucose. – Check vital signs, including temperature and oxygen saturation. Give oxygen if needed. – Rule out delirium and medical causes including poisoning. – Rule out drug and alcohol use. Specifically consider stimulant intoxication and/or alcohol/sedative withdrawal. Go to SUB. – Rule out agitation due to psychosis or manic episode in bipolar disorder. Go to Assessment, mhGAP-IG base course - field test version 1.00 – May 2012

  48. Management of Persons with agitated and/or Aggressive Behavior COMMUNICATION Safety is first! Remain calm and encourage the patient to talk about his or her concerns. Use a calm voice and try to address the concerns if possible. Listen attentively. Never laugh at the person. Do not be aggressive back. Involve carers and other staff members. Remove from the situation anyone who may be a trigger for the aggression. If all possibilities have been exhausted,sit may be necessary to use medication (if available) to prevent injury. mhGAP-IG base course - field test version 1.00 – May 2012

  49. Management of Persons with agitated and/or Aggressive Behavior SEDATION AND USE OF MEDICATION Sedate as appropriate to prevent injury. For agitation due to psychosis consider use of haloperidol 2mg p.o./i.m. hourly up to 5 doses (maximum 10 mg). Caution: high doses of haloperidol can cause dystonic reactions. Use biperiden to treat acute reactions. For agitation due to ingestion of substances, such as alcohol/sedative withdrawal or stimulant intoxication, use diazepam 10-20 mg p.o. and repeat as needed. Go to SUB mhGAP-IG base course - field test version 1.00 – May 2012

  50. Management of persons with aggressive behavior In cases of extreme violence – Seek help from police or staff – Use haloperidol 5mg i.m., repeat in 15-30mins if needed (maximum 15 mg) – Consult a specialist. if the person remains agitated, recheck oxygen saturation, vital signs and glucose. Consider pain. Refer to hospital. Once agitation subsides, refer to the master chart (MC) and select relevant modules for assessment. Special Populations: Consult a specialist for treatment. mhGAP-IG base course - field test version 1.00 – May 2012

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