Medication in Early Onset Psychosis

1. Medication in Early Onset Psychosis Manchester Mental Health & Social Care Trust

2. Aims & Objectives of Session • To increase the awareness of the major issues in the use of anti-psychotic medication • For participants to understand the processes involved in the prescribing of medication. • To present the advantages and side effects of medication and the issues of compliance. • To provide an understanding of how and why this medication works.

3. Medication and Psychosis • Medication is one of the first treatments offered to people who are struggling to cope with confused thinking and strange experiences • The most often used types of drugs are called “anti-psychotic” medication • The choice of anti-psychotic should be a joint decision between clinician and individual

4. Anti- Psychotic Medication • Anti- psychotic medication is used to control psychosis • Psychological treatments are more effective when medication is taken as well • Medication is only ONE PART of a comprehensive package of care that aims to help keep a person stable and to live as normal a life as possible • Anti- psychotic medications are MOST EFFECTIVE at controlling POSITIVE SYMPTOMS (hallucinations, delusions) - less effective at treating negative ones (apathy, withdrawal etc)

5. Prescribing Medication • When taking anti-psychotic medication it is advisable to start on a dose at the lower end of the standard dose range (NICE 2002) • ‘Continuous’ rather than ‘intermittent’ dosing should be used to avoid relapse and deterioration of mental state. • Only one type of anti-psychotic medication should be prescribed at a time, unless this is for a short period to facilitate a change of medication. • If there is no improvement after 6-8 weeks of a therapeutic dose, a change to alternative medication should be considered.

6. How is the medication taken? • Anti -psychotic medication can be taken in several ways: tablets, dissolvable capsules, liquid ‘syrups’ or injections • The method of taking the medication is personal choice as each has advantages and disadvantages • Medication should be continued for at least 6 months. It should never be stopped suddenly

7. How do clients receive their medication? • Most people receive medication as a prescription from their G.P., often following a consultation with a psychiatrist • A repeat prescription can be organised through the local chemist who might deliver it to the persons’ home • Medication can be packaged as a ‘dossette box’ with a separate compartment for each daily dose of medication or a ‘blister-pack’ • Injections or “depots” are given by a nurse at a ‘depot’ clinic, at a GP’s surgery or, in some cases, at home

8. Medication - Group exercise In two large groups - • 1. Consider your own history in taking prescribed medications • 2. As a group, with one person acting as the ‘scribe’, write on flip chart paper all the reasons you can remember for why you DIDN’T take the full course of medication as prescribed • 3. Consider what rationales you would need to take all future medication as prescribed?

9. Helping people to make informed choices about medication • Some people don’t like to take medication (this is true of ANY type of medication) • Forcing people or using heavy-handed methods doesn’t usually work • The best way is to provide information about the drugs that they need • Encourage the consideration of the advantages and disadvantages – this way the person makes an INFORMED choice • Never disguise medication in food or drinks

10. Interventions to enhance concordance • Depot injections are often offered if the person is not able to cope with, or reluctant to take oral medication. • If medication is refused as a result of intolerable side effects, alternative medication should be considered – although this might mean substituting one side effect for another • ‘Motivational interviewing’ techniques may be used to enhance compliance through collaboration, education and empowerment • When two different anti-psychotic medications have been tried over a period of 6-8 weeks, the person might be considered ‘treatment resistant’ and as a result offered clozapine (NICE 2002)

11. What about side effects? • At one time anti-psychotic medication had a reputation for causing serious side effects • More recently types of medication have been developed which have fewer side effects • All medications have potential adverse reactions yet it is important that they are noticed as early as possible so that the drug can be reduced or changed, or another drug can be added to help to cope with it

12. Maintenance Regimes • Antipsychotics are generally continued for 1 - 2 years to prevent further relapse • About 20% of people will still experience a relapse despite maintenance treatment of medication • It is not possible to tell in advance if relapse will occur. Therefore everyone should be offered maintenance treatment. • Withdrawal from antipsychotics should be undertaken gradually, whilst monitoring for relapse for up to 2 years

13. Medication management for a first episode of psychosis? • Generally, antipsychotics are started only by specialist mental health services, following an initial assessment • Antipsychotic medication may be initiated by the GP in the first instance if the person is awaiting and initial meeting with a psyciatrist • Where possible, treatment should be discussed with specialist mental health services before it is started • If ‘acute’ symptoms persist or if the client is at risk an URGENT appointment should be sought with specialist services ( NICE 2002)

14. Choice of medication for a first episode of psychosis • Clozapine or sertindole must ONLY be prescribed by specialist mental health services • Atypical antipsychotics, prescribed at the lower dose range, are the preferred treatment for first episode psychosis, due to reduced risk of ‘extra-pyramidal’ side effects • Avoid Clozapine or Respiridone with clients with a history of any CEREBROVASCULAR DISEASE , TIAs, hypertension • CARDIOVASCULAR DISEASE - Avoid zotepine, respiridone & quetiapine; these drug reduce BP, resulting in reflex tachycardia that may exacerbate angina

15. Medication Management - antipsychotic for first episode • CARDIOVASCULAR DISEASE/ Arrhythmias: Most antipsychotic drugs have the potential to affect the QT interval. Amisulpride is probably safe in people with arrhythmias. Zotepine (and sertindole) should NOT be used • Phenothiazines, higher doses of haloperidol and prescribing ABOVE BNF limits should also be avoided

16. Medication Management - Choice of oral ‘atypical’ antipsychotic • EPILEPSY - All antipsychotic drugs can lower the seizure threshold. Incidence of seizures was low in trials of olanzapine, respiridone and quetiapine. Whichever drug is chosen, start at a low dose and increase dose gradually in a person with epilepsy. • If prescribing antipsychotic medication it important to be aware of those factors that increase the risk of seizures, such as head injuries, previous history of seizures, being on drugs that reduce the seizure threshold and withdrawal from drugs of the central nervous system (alcohol, barbiturates etc)

17. Medication ManagementDiabetes • The incidence of Type II diabetes is more common in people with schizophrenia than the general population. Antipsychotics MAY increase this risk, though no causal link has been established. • Both ‘typical’ and ‘atypical’ antipsychotics have been associated with an increased risk of diabetes especially with olanzapine & clozapine (Sernyak et al 2002; Lean and Pajonk 2003)

18. Medication Management - Adverse effects of antipsychotics • Antipsychotics cause a wide range of side effects, including sedation, weight gain and sexual dysfunction. • Tardive dyskinesia (TD) is a late-onset movement disorder that can occur with prolonged use of antipsychotics. It can be irreversible and may get worse when treatment stops • Around 20% of people on antipsychotics eventually experience TD - older people are more at risk

19. Medication Management - Switching antipsychotics • Changing medication needs to be done with care and is preferably done under medical guidance • Stopping antipsychotics abruptly can lead to relapse or cause withdrawal reactions such as cholinergic rebound (nausea, restlessness, anxiety, insomnia) and withdrawal dyskinesias (extrapyramidal symptoms etc) • The dose of the original drug should be tapered down slowly (over about 8 weeks)

20. Medication Management - minimising effects GPs need to know how to manage side effects as 25% of people with psychosis are managed within primary care teams • Weight gain - occurs mainly in first 6-9 months. Advice and support on healthy eating and exercise is essential • Sedation - Lowering the dose may help • Postural hypotension - Should be carefully monitored - change medication if necessary, though tolerance develops Maudsley (2001) Prescribing Guidelines

21. Medication Management - Minimising adverse effects • Tardive Dyskinesia - Emergence of Extra Pyramidal Symptoms (EPS) is a strong predictor for later TD. Withdrawal of antimuscarinic drugs can help, as can a switch to clozapine or olanzapine • Neuroleptic malignant syndrome – This is a very rare, idiosyncratic but life-threatening adverse effect. Symptoms include hyperthermia, muscle rigidity, autonomic instability, fluctuating consciousness. URGENT medical treatment is essential

22. Changing from a typical anti-psychotic to an atypical? • Do not change medication unless it is necessary (NICE 2002) • ‘Atypical’ antipsychotics should be considered for people taking typical antipsychotics who are experiencing unacceptable side effects, despite adequate symptom control • Might also be considered if client has relapsed and failed to achieve adequate symptom control with typical antipsychotics, or experienced unacceptable adverse effects • This should be a decision by clinician and patient (NICE 2002)

23. Medication - Group Exercise In two large groups - • 1. List all of the different types of medication that you have heard of to help with the symptoms of any mental illness • 2. When you have exhausted this list, attempt to put the drugs into their broad groups (e.g. those for voices ,antidepressants, those for anxiety) • 3. Try and link these drugs with the types of mental health problems they are designed to treat (e.g. antidepressants to treat low mood etc) • 4. Which of these medications have more than one purpose?

24. The Origins of Anti- Psychotic Medication • Anti-psychotic drugs, also called ‘neuroleptic’ drugs - the mainstay treatment for people with psychosis. • They are used to control acute symptoms (hallucinations, delusions, ‘thought disorder’) and assist in relapse prevention. • The first of these drugs was discovered by accident in France when people noticed that it made patients who took it more tired. The drug was called chlorpromazine and it was being investigated as an anti-hay fever drug, not as an antipsychotic!

25. The Central Nervous System • Messages are sent to different parts of the brain by bundles of nerve cells (‘neurons’). These neurons are not connected physically , there is a gap between them called the ‘synaptic cleft’. • Information is sent across this gap by a chemical messenger called a ‘neurotransmitter’. • There are lots of different types of neurotransmitters in the nervous system. • The end of the neuron which receives this chemical message has specialist ‘receptors’ to accept delivery of the message.

26. The Role of Dopamine • One of these chemical messengers or ‘neurotransmitters’ is called ‘dopamine’. It is thought that an over activity of dopamine might be one reason why some people experience psychotic symptoms • This is known as the ‘dopamine hypothesis’ • It could be either that there is an over-production of dopamine from nerve endings or the receiving receptor sites might be too sensitive

27. The Role of Dopamine? • It is thought that dopamine is connected with the way we interpret the world around us • Hallucinations, strange beliefs and disturbances in the way we think can all seem to result from over-activity of dopamine • Anti- psychotic medication controls the amount of dopamine received by the receptor sites. They do this by binding on these sites and blockading them

28. Antipsychotic medication & first onset psychosis • One of the strongest predictors of outcome in psychosis is the length of the duration of untreated psychosis (DUP) (Johnstone et al 1986; Loebel et al 1992) • Use of low-dose anti -psychotics to avoid treatment delay has been advocated by some clinicians,along with CBT (e.g. EPPIC in Melbourne (McGorry et al 2002) • However, other researchers have avoided its early use, opting for psychological management strategies instead (e.g. Morrison et al 2004) • So, which approach is best?

29. To conclude .. the drawbacks of medication • Medication can have stigmatising side effects • The effects on the developing adolescent brain is as yet unknown • If symptoms are not causing distress, should medication be offered? • People often stop taking medication after a short period • There is a risk of medicating ‘false-positive’ patients with potentially high risk drugs (Bentall and Morrison 2002)

30. To conclude – the advantages of medication • It is known to be effective in managing symptoms if carefully prescribed • Careful prescribing can minimise side effects by up to 85% • People with first episode who were given low dose medication managed to become symptom free after a few weeks of treatment (McGorry & Singh 1995) • Families and clients often want rapid relief from difficult and burdensome situations