Why regular blood test is needed?
Frequency of blood test
Monitoring Clozapine
Treatment
Causes/triggers of Schizophrenia
Start of treatment, every week for 18 weeks.
Role of the Pharmacist
Symptom Pathways of Schizophrenia
- Brand and supplier of Clozapine
- Current dose
- Patient adherence
- Watching for adverse effects
- Watch for blood disorders
- Watch for mouth ulcers
- Frequency of FBC tests and when the last one was completed
Mesolimbic Pathway
After one year of treatment, every four weeks.
- One of the side effect of clozapine is that it can cause agranulocytosis.
- This treatment is only given to patients who have a normal blood count.
- Any signs of infection, such as flu-like symptoms, high temperature (fever), sore throat can be an indication of a drop in white blood cells.
Dopaminergic pathway in the brain
Connects the ventral tegmental area to the nucleus accumbens
Rewards and emotion pathway
Genetic influence
- Combination of genes?
- Evidence the disorder is partly inherited comes from study of twins. BUT shows not 100% genetic
Environmental factors
- Upbringing by dysfunction family/traumatic experiences
- Delivery complications in pregnancy
Brain Structure
- Loss of neurones
- Bigger ventricle size
Substance misuse
- Alcohol, drugs such as cannabis which may trigger Schizophrenia in people who are ALREADY genetically susceptible
Weekly or fortnightly for four weeks after completely stopping clozapine.
Positive Symptoms
- Delusions
- Hallucinations
- Movement Disorders
- Thought Disorders
What is Schizophrenia?
Relative to Mr Simpson
Effect of smoking on Clozapine
Reducing Risk of Weight Gain
- A long term mental health condition including a breakdown in the relation between thought, emotion and behaviour; leading to confused perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion.
- Wide Spectrum of disorders
- Division between internal thought and external reality
Weight Gain in Olanzapine
- Studies show teenagers <15 years who use cannabis regularly are up to 4x more likely to develop the disease by the age of 26.
- Sufficient evidence if use cannabis at a young age especially 15 have a higher average risk of developing psychotic illness.
- New evidence that cannabis can cause genetic abnormalities associated with mental illness affecting 1 in 100 people. Using the drug before age of 18 raises the risk of condition in later life by six-fold.
So did the cannabis use cause schizophrenia or was Mr. Simpson using cannabis for medication for a condition that was already pre-determined?
What does cannabis do to a teenage brain?
Loss of business for employers
Caused by histamine receptor blockage
Cannabis has chemicals that resemble molecules produced naturally in our brain called endocannabinoids
Chemicals from Cannabis remove refractory period of neurones by binding to cannabinoid receptors in certain parts of our brain*
Role of the Pharmacist
Perception, imagination magnifies. Users will get caught in the momentum
* Cannabis alters level of dopamine and noradrenaline hence the reasons when 'your high' of euphoria and relaxation
- Cigarettes contain polycarbons and this causes clozapine to be metabolized quicker and therefore results in a lower level of clozapine in plasma.
- Plasma levels of clozapine is reduced by up to 50% in smokers.
- Therefore smokers are prescribed higher doses compared to non-smokers.
- Clozapine plasma concentrations can rise by 1.5 times in the 2–4 weeks following smoking cessation and in some instances by 50–70% within 2–4 days.
- Measure patients height, weight and calculate BMI
- Counsel Patient in lifestyle changes
- Identify if the Olanzapine is causing any weight gain
- Adjust dose or medication if required
Symptom Pathways of Schizophrenia
Impact of mental illness on society
Impact of mental illness on families
Mesocortical
Reduction in household income
Cost of treatment and hospitalisation
Experience social isolation
Dopaminergic pathway in the brain
Connects the ventral tegmental area to the cerebral cortex.
Responsible for cognitive control, motion and emotional response.
Negative Symptoms
- Alogia
- Anhedomia
- Avolition
- Depression
- Reduced speech
References
Our Case...
Side Effect Pathways of Anti-psychotics
Decreased Quality of life
Histamine Blockage
What is NICE?
Impact of mental illness on individuals
- http://www.evidence.nhs.uk/formulary/bnf/current/4-central-nervous-system/42-drugs-used-in-psychoses-and-related-disorders/421-antipsychotic-drugs/second-generation-antipsychotic-drugs/clozapine
- http://www.bap.org.uk/pdfs/BAP_Guidelines-Schizophrenia.pdf
- http://www.nhs.uk/Conditions/Schizophrenia/Pages/Symptoms.aspx
- http://www.centreforsocialjustice.org.uk/UserStorage/pdf/Pdf%20reports/MentalHealthInterimReport.pdf
- http://www.uniteforsight.org/mental-health/module1
- http://www.understand-schizophrenia.com/clozapine-and-smoking.html
- http://apt.rcpsych.org/content/14/5/398.3
- http://www.http://psychopharmacologyinstitute.com
Anti-psychotics can block the histamine receptors
Increases AMPK concentration
Causes an increase in appetite
- Weight gain
- Diabetes
- Metabolic Syndrome
- Cardiovascular Disease
Lowered productivity and poverty
Experiencing social stigma and discrimination
Guidance for our patient
- Suffered from mental illness since teenager
- Mr Simpson has suffered from mental illness from his teenage years.
- Already been diagnosed with schizophrenia
- We go straight to 8 for 'ongoing care for adults with psychosis or schizophrenia'
- National Institute for Health Care and Excellence
- Role: To identify good clinical and public health practice using the best available evidence to help resolve uncertainty for the public, patients and professionals. Decreasing variation in availability of practice and care.
- Nice pathways bring together all NICE guidance, quality standards and support in easy to navigate flowcharts.
- Who is it for? Healthcare professionals and people with the disease, their families and carers.
Side Effect Pathways of
Anti-psychotics
Dosing of Clozapine:
- Prescribed Clozapine after non response to other anti-psychotics
Side Effect Pathways of Anti-psychotics
- Regular monitoring of BP, pulse and temperature are done in the first 4 weeks of treatment
Nigrostriatal
Tuberoinfundibular
Dopamine receptor binding inhibits prolactin release
Regulates production of milk
- Prior to 1st dose
- 15 minutes after 1st dose
- Every hour after 1st dose for a minimum of 6 hours
Contains 80% of the brains dopamine
Involved in motor planning
Dopaminergic receptor stimulation causes powerful movement
D2 receptor antagonist side effects
- Increases the amount of prolactin released
- Hyperprolactemia
- Before every morning dose
- 2 hours after every morning dose
D2 receptor antagonist side effects
- 2 hours after every morning dose
Extrapyramidal symptoms
- parkinsonism
- tardive dyskinea
- Akathisia
NICE guidance on 'Psychosis and schizophrenia'
Treatment strategies for Schizophrenia
Criteria for prescribing Clozapine
Early Intervention Team
Clozapine
Aim: provide help, treatment and support to patient and family
Works as an antagonist at the following receptors:
Atypical Anti-psychotics
Drug Treatment for Schizophrenia
Two types of Antipsychotics
- Dopamine, D2
- Dopamine, D1
- 5-HT2A
- alpha-1 adrenoceptor
- muscarinic
Amisulpride
Risperidone
Community Mental Health Team
1. Review Diagnosis
2. Check adherence
3. Psychological treatment offered?
4. Consider reasons for non-response
- OFFER Clozapine if tried at least 2 types of anti-psychotics, at least on being atypical.
- REVIEW after 8-10 weeks.
Olanzapine
Aim: provide day to day support and treatment while ensuring the patient has independence.
- Weight gain
- Dizziness
- Drowsiness
- Nausea
- Constipation
- Blurred vision
- Tachycardia
Aripiprazole
Lurasidone
Guidance for our Patient
- Social workers
- Nurses
- Occupational therapists
- Counsellors
- Pharmacists
- Psychiatrists
- Each branch will follow onto another flow chart, to give more detail on specific conditions
Psychological Treatment for Schizophrenia
Aim: help patients cope with symptoms of hallucinations and delusions better and to help treat some of the negative symptoms experienced.
Cognitive Behavioural Therapy
Family Therapy
Art Therapy
Treatment strategies for Schizophrenia
Care Programme Approach
Schizophrenia Case Study
1. Assessment
2. Care Plan
3. Care co-ordinator approach
4. Review
Crisis Resolution Team
Aim: treat patients experiencing acute Schizophrenic episodes in least restrictive environment.
Charissa, Olivia, Jincy and Adam