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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

Every two weeks.

  • 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*

Relationship issues

Greater responsibilities

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

Indirect effect

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

Educational difficulties

Mr Simpson

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
  • Male in his 30s

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
  • Habitual use of cannabis
  • 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:

Example...

  • 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

Day 1:

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

Day 2-14:

  • Increases the amount of prolactin released
  • Hyperprolactemia
  • Before every morning dose
  • 2 hours after every morning dose

D2 receptor antagonist side effects

Day 15-28:

  • 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

1. Typical

2. Atypical

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

Side effects:

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

Contain:

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

Four Stages:

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

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