Summary Recall (Schizophrenia, Depression, Bipolar) Flashcards
What are some key clinical features of Schizophrenia? (DSM-5 Criteria)
What exclusions must be made?
Thought Disorder: 2 Sx for 1 month
1. Positive Sx (Hallucination, Delusion, Disorganized thoughts, Grossly disorganized or catatonic behavior)
2. Negative Sx (Affective flattening, Avolition)
Social and Occupational Dysfunction:
1. Work
2. Interpersonal relations
3. Self-care
Total Duration: 6 months
Exclusions:
1. Schizoaffective / Mood Disorders
2. Substance Use
3. Medical Disorders
Pharmacological Management Efficacy, ADR, Algorithm for Schizophrenia
Efficacy:
1. Positive Sx (D2) - FGA and SGA
2. Negative Sx (5HT2A) - SGA
ADRs:
1. EPSE (Muscles) - FGA > SGA
2. Metabolic - SGAs
3. Sedation and Weight gain (SGA -pines)
Algorithm:
1. Antipsychotic
2. Antipsychotic
3. Clozapine
4. Combination FGA + FGA/SGA OR
Clozapine + Add-ons
What is the adequate trial duration for antipsychotics in Schizophrenia?
2-6 weeks (3 months for clozapine)
What adjunctive treatment for schizophrenia?
Benzodiazepines for agitation
Antidepressant for depression
What is considered treatment resistant schizophrenia?
Failed response to at least 2 adequate trials of antipsychotics of which one is an atypical SGA
Monitoring parameters for Clozapine
Baseline and Period FBC (Agranulocytosis)
Schizophrenia
Acute Stabilization Phase: Goals and Choice of Therapy, and Monitoring
- Reduce agitation, aggression, hostility, improve sleep
- Cooperative = PO Antipsychotics +/- Benzodiazepines
- Uncooperative = IM Fast-acting antipsychotics / Benzodiazepines
- Monitor for EPSE (Dystonia, Pseudo-parkinsonian ADRs)
- Monitor Vitals
Schizophrenia
Acute Phase Treatment Dosing
1. Cooperative
PO Lorazepam 1-2 mg
OR
PO Antipsychotics:
Risperidone 1-2 mg
Olanzapine 5-10 mg
Quetiapine 50-100 mg
Haloperidol 2-5 mg with pre-treatment ECG
Schizophrenia
Acute Phase Treatment Dosing
2. Uncooperative:
IM Lorazepam 1-2 mg
OR
IM Antipsychotics
Olanzapine 5-10 mg
Aripiprazole 9.75 mg (Less hypotensive)
Haloperidol 2-5 mg with pre-treatment ECG
Promethazine 25-50 mg
How to manage EPSE for antipsychotics?
- Dystonia, tremors/rigidity:
– Anticholinergics, or
– SWITCH to lower-potency antipsychotics (e.g. Quetiapine, Sulpiride) - Akathisia
– Clonazepam and/or Propranolol (beware of bradycardia/hypotension), or
– SWITCH to SGA or lower-potency antipsychotic - Tardive Dyskinesia (irreversible if detected late in advanced stages)
– Discontinue any anticholinergics
– SWITCH to low potency SGA
– Treat with Valbenazine
How to manage metabolic side effects for antipsychotics?
- Keep current antipsychotic to prevent relapse but treat the emergent DM/dyslipidemia with lifestyle and meds (e.g. Metformin; Statins)
OR
- SWITCH to Aripiprazole, Brexpiprazole, Cariprazine, Lurasidone, Haloperidol
What is the clinical presentation of Major Depressive Disorder? In SAD CAGES
What exclusions?
Interest loss (Must have)
Sleep (More or Less)
Appetite Loss
Depressed Mood (Must have)
Concentration decline
Activity Retardation
Guilt
Energy decline
Suicidality
At least 5 out of 9 with either interest loss or depressed mood during a 2-week period.
Exclusions:
1. Drug-induced
2. Medical Conditions
3. Bipolar Disorder (Identify mania)
Pharmacological Management of MDD is necessary in…
Moderate-severe depression according to the Patient Health Questionnaire-9 (PHQ-9 score > 10)
Phases of Pharmacological Treatment of MDD? What is the adequate trial period?
- Acute Phase = 4-8 week adequate trial
- Physical Sx reduced in 1-2 weeks
- Mood Sx reduced in 4-8 weeks - Continuation Phase = 4-9 months after acute phase for 1st episode uncomplicated MDD
Total duration: 6-12 months
What is considered treatment-resistant depression and what are the options?
2 or more adequate trials fail (Insufficient response = Less than 50% improvement)
Options:
1. ECT (GA)
2. Symbyax Capsule (Olanzapine + Fluoxetine)
