Schizophrenia guidelines 2017

Question 1

Negative symptoms (sci 2017)

Answer 1

• Negative symptoms (4 A’s)
○ Reduction in previous behaviour/drive
§ **Affective flattening- diminished emotional expression
§ **Avolition- reduction in self-initiated purposeful activity
§ Alogia- poverty of speech/thought
§ Anhedonia- decreased ability to experience pleasure

Question 2

First Rank Sx (SCZ 2017)

Answer 2

• First Rank symptoms– more specific to schizophrenia
○ Auditory hallucinations
○ Thought withdrawal, insertion, or interruption
○ Thought broadcasting
○ Somatic hallucinations
○ Delusional perception
○ Feelings or actions controlled by external agents

Question 3

Indications for brain imagine (SCZ 2017)

Answer 3

4. Brain Imaging
   ○ CT or MRI based on specific aspects of hx, neurological exam or neuropsychological testing results on case by case basis
   § Image if: headaches, N&V, seizure-like activity, later age of onset
   § Autoimmune encephalitis– MRI and more extensive evauation
   □ rapid progression of working memory deficits over <3 months, new focal CNS findings, seizures not explained by previous sz disorder

Question 4

Rating scales (SCZ 2017)

Answer 4

○ Use qualitative scales like Positive and Negative Symptoms Scale (PANS) and Brief Psychiatric Rating Scale for positive and negative symptoms
§ Calgary Depression Scale in Schizophrenia helpful to distinguish between negative sx and depression
*AIMS (abnormal involuntary movement scale) or Extrapyramidal Symptom Rating Scale
*suicide: Columbia suicde severity rating scale

Question 5

Antipsychotics and weight gain (SCZ 2017)

Answer 5

highest: chlorpromazine, clozapine, olanzapine
intermediate: lurasidone, other 1st gens, paliperidone, prophenazine, quetiapine, risperidone
lowest: aripiprazole, asenapine, ziprasidone

Question 6

Antipsychotics and EPS (SCZ 2017)

Answer 6

highest: typicals incl halloo and chlorpromazine
moderate: lurasidone, risperidone, paliperidone, ziprasidone
lowest: clozapine, olanzapine, quetiapine, aripiprazole (except akathisia), asenapine

Question 7

Psychosocial tx for adults (SCZ 2017)

Answer 7

1. Family interventions- communication, problem solving, psychoeducation
2. supported employment
3. CBT for psychosis– for those with inadequate sx control
4. cognitive remediation for those with persistent deficits
5. Social kills training for those with deficits
6. Life skills training
7. patient education

Question 8

Psychosocial treatment for children with schizophrenia (SCZ 2017)

Answer 8

1. family intervention- relationship, communication, problem solving, psychoeducation, crisis management and recovery
2. CBT
3. Supported employment/education
4. PSychoeducation for patient and family
5. Cognitive remediation
6. Social skills training

Question 9

Acute antipsychotic treatment (SCZ 2017)

Answer 9

3. Acute Antipsychotic Treatment
   § Continue medication for at least 2 weeks, unless there are significant issues with tolerability
   □ If poor response, monitor for adherence and substance use
   □ No response after 4 weeks, change antipsychotic
   □ Partial response- reassess after 8 weeks, unless there are significant adverse effects
   § Adequate trials are 4-6 weeks
   § Simplify dosing regimes, blister packs, use of dosettes, caregiver support, pill counts and drug monitoring may help monitor adherence
   § Consider LAIs early

Question 10

Treatment duration after 1st episode psychosis (SCZ 2017)

Answer 10

5. Antipsychotic Continuation
   § Following resolution of symptoms of 1st episode, duration of maintenance with antipsychotics should be at least 18 months
   □ 1-20% of patients with 1st episode do not have recurrent episodes although there are no markers, biological or otherwise of who they are
   □ Relapse rates are high with antipsychotic discontinuation and attaining remission/stabilization after a period of remission does not eliminate the risk
   □ Re-achieving remission after relapse is harder

Question 11

Treatment of Relapse (SCZ 2017)

Answer 11

2. Duration of Tx
   § Following resolution of positive symptoms, maintenance tx for 2-5 years or longer
   § Antipsychotic tx effective for relapse prevention, lower hospitalization, and improved QOL
   § No good evidence of FGA vs SGA
3. Antipsychotic Delivery
   § Option of oral or depot should be given to pts
   § Offer LAIs regardless of compliance
   § Earlier use of LAIs is supported as superior in reducing relapse in early schizophrenia

Question 12

Treatment Resistance Schizophrenia (SCZ 2017)

Answer 12

D. Treatment Resistant Schizophrenia
1. Clozapine should be offered to patients with treatment resistance
§ 25-30% of pts with schizophrenia are tx resistant (failed 2 adequate trials of antipsychotics)
§ Response rates to clozapine in TRS is still 30-60%
§ No consistent evidence for high doses, switching or combining antipsychotics
2. Clozapine should be considered if pt has not responded to 2 antipsychotics
§ TRS- < 20% reduction in positive sx after 2 or more adequate courses (4-6 weeks of adequate dose) of non-clozapine antipsychotic medications

Question 13

Clozapine Resistant Schizophrenia (SCZ 2017)

Answer 13

E. Clozapine Resistant Schizophrenia
1. Clozapine Resistant Schizophrenia
§ Adequate medication trial (non-clozapine antipsychotic)
□ Oral- 6 weeks at mid point or greater dose range
□ LAI- 6 weeks after steady state
□ Clozapine- 8-12 weeks at dose of > 400mg/d (trough levels > 350ng/L for daily dosing or >250ng/L for twice daily dosing)
□ Documented adherence
□ Persistence of 2 or more positive symptoms at moderate severity or single positive symptom that is severe, following 2+ adequate trials
2. Tx resistance in schizophrenia is assoc with disability and require ongoing assessment and monitoring
3. Treatment options: No recommendations

Question 14

Treatment of aggression (SCZ 2017)

Answer 14

1. Aggression and Hostility
   § Patient preference, past experience with antipsychotics incl response and adverse events and medical hx should guide tx of irritability, hostility and aggression
   § TRS with aggression/hostility– try clozapine
   § Systematic review found all trials found clozapine clinically superior to tx aggression, especially in TRS

Question 15

Treatment of children with first episode psychosis (SCZ 2017)

Answer 15

3. For children/youth with first episode psychosis, offer antipsychotics in conjunction with psychological/psychosocial interventions
   ○ 1/3 of adults with schizophrenia have onset before 18 yo and schizophrenia identified in children/adolescents is continuous with adult onset
   § Worse prognostic factors including more severe expression, lower premorbid social /emotional adjustment, cognitive impairments and negative symptoms
   § Adolescents have longer treatment delays than adults– ?due to misidentification of presentation
   § Earlies initiation of pharmacologic and psychosocial interventions is important to outcomes

Question 16

Cannabis and youth psychosis (SCZ 2017)

Answer 16

○ Cannabis exposure is associated with increased risk for psychosis in individuals who are genetically vulnerable
§ Cannabis use, other mental comorbidities (eg depression) and medication non-adherence are strongest factors for poor prognosis, including risk of relapse
§ Cannabis, particulalry at critical stages of neurodevelopment may impact expression/neuroprogression of genetic risk for schizophrenia
□ Individuals who regularly use cannabis during adolescence have 2x risk of reporting psychotic symptoms or being diagnosed with schzophrenia during adulthood
□ 40% greater risk of psychotic d/o with any use of cannabis in a ?dose dependant relationship between use and risk of schizophrenia
□ Early cannabis use can decrease age of onset of first episdoe by 2.7 years
□ Cannabis use during tx associated with increased hospitalization, relapse and worse medication adherence

Question 17

Relapse prevention in youth (SCZ 2017)

Answer 17

13. Inform patient/family there is a high risk of relapse if meds are stopped in 1-2 yrs following an acute episode
14. If discontinuing/tapering antipsychotics, do gradually and monitor carefully for relapse
15. After discontinuing/tapering antipsychotic meds, continue monitoring for relapse for at least 2 years.
    ○ Often a positive initial response to antipsychotics, however 80% relapse within 5 years of initial remitted episodes
    § Non-adeherence is strong predictor
    § Persistant psychotic symptoms increases with repeated relapses
    § Relapses lead to reduction in gray matter– reduced responsiveness to medication, negatively influence social, emotional, and vocational goal attainment
    ○ Intensive psychosical strategies, with low-dose antipsychotics are effective at reducing relapse rates in youth/adults
    ○ Maintaining therapeutic alliance with close monitoring after first episode is important for long term recovery
    ○ Many youth will require lifelong maintenance tx with antipsychotic medication.
    § Small number may be able to discontinue after a prolonged remission with long term follow up given high rates of relapse– exact times still unknown

Question 18

Assertive Community Treatment (ACT) (SCZ 2017)

Answer 18

6. Assertive Community Treatment
   ○ ACT should be provided for pt with serious mental disorders (incl schizophrenia) who may high use of inpatient services, have residual psychotic symptoms and a hx of poor engagement with services leading to frequent relapses or social breakdown (eg homelessness, imprisonment)
   ○ Highest level of case management
   ○ Team based and outreach approach with high staff: patient ratio (1:10) with some teams providing 24h call
   ○ Function in clinical and community settings
   ○ Reduce hospital readmission rates and improve housing and occupational function as well as quality of life and service satisfaction
   ○ No cost savings or differential improvement in clinical state

Question 19

Patients with Clinical high risk of psychosis (SCZ 2017)

Answer 19

§ Criteria divide into 3 syndromal subgroups
□ Attenuated positive symptom syndrome
® Emergence or worsening of non-psychotic level disturbances in thought content, thought processes, or perceptual abnormalities over the last year
® Most common
□ Brief intermittent psychotic symptom syndrome (BIPS)
® Presence of any 1 or more threshold positive psychotic symptoms including unusual thought content, suspiciousness, grandiosity, perceptual abnormalities, disorganized communication) that are too brief to meet diagnostic criteria for diagnosis
□ Genetic risk and deterioration (GRD)
® Combination of functional decline and genetic risk (eg schizotypal PD or 1st degree relative with a schziphrenia spectrum diagnosis)

Question 20

Structured interview for Clinically High Risk populations (for psychosis)
(SCZ 2017)

Answer 20

○ Most widely used measures of CHR are Comprehensive Assessment of At Risk Mental States (CAARMS) and Structured Interview of Prodromal Syndromes (SIPS)
§ Measures presence of an at risk state for psychosis, measures symptom severity over time and evaluates the conversion to psychosis