Schizophrenia

1
Schizophrenia

• Although none of us know to what extent our
  perceptions of the world is merely a construct of
  our own minds, persons with schizophrenia are
  confronted with this existential dilemma
  throughout most of their lives.
• Freedman R. NEJM 2003349173849

2
Background

• Schizophrenia is a severe enduring psychotic
  illness with a relapsing-remitting nature
  (PRODIGY)
• The lifetime risk for schizophrenia is around 1
  in 200
• Schizophreniform disorder is 1 in 100 (Bandolier
  July 2003 1136)
• Symptoms differ markedly between individuals and
  between phases of the illness
• Positive symptoms (e.g. hallucinations,
  delusions, thought disorders)
• Negative symptoms (e.g. poverty of speech,
  flattening of affect, apathy)
• In most cases there are periodic acute episodes
  (with positive symptoms), inter-dispersed with
  stable periods of moderate to good functioning,
  although a third have more continuous illness
• Risk factors include genetic factors,
  prenatal/perinatal complications, social
  deprivation, urban living, ethnicity and cannabis
  use

3
Burden of schizophrenia

• Life expectancy reduced by 15 years (vs. general
  population).
• Majority of premature mortality due to CHD
• Main risks are smoking (70 of patients), obesity
  (leading to diabetes) and hypertension
• About 1 in 20 patients with schizophrenia commit
  suicide, usually near illness onset
• Increased risk (10) of alcohol problem or drug
  misuse
• Burden on families and carers
• Widespread stigma

4
Guidance on newer antipsychotics for
schizophrenia (1) NICE June 2002.
www.nice.org.uk

• Should be part of a comprehensive package of care
• Joint decision making
• Newer drugs considered in the choice of
  first-line treatments for newly diagnosed
• Where joint decision not possible, consider newer
  drugs as Rx of choice because of lower
  extrapyramidal side effects
• Switch to newer drugs in established therapy if
  unacceptable adverse effects, and for relapses if
  poor response or side effects with previous
  therapy
• Dont switch if things are going well

5
Guidance on newer antipsychotics for
schizophrenia (2) NICE June 2002. www.nice.org.uk

• Consider prescribing antipsychotics for 1 to 2
  years following an acute episode
• Assess concordance, consider depots where
  appropriate
• Dont co-prescribe older and newer drugs
• Consider clozapine for treatment-resistant
  schizophrenia
• Where appropriate withdraw slowly
• Monitor regularly

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Prescribing summary (1)

• Many older trials are only short-term, though
  this seems to be improving (e.g. CATIE)
• Antipsychotics are considered essential
  psychosocial treatments are additional (after
  recovery)
• Assessing antipsychotic efficacy is complex
• Antipsychotics (atypical and typical) are a
  heterogeneous group of drugs with a range of
  dose-related side effects, which influences
  choice
• No one drug is that effective no size fits all.
  Trials of two or more drugs can be expected in
  most people before the most appropriate is
  identified
• There appears little efficacy difference between
  atypicals and typicals
• Atypicals generally cause fewer extrapyramidal
  side effects than typicals (although incidence
  rises with increasing dose) but more metabolic
  side effects

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Prescribing summary (2)

• Weight gain and metabolic side effects (diabetes)
  are of concern with some atypicals (particularly
  with clozapine and olanzapine) and require
  monitoring in those with, or at risk of, diabetes
• Atypicals are recommended in guidelines as
  first-line
• Typicals can be considered second-line (they are
  as effective and cheaper)
• Clozapine is the treatment of choice for
  treatment resistance but requires careful
  monitoring (cardiac, metabolic and
  haematological)
• As in other chronic conditions, medication
  adherence is an issue. Depot medications can be
  considered for non-adherence with medications
• Co-prescribing antipsychotics and use of doses
  above the recommended range is not evidence based
  and rarely worthwhile, and increases the risk of
  adverse effects
• Prescribing of antipsychotics for patients
  off-license is common. Use in dementia is of
  particular concern (associated with an increased
  risk of stroke)