1 APRIL 2022 ausdoc . com . au specialist review and a trial of clozapine is recommended .
There are multiple antipsychotic medications all with differing profiles of benefits and adverse effects ( see table 3 ). As the disorder is frequently chronic , it is important to think ahead and promote the long-term health of the individual from the time of first treatment . Adverse physical health outcomes are common in schizophrenia ; it is advisable , where possible , to avoid medications with negative consequences for physical comorbidity . These adverse outcomes commonly include weight gain and cardiovascular complications ( particularly olanzapine , clozapine and quetiapine ), movement disorders ( first-generation antipsychotics [ FGAs ]), raised prolactin ( FGAs , amisulpride , risperidone ), sedation ( clozapine , olanzapine , chlorpromazine , quetiapine ) and QTc changes ( amisulpride and ziprasidone ). However , the use of antipsychotics with a heavier burden of adverse effects may be required because of a poor response to other first-line medications .
Antipsychotic medications can be administered as LAIs . There is extensive evidence that relapse is less frequent with the use of LAIs . 21 , 22 These medications can be administered on a fortnightly to three monthly basis — depending upon the preparation — and when combined with effective support provide a useful approach to pharmacological management . A trial of the oral preparation is advisable before using an LAI to ensure there is no allergy or marked difficulty with adverse effects . Different LAIs have specific requirements in regard to the initiation of medication ; paliperidone palmitate uses a loading dose to reach therapeutic drug levels and is effective immediately , aripiprazole LAIs or risperidone LAIs require continued oral medication for between two and four weeks .
POOR TREATMENT ADHERENCE Poor treatment adherence to either pharmacological or psychosocial interventions is common in schizophrenia with between half and three quarters of patients taking their medication 70 % of the time . 23 Improving treatment adherence requires the consideration of factors related to the illness itself ( impaired insight , persecutory fears , cognitive impairment , disorganisation ), the patient ’ s own understanding about their illness , their pre-existing illness beliefs , their rapport and trust in their treating team ), the medication itself ( the range of adverse effects , the frequency and route of administration , its effectiveness and tolerability ) and finally the level of support and structure in the person ’ s environment . If nothing else , keep the medication regimen simple with once daily dosing .
CHANGING PHARMACOLOGICAL TREATMENT It is usual for a person with schizophrenia to ask if their medication can be changed . Given the difficulties in maintaining treatment adherence this request needs to be addressed seriously . Some aspects of the patient ’ s concerns may easily be addressed by a small decrease in the dose of their medication , however even small reductions increase the risk of relapse and require close monitoring . 24 At other times , because of difficulty with a specific adverse effect , a change in medication may be required .
In general , antipsychotic PAGE 40
Table 2 . Investigation and monitoring for schizophrenia Investigation Baseline One month Two months Three months Six months At 12 months and thereafter Physical examination √ √ √ Blood pressure , heart rate √ √ √ √ and repeat every six months Weight , BMI , waist circumference √ √ √ √ √ √ and repeat every six months FBC √ √ and repeat annually Electrolytes , LFTs
Box 1 . Management aims
• Establishing an excellent rapport with the young person and their family .
• Minimising involuntary detention and any challenging aspects of inpatient psychiatric care .
• A detailed assessment of the individual , investigating any possible causes of the disorder and establishing the basic level of functioning .
• Linking with appropriate community care agencies including the GP , specialist mental health team , private psychiatrist , school and so on , as required .
√ Fasting glucose and HbA1c √ √ √ and repeat every six months Blood lipids ( fasting ) √ √ and repeat every six months Ask about and assess for extrapyramidal effects √ √ √ √ and repeat every six months Prolactin √ √ √ √ repeat annually Ask about sexual and reproductive problems √ √ √ repeat annually Thyroid function tests CRP , anti-double stranded DNA antibodies Autoimmune screen * Urine drug screen ECG EEG MRI Psychometric testing Bloodborne virus Pregnancy test
√ √ √ √ √ If indicated √ √ If indicated √
Ophthalmological screening is indicated if the person is being treated with chlorpromazine or quetiapine . This should be considered in the context of signs such as rapid onset ( less than three months ) seizures , movement disorders , disproportionate cognitive impairment or autonomic dysfunction eg , Anti-NMDA , LGI1 , CASPR2 . This requires specialist input . 15
Adapted from The Royal Australian and New Zealand College of Psychiatrists ( RANZCP ) clinical practice guidelines for schizophrenia 16 , Therapeutic Guidelines 17
Leor Zmigrod et al ; Neuroscience and Biobehavioral Reviews ; Elsevier ( 2016 )
Pete S / CC BY-SA / bit . ly / 3srlNno
Figure 6 . Messages covering the windows of a house of a patient with schizophrenia .
Figure 7 . Functional neuroimaging results of the activation likelihood estimation meta-analyses for auditory-verbal hallucinations ( AVH ) and visual hallucinations ( VH ). Representative slices are shown in axial ( top ), coronal ( middle ) and sagittal ( bottom ) views with MNI ( Montreal Neurological Institute ) planar co-ordinates given below each image . AVHs were associated with significant activity in regions that included Broca ’ s and Wernicke ’ s areas , insula , medial temporal lobe , and paracingulate region of the medial prefrontal cortex . VHs were associated with significant activity in lingual and fusiform cortices , and the dorsal cuneus and precuneus . Red = AVH ; Blue = VH .