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Emergency Psychiatry (The Acutely Disturbed Patient)

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Title: TREATMENT OPTIONS IN EMERGENCY PSYCHIATRY Author: cherrie galletly Last modified by: dcash Created Date: 7/31/2005 12:03:49 PM Document presentation format – PowerPoint PPT presentation

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Title: Emergency Psychiatry (The Acutely Disturbed Patient)


1
Emergency Psychiatry (The Acutely Disturbed
Patient)
  • A/Professor David Ash
  • Senior Visiting Consultant
  • Intensive Care Unit
  • Glenside Hospital

2
Introduction
  • 1. A/Professor David Ash
  • Overview
  • Setting
  • Cedars Psychiatric Intensive Care Unit
  • Violence and aggression
  • Pharmacotherapy
  • Agitated, psychotic patient
  • Mania, schizomania
  • Bipolar depression, schizodepression
  • Unipolar depression
  • Patient perspective
  • ECT
  • Substance abuse

3
Overview
  • Emergency psychiatry is a subspecialty of
    psychiatry that has evolved over the last 30
    years.
  • Reduction in inpatient beds has resulted in the
    growth of psychiatric emergency services and an
    increase in the numbers of people seen in the
    community.
  • Principles of crisis intervention.

4
Psychiatric Emergencies
  • No single condition or illness
  • Any situation requiring immediate assessment and
    rapid intervention
  • Involve behavioural disturbance, threat of
    behavioural disturbance, physiological
    disturbance, high risk assessment

5
Psychiatric Emergencies
  • Suicidal Presentations
  • Aggression and Violence
  • Acute psychosis
  • Mood disorders mania and depression
  • Personality disorders in crisis
  • Major disasters

6
Psychiatric Emergencies
  • Alcohol / substance abuse or intoxication
  • Medical conditions
  • Delirium
  • Neuroleptic Malignant Syndrome
  • Serotonin syndrome
  • Lithium toxicity

7
Psychiatric Emergencies
  • Alcohol / substance abuse or intoxication
  • Medical conditions
  • Delirium
  • Neuroleptic Malignant Syndrome
  • Serotonin syndrome
  • Lithium toxicity

8
Risk Assessment
  • Self harm
  • Self neglect
  • Victim of aggression, violence
  • Suicide
  • Disinhibition
  • Impulsivity
  • Restlessness, agitation
  • Harassment, verbal aggression
  • Threatened / actual aggression, violence
  • Absconding risk
  • Available support
  • Insight
  • Ability to work with treating clinicians
  • Availability of suitable accommodation
  • Substance use
  • Alcohol

9
The Setting
  • Community
  • Crisis units / short stay units/ crisis beds
  • Emergency department
  • Inpatient unit
  • High dependency unit (HDU) / Intensive care unit
    (ICU)

10
The Community
  • Location community clinic, patients home
  • Preferred by patients
  • Able to assess persons capacity to cope in
    familiar home environment
  • Presence of family, neighbours, friends
  • Safety issues
  • Work in pairs
  • Risk assessment prior to visit, if necessary
    police in attendance
  • Weapons
  • Ensure front door not deadlocked
  • Decision to detain end interview ensure that
    ambulance, police in attendance

11
I didnt know they made house calls
12
Emergency Department
  • Triage
  • Safe environment for emergency evaluation
  • Weapon screening
  • Rooms in which the examiner cannot be easily
    trapped
  • Open vs enclosed interview area
  • Method to call for help
  • Adequate personnel to respond if help is needed
    including trained security personnel

13
Crisis Units / Short Stay Units/ Crisis Beds,
PECCU
  • Location community, mental health centres,
    psychiatric hospitals (Ash, Galletly), general
    hospitals (Frank et al)
  • Short term crisis admission, triage, transfer
  • Early discharge, community treatment

14
Inpatient Units
  • Higher acuity
  • Aggression and violence
  • Substance abuse
  • Forensic issues
  • Homelessness (Ash, Galletly et al)

15
Inpatient Units
  • Safe environment for patients / staff
  • Time out, restraint, seclusion
  • Guidelines for risk management
  • Staff training / staff morale
  • Leadership / support
  • Linkage and communication with community
    resources

16
Not much of a psychiatric unit, though, is it?
17
ICU / HDU
  • Admission to the ICU / HDU is indicated for
  • Dangerous, aggressive self harming behavior, not
    able to be contained in a less restrictive
    environment
  • Aim for brief admission with
  • Intensive treatment
  • High nurse / patient ratios
  • Calming environment
  • Recovery based services 
  • Potential disadvantages of ICU / HDU 
  • Risk of assault
  • Overmedication
  • Overstimulation
  • Worsening of symptoms
  • PTSD

18
  • Options
  • 1. Central, stand alone ICUs
  • 2. Smaller HDU / ICUs in inpatient units
  • Flexibility, closed / open options
  • 3. Intensive nursing 11 in open ward
  •  Associated Issues
  •  
  • consumer involvement
  • how to reduce trauma associated with inpatient
    care in the HDU / ICU
  • safety care plans
  • sensory modulation
  • debriefing, counselling following seclusion and
    restraint

19
Cedars PICU - Adelaide
  • Intake from CNAHS (North, East), overflow
    from West
  • Rural and Remote (on Glenside Campus) all
    indigenous people
  • 10 beds
  • Cedars PICU Psychiatrist 1.1 FTE
  • Psychiatric Registrars 1 2 FTE
  • CSC 1 FTE
  • CN 1 FTE
  • Primary Nurses 4
  • Social Worker 1 FTE
  • Drug and Alcohol Clinician 0.2 FTE
  • Carer Support Worked 0.5 FTE
  •  
  • Daily handover meetings and clinical review
  • Experienced nursing staff
  • Non-pharmacological interventions include
  • One to one counselling and support
  • Recovery-focussed care
  • Early intervention/de-escalation techniques
  • Psycho-education
  • Drug and alcohol counselling
  • Judicious use of medication, restraint, seclusion

20
Cedars PICU - Adelaide
  • Routine monitoring of electrolytes, renal
    function, liver function, glucose, cholesterol,
    lipid profile, ECG, BMI

21
Treatment of Behavioural Emergencies summary of
expert consensus guidelines
  • Preferred initial interventions for an imminently
    violent patient
  • Verbal intervention
  • Voluntary medication
  • Show of force
  • Emergency medication
  • Offer food, beverage, other assistance
  • Alternate Interventions
  • Physical restraint
  • Locked or unlocked quiet room, seclusion

22
Treatment of Behavioural Emergencies - summary of
expert consensus guidelinesWhen to use physical
restraint
  • Extremely or usually appropriate
  • Acute danger to other patients, bystanders, staff
    or self
  • Sometimes appropriate
  • To prevent an involuntary patients from leaving
    prior to assessment or transfer to a locked
    facility
  • Rarely or never appropriate
  • Lack of resources to supervise patient adequately
  • To prevent a voluntary patient from leaving prior
    to assessment
  • To maintain an orderly treatment environment
  • History of previous self-injury or aggression

23
(No Transcript)
24
Illusion - self deception in regard to the memory
of a past experience
25
Violence and Aggression
  • Aggression Hostile or destructive behaviour or
    actions
  • Violence Physical force exerted for the purpose
    of violating, damaging, or abusing
  • Contemporary concerns
  •  
  • Unprovoked, haphazard violence
  • Violence by people suffering from mental illness
  • Terrorism

26
Models of Aggression
  • Don Grant
  • dehumanization
  • acceptance of violence
  • rage and its control 
  •  
  • Learning Theory
  • Bandura - imitation and modeling of aggression
  •  
  • Megargee
  • over vs under controlled personality
  •  
  • Group dynamics
  • primitive, murderous rage

27
Psychodynamic Concepts of Aggression
  • aggression as an innate drive
  • ambivalence of primary love object
  • deficits in superego development
  • defence against feelings of inferiority or
    impotence
  • splitting
  • displacement
  • projection
  • projective identification

28
Social and Cultural Aspects
  • Young men in low socioeconomic groups have an
    increased risk of violence and of being a victim
    of violence
  • USA nonwhites are more likely to be offenders
    and victims of violence
  • There are differences between countries (e.g.
    Europe compared to USA)
  • Culture 
  • Subcultures of violence
  • Regional cultures of violence
  • Societal values and violence
  • Economic inequality and criminal violence
  • Inequality of opportunity and criminal violence

29
Biological
  • Lorenz aggression is an inherent
    tension-producing drive
  • Amygdala, hypothalamus, prefrontal cortex, limbic
    system
  • Cortical dysfunction e.g. abnormal EEG in
    antisocial personality disorder
  • Genetic e.g. sex chromosome abnormalities
  • Hormonal
  • Neurotransmitters
  • ? GABA, ? serotonin, ? noradrenalin and ?
    dopamine are associated with increased aggression
  • Alcohol, substance abuse

30
Developmental Factors Associated with Adult
Violence
  • Abuse by parents
  • Truancy, school failure, lower IQ
  • Delinquency as an adolescent
  • Arrest for prior assaults
  • Childhood hyperactivity
  • First psychiatric hospitalization by age 18 years
  • Fire setting and animal cruelty
  • History of being a childhood bully

31
Risk Factors for Aggression or Violence
  • young, male
  • developmental factors
  • less education
  • lack of sustained employment
  • lower socioeconomic status
  • history of substance abuse
  • acute intoxication with alcohol and / or
    psychoactive substances
  • past history of violence, aggression
  • violent fantasies
  • forensic history

32
Risk Factors for Aggression and Violence
(continued)
  • chronic anger towards others
  • recent sense of being unfairly treated.
  • residential instability homeless mentally ill
    more likely to offend
  • antisocial / borderline personality disorder
  • mania
  • acute psychosis delusional beliefs involving
    particular individuals
  • command hallucinations
  • delirium
  • dementia

33
Paranoia delusions of persecution
34
Assessing the Aggressive, Violent Patient
  • Aims
  • To ensure your own safety
  • To ensure the safety of staff and other patients
  • To keep the patient safe
  • To detect the presence of acute medical problems
  • To detect the presence of psychiatric illness
  • To achieve rapid stabilization and disposition of
    the patient

35
Clinical Evaluation
  • Remain at a safe distance
  • Privacy but not isolation
  • Offer food, drink, universal language of
    hospitality
  • Look and listen, be respectful
  • Talk with an even, concerned tone of voice
  • Consider the timing of questions and directions
  • Ask simple questions
  • Avoid being provocative
  • Agree to disagree
  • Maintain observational awareness warning signs
  • Obtain collateral history

36
Clinical Evaluation
  • The environment should not be fragile
  • Know where the alarms are located and how to
    activate them
  • Ensure availability, presence of adequately
    trained staff and security personnel
  • Ensure a means of escape

37
Predictors of Impending Violence Include
  • Refusal to cooperate
  • Intense staring
  • Motor restlessness
  • Purposeless movements
  • Labile affect
  • Loud speech
  • Irritability
  • Intimidating behavior
  • Damage to property
  • Demeaning or hostile verbal behavior
  • Direct threat of assault

Hillard and Zatek
38
Management
  • Establish differential diagnosis
  • Attempt where possible to initiate treatment with
    medication to treat underlying illness. 
  • Assess risk to others (specific threats) duty
    to warn
  • Weapons firearms notification
  • Where to treat?
  • Voluntary or detained? 
  • Use verbal strategies initially if necessary use
  • restraint, emergency medication, seclusion
  • Liaise with treating team/clinicians (if any) 
  • If no evidence of psychiatric or medical illness
  • consider involving the police.

39
Pharmacotherapy General Principles
  • Choice of medication is based on
  • diagnostic assessment,
  • past history,
  • medical comorbidities,
  • substance abuse and intoxication

40
Choice of Medication
  • Consider
  • speed of onset
  • oral vs IM
  • duration of action
  • side effects
  • past response
  • patient preference

41
Consumer Perspective
  • Consumers stress the importance of staff treating
    them with respect, communicating, listening,
    involving them in treatment decisions (Allen)
  • Expert Consensus Guidelines (Behavioral
    Emergencies), (Allen)
  • - Verbal interaction
  • - Collaborative approach
  • - Oral medication if possible guided by
    consumers problems, medication experiences and
    preferences
  •  
  • IM medication can be a symbolic assault
    involving
  • Physical trauma
  • emotional trauma
  • Risk of side effects
  • Compromises the clinician patient
    relationship
  • May reduce future medication adherence

42
Consumer Perspective
  • 1/5 of a consumer panel attributed their
    emergency contact to lack of access to more
    routine mental health care
  • almost 50 of consumers said they wanted
    medication and benefited from medication
  • Many complained about forced administration and
    unwanted side effects

43
Consumer Panel Stressed the Importance of
  • Alternatives to traditional emergency room
    services
  • Increased use of advance directives
  • More comfortable physical environments
  • Improved training of emergency unit staff to
    foster a humane, person-centres approach
  • Collaboration between practitioners and consumers
  • Improved discharge planning and reliable ,
    consistent aftercare

44
Benzodiazepines
Exercise caution in the use of benzodiazepines
  • elderly
  • patients with respiratory disease
  • acute intoxication with alcohol
  • severe impairment of hepatic or renal function
  • depressed level of consciousness,
  • patients using other sedating medications

45
Midazolam
  • Midazolam 2 10 mg (IM/IV) is often used in the
    emergency department for agitated, aggressive
    patients
  • Midazolam IM is also used in ICU Brentwood
  • Risk of respiratory depression requires close
    monitoring and ideally pulse oximetry
  • Onset of action 1 15 minutes (depending on
    route of administration)
  • Half life 1 2.8 hours

46
Clonazepam
  • Clonazepam (0.5 2 mg) is a longer acting IM
    alternative to midazolam but risks associated
    with excessive sedation, ataxia 
  • Onset of action 5 15 minutes
  • Peak plasma levels in less than 4 hours
  • Half life 20 40 hours

47
Lorazepam
  • Lorazepam (0.5 2.5 mg) is often favoured over
    diazepam because of the shorter half life
  • Onset of action 5 15 minutes
  • Peak plasma levels in 2 hours (oral and IM have a
    similar absorption profile)
  • Half life 10 20 hours
  • Less respiratory depression than Diazepam and
    Midazolam

48
Diazepam
  • Diazepam (2.5 10 mg) is well absorbed orally
  • IM absorption is erratic
  • Onset of action (oral) up to 30 minutes
  • Half life 14 - 60 hours (has multiple active
    metabolites)

49
Antipsychotic Medication
First Generation Antipsychotics Low Potency
? sedation postural hypotension ? EPS
  • Chlorpromazine (oral)
  • Onset of action up to 20 minutes with oral
    medication
  • Peak plasma levels -2-4 hours
  • Half life 24 hours (range 8-35 hours)

Intermediate Potency e.g. perphenazine
50
First Generation Antipsychotics High Potency
tranquilization ? EPS
  • Haloperidol (oral / IM)
  • Time of Onset of action depends on route of
    administration
  • IV immediate
  • Oral - up to 60 minutes
  • Half life 24 hours

51
Zuclopenthixol
  • Zuclopenthixol HCl (Clopixol) 10, 25mg tablets
  • Onset of action 10-30 minutes
  • Peak plasma levels in less than 4 hours
  • Half life 24 hours

52
Droperidol
  • Droperidol is a high potency Butyrophenone
  • Parenteral preparation 
  • Maximum dose 30 mg over 24 hours
  • Onset action (IM) 1 20 minutes
  • Duration of action 2 4 hours
  • Half life 2.2 hours
  • Prolongation QT interval

53
Acuphase (Zuclopenthixol acetate)
  • Acuphase (Zuclopenthixol acetate) short acting
    depot used when IM medication is required, with
    tranquilization lasting 24 to 72 hours
  • Onset of action 4 to 6 hours
  • Monitor for EPS
  • Exercise caution in treatment naive patients

54
Second Generation Antipsychotics (SGAs)
  • Risperidone (tablets, quicklets, depot)
  • Paliperidone (tablets, depot)
  • Olanzapine (tablets, wafers, short-acting IM,
    depot)
  • Amisulpride (tablets, syrup)
  • Aripiprazole (tablets, short-acting IM)
  • Quetiapine IR, XR (tablets)
  • Ziprasidone (tablets, short-acting IM)
  • Clozapine (tablets, syrup)

55
Second Generation Antipsychotics
  • Until recently research suggested SGAs have
    superior efficacy for negative symptoms,
    cognition and mood in schizophrenia.
  • First episode psychosis (low dose)
  • SGAs are also used
  • For tranquilization and to reduce hostility in
    agitated patients
  • In mania and depression
  • As mood stabilizers
  • In anxiety disorders including GAD and social
    anxiety disorder
  • As augmentation treatments in OCD and
    treatment-resistant depression
  • As monotherapy / augmentation in PTSD and
    borderline personality disorder
  • Behavioral disturbance in dementia and brain
    injury

56
Second Generation Antipsychotics
  • Less likely to cause EPS, although can occur with
    2nd generation antipsychotics esp. Risperidone,
    Amisulpride in higher doses (Aripiprazole
    restlessness)
  • EPS less likely with Quetiapine and Clozapine
  • Metabolic syndrome (predominantly Clozapine,
    Olanzapine)
  • Cardiovascular / cerebrovascular events in the
    elderly ?class effect
  • Postural hypotension (Risperidone, Quetiapine)
  • Hyperprolactinemia (Risperidone, Amisulpride)
  • QTc prolongation (e.g. Ziprasidone, Amisulpride,
    Quetiapine)

57
Second Generation Antipsychotics Controversies,
Unresolved Issues
  • Drug development studies have focused on
    reduction in symptoms severity with restrictive
    inclusion / exclusion criteria.
  • Short term, narrowly focused trials provide
    limited information about the effectiveness of
    drugs in clinical practice.
  • Recent studies have raised questions about the
    advantages of SGAs in schizophrenia (CATIE,
    CAFÉ, CUtLASS 1, EUFEST, Goldberg et al)

58
Risperidone
  • Oral, quicklets
  • 0.5 2 mg stat dose
  • Onset action 10 - 30 minutes
  • Peak plasma levels 1-2 hours
  • Duration of action 6 - 10 hours
  • Half life 19 hours
  • Postural hypotension, EPS (high dose),
    hyperprolactinemia

59
Paliperidone
  • Active metabolite of risperidone
  • Prolonged release tablet
  • Peak plasma concentrations about 24 hours after
    oral dosing
  • Elimination half-life of about 23 hours
  • Similar side effects to risperidone

60
Olanzapine
  • Oral, wafers, IM
  • 2.5 10 mg stat dose
  • Onset of action 15 - 60 minutes
  • Peak plasma levels 15 minutes -8 hours (depending
    on route of administration)
  • Half life 27 hours
  • Metabolic syndrome, sedation

61
Amisulpride
  • Oral tablets, syrup
  • Peak plasma level 1 4 hours
  • Half life 12 hours
  • EPS, hyperprolactinemia and QTc prologation at
    high dose

Aripiprazole
  • Oral tablets
  • Onset action 1 3 hours
  • Peak plasma level 3-5 hours
  • Half life 75 hours
  • Restlessness

62
Quetiapine IR
  • Oral - tablets
  • 50-150mg stat dose
  • Onset of action 10 - 30 minutes
  • Peak plasma level 1-5 hours
  • Duration of Action 4 - 12 hours
  • Half life 6-7 hours
  • Postural hypotnesion,sedation
  • ? QTc prologation at high dose
  • XR form now available, longer half life.

63
Ziprasidone
  • 80 160 mg / day
  • Must be taken with food
  • Low incidence weight gain
  • Akathisia
  • QTc prologation

64
Clozapine
  • Oral - tablets
  • Peak plasma levels 2-5 hours
  • Half life 12 hours
  • Agranulocytosis, myocarditis, cardiomyopathy,
    metabolic syndrome, lower seizure threshold
    balance benefit against risk.


65
Antipsychotics and Risk of Sudden DeathStraus et
al. 2004
  • Precise mechanism uncertain, suggestions include
  • Peripheral vasodilatation and cardiovascular
    collapse
  • Oral laryngeal / pharyngeal dystonia
  • Acute myocarditis
  • Cardiomyopathy
  • QTc prolongation

66
Antipsychotics and Risk of Sudden Death Straus
et al. 2004
  • Integrated Primary Care Information Project
  • 554 cases of sudden cardiac death
  • Current use of antipsychotics was associated with
    a 3 fold increase in the risk of sudden cardiac
    death
  • Risk highest with butyrophenone antipsychotics
    (e.g. haloperidol / droperidol) and short term use

67
QTc Interval
  • Dose dependant prolongation of QTc interval may
    potentiate risk of serious ventricular
    arrhythmias such as Torsade de Pointes (rare
    occurrence lt 0.01)
  • Risk enhanced by existence of
  • bradycardia (lt 55)
  • hypokalaemia
  • congenital prolongation of QTc interval
  • treatment with medications that produce
    pronounced bradycardia, slowing of intracardiac
    conduction or prolongation of QTc interval
  • should not be given with drugs that induce
    arrythmias such as amiodorone, quinidine,
    sotolol, cisapride, thioridazine and erythromycin

68
Medication for agitated, psychotic patients
Generally involves a combination of
  • Oral atypical antipsychotic
  • Oral benzodiazepine in the first instance

If compliance is an issue
  • Olanzapine / risperidone dissolvable wafers or
  • Risperidone / amisulpride syrup

69
Parenteral Medication
  • If patient more agitated or unwilling to accept
    oral medication
  • IM olanzapine or IM haloperidol plus
  • IM lorazepam / clonazepam /midazolam
  • If patient extremely agitated and presents an
    ongoing threat to self or others or has not
    responded to IM olanzapine / IM haloperidol
    consider use of
  • zuclopenthixol acetate plus
  • IM lorazepam / clonazepam / midazolam
  • Monitor level of sedation, respiration. Ideally
    pulse oximetry if using midazolam.

70
Mania / Schizoaffective Disorder with Mania
Medications which have efficacy include
  • Quetiapine
  • Risperidone
  • Aripiprazole
  • Clozapine
  • Lithium Carbonate
  • Sodium Valproate
  • Carbamazepine
  • Olanzapine
  • ziprasidone

In practise second generation antipsychotics are
often used in combination with anticonvulsants /
lithium carbonate. Concurrent use of oral /
parenteral benzodiazepines to sedate and reduce
arousal.
71
Sodium Valproate
  • loading dose 20-30 mg/kg.
  • If no response after 7 - 10 days consider
    alternative mood stabilizer
  • more efficacious in patients with
  • mixed affective states
  • rapid cycling
  • comorbid substance abuse

72
Bipolar Depression / Schizoaffective Disorder
with Depression
  • Optimize mood stabilizer
  • Antidepressant medication ? Efficacy in BP
    depression
  • Benzodiazepines to reduce arousal / agitation
  • SGA to reduce arousal / agitation and/or
    psychotic symptoms, augment treatment of
    depression
  • If compliance has not been an issue consider an
    alternative mood stabilizer
  • Lamotrigine has efficacy in prophylaxis of
    bipolar depression however has limited value in
    the acute setting
  • Monitor mood / suicidal ideation provision of
    treatment in safe environment
  • SGA monotherapy in bipolar depression

73
Unipolar Depression
  • Antidepressant medication
  • Second generation antipsychotic monotherapy
    (quetiapine)
  • Second generation antipsychotic to reduce arousal
    / agitation and / or psychotic symptoms
  • Benzodiazepines to reduce arousal / agitation
  • Monitor mood / suicidal ideation provision of
    treatment in safe environment
  • Consider augmentation strategies e.g. lithium,
    thyroxine, second generation antipsychotic etc.

74
Schizophrenia
  • RANZCP Clinical Practice Guidelines, McGorry et
    al 2005
  • SGA treatment of first choice
  • Conventional antipsychotic in low dosage where
    there is remission, good tolerability, or depot
    medication unavoidable
  • Consider clozapine if there is incomplete
    remission with at least 2 other antipsychotic
    agents
  • Psychosocial interventions assertive community
    treatment, medication adherence therapy,
    (cognitive remediation therapy)
  • Consumer involvement
  • Physical health prevention and early treatment
    of medical illness
  • Shared care with GP.

75
Treatment Resistant Schizophrenia
  • Also
  • Clozapine / amisulpride combination
  • Clozapine / aripiprazole combination
  • Clozapine / ECT

76
ECT - Indications
  • Depression
  • Bipolar depression
  • Unipolar depression
  • Psychotic features
  • Lack of response to pharmacotherapy
  • Severe illness with significant risk to self
    through suicide or self neglect
  • Mania
  • Severe mania unresponsive to pharmacotherapy

77
ECT - Indications
  • Schizophrenia
  • Catatonia
  • Associated depression
  • Inadequate response to pharmacotherapy
  • Severe illness, risk to self, others
  • Evidence for combined clozapine and ECT in
    treatment refractory schizophrenia

78
Shock treatment therapy used to alter favorably
the course of a mental illness
79
Substance Abuse
  • Two to three times more common among those with
    psychiatric illness than in general population.
  • Negative attitudes towards this subset of the
    population hinders the provision of effective
    care.
  • Urine drug screening helpful

80
Common Substances of Abuse
  • Alcohol
  • Cocaine
  • Amphetamine
  • Methamphetamine
  • MDMA (3,4 methylene dioxymethamphetamine),
    (ecstasy)
  • Ketamine
  • Cannabis
  • Opiates

81
The Drug Abusing Patient
  • Patient may present with intoxication or
    withdrawal symptom.
  • Stimulant intoxication may induce paranoid
    symptoms, delirium.
  • Opiate withdrawal marked by pupillary dilatation,
    lacrimation, diarrhoea, cramping
  • Patient may present with physical symptoms and
    demand opiates for pain relief

82
Amphetamine Methamphetamine Abuse
  • Clinical Presentation
  • Acute anxiety
  • Paranoid ideation
  • Loud, demanding behaviour
  • Motor agitation, aggression
  • Stereotypic behaviours sniffing, teeth
    clenching, purposeless searching, picking of skin
  • May be evidence of needle marks
  • Pulse, BP, respiration rate, increased and
    dilated pupils
  • Exacerbation, precipitation of mania/psychosis
  • Persisting delusional state

83
Treatment
  • Support, verbal de-escalation
  • Safety first potential for aggression
  • Benzodiazepines to reduce arousal
  • Second generation antipsychotics
  • i.e. Olanzapine - Quetiapine
  • Monitor for orthostatic hypertension with SGAs
  • ECG QTc
  • General medical including hydration, malnutrition
  • Routine screens including Biochemistry, CBP, Hep
    screens, HIV
  • Assess need for inpatient treatment
  • Referral to specialist drug, alcohol service
    where appropriate

84
Case Presentation
  • Mrs B. 52 year old married woman, lives in a
    country town 200km from Adelaide. 2 sons aged 28,
    33 years.
  • sexual assault by chiropractor, later
    developed severe illness with mood disturbance,
    auditory and ?olfactory hallucinations, passivity
    experiences, religious delusions, delusions of
    reference.
  • Past History postpartum depression social
    anxiety disorder
  • No family history of psychiatric illness
  • Emotional deprivation, physical aggression and
    neglect by parents esp. father.
  • History of sexual assaults in childhood,
    adolescence and adult life
  • Husband emotionally abusive, controlling,
    similarities to father

85
Case Presentation cont.
  • Employed as registered nurse, managed several
    successful businesses prior to illness onset.
  • Self esteem linked to work, parenting, physical
    appearance.
  • Since 1995 chronic, fluctuating psychotic
    symptoms with episodic mood disturbance. Ongoing
    social anxiety and posttraumatic symptoms.
  • Underlying Axis 2 issues although functioned well
    prior to illness onset.
  • Organic screens including EEG, CT head, MRI head,
    ECG, echocardiogram NAD.

86
Case Presentation cont.
  • Intensive outpatient treatment including
  • Supportive psychotherapy
  • Psychoeducation
  • Marital counselling
  • Theological input
  • CBT
  • Cautious exploration of past traumas and
    underlying dynamic issues
  • Pharmacotherapy
  • Second and third opinions
  • Inpatient treatment
  • numerous admissions including ICU due to
    psychotic symptoms and risk of self harm
  • Traumatic experience in hospital

87
Case Presentation cont.
  • Pharmacotherapy
  • FGAs oral / depot
  • SGAs including clozapine
  • Mood stabilisers
  • Antidepressants
  • Current medication
  • Amisulpride 1,000 mg daily
  • Seroquel 300 mg bd
  • Benztropine 2-3 mg daily
  • Lorazepam 1.5 mg daily
  • Temapzepam 10 mg prn nocte
  • Psychotic symptoms have settled, mood stable for
    last 6 months.
  • Still has moderately severe social anxiety.

88
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89
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