SCHIZOPHRENIA. For Primary Care Providers. Project ECHO LA Adult Psychiatry ECHO June 25, 2014

Transcription

1 SCHIZOPHRENIA For Primary Care Providers Project ECHO LA Adult Psychiatry ECHO June 25, 2014 Curley L. Bonds, MD Medical Director Didi Hirsch Mental Health Services

2 SCHIZOPHRENIA The most common psychotic illness 7/1000 people develop the disorder in their lifetime Serious Mental Illness (SMI) 50%-90% of people with SMI have 1 or more chronic medical illness 1 Primary Care Experts are not expected to diagnose schizophrenia, but they should have a working knowledge of the illness, treatment and challenges 1 Gold, Kilbourne, Valenstein

3 CLINICAL SIGNIFICANCE Patients with schizophrenia die earlier than the general population, mostly from preventable treatable medical illnesses.

4 CLINICAL SIGNIFICANCE Patients with schizophrenia die earlier than the general population, mostly from preventable treatable medical illnesses. Higher rates of cardiovascular, infectious, respiratory, endocrine, and gastrointestinal disease are seen in patients with schizophrenia

5 CLINICAL SIGNIFICANCE Patients with schizophrenia die earlier than the general population, mostly from preventable treatable medical illnesses. Higher rates of cardiovascular, infectious, respiratory, endocrine, and gastrointestinal disease are seen in patients with schizophrenia Certain antipsychotic medications contribute to metabolic abnormalities more than others.

6 CLINICAL SIGNIFICANCE Patients with schizophrenia die earlier than the general population, mostly from preventable treatable medical illnesses. Higher rates of cardiovascular, infectious, respiratory, endocrine, and gastrointestinal disease are seen in patients with schizophrenia Certain antipsychotic medications contribute to metabolic abnormalities more than others. Routine physical health monitoring and targeted interventions, especially for cardiovascular disease and its risk factors, are key considerations when caring for this patient population.

7 DIFFERENTIAL DIAGNOSIS Psychosis Primary (psychiatric) Secondary ( organic ) Secondary Intoxication Withdrawal Medical Illness Infections Endocrinopathies Electrolyte and metabolic abnormalities Neurological processes (seizures, tumors, etc)

8 MEDICAL ASSESSMENT To Rule Out Organic Causes of Psychosis: Medical and family hx PE (with focused neuro exam) CBC Electrolytes, Ca++ BUN/Cr LFTs Vit B12 TSH HIV Florescent treponemal Antibody absorption test UA + Tox MRI Other: EEG, Cerulosplasmin, CXR, LP

9 6 Symptom Clusters of Schizophrenia Viron et al Schizophrenia for Primary Care

10 TREATMENT Should involve a multidisciplinary mental health treatment team to provide effective and comprehensive psychiatric care Medication Management Antipsychotics Dopamine blocking agents First Generation Typical older drugs (low to high potency) Side effects include orthostasis, sedation and anticholinergice side effects Second Generation Atypical newer drugs (5HT 2 and D 2 Antagonism) Have a lower liability for side effects Older: risperdone, olanzapine, queitapine, ziprasidone, and aripiprazole Newest: Paliperidone, asenapine, iloperidone, lurasidone Clozapine: requires routine WBC monitoring, + other side effects Therapy Case Management Psychosocial Rehabilitation

11 MEDICAL CARE Mortality rate for schizophrenia is 2-3x higher than in the general population. Elevated risk of death is due to higher rates of mortality from suicides and injuries, as well as multiple categories of medical illnesses. 5% will die by suicide Risk of suicide is 13x greater than the general population Patients often make contact with their PCP before the act Increase risk of CV Disease Higher rates of obesity, smoking, diabetes, HTN, dyslipidemia, and metabolic syndrome

12 ROUTINE MONITORING Personal and family history of obesity, diabetes, dyslipidemia, HTN, or DVD Smoking status Weight (BMI) Waist Circumference Blood Pressure Fasting Plasma Glucose Fasting lipid panel ECG Neurological Exam Prolactin Level Eye Examination (Chlorpromazine and quetiapine)

13 OBSTACLES & CHALLENGES Providing good care to patients with schizophrenia can be challenging. Symptoms of illness my disrupt engagement with a provider or clinic. Negative symptoms such as amotivation can present an obstacle to keeping appointments and following treatment plans. Paranoia may make it difficult for patient to feel comfortable. Therapeutic Nihilism Diagnostic overshadowing Stigma

14 REFERENCE Schizophrenia for Primary Care Providers: How to Contribute to the Care of a Vulnerable Patient Population Viron, Bagget, Hill, et al. The American Journal of Medicine (2012) 125,