Mental%20Health%20Care%20Challenges%20in%20Management%20of%20Schizophrenia%20and%20other%20non%20affective%20psychosis%20presented%20by

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Mental Health CareChallenges in Management
of Schizophrenia and other non affective
psychosispresented by

• Chief Dr H.T.O. LADAPO, MD (Ukraine) FMC Psych..,
  FWACP, FHAN, MPH (Unilag)

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Introduction (1)

• Early Greek physicians described delusions of
  grandeur, paranoia, and deterioration in
  cognitive functions and personality.
• Schizophrenia did not emerge as a medical
  condition worthy of study and treatment until the
  eighteenth century.

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Intoduction (2)

• Emil Kraepelin delineated insanity
  manic-depressive psychosis and dementia praecox
  (or dementia of the young)
• In 1911 Eugen Bleuler suggested the term
  schizophrenia (splitting of the mind) for the
  disorder.

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Intoduction (3)

• He also described four primary symptoms (the four
  As) abnormal associations, autistic behavior and
  thinking, abnormal affect, and ambivalence.

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Intoduction (4)

• Nondisease models
• -The societal reaction theory ("a sane reaction
  to an insane world")
• -Thomas Szasz's theory which states that
  schizophrenia is a myth enabling society to
  manage deviant behavior

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Epidemiology (1)

• Schizophrenia is a leading public health problem
  that exacts enormous personal and economic costs
  worldwide.
• Schizophrenia affects just under 1 percent of the
  world's population (approximately 0.85 percent).

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Epidemiology (2)

• NIMHs Epidemiologic Catchment Area (ECA) study
  lifetime prevalence 1.5
• International Pilot Study of schizophrenia (IPSS)
• Determinant of Outcome studies by WHO (12
  countries)

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Epidemiology (3)

• A 1987 review of over 70 prevalence studies of
  schizophrenia published since 1948 identified
  point prevalence in various population groups
  ranging from 0.06 percent to 1.7 percent, with
  lower rates in developing countries.

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Epidemiology (4)

• Life time risk ranges from 0.7 to 1.3
• The prevalence rate is similar in different
  cultures when assessed using similar instrument (
  Jablensky et al 1992)
• Exceptions include Slovenia, Western Ireland,
  Catholics in Canada and Tamils of Southern India

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Epidemiology (5)

• Low rates have been reported in the Hutterrites
  and the Anabaptist sects in the USA
• Onset usually between the ages of 15 and 45
• Peak age in men 15 - 25years
• Peak age in women 25 35 years

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Risk factors

• Genetic Factors
• Ethnicity and Racial Factors
• Age
• Sex
• Season and Birth Order
• Birth and Fetal Complications
• Social Class downward drift and social
  causation theories

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Risk factors

• Marital Status
• Immigration
• Urbanization and Industrialization
• Life Stressors
• Infections
• Suicide Risk

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Aetilogy (1)

• Cause is unknown
• Results from a complex interplay of genetic,
  environmental and social factors

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Aetiology (2)

• Neurobiological model
• Structural abnormalities include
• enlarged lateral ventricles
• enlarged third ventricle, and
• reduced volume of a number of structures,
  including hippocampus, amygdala, and frontal and
  temporal cortices.

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Aetiology (3)

• Genetic factors
• Family studies
• Twin studies
• Adoption studies

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Population Prevalence ()
Gen pop. 1.0 Non twin sibling 8.0 Child with one parent with schizophrenia 12.0 Dizygotic twin of schizophrenia patient 12.0 Child of two parents with schizophrenia 40.0 Monozygotic twin of a schizophrenia patient 47
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Aetiology (4)

• Genetic factors
• Putative schizophrenia susceptibility loci
  yielding some evidence of confirmation include
  loci on chromosomes 6, 8, and 22.

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Aetiology (5)

• Neurobiology
• blood flow to several brain regions, including
  prefrontal and temporal areas, is altered in
  schizophrenia. These changes may be related to or
  may underlie positive and negative symptoms as
  well as some cognitive deficits.

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Aetiology (6)

• Neurobiology
• Biochemical basis of schizophrenia
• Dopamine
• Serotonin
• glutamate

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Aetiology (7)

• Dopamine hypothesis
• It postulates a hyperactivity of dopamine
  transmission at the D2 receptors in the
  mensecephalic projection to the limbic striatum
  (Synder et al. 1974)

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Aetiology (8)

• Evidence in support of dopamine hyp.
• There is a tight correlation between the
  therapeutic doses of conventional antipsychotic
  drugs and their affinities for D2 receptors
  (Seeman, 1987)
• Indirect dopamine agonists can induced psychosis
  in healthy subjects and at very low doses provoke
  psychotic symptoms in schizophrenia (Carlsson
  1988)

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• Postmortem and PET studies have shown increased
  dopamine D2 receptor level in the brain of
  schizophrenic patients (Wing et al, 1986)
• There is also emerging evidence for a presynaptic
  dopaminergic abnormality in schizophrenia
  (Laruelle et al 1999).
• Existing literature suggested heritable
  abnormalities of prefrontal dopamine function are
  prominent features of schizophrenia (Egan et al,
  2001)

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• Serotonin
• Serotonin receptors are involved in the
  psychotomimetic and psychotogenic properties of
  hallucinogens e.g (LSD)
• the number of cortical 5-HT 2A and 5-HT 1A
  receptors is altered in schizophrenic brains
•  

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• 5-HT 2A and 5-HT 1A receptors play a role in the
  therapeutic and/or side effect profiles of
  atypical antipsychotics (e.g., Clozapine)
• certain polymorphisms of the 5-HT 2A receptor
  gene are associated with schizophrenia
• the trophic role of serotonin in neurodevelopment
  may be usurped in schizophrenia

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• 5-HT 2A receptor-mediated activation of the
  prefrontal cortex may be impaired in some
  schizophrenics
• serotoninergic and dopaminergic systems are
  interdependent and may be simultaneously affected
  in schizophrenia (Liebermann et al. 1998,
  Harrison 1999).

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• Glutamate
• Potent non-competitive antagonist of the NMDA
  subtype of glutamate receptor (NMDA-R), induce
  schizophrenia-like symptoms in healthy
  individuals and worsen some symptoms in
  Schizophrenia (Hirayasu et al. 2001 Andreasen
  1997).
• Postmortem studies of schizophrenic brains
  additionally indicate abnormalities in pre and
  postsynaptic glutamatergic indices.

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• NMDA-R hypofunction in the cortical association
  pathways could be responsible for a variety of
  cognitive and other negative symptoms (Carlsson
  et al 2000).
• It has been proposed that NMDA-R antagonist can
  cause excess compensatory release of glutamate
  that can over activate unoccupied non-NMDA
  glutamate receptors. This might in part be
  responsible for their behavioural effects.

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• The effects of inhibiting NMDA-R may manifest
  through dopamine neurotransmission as dopamine
  and glutamate systems in the central nervous
  system have both anatomical and functional inter
  relationship.
• Finally, NMDA-R hypo function may also produce
  abnormalities in the neuroplasticity of neurons
  by altering synaptic connectivity.

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Aetiology (9)

• Neurodevelopmental hypothesis posits that
  insults occuring in-utero or shortly after birth
  are responsible for the structural abnormalities
  which manifest in symptoms later in
  adolescence/adulthood

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• Evidence in support includes
• Absence of gliosis despite evidence of neuronal
  loss
• Evidence of impaired maturation, migration and
  pruning of neurons in schizophrenic brains
• Cytoarchitectural abnormalities in medial
  temporal lobe

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Aetiology (10)

• Environmental factors
• maternal bonding
• early rearing
• Poverty
• immigration status
• Stress
• viruses.

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Aetiology (11)

• Social factors
• Culture
• Migration
• Residence
• Social isolation
• Occupation and social class

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Aetiology (12)

• Psychosocial stresses
• experiencing life event in the preceding six
  months doubles the risk of developing
  schizophrenia (Paykel 1978)
• There is however, no evidence that schizophrenics
  experience more life events than the general
  population

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Aetiology (13)

• Family
• Deviant role relationship schizophrenogenic
  mother
• Lidzs Lidzs (1948) described marital schism and
  marital skew
• Bateston et al, 1956 described Disorder family
  communications (Double bind theory)

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Aetiology (14)

• Psychodynamic factors
• Mainly of historical interest
• Freud's theory of schizophrenia
• Melanie Kleins theory

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CLINCAL FEATURES

• DIAGNOSTIC CRITERIA
• Schneider
• Langfelt
• New Haven Schizophrenia Index
• St. Louis Criteria
• Research diagnostic Criteria
• Present State Examination (PSE)
• ICD-10
• DSM
• Positive vs. Negative symptoms

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• SCHNEIDERIAN FIRST RANK SYMPTOMS
• Audible thoughts
• Voices arguing or discussing or both
• Voices commenting
• Somatic passivity experiences
• Thought withdrawal and other experiences of
  influenced thought
• Thought broadcasting
• Delusional perceptions
• All other experiences involving volition, made
  affects, and made impulses

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• Second rank symptoms
• Other disorders of perception
• Sudden delusional ideas
• Perplexity
• Depressive and euphoric mood changes
• Feelings of emotional impoverishment
• And several others as well

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• DSM IV and ICD 10

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Types

• Type I schizophrenia was characterized by
  predominantly positive symptoms, good premorbid
  functioning, sudden onset, normal brain
  structures by computed tomography (CT), good
  response to treatment, and a better long-term
  course.

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• Type II schizophrenia was characterized mainly by
  negative symptoms, an insidious onset, poor
  premorbid functioning, abnormalities on CT scans,
  a tendency to drug resistance, and a poorer
  long-term course and outcome, often resulting in
  behavioral deterioration. (Tim Crow)

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Other types

• Paranoid
• Hebephrenic/disorganised
• Catatonic
• Simple
• Residual
• undifferentiated

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TREATMENT

• Pharmacotherapy
• Psychosocial intervention

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Factors Influencing Antipsychotic Drug
Selection
Factors Considerations
Subjective response A dyphoric subjective response to a particular drug predicts poor compliance with that drug Sensitivity to extrapyrimidal A serotonin-dopamine antagonist (SDA) adverse effects Tardive dyskinesia Clozapine or (possibly another SDA) Poor medication compliance Injectable form of a long-acting antagonist or high risk of relapse Haloperidol or fluphenazine) Pregnancy Probably haloperidol (most data supporting its safety) Cognitive symptoms Possibly an SDA Negative symptoms Possibly an SDA
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• Psychosocial intervention
• Individual psychotherapy
• Group therapy
• Family Therapy
• Psychiatric Rehabilitation
• Social Skills Training
• Vocational Rehabilitation
• Residential Treatment And Housing Programs

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Features Weighing Toward Good to Poor Prognosis
in Schizophrenia Good Prognosis
Poor Prognosis Late onset
Young onset Obvious precipitating
factors No precipitating factors Acute onset
Insidious onset Good
premorbid social, sexual, Poor premorbid
social, sexual, and work histories
and work histories Mood disorder
symptoms Withdrawn, autistic behavior
(especially depressive disorders) Married
Single, divorced,
or widowed Family history of mood disorders
Family history of schizophrenia Good support
systems Poor support
systems Positive symptoms
Negative symptoms
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Other features of poor prognosis

• Neurological signs and symptoms
• History of perinatal trauma
• No remissions in 3 years
• Many relapses
• History of assaultiveness

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Other psychotic Disorders

• Delusional Disorders
• Schizophreniform Psychosis
• Reactive Psychosis
• Schizo-Affective
• Atypical-Folie a Deaux, culture bound syndrome,
  Capgras,Cotard,Fregoli
• Schizotypal personality disorder
• Postpartum psychosis

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Recent advances

• Team working in LMU
• Found rare genetic variations that have a major
  influence, but also found frequent genetic
  variations that have only a minor effect on the
  disease risk.
• identify three so-called microdeletions.

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Challenges Of Management Of Psychiatric Disorders

• Available service not centralized but
  concentrated only in the cities within the
  country.
• Non inclusion of services in National health
  Insurance Scheme.
• Problem of stigma and negative perception of
  mentally ill patients
• Challenges of religious doctrines leading to mis
  management and chronicity.

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• Atypical drugs though available has given hope
  for treatment of resistant and chronic condition
  thereby reducing chronicity.
• - cost of drugs is on the high side, many could
  not afford to purchase.
• - Infiltration of fake and genuine drugs in drug
  market.
• - Need for government subsidy of drugs to
  reduced burden of family and community.

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• Iloperidone, also known as Fanapta, and
  previously known as Zomaril, is an
  investigational atypical antipsychotic. It is
  being investigated mainly for the treatment of
  schizophrenia symptoms.

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• THANK YOU FOR LISTENING