Diagnosis:
- Brief Psychiatric Rating Scale (BPRS)
- Positive and Negative Symptom Scale (PANSS) – 7-point, 30 item scale. Requires a 45-minute interview
- Positive Symptom Rating Scale (PSRS) – 1-7 scale
- Brief Negative Symptoms Assessment (BNSA) 1-6 scale
Treatment:
- Antipsychotics are the first line
- The Joint Commission recommends 1 antipsychotic unless:
- 3 failed attempts at monotherapy
- A plan to taper to monotherapy
- Augmentation of clozapine
- Other documentation
Antipsychotics:
- First-generation:
- Mostly treat positive symptoms (hallucinations, delusions, disorganized behavior)
- All lower seizure threshold, cause weight gain, liver toxicity, QT prolongation
- Low potency (anticholinergic > EPS)
- Chlorpromazine (blue-grey skin, also treats hiccups, N/V, RLS) and thioridazine
- High potency (EPS>>anticholinergic)
- Fluphenazine (comes in depot shot), haloperidol (depot too), loxapine (bronchospasm risk), perphenazine, trifluoperazine (don’t give greater than 6 mg/day longer than 12 weeks)
- Smoking may increase metabolism, so may need to decrease dose if patients quits, especially olanzapine and clozapine
- Second Generation (aka atypical):
- Treats mostly positive symptoms, but can improve negative symptoms as well. Cause less extrapyramidal symptoms and tardive dyskinesia. Overall, 2nd generations are better tolerated.
- Some seizure threshold lowering, risk for diabetes and hyperlipidemia, some QT prolongation, hyperprolactinemia, antihistamine effects
- Weight gain worst to least: clozapine > olanzapine > risperidone, paliperidone, iloperidone, quetiapine > ziprasidone, aripiprazole, lurasidone
- Clozapine only for refractory cases due to agranulocytosis risk. Monitor ANC. If <1000, interrupt therapy, if <500 stop.
- May add lamotrigine to clozapine. No data for other anticonvulsants
- Olanzapine should never be taken with lorazepam.
- Risperidone has greater EPS and TD with 6mg or more dosing.
- Ziprasidone has more QT prolongation than others.
- Aripiprazole has more akathisia, low EPS and TD
- Iloperidone causes orthostasis if not properly titrated
- Paliperidone s the active metabolite of risperidone.
- All patients prescribed second-generation antipsychotics should be monitored for weight, blood pressure, fasting, glucose, lipids and waist circumference.
- Benzos may be useful during the acute phase
- Neuroleptic malignant syndrome:
- Can occur with any agent, but more common with high potency first-generation antipsychotics
- Manifested by agitation, confusion, changing levels of consciousness, fever, tachycardia, labile blood pressure, sweating.
- High mortality rate.
- Treatment: Discontinue agent, give supportive therapy including fluids and cooling. Bromocriptine and dantrolene can be used.