TREATMENT REFRACTORY PSYCHOSIS

Featuring Dr Fiona Gaughran, Lead Consultant Nat Psychosis Unit. 

What’s New and What’s Not…..

Interests:  Honoraria/Advisor :  BMS, Roche, Family Professional links;  GSK, Lilly

Previously funds for Conferences/unrestricted research grants/advisory bodies:  Astra-Zeneca, Janssen, BMNS, Lilly

In the presentation it is mentioned about the strong links between the Institute of Psychiatry and South London and Maudsley Trust.

It states why people are referred ie:  Diagnostic DilemmasHigh use of resources, advice on management, treatment resistance, sub-optimal response.

Team – consisting of Psychiatry which notably is at the top!  Psychology, Medical KCH, Social Work, OT, Expert Nursing, Specialist Pharmacy

 

Assessment

Diagnosis

Dimensions

Co-morbidities (Physical health    Mental Health)

What’s been tried and why didn’t it work?  It goes to look at past treatments (past treatments were mainly one drug after another, sometimes more than 1 at the same time)

CBT is mentioned under Psychological Therapies  – CRT, Art therapies, Family Work.  ( family work?  Even if someone is opposed to the treatment you do not treat someone like a criminal to be escorted everywhere and threaten them with arrest).

There is the usual charts and this features Clozapine of course –  CLOZAPINE IS THE WONDER DRUG OF THE NAT PSYCHOSIS UNIT.  I have already featured Dr MacCabe  in his shocking presentation where he speaks of bribery.  I look forward to attending his future courses myself.

The rest of the presentation then seems to be all about Clozapine “its all about Clozapine here – you should have done your research” – said the Lead Nurse.  

Clozapine Optimisation

Not tried – Clinician worries – Declined.     Well that is interesting as Elizabeth declined and was forced – as Dr MacCabe points out under a Section 3 patients can be restrained and forced to take medication – Human rights are disregarded in the desperation to get the patient on Clozapine.  Elizabeth did not even know what drug she was on and that it began with a letter M.  M = Metformine and this is used in conjunction with Clozapine for weight loss but is also contra indicated – now Elizabeth is no longer on this chemical and if this hospital was in any way concerned about a patient’s physical health then why put someone on  contra indicated drugs which I have now challenged and she has been taken off.    

Didn’t Work – Levels / Smoker

The only thing this drug does is to highly sedate someone, Elizabeth has mentioned a strain to her heart.  Emergency doctors called out more than once and NOONE NOTIFIES YOU.  I got to find out as I went shopping for her and rang her.  Elizabeth has mentioned dizziness. “I don’t think the drugs are doing me any good mum”  –  Well that says it all.    There is nothing good in my opinion about this drug and what is horrific is that all along my daughter has not been given a proper assessment.

Worked but Not Tolerated – Levels?

Some people are on as much as 800mg alongside Lithiuim in an equally huge amount –  imagine a young person hardly able to move.  This is an example of what treatment can do for you under the Nat Psychosis Unit.

 

OPTIMIZING CLOZAPINE ESSENTIAL INCLUDING PSYCHOSOCIAL ASPECT

Average Dose in UK around 450mg a day

Response seen in range of 150-900mg  a day

Lower doses required in elderly, females and non smokers and in those prescribed enzyme inhibitors.

 

Plasma Levels –  In male smokers who cannot achieve therapeutic plasma levels, metabolic inhibitors (Fluvoxamine for example can be co-prescribed but extreme caution is required.  It goes into depth about threshold for response.  Importance of norclozapine levels not established but clozapine norclozapine ratio may aid assessment of recent compliance.

 

There is also a chart about weight gain,  Fits – levels, Hypersalivation, Techycardia, Fever, Hyphertension etc

 

Amber

Recheck

WCC lower in am

 

Red

Stop Clozapine

Admit

It features RESTARTING CLOZAPINE AFTER NEUTOPRENIA AND THE IMPORTANCE OF THE RECOGNITION OF BENIGN ETHNIC NEUTROPLENIA IN BLACK PATIENTS DURING TREATMENT WITH CLOZAPINE:  cASE REPORTS AND DATABASE STUDY

OTHER PROBLEMS – POST CARDIAC SIDE EFFECTS

POST PERICARDITIS

POST HEPATITIS

RECHALLENGE AFTER NETROPAENIA

Was it all down to Clozapine?

Do you challenge the CNRD

Benign Ethnic Neutropaenia/other meds at fault?

Does Lithium Help?

When is GCSF useful and how is it best used?

AUGMENTING CLOZAPINE WITH ANOTHER ANTI PSYCHOTIC

Marginal therapeutic benefit but effect size small – Taylor & Smith 2009

Modest therapeutic benefit but effect size small – Taylor et al 2012

Increases Mortality risk

High does guidelines

Interactions can result in higher blood levels and longer QTc as so forth    ……Consider mood stabilisers or anti-depressants especially if evidence of mood disturbance

 

Alternatives to Clozapine are High Dose Olanzapine – weight gain worse on Olanzapine

Combinations of anti-psychotics –  NICE “do not initiate regular combined anti-psychotics  

More work needed

FGA plus Mirtazepine

ECT plus anti-psychotics?

Melperone  …….

WHY DO RCTs promise so much and deliver so little?

Inclusion of treatment -intolerant patients

Compared to unoptimised Clozapine

Impossibility of blind trials with Clozapine

Placebo effect

INTEREST OF SPONSOR

summary:

Full MDT assessment

Optimise Clozapine wherever possible

Manage adverse effects proactively

Augment in partial responders

Collaboration with medical specialities if re-challenge

Limited data for alternatives; consider high does of Olanzapine, anti-psychotic combinations, ECT?

all combined with psychological therapies (CBT CRT FAMILY WORK AND OT). 

 

Comments made herein are just extract/summary of some of the treats in store for patients referred to the National Psychosis Unit.  This is a place where patients are sent away from their families from miles away, where there are few visitors, where experimentation goes on against a patient’s wishes and where they try to make it look good in terms of inviting the family to meetings, a phone call at a designated slot but I have documented what really goes on.    There is forced treatment of patients, imprisonment, exclusion of family and isolation from family as that family may be far away and as I have documented when Elizabeth was sent all the way to Wales,  this does not make it easy on the family financially when you have no support or help and not everyone has a car to drive to visit.  The visitors book was empty when I regularly went to visit Elizabeth.  The beautiful grounds outside were deserted, the swimming pool was used by the local community when I visited.    It was saddening to see young patients so drugged up.   At first I used to visit and take Elizabeth off the ward all day long to visit the lovely area outside of this hospital but then when I was restricted to 1 hour’s visiting rights what could you do in that time.  I was even threatened that police would be called if I was late back.  There were some good members of staff such as the social worker and young nurses but others who were typical and worse name badges back to front and the only time I ever saw life there was at the fete but sadly Elizabeth was too ill to come down and enjoy this and was stuck on the ward all day. 

 

 

 

 

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3 comments
    • It is when you really look into matters that you see how lacking the care system is. I am talking about knowledge of how the drugs work by professionals who prescribe these drugs and are quick to label someone. Not once was Elizabeth’s physical health considered and now I am really looking into all of this and will document things. You only get to hear a one sided account in the press but I hope I get their attention in the near future.

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