Schizophrenia Tutorial Mr Tom Jones

Mental Health

Please provide feedback on Consumer Educators Tutorial

• SFNSW Consumer educator visits– Well received this week: educators enjoyed their

visit and sharing their experiences– Remember: Views of the consumer educators are

their own personal views

– Please e-mail any specific feedback to me: timothy.chen@sydney.edu.au

Resources for this tutorial

• Lecture Notes• TG Psychotropic• AMH 2011• The Maudsley Prescribing Guidelines 10th

edition• Articles – cut and past URL or access via the

library

Papers to Read in Preparation for Tutorial

http://www.nejm.org.ezproxy1.library.usyd.edu.au/doi/pdf/10.1056/NEJMra035458

Papers to Read in Preparation for Tutorial

http://www.sciencedirect.com.ezproxy1.library.usyd.edu.au/science?_ob=MImg&_imagekey=B6T1B-4CN4NJM-V-

1&_cdi=4886&_user=115085&_pii=S0140673604164581&_orig=search&_coverDate=06%2F19%2F2004&_sk=996360573&view=c&wchp=dGLbVzb-

zSkzS&md5=1f28acfb25e485dd4c3318f3d00c021e&ie=/sdarticle.pdf

Papers to Read in Preparation for Tutorial

http://schizophreniabulletin.oxfordjournals.org.ezproxy1.library.usyd.edu.au/cgi/reprint/35/2/443

Papers to Read in Preparation for Tutorial

http://ajp.psychiatryonline.org.ezproxy1.library.usyd.edu.au/cgi/reprint/166/2/152?

maxtoshow=&hits=10&RESULTFORMAT=1&andorexacttitle=and&andorexacttitleabs=and&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=r

elevance&volume=166&firstpage=152&resourcetype=HWCIT

Papers to Read in Preparation for Tutorials (Two)

http://www.mja.com.au/public/issues/181_10_151104/lam10435_fm.pdf

Papers to Read in Preparation for Tutorial

http://www.australianprescriber.com/upload/pdf/articles/1203.pdf

Presentation• Initial Presentation• Mr Tom Jones, aged 21 years, dropped out of his university course

(advanced science) 12 months ago. His parents are very concerned because he has become increasingly withdrawn. He spends most of his time in his upstairs bedroom with the door closed and with the blinds down. His parents have heard him muttering to himself about UFOs which hover around his window. On the rare occasion that he does leave his bedroom, normally to buy cigarettes, Tom Jones reports that the UFOs follow him wherever he goes. He believes that the aliens in the UFOs are monitoring his movements because they want to take him away to a far distant planet where he will be subject to numerous scientific experiments. He is extremely concerned about this. In fact, three days ago when he was buying his cigarettes, he saw the same UFO at the corner shop and heard the aliens saying that they plan to take him away in three days time.

Presentation• History• Tom attended a selective high school in his local area and

was the equal dux of his school. At school he participated in the debating team, the chess team, the orchestra and was captain of the athletics team. Not only was he a talented academically and on the sporting field, he was also one of the most popular students in his year. He made a very smooth transition into university life after taking 12 months off to travel around Australia and Asia. In his first year at university he gained either high distinctions or distinctions in all subjects. Tom joined the university athletics club, the coffee club, the bridge club, the canoe club, the drama society and the mathematics society, amongst others. He met and made lots of new friends.

Presentation• Although Tom took his studies very seriously, he also enjoyed the

‘freedom’ of university life and participated in as many clubs and social events as possible. Tom attended many pub crawls, parties and other social events, especially in the second half of his first year. He stated smoking cigarettes and binge drinking quite heavily at times, partly due to peer pressure. This did not seem to affect his academic grades. Although exposed to illicit drug use quite often, he was never really tempted, until a beach party early in his second year. He started smoking cannabis and by the end of the semester he was a regular cannabis user. That semester his grades deteriorated significantly and he received his first ‘pass grade’ ever. He also failed to submit two compulsory assignments for his favourite subject, advanced calculus, and missed the exam.

Presentation• Tom experienced a number of mild psychotic episodes which a

friend and counsellor attributed to his use of cannabis. He did not seek any medical help, despite being advised, and although over the next twelve months he had periods of up to six weeks without cannabis use, his psychotic symptoms persisted. He dropped out of university and soon lost regular contact with almost all of his friends. He did not return phone calls, e-mails or text messages.

Presentation

• Tom’s parents encouraged him to seek medical attention but he was generally unreceptive to this advice. Tom’s parents suspected that he had a mental disorder. Although neither of his parents had a mental illness, there was a history of mental illness in the family, particularly with psychotic disorders and depression. In desperation one day, his parents organised for a local GP to make a “house call”. A few weeks after this “house call”, the GP had arranged for Tom to see a community-based psychiatrist and Tom was also assigned a mental health case manager.

Presentation

• Medication History - 2008 (22 years old)• Initially Tom was prescribed risperidone at a dose of 1mg

twice daily and alprazolam 0.5mg at night. His dose of risperidone was slowly increased over a period of about 9 months to 3mg BD. Tom received regular visits from his case manager and responded relatively well to treatment with risperidone. However his weight increased from 72kg to 89kg over this 9 months period. He also developed gynaecomastia and galactorrhoea.

Tutorial One Preparation

• What is schizophrenia? What are the signs and symptoms associated with schizophrenia? Are these consistent with Tom’s presentation? What are the positive symptoms and what are the negative symptoms? What are the aetiological factors associated with schizophrenia? Comment on Tom’s situation?

Tutorial One Preparation

• What are the main classes of medicines used in the management of schizophrenia? What are the differences between the first and second generation antipsychotic agents? What are the non-pharmacological treatment measures of schizophrenia? Do the antipsychotic agents differ in their adverse effect profile? Explain.

Tutorial One

• Activities:• Role plays• Selection of antipsychotics• Stigma

Tutorial Two

• Year 2009 (Tom Jones is now 23 years)• Tom’s psychiatrist decided to switch from risperidone

to olanzapine after 12 months of treatment with risperidone. Tom’s risperidone dose was tapered down and olanzapine was added. During this period Tom’s symptoms improved, whilst he was taking both antipsychotic medicines. His dose of risperidone was reduced to 2mg BD and olanzapine was increased gradually to 20mg BD. Tom continued to put on a significant amount of weight (now 101kg).

Tutorial Two

• Year 2010 (Tom Jones is now 24 years)• Tom remained on both agents for a further

year. His weight is now 107kg. His psychiatrist referred him to an endocrinologist as a random fasting BGL was significantly raised and his total cholesterol level was 7.5 mmol/L.

• You interview Tom and now find he takes the following medicines:

Tutorial Two: Medication Profile

• Olanzapine 20mg BD• Risperidone 2-3mg BD• Metformin 850mg BD• Simvastatin 80mg N• Alprazolam 1mg N• Temazepam 10 mg N PRN• Valerian tablets 1 N

Tutorial Two Preparation

• Review individual drug monographs

• Be prepared to work on writing up your specific medication review findings and recommendations