Treatment-Resistant Schizophrenia: Making The Determination

Courtesy of: http://www.psychiatrictimes.com

Some people suffering from schizophrenia never seem to get successful results from medications, and other therapeutic methods. These people are then deemed as having "treatment-resistant schizophrenia", but there's speculation that this is not the case for everyone with that label.

Many factors could influence a psychiatrist to believe someone has treatment-resistant schizophrenia and these should be looked into more thoroughly.

Some of these factors are:

• Medication noncompliance, even partial noncompliance.
• Variations in metabolic rates among individuals, influencing effectiveness of drug dosage.
• Inaccurate initial diagnosis (temporal-lobe epilepsy mimics schizophrenia)
• Lack of multiple medications (many people need several different meds to control for a range of symptoms)
• Adequately assessing success with treatment (how long did you try the medication, under what dosages)

This article attempts to relate proper protocol for certain treatment attempts when dealing with someone suspected of having treatment resistant schizophrenia.

Typical Antipsychotics

These drugs have been found to be very unsuccessful in attempting to treat someone considered "treatment-resistant". A 1998 article found that fewer than 5% of these patients responded to Haldol (haloperidol, a common typical antipsychotic). And in reviewing a 1994 paper, increasing dosage provided increased side effects without comparable increase in effectiveness.

This article states a good length in assessing typical antipsychotic effectiveness is about 6 weeks.

"As an example, little or no response to 20 mg/day of haloperidol after six to eight weeks should be considered a failure. An inadequate response should lead to trials of the atypical antipsychotics"
Atypical Antipsychotics (excluding clozapine)

There is no consistent evidence to conclude one atypical antipsychotic is far superior to another (clozapine is not included in this statement), or that inability to get successful results from one means the rest will also be unsuccessful. They so not appear to be interchangeable. But more research needs to be conducted to fully understand their differences.

"An adequate trial of an atypical antipsychotic should be at least eight to 12 weeks on a higher dose of the medication -- for example 12 mg/day of risperidone, 40 mg/day of olanzapine, 800 mg/day of quetiapine or 200 mg/day of ziprasidone."
This article recommends two trails, and that side effect prevalence should help determine which drugs to try first. Risperidone and Olanzapine seem to have the most promising research supporting their success rates.

Clozapine

Clozapine is considered to be the most successful in treating schizophrenia, but does require special monitoring for some dangerous side effects (a reason physician suggest trying other drugs first). Its main purpose is to treat those considered treatment-resistant.

Because clozapine's full effects take longer than previous meds, this article suggests a trail of 3 to 4 months, and note others believe it should be more like 6 months to 1 year.

"Typical clozapine doses range from 300 mg/day to 500 mg/day, and doses of up to 900 mg/day can be used. Some data suggest that minimum plasma levels between 350 ng/ml and 500 ng/ml are associated with increased therapeutic response (Kronig et al., 1995). A lack of noticeable response at two months may be better assessed with a clozapine blood level."
Augmentation Strategies and Results

Drug combinations are often used in cases where clozapine and not other treatments are successful. There isn't any consistant evidence on which combinations work best, or if they are really helpful at all. All evidence is support by case studies, which is very poor methodology in reflecting the efficacy of the entire population (meaning the results for one individual are not strong enough evidence that it will work for most people)

"We have seen many cases of patients with schizophrenia taking three different antipsychotics, several mood stabilizers, benzodiazepines and an antidepressant without any clear documentation of improvement -- a strategy we have termed irrational polypharmacy."
"A number of augmentation strategies have been proposed, which include the addition of lithium, an anticonvulsant, a second antipsychotic, a benzodiazepine or a course of electroconvulsive therapy (ECT). Psychosocial treatment may also be used as an augmentation strategy."

Based on the available research lithium has not been shown to produce successful results, and combined with clozapine increases severe side effect risks.

Inconsistent results have been found with anticonvulsant medications. Some studies found benefits in the beginning of treatment with anticonvulsants, but that the benefits decreased over time. Combing these drugs with clozapine may be helpful for reducing the risk of seizer. Divalproex is currently being prescribed and still underinvestigation, but shows the most promise for anticonvulsant medications treating schizophrenia.

Combining antipsychotic medications is a trail and error process, meaning no standard has been developed on which combinations work best, or which should be used to account for specific symptoms.

"Since some of the atypical antipsychotics such as clozapine and quetiapine have relatively weak dopamine (D2) antagonism, there may be some justification for adding a more potent D2 antagonist such as haloperidol, risperidone or olanzapine to augment an inadequate response."
ECT (electro convulsive therapy) has evidence supporting its effectiveness in treating those resistant to other methods. But there can be risks, memory loss, and of course many people aren’t willing to participate.

Psychotherapy is another method which needs more research, but has evidence to support its implementation accompanied by medications. This treatment option is great because it's risk level is very low, but requires commitment, so compliance rates might not that high.

Conclusions:

Physicians need to adequately assess a patient before deeming them resistant to treatment. There are many different treatments to consider, and they differ on how long one should wait before deciding it's not effective. Combining many medications and utilizing large dosages may be more harmful than helpful. Psychotherapy is always a safe option to add to medication treatment, and has shown success (mainly CBT, psychoeducation, family involvement).

But there is a select group of individuals who will never get a "favorable" outcome based on our current understanding of how to treat the disorder. The only option is then to settle for the best results possible, and push further research on developing new treatment methods.


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Brain Signs of Schizophrenia Found in Babies

Courtasy of: http://www.sciencedaily.com

ScienceDaily (June 21, 2010) — Schizophrenia is a debilitating mental disorder affecting one in 100 people worldwide. Most cases aren't detected until a person starts experiencing symptoms like delusions and hallucinations as a teenager or adult. By that time, the disease has often progressed so far that it can be difficult to treat.

In a paper published recently online by the American Journal of Psychiatry, researchers at the University of North Carolina at Chapel Hill and Columbia University provide the first evidence that brain abnormalities associated with schizophrenia risk are detectable in babies only a few weeks old.

"It allows us to start thinking about how we can identify kids at risk for schizophrenia very early and whether there things that we can do very early on to lessen the risk," said lead study author John H. Gilmore, MD, professor of psychiatry and director of the UNC Schizophrenia Research Center.

The scientists used ultrasound and MRI to examine brain development in 26 babies born to mothers with schizophrenia. Having a first-degree relative with the disease raises a person's risk of schizophrenia to one in 10. Among boys, the high-risk babies had larger brains and larger lateral ventricles -- fluid-filled spaces in the brain -- than babies of mothers with no psychiatric illness.

"Could it be that enlargement is an early marker of a brain that's going to be different?" Gilmore speculated. Larger brain size in infants is also associated with autism.

The researchers found no difference in brain size among girls in the study. This fits the overall pattern of schizophrenia, which is more common, and often more severe, in males.

The findings do not necessarily mean the boys with larger brains will develop schizophrenia. Relatives of people with schizophrenia sometimes have subtle brain abnormalities but exhibit few or no symptoms.
"This is just the very beginning," said Gilmore. "We're following these children through childhood." The team will continue to measure the children's brains and will also track their language skills, motor skills and memory development. They will also continue to recruit women to the study to increase the sample size.

This research provides the first indication that brain abnormalities associated with schizophrenia can be detected early in life. Improving early detection could allow doctors to develop new approaches to prevent high-risk children from developing the disease. "The research will give us a better sense of when brain development becomes different," said Gilmore. "And that will help us target interventions."

The paper is available now online and will be published in the September issue of the journal. The study was funded by grants from the National Institute of Mental Health and the Foundation of Hope.
In addition to Gilmore, authors of the study were Chaeryon Kang, Dianne D. Evans, Honor M. Wolfe, J. Keith Smith, Weili Lin, Robert M. Hamer, Martin Styner, and Guido Gerig. Author Jeffrey A. Lieberman, chairs the Department of Psychiatry at Columbia University.

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-- Post From My iPhone

First drug and Mental Health Expo for Macarthur

Courtasy of: www.macarthuradvertiser.com.au

WOULD you know where to go if a family member was suffering from mental health or drug problems?

The answer is often no, says Mary Ashby, a counsellor at Maryfields Day Recovery Centre in Campbelltown.
That's why Maryfields and several other local organisations have joined to create the first annual Macarthur Drug Free Expo.

The expo, to be held at Campbelltown Civic Centre on June 25, will offer information packs to the community about mental health and drug education.

``It still surprises me that people ring up and they don't know where to go for these services,'' Mrs Ashby said.

``People often self-medicate, when they become mentally unwell, with alcohol and drugs. They feel better but it actually makes it worse but if families can recognise this, they can be directed to the right care.''
Mrs Ashby, who has worked at Maryfields for the past eight years, said there was ``always a need'' for an event like the expo.

``It's also good for mums and dads who want to teach their kids about drugs,'' she said.
``We hope it's going to grow from here. We're very excited.''

The expo will coincide with Drug Action Week (June 20-26) and is partly funded by the Community Drug Action Team.

Campbelltown rehabilitation centre Odyssey House is also involved, as well as Lifeline and the Drug and Alcohol Women's Network.

Odyssey House chief executive James Pitts was pleased at the combined effort of all of the organisations involved.

``People will learn about the comprehensive services we provide for people who have complex needs relating to alcohol and other drug misuse including mental health issues,'' he said.
``We hope the expo will inform and engage the local community as to the services available to them and there are some innovative and fun events planned for the day.''

The first annual Macarthur Drug Free Expo will be held at Campbelltown Civic Centre, corner of Queen and Broughton streets, on June 25 from 10am to 2pm.

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MH OT

Expert Warns of Revisions to Psychiatric 'bible' DSM

Courtasy of: http://www.nationalpost.com

As Dr. Allen Frances read through the list of proposed changes to psychiatry's bible of mental sickness, alarms started ringing in his own mind.

"I was surprised," the renowned U.S. psychiatrist says, "that the proposals managed to be much worse than my most pessimistic expectations."

By the time he was finished reading, Frances had calculated that the recommendations contained within the first draft for the fifth and latest revision of the Diagnostic and Statistical Manual of Mental Disorders -- a hugely influential book used daily by doctors worldwide, psychiatry's official classification of all the ways humanity can go "mad"--could unnecessarily trigger wholesale "epidemics" of mental illness and expose millions more adults and children to potentially harmful psychiatric drugs.

Dr. Frances, more than most, knows the kind of surprises that may be lurking. He chaired the task force that wrote the current edition of the manual -- referred to as DSM-IV -- which he says is a book that unintentionally contributed to vast and sudden increases in the diagnosis of attention-deficit hyperactivity disorder, autism and childhood bipolar disorder (manic depression), after it made changes in those definitions. Rates of bipolar disorder alone jumped 40-fold in the U.S. after the definition was broadened to suggest that children don't have to experience the typical manic symptoms seen in adults to be diagnosed bipolar -- and that depression in kids can be a persistent irritable mood. "Most of this was not our fault," Dr. Frances said.

Rather, he blames "a runaway fad led by thought leaders and pushed by drug companies and advocacy groups."

"We were remarkably conservative and very careful. We laboured very carefully not to have surprises, not to have unintended consequences," said Dr. Frances, former chair of the psychiatry department at Duke University's School of Medicine.

But once a diagnosis gets out of the bottle, he says, "it spreads like wildfire in ways you could never imagine."

This psychiatrists' bible is in the midst of its first major rewrite in 16 years, coming at a time when anti-depressants, tranquillizersandotherpsychoactive drugs have become the second most-prescribed drug class in the country, second only to cardiovasculars, according to prescription drug tracking firm IMS Health Canada. Across Canada, pharmacies last year dispensed 61.2 million prescriptions for psychotherapeutics, worth nearly $2.4 billion.

Increasingly, some of the most potent, mood-altering drugs are going to children. Between 2005-09, the number of prescriptions forsecond-generation antipsychotics for children under 13 more than doubled, according to IMS data. Last year, nearly 700,000 prescriptions for such antipsychotics were dispensed for kids under 13.

The changes being proposed for the manual of mental illness -- whose sales since 2000 have topped $40-million -- would create even more patients for whom psychoactive drugs can be prescribed.

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MH OT

An OT built a sensory wall at the playground outside the Whistler Medals Plaza at the Vancouver Olympics

Although this is not actually a metal health story, Sensory Modulation can play a large part in our practice.....and its always good to see OT as a profession getting some positive exposure on a world stage :)

Courtasy of:http://www.piquenewsmagazine.com

Wall-Fly Michael from North Vancouver tests out the RMOW’s new sensory wall. Photo by Scott Brammer, coastphoto.com

Mar 10, 2010 2:47pm

Appealing to kids senses

Regionally-inspired sensory wall stimulates children's motor skills By Holly Fraughton

The concerts that took place at Whistler Medals Plaza may have been the main event for adults during the Olympics but kids were more amped about an attraction just outside of the gates. Since Feb. 1, children of all ages have been eagerly clambering over the new sensory wall located at the edge of the municipality's brand-new inclusive playground.

The popular structure was designed by Jennifer Gellis, an occupational therapist and graduate of Emily Carr University of Art and Design's industrial design program. While on the surface, occupational therapy and industrial design don't seem to be directly related, Gellis has found many parallels and complementary aspects between the two fields.

"...They actually have a lot of similarities in them in terms of the way occupational therapists and designers approach problems; they approach them in the same way and they go through this sort of iterative process with a problem or a challenge."

The North Vancouver resident caught wind of Whistler's sensory wall project through a friend who lives in Whistler.

Sensory walls are small walls often found in playgrounds and public parks, designed to strengthen children's motor skills by stimulating the senses. It's also therapeutic for kids with autism.
"The nice thing about having different components in a sensory wall is that hopefully it can appeal to kids who have different abilities and who may rely on their sense of vision more than their sense of hearing, or their sense of touch more than another sense," Gellis said.

So, a child who is visually-impaired and has a heightened sense of touch or hearing will appreciate the tactile and auditory components of the wall.

"Maybe they'll really be attuned to the shape of the leaf tiles that are in the wall," Gellis suggested, "and the tiles that are round and smooth versus the ones that are angular and rough."
Gellis saw the project as a challenging opportunity to draw on the training and creativity she's gained from her two fields of study. So, she created a proposal, applied and waited. A few weeks later, at the end of August, she was notified that she had been selected for the project. It carried a $30,000 budget to cover all artist fees and expenses, including material costs, consultations with other professionals, travel, insurance and accommodation.

The wall is just one part of the new inclusive playground that the municipality has built in front of Whistler Medals Plaza.

"From what I understand, (the municipality) really wanted the playground to be quite natural and to fit in with the landscape and the theme of other artwork in Whistler," she explained.

Designed to look like mountains, representing Whistler and Blackcomb, the wall is encrusted with natural materials that are meant to be both tactile and visual, including a myriad of sensory components that might not be apparent to the adult eye.

"It's actually based on the skyline of Whistler Blackcomb, so you've got the front side and the back side of the mountain and then where the musical chimes are, that's meant to be where Musical Bumps might be," Gellis said.

There are peek-a-boo holes, a basalt column that represents Black Tusk, and on the back of one hole, "Fitzsimmons' Creek" leads to the base of a tunnel lined with golden tiles to represent the legendary secret gold mine. The sides of the structure are studded with hand-made leaf and snowflake tiles that were painted at Orkidz Art Studio by kids from the community.

But not everything went according to her original vision. "I also really wanted to try and incorporate the sense of smell and taste, but in Whistler we can't have certain plants because of the risk for bears and that type of thing," Gellis said with a laugh. The strawberry plants, a huge bear attractant, were quickly kiboshed.

All of the installation work was done on-site in early winter, which was a real challenge given the early snowfall Whistler experienced this season. It was also a real challenge to get a good portion of the work done in time for the Olympics; there's still more work to be done. They're getting ready to install a metal rain tumbler created by a Vancouver metalwork artist before a ribbon-cutting event on ribbon cutting on Thursday, March 11 at 2:30 p.m

Gellis said it's been particularly exciting to work on this project because it's located in one of the host towns of the Paralympic Games, where children of all abilities will have a chance to check it out.

Peace & Balance

MH OT

Should OT's discuss assessment results with patients in acute mental health?

Courtasy of:http://metaot.com

Assessing patients is part of the rubric of everyday life for most occupational therapists (OT’s). OT’s are trained to gather information from multiple sources and formulate complete, competent and accurate appraisals of the patient’s occupational status, often in the face of time restraints and limited quality contact with the individual. The result of this process is a valuable document reflecting the OT’s unique perspective on the patient’s level of functioning and arguably the closest representation of the patient’s own preferences for treatment. The lifespan of this document, however, does not necessarily end after it has been completed and filed away. Exploration of its uses should justify the rigors of its acquisition. A large and immovable aspect of this exploration is to what extent assessment results can be shared with the subjects themselves.

OT’s legal obligation

The law states that we, as OT’s, have a legal obligation to share assessment results with all patients, regardless of the setting. The Access to Health Records Act (Department of Health (DoH), 1990) was the first Bill to specifically address the responsibility of occupational therapists to disclose any information; ”˜relating to the physical or mental health of an individual who can be identified from that information, or from that and other information in the possession of the holder of the record’ (section 2.1 (f) DoH, 1990). Since this benchmark legislation both the Data Protection Act 1998, European Union Data Directive (1998) and the Freedom of Information Act (FOI) (2000) have refined and reinforced this policy. Significantly for health-care professionals the FOI was designed to promote and highlight patients rights to publicly held information, after the Audit Commission in 1995 found that many health professionals were reticent in permitting patients free access to their records. In light of this legislation, omitting results of a MOHOST assessment, for example, is of equal offence to omitting medical records (section 2.1 (f) DoH, 1990).

The Code of Ethics and Professional Conduct for Occupational Therapy (COT 2005) echoes government directives for information access by stating ”˜access to records shall be granted in accordance with current statutory requirements’ (2.3.5, COT, 2005). The Code also refers to a clause in the Data Protection Act (1998) that exempts information that is ”˜likely to cause substantial damage or substantial distress to him or to another’ (Data Protection Act 1998 section 10A). The closest statement within the code of ethics relating specifically to the process of assessment feedback itself is that ”˜reasonable steps shall be taken to ensure that the client understands”¦the proposed intervention(s) (2.1.4, COT, 2005).

"The Evidence”

Over the last three decades piecemeal research on this subject has been produced, often contrasting psychiatric notes with medical notes to gain insights. A study by Critchon, Douzenis, Leggatt and Hughes (1992), titled ”˜Are psychiatric case notes offensive’, found that acute in-patients found the formulation “chronic schizophrenic” to be offensive but not the formulation “chronic diabetic”, in those patients with a duel diagnosis. Other studies have attempted to measure anxiety levels in patients who were exposed to candid reports about themselves in clinical records, revealing contrasts between physical and psychiatric patients. In one randomized trial, 11% of medical outpatients reported they had “upsetting feelings” as a result of reading their records (Golodetz, Ruess, Milhous, 1976). In a non-randomised controlled trial, 23% of obstetic patients reported that records were “worrying” (Elbourne, Richardson, Chalmers, Waterhouse, Holt, 1987). In three separate studies of psychiatric patients’ anxiety levels, using varied research methods, however, results range from 12% to 50% of patients reporting discontent after reading their clinical reports (Beradt, Gunning, Quenstedt, 1991; Miller, Morrow, Kaye, Maier, 1987; Stein, Furedy, Simonton, Neuffer, 1979).

Within OT itself very little has been written about the way patients interface with assessment results. Kielhofner (2005) admits that although it is common-place to discuss assessment results with patients in both mental and physical health within the MOHO tradition, there is no explicit guidance for practitioners in this area or adequate evidence-base (personal correspondence, 2005). The few examples that exist show the positive effect of sharing feedback between patient and OT, and the scope for creativity in this field.

In a case study by Auzmendia, Gloria de las Heras, Kielhofner and Miranda (2002) the results of a Volitional Questionnaire, an observational assessment ascertaining the level of volition of the individual, were shared with a community outpatient who has a bipolar disorder. At first the OT refrained from sharing the assessment results and instead used it to learn more about the individual. As the goal setting process became more concrete the OT began sharing the results with him and eventually taught him to use the measure himself as a self-assessment.

Kirsty Forsyth, author of the MOHOST, sounds a cautionary note on whether or not a there should be a blanket feeding back of assessment results to patients by stating that sharing is not always appropriate and needs to be flexible (personal correspondence, 2005). A good example of this flexibility is illustrated by Kielhofner, Brenneman Baron, Mentrup, Schulte and Shepard (2002) who describe how an Assessment of Communication and Interaction Skills (ACIS), another observational assessment, was used to help an acute patient with depression self analyze whilst watching a videotape of his social interaction. This empowered the patient to be the main definer of his problems rather than have them defined for him by a health-care professional. An important footnote in this example is that the client had volunteered to be assessed by this method, so would have been more conducive to such a candid process.

If communicated effectively, therefore, the feeding back of assessment results can provide a foundation to mutual and therapeutic goal setting. If communicated bluntly, on the other hand, it can serve to offend the patient (Starke, Andrews, Griffin, Rebeiro, 2001). It is essential for more evidence-based research in the field to be generated because of the unique nature of the OT assessment and partnership between OT and patient. For this reason conclusions from other professions cannot be borrowed. More needs to be learnt about what factors influence the feedback process and how patients and practitioners feel about it. Acute mental health is the ideal platform on which to stimulate debate on this subject.

Peace & Balance

MH OT

10 Common myths about bipolar disorder

Adrienne Carlson has compiled a list of 10 common myths about bipolar disorder with lots of useful information aimed at combating some of the stigma around the condition. The myths are:

1. Bipolar disorder is merely mood swings
2. Manic episodes are characterized by extreme happiness
3. Bipolar shifts happen very quickly
4. It is OK to quit taking medication during manic episodes
5. Bipolar disorder is very rare
6. Bipolar disorder is not an illness
7. People with bipolar disorder are inherently unstable or violent
8. Most people with bipolar disorder are women
9. Prolonged drug abuse can eventually lead to bipolar disorder
10. People with bipolar disorder cannot hold down jobs

You can find out more about these issues on Adrienne's blog at

http://www.x-raytechschools.org/10-common-myths-about-bipolar-disorder/