Day # 21: Review Quiz -> Psychosis Final Review

I want to provide an important update to the frequency of these posts. I received some feedback that the daily nature of these posts makes it difficult to keep up on the readings if you miss a day or two. Because of this I sent out a survey to readers to see how I can best serve you. The small majority of you prefer to receive these readings three days per week as opposed to daily and almost all of the survey responders said they would be able to read 75-100% of the posts if it was changed to this format. So, we are going to adjust fire and move to a Mon, Wed, Fri schedule starting this week. Keep the feedback coming!


I hope you had a great weekend. Today we will have our last review quiz of the psychotic disorders theme.



1) Weight gain is a known side effect of antipsychotic medications. This list contains the medications in this class that are least likely to cause weight gain. Which medication does not belong in this group?

a) Lurasidone (Latuda)

b) Aripiprazole (Abilify)

c) Quetiapine (Seroquel)

d) Ziprasidone (Geodon)

e) Loxapine (Loxitane)



2) Which of the following antipsychotic prescriber guidelines are true?

  1. Patients with schizophrenia should not be involved in the choice of which antipsychotic to take since they lack the insight to make this decision.

  2. There is firm evidence that high doses of antipsychotic medication are more effective than standard doses for schizophrenia.

  3. Combination antipsychotics should be utilized whenever possible to take advantage of their different receptor targets.

  4. Use the lowest dose possible (at least the minimum effective dose). Wait for a treatment response for 1-2 weeks before escalating the dose.



3) Which of the following is the correct criteria for diagnosing treatment resistant schizophrenia? (according to the TRRIP criteria)

  1. Inadequate response to at least two antipsychotic trial of ≥8 weeks at therapeutic dose with 100% adherence of prescribed doses.

  2. Inadequate response to at least two antipsychotic trials of ≥6 weeks at therapeutic dose with adherence ≥80% of prescribed doses.

  3. Inadequate response to at least three antipsychotic trials of ≥8 weeks at therapeutic dose with adherence ≥80% of prescribed doses.

  4. Inadequate response to at least three antipsychotic trials of ≥6 weeks at therapeutic dose with adherence ≥80% of prescribed doses.



4) Which of the following is NOT a black box warning for clozapine?

a) Agranulocytosis

b) Seizure

c) Myocarditis

d) Tardive dyskinesia

e) Orthostatic hypotension

f) Increased mortality in elderly patients with dementia-related psychosis



5) Perseveration, verbigeration, and echolalia are similar terms that are commonly confused (by myself included!). Which of the terms fits the following definition: Repetition of random words without a stimulus (not in response to a question or conversation).

a) Perseveration

b) Verbigeration

c) Echolalia



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Answers


DON'T LOOK UNTIL YOU HAVE FINISHED THE ENTIRE QUIZ


Question 1:

From Day 17


Answer: c

Quetiapine (Seroquel) has moderate weight gain.


Explanation:

Lurasidone (Latuda), Aripiprazole (Abilify), Ziprasidone (Geodon), and Loxapine (Loxitane) are in the lower risk category for weight gain among antipsychotics.



Question 2:

From Day 18


Answer: 4

Use the lowest dose possible (at least the minimum effective dose). Wait for a treatment response for 1-2 weeks before escalating the dose.


Explanation:


•As discussed, most antipsychotic medications are comparable in effectiveness. The most important element of treatment is likely whether they actually take the medications! Per NICE guidelines, patients should be as involved in decisions about the choice of medicines as possible.


•Use the LOWEST dose possible (at least the minimum effective dose). Wait for a treatment response for 1-2 weeks before escalating the dose. Do not keep increasing the dose day after day in the hospital. Lack of response at 2 weeks is a potent predictor of later poor outcome unless the dose or drug is changed.


•There is no firm evidence that high doses of antipsychotic medication are any more effective than standard doses for schizophrenia. Despite this, approximately 25-33% of hospitalized patients are on a “high dose” (above 100% of recommended dose) above licensed ranges. Efficacy appears to be optimal at relatively low doses. If high doses are trialed, target symptoms should be assessed after 6 weeks and 3 months and if insufficient improvement in symptoms, the dose should be decreased to the normal range. 7


Combination antipsychotics should be avoided unless absolutely necessary. There is very little evidence to support this practice although it is routinely done. Single antipsychotic (with or without additional mood stabilizer or sedatives) is recommended. An exception is clozapine augmentation. In addition to general side effects, polypharmacy should be avoided due to high risks of QTc prolongation and sudden cardiac death. 8



Question 3:

From Day 19


Answer: 2

Inadequate response to at least two antipsychotic trials of ≥6 weeks at therapeutic dose with adherence ≥80% of prescribed doses.


Explanation:


Minimal TRRIP criteria:

  • Must have DSM-V diagnosis of schizophrenia.

  • Must have at least moderate symptom severity (>3) using a standardized scale (PANSS or BPRS).

  • Must have at least moderate functional impairment using validated scale (Social and Occupational Functioning Assessment Scale).

  • Inadequate response to at least two antipsychotic trials of ≥6 weeks at therapeutic dose with adherence ≥80% of prescribed doses.

Optimal TRRIP criteria:

  • Symptom reduction <20% over six weeks using standardized scale (PANSS or BPRS)

  • +/- One of the two antipsychotics should ideally be a long-acting injectable.

  • Antipsychotic adherence should be confirmed by ≥2 plasma levels.


Question 4:


From Day 20


Answer: d (tardive dyskinesia is not a black box warning)


Explanation:


Clozapine has five black box warnings:

  • Agranulocytosis

  • Seizure

  • Myocarditis

  • Orthostatic hypotension with syncope or cardiorespiratory arrest

  • Increased mortality in elderly patients with dementia-related psychosis

Overview of clozapine side effects:

  • Less likely to cause tardive dyskinesia and EPS in general.

  • Can cause tachycardia and hypersalivation. Can treat hyper salivation with glycopyrrolate.

  • Most severe anticholinergic side effects.

  • Significant constipation. Can lead to toxic megacolon / ogilvie syndrome.

  • Very sedating.

  • Clozapine and olanzapine most severe weight gain and metabolic syndrome.

  • Higher risk of hypotension among SGA's (along with quetiapine and risperidone).

  • Small risk of myocarditis.

  • 1% incidence of agranulocytosis. Highest risk during first 6 months of treatment. Risk also increases with age. Must be stopped if ANC drops below 1,500/microliter.

  • 4% incidence of seizures (highest of all antipsychotics). Increased risk at higher doses and fast titrations.



Question 5:

From Day 8


Answer: b (verbigeration)


Explanation:


Perseveration is repetition of random words in response to a stimulus/question.

Verbigeration occurs when a person repeats words without a stimulus.

Echolalia is when a person repeats another persons words.



Conclusion


Congratulations! You are officially finished your first Bullet Psych theme (Psychotic disorders). Good job today. I hope this new format of the weekly review is helpful. Due to reader feedback we are going to adjust fire and move to a Mon, Wed, Fri reading schedule. See ya back here on Wednesday where we will start day # 1 of our next them: depressive disorders.

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