Biological Treatments of Schizophrenia in Youth - Research Paper Example

The Biological Treatment of Schizophrenia in Young People Contents Introduction Justification for this Study Thesis Methodology LiteratureReview and Analysis Future Practice Conclusion References Abstract This essay considers biological inventions used in the treatment of schizophrenia in young people. It considers the particular needs of this age group as well as how, in some cases, specialist care is not available, and also how there can be wide variations in prescribing patterns. Guidelines are considered, as are suggestions for future practice. Introduction The English term schizophrenia is derived from two Greek words that mean "split mind." The term was first used before the First World War by Eugen Bleuler, a Swiss doctor who was trying to describe what he saw as the splitting apart of mental functions ( Nursing Care Documents 2014) . Schizophrenia is a psychotic disorder, or group of disorders, which are marked by severely impaired thinking processes which affect both emotions, and behaviours. Those who suffer from this condition find themselves withdrawing from normal interactions with others if no medical intervention takes place. Often these people have difficulties in dealing with sensory stimuli, and may experience enhanced perceptions of the sounds and colours encountered in their environment. It affects about one person in a hundred (Royal College of Psychiatrists, 2012) In children aged between 5 and 18 years it has been estimated to occur at a rate of 0.4% and a diagnosis of schizophrenia accounts for almost a quarter of all psychiatric admissions for young people aged 10–18 years, with rising numbers as the age rises, with the highest incidence rates after the age of 15 ( Nice, 2014). Also, according to NICE (page 3, 2014) if such psychosis presents at a very young age, then outcomes are often worse than if this happens later. Around the world schizophrenia across all age ranges is a very common condition which affects about 1% of the global population,and is said to be one among the highest reasons long-term disability. No one cause can be defined, but a number of factors may combine either to make the development of schizophrenia more likely, or to trigger an episode of the condition. These include drug use, genetic factors, and individual environment and circumstances ( Young Adult Health , 2012) It is more common among members of lower social classes, as are other mental illnesses ( Murali and Oyebode, 2004). In Nice guidelines (CG 155, 2014) the authors describe how, in young people, psychosis may be preceded by a prodromal period, when behaviour and the person’s experience will change over a period of about a year. They may become very suspicious and withdrawn. The guidelines also describe both positive and negative symptoms. The negatives described include emotional apathy, poverty of speech, social withdrawal, a lack of drive and self-neglect. These may be present for a considerable time before positive symptoms such as delusions and hallucinations present. Each young person affected by psychosis has a personal and unique collection of symptoms and experiences, and the pattern these take will be affected by the stage of development the young person has reached , and their individual circumstances. It is also pointed out that not every young person who exhibits these symptoms will continue to do so, and the problems may be transient. In those who do develop schizophrenia, about one in five these children and young people will have only the mildest impairment , but in one in three the impairment is quite severe and requires intensive social and psychiatric intervention and support. Justification for this Study Early onset schizophrenia is a condition which affects many thousands of young people right round the globe. This study will consider various methods of biological treatment available for affected young people in order to arrive at pointers for future practice and care, in order that the best possible interventions can be used, so as to achieve the highest possible quality of life for those affected. Thesis Schizophrenia in young people can present in rather different ways to the way it presents when it occurs later in life, and may therefore require different interventions. Methodology This will be done by undertaking a Boolean literature search and critical review using search terms such as mental health, young people and schizophrenia and the biological treatment of schizophrenia, adolescents and schizophrenia. The texts found in this way will be considered for their possible strengths and weaknesses and their relevance. They will include research findings, but also guidelines issued , government statutes, and some details about the various drugs used. The findings will be analysed in order to discover possible steps to take in future practice. As far as possible the most recent texts will be considered so that the latest information can be accessed. Literature Review and Analysis With regard to biological interventions in young people with schizophrenic symptoms ,according to Pappadopulos, et al ( 2002), research has shown that almost 98% of children and adolescents in care in psychiatric hospitals are prescribed psychotropic drugs and for 45-85% of then several medications at used at the same time, despite the fact that guidelines such as those produced by the FDA(2010) state that more than one of these powerful medications should not be used at the same time. Nice (page 6, 2014) describes a number of possible medications, and stresses the need for informed decisions to be made, both by medical staff, but also by patients, with regard to care given. In the case of those under age then guidelines issued by the Department of Health ( Seeking consent: working with children, 2001), or very similar ones in other countries, should be followed. It is also possible that older patients may be considered as being unable to give informed consent because of their lack of capacity. In these cases too there is a code of practice which should be used with the Mental Capacity Act (2005). Moller, as cited by Huo,( 2004) has explained that drug therapy alone is often not enough. He stresses a psycho-educational and holistic method of care is required. With regard to drugs Moller (2004, cited by Huo, 2004) believes that these should best be based upon phase 4 trials, that is those with the highest level of evidence, that is those based upon at three moderately large , controlled and randomised double-blind trials. Drugs are usually prescribed at an early stage in order to control symptoms. Antipsychotics are the most common prescriptions written for such inpatient settings. The researchers describe how drugs may be used in two ways, as emergency medication , which may be continued during the first three weeks after admission, and may be mainly to control aggression, and then in the longer term to control symptoms. The writers are particularly concerned with the use of clozapine. This however, although effective, is a very dangerous medication, as are many used to treat schizophrenia. It has a number of possible serious side effects including very serious blood infections ( Drug.com, 2014). There are many different antipsychotic medications in use. Dosage and type will vary according to the needs of each person. These non-addictive medications are available as tablets, in liquid form and as injections. The dosage needs to continue as long as needed to control the symptoms experienced and also to prevent the possibility of relapse. It is known that compliance can be a problem, especially if the person has little insight into their condition, and some simply forget. In such cases monthly long-lasting (depot) injections may be given ( Centre for Addiction and Mental Health, 2010). Otasowie et al, ( 2010) undertook a wide spread and longitudinal study of children in the former Trent area of England. They were considering the prescribing practices of all child and adolescent psychiatrists and community paediatricians in the area. These were asked about their antipsychotic prescribing practice during the previous year, including any monitoring undertaken. The doctors involved were asked whether or not they wanted consensus guidelines, such as those described by Kuo (2004) with regard to the prescribing and monitoring of antipsychotics in the case of children and adolescents. It was found that the child psychiatrists and paediatricians had prescribed atypical medications for non-psychotic developmental disorders, but almost exclusively it was psychiatrists who issued prescriptions for psychosis. Routine measurements were made of height, weight and blood pressure, but there was very wide variations found in measuring and in monitoring other parameters such as blood glucose, prolactin and the occurrence of extrapyramidal side-effects such as tremor ; akathisia or inner feelings of restlessness ; slurring of speech; dystonia or abnormal muscle contractions; bradyphrenia which means slowing of the thought processes ; bradykinesia, the impairment of the ability to change the body position and muscular rigidity ( Purse 2012). The researchers note an absence of waist measurements, despite the fact that it is known that the use of these drugs is associated with weight gain and produce metabolic changes ( Bachmann et al , 2012) Otasowie et al ( 2010 found that atypical antipsychotic medication were being increasingly prescribed ‘off label’ to children and adolescents for a range of conditions, and this included psychoses. This was compared to earlier practice in the 1990s in the same area. The researchers describe several possible reasons for alterations for these changes in prescribing practice. They say that it may be because of increased evidence of efficacy; because of concerns about adverse effect profiles of typical antipsychotics when used in young people; better paediatric psychopharmacology training and the better availability and promotion of the drugs. Also mentioned is a lack of suitable alternative non-pharmacological interventions, and the pressure on clinicians to obtain positive results quickly. The physicians were also asked how the possibility of adverse side effects affected their prescribing patterns. Typical antipsychotics were prescribed by only 2 out of 55 of those surveyed. Risperidone was the most commonly atypical antipsychotic prescribed, and in the U.S.A. this is the only such drug allowed for the treatment of children aged from 13 -17 by the Food and Drug Administration ( 2009), despite controlled studies which reveal a number of side effects , including very serious ones. The same organisation does say however that physicians should not prescribe any antipsychotic medications for whatever reason without conducting an appropriate primary evaluation and suitable ongoing monitoring. Nor should they prescribe two or more antipsychotic medicines at the same time. Of those surveyed Aripiprazole was prescribed by 20%, olanzapine by 18% and clozapine , quetiapine and amisulpride were prescribed less often . None of the doctors concerned prescribed ziprasidone. Yet, according to Oqbru ( 2014), ziprasidone is the one anti-psychotic drug which does not produce either weight gain or raised cholesterol levels. The drugs listed act on the dopamine system, as well as blocking serotonin receptors in the brain, and so are responsible for lessening side effects. Three-quarters of those surveyed felt there was a need for a guide to the prescribing and monitoring of atypical antipsychotic therapy. We are not told however whether the participants were aware of the wide variations in prescribing patterns that the survey revealed. If they had known perhaps even more would have considered that such guidance was needed. It was found that among respondents to this survey psychiatrists were more likely to be to be influenced by NICE guidelines than paediatricians were. Psychiatrists , as well as young people and their parents, need to be aware of links between cannabis use and the possible development of psychotic symptoms ( Kuepper et al, 2011) . This was a long term study, but we are not told how much cannabis was being used and how often. This is a real weakness, but it is realised how difficult it would be to obtain exact figures in such situations. Although this German study was not dealing with solely schizophrenia, drug use is a factor to be considered. On the other hand a study by Phillips et al ( 2002) failed to find a correlation between drug use and the development of psychosis, so this seems to be an area of contention, especially when it is admitted by these researchers that the actual level of cannabis use in the cohort studied was very low and a lack of monitoring are weaknesses of this study. According to Schizophrenia.com (2010) there have been more than thirty studies which do show how the two are connected i.e. that there are definite links between cannabis use and the onset of psychosis. In the Bachmann et al study ( 2012) the concern was with the weight and BMI gains experienced by young people being treated with atypical antipsychotics to treat schizophrenia. It was found that a rise in BMI was associated with impaired physical functioning, and also with perceived negative body appraisal. There were however differences between the young women and the males surveyed, with females being negatively affected to a greater degree with regard to bodily function and their bodily appraisal. Males were more affected by greater hunger and with impaired body appraisals, but the latter was not as severe as in their female counterparts. These findings emphasise the way in which there are differences between the way drugs affect young schizophrenics, in this case depending upon sex, and so leads to the conclusion that care plans cannot be a one size fits all pattern, but must be individualised. In particular the very young ages of those concerned must be taken into account. Clark (2001) notes that initial treatment in youth may well just be the beginning of a whole lifetime of contact with medical services. He believes that accurate diagnosis at an early stage, when linked with appropriate treatment regimes, is necessary in order to minimise handicaps experienced. He then mentions a lack of age-appropriate care provision, which then results that psychiatrists more used to dealing with adults are at times called on to manage and treat very young teenagers presenting with psychotic disorders such as schizophrenia. Clark (2001) states his belief that :- Professionals are frequently unfamiliar with some aspects of presentation or management and that appropriate service provision is not readily available (e.g. admission directly into an in-patient bed in an age-appropriate environment). Yet it seems obvious that the care required by a 12 year old will be considerably different in some aspects to that needed by a much older person, and also that it needs to take place in an environment which is best suited to their age. Also it should be pointed out that a definite stigma against mental illness, and in particular against those with schizophrenia, may result in delays before help is sought, and positive interventions carried out (World Fellowship for Schizophrenia and Allied Disorders, 2009) Clark describes possible difficulties in arriving at an adequate diagnosis, more so in young people than in older ones perhaps, but he mentions that a lack of maturation in a young person may well be the equivalent of deterioration among older schizophrenics. He claims that the difficulty in applying such a diagnosis could because of a reluctance to apply a label which may result in stigmatism, but without the diagnosis it is harder to come up with possible successful interventions. He also describes how a full history needs to be taken in order that a prognosis can be arrived at. This will involve the young person and his parents and carers, and should where possible also include information form the school or college attended, or perhaps their place of work as applicable. A careful and detailed history should be obtained both from the young person. Clark describes how making such contacts is familiar practice to psychiatrists who work with children and adolescents, but says that adult psychiatrists are necessarily used to routine contact with employers. Future Practice Reasons for the wide variations in the prescribing practices of doctors involved should be considered, and where these can be mitigated this should be done At the same time plans should put in place to produce up to date guidelines, based upon the best possible evidence, while at the same time allowing physicians freedom to prescribe off label when they can see this as the correct decision in certain circumstances. There is evidence that the use of cannabis can lead on to the development of a psychosis. Young people therefore need to know this, not at the age of 21, but long before cannabis use becomes a possibility. The amount of young people likely to be affected by schizophrenia can be calculated in an area or a country. Steps must then be taken to match these numbers with available provision, especially with regard to paediatric psychiatric care. Research must continue into medications which can be used to treat schizophrenia in young people which have less serious, or the absence of, serious side effects. This is justified by the impact this condition has upon so many young people and the fact that there is, as yet, no cure, for schizophrenia. It seems from the research considered that early diagnosis and treatment can produce better long term results. Steps must therefore be taken to minimise the stigma attached to mental illness, and also make initial links with the mental health team easier to access for young people, with the possibility of rapid referral when this is felt to be necessary. It is likely that some young people with schizophrenia will continue on occasions to be seen by adult, rather than paediatric psychiatrists. For this reason those physicians involved must be very aware of possible differences in the young people, and the way they present and the treatment required. This will involve taking a full background history, including contact with family and school or college. Conclusion This is a relatively short study, but it is clear from the texts considered above that schizophrenia in young people is a very variable condition, and so , although guidelines may be useful, care plans, including the biological help given, need to be individualised in order to try and ensure the best possible care and outcomes for these vulnerable young people. These need to allow for the chronological age of the person, but also their real capacity to understand what is going on. It is also clear that such young people, and the symptoms they exhibit, may be very challenging, but this does not affect the responsibilities of the health care services towards them. References Brachmann, C., Gebhardt. S., Lehr, D., Haberhausen, M., Kaiser, C., Otto, B. and Theisen, F., (2012) Subjective and biological weight-related parameters in adolescents and young adults with schizophrenia spectrum disorder under clozapine or olanzapine treatment., Zeitschrift fur Kinder Jugendpsychiatrie und Psychotherapie, May 40 (3) pp 151-158, retrieved from http://www.ncbi.nlm.nih.gov/pubmed/22532107 Centre for Addiction and Mental Health, (2010), Treatment : schizophrenia , an information guide, retrieved from http://www.camh.ca/en/hospital/health_information/a_z_mental_health_and_addiction_information/schizophrenia/schizophrenia_information_guide/Pages/schizophrenia_treatment.aspx Clark, A., (2001) Proposed treatment for adolescent psychosis. 1: Schizophrenia and schizophrenia-like psychoses, Advances in Psychiatric Treatment, 7, pages 16-23 retrieved from http://apt.rcpsych.org/content/7/1/16.full. Department of Health, (2001), Seeking Consent: Working with Children, retrieved from www.health.wa.gov.au/mhareview/.../UK_DoH_Consent_children.pdf Drug .com, Clozapine, (2014), retrieved from http://www.drugs.com/clozapine.html Drugs.com, (2014), retrieved from Risperidone blog, http://www.drugs.com/answers/support-group/risperidone/blog/ Food and Drug Administration, (2009), Risperdal, Highlights of Prescribing Information, retrieved from http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020272s056,020588s044,021346s033,021444s03lbl.pdf Kuepper, R., van Os,J., Lieb, R., Wittchen ,H., Hofler, M. and Henquet, C. (2011), Continued cannabis use and risk of incidence and persistence of psychotic symptoms: 10 year follow-up cohort study, British Medical Journal, March 1, p342, retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21363868 Kuo, I., (2004), Acute and Long-term Biological Treatment of Schizophrenia, MedScape, retrieved from http://www.medscape.org/viewarticle/471570 Mental Capacity Act, (2005), retrieved from http://www.legislation.gov.uk/ukpga/2005/9/contents Murali, V. and Oyebode, F., (2004), Poverty, social inequality and mental health, Advances in Mental Treatment, 10 pp 216-224, retrieved from http://apt.rcpsych.org/content/10/3/216.full Nice Guidelines , CG155, Psychosis and schizophrenia in children and young people: Recognition and management, issued 2013, 2014, retrieved from www.nice.org.uk/nicemedia/live/14021/62389/62389.pdf Nursing Care Documents, Schizophrenia, (undated) The Free Dictionary. retrieved from http://medical-dictionary.thefreedictionary.com/schizophrenia Oqbru, O., (2014), ziprasidone, Geodon, MedicineNet.com, retrieved from http://www.medicinenet.com/ziprasidone/article.htm Otasowie, J., Duffy, R., Freeman, J. and Hollis, C.,(2010) Antipsychotic prescribing practice among child psychiatrists and community paediatricians, The Psychiatric Bulletin, 36, pages 126-129, retrieved from http://pb.rcpsych.org/content/34/4/126.full Pappadopulos, E., Jensen, P., Schur, S., MacIntyre, J., Ketner, S., Van Orden, K., et al. (2002). "Real World" atypical antipsychotic prescribing practices in public child and adolescent inpatient settings. Schizophrenia Bulletin, 28(1), 111-21. Phillips, L., Curry,C., Yung, A., Yuen,H., Adlard,A. and McGorry, P.,(2002), Cannabis use is not associated with the development of psychosis in an ‘ultra’ high-risk group, Australian and New Zealand Journal of Psychiatry, Volume 36, issue 6 pages 800-802 http://onlinelibrary.wiley.com/doi/10.1046/j.1440-1614.2002.01089.x/abstract Purse, M., (2012) Extrapyramidal Side Effects, About.com, http://bipolar.about.com/od/glossary/g/gl_extrapyramid.htm Royal College of Psychiatrists, (2012), Schizophrenia: information for young people, http://www.rcpsych.ac.uk/healthadvice/parentsandyouthinfo/youngpeople/schizophreniaforyoungpeople.aspx Schizophrenia.com, (2010), http://schizophrenia.com/diag.php World Fellowship for Schizophrenia and Allied Disorders, (2009), Aspects of Stigma, http://www.world-schizophrenia.org/stigma/aspects.html Young Adult Health, Schizophrenia, (2012), teenmentalhealth.org/for-families-and-teens/schizophrenia Read More