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aparanjothi

Treatment resistant Schizophrenia

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can you share the experience of treating treatment resistant schizophrenia

-clozapine resistant.

-non compliance with clozapine.

i've read the maudsley giudelines

any hands on experience

my consultant is considering ECT and flupenthixopl for a patient and asked me to study some papers.

any relevant links appreciated.

thanks.

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http://bjp.rcpsych.org/cgi/content/full/181/3/184

http://ajp.psychiatryonline.org/cgi/content/full/158/4/518?ijkey=aee6726cc9a71fa4334f05b7eaba7e3c356d5b24

http://archpsyc.ama-assn.org/cgi/content/full/56/10/950?ijkey=ee1657afe1b31b21f5b9226b80a45bcf0861f5e5&keytype2=tf_ipsecsha

Latest articles....

S. W. Lewis, T. R. E. Barnes, L. Davies, R. M. Murray, G. Dunn, K. P. Hayhurst, A. Markwick, H. Lloyd, and P. B. Jones

Randomized Controlled Trial of Effect of Prescription of Clozapine Versus Other Second-Generation Antipsychotic Drugs in Resistant Schizophrenia

Schizophr Bull, October 1, 2006; 32(4): 715 - 723.

J. P. McEvoy, J. A. Lieberman,et al.... This one is from the CATIE trial

Effectiveness of Clozapine Versus Olanzapine, Quetiapine, and Risperidone in Patients With Chronic Schizophrenia Who Did Not Respond to Prior Atypical Antipsychotic Treatment

Am J Psychiatry, April 1, 2006; 163(4): 600 - 610.

W. G. Honer, A. E. Thornton, E. Y.H. Chen, R. C.K. Chan, J. O.Y. Wong, A. Bergmann, P. Falkai, E. Pomarol-Clotet, P. J. McKenna, E. Stip, R. Williams, G. W. MacEwan, K. Wasan, R. Procyshyn, and the Clozapine and Risperidone Enhancement (CARE) S

Clozapine Alone versus Clozapine and Risperidone with Refractory Schizophrenia

N. Engl. J. Med., February 2, 2006; 354(5): 472 - 482.

Jones PB, Barnes TRE, Davies L, Dunn G, Lloyd H, Hayhurst KP et

al. Randomized controlled trial of the effect on quality of life

of second- vs first-generation antipsychotic drugs in

schizophrenia: cost utility of the latest antipsychotic drugs in

schizophrenia study (CUtLASS 1). Arch Gen Psychiatry 2006; 63:

1079-1087. This one is from UK.... but not on TRS

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ECT in schizophrenia...

Great if you could get hold of the JECT:

Fair evidence from the Sackeim group and the Max Fink group

Chanpattana W, Chakrabhand MLS, Sackeim HA, Kitaroonchai W,

Kongsakon R, Techakasem P et al. Continuation ECT in treatment-

resistant schizophrenia: a controlled study. J ECT 1999; 15: 129-

139.

Chanpattana W. Combined ECT and clozapine in treatment-resistant

mania. J ECT 2000; 16: 204-207.

Fink M (1998). ECT and clozapine in schizophrenia. J ECT; 14:

223-226.

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-clozapine resistant.

-non compliance with clozapine.

those two suggest that the patient is not necessarily treatment resistant, but that they have actually not been fully treated.

drugs don't work if patients don't take them reliably.

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you have to look at the clozapine levels, compliance issues (as j suggested),other maintaining facors as drug use,family dynamics ....

in my experience in rehab, augmentation with sulpiride as well as amisulpride showed significant improvements.in one patient we had to go above 900 mg/day (clozapine max dose)after seeking second opinion and informing all the relevant people. i don't have any experience with ect in tr resistant scz.

in people with whom you cannot use clozapine (generally non compliant and insightless rather than having problems with blood results) i had some positive results with depot + atypical antipsychotic,as well as going above bnf limits with olanzapine(sepecially with partial responders on 20 mg/day)

i guess the other links will be helpful as well...

cheers :)

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APT - March 2005; 11 (101-106) - Management of Clozepine resistant schizophrenia

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One can argue that schizophrenia by its very nature is treatment resistant!

Try Clozapine. Do a level, if less than 0.35, increase.

Supplement with low dose amisulpiride.

Try lamotrigine, valproate, Maxepa

Look at diagnosis, compliance, illicit drug use!

Don't know whether ECT is indicated, doubt it!

If no joy, try another drug from another class that patient hasn't had.

If that doesn't work, see what they were more settled on and try that

Don't forget all the psychosocial stuff!!

Who said PMPs were a waste of time? Good old fashioned exams...none of this Part III rubbish!!

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One can argue that schizophrenia by its very nature is treatment resistant!

one could also argue that schizophrenia doesn't exist or that schizophrenia is also lots of different things, some of which are treatment resistant, others are easily treated, others more complex and others treatment resistant. the fact that 20%ish with schizophrenia only have one episode is a strong arguement against the idea that by it's nature it is treatment resistant.

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