1.  General guidelines about Schizophrenia

·        A major psychotic disorder characterized by abnormalities in the perception or expression of reality. It affects the cognitive and psychomotor functions. Common clinical signs and symptoms include delusions, hallucinations, disorganized thinking, and retreat from reality.

·        A severe emotional disorder of psychotic depth characteristically marked by a retreat from reality with delusion formation, hallucinations, emotional disharmony, and regressive behavior.

·        A disorder that affects a person's ability to think, feel and behave clearly.

·        People may experience

Ø  Behavioural: social isolation, disorganized behaviour, aggression, agitation, compulsive behaviour, excitability, hostility, repetitive movements, self-harm, or lack of restraint

Ø  Cognitive: thought disorder, delusion, amnesia, belief that an ordinary event has special and personal meaning, belief that thoughts aren't one's own, disorientation, mental confusion, slowness in activity, or false belief of superiority

Ø  Mood: anger, anxiety, apathy, feeling detached from self, general discontent, loss of interest or pleasure in activities, elevated mood, or inappropriate emotional response

Ø  Psychological: hallucination, paranoia, hearing voices, depression, fear, persecutory delusion, or religious delusion

Ø  Speech: circumstantial speech, incoherent speech, rapid and frenzied speaking, or speech disorder

Also common: fatigue, impaired motor coordination, lack of emotional response, or memory loss

History taking and examination including MSE                                                                                                                      Annexure 1

2.a) Investigations required

a.  Psychometric investigations: Positive and Negative Symptom Scale (PANNS)

b.  Laboratory: (if physical complications are present)

a)      Comorbidity: Major depression, alcohol and drug induced psychoses, obsessive compulsive disorder and anxiety disorder.

b)    Differential Diagnosis: Substance-induced psychotic disorder, Mood disorders with psychotic features, Sleep-related disorders, Delusional disorder, Paranoid personality disorder, Schizotypal personality disorder, Pervasive developmental disorder, Psychosis secondary to organic causes.

3.  Treatment

a)     Psychopharmacology Investigations

Though no specific test is diagnostic, but depending on the possible list of differentials for causes of organic psychosis, investigations can be advised. Look for concurrent conditions e.g. alcohol use, signs or symptoms suggestive of stroke/ diabetes/ hypertension/ HIV or AIDS/ cerebral malaria/ medications usage (e.g. steroids, ATT).

Treatment

A comprehensive treatment program includes:

1.  Antipsychotic medication, which forms the cornerstone of treatment of psychosis

2.  Education of the individual about his/her illness and treatment

3.  Family education and support

4.  Support groups and social skills training

5.  Rehabilitation to improve the activities of daily living

6.  Vocational and recreational support

Pharmacological management

After identification of the case, antipsychotic medications should be started depending on the clinical status. The treatment can be broadly divided into two phases: acute and maintenance. The goals of acute phase of treatment are to reduce symptoms, to prevent harm to self/others and improve biological functions. The goal of maintenance phase of treatment is to prevent relapse and to help patient improve one’s level of functioning.

Selection of antipsychotic drugs: Two classes of antipsychotic drugs are available, typical antipsychotics (haloperidol, chlorpromazine, trifluoperazine) and atypical antipsychotics (risperidone, olanzepine, quetiapine). Both the groups are equally effective, but differ in their side effect profiles. In typical antipsychotics, high potency drugs (e.g. haloperidol) have more extra pyramidal side (EPS) effects and low potency drugs (e.g. chlorpromazine, fluphenazine, trifluoperazine) have more anticholinergic side effects (e.g. dryness, urinary retention, constipation) and cardiovascular side effects (e.g. tachycardia, postural hypotension)

Managing side effects

Monitoring for common acute side effects is essential

1.     Extrapyramidal side effects (drooling of saliva, rigidity, fine tremors in hands), acute dystinia (sudden sustained contraction of a group of muscles, most commonly neck and oral musculatures are affected), oculogyuric crisis (sudden up rolling of eyeballs), rabbit syndrome (fine perioral tremors). Manage extra pyramidal side effects by reducing antipsychotic dosage or addition of oral anticholinergic drug e.g. trihexyphenidyl or acutely by giving injection promethazine.

2.     Cardiovascular side effects (hypotension, bradycardia, QTc prolongation in ECG): These side effects require reducing dosage or switching to other agents.

Non pharmacological management

Psycho-education: Discuss with the patient and family regarding: The person’s ability to recover;

-        The importance of continuing regular social, educational and occupational activities as far as possible

-        The suffering and problems can be reduced with treatment

-        The importance of taking medication regularly;

-        The right of the person to be involved in every decision that concerns his or her treatment

-        Importance of staying healthy (e.g. following healthy diet, staying physically active, maintaining personal hygiene).

-        Additional messages to family members of people with psychosis

-        The persons with psychosis may hear voices or may firmly believe things that are untrue

-        The person with psychosis often does not agree that he or she is ill and may sometimes be hostile

-        The importance of recognizing the return/worsening of symptoms and of coming back for re-assessment should be stressed

-        The importance of including the person in family and other social activities should be stressed

-        Family members should avoid expressing constant or severe criticism or hostility towards the person with psychosis.

-        Person with psychosis may have difficulties recovering or functioning in high-stress working or living environments.

-        It is best for the person to have a job or to be otherwise meaningfully occupied.

Follow up care

People with psychosis require regular follow-up. In this phase, particularly general physicians can be of great help. Once a patient is in remission, or behaviourally stable, can continue to follow up locally with nearest general physician. Subsequently, patient can be referred to specialised mental health services only on need basis.

Follow up frequency:

Acute phase: Follow up one or twice weekly. Maintenance phase: Follow up every one to three months.

Follow up assessment: During follow up visits, assess for the following:

-        Level of symptoms

-        Side-effects of medications

-        Treatment adherence: Treatment non-adherence is common, address it

-        Assess for and manage concurrent medical conditions

-        Assess for the need to psychosocial interventions at each follow-up

-        Maintain realistic hope and optimism during treatment

-        Involvement of carers is critical during such periods

b)    Psychosocial Interventions

i)      Psychoeducation: Nature of illness, etiology, progression, consequences, prognosis, treatment.

ii)  Family Therapy

iii)  Support Group and social skills training

b. If patient is in mid or late stage

i)  Rehabilitation – to improve the activities of daily living

ii)  Cognitive Behavioural Therapy (CBT)

iii)  Vocational and recreational support

4.  Follow-up

a.  Psychiatry OPD/ DMHP

·       Initially once in two weeks for 2 months

·       Monthly check up for 1 year.

b.  Physical check-up at OPD

c.  Through telephonic conversation/TeleManas 14416/18008914416

5.  Referrals

a.   Depending upon the severity and complications of the patient, he/she may need to be referred to Psychiatry department.

b.  To TeleManas

c.  To the nearest DMHP

d.  To psychiatry OPD at Kulikawn Hospital or ZMC

e.  To higher centers outside Mizoram through Referral Board.