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abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

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Clinical Conversation: Schizophrenia

Rory Hafford talks to Dr Eamonn Kenny and Dr Sean O'Domhnaill about their work treating and researching schizophrenia at Tallaght and St James's hospitals, respectively, and where we're going

Dr Eamonn Kenny is perched – a little precariously it has to be said – on the edge of a table in the Training Unit in Tallaght Hospital. We’re talking about schizophrenia, the role of the GP in the management of the condition and the way the service has been affected in Ireland by the ‘economic downturn’.

An intelligent, self-effacing man, Dr Kenny has worked as a Consultant Psychiatrist in the Dublin hospital since 2004. He likes what he does and can’t see any reason to change at the present moment.

It’s a good time to be working in the speciality. Medical scientists are beginning to unravel the shackles that bind people to this terrfiying and disabling disease. Ongoing research is leading to new and safer medications: the study of molecular genetics is causing a bit of a stir, as is the investigation of how the condition manifests in different population bases.

The technology is also helping. More targeted methods of imaging the strucure of the brain are coming on stream and the multi-discipline services used to ring-fence the worst excesses of schizophrenia are becoming more and more refined.

“We’re lucky in Tallaght,” says Dr Kenny. “We have been using the Home Care model for some time, which means the disease can be treated in the community, rather than tying up hospital facilities. Obviously, some people have to be admitted but, largely speaking, Home Care is working.”

The treatment of schizophrenia usually involves a combination of antipsychotic medicines, psychological therapies and community mental health teams (CMHT). Typically, the CMHT consists of social workers, community mental health nurses, counsellors and psychotherapists, psychologists and psychiatrists. It’s a model that also allows for direct GP intervention.

According to Dr Kenny, GPs can manage the condition in the community ‘very successfully’, provided the patient does not suffer from ongoing severe psychiatric crises and the proper structures are in place. We do have a slight problem, however. It’s called the financial meltdown!

Dr Sean O’Domhnaill prefers to remain upbeat. The Consultant Psychiatrist, who plies his trade at the Jonathan Swift Clinic in St James’s Hospital, says that it is very reassuring to see such a wide variety between multiple pharmaceutical options, psychological interventions and social and rehabilitative programmes.

Inevitable proviso
And then comes the inevitable proviso: ‘Unfortunately the services are very sporadically resourced in the public service. On the other hand, the private sector has a very high quality of service, but not necessarily better all around. Many public sector workers are providing innovative services without significant resource consumption. Necessity is proving to be the mother of invention fortunately.”

Everything about Dr Kenny appears positive. He is one of the main drivers of the psychiatric services in Tallaght, he is heavily involved in the tutoring process and he believes that we can make a real difference in the treatment of this torturous condition. But you do get the impression that the cutbacks are beginning to irritate him...just a little.

“Let me give you a for instance,” he says, eyeing me intently to make sure I’m on the same page. “In places like Ballyfermot and Lucan we don’t have the finances to ensure that the people we are treating have access to a psychologist...”

He stops just short of condeming this, but you can see he’s not happy about it. Sure, everything has been affected by the fallout caused by the Sub Prime farce. But some things should be immune. They’re just too important. Mental health, it could be argued, is one of those things.

But we’re getting ahead of ourselves. Let’s back up just a bit so we can pull back the cloak and put a little shape on the treatment options. Schizophrenia affects 1 per cent of the population. This figure has remained pretty constant over the years. Are there more cases of schizophrenia presenting? is the wrong way to frame the question.

Dr O’Domhnaill explains: “There have been a number of initiatives in the early detection of psychosis, which is great for the long-term treatment outcomes. We are seeing more cases of schizophrenia earlier, possible due to the generalised move to more centralised urban living and the associated increase in the use of primary care.”

“Pretty much everyone can be affected,” says Dr Kenny, with a wide sweep of his hand. More specifically, the literature tells us that men and women can be targeted in equal measure. However, men are often affected earlier, usually in their late teens or early twenties; while women are more likely to succumb in their twenties to early thirties. It is believed that genetic susceptibility alone is insufficient to cause schizophrenia and environmental factors are also necessary.

Exposure to infection, stress and/or marijuanna-type drugs can be implicated and causative. Excess dopamine levels may also be involved as all antipsychotic drugs block dopamine, and drugs that release dopamine can trigger schizophrenia. Low levels of glutamate receptors have also been identified in people with schizophrenia.

A big problem
“Drugs are a big problem in schizophrenia,” says Dr Kenny. “We see cannabis being used on a farily widespread level and even so-called plant food products in shops is now being abused.” Substance abuse needs to be monitored closely as it reduces the likelihood that patients will follow the treatment plans recommended by their doctors.

Dr O’Domhnaill concurs: “Obviously the massive increase in cannabis and psychostimulant use means that more of those with a genetic predisposition to schizophrenia are having their conditions triggered off than previously. The evidence from the reclassification of cannabis use in the UK would seem to support this hypothesis.”

With this profile it’s not surprising that the lower socio-economic groups are putting themselves more in the firing line, genetic predispositions aside. At this point the general practitioner could be forgiven for looking for an exact definition of what it is we are dealing with. Dr O’Domhnaill is happy to provide one.

“I think that schizophrenia is best defined as a collection of psychiatric syndromes characterised by a set of positive psychotic symptoms, including thought disorder or perceptual abnormality, a set of negative symptoms characterised by the paucity of interpersonal and cognitive functions, and/or both. I favour a broad definition since there is such a broad range of clinical presentations.”

‘Word salad’
Broadly speaking, the manifestations haven’t changed: delusions; hallucinations, especially auditory; jumbled, incoherent speech often referred to as ‘word salad’; inappropriate emotions, such as amusement at bad news; social isolation; neglect of personal health and hygiene; catatonia.

“Treating the condition in a general practice setting, it helps to be able to consult with a family member or a friend of the patient. This, however, needs to be handled sensitively. Some patients may feel that you are plotting against them by consulting people behind their back.”

Paranoia affects roughly one-third of people with schizophrenia.
It is also important to rule out other illnesses. But a word of caution here from Dr Kenny: “Early intervention is key.”

When it comes to the treatment of schizophrenia it could be argued that it is cheaper than most other conditions. Sure, there are tests that you may wish to carry out, but by and large, the approach is assessment rather than mechanical.

Drug treatments have moved apace since 1990. Clozaril, for example, has been shown to be highly effective in certain patients at reducing symptoms, but it does need to be monitored for possible agranulocytosis.

The newer antipsychotic drugs such as Risperdal and Zyprexa are safer than the older drugs and appear to be better tolerated. There are a number of new antipsychotics currently under development. Psychotherapy is often indicated as part of the treatment package and it is something that can be carried out quite successfully outside of the hospital setting.

Typically these sessions focus on current or past problems, experiences, thoughts, feelings and relationships. By talking about their world with someone outside their world some people with schizophrenia may gradually come to understand more about themselves and, perhaps most importantly, learn to separate the real from the distorted.

“We have a range of choice of neuroleptics/anti-psychotics,” says Dr O’Domhnaill.

“However, the real challenge is to match the medication to the particular clinical syndrome of schizophrenia encountered while minimising the collateral damage caused by the drugs. These are high-impact medications, as the long-term effects will show. We’ll learn more with time and research.”

I’m half afraid to put the question ‘are you happy’ to the two doctors; after all, they are psychiatrists and a question of this magnitude could set off a bit of a psychological cascade. However, I persist.

“Am I happy?” Dr O’Domhnaill repeats and then ponders for a moment. “I’ve always considered myself as a vocational professional rather than a careerist, despite what my wife might say! But my empathic answer would be in the negative. I have never regretted my choice of work. I feel very fortunate to wake up every morning and get into the car looking forward to the day ahead. I’m blessed.”

Controlled animation
You get the impression that Dr Eamonn Kenny is right where he wants to be: there is a controlled animation about him when he talks about the condition; he is clearly passionate about his teaching duties; he appears constantly challenged and is hopeful for the future.

“I am happy to work in this area. The future is very positive. Attitudes are changing and when this happens improvements are seen. We need to push for better services and we need to stress early intervention. But we are definitely going in the right direction.”

Dr O’Domhnaill agrees: “The future is bright for those with this condition and we need to communicate this to our patients forcefully and repetitively.”

He says that, presumably, we’ll see some form of genetic tailoring in the long-term.
“Before that I hope we’ll see more pharmacological advances accompanied by more widespread training in the psychological therapies to help reduce the personal impact of psychotic illness on the personality.”

Posted in Mental Health & CNS on 11 December 2009
Tags: schizophrenia

Tagcloud

abortion, accupuncture, ACE inhibitors, acne, ADHD, alcohol, allergies, Alzheimer's, anaemia, anaethesia, anorexia, antibiotics, antidepressants, antihistamine, anxiety, appetite control, arthritis, ASCOT, aspirin, asthma, atherosclerosis, autism, autoantibodies, back pain, beta carotene, beta-blockers, bipolar disorder, birth, bleeding, blindness, blood pressure, body dysmorphic disorder, body mass, breast cancer, breast feeding, bronchitis, Caesarean section, calcium, cancer, carcinogens, carcinoma, cardiac syncope, cardiolgy, cataracts, cervical cancer, chemotherapy, child psychiatry, children, cholesterol, clinical trial, clopidogrel, Clostridium difficile, cognitive behavioural therapy, colectomy, colic, colorectal cancer, complementary and alternative therapies, contraception, COPD, coronary care, coronary stents, Crohn's, cystic fibrosis, defibrillator, dementia, depression, dermatology, diabetes management, diet, disability, DNA, Down's syndrome, eating disorders, echinacea, ECT, eczema, elderly people, endoscopy, epilepsy, erectile dysfunction, euthanasia, exercise, fat, fertility, fitness, flu pandemic, fluoxetine, folic acid, food labelling, fracture, fragile X syndrome, general surgery, genetics, gerontology, GIK infusion therapy, GORD, gout, haemodialysis, hearing, heart attack, heart disease, heart failure, heart health, hepatitis, HIV, hospital care, HPV, HRT, hyperglycaemia, hypertension, hypoglycaemia, IBD, ICU, incontinence, infant, infant mortality, infection, inflammatory bowel disease, influenza, invasive candidiasis, IQ, Irish Heart Foundation, irritable bowel syndrome, keyhole surgery, kidney disease, laser, learning difficulties, leukaemia, liver disease, lumbar disk herniation, lung cancer, lung disease, lymph nodes, macular degeneration, macular oedema, magnetic resonance imaging (MRI), malaria, malnutrition, Marfan syndrome, media, medical ethics, medical research, medication, meningitis, mental illness, metabolic syndrome, migraine, miscarriage, mortality rate, MRSA, multiple sclerosis (MS), NCHDs, nephrology, neurology, OAB, obesity, obstetrics, occupational health, ocular medicine, omega-3, opthalmology, oral cancer, organ transplantation, orthopaedics, osteoporosis, otolaryngology, ovarian cancer, paediatrics, pain management, pancreatic cancer, panic, Parkinson’s disease, patient safety, patient-physician communication, personality disorders, physiotherapy, plastic surgery, polio, practice, pre-eclampsia, pregnancy, preventative health care, probiotics, prostate cancer, psoriasis, psychiatric admission, psychiatry, psychotherapy, PTSD, public health, quality of life, radiology, radiotherapy, rectal cancer, reproductive health, research, resuscitation, rheumatoid arthritis, rheumatology, rhinitis, salt, SARS, schizophrenia, screening, seizures, self harm, sexual abuse, sexual health, sexually transmitted infections, SGA, sinusitis, skin cancer, sleep disorders, smoking, smoking ban, spinal injury, sports medicine, statins, stress, stroke, substance abuse, suicide, supplement, surgery, syncope, technology, teenagers, testosterone, thoracic surgery, thrombosis, thyroid cancer, tonsillectomy, tonsillitis, Tourette's syndrome, toxicology, travel medicine, tuberculosis, tumour angiogenesis, type 1 diabetes, type 2 diabetes, ulcer, ulcerative colitis, urinary incontinence, vaccine, vitamins, weight, WHO, women's health, World Health Assembly

«Previous article | Next article»

Clinical Conversation: Schizophrenia

Rory Hafford talks to Dr Eamonn Kenny and Dr Sean O'Domhnaill about their work treating and researching schizophrenia at Tallaght and St James's hospitals, respectively, and where we're going

Dr Eamonn Kenny is perched – a little precariously it has to be said – on the edge of a table in the Training Unit in Tallaght Hospital. We’re talking about schizophrenia, the role of the GP in the management of the condition and the way the service has been affected in Ireland by the ‘economic downturn’.

An intelligent, self-effacing man, Dr Kenny has worked as a Consultant Psychiatrist in the Dublin hospital since 2004. He likes what he does and can’t see any reason to change at the present moment.

It’s a good time to be working in the speciality. Medical scientists are beginning to unravel the shackles that bind people to this terrfiying and disabling disease. Ongoing research is leading to new and safer medications: the study of molecular genetics is causing a bit of a stir, as is the investigation of how the condition manifests in different population bases.

The technology is also helping. More targeted methods of imaging the strucure of the brain are coming on stream and the multi-discipline services used to ring-fence the worst excesses of schizophrenia are becoming more and more refined.

“We’re lucky in Tallaght,” says Dr Kenny. “We have been using the Home Care model for some time, which means the disease can be treated in the community, rather than tying up hospital facilities. Obviously, some people have to be admitted but, largely speaking, Home Care is working.”

The treatment of schizophrenia usually involves a combination of antipsychotic medicines, psychological therapies and community mental health teams (CMHT). Typically, the CMHT consists of social workers, community mental health nurses, counsellors and psychotherapists, psychologists and psychiatrists. It’s a model that also allows for direct GP intervention.

According to Dr Kenny, GPs can manage the condition in the community ‘very successfully’, provided the patient does not suffer from ongoing severe psychiatric crises and the proper structures are in place. We do have a slight problem, however. It’s called the financial meltdown!

Dr Sean O’Domhnaill prefers to remain upbeat. The Consultant Psychiatrist, who plies his trade at the Jonathan Swift Clinic in St James’s Hospital, says that it is very reassuring to see such a wide variety between multiple pharmaceutical options, psychological interventions and social and rehabilitative programmes.

Inevitable proviso
And then comes the inevitable proviso: ‘Unfortunately the services are very sporadically resourced in the public service. On the other hand, the private sector has a very high quality of service, but not necessarily better all around. Many public sector workers are providing innovative services without significant resource consumption. Necessity is proving to be the mother of invention fortunately.”

Everything about Dr Kenny appears positive. He is one of the main drivers of the psychiatric services in Tallaght, he is heavily involved in the tutoring process and he believes that we can make a real difference in the treatment of this torturous condition. But you do get the impression that the cutbacks are beginning to irritate him...just a little.

“Let me give you a for instance,” he says, eyeing me intently to make sure I’m on the same page. “In places like Ballyfermot and Lucan we don’t have the finances to ensure that the people we are treating have access to a psychologist...”

He stops just short of condeming this, but you can see he’s not happy about it. Sure, everything has been affected by the fallout caused by the Sub Prime farce. But some things should be immune. They’re just too important. Mental health, it could be argued, is one of those things.

But we’re getting ahead of ourselves. Let’s back up just a bit so we can pull back the cloak and put a little shape on the treatment options. Schizophrenia affects 1 per cent of the population. This figure has remained pretty constant over the years. Are there more cases of schizophrenia presenting? is the wrong way to frame the question.

Dr O’Domhnaill explains: “There have been a number of initiatives in the early detection of psychosis, which is great for the long-term treatment outcomes. We are seeing more cases of schizophrenia earlier, possible due to the generalised move to more centralised urban living and the associated increase in the use of primary care.”

“Pretty much everyone can be affected,” says Dr Kenny, with a wide sweep of his hand. More specifically, the literature tells us that men and women can be targeted in equal measure. However, men are often affected earlier, usually in their late teens or early twenties; while women are more likely to succumb in their twenties to early thirties. It is believed that genetic susceptibility alone is insufficient to cause schizophrenia and environmental factors are also necessary.

Exposure to infection, stress and/or marijuanna-type drugs can be implicated and causative. Excess dopamine levels may also be involved as all antipsychotic drugs block dopamine, and drugs that release dopamine can trigger schizophrenia. Low levels of glutamate receptors have also been identified in people with schizophrenia.

A big problem
“Drugs are a big problem in schizophrenia,” says Dr Kenny. “We see cannabis being used on a farily widespread level and even so-called plant food products in shops is now being abused.” Substance abuse needs to be monitored closely as it reduces the likelihood that patients will follow the treatment plans recommended by their doctors.

Dr O’Domhnaill concurs: “Obviously the massive increase in cannabis and psychostimulant use means that more of those with a genetic predisposition to schizophrenia are having their conditions triggered off than previously. The evidence from the reclassification of cannabis use in the UK would seem to support this hypothesis.”

With this profile it’s not surprising that the lower socio-economic groups are putting themselves more in the firing line, genetic predispositions aside. At this point the general practitioner could be forgiven for looking for an exact definition of what it is we are dealing with. Dr O’Domhnaill is happy to provide one.

“I think that schizophrenia is best defined as a collection of psychiatric syndromes characterised by a set of positive psychotic symptoms, including thought disorder or perceptual abnormality, a set of negative symptoms characterised by the paucity of interpersonal and cognitive functions, and/or both. I favour a broad definition since there is such a broad range of clinical presentations.”

‘Word salad’
Broadly speaking, the manifestations haven’t changed: delusions; hallucinations, especially auditory; jumbled, incoherent speech often referred to as ‘word salad’; inappropriate emotions, such as amusement at bad news; social isolation; neglect of personal health and hygiene; catatonia.

“Treating the condition in a general practice setting, it helps to be able to consult with a family member or a friend of the patient. This, however, needs to be handled sensitively. Some patients may feel that you are plotting against them by consulting people behind their back.”

Paranoia affects roughly one-third of people with schizophrenia.
It is also important to rule out other illnesses. But a word of caution here from Dr Kenny: “Early intervention is key.”

When it comes to the treatment of schizophrenia it could be argued that it is cheaper than most other conditions. Sure, there are tests that you may wish to carry out, but by and large, the approach is assessment rather than mechanical.

Drug treatments have moved apace since 1990. Clozaril, for example, has been shown to be highly effective in certain patients at reducing symptoms, but it does need to be monitored for possible agranulocytosis.

The newer antipsychotic drugs such as Risperdal and Zyprexa are safer than the older drugs and appear to be better tolerated. There are a number of new antipsychotics currently under development. Psychotherapy is often indicated as part of the treatment package and it is something that can be carried out quite successfully outside of the hospital setting.

Typically these sessions focus on current or past problems, experiences, thoughts, feelings and relationships. By talking about their world with someone outside their world some people with schizophrenia may gradually come to understand more about themselves and, perhaps most importantly, learn to separate the real from the distorted.

“We have a range of choice of neuroleptics/anti-psychotics,” says Dr O’Domhnaill.

“However, the real challenge is to match the medication to the particular clinical syndrome of schizophrenia encountered while minimising the collateral damage caused by the drugs. These are high-impact medications, as the long-term effects will show. We’ll learn more with time and research.”

I’m half afraid to put the question ‘are you happy’ to the two doctors; after all, they are psychiatrists and a question of this magnitude could set off a bit of a psychological cascade. However, I persist.

“Am I happy?” Dr O’Domhnaill repeats and then ponders for a moment. “I’ve always considered myself as a vocational professional rather than a careerist, despite what my wife might say! But my empathic answer would be in the negative. I have never regretted my choice of work. I feel very fortunate to wake up every morning and get into the car looking forward to the day ahead. I’m blessed.”

Controlled animation
You get the impression that Dr Eamonn Kenny is right where he wants to be: there is a controlled animation about him when he talks about the condition; he is clearly passionate about his teaching duties; he appears constantly challenged and is hopeful for the future.

“I am happy to work in this area. The future is very positive. Attitudes are changing and when this happens improvements are seen. We need to push for better services and we need to stress early intervention. But we are definitely going in the right direction.”

Dr O’Domhnaill agrees: “The future is bright for those with this condition and we need to communicate this to our patients forcefully and repetitively.”

He says that, presumably, we’ll see some form of genetic tailoring in the long-term.
“Before that I hope we’ll see more pharmacological advances accompanied by more widespread training in the psychological therapies to help reduce the personal impact of psychotic illness on the personality.”

Posted in Mental Health & CNS on 11 December 2009
Tags: schizophrenia