| What is a suggested approach if there is medication non-adherence? | long-acting preparations in addition to other measures for managing non-adherence | At any point, consider electroconvulsive therapy if: 1. Serious suicidal risk 2. Catatonia not responding to Lorazepam 3. Refusal of food / fluids 4. Severe aggression / violence 5. Refractory / intolerance to clozapine * Treat with adequate dose as shown in table-1 for 6 – 8 weeks to assess efficacy #While choosing alternative AP, consider adverse effect profile and cost ^ At any point, if there is medication non-adherence, consider long-acting preparations in addition to other measures for managing non-adherence ? | 438 | summary | 0.970 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | Refractory / intolerance to clozapine * Treat with adequate dose as shown in table-1 for 6 – 8 weeks to assess efficacy #While choosing alternative AP, consider adverse effect profile and cost ^ At any point, if there is medication non-adherence, consider long-acting preparations in addition to other measures for managing non-adherence ? | 1 | page=1,block=105 | 0.700 | valid |
| What should be monitored and managed during follow-up and rehabilitation in primary care? | challenges in treatment continuation | #Encourage follow up in primary care after addressing referral issues * Watch for adverse effects as SSRIs may increase serum levels of antipsychotics Identify, educate and refer to PHC If immediate threat to self/ others, refer to Taluk / District center FOLLOW-UP AND REHABILITATION: • Monitor & manage challenges in treatment continuation • If unsatisfactory outcome despite regular treatment: - Liaise with higher centers for optimal outcome - Liaise with social welfare department for disability certification & welfare benefits if continued poor outcomes | 305 | summary | 0.890 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | #Encourage follow up in primary care after addressing referral issues * Watch for adverse effects as SSRIs may increase serum levels of antipsychotics Identify, educate and refer to PHC If immediate threat to self/ others, refer to Taluk / District center FOLLOW-UP AND REHABILITATION: • Monitor & manage challenges in treatment continuation • If unsatisfactory outcome despite regular treatment: - Liaise with higher centers for optimal outcome - Liaise with social welfare department for disability certification & welfare benefits if continued poor outcomes |
| What activities are included in day care interventions? | vocational training, recreational activities, living-skill training, etc. | Poor outcome: +Following psychosocial interventions may be offered in isolation or in combination depending on the context in inpatient, outpatient or day-boarding settings INTERVENTION CONTEXT IN WHICH USEFUL Poor adherence; high family expressed emotions Psychoeducation Family therapy Cognitive remediation Cognitive behavior therapy Social skills training Vocational rehabilitation and supported education Day care with interventions including vocational training, recreational activities, living-skill training, etc. | 448 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | Poor outcome: +Following psychosocial interventions may be offered in isolation or in combination depending on the context in inpatient, outpatient or day-boarding settings INTERVENTION CONTEXT IN WHICH USEFUL Poor adherence; high family expressed emotions Psychoeducation Family therapy Cognitive remediation Cognitive behavior therapy Social skills training Vocational rehabilitation and supported education Day care with interventions including vocational training, recreational activities, living-skill training, etc. |
| What interventions are recommended for poor adherence and high family expressed emotions? | Psychoeducation Family therapy Cognitive remediation Cognitive behavior therapy Social skills training Vocational rehabilitation and supported education | Poor outcome: +Following psychosocial interventions may be offered in isolation or in combination depending on the context in inpatient, outpatient or day-boarding settings INTERVENTION CONTEXT IN WHICH USEFUL Poor adherence; high family expressed emotions Psychoeducation Family therapy Cognitive remediation Cognitive behavior therapy Social skills training Vocational rehabilitation and supported education Day care with interventions including vocational training, recreational activities, living-skill training, etc. | 257 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | Poor outcome: +Following psychosocial interventions may be offered in isolation or in combination depending on the context in inpatient, outpatient or day-boarding settings INTERVENTION CONTEXT IN WHICH USEFUL Poor adherence; high family expressed emotions Psychoeducation Family therapy Cognitive remediation Cognitive behavior therapy Social skills training Vocational rehabilitation and supported education Day care with interventions including vocational training, recreational activities, living-skill training, etc. |
| What should be checked two weeks after the initial contact? | changes in symptoms and adverse effects (excess sleep, extrapyramidal symptoms (EPS), tiredness) | • 2 weeks after initial contact: Check for changes in symptoms and adverse effects (excess sleep, extrapyramidal symptoms (EPS), tiredness) adjust the dose of risperidone and THP accordingly; address questions if any; advise gradual return to work/school; give specific follow-up date; liaise with wellness center for ensuring continuity of care • Once in 1 – 2 months: Check for symptoms, functioning and adverse effects (EPS, weight-gain, menstrual/sexual dysfunction); adjust the dose of Risperidone (range: 2 – 8 mg/day) and THP (range 2 – 6 mg/day); liaise with wellness center for ensuring continuity of care | 43 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | • 2 weeks after initial contact: Check for changes in symptoms and adverse effects (excess sleep, extrapyramidal symptoms (EPS), tiredness) adjust the dose of risperidone and THP accordingly; address questions if any; advise gradual return to work/school; give specific follow-up date; liaise with wellness center for ensuring continuity of care • Once in 1 – 2 months: Check for symptoms, functioning and adverse effects (EPS, weight-gain, menstrual/sexual dysfunction); adjust the dose of Risperidone (range: 2 – 8 mg/day) and THP (range 2 – 6 mg/day); liaise with wellness center for ensuring |
| What should be considered when choosing an alternative antipsychotic medication? | adverse effect profile and cost | At any point, consider electroconvulsive therapy if: 1. Serious suicidal risk 2. Catatonia not responding to Lorazepam 3. Refusal of food / fluids 4. Severe aggression / violence 5. Refractory / intolerance to clozapine * Treat with adequate dose as shown in table-1 for 6 – 8 weeks to assess efficacy #While choosing alternative AP, consider adverse effect profile and cost ^ At any point, if there is medication non-adherence, consider long-acting preparations in addition to other measures for managing non-adherence ? | 343 | list | 0.820 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | Refractory / intolerance to clozapine * Treat with adequate dose as shown in table-1 for 6 – 8 weeks to assess efficacy #While choosing alternative AP, consider adverse effect profile and cost ^ At any point, if there is medication non-adherence, consider long-acting preparations in addition to other measures for managing non-adherence ? | 1 | page=1,block=105 | 0.700 | valid |
| What is suggested for clarifying diagnostic confusion? | Inpatient observation for clarification of history, thorough neurological / mental status examination, diagnostic psychometry, brain CT Scan or MRI, neurology consultation and urine toxicology screen | Diagnostic confusion Poor response to Risperidone Intolerance to Risperidone Poor adherence to treatment Comorbid conditions Challenging situations Rehabilitation needs Pregnancy 1. Diagnostic confusion: Inpatient observation for clarification of history, thorough neurological / mental status examination, diagnostic psychometry, brain CT Scan or MRI, neurology consultation and urine toxicology screen 2. | 204 | list | 0.780 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | Diagnostic confusion: Inpatient observation for clarification of history, thorough neurological / mental status examination, diagnostic psychometry, brain CT Scan or MRI, neurology consultation and urine toxicology screen 2. | 1 | page=1,block=58 | 0.700 | valid |
| What should be considered for managing depression or anxiety in patients with negative symptoms? | Brief psychological intervention; consider SSRIs* | Clarify diagnosis; neuroimaging if organicity is suspected Positive symptoms: Follow algorithm Negative symptoms: • Rule out or manage depression/ anxiety and extrapyramidal symptoms; • Family counseling if understimulated/ over-protected • Consider less-sedating antipsychotics and adding SSRIs* Follow algorithm • Assessment of factors causing poor adherence & specific manage- ment • Consider depot anti- psychotics • Liaise with primary care for assertive follow up • Depression/ anxiety: Brief psychological intervention; consider SSRIs* • Substance use: Detoxification and brief interventions (see SUD module) • Developmental disabilities: Behavioral assessment & management • Suicidality: -Inpatient care, -Crisis management, -Management of comorbidity; -Consider ECT • Violence: -Verbal de-escalation -IV sedation, -Brief inpatient care • Assess disability & counsel about welfare benefits • Rehabilitation counseling - Family intervention for expressed emotions and attitudes & behaviors interfering with functioning - Brief interventions for cognitive & social-skill deficits - Address vocational/ educational challenges involving governmental/ non-governmental agencies • Proactively address sexual and endocrine problems when relevant • Educate about risk of obstetric outcomes, risk of relapse & risk of psychosis in the offspring INDICATION FOR REFERRAL |
| What are some conditions that might cause diagnostic confusion? | organic condition | • Diagnostic confusion / suspicion of organic condition • Substantial risk of harm to self or others and catatonic symptoms • Comorbid substance use, depression/anxiety, intellectual disability • Poor symptom-control or functioning despite regular treatment or poor treatment adherence • Significant adverse effects: weight-gain, metabolic adverse effects, tardive dyskinesia • Questions regarding marriage, pregnancy, sexual dysfunction | 38 | factual | 0.490 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf | • Diagnostic confusion / suspicion of organic condition • Substantial risk of harm to self or others and catatonic symptoms • Comorbid substance use, depression/anxiety, intellectual disability • Poor symptom-control or functioning despite regular treatment or poor treatment adherence • Significant adverse effects: weight-gain, metabolic adverse effects, tardive dyskinesia • Questions regarding marriage, pregnancy, sexual dysfunction | 1 | page=1,block=14 | 0.700 | valid |
| What is the recommended duration of treatment for a first episode of psychosis? | About 2 years | Interventions for substance-use High family expressed emotions; family discord Poor neuro and social cognitive functions Depression, anxiety, obsessions, persistent psychotic symptoms Poor social skills Poor occupational functioning, challenges in studying or getting / pursuing gainful occupation Negative symptoms, poor socio-occupational functioning, combination of other symptoms listed in the table Hazardous use of substance or substance use disorder Pregnancy – puerperium services Pre-pregnancy, pregnancy and post-partum advise and interventions Pre-pregnancy, pregnancy and post-partum advise and interventions Presence of delusions (suspiciousness and fear without obvious explanation) Risperidone* Stabilization phase: For 6 months: same dose of AP; Maintenance phase: Attempt to reduce dose to minimum possible dose. 1st episode: About 2 years. 1+ episodes: indefinite period Investigate for medical/ neurological causes of non-response and treat them No cause found or poor response despite treatment of the cause Good response without intolerable side effects Intolerable side effects or inadequate effect Intolerable side effects or inadequate effect Inadequate effect for 2+ APs Choose different AP*#^ | 843 | factual | 0.490 | https://www.icmr.gov.in/icmrobject/uploads/STWs/1725952331_psychiatry_psychosis.pdf |