Risk of arrhythmia induced by psychotropic medications: a proposal for clinical management.

Several drugs used in the treatment of mental diseases are associated with an increased risk of sudden cardiac death (SCD). A general cause-relationship between the intake of these drugs and SCD is unattainable, but numerous case reports of drug-induced malignant arrhythmia and epidemiological studies, associating the use of specific drugs with SCD, strongly support the presence of an increased risk. Whereas the absolute risk of drug-induced life-threatening arrhythmia may be relatively low, even small increments in risk of SCD may have a major health impact considering that millions of patients are treated with psychotropics. In subgroups of pre-disposed patients, e.g. patients with cardiac diseases or other co-morbidities, the elderly or patients treated with other negatively interacting drugs, the absolute risk of drug-induced arrhythmia may be considerable. On the other hand, several of the major mental disorders are associated with a large risk of suicide if untreated. The observed risk of malignant arrhythmia associated with treatment with psychotropic drugs calls for clinical guidelines integrating the risk of the individual drug and other potentially interacting risk factors. In this review, data from various authorities on the risk of arrhythmia associated with psychotropic medications were weighted and categorized into three risk categories. Additionally, we suggest a clinically applicable algorithm to reduce the risk of malignant arrhythmia in patients to be treated with psychotropic medications. The algorithm integrates the risk categories of the individual drugs and pre-disposing risk factors and suggests a prudent follow-up for patients with an increased risk. We believe this clinically manageable guideline might improve safety in the many and rapidly increasing number of patients on psychotropic drugs.

Antipsychotic polypharmacy in a treatment-refractory schizophrenia population receiving adjunctive treatment with electroconvulsive therapy.

BACKGROUND: Antipsychotic polypharmacy (APP) is frequent, but its pattern is unknown in treatment-refractory schizophrenia-spectrum patients receiving electroconvulsive therapy (ECT). METHODS: We performed a retrospective chart review of ECT-treated inpatients hospitalized at 2 Danish University hospitals from 2003 to 2008, focusing on APP patterns in patients with schizophrenia-spectrum disorders (n = 79, 13.2%). In addition to univariate analyses, a multivariate logistic regression analysis was performed to identify independent predictors of APP. RESULTS: Of 79 antipsychotic-treated patients (aged 48.6 ± 14.2 years; illness duration, 18.3 ± 10.6 years) ultimately treated with ECT, 86.1% received 2 or more psychotropic medications, including mood stabilizers (19.0%), antidepressants (32.9%), and APP (72.2%; 2 antipsychotics = 41.8%, 3 = 21.5%, 4-5 = 7.6%). Most patients received first-generation antipsychotic (FGA) + second-generation antipsychotic (SGA) (48.1%), followed by SGA + SGA (24.1%), SGA monotherapy (22.8%), and FGA monotherapy (5.1%). Individual antipsychotics included olanzapine (44.3%), risperidone (26.6%), clozapine (26.6%), quetiapine (22.1%), ziprasidone (13.9%), aripiprazole (10.1%), and sertindole (3.8%). Antipsychotic polypharmacy was associated with a greater number of FGAs (0.8 ± 0.7 vs 0.1 ± 0.4, P < 0.0001) and SGAs (1.7 ± 0.8 vs 0.8 ± 0.4, P < 0.0001), zuclopenthixol use (31.6% vs 0%, P = 0.0019), olanzapine use (52.6% vs 22.7%, P = 0.017), less serotonin-noradrenaline reuptake inhibitor use (3.5% vs 18.2%, P = 0.027), and a trend toward more good to excellent ECT response (86.0% vs 68.2%, P = 0.071). In the logistic regression analysis, APP was independently associated with a higher number of FGAs (P = 0.0002) and olanzapine use (P = 0.0098) (r = 0.314, P < 0.0001). DISCUSSION: Only 22.6% of this treatment-refractory population received clozapine, yet 72.4% received APP. Following the results from our study as well as the general level of evidence, patients with refractory schizophrenia-spectrum disorder should receive clozapine or ECT before being tried on APP.

The use of electroconvulsive therapy in a cohort of forensic psychiatric patients with schizophrenia.

BACKGROUND: In Denmark, over 2500 people are in psychiatric treatment in forensic mental health services at any one time, most suffering from schizophrenia. Many of them have illnesses that are resistant to medication. There is evidence of the effectiveness of electroconvulsive therapy (ECT) for schizophrenia, but not explicitly for this complex forensic group. AIMS: The aim of this study was to describe the outcome of using ECT as augmentation therapy in a cohort of forensic psychiatric patients with schizophrenia who were failing to respond to antipsychotic medication. METHODS: In one university-based psychiatric clinic, data were extracted from the medical records of all patients treated with ECT during a 6-year period. Fifty-nine of these patients were diagnosed within the schizophrenia spectrum and eight were in specialist forensic hospital services. RESULTS: The mean duration of illness for the forensic cohort was 16 years (range 3-33 years), with the index episode having lasted a mean of 34 months (3 weeks to 8 years) in spite of treatment with at least two antipsychotic drugs. Psychotic symptoms were accompanied by seriously assaultive behaviour in all cases. All but one of these patients had an excellent or good symptomatic and behavioural response to ECT. Half (four) went on to maintenance ECT. No adverse effects were documented. CONCLUSION: ECT is rarely used in specialist secure services, but should not be forgotten as a treatment that may enable medication-resistant, assaultive psychotic patients to progress safely out to the community.

Electroconvulsive therapy for treating schizophrenia: a chart review of patients from two catchment areas.

To examine disease and treatment characteristics of patients with schizophrenia treated with electroconvulsive therapy (ECT). We examined charts from 79 patients diagnosed with schizophrenia (n = 55), persistent delusional disorders (n = 7), and schizoaffective disorders (n = 17) between 2003 and 2008. We recorded age, sex, indication for ECT, number of ECT sessions, ECT series, outcome, maintenance ECT, use of antipsychotics, duration of illness, and duration of the current exacerbation. All patients were taking antipsychotics at the time of enrolment in the study. Acute ECT included 2-26 sessions; maintenance ECT (M-ECT) was given to 18 patients for up to 12 years. Initial indications for ECT included psychosis (n = 28), pronounced affective symptoms (n = 28), delirious states (n = 20), and M-ECT (n = 3). Most patients experienced excellent/good outcomes (n = 66), but others experienced moderate (n = 8) or poor (n = 5) outcomes. No factors were identified that predicted treatment responses in individual patients. ECT proved to be effective in a population of patients that were severely ill with treatment-refractory schizophrenia. This does not imply that the patients were cured from schizophrenia. Rather, it reflects the degree of relief from psychosis and disruptive behaviour, as described in the patient charts. The treatment was often offered to patients after considerable disease durations.

[Airborne contact allergy provoked by kathon in water-based plastic paint]. / Luftbåren kathonkontaktallergi udløst af vandbaseret plasticmaling.

We describe two cases of airborne contact allergy to plastic paint containing Kathon. Two women with known kathon allergy, aged 33 and 50 years, developed severe dermatitis and systemic reactions after painting their homes with water-based plastic paint with Kathon as preservative. Both required treatment with systemic steroids. On return to their homes, the symptoms immediately recurred, and they were forced to stay away for several weeks afterwards. Patients allergic to Kathon should be informed of the risk of airborne contact allergy when exposed to paints preserved with Kathon.

Postoperative cognitive dysfunction in middle-aged patients.

BACKGROUND: Postoperative cognitive dysfunction (POCD) after noncardiac surgery is strongly associated with increasing age in elderly patients; middle-aged patients (aged 40-60 yr) may be expected to have a lower incidence, although subjective complaints are frequent. METHODS: The authors compared the changes in neuropsychological test results at 1 week and 3 months in patients aged 40-60 yr, using a battery of neuropsychological tests, with those of age-matched control subjects using Z-score analysis. They assessed risk factors and associations of POCD with measures of subjective cognitive function, depression, and activities of daily living. RESULTS: At 7 days, cognitive dysfunction as defined was present in 19.2% (confidence interval [CI], 15.7-23.1) of the patients and in 4.0% (CI, 1.6-8.0) of control subjects (P < 0.001). After 3 months, the incidence was 6.2% (CI, 4.1-8.9) in patients and 4.1% (CI, 1.7-8.4) in control subjects (not significant). POCD at 7 days was associated with supplementary epidural analgesia and reported avoidance of alcohol consumption. At 3 months, 29% of patients had subjective symptoms of POCD, and this finding was associated with depression. Early POCD was associated with reports of lower activity scores at 3 months. CONCLUSIONS: Postoperative cognitive dysfunction occurs frequently but resolves by 3 months after surgery. It may be associated with decreased activity during this period. Subjective report overestimates the incidence of POCD. Patients may be helped by recognition that the problem is genuine and reassured that it is likely to be transient.