[Disulfiram encephalopathy: an underrecognized complication of accidental overdose]. / Disulfiramencefalopathie: een mogelijke complicatie bij accidentele overdosering.

In this paper we discuss the case of a 52-year-old man who consulted the emergency department because of confusion. Based on anamnesis, clinical presentation, various technical investigations and recovery after discontinuation of disulfiram, the diagnosis of disulfiram encephalopathy is made. This is a less common but serious complication of a frequently used therapy and underscores the importance of early recognition and careful but also controlled prescription of disulfiram. We describe the pathophysiology behind this complication and reflect on some important numbers.

[Interstitial pneumonia and venlafaxine use]. / Interstitiële pneumonie bij venlafaxine-gebruik.

We describe a 71-year-old woman who developed interstitial pneumonia within a complex somatic state. Diagnostic clearance suggested venlafaxine-induced interstitial pneumonia. In the literature, we found 13 cases of venlafaxine-induced interstitial pneumonia. Case reports were also described for other antidepressants. Based on these case reports, there is consensus in the literature that antidepressants may in rare cases give rise to (sub)acute or chronic interstitial pneumonia. Although a rare side effect, it seems important to be aware of this as a psychiatrist.

[Catatonia as an initial presentation of acute disseminated encephalomyelitis]. / Katatonie als initiële uiting van acute gedissemineerde encefalomyelitis.

We describe a case of a 36-year-old woman with no psychiatric or somatic history who was presented to the emergency department with a profound change in mental status, more precisely a catatonic status and auditory hallucinations. Due to the unclear aetiology and suspicion of underlying psychiatric problems, the patient was admitted to the psychiatric ward. After discharge against medical advice, readmission was necessary due to deterioration and sudden onset of myoclonus. On further examination, acute disseminated encephalomyelitis (ADEM) was diagnosed. This case illustrates that ADEM can present itself as an initial psychiatric problem and emphasizes the importance of extensive medical clearance at presentation and continued attention for possible somatic origin, even when the initial clearance turns out to be negative.

[Lithium use in women with bipolar disorder during peripartum]. / Lithiumgebruik bij vrouwen met een bipolaire stoornis tijdens het peripartum overzichtsartikel.

BACKGROUND: Lithium use during peripartum requires careful consideration due to a risk of teratogenic effects, adverse side effects and risk of neonatal complications. However, given the effectiveness of lithium, use during the peripartum period may be indicated. AIM: To provide an overview of the current evidence regarding the clinical use of lithium during peripartum, including risk of relapse in case of (dis)continuation and evolution of lithium levels. METHOD: A review was performed in the Medline and ScienceDirect database. RESULTS: Ten studies were included. Six studies concerned the risk of relapse in case of (dis)continuation of lithium during the peripartum. Four studies concerned the evolution of lithium levels throughout the peripartum. Lithium discontinuation during pregnancy leads to an increased risk of relapse during pregnancy and postpartum. At the same dose, lithium levels are lower than preconceptual in all trimesters. CONCLUSION: Risk and benefits of lithium use during the peripartum should be carefully considered, if possible prior to conception. Close monitoring of maternal lithium levels and renal function is necessary due to significant fluctuations during peripartum.

Melancholie bij ouderen in tijden van COVID-19.

Melancholy in the elderly in times of COVID-19.

[Delirium due to intoxication with quetiapine: a systematic literature review]. / Delier ten gevolge van intoxicatie met quetiapine: een systematisch literatuuronderzoek.

BACKGROUND: Quetiapine is a frequently prescribed antipsychotic and therefore often used in overdose. Delirium (with anticholinergic delirium as a specific condition) is described as a serious complication of quetiapine intoxication.
AIM: To assess the scientific literature on delirium as a side effect of quetiapine intoxication: incidence, symptoms and treatment.
METHOD: A systematic Medline literature search.
RESULTS: The systematic literature search resulted in 36 papers: 11 cohort studies, 24 case reports (22 papers) and 3 review papers. The reported incidence varied greatly, probably due to different quality of assessment. The clinical picture is characterized by a varying combination of peripheral and central symptoms, with agitation occurring frequently. Treatment is mainly supportive. Physostigmine is described as a specific treatment for anticholinergic delirium/toxidrome. Effectiveness of other pharmacological interventions remains unclear.
CONCLUSION: Delirium due to quetiapine intoxication is described repeatedly. Presumably there is an underreporting of this condition and associated symptoms. Better knowledge could lead to better detection and treatment.

[The use of dexmedetomidine in extreme agitation]. / Het gebruik van dexmedetomidine bij extreme agitatie.

BACKGROUND: In clinical practice antipsychotics, benzodiazepines and/or antihistamines are used to calm agitated patients. If agitation persists and patients have contraindications for these substances, then anesthetics, such as propofol, can also be used as well, to serve as a sedative. Our attention was drawn to a particular case in which dexmedetomidine was used as a sedative.
AIM: To study the literature on the use of α2-agonists, such as dexmedetomidine, in the treatment of extreme agitation.
METHOD: We reviewed the relevant scientific literature.
RESULTS: α2-agonists, such as dexmedetomidine, are new anesthetic agents that have analgetic and sympatholytic effects without suppressing respiration. These agents are used frequently in intensive care because their sedative effect are short-lived and do not cause amnesia, sleep deprivation or cognitive disturbance. Excited delirium syndrome (eds) is a type of extreme agitation for which dexmedetomidine can be used.
CONCLUSION: There may well be a place for dexmedetomidine in the treatment of extreme agitation when standard treatments have failed. Further research is needed in order to ascertain whether dexmedetomidine should play a role in such treatment.

[Rapid tranquillisation for agitated patients with psychostimulant intoxication]. / Acute ingrijpmedicatie bij de geagiteerde patiënt met intoxicatie met psychostimulantia.

BACKGROUND: Because psychostimulant intoxication can lead to serious health risks for the patient, it is often necessary to ensure that the patient receives both adequate medical surveillance and rapid tranquillisation.
AIM: To find out whether there is scientific evidence that psychopharmacological intervention helps patients with psychostimulant intoxication to manage aggression and agitation.
METHOD: We searched the literature systematically.
RESULTS: Our study showed that intravenous droperidol worked faster and was more effective than intravenous lorazepam in inducing sedation in patients intoxicated with psychostimulants. In other studies the number of patients intoxicated with psychostimulants was too small or the patient population was not described in sufficient detail for any meaningful conclusions to be drawn.
CONCLUSION: So far, research has been so limited that it has not yet provided convincing evidence about the best medication to use in the treatment of aggressive patients intoxicated with psychostimulants.

[Clotiapine in the treatment of acutely agitated patients: hardly any evidence]. / Clotiapine als acute ingrijpmedicatie: nauwelijks wetenschappelijke onderbouwing.

BACKGROUND: In Flemish emergency psychiatry, clotiapine is still one of the options available for the treatment of agitation. However, there is a lack of evidence concerning the efficacy of this practice.
AIM: To find out whether there is sufficient evidence to justify the continued use of clotiapine in the treatment of agitation.
METHOD: On searching the literature systematically, we identified controlled trials of clotiapine.
RESULTS: The efficacy and safety of clotiapine were studied in two randomised controlled trials. Clotiapine (administered intramuscularly) was compared with zuclopenthixol acetate and lorazepam. Clotiapine was found to be just as efficient as the control treatments, causing fewer anticholinergic side-effects than zuclopenthixol but more extrapyramidal side-effects than lorazepam. The study population comprised only 102 patients, 51 of whom were treated with clotiapine. Because the quality of the reported data was low, straightforward conclusions were difficult to draw.
CONCLUSION: Scientific evidence to support the use of clotiapine in the treatment of agitation ranges from meagre to practically non-existent. Since alternative treatment options are available, the contained use of clotiapine should be questioned.

[Ethical advice regarding the relationship between psychiatrists and the pharmaceutical industry]. / Deontologisch advies inzake de omgang van psychiaters met de farmaceutische industrie.

BACKGROUND: The pharmaceutical industry is an important partner in mental health care. AIM: To provide ethical advice that will help psychiatrists build a balanced relationship with the pharmaceutical industry. METHOD: In this article we present the current advisory principles that have been developed by the Flemish Psychiatric Association (Vlaamse Vereniging voor Psychiatrie; VVP). RESULTS: Not only do we give general advice that is relevant for all psychiatrists, but we also give advice that is applicable specifically to the psychiatrist-researcher, teachers and psychiatric trainees. Finally, we explain more fully how the VVP, as an organisation, deals with these issues. CONCLUSION: It is important that the psychiatrists and the pharmaceutical industry deal with each other in a balanced and constructive manner, thereby stimulating progress in the field of psychiatry. For this purpose the VVP has formulated a number of ethical principles which, in our view, define the way in which psychiatrists should deal with the pharmaceutical industry.

[Alcohol-induced psychotic disorder: a systematic literature review]. / Psychotische stoornis door alcohol: een systematisch literatuuroverzicht.

BACKGROUND: From the second half of the 19th century eminent psychiatrists began referring to alcohol-induced psychotic disorder (AIPD) as a specific alcoholic psychosis. Over the last decades interest in AIPD seems to have declined: the last review dates form 1989. AIM: To review the recent literature on AIPD, revive interest in the disorder, evaluate the current scientific evidence and assess its clinical value. METHOD: We performed a Medline search based on the following terms: 'Psychoses, Alcoholic' [Mesh] OR 'alcohol induced psychotic disorder' OR 'alcoholic hallucinosis' OR 'alcohol hallucinosis'. Our search was restricted to articles written in English or Dutch and published between 1-1-1988 and 31-1-2013. RESULTS: We found 164 papers, from which we selected 21 for further discussion. The quality of the papers selected was variable, most of the papers being the result of clinical research. The most important findings referred to epidemiology: 0.4% lifetime prevalence in the general population, 4.0% in patients with alcohol dependence. We found only limited evidence of psychopathological differentiation between delirium and primary psychotic disorder. Correct diagnosis of AIPD is important because of the implications regarding the length and nature of the treatment: short or long course of antipsychotics, referral to a substance-abuse unit. CONCLUSION: AIPD has survived as a clinical entity. However, scientific evidence of this is limited. Further research is needed because it is vitally important that the patient receives the most appropriate treatment.

[Irreversible monoamine oxidase inhibitors (IMAOI) to treat depressive disorders - limited use at present in Flanders]. / Irreversibele monoamineoxidaseremmers bij depressieve stoornissen: snel afgenomen gebruik in Vlaanderen.

BACKGROUND: Irreversible monoamine oxidase inhibitors (imaoi) are rarely used in Flanders. Such an anti-imaoi policy is not in keeping with the role that imaoi now play in the general guidelines for the treatment of depressive disorders. AIM: To provide an overview of the history and the current use of imaoi in Flanders. METHOD: We searched the literature and the literature used in the psychiatric courses taught at Ghent University and the Catholic University of Leuven and we consulted the Acta (Neurologica et) Psychiatrica Belgica. The information we collected was supplemented by personal communications from experts and by data about the period of commercialisation, the pharmaceutical companies producing imaoi and the use of imaoi. RESULTS: imaoi were introduced rapidly onto the Flemish market but their popularity was short-lived. University courses did not give much attention to imaoi and the attitude to these inhibitors was negative. At the moment, phenelzine is the only imaoi available on the Flemish market and is only rarely prescribed. CONCLUSION: Following the international trend, imaoi in Flanders initially enjoyed a short period of popularity. However, the limited use of phenelzine at present is not in line with the current guidelines for the treatment of depressive disorders. Practitioners and health professionals need to be better informed. Better education and wider use of imaoi in Flanders are recommended.

[Droperidol for the treatment of acutely agitated patients: still an option]. / Droperidol in de behandeling van acute agitatie: nog steeds een plaats.

BACKGROUND: In Flemish emergency psychiatry droperidol is still an option for the treatment of agitation. However, its efficacy and safety are contested. AIM: To find out whether the continuing use of droperidol to treat agitation is justified on scientific grounds. METHOD: Randomised controlled trials of droperidol (intramuscular or intravenous) were traced via a systematic search of the literature. These data were supplemented with a description of the drug's most important pharmacological properties and a survey of the literature on cardiac side-effects and of the place accorded to droperidol in some guidelines. RESULTS: The efficacy and safety of droperidol (IM/IV) were studied in 8 randomised control-led trials: 352 patients treated with droperidol. Droperidol was compared with benzodiazepines, antipsychotics and combination treatment. A single injection of droperidol was successful in 64-92% of patients. Droperidol tended to act faster and be more effective than haloperidol and lorazepam. There were very few side-effects. No clinically important cardiac side-effects were reported; this is also in keeping with evidence revealed in systematic reviews on the subject. The ecological validity of the trials was high. CONCLUSION: In spite of a decline in the popularity of droperidol in most guidelines, the drug still seems to play a valuable role in the treatment of the agitated patient. Because it acts rapidly over a short period of time and is safe to use in patients with high (co)morbidity, it is still in favour with many health professionals.

[Is there a causal link between idiopathic intracranial hypertension and the use of lithium? A case-study and a review of the literature]. / Intracraniële hypertensie bij lithiumgebruik: gevalsbeschrijving en systematisch literatuuronderzoek.

BACKGROUND: The first case-study of idiopathic intracranial hypertension (IIH) linked to the use of lithium appeared in 1978. Since then several new case-studies have been published sporadically. A recurrent problem for therapists seems to be whether to continue or discontinue treatment with lithium. AIM: To review the literature on the alleged link between IIH and the use of lithium. METHOD: We performed a systematic review of published papers relating to the use of lithium in the treatment of IIH. RESULTS: We found 16 cases. The typical clinical picture of IIH was present in most of the cases. There was a large variation in the course of the illness. In many cases the nature of the link (coincidental or causal) remained unclear. Strong arguments in favour of a causal link were found in only two cases. CONCLUSIONS: IIH linked to the use of lithium is a very rare condition. In most cases it is not clear whether the link is coincidental or causal. If a patient being treated with lithium is definitely diagnosed with IIH and no other more plausible cause is found, then it is advisable to discontinue treatment with lithium. However, the therapist should feel free to re-start treatment with lithium in certain circumstances, for instance if patients have clearly benefited from lithium in previous maintenance treatment, if there is an unclear association between lithium and the onset and course of pseudotumour cerebri (PTC), or if the patient's condition has clearly deteriorated after lithium treatment has been discontinued.

[Teratogenic effects of lamotrigine in women with bipolar disorder]. / Teratogene effecten van lamotrigine bij vrouwen met een bipolaire stoornis.

BACKGROUND: There is some doubt whether medication for women who have bipolar disorder and are pregnant should be adjusted during pregnancy or following childbirth. It is possible that adjustment during pregnancy may damage the foetus. Lithium is hardly teratogenic, whereas carbamazepine and valproic acid are teratogenic. The anticonvulsant lamotrigine is also used regularly to treat or prevent bipolar depressive episodes. AIM: To provide an overview of the available literature concerning the prevention of congenital malformations following the use of lamotrigine (LMT) during pregnancy. METHOD: The Medline database was searched using the search terms: 'pregnancy register' and ('lamotrigine' [Substance name] or 'anticonvulsants'[MeSH]) . RESULTS: Ten studies and birth registers were selected which reported data concerning the use of LMT by women with epilepsy. There were no data concerning the use of LMT during the pregnancy of women with a bipolar disorder. The risk of a major congenital malformation (MCM) for LMT varied between 1 and 4.0%. CONCLUSION: There are no strong indications that the use of LMT during pregnancy results in an increased number of major congenital malformations.