Should intramuscular clozapine be adopted into mainstream clinical practice?

Clozapine is under-used in the UK, and Casetta et al's recent paper in the BJPsych adds to a growing number of small studies that support the use of intramuscular clozapine to initiate and maintain treatment with oral clozapine. However, intramuscular clozapine remains unlicensed and, because of the risks associated with its administration, it should be used only cautiously before it can be adopted more widely into mainstream clinical practice.

Evidence-based consensus guidelines for the management of catatonia: Recommendations from the British Association for Psychopharmacology.

The British Association for Psychopharmacology developed an evidence-based consensus guideline on the management of catatonia. A group of international experts from a wide range of disciplines was assembled. Evidence was gathered from existing systematic reviews and the primary literature. Recommendations were made on the basis of this evidence and were graded in terms of their strength. The guideline initially covers the diagnosis, aetiology, clinical features and descriptive epidemiology of catatonia. Clinical assessments, including history, physical examination and investigations are then considered. Treatment with benzodiazepines, electroconvulsive therapy and other pharmacological and neuromodulatory therapies is covered. Special regard is given to periodic catatonia, malignant catatonia, neuroleptic malignant syndrome and antipsychotic-induced catatonia. There is attention to the needs of particular groups, namely children and adolescents, older adults, women in the perinatal period, people with autism spectrum disorder and those with certain medical conditions. Clinical trials were uncommon, and the recommendations in this guideline are mainly informed by small observational studies, case series and case reports, which highlights the need for randomised controlled trials and prospective cohort studies in this area.

Hyperprolactinemia and delusion of pregnancy.

We describe the case of a 44-year-old woman admitted with mania with psychotic symptoms who presented with delusion of twin pregnancy a month after admission, which temporally correlated with hyperprolactinemia secondary to antipsychotic medication. Modification of antipsychotic medication was associated with fall in serum prolactin and disappearance of delusion of pregnancy. In light of this clinically striking temporal association between hyperprolactinemia and delusion of pregnancy, we review the literature to examine the hypothetical relationship. We highlight the clinical significance of examining the various factors, including antipsychotic-induced hyperprolactinemia, which could trigger the development of delusion of pregnancy.

Musical obsessions: a comprehensive review of neglected clinical phenomena.

Intrusive musical imagery (IMI) consists of involuntarily recalled, short, looping fragments of melodies. Musical obsessions are distressing, impairing forms of IMI that merit investigation in their own right and, more generally, research into these phenomena may broaden our understanding of obsessive-compulsive disorder (OCD), which is phenomenologically and etiologically heterogeneous. We present the first comprehensive review of musical obsessions, based on the largest set of case descriptions ever assembled (N=96). Characteristics of musical obsessions are described and compared with normal IMI, musical hallucinations, and visual obsessional imagery. Assessment, differential diagnosis, comorbidity, etiologic hypotheses, and treatments are described. Musical obsessions may be under-diagnosed because they are not adequately assessed by current measures of OCD. Musical obsessions have been misdiagnosed as psychotic phenomena, which has led to ineffective treatment. Accurate diagnosis is important for appropriate treatment. Musical obsessions may respond to treatments that are not recommended for prototypic OCD symptoms.

Antipsychotic-induced hyperprolactinemia and delusion of pregnancy.

The authors describe 12 patients with antipsychotic-induced hyperprolactinemia. Six patients had erroneous ideas of being pregnant (four delusional and two non-delusional) temporally associated with hyperprolactinemia and resolving as prolactin levels returned to normal. The remaining six patients did not develop such ideas. Contrasting the clinical features of the two groups of patients in the context of existing literature informs on the possible biological and cognitive mechanisms that can be hypothesized to underlie the relationship between hyperprolactinemia due to antipsychotics and the development of inaccurate beliefs and feelings about pregnancy, and the effect of current mental state on the propensity to develop these beliefs.

Katatonia: a new conceptual understanding of catatonia and a new rating scale.

MODERN PSYCHIATRIC NOSOLOGIES SEPARATE CATATONIA ALONG THE LINES OF PRESUMED ETIOLOGY: bipolar, major depression, schizophrenia, and/or due to a general medical condition. Catatonic signs have always possessed significant diagnostic, therapeutic, and prognostic value. Kahlbaum's description of this syndrome in his monograph "Katatonia" included careful documentation of phenomenology. Kahlbaum selected the term katatonia to describe "tension insanity." He felt that the neuromotor signs were more important than the content of delusions (e.g. megalomania). While he felt that he was describing a unitary illness, he did identify mood disturbance, psychosis, and medical factors in this new illness.(1) In modern times, the term catatonia has become limited to describe a specifier of neuropsychiatric illnesses.The authors of this article feel that the term katatonia should be used to describe a group of neuropsychiatric illnesses presenting with catatonic signs. This may prevent the misconception that "catatonia is schizophrenia" and improve the detection of katatonia in patients. Specifically, katatonia is also observed in mood disorders, general medical conditions, and pervasive developmental disorders. The literature also supports the view of Dr. Leo Kanner and his description for neuromotor and neuropsychiatric signs in autistic disorder. This scale is named in honor of Dr. Kanner. It was developed by the authors and includes some of Dr. Kanner's core concepts. This paper will identify the clinical features of katatonia and introduce the KANNER scale (see Appendix 1) to improve conceptualization, detection, and measurement of this important clinical syndrome.

The detection and measurement of catatonia.

Catatonia is a complex neuropsychiatric syndrome that occurs with primary psychiatric disorders or secondary to general medical conditions. Catatonia is often neglected when screening and examining psychiatric patients. Undiagnosed catatonia can increase morbidity and mortality, illustrating the need to effectively screen patients for presence of catatonia as well as their response to treatment. There are many barriers to the diagnosis of catatonia that may explain the low rates of diagnosis in modern psychiatry. This article will review the many barriers that exist in the detection, recognition, and diagnosis of catatonia. Various criteria and rating scales have been applied to catatonia. The lack of precise definitions and validity of catatonia has hindered the detection of catatonia, thus delaying diagnosis and appropriate treatment. This review article will illustrate the need for a new rating scale to screen and detect catatonia as it occurs in a variety of healthcare settings. This article will also review the characteristics such a scale should possess to produce a quality instrument to aid in the appropriate care of the catatonic patient.

Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes.

Catatonia is a common neuropsychiatric syndrome which may arise from GABA-A hypoactivity, dopamine (D2) hypoactivity,and possibly glutamate NMDA hyperactivity. Amantadine and memantine have been reported as effective treatments for catatonia in selected cases, and probably mediate the presence of catatonic signs and symptoms through complex pathways involving glutamate antagonism. The authors identified 25 cases of catatonia treated with either agent. This article provides indirect evidence that glutamate antagonists may improve catatonic signs in some patients who fail to respond to established treatment, including lorazepam or electroconvulsive therapy. Further study of glutamate antagonists in the treatment of catatonia is needed.