Guideline for the pharmacotherapy of treatment-resistant schizophrenia. Royal College of Psychiatrists of Thailand.

The authors proposed to develop an evidence-based guideline relevant to drug use for treatment-resistant schizophrenia (TRS), which will be called "Guideline for the Pharmacotherapy of Treatment-Resistant Schizophrenia or PTRS Guideline". The authors performed a MEDLINE search (between 1966 and December 1998) and classified the study designs of those trials by using the system proposed by the Agency for Health Care Policy and Research (AHCPR). The levels of evidence were graded and recommendations were made by the use of a system modified from that of the AHCPR. One hundred and sixty-three articles met the inclusion criteria for the review. For a schizophrenic patient who does not respond to a classical antipsychotic, physicians should switch from the first classical antipsychotic to the second one, which belongs to a different class. A schizophrenic patient who does not respond to at least two adequate trials of classical antipsychotics should be classified as a TRS patient. Clozapine should be considered as a first-line treatment for TRS. Risperidone should be considered in a TRS patient who refuses to have regular blood monitoring or has contraindication for clozapine. Physicians should use this guideline to accompany others that suggest the overview of treatment for schizophrenia. Appropriate application and the limitations of the guideline are also discussed.

Severe catatonia and neuroleptic malignant syndrome: report of 3 cases.

Catatonia is a syndrome characterized by motor rigidity or stupor, negativism, mutism and inappropriate or bizarre posture. Without proper management, patients may have significant morbidity and mortality from stupor, coma and death (lethal or malignant catatonia). Neuroleptic malignant syndrome (NMS) is characterized by a sudden appearance of motor rigidity, fever, autonomic effect, increased white blood cell count, serum creatinine phosphokinase, liver enzymes, and myoglobin. The mortality rate is 15 per cent to 25 per cent or even higher when depot form of neuroleptic is used. We report a patient with severe catatonia and two cases of NMS. Death was encountered with one of the latter.

Erotomania in Thai patients: a study of 20 cases.

The study presented included 20 Thai erotomanic patients, 16 women and 4 men. The age at the onset of delusion ranged from 15 to 45 years with a median age of 23 years. The majority of the patients suffered from secondary erotomania, whereas, primary erotomania was diagnosed in three cases. Bipolar affective disorder represents the most common diagnosis associated with this delusion, followed by schizoaffective disorders. Two patients were sisters. The occurrence of intrafamilial cases is unusual and has not been reported previously. Most love objects are of the opposite gender. Only in one instance, was erotomania found in a lesbian context. Teachers and medical doctors are at increased risk for attracting individuals prone to erotomania.

Drug-induced akathisia and suicidal tendencies in psychotic patients.

Five patients, while being treated with high potency antipsychotic drugs developed akathisia and tended towards committing suicide as a consequence of the inner agitation and restlessness they were suffering. Upon discontinuation of the respective medication or switching to low potency drugs, as well as addition of anti-parkinson drugs or benzodiazepines, the akathisia and suicidal tendencies abated. Clinicians ought to be aware of suicidal impulses emerging in patients suffering from akathisia. By prompt recognition and treatment of akathisia such suicidal tendencies and attempts can be prevented.

Health-related self-report (HRSR) scale: the diagnostic screening test for depression in Thai population.

In this study we introduced a health-related self-report (HRSR) diagnostic scale for detecting depression in Thai population. The scale composed of 20 symptom items including two objective signs (people said I look worried or sad) and previous suicidal attempt both of which were helpful in detecting and confirming depression and suicidal risk. There were 3 positive items (feel well, life is pleasant and meaningful and feel self-worth) which clearly distinguished normal subjects and depressed patients. The reliability coefficient (Chronbach's alpha) of the HRSR scale was 0.91 and was found to possess a clear factorial structure and clinical validity. The cut-off score at 30 gave 90.2 per cent specificity and 85.3 per cent sensitivity for major depression. Score > or = 25 provided higher specify (93.4%) but lower sensitivity (75.1%) and could detect probable cases of depression or other mental illnesses in the community. Thus it can be used as a diagnostic screening instrument.

Localized necrotizing arteritis of the central nervous system.

We describe a case of necrotizing arteritis of the brain in a 26-year-old man who presented as organic brain syndrome. The lesion has been confused clinically with acute encephalitis. At necropsy, no other abnormalities suggestive of systemic arteritis were found. Such CNS-restricted necrotizing arteritis of medium and small arteries in the absence of granuloma is extremely uncommon.

Reversible delirium after discontinuation of fluoxetine.

An elderly patient developed confusion, disorientation and visual hallucination twice following discontinuation of fluoxetine. The mental symptoms, however, disappeared after ingestion of this antidepressant drug. Such an apparent withdrawal complication of fluoxetine has not been reported previously.

Encephalitis presenting as schizophreniform disorder and dysphagia.

We report a case of encephalitis in a 32-year-old woman who initially developed a schizophreniform disorder. The symptoms were further complicated by abnormal movements, dysphagia, progressive weight loss, and aspiration pneumonia. At necropsy, the lesion was noted in various parts of cerebrum and brainstem. Such unusual presentation in patient with encephalitis appears unique and has not been previously reported.

Death following intentional overdose of psychotropic drugs.

A case of successful suicide from overdose of amitriptyline, perphenazine, and midazolam is described. Postmortem findings were inadequate to explain the death. Sudden cardiac arrest suggested that the death from overdose probably resulted from drug cardiotoxicity. The physicians should be aware of this serious complication when prescribing a combination of these potential lethal drugs. A limited supply should be given to depressed patients.