Neuroleptic dosing and neuroleptic plasma levels in schizophrenia: determining the optimal regimen.

OBJECTIVE: To recommend dose range and therapeutic plasma concentration for several neuroleptics, and to discuss conditions under which neuroleptic plasma levels are clinically useful. METHOD: Neuroleptic drug therapy is a major component of the acute and maintenance treatment of schizophrenia. However, there is no consensus on what constitutes an appropriate or optimal dose of antipsychotic drug in individual patients. Low-dose medication has the potential to improve psychosocial function and reduces the frequency of side effects but can lead to an increase in positive symptoms and schizophrenic relapse. High doses may be associated with behavioural toxicity, symptom exacerbation, a worsening of secondary deficit symptoms, impaired social functioning and increased adverse effects such as acute extrapyramidal symptoms and tardive dyskinesia. Numerous clinical studies have attempted to determine the degree of correlation between dose, neuroleptic blood levels, and clinical response. RESULTS: To date, this approach has met with only limited success: neuroleptic dose overall appears to be a poor predictor of clinical outcome, and the suggested therapeutic plasma level concentrations of some antipsychotic drugs cannot be regarded as established by any means. Furthermore, the ability to conduct neuroleptic plasma levels is not readily accessible in the usual clinical setting. In the acute treatment phase, titrating the dose until the onset of minimal cogwheel rigidity or hypokinesia (neuroleptic threshold dose) has met with some success and is preferable to standard dosing as a means of individualizing pharmacotherapy. During the maintenance phase, a slow and gradual dosage reduction with adjunctive psychosocial and psychotherapeutic intervention is the preferred strategy. CONCLUSION: Reinforcing patient and physician compliance is a key element in achieving an optimal treatment regimen.

You drive me crazy: a case report of acute psychosis and neurocysticercosis.

Cysticercosis is a parasitic disease endemic in several developing countries where people consume raw or insufficiently cooked pork. The authors present a clinical picture of an organic psychosis in a 24 year old female with CNS cysticercosis. The neuroradiologic follow-up of this patient pre and post treatment with praziquantel is presented. The implications of this case with regard to the pathophysiology of schizophrenia and schizophrenia-like psychoses is discussed.

Vitamin E in the treatment of tardive dyskinesia: a double-blind placebo-controlled study.

The authors compared vitamin E with placebo in a double-blind randomized crossover study of 27 patients with tardive dyskinesia. Each treatment period lasted for 6 weeks. Vitamin E showed no differences from placebo in the treatment of tardive dyskinesia.

Tardive dyskinesia: legal and preventive aspects.

Tardive dyskinesia is a complication associated with long term neuroleptic drug treatment that can be the object of litigation. Such litigation has occurred recently in the United States, where awards of considerable value have been granted to plaintiffs. Circumstances that can lead to TD litigation are presented as well as guidelines for the prescription of neuroleptics, the prevention of litigation and of the syndrome itself. Five lawsuits associated with TD serve as a backdrop for the discussion.

[Tardive dyskinesia: a current review]. / Dyskinésie tardive: mise a jour.

Tardive Dyskinesia (TD) is a neurological syndrome associated with long-term use of antipsychotic drug treatment (APD). Its significant prevalence (estimated 15-20%) and potential irreversibility are a major concern in psychiatry. The clinical picture is characterized by involuntary repetitive movements of choreoathetotic and dystonic nature varying in location and intensity. The individual outcome of TD is unpredictable but recent long-term studies give reason for prudent optimism. All neuroleptics are involved in the disorder, numerous risk factors have been suggested; advancing age is the only one which has a clearly definite role. Even though several hypotheses have been suggested, the pathophysiology of the disorder remains a mystery. Informed consent is discussed in this update with regard to the legal implications of the disorder. Because of lack of effective treatment, prevention of TD is essential. The present treatment of choice is gradual reduction (and ideally discontinuance) of APD treatment when possible.