Valproic Acid Induced Hyperammonemia in a Long Time Treated Patient.

We report a case of a patient who had been on long time valproic acid for treatment of bipolar affective disorder. While being an inpatient, serology ammonia level testing revealed a very high ammonia level despite being asymptomatic. Dual therapy of carnitine and lactulose was provided to the patient for treatment of the hyperammonemia. It should also be noted that, during this treatment, valproic acid was not stopped. Consequently, this case illustrates that patients can present asymptomatically despite very high ammonia levels and hyperammonemia can occur in chronic valproic acid despite not increasing the dose of the medication and psychiatrists do not need to discontinue valproic acid in the presence of elevated levels of ammonia if the patient shows no signs of encephalopathy or delirium.

Report on ISCTM Consensus Meeting on Clinical Assessment of Response to Treatment of Cognitive Impairment in Schizophrenia.

If treatments for cognitive impairment are to be utilized successfully, clinicians must be able to determine whether they are effective and which patients should receive them. In order to develop consensus on these issues, the International Society for CNS Clinical Trials and Methodology (ISCTM) held a meeting of experts on March 20, 2014, in Washington, DC. Consensus was reached on several important issues. Cognitive impairment and functional disability were viewed as equally important treatment targets. The group supported the notion that sufficient data are not available to exclude patients from available treatments on the basis of age, severity of cognitive impairment, severity of positive symptoms, or the potential to benefit functionally from treatment. The group reached consensus that cognitive remediation is likely to provide substantial benefits in combination with procognitive medications, although a substantial minority believed that medications can be administered without nonpharmacological therapy. There was little consensus on the best methods for assessing cognitive change in clinical practice. Some participants supported the view that performance-based measures are essential for measurement of cognitive change; others pointed to their cost and time requirements as evidence of impracticality. Interview-based measures of cognitive and functional change were viewed as more practical, but lacking validity without informant involvement or frequent contact from clinicians. The lack of consensus on assessment methods was viewed as attributable to differences in experience and education among key stakeholders and significant gaps in available empirical data. Research on the reliability, validity, sensitivity, and practicality of competing methods will facilitate consensus.

Aripiprazole for the treatment of schizophrenia with co-occurring social anxiety: an open-label cross-taper study.

OBJECTIVES: Co-occurring social anxiety in patients with schizophrenia is common and often severe. Pharmacologic agents with serotonin receptor 1A agonist properties such as aripiprazole are believed to be effective anxiolytic drugs. This open-label study tested the hypothesis that a switchover to aripiprazole would reduce the severity of social anxiety in patients, who have schizophrenia with co-occurring social anxiety, treated with neuroleptic medications. STUDY DESIGN: Eligible consenting outpatients meeting the criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, for schizophrenia or schizoaffective disorder with co-occurring social anxiety symptoms completed baseline assessments, after which their neuroleptic medication was gradually cross-titrated over to a maximum of 30 mg of aripiprazole orally per day. Patients who completed the 2-month short-term study had the option to continue for 10 more months in the extension phase of the study. Complete baseline assessments were performed after 1, 2, 4, 6, 9, and 12 months. The study hypothesized that a switchover to aripiprazole would significantly improve social anxiety symptoms and quality of life ratings in the short term and that treatment continuation would help maintain and strengthen those effects, as assessed on the Liebowitz Social Anxiety and Sheehan Disability scales and on preselected specific global items of the Lehman Quality of Life Interview. RESULTS: Sixteen patients were enrolled in the short-term study, and 10 of them entered the extension phase study. Last observation carried forward analysis showed significant improvements from baseline to the end of month 2 and from baseline to the end of month 12 in social anxiety scores (Liebowitz Social Anxiety Scale total, avoidance, and anxiety), social disability scores (Sheehan Disability Scale total, work, social life, and family), and in the Lehman Quality of Life Interview overall function, average life in general, and emotional well-being scores and psychosis (Positive and Negative Syndrome Scale total) scores. CONCLUSIONS: These findings suggest that the switchover to aripiprazole effectively improved social anxiety, psychosis, and quality of life in patients with schizophrenia who were treated with neuroleptic medications. These improvements occurred within the first 8 weeks of treatment and persisted when treatment was continued for up to 1 year. Further studies are warranted to replicate these findings in controlled trials.