A review of compliance, depot intramuscular antipsychotics and the new long-acting injectable atypical antipsychotic risperidone in schizophrenia.

BACKGROUND: Several oral atypical antipsychotics are available for schizophrenia management. Besides positive and negative symptom control, they may improve cognition. Due to their limited availability as oral agents only, benefits are limited by noncompliance. METHODS: Using Medline and PsycINFO databases, literature was reviewed to address: (1) factors underlying medication noncompliance; (2) available evidence on efficacy of depot intramuscular (IM) typical antipsychotics; and (3) current knowledge of long-acting atypicals. RESULTS: Noncompliance remains high due to illness-, treatment-, and clinician-related factors. Compared to oral typicals, atypicals may improve compliance, even though noncompliance remains high. Depot IM typicals are efficacious (reduced relapses and rehospitalizations), but extrapyramidal symptoms are problematic. Available data on long-acting atypical risperidone suggest that it is safe and efficacious. CONCLUSION: Development of long-acting injectable atypical agents is warranted since noncompliance remains high. Future long-acting IM atypical trials should include outpatient functioning, and preferably be of longer duration to address cost-effectiveness.

Extrapyramidal symptoms related to adjunctive nizatidine therapy in an adolescent receiving quetiapine and paroxetine.

Weight gain is a serious problem with recently introduced atypical antipsychotic agents. Nizatidine, a histamine2 (H2)-receptor antagonist, may help reduce this weight gain. To our knowledge, no adverse effects have been reported when nizatidine is given at recommended doses with atypical antipyschotic agents. We describe, however, an adolescent who was receiving quetiapine and paroxetine for schizophrenia and depression, and developed extrapyramidal symptoms (EPS; parkinsonism and akathisia) after taking nizatidine for weight loss. Based on a report of another patient who developed EPS after taking higher-than-recommended doses of nizatidine, we reviewed the literature on treatment with H2-receptor antagonists for weight gain and on central nervous system adverse effects of nizatidine. Nizatidine may be effective for reducing weight gain associated with both medical and psychiatric conditions. Its safety profile is usually benign, although some patients may develop serious adverse effects, such as EPS and delirium. Therefore, the drug is recommended for short-term management of weight gain associated with atypical antipsychotic agents. Patients receiving nizatidine therapy should be monitored closely for development of EPS, particularly when high doses are prescribed.

Using the literature in developing McGill's guidelines for interactions between residents and the pharmaceutical industry.

Evidence suggests that the pharmaceutical industry exerts a large influence on residents' education and practice. Yet existing guidelines by professional bodies do not cover the specifics of residents' interactions with the pharmaceutical industry. At the psychiatry residency program of the McGill University Health Center, the authors set out to systematically evaluate areas of concern for residents and to develop guidelines for use by residents during and outside their training. Areas of concern included educational activities, training, fundraising, and other specific resident-industry interactions. In 1998, a committee of residents and faculty systematically evaluated areas of concern and, based on a review of the literature and discussions with experts, in 2000 developed guidelines for use by McGill's psychiatry program residents. The process for guideline development and methods for their implementation in 2001 are described. Education and training of residents on resident-industry interactions were included early in the curriculum. Guidelines were developed to address limitations on fundraising activities; restriction of direct gifts to residents; the appropriateness and awarding of industry fellowships; and the handling of drug samples, meals, and other presentations to residents. While guidelines for residents are useful adjuncts for guiding residents' interactions with the pharmaceutical industry, the authors conclude that they need to be reinforced with education and sensitization by faculty.

Psychiatric aspects of patients with hypothalamic hamartoma and epilepsy.

Uncontrolled rage, while long associated with hypothalamic hamartoma, has not been as extensively studied as the epilepsy. Rage can be more detrimental to quality of life than seizures. It is now realized that behavior and aggression improve after a complete resection of the hypothalamic hamartoma correlating with a good seizure control post-surgically. We report on the longitudinal psychiatric history of a patient with hypothalamic hamartoma and rage whose severe and refractory epilepsy was ultimately treated by thalamic and intrahamartoma chronic stimulation. Our patient did not exhibit sham rage typical of hypothalamic lesions, but rather multifactorial aggressive bouts typical of challenging behaviors seen with mental retardation. The anxious and social features of the aggression suggest that psychiatric interventions, which have been neglected as the emphasis has been on seizure control, are worthwhile in the overall management of this difficult case.

Persistent tardive rebound panic disorder, rebound anxiety and insomnia following paroxetine withdrawal: a review of rebound-withdrawal phenomena.

OBJECTIVE: To describe tardive rebound anxiety phenomena (panic, anxiety and insomnia) following abrupt paroxetine discontinuation. METHOD: Case report, with comprehensive literature review on rebound and withdrawal phenomena associated with psychotropic medications. RESULTS: Three different discontinuation syndromes with psychotropics are described: (1) new-onset CNS-depressant type withdrawal symptoms (minor and major); (2) rebound syndromes; and (3) supersensitivity symptoms. Abrupt paroxetine discontinuation has been well described and fits the first category. Tardive rebound panic disorder-phenomena with paroxetine has some features of the supersensitivity category. CONCLUSION: Chronic paroxetine treatment may lead to 5-HT2-receptor down regulation, with desensitization of 5-HT1A and 5-HT2 receptors, which may contribute to tardive rebound symptoms upon abrupt withdrawal. Early reports suggest that genetic factors may also contribute to withdrawal symptoms in susceptible individuals. Cholinergic rebound may also occur and could explain tardive insomnia and anxiety in paroxetine withdrawal.

Emergent complications following donepezil switchover to galantamine in three cases of dementia with Lewy bodies.

Delayed disease progression and symptomatic improvement occur with cholinesterase inhibitors (ChEIs) in dementia with Lewy bodies (DLB). In this study, complications (insomnia, dyskinesias, agitation, and delirium) occurred in three patients switched from donepezil to galantamine. The authors describe evidence-based recommendations for ChEI switchover in DLB.

Managing schizophrenia during the stable phase: is there consensus among practice guidelines?

METHOD: We performed a literature search using Medline and Psycinfo databases and Google Internet search engine. RESULTS: We identified 6 clinical practice guidelines (CPGs). All stress the need for antipsychotic therapy and psychosocial interventions. Differences lie in types of antipsychotics recommended, duration of antipsychotic trial, management of extrapyramidal symptoms, and types of psychosocial interventions. Areas poorly addressed by all guidelines include definition of the stable phase of schizophrenia, management of adverse effects with atypical agents, management of clozapine nonresponders, and management of personality issues. CONCLUSION: Published CPGs are helpful in the management of the stable phase of schizophrenia, although no single CPG series appears to address all treatment needs faced by practising clinicians.