Efficacy of lorazepam and haloperidol for rapid tranquilization in a psychiatric emergency room setting

The efficacy of a benzodiazepine was compared with that of a neuroleptic for the rapid tranquilization of patients presenting at a psychiatric emergency room service. Thirty-seven highly agitated patients exhibiting psychotic symptoms were randomly assigned to receive either 2 mg lorazepam or 5 mg haloperidol as needed every 30 min for 4 h. Administration route was either intramuscular injection or oral concentrate. Symptom ratings were conducted each hour using double-blind procedures. Both medications reduced symptom ratings on the Brief Psychiatric Rating Scale and Global Clinical Impression of Overall Symptom Severity Scale. Global Clinical Impression scores for the two medication groups did not differ significantly either at baseline or at 4 h after entry into the study. However, Global Clinical Impression scores of patients in the lorazepam group were less severe at intermittent ratings. The groups did not differ on the Brief Psychiatric Rating Scale at any rating time. No differences were found either in the number of doses administered or in the administration route selected. Given the potential for severe extrapyramidal symptoms developing hours or days after a single dose of haloperidol, lorazepam may provide an excellent alternative for the rapid tranquilization of the acutely agitated psychotic patient in the emergency room setting.

The effects of clozapine on symptom clusters in treatment-refractory patients

Preliminary results of a double-blind clozapine study in a population of chronic psychotic patients at a state psychiatric facility are reported. Thirty "treatment-refractory" schizophrenic patients given a diagnosis according to DSM-III-R criteria (mean age of 44 +/- 9.1 years and a duration of illness of 24.9 +/- 8.8 years) who received 300 mg or 600 mg of clozapine and randomized in a double-blind fashion were analyzed. Subjects were evaluated using the Brief Psychiatric Rating Scale (BPRS) and the Clinical Global Impression (CGI) Scale on a weekly basis for 16 weeks. Based on the changes in their CGI scores at week 16 of clozapine treatment, subjects were retrospectively categorized as "improvers" (N = 12) and "nonimprovers" (N = 18). The two groups were compared for changes in total BPRS and BPRS factor scores. In terms of total BPRS scores, we expected a difference between the two groups because they were categorized based on changes in their CGI scores. However, the total BPRS scores in improvers showed a significant decrease by week 6 of clozapine treatment. On analyzing the four BPRS factors, the improvers showed improvement in the thinking disturbance factor by week 1 that remained steady from week 7. On the hostility-suspiciousness factor, the improvers showed an improvement across time when compared with nonimprovers. The withdrawal-retardation factor showed improvement in both groups across time, whereas the anxiety-depression factor was least influenced by clozapine. These observations suggested that all BPRS symptom factors did not uniformly contribute to improvement in overall psychopathology, which was observed as a decrease in total BPRS scores.

A study of bedside screening procedures for cognitive deficits in chronic psychiatric inpatients

The Mini-Mental State Examination (MMSE) and the Trail Making Test, part B (TMT-B) were compared for screening cognitive deficits in a sample of 104 psychiatric inpatients at a long-term hospital. The TMT-B classified 84% of the patients as impaired. The classic MMSE cutoff score (< or = 23) using serial sevens and spelling classified 42% and 24% of the patients respectively, as impaired. The new MMSE cutoff classified 71% as impaired. Education, gender, and medication may influence impairment when using the MMSE classic cutoff scores. In TMT-B only, impairment was influenced by chronicity. The TMT-B was able to distinguish patients impaired in the MMSE. The TMT-B, therefore, may be more useful than the MMSE to screen for cognitive deficits in chronic psychiatric inpatients.

Polydipsia and water intoxication in a long-term psychiatric hospital

This cross-sectional survey attempts to establish the prevalence of polydipsia and water intoxication at a state hospital (N = 360) using staff diagnosis, specific gravity of the urine (SPGU), weight changes, and chart review. There were 150 [42%, 95% confidence interval (CI) 37-47%] patients diagnosed as polydipsic by the staff or by SPGU. At least 93 (26%, CI 21-30%) had primary polydipsia not explained by other causes. Chart review identified 17 (5%, CI 3-7%) patients with a history of water intoxication. Using a case-control study design, schizophrenia, extended duration of hospitalization, and heavy smoking were associated with primary polydipsia in a logistic regression analysis (respective odds ratios were 1.6, 1.8, and 3.6). All patients with a history of water intoxication were Caucasian (versus 83% in those without a history) and had significantly more extended hospitalizations (94 vs. 49%). Future case-control studies should combine longitudinal identification of true cases and controls and exhaustive collections of clinical information in a standardized way.

Diurnal and weekly variation of tardive dyskinesia measured by digital image processing

The diurnal and weekly variability of tardive dyskinesia (TD) was assessed instrumentally by digital image processing. Weekly assessments were obtained in ten patients over a 6-week period. In six of the ten patients, assessments were obtained four times over a single 12-h period. Results indicate that TD movements measured by instrumental assessment vary from week to week and throughout the day. Factors that appear to have affected the variability were changes in medications and the time of day when the assessments were conducted.

Clozapine withdrawal effects and receptor profiles of typical and atypical neuroleptics

Withdrawal effects of neuroleptics have not received much attention. Clozapine withdrawal phenomena have been attributed to psychosis arising from D2 supersensitivity, which is unlikely since it has minimal action on D2 receptors. The time course and clinical features of this phenomenon suggest that cholinergic overdrive and gamma-aminobutyric acid (GABA) supersensitivity occurs after withdrawal, since it is strongly anticholinergic and has a GABAergic action. Recently, a number of patients showed marked decompensation when they were switched from clozapine to risperidone, especially when they were rapidly tapered off clozapine. This was probably more due to withdrawal effects than the primary psychosis or a lack of efficacy of risperidone. A slow withdrawal schedule would facilitate homeostatic mechanisms; anticholinergics would be useful in clozapine withdrawal. This area has not received any attention from researchers, nor are there any guidelines for clinicians. This will be particularly important with the widespread use of atypical agents in the future.

Fluphenazine plasma levels, dosage, efficacy, and side effects

OBJECTIVE

The authors sought to determine whether fluphenazine dose or plasma level predicts clinical improvement or side effects during acute treatment.

METHOD

Oral fluphenazine was given in fixed, randomized, double-blind doses (10, 20, or 30 mg/day) for 4 weeks to 72 inpatients with acute schizophrenic exacerbations. Outcome measures included percentage improvement in ratings of positive symptoms (hallucinations, delusions, and thought disorder), percentage improvement in negative symptoms, and maximum score for extrapyramidal symptoms. Response was defined as an improvement in positive symptoms of 40% or more.

RESULTS

The 42 responders had a shorter duration of illness, less chronic course, and lower rate of akathisia. Plasma level and dose did not differentiate responders and nonresponders, but they did predict percentage improvement in positive symptoms within the responder subgroup. Akathisia was more common and extrapyramidal symptoms were more severe at higher plasma levels.

CONCLUSIONS

Responders showed the greatest improvement at fluphenazine plasma levels above 1.0 ng/ml and doses above 0.20-0.25 mg/kg per day. Since the literature suggests that optimal plasma levels are similar during acute and maintenance treatment, monitoring of plasma levels may thus be useful. Conditions for applying the "responder-only" analytic strategy in future studies are discussed.

Continuous infusion of clozapine increases mu and delta opioid receptors and proenkephalin mRNA in mouse brain

The biochemical mechanisms involved in the actions of the atypical antipsychotic clozapine are still unclear. Because elevated levels of enkephalin in certain areas of the central nervous system may be necessary for antipsychotic activity, we have examined the effect of clozapine on certain receptors and mRNA transcripts involved in the opioid peptidergic system. Clozapine was infused continuously into mice for 21 days and the density of mu and delta opioid receptors was measured in the brains by quantitative receptor autoradiography, and the level of proenkephalin mRNA and dopamine D1 and D2 receptor mRNA were measured by in situ hybridization histochemistry. The results showed that continuous infusion of clozapine increased the density of D1 but not D2 receptors. However, it failed to alter the levels of either D1 or D2 dopamine receptor mRNA. By contrast, clozapine increased the density of mu and delta opioid receptors and increased the levels of proenkephalin mRNA. These results indicate that continuous treatment with clozapine increases opioid peptidergic activity in mouse brain and suggest that alteration of peptidergic activity as well as alteration of dopaminergic activity may be involved in its antipsychotic action.

Treatment of polydipsia and hyponatremia in psychiatric patients. Can clozapine be a new option?

Polydipsia occurs frequently in chronic schizophrenic patients, some of whom develop intermittent hyponatremia. Most therapeutic efforts have tried to control the hyponatremia. Four schizophrenic patients, followed for more than one year, showed improvement on clozapine. Case 1 was an outpatient without history of hyponatremia who improved from polydipsia and psychosis. The last three were inpatients with polydipsia, intermittent hyponatremia, and psychosis who showed minimal improvement of psychosis but significant decrease in polydipsia and water intoxication. Case 2 relapsed to polydipsia when clozapine was discontinued on two occasions. Case 3 demonstrated polyuria during 39% of days before clozapine and in 0% of days after two weeks of clozapine. In case 4, most baseline sodium levels were abnormal, but all became normal after clozapine. A time-series analysis for intervention effects showed a significant effect of clozapine (p = .017). The limited information provided by these case reports suggest the need for controlled studies of the clozapine effect on polydipsic patients.

Misidentification syndromes in schizophrenia: case reviews with implications for classification and prevalence

Misidentification syndromes represent false, delusionally-based identification of self and/or others. These are variants of the Capgras Syndrome. Although the frequency of misidentification syndromes in schizophrenic populations has not yet been established, the authors believe this syndrome is more prevalent than previously described. Seven of twenty-five (28%) consecutive patients admitted to a chronic clozapine unit with a variant of misidentification syndrome will be described. Their symptoms are categorised according to traditional classification, and Silva's proposed nomenclature. Problems inherent in these classifications are discussed. The need for a more systematic classification of misidentification syndromes is emphasised. Longitudinal studies of misidentification syndrome, and the development of a standardised assessment tool for clinicians who treat chronically psychotic patients, are encouraged.

Schizophrenia and smoking: an epidemiological survey in a state hospital

OBJECTIVE

The authors sought to determine whether smoking is related to schizophrenia or neuroleptic treatment.

METHOD

Cigarette smoking was measured in all patients hospitalized at a state hospital (N = 360) and compared in relation to gender and diagnosis (schizophrenic versus nonschizophrenic).

RESULTS

The overall frequency of smoking was 79% (N = 284). Male schizophrenic patients had the highest frequency of smoking, followed by male nonschizophrenic patients, female schizophrenic patients, and female nonschizophrenic patients, respectively. Schizophrenia and polydipsia were associated with both smoking and heavy smoking.

CONCLUSIONS

After correction for other variables, schizophrenia appears to increase the risk of being both a smoker and a heavy smoker. There was a possible association between high doses of neuroleptics and smoking but only for nonschizophrenic patients.

Oral tardive dyskinesia: validation of a measuring device using digital image processing

The present study was performed to investigate the reliability and validity of a new device for the assessment of oral dyskinesias by means of digital image processing. Twenty schizophrenic patients with tardive dyskinesia (TD) and ten healthy controls were studied. In patients instrumental scores were compared to different clinical rating scale scores. Measurements were repeated after 2 weeks under the same circumstances to assess test-retest stability. Instrumental scores discriminated well between normal subjects and dyskinetic patients and correlated significantly with clinical ratings (r = 0.63). The test-retest correlations showed a correspondence not larger than 40%, detecting thus the fluctuation of the TD intensity over time. These results suggest that our device is a reliable and easy to handle technique for the assessment of TD. Furthermore, the ability of the device to analyze the frequency distribution of movements makes it a useful tool for the quantitative and qualitative analysis of TD.

Polydipsia and water intoxication in psychiatric patients: a review of the epidemiological literature

Polydipsia among chronic psychiatric patients is poorly understood and underdiagnosed. It may have three stages: simple polydipsia, polydipsia with water intoxication, and physical complications. Epidemiological surveys have used staff reports and polyuria measures to identify polydipsic patients. Water intoxication has been screened by chart review, weight, or serum sodium data. According to these surveys, polydipsia, not explained by medically induced polyuria, may be present in more than 20% of chronic inpatients. Up to 5% of chronic inpatients had episodes of water intoxication although mild cases may have been missed. Single time point surveys show that 29% of polydipsic patients had presented water intoxication. Methodologically limited clinical studies suggest that polydipsia with water intoxication rather than simple polydipsia may be associated with poor prognosis in schizophrenia. Epidemiological surveys found polydipsia with water intoxication to be associated with chronicity, schizophrenia, smoking, some medications, male gender, and white race. New pathophysiological models need to elucidate these findings.

Germination response to phytochrome depends on specific dormancy states in wild oat (Avena fatua)

Effects of brief red and far-red light on germination of seeds from dormant lines of wild oat (Avena fatua L.) were studied in combination with mechanical injury to the seed coat, application of gibberellin A3, or changes in relative humidity during afterripening. Aberrant germination responses to phytochrome action were observed in the mechanically injured seeds in some of the lines, i.e., brief red light inhibited or delayed germination induced by injury, and immediately following far-red light cancelled the negative effects. Phytochrome action influenced germination of the gibberellin-treated seeds in a normal fashion, although effects of the gibberellic acid and brief red light on germination were not additive. Brief red light inhibited germination of seeds afterripened in zero relative humidity; the same light promoted germination of those in 30 and 60% relative humidity. Germination response to phytochrome in wild oat depends on specific seed dormancy states, illustrated by genetic origins, dormancy-breaking methods and afterripening conditions. Key words: Avena fatua, dormancy, mechanical injury, gibberellin A3, phytochrome, relative humidity.

The test-retest reliability of the Mini-Mental State Examination in chronic schizophrenic patients

The test-retest reliability of the Mini-Mental State Examination (MMSE) was explored in a sample of 22 inpatients suffering from chronic schizophrenia by DSM-III-R criteria. Patients were tested 4 times during a period of 4-6 weeks. The total score for serial sevens showed consistently significant reliability at about 0.7, and the total score for spelling displayed a lower reliability at about 0.4, which was of borderline significance. In this short period of time, 36% and 27% of the patients shifted between being demented and nondemented when the serial sevens and spelling, respectively, were used to calculate total scores. The MMSE should not be used to categorize schizophrenics as demented or nondemented in biological studies using relatively stable variables.