A multicenter double-blind trial of paroxetine versus amitriptyline in depressed inpatients

The phenylpiperidine derivative paroxetine is a selective serotonin reuptake inhibitor. In a double-blind 6-week trial, paroxetine was compared with amitriptyline in hospitalized patients suffering from major depression (DSM-III). One hundred fifty-three patients were enrolled in the study in seven centers in Austria and Germany. Results showed similar efficacy of both drugs after 6 weeks. The differences between groups in Montgomery-Asberg Depression Rating Scale and Clinical Global Impression ratings did not reach statistical significance at any time. Side effects were distributed similarly but with a significantly higher incidence of anticholinergic effects in patients treated with amitriptyline (p < or = 0.001), whereas agitation and insomnia were registered more often in the paroxetine group. This study supports the antidepressive efficacy of paroxetine in a sample of severely depressed inpatients.

Negative symptoms in schizophrenia: considerations for clinical trials. Working group on negative symptoms in schizophrenia

There is little agreement about the methodology of clinical trials of antipsychotic drugs in patients with negative symptoms. A literature review revealed wide variation in experimental design, rating scales and study duration. This reflects differing views as to the definition and response to treatment of negative symptoms. Some degree of standardization would improve comparability of studies and aid the development of new compounds. Patients included in such studies should have displayed negative symptoms for at least 6 months. Depressive symptoms, positive schizophrenic symptoms and extrapyramidal signs may all influence or be confused with negative symptoms and may respond to treatment; they should be at a low level at baseline and should be measured during the study period. Studies should last at least 8 weeks. Several scales are available for measuring negative symptoms and are reviewed; a global impression score should be used additionally.

Carbamazepine in the prophylaxis of major depression: a 5-year follow-up

BACKGROUND

The prophylaxis of unipolar depression is still controversial. Some physicians prefer lithium, others maintenance treatment with antidepressants. The role of carbamazepine remains unclear. Only a few patients have been described in the literature; most are lithium nonresponders or rapid cyclers.

METHODS

In an open-label naturalistic study, 15 patients suffering from major depression with melancholia (DSM-III, 296.2, 296.3) and receiving long-term prophylaxis with carbamazepine were followed for 5 years. Four had been pretreated with lithium without satisfactory effects, 11 were prophylaxis naive. We compared the number of depressive episodes before and during carbamazepine treatment.

RESULTS

The mean time span patients received carbamazepine was 49.5 months. Seventy-three percent (11 of 15) of the patients gained substantial benefit from carbamazepine. Side effects were infrequent.

CONCLUSION

Our results encourage further controlled and prospective studies using carbamazepine for maintenance treatment of patients with unipolar major mood disorder.

EEG alterations in patients treated with clozapine in relation to plasma levels

It is well known that psychotropic drugs can induce EEG alterations. Dose dependence seems established; however, there are no data concerning the impact of plasma levels. The authors investigated the influence of clozapine plasma levels on the frequency of EEG alterations. Data from 29 inpatients (18 male, 11 female, 31.7 +/- 10.2 years) receiving clozapine in a dose range between 25 and 600 mg were collected prospectively. There was no psychotropic or anticholinergic comedication. All patients had normal EEGs before taking clozapine. Fifteen patients showed pathological changes (group 2) and 14 no changes (group 1). Discriminant analysis showed that EEG changes are dependent on plasma levels (P = 0.0009, plasma levels in group 1 mean 81.6 ng/ml, +/- SD 64.6, in group 2 235.7 ng/ml, +/- 169.8). A total of 72.4% of the patients were correctly classified as having either pathological EEG changes or none by this analysis. Variables such as dose, age, sex, weight and duration of treatment were not statistically relevant. It can therefore be suggested that clozapine plasma levels are a valid indicator for the appearance of electrophysiological reactions.

Antipsychotic maintenance treatment of schizophrenia patients: is there a consensus?

We obtained pharmaco-epidemiologic data regarding the antipsychotic maintenance treatment (AMT) of schizophrenia patients through a postal survey sent to all Austrian psychiatrists and neurologists. Drug therapy was considered the most important therapeutic approach in the long-term management of schizophrenia. However, the majority of the respondents clearly were not satisfied with the current status of scientific knowledge about dosage and duration of AMT. Single-drug treatment with antipsychotics was preferred by the respondents; oral and depot neuroleptics were used with equal frequency. Haloperidol was the oral drug most frequently mentioned as first choice (44% of the respondents), followed by clozapine (14.1%) and thioridazine (9.2%). The proposed mean daily doses showed striking variations among respondents. The proposed mean length of maintenance treatment in first-episode patients was 7.3 months; in multi-episode patients, it was 20.1 months. The results show considerable variation in physicians' attitudes toward AMT.

The effect of activation procedures on neuroleptic-induced akathisia

Two studies have been performed to evaluate the effect of activation tasks on neuroleptic-induced akathisia (NIA). In the first sample (30 patients) we found a consistent increase of symptoms during mental activation while motor activation led to a decrease. In a second study 34 patients with the same diagnosis were evaluated, using slightly different statistical procedures: while the effects of motor activation were corroborated, mental activation did not change NIA. Since mental and motor activation are usually considered to increase tardive dyskinesia and Parkinsonism, these measures might be helpful in differentiating NIA from other antipsychotic-induced movement disorders.

Effects of clozapine on hematopoiesis and the cytokine system

Using a bioassay for hematopoietic progenitor cells we looked for mechanisms causing clozapine induced neutropenia and agranulocytosis. Micro-agar-cultures of normal peripheral blood mononuclear cells (MNC) of eight patients currently treated with clozapine and of eight probands not receiving any kind of pharmacological treatment were incubated with increasing concentrations of clozapine (0, 7.5, 15, 30 micrograms/ml). Erythropoiesis and megakaryopoiesis were totally unaffected by clozapine. A biologically relevant suppression of granulopoiesis (CFU-GM) could only be shown in cultures incubated with 30 micrograms/ml clozapine. Cytokine analysis presented a strictly dose-dependent suppression of GM-CSF and neopterin release in all cultures. There was no difference between patients and controls at any clozapine concentration. The data support a possible role for cytokines as one mediator of the agranulocytosis producing effects of clozapine.

[Clozapine in long-term treatment of schizophrenic patients]

Clozapine has advantages over standard antipsychotics in refractory schizophrenia. Studies on the efficacy of clozapine in the maintenance treatment are sparse and suffer from methodological limitations. Despite this fact clozapine ranked second in a survey dealing with the preference of this antipsychotic in the long-term treatment of schizophrenia. Doctors report on using a mean of 130 mg/d in this indication which is considerably less than the doses used in most of the published long-term trials. The discrepancy between the popularity of clozapine and the lack of sound empirical data on its long-term efficacy is discussed.

Intravenous flunitrazepam in the treatment of alcohol withdrawal delirium

Alcohol withdrawal delirium (AWD) requires treatment with an adequate sedative, anticonvulsant, and antipsychotic agent next to general intensive care measures. Optimal medication should have a rapid onset of action and the possibility of parenteral application. A specific antagonist should be available. Flunitrazepam is a benzodiazepine that fulfills all these criteria. Twenty five patients suffering from AWD (mean age 45 years) took part in an open trial and underwent treatment with infusions of flunitrazepam (concentration: 8 mg/250 ml NaCl; speed, 250 ml/hr). Psychopathological, vegetative, and vital parameters were assessed every hour. All patients survived. They were treated with a mean total dose (SD) of 83.9 (45.4) mg of flunitrazepam (1.3 mg/kg body weight), which induced sedation 13.2 (5.3) min after the initiation of intravenous treatment. The mean duration of AWD (85.1 +/- 39.4 hr) corresponded to other studies, whereas the frequency of preexisting and concomitant diseases was higher (92%) in our patients. A patient who suffered from bronchitis and had a nasopharyngeal tamponade showed severe respiratory depression after having received 4 mg of flunitrazepam. This complication remitted immediately when 0.5 mg of flumazenil was given intravenously. No epileptic manifestation was observed during the treatment or after discontinuation of flunitrazepam. Vegetative and psychopathological symptoms (tremor, sweating, hallucinations, confusion, and restlessness) remitted rapidly. Our data suggest that intravenous flunitrazepam can be an efficacious and safe alternative to traditional treatment strategies of AWD.

Localized proton and phosphorus magnetic resonance spectroscopy following electroconvulsive therapy

Animal studies show that cerebral lactate increases after electrically induced seizures. We investigated three adult psychiatric patients by means of localized proton and phosphorous magnetic resonance spectroscopy in order to evaluate if such effects can be observed after electroconvulsive therapy (ECT). None of the patients had changes in cerebral energy metabolism following ECT. Within the limitations of in-vivo spectroscopy in a clinical setting, our results suggest that if lactate production increases after ECT, this effect is either very short or increased perfusion causes an efficient efflux of cerebral lactate.

The role of carbamazepine in the prophylaxis of unipolar depression

The prophylaxis of unipolar depression is still a controversial subject. Some authors prefer lithium, others maintenance treatment with antidepressants. The role of carbamazepine remains unclear. Few patients have been described in the literature, and most are lithium nonresponders or rapid cyclers. In an open-label naturalistic study, 15 patients suffering from unipolar depression (DSM-III, 296.2, 296.3) and receiving long-term prophylaxis with carbamazepine were followed for 5 years. Four had been pretreated with lithium without satisfactory effects, 11 were prophylaxis naive. The mean time span patients received carbamazepine was 49.5 months. 73% of the patients gained substantial profit from carbamazepine. Side effects were infrequent.

Are patterns of benzodiazepine use predictable? A follow-up study of benzodiazepine users

A sample of 171 patients taking benzodiazepines (BZDs) who had been investigated in 1988 was followed up in 1991. From 140 patients who were still alive and willing to participate, 25% had stopped BZDs after an average duration of intake of 34 months. Of the 105 persons still taking a BZD, 37% were taking the same dose, 26% had reduced the dose and 37% had increased it. Characteristics of BZD long-term users and patients potentially at risk for abuse and/or dependence that were established from the 1988 data were reexamined: patients with continued BZD use more often suffered from somatic illness which often had deteriorated, they had a longer duration of intake and used higher daily doses. In most cases the indication was insomnia. Patients with a clinically relevant dose increase were more often males, frequently found to be dependent on alcohol and/or illegal drugs.

Benzodiazepines and other psychotropic drugs abused by patients in a methadone maintenance program: familiarity and preference

Physicians often face the problem that they have to treat anxiety and insomnia in patients who are dependent on narcotics or other substances. Reports about different reinforcing properties of different benzodiazepines and increasing concern about their misuse, often in combination with other drugs, call for studies that help to establish recommendations for choosing psychopharmacologic agents in the treatment of these patients. Opiate addicts enrolled in a methadone maintenance program were interviewed about their subjective "liking" of all psychotropic substances with which they had personal experience. The results confirm previous reports that certain benzodiazepines, especially flunitrazepam and diazepam, stand out from others in terms of positive reinforcing properties. Overall, the attractiveness of benzodiazepines as drugs of abuse for poly-drug abusers is lower than that of other sedative/hypnotics.

The effects of alcohol and benzodiazepines on the severity of ski accidents

Urine samples from 402 victims of ski accidents were analyzed for the presence of benzodiazepines (BZD) and alcohol. Eighty-one (20%) samples were positive for alcohol; BZD were detected in 34 (8.5%) cases. Ten of the samples (2.5%) were found to be positive for both alcohol and BZD. Subjects who were positive for either alcohol or BZD or both were older than the other persons examined. The prevalence of alcohol was significantly higher among male accident victims. BZD intake could be demonstrated to have a significant influence on the severity of injuries. Besides an increased awareness of the need for skier education regarding drug use, heightened attention of medical caregivers is warranted to inform their patients about potential accident hazards in sport activities when BZD are prescribed.

Granulocyte-macrophage colony-stimulating factor (GM-CSF) treatment of clozapine-induced agranulocytosis: a case report

BACKGROUND

Granulocytopenia and agranulocytosis are severe side effects of clozapine therapy. Even if these side effects are detected early and if clozapine is discontinued, patients suffering from agranulocytosis are extremely endangered by infectious diseases for up to 3 to 4 weeks until hematologic recovery. Therefore, any treatment that reduces this critical time span would decrease the risks of clozapine treatment.

METHOD

The case of a patient in whom severe agranulocytosis developed after 7 weeks of clozapine treatment is presented.

RESULTS

After clozapine discontinuation, treatment with granulocyte-macrophage colony-stimulating factor (GM-CSF), a glycoprotein that has been shown to stimulate the proliferation of precursor cells in the bone marrow and their differentiation into granulocytes and macrophages, was initiated. Under GM-CSF treatment, total granulocyte count rose from 63/cu mm to a value greater than 1500/cu mm within 5 days without complications or major side effects.

CONCLUSION

This case report suggests that treatment with GM-CSF may lower the risks associated with clozapine-induced agranulocytosis and therefore may indirectly improve the safety of clozapine therapy.

Neopterin production in acute schizophrenic patients: an indicator of alterations of cell-mediated immunity

This longitudinal study analyzed how the activation of cell-mediated immunity (CMI) was related to the severity of symptomatology in 25 acute schizophrenic inpatients (DSM-III-R, 295.31). Neopterin, which was used to monitor the activation of T-cells and macrophages, was found to be within the normal range, but the lowest neopterin concentrations were measured on day 0. By day 3, a significant increase of neopterin was observed. Compared with healthy controls, patients had significantly lower neopterin levels at baseline. The highest scores on the Clinical Global Impressions Scale and the Brief Psychiatric Rating Scale occurred on day 0 and decreased significantly over the observation period. In general, the increase of neopterin was accompanied by a decrease in psychopathological symptoms. These results' indicate that at study entry, when patients are acutely ill, activation of the CMI is reduced rather than increased. Possible pathophysiological mechanisms are discussed.

Carbamazepine versus oxazepam in the treatment of alcohol withdrawal: a double-blind study

The use of more than 130 drugs and drug combinations against the alcohol withdrawal syndrome reflects the fact that views on its treatment are far from being unequivocal. Benzodiazepines are the first choice treatment but it should not be disregarded that they have side effects and, above all, a varying risk of dependency themselves. In recent years many trials have focused on carbamazepine in this respect. Its efficacy was proven in various open and double-blind studies, most of them using concomitant sedative drugs, thereby diminishing the reliability of the results. In a double-blind study we compared the efficacy of carbamazepine with that of oxazepam, in 60 in-patients suffering from alcohol withdrawal syndrome. The main rating instrument was the Clinical Institute Withdrawal Scale--Alcohol (CIWA-A). The 7-day trial showed equal efficacy of carbamazepine and oxazepam during the first 5 days and a statistically significant superiority of carbamazepine on days 6 and 7. Four patients in each group had to be dropped from the study due to side effects or after having withdrawn informed consent. There was no decrease in white blood counts under carbamazepine. The experiences with carbamazepine up to now suggest a more widespread use, especially in non-delirious withdrawal states.

The effect of ritanserin on treatment-resistant neuroleptic induced akathisia: case reports

1. The authors report three cases of neuroleptic induced akathisia resistant to treatment with anticholinergics, benzodiazepines and betablockers. 2. All three patients were treated with Ritanserin 10 mg bid and improved rapidly and substantially. 3. Discontinuation of Ritanserin led to a recurrence of akathisia.

Zotepine in the treatment of schizophrenic patients with prevailingly negative symptoms. A double-blind trial vs. haloperidol

Zotepine, a neuroleptic agent with additional 5-HT2 blocking properties, was compared with haloperidol in the treatment of schizophrenic patients with predominantly negative symptoms using a double-blind design. During the investigation period zotepine treated patients showed significant improvements in all rating instruments whereas haloperidol treated patients did not. Patients in the zotepine group developed fewer clinical side effects. The results of the presented study confirm the positive impressions gained in earlier open trials with zotepine.

A multicenter double-blind study of three different doses of the new cAMP-phosphodiesterase inhibitor rolipram in patients with major depressive disorder

A multicenter randomized 4-week interindividual double-blind study was carried out in 58 hospitalized patients with major depressive disorder (DSM III 296.23, 296.22, 296.33, 296.32, 296.53 and 296.52) to test the dose-effect relationship of three different doses of the new cAMP-phosphodiesterase inhibitor rolipram: 3 x 0.25 mg, 3 x 0.50 mg and 3 x 1.00 mg rolipram/day. With respect to the desired effect, the 3 x 0.50 mg dosage stood out from the others in almost all relevant parameters. With respect to the response rate, the efficacy of the 3 x 0.25 mg dosage was about the same as that reported in the literature for placebo. The inferior performance of the 3 x 1.00 mg dosage compared to the 3 x 0.50 mg dosage might indicate a reverse U-shaped dose-effect relationship. There was good tolerance to all three dosages. There were no findings that might cast doubt on the safety of the dosages tested.

[Effect of alcohol and benzodiazepines on the severity of ski accidents]

Urine samples from 402 victims of ski accidents were analyzed for the presence of alcohol and benzodiazepines. In a second stage of the investigation, patients were asked to fill in a questionnaire evaluating among other things the consumption of alcohol and the use of benzodiazepines during the last 24 hours before the accident. 81 (20.1%) samples were found to be positive for alcohol, in 34 cases (8.5%) benzodiazepines were detected by urinalysis. 10 samples were positive for both alcohol and benzodiazepines. Subjects positive for alcohol and benzodiazepines presented with significantly more severe injuries than the negative controls. Native accident victims were significantly less frequently positive for alcohol than were subjects from foreign countries. Accidents most commonly occurred early in the afternoon, the positive urine samples, however, were evenly distributed over the whole day. The questionnaire was answered and returned by 76.6% of the study population. 80% of the patients with urine samples positive for alcohol reported having consumed alcohol before the accident, whereas none of those who had been positive for benzodiazepines admitted having ingested tranquilizers.

[Zotepine: treatment of schizophrenic patients with predominantly negative symptoms. A double-blind study vs. haloperidol]

Zotepine, a neuroleptic exercising a 5-HT2-antagonistic effect, was employed in a double-blind study in the treatment of schizophrenic patients with predominantly negative symptoms and was compared to haloperidol. In contrast to the patients treated with haloperidol, significant improvements were seen in the zotepine group during the observation period, according to all assessment scales that were employed. The patients of the zotepine group also developed fewer clinical side effects. The results of the study confirm previous positive impressions gained in earlier open studies with zotepine.

[Zotepine vs. haloperidol in paranoid schizophrenia: a double-blind study]

The efficacy and tolerance of zotepine and haloperidol were examined in 40 patients suffering from paranoid schizophrenia (DSM III). The study period was 6 weeks. Psychopathology was assessed with BPRS and CGI. Documentation of side effects was done with DOTES. The safety parameters were pulse, blood pressure, leucocyte count, liver enzymes, ECG and EEG, determined at different times. Both treatment groups improved significantly without any differences in respect to efficacy. The patients who had been treated with zotepine had significantly fewer extrapyramidal side effects. However, transient increases in liver enzyme levels were seen more frequently in the zotepine group. There were no differences between the groups in respect to other side effects.

Vulnerable phases in adolescence represented by means of committed suicide

This study deals with suicides of children and adolescents in the region of Tyrol, Austria from 1976-1984. The upper age limit was set at 19 years. During the time period stated above, 54 suicides were registered for the relevant age group, using police records as a source of information. Special attention was paid to the distribution of age, sex and occupation, as well as to the suicide methods. As far as age distribution is concerned, a significant increase of suicides was registered at the age of 15 and again at the age of 19. According to the authors, the reason for this increase is pronounced psychosocial changes which occur especially in these age groups and weaken social integration. The various implications ensuing from the available data are discussed.

Change in HIV-antibody seroprevalence rates in i.v. drug dependent prisoners

In 1985 a high HIV-seroprevalence (44.2%) was found in a cohort of parenteral drug addicted prisoners in Innsbruck, Austria. In a longitudinal study from March 1985 to March 1989 we investigated the epidemiology of HIV-infection as well as possible changes in the drug taking behaviour of this defined population at risk. During the study HIV-seroprevalence rates in drug dependent prisoners showed a statistical decrease to 30%. A concomitant increase in admission to any kind of therapy programmes as well as an increasing change from 'heavy use' (mainly taking heroin i.v.) to 'non-heavy use' (mainly taking drugs orally) could be noted. The influence of preventive measures, such as comprehensive AIDS-information, special therapy programmes including the methadone substitution programme, and the unrestricted availability of needles and syringes is discussed.

The Hillside Akathisia Scale: a reliability comparison of the English and German versions

Akathisia usually consists of two components, subjective restlessness and typical movements such as shuffling of the legs, pacing, shifting weight from one leg to the other, and rocking movements of the trunk. The ability to measure akathisia reliably is essential for the assessment of treatments for akathisia and for the evaluation of drug-induced side effects in general. To date, investigators have generally used self-constructed assessment scales without reporting data about reliability or validity. The Hillside Akathisia Scale (HAS) has two subjective and three objective items for which anchored rating points are provided. Reliability was 0.89 for the HAS total score. Reliability for rating subjective symptoms ranged from 0.86 to 0.92, and the objective scores ranged from 0.51 to 0.89. The correlation between HAS and a global assessment of akathisia (modified CGI) was 0.87. These values compare favorably with the original report on the scale indicating that the Hillside Akathisia Scale can validly quantify akathisia with a satisfactory degree of interrater reliability.

Characteristics of benzodiazepine long-term users: investigation of benzodiazepine consumers among pharmacy customers

A sample of 171 benzodiazepine (bzd) users was investigated in the pharmacy where the patients filled in their prescriptions. Of the sample, 29.8% were males and 70.2% were females. About 60% of the patients had their current prescription from a general practitioner, the rest from different specialists. 70.8% stated to take bzds on more than 3 days of the week. The mean duration of intake of the entire sample was 4.5 years. The most frequent reasons for bzd intake were sleep disturbance followed by nervousness and somatic diseases. A total of 74.9% of the patients turned out to be well informed about the potential dependence hazards of bzd long term intake, but less than half of them had been informed by the prescribing physician. In a second step it could be demonstrated by means of multiple stepwise logistic regression analysis that certain characteristic parameters differentiate long-term users and persons with signs of potential abuse and dependence from other bzd users.

Influence of patient-related variables on clozapine plasma levels

The authors investigated the clozapine plasma levels of 148 psychiatric inpatients. Multiple regression analysis revealed a linear relationship between dose of clozapine and plasma concentrations. The analysis showed a significant influence of dose, sex, smoking, weight, and age on the plasma concentrations of clozapine under clinical conditions. These results remained significant when clozapine doses below 150 mg/day and above 500 mg/day were excluded from the analysis.

Carbamazepine monotherapy in the treatment of alcohol withdrawal

More than 135 different strategies for medical treatment have been described for the treatment of alcohol withdrawal syndromes. The substances used most frequently (benzodiazepines, barbiturates, or clomethiazol) themselves pose some risk for abuse or addiction. Anticonvulsants, especially carbamazepine (CBZ), have been discussed for the treatment of alcohol withdrawal since the early seventies. Various studies report favourable results with CBZ, usually combined with sedative agents. Nineteen out-patients and 19 in-patients took part in an open study of CBZ in alcohol withdrawal. The dose of CBZ was adjusted individually and ranged from a mean dose of 761 mg on day 1 to 616 mg on day 3 and to 388 mg on day 7 in the group of out-patients, and from 789 mg on day 1, 694 mg on day 3 to 562 mg on day 7 in the sample of in-patients. The "Objective Clinical Scale in Assessment and Measurement of Alcohol Withdrawal" (OCSAMAW) was used for treatment evaluation. Statistical analysis showed a significant improvement on the 5%-level in both groups; four in-patients needed concomitant treatment with oxazepam. Nausea and pruritus were the most common side-effects of CBZ treatment.

The pharmacologic treatment of neuroleptic-induced akathisia

Akathisia is a frequent and distressing side effect of neuroleptic medications. The literature regarding the pharmacologic treatment of acute neuroleptic-induced akathisia is critically reviewed, including nine reports of the use of anticholinergic agents, 15 of the use of beta-blocking agents, and six of the use of benzodiazepines. Reports of trials on clonidine, amantadine, piracetam, and of a patient treated with amitriptyline are also discussed. Tentative recommendations for the management of acute akathisia are proposed.

Carbamazepine in the prophylaxis of mood disorders

Alternatives to lithium are desirable in the prophylaxis of affective disorders, especially in patients who are intolerant of or do not respond to that drug. In the past few years the anticonvulsant carbamazepine has been in the foreground of discussion. Twenty-four patients with affective disorders (17 unipolar depressed, six bipolar, and one unipolar manic) were included in a comparative trial of lithium and carbamazepine; 12 had been pretreated with lithium without a satisfactory effect. All patients received carbamazepine (four received it in combination with lithium) over a mean time span of 20.2 months. Eighty percent of the patients improved with carbamazepine treatment. Side effects were infrequent.

The neuroleptic malignant syndrome and its differentiation from lethal catatonia

Neuroleptic malignant syndrome and lethal catatonia are potentially life-threatening diseases with similar clinical features, including fever, akinesia and rigidity. Differential diagnosis is difficult but possible by exact clinical observation and a detailed history of the 2 weeks prior to the onset of illness.

High versus low-dose piracetam in alcohol organic mental disorder: a placebo controlled study

A marked tendency to increase the dose of piracetam in the treatment of organic mental disorder can be observed in clinical practice. A placebo controlled study comparing two doses (i.e. 6 g and 24 g per die) was performed to evaluate the benefits of high dose piracetam in the treatment of organic mental disorder of chronic alcohol addicts. 60 inpatients participated in the study. Cognitive impairment was verified by various psychological tests on day 0; patients were also evaluated on days 7, 14, 28 and 42 of the trial. While the patients of all three groups showed a significant amelioration during the treatment period, a modest but significant superiority was indicated for the high piracetam dose. There was no difference between the placebo group and the patients receiving low dose piracetam.

The behavioral toxicity of bromocriptine in patients with psychiatric illness

Dopamine agonists may be useful in the treatment of neuroleptic-induced hyperprolactinemia and movement disorders; it is a treatment approach that has been avoided for fear of inducing or exacerbating psychotic symptoms. The risks of giving dopamine agonists to psychiatric patients have been well documented in the literature. To further evaluate the psychotogenic effects of bromocriptine, a dopamine receptor agonist, we conducted a double-blind study in which 16 psychiatrically stable patients were treated for tardive dyskinesia with neuroleptics plus high doses of bromocriptine (N = 11) or placebo (N = 5) for 10 weeks. The diagnoses included schizophrenia, schizoaffective disorder, and major depression with psychotic features. Patients were evaluated weekly with the Brief Psychiatric Rating Scale and the Clinical Global Impression Scale during the 10-week treatment phase and for 8 weeks after medication was withdrawn. There were no statistically significant differences between active and placebo groups in behavioral ratings at baseline, week 10, and week 18. These results are compared with the findings of previous studies in which bromocriptine was given to psychiatric patients. Although the literature suggests that bromocriptine can induce or exacerbate psychosis in psychiatric patients, this occurs primarily in those with a psychotic diathesis and who are not currently receiving neuroleptic medication. Other important factors include the dose of bromocriptine, duration of treatment, and the clinical state of the patient at the time bromocriptine treatment is initiated. These results suggest that bromocriptine can be safely used in patients at risk for psychotic illnesses as long as patients are clinically stable and maintained on neuroleptics.

Is schizophrenia linked to alteration in cellular immunity?

To reinvestigate the viral hypothesis of schizophrenia as well as possible immunological dysfunction, neopterin, which is an indicator of the activity in the cellular immune system, was determined in acute and chronic schizophrenics. Both diagnostic groups showed neopterin levels within the normal range. Patients with chronic schizophrenia of the residual type presented a significant dependency between neopterin concentrations and Brief Psychiatric Rating Scale (BPRS) total scores. In a long-term observation of 14 acute schizophrenic (paranoid type) inpatients, neopterin levels were found to be lowest at day 0. During the first week of treatment neopterin concentrations increased significantly whereas a concomitant decrease of the psychopathological symptoms could be observed. In comparison to healthy controls patients showed significantly lower neopterin levels at baseline. These findings will be discussed referring to the viral hypothesis of schizophrenia as well as to possible immunological alterations caused by stress or by changes in neurotransmitter synthesis.

Benzodiazepines: utilization and patterns of use in a university hospital

Information on the number of benzodiazepine prescriptions in all the departments of the Innsbruck University Clinics in 1985 was obtained from the hospital pharmacy. Expenditure on benzodiazepines amounted to 0.5% of total medication costs. In a second step, the authors questioned 264 patients from the five largest departments about benzodiazepine use. On the day of the interview, 24.1% of all investigated male patients and 20.5% of the female patients were taking benzodiazepines. Of the patients found to take benzodiazepines, 34.5% had already been using these before hospital admission. One-fifth of these patients reported problems when trying to stop medication.

Dose-related plasma levels of clozapine: influence of smoking behaviour, sex and age

Drug monitoring in psychiatry is of increasing interest due to compliance problems, side effects of psychoactive drugs and the search for adequate dosage. In the present study, plasma levels of clozapine, as determined by high performance liquid chromatography, were investigated in 148 patients receiving a daily dose between 12.5 and 700 mg clozapine. Regression analysis revealed a linear relationship between dose and plasma concentrations. Plasma concentrations at a given dose (level divided by dose and body weight) in male patients reached only 69.3% of the concentrations in female patients (Mann-Whitney U Test P less than 0.001). When the patients were divided into smokers and non-smokers, the corresponding plasma levels were also found to be linearly dose dependent in each of the two groups. However, the average plasma concentration at a given dose was only 81.8% in smokers, compared to non-smokers. This difference was statistically significant (variance analysis P = 0.022). Dividing female patients into smokers and non-smokers, the smokers reached nearly the same plasma levels as the non-smokers. Male smoking patients reached average plasma concentrations which were only 67.9% of those of non-smokers. This difference was statistically significant (Mann-Whitney U Test P = 0.0083). The plasma levels of the different age groups at a given dose per kg body weight were compared using the Mann-Whitney U Test. Significant differences were found between group 1 (18-26) and group 4 (45-54) (P less than 0.01) and group 2 (27-35) and group 4 (P less than 0.01) showing higher plasma levels in the older age group.(ABSTRACT TRUNCATED AT 250 WORDS)