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Uliana DL, Lisboa JRF, Gomes FV, Grace AA. The excitatory-inhibitory balance as a target for the development of novel drugs to treat schizophrenia. Biochem Pharmacol 2024; 228:116298. [PMID: 38782077 PMCID: PMC11410545 DOI: 10.1016/j.bcp.2024.116298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/13/2024] [Accepted: 05/16/2024] [Indexed: 05/25/2024]
Abstract
The intricate balance between excitation and inhibition (E/I) in the brain plays a crucial role in normative information processing. Dysfunctions in the E/I balance have been implicated in various psychiatric disorders, including schizophrenia (SCZ). In particular, abnormalities in GABAergic signaling, specifically in parvalbumin (PV)-containing interneurons, have been consistently observed in SCZ pathophysiology. PV interneuron function is vital for maintaining an ideal E/I balance, and alterations in PV interneuron-mediated inhibition contribute to circuit deficits observed in SCZ, including hippocampus hyperactivity and midbrain dopamine system overdrive. While current antipsychotic medications primarily target D2 dopamine receptors and are effective primarily in treating positive symptoms, novel therapeutic strategies aiming to restore the E/I balance could potentially mitigate not only positive symptoms but also negative symptoms and cognitive deficits. This could involve, for instance, increasing the inhibitory drive onto excitatory neurons or decreasing the putative enhanced pyramidal neuron activity due to functional loss of PV interneurons. Compounds targeting the glycine site at glutamate NMDA receptors and muscarinic acetylcholine receptors on PV interneurons that can increase PV interneuron drive, as well as drugs that increase the postsynaptic action of GABA, such as positive allosteric modulators of α5-GABA-A receptors, and decrease glutamatergic output, such as mGluR2/3 agonists, represent promising approaches. Preventive strategies aiming at E/I balance also represent a path to reduce the risk of transitioning to SCZ in high-risk individuals. Therefore, compounds with novel mechanisms targeting E/I balance provide optimism for more effective and tailored interventions in the management of SCZ.
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Affiliation(s)
- Daniela L Uliana
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Joao Roberto F Lisboa
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Felipe V Gomes
- Department of Pharmacology, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, SP, Brazil
| | - Anthony A Grace
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA.
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de Toffol B. Epilepsy and psychosis. Rev Neurol (Paris) 2024; 180:298-307. [PMID: 38336524 DOI: 10.1016/j.neurol.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 02/12/2024]
Abstract
Psychotic disorders are eight times more frequent in epilepsy than in the general population. The various clinical syndromes are classified according to their chronology of onset in relation to epileptic seizures: ictal psychoses (during epileptic discharge), post-ictal psychoses (PIP, after a seizure), interictal psychoses (IIP, with no chronological link) and those related to complete seizure control. Antiepileptic drugs can cause psychotic disorders in all these situations. Post-ictal psychoses (PIP) are affective psychoses that occur after a lucid interval lasting 12 to 120hours following a cluster of seizures. They last an average of 10days, with an abrupt beginning and end. PIP are directly linked to epileptic seizures, and disappear when the epilepsy is controlled. Interictal psychoses are schizophrenias. The management of psychotic disorders in epilepsy is neuropsychiatric, and requires close collaboration between epileptologists and psychiatrists. Antipsychotics can be prescribed in persons with epilepsy. Even today, psychotic disorders in epilepsy are poorly understood, under-diagnosed and under-treated.
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Affiliation(s)
- B de Toffol
- Université des Antilles, Neurology Department, Centre Hospitalier de Cayenne, CIC Inserm 1424, rue des Flamboyants, 97300 Cayenne, French Guiana.
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3
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Dhungel O, Shrestha A, Pathak P, Sharma P. Levetiracetam-Induced Acute Psychosis in an Adolescent. Case Rep Psychiatry 2023; 2023:5575900. [PMID: 37745836 PMCID: PMC10516691 DOI: 10.1155/2023/5575900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 08/02/2023] [Accepted: 08/26/2023] [Indexed: 09/26/2023] Open
Abstract
Levetiracetam (LEV), a second-generation antiepileptic, is used as an adjunct therapy in primary generalized tonic-clonic seizures, refractory partial-onset seizures, and seizure prophylaxis after brain surgery. It is well tolerated, effective and has a convenient dosing regimen. As any other drugs, it has some adverse drug effects, including neuropsychiatric adverse effects ranging from agitation and mood symptoms to psychosis and suicide. Strong diagnostics guidelines are yet to be formulated for LEV-induced psychosis; however, complete recovery from psychotic symptoms after stopping LEV supports the possible adverse reaction from Naranjo's algorithm and, hence, the diagnosis. This case report presents a 16 years boy with focal onset generalized tonic-clonic seizure, whose drug regimen was switched to LEV, following which he had the delusion of persecution, second-person auditory hallucination, and aggressive behavior, which decreased on the 2nd day of cessation of LEV.
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Affiliation(s)
- Omkar Dhungel
- Patan Academy of Health Sciences, School of Medicine, Department of Psychiatry, Lalitpur, Nepal
| | - Amit Shrestha
- Patan Academy of Health Sciences, School of Medicine, Department of Psychiatry, Lalitpur, Nepal
| | - Pankaj Pathak
- Patan Academy of Health Sciences, School of Medicine, Department of Psychiatry, Lalitpur, Nepal
| | - Pawan Sharma
- Patan Academy of Health Sciences, School of Medicine, Department of Psychiatry, Lalitpur, Nepal
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Rubboli G, Beier CP, Selmer KK, Syvertsen M, Shakeshaft A, Collingwood A, Hall A, Andrade DM, Fong CY, Gesche J, Greenberg DA, Hamandi K, Lim KS, Ng CC, Orsini A, Striano P, Thomas RH, Zarubova J, Richardson MP, Strug LJ, Pal DK. Variation in prognosis and treatment outcome in juvenile myoclonic epilepsy: a Biology of Juvenile Myoclonic Epilepsy Consortium proposal for a practical definition and stratified medicine classifications. Brain Commun 2023; 5:fcad182. [PMID: 37361715 PMCID: PMC10288558 DOI: 10.1093/braincomms/fcad182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 03/21/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023] Open
Abstract
Reliable definitions, classifications and prognostic models are the cornerstones of stratified medicine, but none of the current classifications systems in epilepsy address prognostic or outcome issues. Although heterogeneity is widely acknowledged within epilepsy syndromes, the significance of variation in electroclinical features, comorbidities and treatment response, as they relate to diagnostic and prognostic purposes, has not been explored. In this paper, we aim to provide an evidence-based definition of juvenile myoclonic epilepsy showing that with a predefined and limited set of mandatory features, variation in juvenile myoclonic epilepsy phenotype can be exploited for prognostic purposes. Our study is based on clinical data collected by the Biology of Juvenile Myoclonic Epilepsy Consortium augmented by literature data. We review prognosis research on mortality and seizure remission, predictors of antiseizure medication resistance and selected adverse drug events to valproate, levetiracetam and lamotrigine. Based on our analysis, a simplified set of diagnostic criteria for juvenile myoclonic epilepsy includes the following: (i) myoclonic jerks as mandatory seizure type; (ii) a circadian timing for myoclonia not mandatory for the diagnosis of juvenile myoclonic epilepsy; (iii) age of onset ranging from 6 to 40 years; (iv) generalized EEG abnormalities; and (v) intelligence conforming to population distribution. We find sufficient evidence to propose a predictive model of antiseizure medication resistance that emphasises (i) absence seizures as the strongest stratifying factor with regard to antiseizure medication resistance or seizure freedom for both sexes and (ii) sex as a major stratifying factor, revealing elevated odds of antiseizure medication resistance that correlates to self-report of catamenial and stress-related factors including sleep deprivation. In women, there are reduced odds of antiseizure medication resistance associated with EEG-measured or self-reported photosensitivity. In conclusion, by applying a simplified set of criteria to define phenotypic variations of juvenile myoclonic epilepsy, our paper proposes an evidence-based definition and prognostic stratification of juvenile myoclonic epilepsy. Further studies in existing data sets of individual patient data would be helpful to replicate our findings, and prospective studies in inception cohorts will contribute to validate them in real-world practice for juvenile myoclonic epilepsy management.
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Affiliation(s)
- Guido Rubboli
- Danish Epilepsy Centre, Filadelfia, Dianalund 4293, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen 2200, Denmark
| | - Christoph P Beier
- Department of Neurology, Odense University Hospital, Odense 5000, Denmark
| | - Kaja K Selmer
- Department of Research and Innovation, Division of Clinical Neuroscience, Oslo University Hospital, Oslo 0372, Norway
- National Centre for Epilepsy, Oslo University Hospital, Oslo 1337, Norway
| | - Marte Syvertsen
- Department of Neurology, Drammen Hospital, Vestre Viken Health Trust, Oslo 3004, Norway
| | - Amy Shakeshaft
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
| | - Amber Collingwood
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Anna Hall
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
| | - Danielle M Andrade
- Adult Epilepsy Genetics Program, Krembil Research Institute, University of Toronto, Toronto M5T 0S8, Canada
| | - Choong Yi Fong
- Division of Paediatric Neurology, Department of Pediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Joanna Gesche
- Department of Neurology, Odense University Hospital, Odense 5000, Denmark
| | - David A Greenberg
- Abigail Wexner Research Institute, Nationwide Children’s Hospital, Columbus 43215, USA
| | - Khalid Hamandi
- Department of Neurology, Cardiff & Vale University Health Board, Cardiff CF14 4XW, UK
| | - Kheng Seang Lim
- Division of Neurology, Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Ching Ching Ng
- Institute of Biological Sciences, Faculty of Science, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Alessandro Orsini
- Department of Clinical and Experimental Medicine, Pisa University Hospital, Pisa 56126, Italy
| | - Pasquale Striano
- Pediatric Neurology and Muscular Disease Unit, IRCCS Istituto ‘G. Gaslini’, Genova 16147, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genova 16132, Italy
| | - Rhys H Thomas
- Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
- Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne NE1 7RU, UK
| | - Jana Zarubova
- Department of Neurology, Second Faculty of Medicine, Charles University, Prague 150 06, Czech Republic
- Motol University Hospital, Prague 150 06, Czech Republic
| | - Mark P Richardson
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
- School of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
| | - Lisa J Strug
- Program in Genetics and Genome Biology, The Hospital for Sick Children, Toronto M5G 1X8, Canada
- Departments of Statistical Sciences and Computer Science and Division of Biostatistics, The University of Toronto, Toronto M5G 1Z5, Canada
| | - Deb K Pal
- Department of Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London SE5 8AF, UK
- MRC Centre for Neurodevelopmental Disorders, King’s College London, London SW1H 9NA, UK
- School of Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London SE5 8AF, UK
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Knight S, McCutcheon R, Dwir D, Grace AA, O'Daly O, McGuire P, Modinos G. Hippocampal circuit dysfunction in psychosis. Transl Psychiatry 2022; 12:344. [PMID: 36008395 PMCID: PMC9411597 DOI: 10.1038/s41398-022-02115-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/09/2022] Open
Abstract
Despite strong evidence of the neurodevelopmental origins of psychosis, current pharmacological treatment is not usually initiated until after a clinical diagnosis is made, and is focussed on antagonising striatal dopamine receptors. These drugs are only partially effective, have serious side effects, fail to alleviate the negative and cognitive symptoms of the disorder, and are not useful as a preventive treatment. In recent years, attention has turned to upstream brain regions that regulate striatal dopamine function, such as the hippocampus. This review draws together these recent data to discuss why the hippocampus may be especially vulnerable in the pathophysiology of psychosis. First, we describe the neurodevelopmental trajectory of the hippocampus and its susceptibility to dysfunction, exploring this region's proneness to structural and functional imbalances, metabolic pressures, and oxidative stress. We then examine mechanisms of hippocampal dysfunction in psychosis and in individuals at high-risk for psychosis and discuss how and when hippocampal abnormalities may be targeted in these groups. We conclude with future directions for prospective studies to unlock the discovery of novel therapeutic strategies targeting hippocampal circuit imbalances to prevent or delay the onset of psychosis.
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Affiliation(s)
- Samuel Knight
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK.
| | - Robert McCutcheon
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Daniella Dwir
- Center for Psychiatric Neuroscience, Department of Psychiatry, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Anthony A Grace
- Departments of Neuroscience, Psychiatry and Psychology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Owen O'Daly
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Philip McGuire
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- NIHR Maudsley Biomedical Research Centre, London, UK
| | - Gemma Modinos
- Department of Psychosis Studies, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
- MRC Centre for Neurodevelopmental Disorders, King's College London, London, UK
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A Manic Episode With Psychotic Features Associated With Levetiracetam: A Case Report, a Proposal of Prodromal and Discriminative Symptoms and a Possible Pathophysiological Mechanism. J Clin Psychopharmacol 2022; 42:316-317. [PMID: 35121708 DOI: 10.1097/jcp.0000000000001525] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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7
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Levetiracetam-Induced Psychosis in the Setting of Intracranial Cavernomas. Case Rep Psychiatry 2022; 2022:9114118. [PMID: 35356150 PMCID: PMC8960016 DOI: 10.1155/2022/9114118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 02/26/2022] [Accepted: 03/04/2022] [Indexed: 01/17/2023] Open
Abstract
Levetiracetam is a commonly used antiepileptic medication that has been associated with the development of psychosis. Cavernomas are vascular malformations that have been associated with psychosis as well, especially in the setting of hemorrhagic transformation. This case report describes a patient with cavernomas who developed psychotic symptoms after restarting her levetiracetam at a high dose (2000 mg twice a day) without gradual uptitration. Her symptoms improved upon the reduction of the levetiracetam as well as the initiation of paliperidone. This case highlights the importance of considering the biologic and medication-related factors for the development of psychosis, as well as the importance of gradual medication adjustments.
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8
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Ma ZZ, Li L, Han YX, Duan YD, Wang WZ, Niu ME. Analysis of risk factors for early urinary tract infection after kidney transplantation. Transl Androl Urol 2020; 9:2211-2217. [PMID: 33209685 PMCID: PMC7658162 DOI: 10.21037/tau-20-1248] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Urinary tract infection (UTI) is the most common kind of infection in the early stage after kidney transplantation. Although many studies have investigated the risk factors for UTI following kidney transplantation, few studies have focused on the risk factors for UTI in the early stage after transplantation. Methods The early-stage data of patients who underwent kidney transplantation between January 2018 and December 2019 in a first-class tertiary hospital in Suzhou, China, were retrospectively analyzed. The general and UTI information of the recipients was subjected to univariate analysis. Variables with statistical significance in the univariate analysis were included in a multivariate logistic regression model. Results A total of 129 recipients were recruited, among whom 62 patients had a UTI in the early stage after kidney transplantation (48.1%), and the median (interquartile range) of onset time was 5 (4, 10) days after the surgery. A total of 324 strains of UTI pathogens were detected in the 62 recipients after kidney transplantation, 279 of which were gram-negative bacilli (86.1%). Multivariate logistic regression analysis showed that female sex and delayed graft function (DGF) were independent risk factors for early-stage UTI, with odds ratios of 0.095 and 3.753, respectively. Conclusions The incidence of early UTI after kidney transplantation is high. Females and DGF patients are more prone to UTIs. Comprehensive prevention and treatment measures should be taken as early as possible against the risk factors to reduce the incidence of UTI.
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Affiliation(s)
- Zheng-Zheng Ma
- Department of Urology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Li Li
- Department of Urology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yan-Xia Han
- Department of Nursing, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Ya-Dong Duan
- Department of Urology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei-Zhen Wang
- Department of Urology, the First Affiliated Hospital of Soochow University, Suzhou, China
| | - Mei-E Niu
- Department of Nursing, the First Affiliated Hospital of Soochow University, Suzhou, China
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9
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Understanding and Responding to Prescribing Patterns of Sodium Valproate-Containing Medicines in Pregnant Women and Women of Childbearing Age in Western Cape, South Africa. Drug Saf 2020; 44:41-51. [PMID: 32844313 PMCID: PMC7813724 DOI: 10.1007/s40264-020-00987-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Growing evidence of the teratogenic potential of sodium valproate (VPA) has changed prescribing practices across the globe; however, the impact of this research and the consequent dissemination of a Dear Health Care Professional Letter (DHCPL) in December 2015, recommending avoidance of the teratogen VPA in women of childbearing age (WOCBA) and pregnant women in South Africa, is unknown. We explored trends and reasons for VPA use among pregnant women and WOCBA in the public sector in Western Cape Province from 1 January 2015 to 31 December 2017. METHODS Using the provincial health information exchange that collates routine electronic health data via unique patient identifiers, we analysed clinical and pharmacy records from 2015 to 2017 to determine prescription patterns of VPA and other antiepileptic drug (AED) and mood-stabilising medicine (MSM) use in WOCBA and pregnant women. Senior clinicians and policy makers were consulted to understand the determinants of VPA use. RESULTS At least one VPA prescription was dispensed to between 8205 (0.79%) and 9425 (0.94%) WOBCA from a cohort of approximately 1 million WOCBA attending provincial health care facilities per year. Prescriptions were more likely in HIV-infected women compared with HIV-uninfected women (1.1-1.3% vs. 0.7-0.9%; p < 0.001). VPA use in WOCBA remained stable at 0.8-0.9% over the review period despite the 2016 DHCPL. VPA was the most prescribed AED/MSM, constituting 43.2-45.5% of all WOCBA taking at least one such agent, while lamotrigine, the other recommended first-line agent, was only prescribed in 7.8-8.9% of WOCBA. Over 3 years, approximately 663 pregnancies were exposed to VPA, with a steady rise in the number of exposures each year (n = 204, 214 and 245, respectively). CONCLUSION Despite warnings, VPA remained the most frequently prescribed AED or MSM in WOCBA. Contributing factors are described.
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Levetiracetam Induced Behavioral Abnormalities in a Patient with Seizure Disorder: A Diagnostic Challenge. Case Rep Psychiatry 2020; 2020:8883802. [PMID: 32908767 PMCID: PMC7450317 DOI: 10.1155/2020/8883802] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 08/03/2020] [Accepted: 08/10/2020] [Indexed: 11/18/2022] Open
Abstract
Levetiracetam is a second-generation antiepileptic drug that is chemically unrelated to other antiepileptic drugs. Levetiracetam is a broad-spectrum antiseizure medication that is approved as an adjunctive therapy in the treatment of partial and generalized tonic-clonic seizures in children and adults with epilepsy. The mechanism by which Levetiracetam induces behavioral changes remains unknown. Its proposed mechanism of action involves binding to synaptic vesicle protein 2A (SV2A) and this leads to neuronal inhibition. Though, the drug has a convenient dosing regimen and is relatively well tolerated, neuropsychiatric side effects can emerge beyond the initial titration period and may be the most common reason for drug discontinuation. Levetiracetam has been reported to cause varying degrees of psychiatric adverse effects including behavioral disturbance such as agitation, hostility and psychosis, and mood symptoms and suicidality. It has been shown to induce psychiatric side effects in 13.3% of adults, with only 0.7% presenting with severe symptoms such as depression, agitation, or hostility. The prevalence rate of development of psychosis in these patients is estimated to be about 1.4%. A review of literature has demonstrated a relative correlation between Levetiracetam use and the development of neurobehavioral symptoms which is increased in predisposed individuals. This research describes the case of a 28-year-old woman with seizure disorder and a psychiatric history of schizoaffective disorder who developed aggressive behavior, paranoia, and severe hostility following administration of Levetiracetam 750 mg orally twice daily. She developed acute behavioral symptoms which were reversed with cessation of Levetiracetam. This report emphasizes the need for developing an appropriately high index of suspicion in promoting surveillance and prompt identification of behavioral adverse effects associated with Levetiracetam especially in high-risk patient population.
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de Toffol B, Adachi N, Kanemoto K, El-Hage W, Hingray C. [Interictal psychosis of epilepsy]. Encephale 2020; 46:482-492. [PMID: 32594995 DOI: 10.1016/j.encep.2020.04.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 03/23/2020] [Accepted: 04/07/2020] [Indexed: 02/06/2023]
Abstract
Interictal psychosis (IIP) refers to psychosis that occurs in clear consciousness in persons with epilepsy (PWE) with temporal onset not during or immediately following a seizure. The pooled prevalence estimate of psychosis in PWE is 5.6%. PWE and schizophrenia have very high mortality, and more than one in four persons with both disorders die between the age of 25 and 50years. IIP can manifest in brief or chronic forms. The chronic forms of IIP may closely resemble schizophrenia. However, some authors have described the typical presence of persecutory and religious delusions, sudden mood swings and the preservation of affect, as well as rarity of negative symptoms and catatonic states, but these differences remain controversial. Typically, IIP starts after many years of active temporal lobe epilepsy. Several epilepsy-related variables are considered pathogenically relevant in IIP including epilepsy type and seizure characteristics. Risk factors for developing IIP are family history of psychosis, learning disability, early age of onset of epilepsy, unilateral or bilateral hippocampal sclerosis, history of status epilepticus, history of febrile seizures, and poorly controlled temporal lobe epilepsy. In patients with epilepsy and psychosis, structural imaging studies have shown several relevant changes leading to conflicting findings. Altered neuronal plasticity and excitability have been described in epilepsy and psychotic disorders. Neuropathological data suggest that IIP are not the result of classic epileptic pathology of the temporal lobe. Forced normalization (FN) and alternating psychosis refer to patients with poorly controlled epilepsy (focal or generalized) who have had psychotic episodes associated with remission of their seizures and disappearance of epileptiform activity on their EEGs. FN mainly occurs in temporal lobe epilepsy when patients have frequent seizures that are abruptly terminated triggered by an antiepileptic drug, vagus nerve stimulation or epilepsy surgery. Treatment is based on withdrawal of the responsible drug, and by transient use of antipsychotics for acute symptomatic control on a case-by-case basis. FN is an entity whose pathophysiology remains uncertain. Antiepileptic drugs (AEDs) may sometimes induce psychotic symptoms and psychosis could be a direct effect of the AEDs. IIP has been reported more frequently following the initiation of zonisamide, topiramate, and levetiracetam when compared with other antiepileptic drugs. However, AEDs do not appear to be the only determinant of IIP. The management of IIP requires a multidisciplinary approach with early involvement of a liaison psychiatrist associated with a neurologist. IIP are underdiagnosed and mistreated. Existing recommendations are extrapolated from those established for the treatment of schizophrenia with some additional guidance from expert opinions. A two-step procedure, not necessarily consecutive, is suggested. The first step requires reevaluation of the antiepileptic treatment. The second step requires initiation of atypical neuroleptics. Antipsychotic drugs should be selected with consideration of the balance between pharmacological profiles, efficacy, and adverse effects. Regarding pharmacokinetic interactions, AEDs with inducing properties reduce the blood levels of all antipsychotics. It is important to consider implications of combining neuroleptics and AEDs with a similar spectrum of side effects. Regarding the duration of treatment, IIP episodes are more likely to be recurrent than in primary schizophrenia. In practice, atypical neuroleptics with few motor side effects such as risperidone can be used as first choice, given the low propensity for drug-drug interactions and the low seizure risk, with the added suggestion to start low and go slow. Clozapine could be prescribed in selected cases.
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Affiliation(s)
- B de Toffol
- Service de neurologie et de neurophysiologie clinique, U1253 ibrain, Inserm, université de Tours, Tours, France; CHU Bretonneau, 2 bis, boulevard Tonnellé, 37044 Tours cedex, France.
| | - N Adachi
- Adachi Mental Clinic, Kitano 7-5-12, Kiyota, Sapporo 004-0867, Japon
| | - K Kanemoto
- Aichi Medical University, Neuropsychiatric Department, Nagakute, Japon
| | - W El-Hage
- U1253, iBrain, Inserm, CHRU de Tours, université de Tours, Tours, France
| | - C Hingray
- Service de neurologie, CHRU Nancy, 54000 Nancy, France; Pôle universitaire de psychiatrie du grand Nancy, CPN, 54520 Laxou, France
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