Psychosis in Parkinson's disease

Pimavanserin: A Truly Effective Treatment for Parkinson's Disease Psychosis? A Review of Interventions

Parkinson's disease (PD) is the second-most common neurodegenerative disorder with a long-term 60% cumulative prevalence of PD psychosis. Medical treatment is limited to few atypical antipsychotic drugs with low affinity to dopamine D2 receptors. In 2016, pimavanserin, a selective 5-HT2A inverse agonist/antagonist, was approved by the US Food and Drug Administration (FDA) as the only treatment for PD psychosis (PDP). This article provides an overview of the epidemiology, pathophysiology, and treatment options for PDP and illuminates the mode of action and therapy options with pimavanserin and the current study data.

Psychosis in Parkinson's Disease: Current Treatment Options and Impact on Patients and Caregivers

Parkinson's disease (PD) is the second most common neurodegenerative disease seen in older adults after Alzheimer's disease, with increasing prevalence worldwide. Parkinson's disease psychosis (PDP) is a common, non-motor feature of PD, which increases caregiver stress and is a risk-factor for nursing home placement. In this paper we review PDP epidemiology, features, diagnosis, and treatment. PDP most often presents with sequential development of minor and then increasingly complex visual hallucinations mediated by dopaminergic-serotonergic interactions activating the mesolimbic pathway, with contributions from other structures and neurotransmitters. Appropriate evaluation of differential diagnoses for psychosis is vital before diagnosing PDP. Initial treatment should involve non-pharmacologic approaches. If these are unsuccessful and PDP symptoms significantly impact the patient's and or their caregivers' quality of life and functions, then pharmacotherapy is indicated. Pimavanserin is a recently FDA-approved pharmacologic treatment for PDP with a better profile of balanced effectiveness and safety compared to previous use of atypical antipsychotics. Early diagnosis and safer, more effective treatments for PDP should help reduce caregiver burden and enable caregivers to continue to provide care at home versus institutionalization.

Movement Disorder Emergencies

Acute presentation of new movement disorders and acute decompensation of chronic movement disorders are uncommon but potentially life-threatening. Inadvertent or purposeful overdose of many psychiatric medications can result in acute life-threatening movement disorders including serotonin syndrome, neuroleptic malignant syndrome, and malignant catatonia. Early withdrawal of potentiating medications, treatment with benzodiazepines and other diagnosis-specific drugs, and providing appropriate supportive care including airway and breathing management, hemodynamic stabilization, fluid resuscitation, and renal support including possible hemodialysis are the mainstays of acute management. Many of these conditions require admission to the neurologic intensive care unit.

UFO: A tool for unifying biomedical ontology-based semantic similarity calculation, enrichment analysis and visualization

Background

Biomedical ontologies have been growing quickly and proven to be useful in many biomedical applications. Important applications of those data include estimating the functional similarity between ontology terms and between annotated biomedical entities, analyzing enrichment for a set of biomedical entities. Many semantic similarity calculation and enrichment analysis methods have been proposed for such applications. Also, a number of tools implementing the methods have been developed on different platforms. However, these tools have implemented a small number of the semantic similarity calculation and enrichment analysis methods for a certain type of biomedical ontology. Note that the methods can be applied to all types of biomedical ontologies. More importantly, each method can be dominant in different applications; thus, users have more choice with more number of methods implemented in tools. Also, more functions would facilitate their task with ontology.

Results

In this study, we developed a Cytoscape app, named UFO, which unifies most of the semantic similarity measures for between-term and between-entity similarity calculation for all types of biomedical ontologies in OBO format. Based on the similarity calculation, UFO can calculate the similarity between two sets of entities and weigh imported entity networks as well as generate functional similarity networks. Besides, it can perform enrichment analysis of a set of entities by different methods. Moreover, UFO can visualize structural relationships between ontology terms, annotating relationships between entities and terms, and functional similarity between entities. Finally, we demonstrated the ability of UFO through some case studies on finding the best semantic similarity measures for assessing the similarity between human disease phenotypes, constructing biomedical entity functional similarity networks for predicting disease-associated biomarkers, and performing enrichment analysis on a set of similar phenotypes.

Conclusions

Taken together, UFO is expected to be a tool where biomedical ontologies can be exploited for various biomedical applications.

Availability

UFO is distributed as a Cytoscape app, and can be downloaded freely at Cytoscape App (http://apps.cytoscape.org/apps/ufo) for non-commercial use

Pimavanserin versus quetiapine for the treatment of psychosis in Parkinson's disease and dementia with Lewy bodies

INTRODUCTION

Psychosis is common among patients with Parkinson's disease (PD) and dementia with Lewy bodies (DLB). Limited data exist on the most effective therapies.

METHODS

Retrospective cohort study comparing patients with PD or DLB initiated on quetiapine or pimavanserin for psychosis. Primary outcome was time to discontinuation of pimavanserin or quetiapine using Kaplan-Meier survival analysis. We hypothesized the rate of antipsychotic discontinuation would be lower in the pimavanserin group. Subjects were included if the indication for treatment was psychosis and excluded if there was a history of major mental illness or no follow up data were available.

RESULTS

Forty-seven patients were included in the quetiapine cohort and 45 in the pimavanserin cohort. Patients in the pimavanserin cohort were more likely to have a diagnosis of DLB (33% vs. 11%, P = 0.01) and to have been prescribed an antipsychotic previously (62% vs. 6%, P < 0.01); otherwise, the groups were similar. Time to discontinuation analysis, which accounts for efficacy, safety and tolerability, revealed a lower early pimavanserin discontinuation rate and a higher late pimavanserin discontinuation rate (HR < 1 before day 43, HR > 1 after day 43; P = 0.04). There was no difference in mortality in the pimavanserin group compared to the quetiapine group (HR 0.37, 95% CI 0.06 to 2.45; P = 0.88). More individuals had a documented secondary indication for taking quetiapine than pimavanserin (38% vs. 4%; P = 0.001).

CONCLUSION

Accounting for efficacy, safety and tolerability, pimavanserin may be more clinically useful for promptly managing psychosis, while quetiapine may confer additional secondary benefits long-term.

Translational Investigation of the Therapeutic Potential of Cannabidiol (CBD): Toward a New Age

Background: Among the many cannabinoids in the cannabis plant, cannabidiol (CBD) is a compound that does not produce the typical subjective effects of marijuana. Objectives: The aim of the present review is to describe the main advances in the development of the experimental and clinical use of cannabidiol CBD in neuropsychiatry. Methods: A non-systematic search was performed for studies dealing with therapeutic applications of CBD, especially performed by Brazilian researchers. Results: CBD was shown to have anxiolytic, antipsychotic and neuroprotective properties. In addition, basic and clinical investigations on the effects of CBD have been carried out in the context of many other health conditions, including its potential use in epilepsy, substance abuse and dependence, schizophrenia, social phobia, post-traumatic stress, depression, bipolar disorder, sleep disorders, and Parkinson. Discussion: CBD is an useful and promising molecule that may help patients with a number of clinical conditions. Controlled clinical trials with different neuropsychiatric populations that are currently under investigation should bring important answers in the near future and support the translation of research findings to clinical settings.

Pimavanserin (Nuplazid™) for the treatment of Parkinson disease psychosis: A review of the literature

Introduction:

Pimavanserin (Nuplazid™) is an atypical antipsychotic currently indicated for the treatment of hallucinations and delusions associated with Parkinson disease psychosis. The antipsychotic effects of this new agent are believed to occur via selective inverse agonist activity at serotonin 5-HT_2a receptors.

Methods:

Study authors completed a literature review of 2 published randomized controlled trials of pimavanserin for the treatment of Parkinson disease psychosis. The Food and Drug Administration Briefing Document by the Psychopharmacologic Drugs Advisory Committee for the review of pimavanserin dated March 29, 2016, was reviewed for additional information on 2 unpublished trials.

Results:

Pimavanserin has demonstrated no worsening of motor symptoms of Parkinson disease, but only 1 of 4 trials has shown consistent statistically significant improvements in psychotic symptoms compared with placebo.

Discussion:

Options for the treatment of Parkinson disease psychosis are limited. The selective receptor profile of pimavanserin offers advantages for tolerability. Further studies are warranted to better provide clinicians and patients with information regarding the clinical utility of this agent.

Schizophrenia with Comorbid Idiopathic Parkinson's Disease: A Difficult Clinical Management Scenario

Comorbidity of idiopathic Parkinson's disease (IPD) and schizophrenia is an uncommon and rare scenario, which often poses a difficult and challenging situation for management. Both the disorders have completely opposite pathophysiology and treatment of one disorder with available pharmacological agents can pose a threat to the other disorder. The situation becomes graver and risk of adverse side effects increases when an individual presents at a later age with both these disorders along with compromised physical and mental health. Of all the available psychopharmacological agents, clozapine has been found to be quite helpful for the management of psychosis without deterioration of existing movement problems of Parkinson's disease. In this case report, we present the case of a 60-year-old female with long-standing paranoid schizophrenia for the last 30 years, who later developed IPD and discuss the various management issues encountered during her treatment.

Successful Use of Escitalopram for the Treatment of Visual Hallucinations in Patients With Parkinson Disease

INTRODUCTION

Patients with Parkinson disease (PD) frequently experience visual hallucinations (VH). Visual hallucinations are most often viewed as an adverse effect of antiparkinsonian treatment. Possible treatments for this disturbance include a reduction of antiparkinsonian medications, adding atypical antipsychotics, or cholinesterase inhibitors. Some studies demonstrated that selective serotonin reuptake inhibitors may be an optional treatment for patients experiencing psychosis or agitation in dementia. Currently, there is no standard recommended treatment for VH in patients with PD. We present here our clinical experience with escitalopram (selective serotonin reuptake inhibitor) for treating this disturbance.

METHODS

Thirteen patients with PD (8 men and 5 women; age range 67-83 years) experiencing VH were openly treated with escitalopram 10 or 15 mg/d as add-on. Efficacy was assessed at baseline, then after 4 and 8 weeks of treatment using Clinical Global Impression-Severity and Clinical Global Impression-Improvement.

RESULTS

At the end of the 4th week of treatment, of 13 patients, 11 subjects demonstrated improvement, and in only 2 patients were there no changes in their condition. After an additional 4 weeks, 2 of the responders showed very significant improvement, 6 demonstrated much improvement, and 3 patients demonstrated minimal improvement. Only 1 patient showed no change in his condition. One additional patient stopped taking escitalopram after 5 weeks because of an absence of improvement in his state.

CONCLUSIONS

Escitalopram was well tolerated as treatment of VH in PD patients. This medication could be a promising optional therapy for this disturbance; however, further randomized controlled and bigger studies are necessary.

Management of Psychosis in Parkinson's Disease: Emphasizing Clinical Subtypes and Pathophysiological Mechanisms of the Condition

Investigation into neuropsychiatric symptoms in Parkinson's disease (PD) is sparse and current drug development is mainly focused on the motor aspect of PD. The tight association of psychosis with an impaired quality of life in PD, together with an important underreporting of this comorbid condition, contributes to its actual insufficient assessment and management. Furthermore, the withdrawal from access to readily available treatment interventions is unacceptable and has an impact on PD prognosis. Despite its impact, to date no standardized guidelines to the adequate management of PD psychosis are available and they are therefore highly needed. Readily available knowledge on distinct clinical features as well as early biomarkers of psychosis in PD justifies the potential for its timely diagnosis and for early intervention strategies. Also, its specific characterisation opens up the possibility of further understanding the underlying pathophysiological mechanisms giving rise to more targeted therapeutic developments in the nearer future. A literature review on the most recent knowledge with special focus on specific clinical subtypes and pathophysiological mechanisms will not only contribute to an up to date practical approach of this condition for the health care providers, but furthermore open up new ideas for research in the near future.

Psychosis in Parkinson Disease: A Review of Etiology, Phenomenology, and Management

Parkinson disease psychosis (PDP) is a common phenomenon in Parkinson disease (PD) patients treated with dopaminergic drugs, and is associated with high morbidity and mortality. It also correlates with depression and dementia, and can contribute to considerable caregiver stress and burnout. While symptoms can be relieved by decreasing doses or number of anti-PD medications, this may lead to an unacceptable worsening of motor function. When general medical or psychiatric conditions have been ruled out, and decreasing dopaminergic agents is not effective in treating psychosis, therapies include atypical antipsychotics, primarily clozapine and quetiapine. Of these, clozapine is effective but is associated with a poor side-effect profile and the necessity for frequent blood draws. Clinicians prefer quetiapine for its theoretically better safety profile, although there is no evidence for efficacy in treating psychosis. All atypical antipsychotics are associated with increased mortality in this patient population. Cholinesterase inhibitors can ameliorate psychosis symptoms. The serotonin 5-HT_2A receptor inverse agonist pimavanserin was recently approved by the US FDA for the treatment of PDP and may prove to be a more targeted therapy without the downsides of atypical antipsychotics.

Medical mimics: Differential diagnostic considerations for psychiatric symptoms

Patients with underlying medical disease can present to the health care system with psychiatric symptoms predominating. Identification of an underlying medical condition masquerading as a psychiatric disorder can be challenging for clinicians, especially in patients with an existing psychiatric condition. The term medical mimic or secondary psychosis has been used to describe this clinical situation. Diagnostic categories from The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, that may encompass medical mimics include substance-induced disorders, which includes medications, and unspecified mental disorder due to another medical condition in situations where the clinician may lack needed information for a complete diagnosis. At this time, there is no single diagnostic test or procedure available to differentiate primary versus secondary psychosis on the basis of psychopathology presentation alone. When considering a diagnosis, clinicians should evaluate for the presence of atypical features uncharacteristic of the psychiatric symptoms observed; this may include changes in functionality and/or age of onset and symptom presentation severity. The purpose of this work is to provide a structured clinical framework for evaluation for medical mimics, identify groups considered to be at highest risk for medical mimics, and present common syndromic features suggestive of a medical mimic. Selected case scenarios are used to illustrate key concepts for evaluating and assessing a patient presenting with acute psychiatric symptomatology to improve judgment in ruling out potential medical causality.

The clinical symptoms of Parkinson's disease

In this review, the clinical features of Parkinson's disease, both motor and non-motor, are described in the context of the progression of the disease. Also briefly discussed are the major treatment strategies and their complications. Parkinson's disease is a slowly progressing neurodegenerative disorder, causing impaired motor function with slow movements, tremor and gait and balance disturbances. A variety of non-motor symptoms are common in Parkinson's disease. They include disturbed autonomic function with orthostatic hypotension, constipation and urinary disturbances, a variety of sleep disorders and a spectrum of neuropsychiatric symptoms. This article describes the different clinical symptoms that may occur and the clinical course of the disease. This article is part of a special issue on Parkinson disease.

MitoPark mice, an animal model of Parkinson's disease, show enhanced prepulse inhibition of acoustic startle and no loss of gating in response to the adenosine A(2A) antagonist SCH 412348

RATIONALE

Psychoses are debilitating side effects associated with current dopaminergic treatments for Parkinson's disease (PD). Prepulse inhibition (PPI), in which a non-startling stimulus reduces startle response to a subsequent startle-eliciting stimulus, is important in filtering out extraneous sensory stimuli. PPI deficits induced by dopamine agonists can model symptoms of psychosis. Adenosine A(2A) receptor antagonists, being developed as novel PD treatments, indirectly modulate dopamine signaling in the basal ganglia and may have an improved psychosis profile which could be detected using the PPI model.

OBJECTIVES

The aims of this study is to characterize PPI in MitoPark mice, which exhibit progressive loss of dopamine signaling and develop a Parkinson-like motor phenotype, and assess standard and novel PD treatment effects on PPI in MitoPark mice, which more closely mimic the basal ganglia dopamine status of PD patients.

RESULTS

MitoPark mice displayed enhanced PPI as dopamine tone decreased with age, consistent with studies in intact mice that show enhanced PPI in response to dopamine antagonists. Paradoxically, older MitoParks were more sensitive to PPI disruption when challenged with dopamine agonists such as apomorphine or pramipexole. Alternatively, SCH 412348, an adenosine A(2A) antagonist, did not disrupt PPI in MitoPark mice at doses that normalized hypoactivity.

CONCLUSION

Use of MitoPark mice in the PPI assay to assess the potential for PD treatment to produce psychoses likely represents a more disease-relevant model. SCH 412348 does not differentially disrupt PPI as do dopamine agonists, perhaps indicative of an improved psychosis profile of adenosine A(2A) antagonists, even in PD patients with decreased dopamine tone in the basal ganglia.

Nonmotor symptoms of Parkinson’s disease

Nonmotor symptoms occur commonly in Parkinson's disease (PD) patients and are frequently under-recognized and undertreated. Symptoms include sleep abnormalities, fatigue, autonomic disturbances, mood disorders and cognitive dysfunction. Early recognition and treatment of nonmotor symptoms in PD is critical to providing optimal management. A new screening questionnaire and the revised Unified PD Rating Scale should assist healthcare providers to better identify and evaluate these symptoms. This article reviews the identification and treatment of nonmotor symptoms in PD.

The current and projected economic burden of Parkinson's disease in the United States

Parkinson's disease (PD), following Alzheimer's disease, is the second-most common neurodegenerative disorder in the United States. A lack of treatment options for changing the trajectory of disease progression, in combination with an increasing elderly population, portends a rising economic burden on patients and payers. This study combined information from nationally representative surveys to create a burden of PD model. The model estimates disease prevalence, excess healthcare use and medical costs, and nonmedical costs for each demographic group defined by age and sex. Estimated prevalence rates and costs were applied to the U.S. Census Bureau's 2010 to 2050 population data to estimate current and projected burden based on changing demographics. We estimate that approximately 630,000 people in the United States had diagnosed PD in 2010, with diagnosed prevalence likely to double by 2040. The national economic burden of PD exceeds $14.4 billion in 2010 (approximately $22,800 per patient). The population with PD incurred medical expenses of approximately $14 billion in 2010, $8.1 billion higher ($12,800 per capita) than expected for a similar population without PD. Indirect costs (e.g., reduced employment) are conservatively estimated at $6.3 billion (or close to $10,000 per person with PD). The burden of chronic conditions such as PD is projected to grow substantially over the next few decades as the size of the elderly population grows. Such projections give impetus to the need for innovative new treatments to prevent, delay onset, or alleviate symptoms of PD and other similar diseases.

Relationship of dementia and visual hallucinations in tremor and non-tremor dominant Parkinson's disease

OBJECTIVES

Both visual hallucinations and cognitive dysfunction are experienced by a significant number of patients with Parkinson's disease. There were three main objectives of this study: (1) to determine if there is a difference in the prevalence of dementia in patients with tremor versus non-tremor dominant Parkinson's; (2) to determine if there is a difference of prevalence of visual hallucinations in patients with tremor and non-tremor dominant Parkinson's disease; and (3) to determine if there is a relationship between visual hallucinations and dementia in Parkinson's disease patients.

BACKGROUND

Dementia and visual hallucinations are common non-motor symptoms of Parkinson's disease that affect a significant number of patients. Previous research has shown that visual hallucinations may be predictive of future onset of dementia. We wanted to compare the prevalence of these non-motor symptoms in tremor vs. non-tremor dominant Parkinson's disease, although previous research has shown that dementia may be more common in the akinetic rigid variant of Parkinson's disease without tremor. Visual hallucinations have not yet been studied in this way.

METHODS

We performed a retrospective chart analysis on 314 patients with Parkinson's disease in this study. Patients meeting the inclusion criteria were stratified into several categories based on the presence or absence of tremor dominant PD, akinetic rigid dominant PD, dementia and visual hallucinations. Nonparametric tests were used for performing statistical analyses. The Chi Squared test was used for the analysis of categorical variables.

RESULTS

Patients without tremor had a higher prevalence of dementia (29%) than those with tremor (14%). There was no difference in visual hallucinations in tremor versus non-tremor patients, although there was a significant trend between tremor and visual hallucinations in female patients. A significant correlation was found between dementia and visual hallucinations in the sample, however further investigation showed this was largely associated with female Parkinson's disease patients.

Patterns and trends in antipsychotic prescribing for Parkinson disease psychosis

BACKGROUND

Antipsychotic (AP) use is common in Parkinson disease (PD), but APs can worsen parkinsonism, evidence for efficacy is limited, and use in patients with dementia increases mortality.

OBJECTIVE

To examine the frequency and characteristics, including changes over time, of AP use in a large cohort of patients with PD.

DESIGN

Using Veterans Affairs data from fiscal year (FY) 2008, rates and predictors of AP prescribing were determined for patients with PD and psychosis stratified by dementia status (N = 2597) and a comparison group of patients with dementia and psychosis without PD (N = 6907). Fiscal year 2008 and FY2002 data were compared to examine changes in AP prescribing over time.

SETTING

Department of Veterans Affairs outpatient facilities.

PARTICIPANTS

Outpatients with PD and psychosis and outpatients without PD with dementia and psychosis, all receiving care at Veterans Affairs facilities in FY2002 and FY2008.

MAIN OUTCOME MEASURE

Antipsychotic prescribing, including overall, class, and specific medications.

RESULTS

In FY2008, 50% of patients with PD having a diagnosis of psychosis were prescribed an AP. Among treated patients, the atypical AP quetiapine was most frequently prescribed (66%), but approximately 30% received high-potency APs. Clozapine was rarely prescribed (<2%). In multivariate models, diagnoses of PD and dementia were associated with AP use. Comparing FY2008 with FY2002, AP use in PD was unchanged, with decreases in risperidone and olanzapine use offset by an increase in quetiapine prescribing and the introduction of aripiprazole.

CONCLUSIONS

Half of the patients with PD and psychosis receive APs, not uncommonly high-potency agents associated with worsening parkinsonism, and frequency of use has been unchanged since the "black box" warning for AP use in patients with dementia was issued. Recent trends are a shift to quetiapine use and the common use of aripiprazole. As psychosis and dementia are frequently comorbid in PD, safety risks associated with AP use in this population need to be assessed.

Improvements in nocturnal symptoms with ropinirole prolonged release in patients with advanced Parkinson's disease

BACKGROUND

The 24-week, double-blind Efficacy and Safety Evaluation in PD-Adjunct (EASE-PD Adjunct) study randomized patients with advanced Parkinson's disease (PD) suboptimally controlled with levodopa to once-daily placebo or adjunctive ropinirole prolonged release (2-24 mg/day). We investigated the effect of ropinirole prolonged release on nocturnal symptoms in these patients.

METHODS

Total and grouped item PD Sleep Scale (PDSS) scores were analyzed post hoc in patients with baseline PDSS total scores ≤ 100 (troublesome nocturnal symptoms) and >100.

RESULTS

Baseline PDSS total score was ≤ 100 in 93 of 198 (47%) and 89 of 189 (47%) patients receiving ropinirole prolonged release and placebo, respectively; this subgroup displayed evidence at baseline of greater daily awake 'off' time, reduced night-time sleep and worse quality of life, than the PDSS >100 subgroup. Significant improvements with ropinirole prolonged release versus placebo in PDSS score from baseline to Week 24 last observation carried forward were observed for those with baseline PDSS ≤ 100 [adjusted mean treatment difference 9.0 (95% CI: 2.76, 15.33; P = 0.0051)], but not >100. The PDSS ≤ 100 subgroup demonstrated treatment benefits for PDSS groupings of motor symptoms on waking and global quality of sleep. Changes in daytime sleepiness were similar between treatment groups. The PDSS >100 subgroup demonstrated significant treatment benefit for global quality of sleep. The unadjusted odds ratio for a positive response with ropinirole prolonged release relative to placebo, for the PDSS ≤ 100 subgroup, was 2.90 (95% CI: 1.42, 5.95, P = 0.004).

CONCLUSIONS

Once-daily ropinirole prolonged release improves nocturnal symptoms in patients with advanced PD not optimally controlled with levodopa who suffer troublesome nocturnal disturbance.

Nonmotor symptoms in Parkinson’s disease: the dark side of the moon

Nonmotor symptoms may appear during the course of Parkinson’s disease, complicating the advanced phase in particular, but are also common in the premotor phase of Parkinson’s disease. The appearance of nonmotor manifestations represents a milestone, determining a worse prognosis and lower quality of life; however, they are often misdiagnosed and untreated. The spectrum of nonmotor symptoms encompasses mood disorders, psychosis, dementia, sleep disorders, impulse-control disorders and autonomic dysfunctions. This article describes these nonmotor symptoms and their management.

Hallucinations and psychosis in Parkinson's disease

Although Parkinson's disease (PD) is considered mainly a movement disorder, robust information accumulated during the last 30 years has shown that about 30% of PD patients may also suffer from psychosis, which deeply affects their quality of life and eventually brings them to permanent hospitalization in nursing homes. PD psychosis (PDPsy) mainly occurs after 10 or more years of treatment. The main features of PDPsy include recurrent and continuous hallucinations and delusions for at least 1 month. In addition, a recent consensus of the National Institute of Neurological Disorders and Stroke and National Institute of Mental Health Working Group also included illusions and a false sense of presence as "minor symptoms" supporting the diagnosis. In addition, accumulated clinical data have shown that "minor symptoms" and benign hallucinations also imply a bad prognosis with time. In the diagnostic criteria for PDPsy, it is considered that patients suffer from PD for at least more than 1 year before psychosis develops. If this is not the case, there is an unsolved problem of an overlapping diagnosis with Dementia with Lewy Bodies. Most clinicians consider that the main cause of psychosis is chronic exposure to dopaminergic medication. However, from an operational point of view there remain difficulties in defining a specific time of exposure and dose of treatment and the occurrence of PDPsy. Specific rating scales have been developed for the evaluation of PDPsy, such as the Parkinson Psychosis Rating Scale. The Scale for the Assessment of Positive Symptoms usually applied in schizophrenic patients has also proved useful for scoring psychotic symptomatology in PD. Clozapine in low doses has been proven to be the most effective antipsychotic medication for PDPsy. However, its use may cause neutropenia. Therefore, new atypical antipsychotic drugs with serotonin 5-HT2A receptor inverse agonist properties have been developed. Recently, pimavanserin--a 5-HT2A inverse agonist--has been studied. We hope that soon we will have the possibility to include new agents for the management of PDPsy.

An interpretative phenomenological analysis of delusions in people with Parkinson's disease

PURPOSE

The aim of this qualitative study was to explore what delusional experiences mean for people with Parkinson's disease (PD) and to examine how psychosocial factors contribute to the development and maintenance of delusional beliefs.

METHOD

Eight participants were interviewed, and interpretative phenomenological analysis was used to identity themes within their accounts. Participants were either recruited from a hospital-based outpatient movement disorder clinic or from a PD support group in the north-west of England.

RESULTS

Four themes emerged from the analysis: (1) 'I got very frightened': The emotional experience associated with delusions; (2) 'Why the hell's that happening?': Sense of uncertainty and of losing control; (3) 'I feel like I'm disintegrating': Loss of identity and sense of self; (4) 'I've just tried to make the best of things': Acceptance and adjustment to experience of delusions. These interconnected themes in participants' accounts of delusional beliefs were reflected in their descriptions of living with, and adjusting to, PD.

CONCLUSIONS

The results of this study add to the evidence base indicating the urgent examination of psychological alternatives to conventional, medication-based approaches to alleviating the distress caused by delusions in people with PD.

Uso terapêutico dos canabinoides em psiquiatria

OBJETIVO: Revisar os principais avanços no potencial uso terapêutico de alguns compostos canabinoides em psiquiatria. MÉTODO: Foi realizada busca nos bancos de dado PubMed, SciELO e Lilacs e identificados estudos e revisões da literatura sobre o uso terapêutico dos canabinoides em psiquiatria, em particular canabidiol, rimonabanto, Δ9-tetraidrocanabinol e seus análogos. RESULTADOS: O canabidiol demonstrou apresentar potencial terapêutico como antipsicótico, ansiolítico, antidepressivo e em diversas outras condições. O Δ9-tetraidrocanabinol e seus análogos demonstraram efeitos ansiolíticos, na dependência de cannabis, bem como adjuvantes no tratamento de esquizofrenia, apesar de ainda carecerem de mais estudos. O rimonabanto demonstrou eficácia no tratamento de sintomas subjetivos e fisiológicos da intoxicação pela cannabis e como adjuvante no tratamento do tabagismo. Os potenciais efeitos colaterais, de induzir depressão e ansiedade limitaram o uso clínico deste antagonista CB1. CONCLUSÃO: Os canabinoides têm demonstrado que podem ter amplo interesse terapêutico em psiquiatria, porém mais estudos controlados são necessários para confirmar estes achados e determinar a segurança destes compostos.

Cannabidiol for the treatment of psychosis in Parkinson's disease

The management of psychosis in Parkinson's disease (PD) has been considered a great challenge for clinicians and there is a need for new pharmacological intervention. Previously an antipsychotic and neuroprotective effect of Cannabidiol (CBD) has been suggested. Therefore, the aim of the present study was to directly evaluate for the first time, the efficacy, tolerability and safety of CBD on PD patients with psychotic symptoms. This was an open-label pilot study. Six consecutive outpatients (four men and two women) with the diagnosis of PD and who had psychosis for at least 3 months were selected for the study. All patients received CBD in flexible dose (started with an oral dose of 150 mg/day) for 4 weeks, in addition to their usual therapy. The psychotic symptoms evaluated by the Brief Psychiatric Rating Scale and the Parkinson Psychosis Questionnaire showed a significant decrease under CBD treatment. CBD did not worsen the motor function and decreased the total scores of the Unified Parkinson's Disease Rating Scale. No adverse effect was observed during the treatment. These preliminary data suggest that CBD may be effective, safe and well tolerated for the treatment of the psychosis in PD.

Parkinson disease: systemic and orofacial manifestations, medical and dental management

BACKGROUND

More than 1.5 million Americans have Parkinson disease (PD), and this figure is expected to rise as the population ages. However, the dental literature offers little information about the illness.

TYPES OF STUDIES REVIEWED

The authors conducted a MEDLINE search using the key terms "Parkinson's disease," "medical management" and "dentistry." They selected contemporaneous articles published in peer-reviewed journals and gave preference to articles reporting randomized controlled trials.

RESULTS

PD is a progressive neurodegenerative disorder caused by loss of dopaminergic and nondopaminergic neurons in the brain. These deficits result in tremor, slowness of movement, rigidity, postural instability and autonomic and behavioral dysfunction. Treatment consists of administering medications that replace dopamine, stimulate dopamine receptors and modulate other neurotransmitter systems.

CLINICAL IMPLICATIONS

Oral health may decline because of tremors, muscle rigidity and cognitive deficits. The dentist should consult with the patient's physician to establish the patient's competence to provide informed consent and to determine the presence of comorbid illnesses. Scheduling short morning appointments that begin 90 minutes after administration of PD medication enhances the patient's ability to cooperate with care. Inclination of the dental chair at 45 degrees, placement of a bite prop, use of a rubber dam and high-volume oral evacuation enhance airway protection. To avoid adverse drug interactions with levodopa and entacapone, the dentist should limit administration of local anesthetic agents to three cartridges of 2 percent lidocaine with 1:100,000 epinephrine per half hour, and patients receiving selegiline should not be given agents containing epinephrine or levonordefrin. The dentist should instruct the patient and the caregiver in good oral hygiene techniques.

Development of Parkinsonism following exposure to aripiprazole: two case reports

INTRODUCTION

Aripiprazole is a novel atypical neuroleptic used in the treatment of psychosis. A few recent studies have demonstrated an association between the use of aripiprazole and an exacerbation of Parkinsonism, although this relationship is poorly defined. To our knowledge, this is the first case series describing an onset of Parkinsonism in patients without prior history of Parkinson's disease following aripiprazole treatment.

CASE PRESENTATION

We describe two patients, ages 69 and 58, who developed cardinal features of Parkinson's disease shortly after receiving aripiprazole. Both patients were male veterans with a history of bipolar disorder treated with aripiprazole. They initially presented with asymmetric arm tremor, and subsequently developed rigidity, bradykinesia, and postural instability. On examination, they were found to be at a Hoehn and Yahr stage of 2.5 for their Parkinsonism.

CONCLUSIONS

While aripiprazole has been associated with infrequent extrapyramidal side effects, these cases raise concerns that its chronic exposure may lead to D2 receptor hypersensitivity and/or dysfunction and subsequent development of a syndrome mimicking idiopathic Parkinson's disease. With the available atypical neuroleptics becoming widely used in treating psychotic symptoms associated with a broad range of disorders, we advise closer monitoring due to their potential for inducing Parkinsonism.

Auditory hallucinations in those populations that do not suffer from schizophrenia

The following article discusses the phenomenon of auditory hallucinations in those who do not suffer from schizophrenia. Research has shown the occurrence of auditory hallucinations in the general population to such an extent that they cannot be said to be pathognomonic of psychiatric illness. In addition, it has long been known that certain hallucinatory experiences occur in health, such as hypnagogic and hypnopompic hallucinations. However, there are fundamental differences in the characteristics of these experiences. In the psychiatric population, these tend to be frequent, intrusive, and distressing. In contrast, in the nonclinical population, these are often predominantly positive and nonthreatening. The exact mechanism for the occurrence of auditory hallucinations is not yet known, but it is hoped that through the study of those in health, the mechanisms that underpin pathophysiologic processes in clinical conditions also can be elucidated.

Recent Publications on Medications and Pharmacy

Hospital Pharmacy presents this new feature to keep pharmacists abreast of new publications in the medical/pharmacy literature. Articles of interest will be abstracted monthly regarding a broad scope of topics.