Monotherapy versus polypharmacy for hospitalized psychiatric patients.
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Antipsychotic Agents↗
Biomedical subjects
Vladimir Lerner
Publications and source records attributed to Vladimir Lerner.
The appearance of the artist to the people: the creativity, personality and malady of Alexander Ivanov (1806-58).
Alexander Ivanov was an outstanding Russian painter who lived in the middle of the nineteenth century, during the romantic period. He did not accept romanticism but instead tried to create his own original style, an ambitious combination of spiritual profundity and a manner of execution unparalleled in Western European art. Ivanov's intention and style are best reflected in his major work The Appearance of Christ to the People, a picture on which he worked for over 20 years. He painted more than 400 sketches of the picture while attempting to bring his masterpiece to perfection. At the end of his life Ivanov became disillusioned, renounced his strong religious conviction and became suspicious. This study examines the influence of his background, life story and personality on the creative process. From a diagnostic perspective, Ivanov's personality featured obsessive, narcissistic and schizoid traits. In his final years he suffered from a delusional disorder.
Creativity↗
Beneficial effect of donepezil in the treatment of elderly patients with tardive movement disorders.
BACKGROUND: Tardive dyskinesia and other delayed-onset abnormal involuntary movement disorders may occur as a result of the use of psychotropic drugs. A distinction is usually made between classic tardive dyskinesia (TD) (orobuccal-lingual-facial) and tardive dystonia, tardive tremor (TT), tardive akathisia, and other related syndromes. In spite of the development of atypical antipsychotics with fewer side effects, tardive movement disorders nevertheless continue to present a significant clinical and therapeutic challenge. Several reports have suggested that donepezil may be helpful in the treatment of TD. METHOD: A preliminary study was conducted of 7 patients (5 women and 2 men) enrolled over a period of 6 months who had been experiencing TT for a period of at least 1 year. The ages of the patients ranged from 64 to 79 years, and all patients were on stable antipsychotic therapy. Donepezil was added to their usual treatment for 8 weeks. The severity of patients' extrapyramidal symptoms was assessed using the tremor subscale of the Simpson-Angus Scale (SAS) and self-rated with a modification of the Clinical Global Impressions scale, the Subjective Clinical Improvement Impression scale. The clinical response was evaluated by comparing the rating scores at baseline prior to donepezil treatment and every 2 weeks thereafter. RESULTS: The addition of donepezil (up to 10 mg/day) was associated with a clinically significant improvement (from 37.5% to 63.6%) on the SAS tremor subscale following 4 weeks of therapy. Only 1 patient discontinued follow-up due to side effects. CONCLUSION: The results suggest that donepezil may be effective in the treatment of TT, and this finding should be evaluated further by a randomized controlled study.
Aged↗
Combination of "atypical" antipsychotic medication in the management of treatment-resistant schizophrenia and schizoaffective disorder.
BACKGROUND: This article reviews the published clinical data on treatment-resistant schizophrenic and schizoaffective patients managed with combinations of "atypical" antipsychotic medication. METHOD: A computerized MEDLINE literature search covering an 18-year period (1985-2003) was conducted. All pertinent papers on the subject of the use of combination "atypical" antipsychotic medication in the management of treatment-resistant schizophrenia and schizoaffective disorder were obtained with subsequent analysis and discussion of the retrieved data. RESULTS: The search identified 29 case reports and case series reports (172 patients) and one double-blind placebo-controlled trial (28 patients) describing the use of combination "atypical" antipsychotic medication (clozapine-risperidone; clozapine-sulpiride; clozapine-olanzapine; clozapine-quetiapine; olanzapine-sulpiride; olanzapine-quetiapine; risperidone-olanzapine; risperidone-quetiapine) in the treatment of resistant schizophrenic and schizoaffective patients. An overview of results suggests that the combinations were beneficial in the described patients with reduction of positive symptoms and occasionally negative symptoms. Significant adverse effects, while rare, were reported in a few cases and did not appear to different in nature from those managed on monotherapeutic regimens. CONCLUSION: Combinations of "atypical" antipsychotic medications are well tolerated and may be effective in the management of treatment refractory schizophrenia and schizoaffective disorder. However, further double-blind placebo-controlled trials are required in order to test and confirm these observations.
Antipsychotic Agents↗
Vitamin B6 treatment in acute neuroleptic-induced akathisia: a randomized, double-blind, placebo-controlled study.
BACKGROUND: Treatment strategies for acute neuroleptic-induced akathisia (NIA) contain anticholinergic (antimuscarinic) agents, dopamine agonists, gamma-aminobutyric acid (GABA)-ergic agents, beta-blockers, benzodiazepines, and serotonin antagonists. Nevertheless, many patients who suffer from acute akathisia fail to respond to treatment. In earlier studies, vitamin B6 was found to be effective in the treatment of neuroleptic-induced movement disorders. The purpose of this study was to evaluate the efficacy of vitamin B6 in the treatment of acute NIA. This is the first report of B6 as a treatment for NIA. METHOD: This study was conducted in 2 mental health centers from February 2003 to November 2003. Twenty schizophrenia and schizoaffective inpatients with a DSM-IV diagnosis of NIA were randomly divided to receive vitamin B6 600 mg/day b.i.d. (N = 10) or placebo (N = 10) twice a day for 5 days in a double-blind design. The Barnes Akathisia Scale (BAS), the Brief Psychiatric Rating Scale (BPRS), and the Clinical Global Impressions scale (CGI) were used to assess the severity of NIA and psychotic symptoms. The BAS assessment was made at baseline and every day during the study. The BPRS and CGI were completed at baseline and at the end of the study. RESULTS: The vitamin B6-treated patients in comparison with the placebo group showed a significant improvement on the subjective-awareness of restlessness (p = .0004), subjective-distress (p = .01), and global (p = .004) subscales of the BAS. The objective subscale did not demonstrate significant positive results (p = .079), but there was a trend of symptom amelioration in the vitamin B6 group. A reduction of at least 2 points on the BAS global subscale was noted in 8 patients in the vitamin B6 group (80%), and in only 3 patients in the placebo group (30%) (p = .037). CONCLUSION: Our preliminary results indicate that high doses of vitamin B6 may be useful additions to the available treatments for NIA, perhaps due to its combined effects on various neurotransmitter systems.
Acute Disease↗
Victor Kandinsky, MD: psychiatrist, researcher and patient.
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Episode of Care↗
The flight and the downfall of the demon: creativity and illness in Vrubel's life.
The life of Mikhail Vrubel (1856-1910), the Russian painter, combined remarkable artistic accomplishments with severe psychopathology. We have attempted to examine the influence of the changes in the artist's emotional state on the creative process. The contradictions that abound in the descriptions of Vrubel's character and conduct should, in all likelihood, be attributed not only to the complexity of his personality but also to the effect of psychopathology on his behaviour. We believe that Vrubel suffered from mood disorder, complicated by syphilis.
Bipolar Disorder↗
High-dose olanzapine-induced improvement of preexisting type 2 diabetes mellitus in schizophrenic patients.
OBJECTIVE: During the last few years there have been numerous publications concerning glucose dysregulation and antipsychotic treatment with new-onset diabetes and exacerbation of existing disease being reported. At the same time three anecdotal reports describing decrease of blood glucose level during clozapine and olanzapine treatment were published. Here we report two cases of clinically significant dose-related reductions in glucose levels in schizophrenic and schizoaffective patients suffering from pre-existing type 2 diabetes during high dose (40 mg/day) olanzapine treatment. To the best of our knowledge, this is a first report of decreasing glucose blood levels in association with olanzapine therapy in pre-existing type 2 diabetes. Antipsychotic treatment with high doses of olanzapine showed that the relationship between olanzapine and glucose regulation is more unambiguous than usually assumed. CONCLUSIONS: There is a need for further studies in order to define the influence of high dose olanzapine for schizophrenic and schizoaffective patients suffering from type 2 diabetes.
Antipsychotic Agents↗
Kandinsky-Clerambault's Syndrome: concept of use for Western psychiatry.
The aim of our paper is to describe Kandinsky-Clerambault's Syndrome, which has important cultural-historical value in the history of psychiatry, and to illustrate the syndrome by means of a case report. Although its component symptoms are known among Western psychiatrists, the syndrome's specific name is generally unknown. The authors suggest that detailed clinical descriptions of some specific conditions may contribute to a more detailed knowledge of psychopathology, a more colorful and memorable view of conditions, with an increased awareness of the historical and cultural origins of psychiatry.
Adult↗
[Vitamin B6 add-on therapy in treatment of schizophrenic patients with psychotic symptoms and movement disorders].
INTRODUCTION: Although there is great progress in the treatment of positive symptoms in schizophrenic patients and movement disorders induced by neuroleptics, it is still a problem for clinicians. In this study vitamin B6 treatment was provided to 15 patients who suffered from schizophrenia and schizoaffective disorder with positive psychotic symptoms and tardive dyskinesia. METHODS: This study was a double-blind crossover controlled during 9 weeks. Each patient was treated with up to 400 mg/day vitamin B6 versus placebo. Every week the patients' conditions were evaluated with Positive and Negative Symptoms Scale (PANSS), Extrapyramidal Symptoms Rating Scale (ESRS) and a blood sample of level pyridoxal was taken. RESULTS: The results did not show any therapeutic effect of psychotic symptoms from vitamin B6 added to antipsychotic agents, which patients received on a constant base. On the other hand, there was significant improvement in tardive dyskinesia and parkinsonian symptoms. There was no direct correlation between pathological symptoms and the serum baseline level of vitamin B6 nor its level during the treatment. CONCLUSION: The authors suggest that vitamin B6 may be efficient as the treatment for tardive dyskinesia and parkinsonism induced by neuroleptic agents. There is a need for further studies with larger samples and higher doses of vitamin B6 in order to examine the possibility of a positive therapeutic effect as an augmentation agent for the treatment of psychotic symptoms.
Adolescent↗
Creativity and affective illness.
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Bipolar Disorder↗
Acute dementia with delirium due to vitamin B12 deficiency: a case report.
OBJECTIVE: Vitamin B12 (cobalamin) is a key component in the catabolism of monoamines. B12 deficiency is associated with various neuropsychiatric disorders and may be more frequent in psychiatric inpatients. The authors describe a case report of a newly admitted and relatively young patient (52 years old) with organic psychosis secondary to vitamin B12 deficiency. No other overt clinical features of cobalamin deficit were observed. Symptoms were resolved with B12 and folate replacement. The patient's mental status remained stable over the 3 months after the treatment. The authors note that organic mental changes were reversible with B12 replacement. CONCLUSIONS: The authors propose that determination of serum vitamin B12 and folic acid levels should be recommended as routine screening in all new admissions of psychiatric patients regardless of their age or previous state of health.
Humans↗
Lithium-induced tremor treated with vitamin B6: a preliminary case series.
OBJECTIVE: The occurrence of tremor in patients receiving lithium is well known, but the management of this side effect is a significant problem both for patients and physicians. Although some reports have suggested that beta-blockers may be useful in treating lithium-induced tremor (LT), these agents have different side effects which limit the possibility of their use. Vitamin B6 has been reported to be effective in treatment of patients suffering from different kinds of neuroleptic-induced movement disorders including parkinsonism and tardive dyskinesia. METHODS: This report presents the results of a preliminary four-week open-label clinical trial of five patients who suffered from LT and who were treated with vitamin B6 (900-1200 mg/d). The severity of tremor was assessed using the tremor subscale from the Simpson-Angus Scale (SAS) and Subjective Clinical Improvement Impression scale (SCII). RESULTS: After the addition of vitamin B6 to their treatment, according to the SAS scores four patients showed an impressive improvement until total disappearance of tremor. The subjective scale, on which the patients' scored their impression of clinical improvement, showed similar results. None of the patients suffered from any side effects attributable to vitamin B6. CONCLUSIONS: The results suggest that vitamin B6 may alleviate LT, double-blind controlled trials are needed to establish this effect.
Adult↗
Vitamin B6 as add-on treatment in chronic schizophrenic and schizoaffective patients: a double-blind, placebo-controlled study.
BACKGROUND: Vitamin B6, or pyridoxine, plays an intrinsic role in the synthesis of certain neurotransmitters that take part in development of psychotic states. Several reports indicate that vitamin B6 may be a factor in a number of psychiatric disorders and related conditions, such as autism, Alzheimer's disease, hyperactivity, learning disability, anxiety disorder, and depression. Moreover, there are anecdotal reports of a reduction in psychotic symptoms after vitamin B6 supplementation of psychopharmacologic treatment of patients suffering from schizophrenia or organic mental disorder. The aim of this study was to examine whether vitamin B6 therapy influences psychotic symptoms in patients suffering from schizophrenia and schizoaffective disorder. METHOD: The effects of the supplementation of vitamin B6 to antipsychotic treatment on positive and negative symptoms in 15 schizophrenic and schizoaffective patients (DSM-IV criteria) were examined in a double-blind, placebo-controlled, crossover study spanning 9 weeks. All patients had stable psychopathology for at least 1 month before entry into the study and were maintained on treatment with their prestudy psychoactive and antiparkinsonian medications throughout the study. All patients were assessed using the Positive and Negative Syndrome Scale (PANSS) for schizophrenia on a weekly basis. Patients randomly received placebo or vitamin B6, starting at 100 mg/day in the first week and increasing to 400 mg/day in the fourth week by 100-mg increments each week. RESULTS: PANSS scores revealed no differences between vitamin B6- and placebo-treated patients in amelioration of their mental state. CONCLUSION: Further studies with larger populations and shorter duration of illness are needed to clarify the question of the possible efficacy of vitamin B6 in treatment of psychotic symptoms in schizophrenia.
Adult↗
Successful use of donepezil for the treatment of psychotic symptoms in patients with Parkinson's disease.
The risk of psychosis among patients with Parkinson's disease (PD) is high, and the management of these patients remains a substantial problem for physicians. Atypical antipsychotics, despite their advantages over conventional antipsychotics, can cause different side effects and deterioration of PD. Several reports have suggested that donepezil can be helpful in the treatment of psychotic conditions in patients with dementia with Lewy bodies and Alzheimer's disease. This report presents the results of preliminary study of six patients (four women, two men; age range, 60-75 years) with PD (range of duration, 3-7 years) and dementia complicated by psychosis. All patients were treated with antiparkinsonian therapy, and donepezil was added to their regular treatment. The severity of the psychotic symptoms was assessed using the Scale for the Assessment of Positive Symptoms, and extrapyramidal symptoms were assessed using the Simpson-Angus Scale. With the addition of donepezil (as much as 10 mg/day) to their constant antiparkinsonian treatment, five patients had clinically significant (more than 53%) improvement on the assessment scale, and one patient had minimal (24%) improvement after 6 weeks of the treatment. None of the patients had side effects or deterioration of parkinsonian symptoms. The results suggest that donepezil may ameliorate psychotic symptoms in patients with PD, but this will need to be tested further in controlled, double-blind trials.
Aged↗
High-dose olanzapine for treatment-refractory schizophrenia.
To date there is no common or adequate therapeutic strategy for treatment of refractory schizophrenic patients. Increasing antipsychotics' doses in treatment-resistant schizophrenic patients is the most common intervention used by clinicians. Olanzapine is an atypical antipsychotic, which in a number of double-blind, placebo-controlled studies has been found to be more effective than haloperidol for the treatment of positive and negative symptoms of schizophrenia. During the last few years there have been several reports of successful results in prescribing olanzapine at dosages of more than 25 mg/day for treatment-resistant schizophrenic and schizoaffective patients. This report presents the results from the treatment of three resistant schizophrenic patients treated successfully with high dosages of olanzapine (35, 40, and 60 mg/day). None of the patients had any side effects, including abnormal laboratory levels and weight gain. The results and literature data suggest that in clinical practice some schizophrenic patients resistant to conventional neuroleptic treatment and not responding to olanzapine at recommended dosages as high as 20 mg/day may respond to higher dosages such as 40 or 60 mg/day, and these dosages are well tolerated. Further prospective clinical studies are needed.
Adult↗
Donepezil as add-on treatment of psychotic symptoms in patients with dementia of the Alzheimer's type.
Traditionally, the neuropsychiatric symptoms of Alzheimer's disease (AD) have been managed with neuroleptics or benzodiazepines, which have serious side effects. Preliminary observations suggest the possible value of cholinesterase inhibitors in the amelioration of psychotic symptoms in patients with dementia of the Alzheimer's type, dementia with Lewy bodies, and in patients with Parkinson's disease. Twelve inpatients with AD with psychotic symptoms and lack of improvement of their delusions/hallucinations during perphenazine treatment (8 mg/day) for 3 weeks received random open-label donepezil 5 mg daily in addition to an ongoing treatment of 8 mg/day perphenazine or 16 mg/day perphenazine. Assessments conducted at baseline and after weeks 2 and 4 included the Mini-Mental State Examination, the Global Deterioration Scale, the Positive and Negative Symptoms Scale, and the Clinical Global Impressions scale. Frequency of extrapyramidal symptoms was measured according to the Abnormal Involuntary Movement Scale. The donepezil-perphenazine group exhibited substantially greater and clinical improvements in mental state. At the end of the trial (4 weeks), Positive and Negative Symptoms Scale scores revealed significant differences between both groups (p = 0.006). The Clinical Global Impressions scale and the Mini-Mental State Examination scores also showed significant differences between the donepezil-perphenazine group and the perphenazine group (p = 0.028 and p = 0.027 respectively). No significant differences were found in the Global Deterioration Scale scores. Abnormal Involuntary Movement Scale scores showed a significant deterioration in extrapyramidal symptoms in the perphenazine group compared with the donepezil-perphenazine group (p = 0.016). Donepezil augmentation of neuroleptics may be appropriate for those patients for whom neuroleptic monotherapy either does not lead to symptom remission or is associated with intolerable adverse effects. This was an open-label study and there is need for larger studies with double-blind control and a long-term study design to define the efficacy of donepezil for patients with AD and psychotic symptoms.
Aged↗
Augmentation with amisulpride for schizophrenic patients nonresponsive to antipsychotic monotherapy.
Despite the effectiveness of antipsychotic medications in treatment of schizophrenia, about 30% of patients who receive an adequate treatment have significant persisting symptoms. The problem of treatment-resistant psychosis is an important and difficult one. The aim of this study was to retrospectively evaluate the efficacy and safety of amisulpride augmentation in treatment-resistant schizophrenic patients. To the best of our knowledge, this is the first report about resistant schizophrenic and schizoaffective patients treated with the combinations of risperidone and amisulpride and ziprasidone and amisulpride. Data were collected from patient records. A total of 15 resistant schizophrenic patients (7 men, 8 women, 54.0 +/- 16.9 years old) were included in the study. Before addition of amisulpride, the patients were treated with monotherapy by atypical neuroleptics (clozapine, olanzapine, risperidone, or ziprasidone). The mean amisulpride dose was 693.3 +/- 279.6 mg/d. The mental state of 12 (80%) patients treated with combination was improved. Three (20%) patients showed no change in their mental state. Only 2 patients treated with a combination of risperidone and amisulpride had mild side effects. The results are preliminary and require confirmation in a randomized controlled trial. The authors suggest that amisulpride may be a promising option as an augmentation strategy in treatment-resistant schizophrenic patients.
Adult↗