Clozapine withdrawal catatonia, psychosis and associated neuroleptic malignant syndrome

© 2017 Elsevier. This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (August 2017) in accordance with the publisher's archiving policy

Divided we fall: clinicians and academic psychiatrists need to stand together

Copyright © 2017 The Royal Australian and New Zealand College of Psychiatrists. Reprinted by permission of SAGE PublicationsObjective: Psychiatry faces urgent problems requiring united action. These problems affect academic psychiatrists in the universities, and clinicians in publicly funded mental health services. Academic units are isolated and endangered, finding it difficult to recruit. They could benefit from closer relationships with public mental health services, in terms of recruitment, shared teaching and clinical research. However, mental health services are preoccupied with their own problems, particularly in relation to acute clinical demand. How can we stand together to improve academic units and clinical psychiatry? Conclusions: Clinicians and academic psychiatrists can stand together on important matters, but it takes initiatives from local leaders to overcome the structural barriers between health services and the universities. An example is given of united action by clinicians and academic psychiatrists to address a crisis within a state mental health system. First, psychiatrists undertook independent health services research that compared the state system with those in other Australian and international jurisdictions. The comparative data was used to generate solutions, which were presented at every level from ministerial offices through to service managers. Finally, psychiatrists took up joint academic and clinical leadership roles in the university and the mental health system. This united research-led approach turned around the crisis in the state mental health syste

Australian private practice metropolitan telepsychiatry during the COVID-19 pandemic: analysis of Quarter-2, 2020 usage of new MBS-telehealth item psychiatrist services

Objective: The Australian Commonwealth Government introduced new psychiatrist Medicare-Benefits-Schedule (MBS)-telehealth items in the first wave of the COVID-19 pandemic to assist with previously office-based psychiatric practice. We investigate private psychiatrists’ uptake of (1) video- and telephone-telehealth consultations for Quarter-2 (April–June) of 2020 and (2) total telehealth and face-to-face consultations in Quarter-2, 2020 in comparison to Quarter-2, 2019 for Australia. Methods: MBS item service data were extracted for COVID-19-psychiatrist-video- and telephone-telehealth item numbers and compared with a baseline of the Quarter-2, 2019 (April–June 2019) of face-to-face consultations for the whole of Australia. Results: Combined telehealth and face-to-face psychiatry consultations rose during the first wave of the pandemic in Quarter-2, 2020 by 14% compared to Quarter-2, 2019 and telehealth was approximately half of this total. Face-toface consultations in 2020 comprised only 56% of the comparative Quarter-2, 2019 consultations. Most telehealth provision was by telephone for short consultations of ⩽15–30 min. Video consultations comprised 38% of the total telehealth provision (for new patient assessments and longer consultations). Conclusions: There has been a flexible, rapid response to patient demand by private psychiatrists using the new COVID-19-MBS-telehealth items for Quarter-2, 2020, and in the context of decreased face-to-face consultations, ongoing telehealth is essential

Conversion Parkinson’s Disease with Levodopa Abuse and Psychosis

This manuscript version is made available under the CC-BY-NC-ND 4.0 license http://creativecommons.org/licenses/by-nc-nd/4.0/ This author accepted manuscript is made available following 12 month embargo from date of publication (Sept 2017) in accordance with the publisher’s archiving policyConversion disorder (CD) now recognised as functional neurological symptom disorder (DSMV) presents with physical symptoms that are not well explained by organic aetiology. We describe a unique case of Conversion Parkinson’s Disease (PD)

Neuropsychiatric aspects of frontal lobe meningioma

© 2017 Elsevier B.V. This manuscript version is made available under the CC-BY-NC-ND 4.0 license: http://creativecommons.org/licenses/by-nc-nd/4.0/Brain tumours are known to typically present with neurological signs. Rarely, psychiatric symptoms can be the only manifestation of a brain tumour (Madhusoodanan et al., 2015). Though it is not uncommon for patients to present with psychiatric symptoms as the first clinical manifestation of a brain tumour, they are often non-specific and do not assist in localising the lesion. With the limited available research, it is found that neuropsychiatric disturbances are more frequently associated with frontal and temporolimbic lesions (Filley and Kleinschmidt-DeMasters, 1995). We present a case of a woman with frontal lobe meningioma who presented with a neuropsychiatric syndrome. Ms S is a 50 years old woman with chronic schizophrenia that was stable for several years on a combination of 4 mg of Risperidone and 50 mg of Quetiapine. In early April, she presented with abrupt onset of fever, tremors, generalised weakness, lethargy, confusion, vomiting and loose bowels. On examination, she was noted to have a body temperature of 37.8 °C with borderline tachycardia, bradykinesia, cogwheel rigidity and increased deep tendon reflexes. She did not have diaphoresis or autonomic instability. Laboratory tests showed elevated Creatine Kinase (CK) of 1800 U/L and neutrophilia. With clinical suspicion for NMS, her antipsychotic medications were ceased leading to a decrease in her CK to 60. She was discharged after being commenced on Olanzapine 2.5 mg daily, with positive effect for her psychotic symptoms. Nine days following discharge Ms S presented again with some symptoms of NMS such as worsening tremors, two episodes of fever, rigidity, bradykinesia and was disoriented to time. Her CK and white cell count, however, were within normal levels. She also had catatonic features such as increasingly withdrawn behaviour, mutism and negativism. On hospital presentation, she was afebrile and septic screen was negative, and she was admitted to the psychiatric unit for further investigation. Whilst assessment by the emergency physician suggested that the etiology of her symptoms were related to psychotropic drugs, the psychiatrist opined that it was more likely to be delirium and also considered a differential diagnosis of organic catatonia. CT head was done following the recommendation of the psychiatrist and it showed left frontal lobe meningioma with 12 cm midline shift with surrounding oedema. Ms S then was referred to the neurosurgery department and underwent surgical resection of the meningioma, which was successful. Ms S was a patient with a stable psychiatric illness, who presented with overlapping features of NMS and catatonia but no overt psychotic symptoms. Her neuropsychiatric symptoms were likely to be the pressure effect of a left frontal meningioma. The nature of her presentation made the process of diagnosis challenging, especially with the initial absence of neuroimaging, which resulted in a delay in diagnosis and appropriate treatment. Frontal lobe tumours have higher chances of producing mental status and personality changes with left sided lesions being more associated with inhibition of motor activity, impairment in motor and initiative aspect of speech, diminished generalization ability and general inertia of mental processes as seen in Ms S (Belyi, 1987). Given the absence of frank neurological symptoms to help localise the lesion, a high degree of clinical suspicion is usually required for early diagnosis. In patients suffering from schizophrenia, these symptoms can be explained by the illness itself and the side effects of the medications, thereby increasing the chances of missing the organic pathology due to diagnostic overshadowing of the primary psychiatric illness. Neuroimaging should be considered in patients with atypical psychiatric symptoms, new-onset psychosis, recurrence of previously well-controlled psychiatric symptoms, and if they become refractory to psychiatric treatment (Madhusoodanan et al., 2015). Clinical suspicion must be raised when these symptoms are vague, rare, non-specific, with no clear cause or trigger and are associated with several causative etiologies. Despite the many studies that have been done to correlate clinical presentation to the location of brain lesions, symptoms are still extremely unreliable diagnostic tools, and neuroimaging should be done when there is high suspicion index for organic pathology

Neutropenia Associated with Quetiapine, Olanzapine, and Aripiprazole

Matthew Lander and Tarun Bastiampilla

Measurement issues: 'Paediatric bipolar disorder' rates are lower than claimed - a reexamination of the epidemiological surveys used by a meta-analysis

Background: ‘Paediatric bipolar disorder’ (PBD) is a controversial diagnosis where often prepubertal children as well as adolescents, who may have a range of psychiatric disorders or symptoms, are diagnosed with a severe mental illness requiring lifelong medication. Clinically, it has often been applied in the United States but rarely in most other countries. A meta-analysis (Van Meter et al., Journal of Clinical Psychiatry, 72, 1250) claimed that the prevalence of PBD was similar to adults at 1.8% with no difference between the United States and other countries. This conclusion has been highly cited. Methods: The heterogeneous nature of the original 12 epidemiological surveys warrants a qualitative analysis, rather than statistical meta-analysis as performed by Van Meter et\ua0al. (Journal of Clinical Psychiatry, 2011, 72, 1250). Thus, the meta-analysis and each of the 12 studies (six from the United States; six from other countries) were reexamined. Results: Most of the 12 surveys predated the emergence of the PBD hypothesis. The 12 surveys were mainly of adolescents and at times young adults with few prepubertal children. Prevalence rates in the 12 studies suggest a lower rate of bipolar disorder, especially in non-US samples. For example, the Van Meter et\ua0al. (Journal of Clinical Psychiatry, 2011, 72, 1250) meta-analysis chose a rate of 2.8% by summation of adolescent and parent responses in a Dutch survey, however the rate fell to 0% if requiring concordance of adolescent and parent responses. Indeed, it could be argued that four of the non-US studies show 0% rates of PBD. Conclusions: Rates of PBD were generally substantially lower than 1.8%, particularly in non-US surveys, and if both parent and adolescent reports were required to meet the diagnostic threshold they fell to close to zero. The reanalysis suggests that bipolar disorder is rare before the expected age of onset in later adolescence