Management of treatment resistant schizophrenia

Whilst gains have been made in recent years in the pharmacological treatment of schizophrenia, a number of patients still have residual symptoms and disabilities, or simply do not show response to antipsychotic medications. For such 'treatment resistant' patients, there is little by way of randomised controlled data to support any particular type of further intervention, but combinations of agents (combined antipsychotics, augmentation with mood stabilisers, antidepressants, and other agents)can show benefit in certain patients in certain domains of symptomatology and psychosocial functioning. Certain psychological and psychosocial treatment strategies can also be of benefit in this regard. This article selectively reviews the literature treatment resistance in schizophrenia, and emphasises the importance of an holistic approach to individual patients. Keywords: schizophrenia, treatment resistance, antipsychotics, augmentation, psychosocial treatments South African Psychiatry Review Vol. 9(1) 2006: 17-2

Anxiety, psychosis and substance use: prevalence, correlates and recognition in an outpatient mental health setting

Objective: The current study examined anxiety in people with substance use disorder (SUD) and a psychotic disorder. It is hypothesised that: anxiety disorders (AD) would be highly prevalent (greater than 20%) in people identified as having SUD and psychotic disorders; those with comorbid AD would fair worse than those without, on measures of quality of life, severity of substance dependence, locus of control, suicidality and psychotic symptoms; and, the presence of such anxiety disorder symptomatology would be under-detected by their mental health case mangers. Method: Outpatients with co-occurring substance use disorder and psychosis were interviewed to collect data about their diagnosis, depressive and psychotic symptoms, severity of dependence on substances, quality of life and locus of control. Participants’ case managers made blind ratings of the presence and severity of participants’ anxiety. Results: Fifty eight percent of participants had at least one anxiety disorder. Of these, 56% – 70% had case managers who had identified them as having an anxiety problem. The occurrence of anxiety disorder was associated with more external locus of control, greater intensity of suicidal thinking, worse psychotic symptoms, lower quality of life and greater severity of dependence on substances. Conclusion: This research suggests anxiety in people with substance use disorder and psychosis is highly prevalent, is associated with poorer outcomes, and is under detected by case managers. Further examination of this issue may lead to important advances in the treatment and prognosis of people with substance use disorder and psychosis.Keywords: Anxiety disorders; Substance-related disorders; Psychotic disorders; Comorbidity; Diagnosis; Prevalence

The oculocerebral syndrome in association with generalised hypopigmentation A case report

A 14-year-old girl with generalised hypopigmentation, mental retardation, abnormal movements, and ocular anomalies is described. It is suggested that she represents a further case of oculocerebral albinism, a rare autosomal recessive condition. Reference is made to previous similar cases

Is body dysmorphic disorder associated with abnormal bodily self-awareness? A study using the rubber hand illusion.

Evidence from past research suggests that behaviours and characteristics related to body dissatisfaction may be associated with greater instability of perceptual body image, possibly due to problems in the integration of body-related multisensory information. We investigated whether people with body dysmorphic disorder (BDD), a condition characterised by body image disturbances, demonstrated enhanced susceptibility to the rubber hand illusion (RHI), which arises as a result of multisensory integration processes when a rubber hand and the participant\u27s hidden real hand are stimulated in synchrony. Overall, differences in RHI experience between the BDD group and healthy and schizophrenia control groups (n = 17 in each) were not significant. RHI strength, however, was positively associated with body dissatisfaction and related tendencies. For the healthy control group, proprioceptive drift towards the rubber hand was observed following synchronous but not asynchronous stimulation, a typical pattern when inducing the RHI. Similar drifts in proprioceptive awareness occurred for the BDD group irrespective of whether stimulation was synchronous or not. These results are discussed in terms of possible abnormalities in visual processing and multisensory integration among people with BDD

May I have your consent? Informed consent in clinical trials- feasibility in emergency situations

Clinical researchers in acute emergency settings are commonly faced with the difficulty of satisfying the conventional ethical requirement of obtaining informed consent, whilst ensuring a representative group of patients is recruited into studies. We discuss our own experience in addressing institutional ethical requirements to obtain informed consent in a multi-centre trial, recruiting highly agitated patients in the emergency setting in Melbourne, Australia. We suggest that, through the application of existing ethical and legal frameworks and pre-emptive communication with the key stakeholders in ethics committees, hospital insurers and legal representatives, a balance can be struck between ethical and legal requirements on the one hand, and the integrity of the research question, on the other.published_or_final_versio

Intravenous Midazolam-Droperidol (combination), Droperidol (only) or Olanzapine (only) for the acutely agitated patient: A multi-centred, randomised, double-blind, triple-dummy, clinical trial

AIM: To determine the most efficacious of three currently used drug regimens for the sedation of acutely agitated patients in the emergency department ...postprin

Antipsychotics and Risk of Neuroleptic Malignant Syndrome: A Population-Based Cohort and Case-Crossover Study

BACKGROUND: Neuroleptic malignant syndrome (NMS) is a rare and acute adverse drug reaction associated with antipsychotic therapy. However, few data on the risk and epidemiology of NMS are available. OBJECTIVES: The aim of this study was to ascertain the incidence risk and all-cause mortality of NMS associated with antipsychotic use, and to assess the association of recent antipsychotic exposure and NMS. METHODS: We did a population-based study using data from the Hong Kong Hospital Authority’s Clinical Data Analysis and Reporting System database. Cases had a first diagnosis of NMS between 1 January 2004 and 30 November 2017. A case-crossover analysis was used to compare antipsychotic exposure 30 days before the diagnosis of NMS (index date) and a reference period 91–120 days before the index date. To adjust for potential time trends in antipsychotic exposure, we sampled from cases to match current cases and future cases, and further adjusted for select medications and acute medical conditions. RESULTS: 297,647 patients were prescribed antipsychotics, and the incidence risk of NMS was 0.11%. Of the 336 cases included in the case-crossover analysis, 20 (6%) died within 30 days after the index date; only one case had NMS recorded as the primary cause of death. When compared with the reference period, cases were more frequently prescribed multiple antipsychotics (15.8% vs 26.8%; standardized mean difference [SMD] 0.27) and short-acting injectable antipsychotics (3.6% vs 13.7%; SMD 0.37) during the 30 days prior to the diagnosis of NMS. Odds ratios for antipsychotic exposure in the case-crossover, case-crossover adjusted for time trend, and case-crossover adjusted for time trend and potential confounders analysis were 8.00 (95% confidence interval 3.42–18.69), 5.88 (2.46–14.04), and 4.77 (1.95–11.66). CONCLUSIONS: Our results suggest that recent use of antipsychotics is associated with NMS. Although a case-only design inherently controls for confounding by time-invariant factors, residual confounding by acute medical conditions with similar presentations to NMS cannot be fully excluded

Internet-based psychoeducation for bipolar disorder: a qualitative analysis of feasibility, acceptability and impact

<p>Background: In a recent exploratory randomised trial we found that a novel, internet-based psychoeducation programme for bipolar disorder (Beating Bipolar) was relatively easy to deliver and had a modest effect on psychological quality of life. We sought to explore the experiences of participants with respect to feasibility, acceptability and impact of Beating Bipolar.</p> <p>Methods: Participants were invited to take part in a semi-structured interview. Thematic analysis techniques were employed; to explore and describe participants’ experiences, the data were analysed for emerging themes which were identified and coded.</p> <p>Results: The programme was feasible to deliver and acceptable to participants where they felt comfortable using a computer. It was found to impact upon insight into illness, health behaviour, personal routines and positive attitudes towards medication. Many participants regarded the programme as likely to be most beneficial for those recently diagnosed.</p> <p>Conclusions: An online psychoeducation package for bipolar disorder, such as Beating Bipolar, is feasible and acceptable to patients, has a positive impact on self-management behaviours and may be particularly suited to early intervention. Alternative (non-internet) formats should also be made available to patients.</p&gt

Relation of substance use disorders to mortality, accident and emergency department attendances, and hospital admissions: A 13-year population-based cohort study in Hong Kong

BACKGROUND: The impact of substance use disorders (SUD) in an Asian population has not been fully explored. We aimed to assess the risk of mortality, accident and emergency (A&E) department attendances, and hospital admissions associated with SUD in a population-based cohort study. METHOD: Patients diagnosed with SUD in public A&E departments from 2004 to 2016 (N = 8,423) were identified in the Clinical Database Analysis and Reporting System of the Hong Kong Hospital Authority and 1:1 matched to patients without SUD by propensity score (N = 6,074 in each group). Relative risks of mortality, A&E attendances and hospital admissions were assessed using Cox regression and Hurdle negative binomial regression. RESULTS: Patients with SUD had higher mortality (hazard ratio=1.43; 95% confidence interval [CI]=1.26-1.62) and more often died from poisoning or toxicity and injuries. The odds ratio (OR) for A&E attendances and all-cause hospital admissions associated with SUD were 2.80 (95% CI=2.58-3.04) and 3.54 (95% CI=3.26-3.83), respectively. The impact of SUD on the above outcomes was greatest among school-aged individuals (≤ 21 years) and decreased with age. The relative risk of mental disorder-related hospital admissions was much higher than that for infections, respiratory diseases, and cardiovascular diseases. In patients with SUD, ketamine and amphetamine use were associated with increased A&E attendances than opioid use. CONCLUSIONS: SUD was associated with increased mortality, A&E attendances and hospital admissions, especially in school-aged individuals. Our findings suggest prioritising early treatment and preventive interventions for school-aged individuals and focusing on the management of comorbid mental disorders and the use of ketamine and amphetamine

Mechanical stimulation of 3D bio-engineered skeletal muscle

Skeletal muscle is a highly plastic tissue, responding to exercise and mechanical loading. In vitro culture systems have been used to replicate this mechanical stimulus in order to study cellular and molecular adaptations. Previous research using such models has often lacked bio-mimicity, with respect to the in vitro culture, the mechanical loading, or both. This has lead to contradictory findings with regards to a variety of molecular outputs. Cell culture matrix and environment (2D or 3D), the type of mechanical loading (uni-axial or multi-axial) and the extent, speed and duration of stretching, are all likely to affect the adaptive responses of the cells and their maturation into functional muscle models. It is therefore necessary to develop a model which has greater physiological relevance if such models are to be used to further understand in vivo physiology