Christopher Thomas

Diagnosing Subtypes of Neuroleptic Malignant Syndrome: An Introduction to the Lee-Carroll Scale

BACKGROUNDnNeuroleptic malignant syndrome (NMS) shares common features with catatonia and serotonin syndrome (SS). For instance, catatonia is a risk factor for the development of NMS.nnnMETHODSnWe performed a pilot study to examine if the Lee-Carroll Scale is able to differentiate the proposed NMS subtypes and explore possible relationship between NMS and SS. A consecutive series of cases reported to the Neuroleptic Malignant Syndrome Information Service (NMSIS) were reviewed with 29 cases of definite NMS. The Hynes-Vickar Scale (an NMS scale), Hegerl Scale (a SS scale), and Lee-Carroll Scale (an NMS subtype scale) were applied to these case report forms.nnnCONCLUSIONSnAlthough the groups were too small for statistical analysis, the 2 catatonic NMS subtypes appear to have higher NMS scores on the Hynes-Vickar Scale, and lower SS scores on the Hegerl Scale than the non-catatonic NMS subtype. The scores on the Lee-Carroll Scale were highest for non-catatonic NMS subtype. This pilot study suggests that the Lee-Carroll scale may help differentiate the subtypes of NMS, and provides some support that non-catatonic NMS may be a form of SS. NMS subtypes may be important in the early detection and treatment of NMS.

Schizophrenia with catatonic features deserves further study

Dear Sirs, We read with interest the review by Falkai et al. in The World Journal of Biological Psychiatry, ‘‘WFSBP Guidelines for Biological Treatment of Schizophrenia, part 1. Acute treatment of schizophrenia’’ 2005, Volume 6, Number 3, pp. 132 /191. We were pleased to read the section ‘‘Schizophrenia with Catatonic Features’’ on page 162. In spite of the fact that ICD-10 and DSM-IV nosology include catatonic schizophrenia and schizophrenia, catatonic type, clinicians are unlikely to identify catatonic features. We stand at a crossroads. There is recognition of catatonic features in schizophrenia by these international guidelines but the criteria used to define catatonia are inadequate (van der Heijden et al. 2005). Catatonia can be detected by the presence of two or more catatonic signs (Bush et al. 1996; Lee et al. 2000). However, many catatonic signs are not included in DSM-IV or ICD-10. Detection and diagnosis require the application of a rating scale for catatonia (van der Heijden et al. 2005). While the severity of catatonic signs has been addressed in rating scales, it remains unaddressed in DSM-IV and ICD-10. The catatonic signs that require acute treatment include such as: stupor, combativeness, refusal to eat and excitement. These patients will not be admitted or treated for echopraxia, peculiarities of speech, stereotypies, mannerisms or grimacing. Consequently, the catatonic signs listed criteria in DSM-IV and ICD-10 are not the catatonic signs that are the targets of treatment and response. There has been much that has occurred since descriptions of catatonia in the 19th and early 20th centuries. Both Kahlbaum and Kraepelin studied hospitalized patients over months and years. In the 21st century patients with catatonia are hospitalized for 2 days to 2 weeks. These patients may require involuntary hospitalization, intramuscular benzodiazepines, ECT or nutritional support. Once the severe catatonic signs improve, these patients with schizophrenia are discharged from the hospital. Many of these patients are in convalescent institutions, group homes or in other settings in community. They are far away from academic medical centers. Whenever they do present for acute treatment, they tend to be uncooperative, uncommunicative and very unlikely to be included in any research studies (Khan et al. 2005). Yet, our own research suggests that schizophrenia with catatonic features may respond to adjunctive memantine (Thomas et al. 2005). This finding supports a novel mechanism for catatonia and neural pathways that may help to explain the response to benzodiazepines, ECT and NMDA antagonists (Carroll et al. 2005; Northoff 2002). Nonetheless, the DSM-IV and ICD-10 criteria fail to identify those patients with schizophrenia with catatonic features who might benefit from these treatments. We thank the WFSBP for identifying Schizophrenia with Catatonic Features as an important step to understanding and treating this form of psychosis.

Review of cariprazine in management of psychiatric illness

Schizophrenia and bipolar disorder are severe and debilitating psychiatric disorders. Despite the availability of numerous antipsychotic drugs, many patients still experience poor outcomes and treatment-limiting adverse side effects. Cariprazine is a novel antipsychotic with unique pharmacodynamic and pharmacokinetic properties. It is both a dopamine type 2 and dopamine type 3 partial agonist with 2 equipotent metabolites, desmethyl cariprazine and didesmethyl cariprazine, of which didesmethyl cariprazine has a half-life of 1 to 3 weeks. The objective of this article is to review the literature regarding efficacy and tolerability of cariprazine in the management of psychiatric disorders to determine its current place in therapy.

Evaluation of buprenorphine/naloxone dose and use of sedating supportive medication on treatment outcomes in veterans with opioid use disorder

Introduction: This retrospective cohort study evaluated effects of buprenorphine/naloxone dose and concomitant use of selected sedating medications on treatment outcomes in patients with opioid use disorder. Methods: Patients enrolled in the buprenorphine/naloxone clinic at the study institution from 2009 until April 2013 were included. There were no exclusion criteria. Part 1 assessed treatment failure within 6 months and time to treatment failure with buprenorphine doses >8 mg and ≤8 mg. Part 2 assessed for treatment failure within 6 months and time to treatment failure with use of selected sedating medications. Sedating medications were cyproheptadine, hydroxyzine, quetiapine, and trazodone. Treatment failure was defined as documentation of illicit opioid use per patient report, urine drug screen showing opioid use, or patient lost to follow-up. Results: There were 132 patients included in this study, but 163 separate encounters due to multiple enrollments. Treatment failure was experienced within 6 months 51 times a patient was prescribed ≤8 mg (66.2%) and 26 times a patient was prescribed >8 mg (33.8%) (Pu2009=u2009.0005). Average time to treatment failure was 5.1 months with ≤8 mg and 8.4 months with >8 mg. The 48% of patients who received sedating medications did not demonstrate any significant differences in treatment response at 6 months (Pu2009=u2009.2746) or time to treatment failure (Pu2009=u2009.2209). Discussion: Doses of buprenorphine/naloxone >8 mg demonstrated better treatment response and prolonged time to treatment failure. Concomitant sedating medications did not have a statistically significant effect on treatment response or time to treatment failure.