Constantin Tranulis

Benefits and risks of antipsychotic polypharmacy: an evidence-based review of the literature.

Combination antipsychotic prescription is an increasingly common practice in clinical psychiatry. This clinical practice is at odds with clinical guidelines promoting antipsychotic monotherapy. Moreover, there has been increased concern over the safety profile of atypical antipsychotics in the last 10–15 years. We reviewed the literature on antipsychotic combinations with a focus on safety and efficacy. Multiple electronic database searches were complemented by relevant bibliography cross-checking and expert discussions. The review showed a literature that is dominated by case reports and uncontrolled studies. Polypharmacy was unequally studied, with some recent combinations (i.e. clozapine and risperidone) being extensively, albeit inconclusively, studied and other more commonly used combinations (first-with second-generation agents) receiving little attention. From an evidence-based perspective, further trials of antipsychotic association of sufficient power to address safety issues are needed before recommending any antipsychotic combination. Particular weaknesses of the present literature are low number of participants, lack of adequate control of confounding variables, short duration of experimental follow-up and inadequate monitoring of potential adverse effects.

Insight and Psychosis: Comparing the Perspectives of Patient, Entourage and Clinician

Background: The construct of insight in psychosis assumes congruence between patient and clinician views of the meaning of symptoms and experience. Current definitions and measures of insight do not give systematic attention to the impact of interpersonal, cultural and socio-economic contexts. Aims: We hypothesized that socio-cultural factors influence insight in patients with schizophrenia. Methods: We tested this hypothesis through comparison of insight in 18 triads, each composed of a patient, a family member and a clinician. The sample consisted of patients who were first diagnosed with psychosis in the last two years, and who were either immigrants from Africa or the Caribbean Islands, or Canadian born. Insight was assessed by analysis of narratives collected from patients, family members and clinicians for a research project on the negotiation of treatment. Each narrative was scored for insight along multiple dimensions with the Extracted Insight Scale (EIS), developed for this project. Results: There was a significant correlation of insight on the EIS between patients and family members (r = 0.51, p = 0.03) but not between patient and clinician or family and clinician. The mean levels of insight across the three groups were comparable. Qualitative analysis of the illness narratives suggested that insight was based on the meanings constructed around psychotic experiences and that the process of interpreting and attributing psychotic experiences reflected each persons cultural background, life experiences, and other social determinants, especially stigma. Conclusion: Forms of insight can occur in the context of discordance or disagreement with the clinicians opinion. We present a testable model of the socio-cultural determinants of insight that can guide future studies.

Insight in first episode psychosis: who is measuring what?

Aims: To compare different self‐administered or clinician‐rated insight scales in an FEP population.

The paradox of quetiapine in obsessive-compulsive disorder.

Schizophrenia and obsessive-compulsive disorder (OCD) have historical, clinical, and epidemiological links. The clinical use of atypical neuroleptics (ie, dual serotonin-dopamine antagonists) to treat both conditions sheds a new light on them. We report the first two cases of obsessive-compulsive symptoms (OCS) induced by quetiapine in schizophrenia patients. A case of successful augmentation by quetiapine in refractory OCD is also presented. A review of the literature on OCS induced by atypical neuroleptics follows. This paradoxically induced OCD symptomology in schizophrenia patients administered atypical neuroleptics is discussed from new pathophysiological and clinical perspectives. The discussion emphasizes the prognostic implications of OCS in schizophrenia and available therapies for this comorbidity.

Changing the Name of Schizophrenia: Patient Perspectives and Implications for DSM-V

Introduction The diagnosis of schizophrenia is increasingly contested by researchers, clinicians, patients and family members. Preeminent researchers proposed its replacement with the salience syndrome concept, arguing for increased validity and less stigmatizing potential. This is the first study exploring the effects on stigma of this nosological proposal. Methods Two studies were conducted: one with 161 undergraduate students regarding their stigmatizing attitudes linked to the label of schizophrenia or salience syndrome, the other involved in-depth qualitative interviews with 19 participants treated in a first episode psychosis program. The interviews explored the subjective validity, acceptability and effects on stigma of a diagnosis of schizophrenia or salience syndrome. Results Overall, no significant differences were found between labels in study 1. For study 2, the majority of participants preferred a diagnosis of salience syndrome, considering it less stigmatizing mostly because of its novelty and the concealing potential of the new diagnostic entity, though many found it hard to relate to and somewhat difficult to understand. Discussion Our results suggest that the label change does not impact the stigmatizing potential for individuals who are not familiar with mental illness - they appear to base their attitudes on descriptions rather than the label alone. For those suffering from mental illness, a name change for schizophrenia to “salience syndrome” might offer only a temporary relief from stigma. Claims of de-stigmatizing effects should be grounded in sound scientific models of stigma and ideally in empirical data.

Narrative insight: rethinking insight in psychosis

This paper revisits the epistemological and clinical foundations of insight into psychosis. After a brief introduction of its importance in psychiatry, we will explore the empirical data on ‘lack of insight’ in psychosis. To overcome the significant shortcomings of the prevailing view of insight, we are proposing to focus on the subjective dimension of insight and to conceptualize insight as a particular form of narrative production, which we call narrative insight. The narrative perspective emphasizes the subject, the process of insight formation and the importance of the audience, the intended effects and its pragmatic purposes. The narrative insight approach focuses not only on the content and the form of the narratives, but also on the temporal dimension and the potential specific phases of insight. We conclude by proposing specific topics for future research into the links between insight, clinical approaches to psychosis and culture.

Early Intervention in Psychosis: A Case Study on Normal and Pathological

Accumulating evidence suggests that delays in receiving treatment are associated with poorer prognosis and longer periods of unneeded suffering. The duration of untreated psychosis (DUP) is considered to be one of the most important determinants of outcome in the first episode of psychosis. However, the focus on decreasing the length of untreated illness tends to overlook the difficult task of making sense of psychotic experiences during a first episode. Using a qualitative analysis of narratives obtained from interviews with an individual and her husband, we examine what delayed her seeking help, how she became convinced that she needed treatment and what this meant for her and her husband. Additionally, we look at the five-year development of both a literal and a figurative space within which both the subject and her husband came to utilize, whether consciously or unconsciously, the ‘stories’ of her psychotic experiences to construct a shared and even ‘safe’ and familiar means of spousal connection. The exploration of this shared space reveals the normative and moral values embedded in the concept of DUP and suggests alternative ways of understanding the help-seeking behaviors in early psychosis.

Somatic augmentation strategies in clozapine resistance--what facts?

Background: Polypharmacy without evidence-based support is sometimes needed for patients treated with 40% to 70% clozapine who are clozapine nonresponders. Several somatic augmentation strategies are proposed in the scientific literature, with different levels of evidence for safety and efficacy. Objectives: The purpose of the present study is to review the available literature on the efficacy and safety of clozapine augmentation with somatic agents other than antipsychotics. The following classes of agents are considered: (1) mood stabilizers, (2) antidepressants, (3) electroconvulsive therapy and repetitive transcranial magnetic stimulation, (4) glutamatergic agents, (5)fatty acids supplements, and (6) benzodiazepines. Results: Case controls and small-size clinical trials largely dominate the literature, limiting the power to draw conclusions concerning safety issues and the meaning of negative studies. Moreover, variable definitions of clozapine resistance, heterogeneous outcome measures, and short duration of treatment trials are additional limitations. Conclusion: Generally, adjunctive strategies for clozapine-resistant patients remain based on scarce evidence of efficacy and significant safety concerns. Low-frequency repetitive transcranial magnetic stimulation, fatty acids supplements, and mirtazapine showed good tolerability and some efficacy, but the results need replication.

Morgellons Disease, or Antipsychotic-Responsive Delusional Parasitosis, in an HIV Patient: Beliefs in The Age of the Internet

“Which was worse, the real condition or the self-created one; and did it matter?” — Don DeLillo: “White Noise” Viking Press

Depressive Symptoms in Schizophrenia Outpatients— Prevalence and Clinical Correlates

Background: Depressive symptoms are common in schizophrenia and can occur during any phase of the illness. Our goal was to establish the prevalence and correlates of depressive symptoms in a cohort of schizophrenia outpatients at varying stages of their illness who were receiving first- and second-generation antipsychotics. Method: In a crosssectional study, we comprehensively assessed psychopathology in 131 schizophrenia outpatients. Correlations and multiple linear regressions were used to explore correlates of depression, specifically illness course variables, residual positive symptoms, insight and treatment. Results: Using a cutoff threshold of fourteen on the Hamilton Depression Rating Scale (HAM-D), 14% of patients experienced clinically significant depression, regardless of age of illness onset or duration of illness. While 22% of the cohort received antidepressants, the treated subgroup was not different from the untreated cohort with regard to depressive symptoms. Patients treated with first-gen...