George B. Murray

Use of high-dose intravenous haloperidol in the treatment of agitated cardiac patients.

Although previous reports have documented the safe and effective use of intravenous haloperidol in agitated cardiac patients, the dosages advocated have in general been relatively low: 1 to 2 mg every 2 to 4 hours. In this report, the authors demonstrate that such doses may be insufficient to control severe agitation in coronary care unit patients. Four cases are presented in which more than 100 mg/day of intravenous haloperidol were required for safe and effective control of confusion and agitation.

Psychostimulants for Secondary Depression in Medical Illness

The hospital charts of 198 patients with acute medical or surgical illnesses who had been treated with either dextroamphetamine or methylphenidate for secondary depression during a 5-year period at the Massachusetts General Hospital were examined. Eighty-two percent of patients showed improvement following psychostimulant treatment. Seventy percent of all patients demonstrated marked or moderate improvement in depressive symptoms. No significant differences in efficacy between the two psychostimulants or across diagnostic categories for depression were observed. Patients improved quickly, usually within the first 2 days of treatment. Adverse reactions necessitating the termination of psychostimulant treatment occurred in 10% of trials. Anorexia was not observed as a side effect of treatment.

Use of psychostimulants in medically ill depressed patients.

Abstract Five medically ill depressed patients in a general hospital responded well to methylphenidate and dextroamphetamine. These patients were either not able to tolerate tricyclic antidepressants or had a medical illness contraindicating their use. Depressive symptomatology remitted rapidly with no adverse side effects, this being consistent with the findings of other investigators. Further evaluation of the therapeutic role of psychostimulants in the treatment of medically ill depressed patients is recommended.

Use of psychostimulants in medically ill patients with neurological disease and major depression

The effective therapeutic response to dextroamphetamine and methylphenidate by five depressed patients with neurological disease is described. In four of these patients tricyclic antidepressants had to be discontinued due to the concomitant deterioration of their cognitive functions, and in one case they were not used due to cardiovascular complications. There was a rapid remission of depressive symptomatology with no adverse side effects, consistent with the findings of other investigators. The possible association of right hemisphere strokes and depression is also discussed. Further evaluation of the therapeutic role of psychostimulants in the treatment of depressed patients with structurally-compromised brain function is recommended.

Psychostimulant Treatment of Geriatric Depressive Disorders Secondary to Medical Illness

The records were reviewed for 129 medically ill geriatric inpatients treated with either dextroamphetamine or methylphenidate for secondary depression during a five year period at the Massachusetts General Hospital. Eighty-one percent of patients demonstrated at least some improvement following psychostimulant treatment. Sixty-six percent of these experienced marked to moderate amelioration of their depressive symptoms. Improvement was rapid and usually occurred within the first or second day of treatment. No significant difference in efficacy was noted between the two psychostimulants or across diagnostic categories for depression. Only 8% of patients experienced adverse reactions significant enough to warrant termination of the psychostimulant trial. No instances of anorexia due to psychostimulant treatment were observed. (J Geriatr Psychiatry Neurol 1990;3:146-151).

Neuropsychiatric presentation of men with pituitary tumors (the ‘four A's’)

Abstract A chart review of 16 male patients with prolactin-secreting pituitary adenomas revealed the frequent presence of four neuropsychiatric signs and symptoms: apathy, asexuality, adiposity, and (head)ache. This symptom constellation can be easily mistaken for that of an affective disorder. Male patients displaying these four signs and symptoms should be referred for an endocrinologie consultation. A case report further illustrates the clinical picture.

Neuropsychiatric Aspects of Carbon Monoxide Poisioning: A Review and Single Case Report Suggesting a Role for Amphetamines

Sublethal exposure to carbon monoxide (CO) can result in severe neurologic and psychiatric complications. Once in the body, CO can wreak havoc on virtually every organ system, with the brain being the most vulnerable to the damaging effects. Neuropathological injury is frequently widespread, and while white matter injury is most common, both gray and white matter injury occurs. Consequently, no neurologic or psychiatric syndrome is pathognomonic for CO poisoning. There are currently no effective treatments for the delayed neuropsychiatric sequelae of CO poisoning, and medical management focuses on correcting immediate symptoms through the use of oxygen, hyperbaric oxygen therapy, and supportive measures. Preliminary data suggest, however, that dopaminergic agents may be useful for the treatment of some of the delayed sequelae of CO neurotoxicity. To our knowledge, ours is the first case report in which dextroamphetamine (DAMP), a potent dopaminergic agent, has been used for treating the neuropsychiatric symptoms of CO poisoning. Our data demonstrate that it is effective in shortening cognitive and motor recovery time, that psychostimulant actions occur slightly sooner than locomotor effects, and that theraputic benefit is most dramatic within the first ten days of use. Therefore, DAMP appears to be a pharmacological agent that can be combined with supportive interventions to reverse, attenuate, or symptomatically improve the delayed sequelae that occur in these patients.

Analytic Reviews : Neuropsychiatric Toxicity of Meperidine:

The use of meperidine can lead to neuropsychiatric tox icity manifested by excitatory states and seizure. Nor meperidine, an active metabolite, is the agent responsi ble for this toxicity; its long half-life of elimination allows for significant accumulation with repeated dosing of the parent compound. Normeperidine is proconvul sant, and this property alone may account for the toxic symptoms. Psychiatric symptoms often herald the onset of toxicity and may be the result of complex partial seizure. A pathophysiological mechanism of toxicity is suggested, and management of the toxic patient is dis cussed.

Low Incidence of Extrapyramidal Symptoms in Treatment of Delirium with Intravenous Haloperidol and Lorazepam in the Intensive Care Unit

We retrospectively reviewed 11 patients in an intensive care unit who were treated for delirium with intrave nously administered haloperidol and lorazepam. The cu mulative doses for each episode of delirium ranged from 25.5 to 1,929 mg of haloperidol and 19.5 to 2,274 mg of lorazepam. Neuroleptic-induced rigidity developed in 1 patient. After administration of the neuroleptic was dis continued, there were no residual extrapyramidal symp toms.

Salutary change after frontal brain trauma

Adverse behavioral effects of frontal traumatic brain injury are well-known. Patients may suffer changes in personality ranging from disinhibition to apathy. Beneficial effects of traumatic brain injury are rarely described. We report three cases of patients who sustained frontal traumatic brain injury, one of whose social phobia resolved and the other two of whom had an improvement in impulsive and antisocial behavior. In one case the brain injury may have caused disinhibition of an inhibited state; in the other cases disinhibition associated with impulsivity was replaced by a more restrained state. This adds to the data on the integrative role of the frontal lobes in varied psychopathologic conditions.