Michel Maron

Test for Catatonia with zolpidem

Catatonia is associated with severe motor and behavioural signs and has psychiatric and other general medical aetiologies. The effectiveness of benzodiazepines for catatonia has been shown. Mastain et al described a case of reproducible relief of a catatonic syndrome with zolpidem, a selective -aminobutyric acid A (GABA-A) agonist with a hypnoselective profile. GABA-A agonists enhance GABA activity that may reverse abnormal basal ganglia dopaminergic activity which has been postulated to explain the motor abnormalities of catatonia. We report clinical changes in relation to zolpidem plasma concentrations that confirm the improvements of catatonia syndrome with zolpidem. A 21-year-old woman with a first episode of schizoaffective disorder was treated with haloperidol 4 weeks after onset of the episode. Since her condition deteriorated haloperidol was discontinued. She met the criteria for diagnosis of catatonia according to DSM-IV. She displayed severe oppositional behaviour, mutism, staring, posturing, and food and drink refusal. 1 month after haloperidol withdrawal she was given zolpidem 10 mg orally with informed consent from her father. Zolpidem plasma concentrations were monitored every 15 min with concomitant rating assessments of the catatonic symptoms with the scale proposed by Rosebush et al. All her motor and behavioural signs resolved. The improvement occurred 15 min after administration of zolpidem as the plasma concentration reached 90 ng/mL and lasted 4 h. Relapse occurred when plasma concentrations fell below 90 ng/mL (see figure). The trial was replicated 24 h later with an identical threshold effect. She was then placed on alprazolam 2 mg three times daily and the catatonia resolved. Response to zolpidem is consistent with the effectiveness of GABA-A agonists in catatonia. Zolpidem may be an effective and prompt pharmacological test for catatonia.

Carbamazepine in the treatment of neuroleptic malignant syndrome

BACKGROUND Neuroleptic malignant syndrome (NMS) is a potentially lethal adverse effect to neuroleptic drugs. METHODS We report on 2 cases where NMS dramatically improved with carbamazepine. Incidental removal and reapplication of carbamazepine attests to its effectiveness for this condition. RESULTS A 34-year-old woman treated for a major depressive disorder experienced NMS with a phenothiazine. Her condition dramatically improved in 8 hours after she was administered carbamazepine. Since carbamazepine was discontinued, NMS recurred in 10 hours and remitted anew within less than 24 hours after reintroduction. A 31-year-old woman experiencing a schizoaffective disorder displayed NMS with aphenothiazine and a butyrophenone. NMS completely resolved within 8 hours after she was administered carbamazepine. NMS recurred within 12 hours after carbamazepine discontinuation. CONCLUSIONS These data thus account for a cause-effect relationship between carbamazepine administration and NMS relief, and argue against the neuroleptic withdrawal to be responsible by itself for NMS relief.

Pain as a confounding factor in postnatal depression screening.

Background. Postnatal depression (PND) is one of the most serious complications following delivery in developed countries today. Thus, early screening strategies by first-line healthcare workers are of primary importance. Pain following childbirth has been proposed as a possible risk-marker for later depressive disorder. We tested this assumption and explored the possible link between pain and overestimation of PND risk in routine clinical screenings. Methods. We assessed 320 women between the third and fifth day after delivery as well as at 8 weeks post-partum (PP). Midwives were asked to evaluate the risk of later PND upon discharge from the maternity unit; additionally, pain measurements were obtained using the Visual Analogic Scale (VAS) over the same time period. A stepwise logistic regression analysis was performed to identify the risk markers linked to a positive depressive disorder diagnosis (according to the MINI-DSM-IV) at 8 weeks PP. Results and discussion. Multivariate risk analysis showed no statistical link between physical pain shortly after childbirth and subsequent PND diagnosis at 8 weeks PP. However, VAS measurements for pain were significantly higher for women that the midwives estimated to be at risk for PND (|Z| = 2.78, p = 0.005), suggesting the routine clinical screening for PND is susceptible for false-positives. Psychiatrists should encourage midwives to have an empathetic approach, to increase the detection as well as treatment of mental and physical suffering in early postpartum. At the same time, adequate education programmes for early PND screening should be proposed to non-psychiatric staffs to demonstrate that women at risk of PND often show minimal physical symptoms.

Les traitements adjuvants au cours de l'épisode maniaque

When treating patients with manic states, the physician has to deal with at least two main Issues. First, the therapeutic decision has to be rapid because of the unpredictability of its immediate course. This concerns often results in polypharmacy with adjunct treatments. However, the therapeutic choice has to be cautious since part of the treatment will be maintained for prophylaxis. According to recent guidelines, the use of monotherapy with mood stabilisers during acute manic states concerns only few patients with mostly hypomania to moderate mania. Up to date, antipsychotics and benzodiazepines are considered as adjunct treatment in mania with psychotic symptoms or hostility. However, survey studies show that antipsychotics are widely used as adjunct treatments to mood stabilisers, indeed beyond the indications held by the guidelines. Our objective was to describe the clinical situations justifying the addition of an adjunct treatment during acute mania and to clear up from published data, the advantages and the inconveniences of combining antipsychotics and/or benzodiazepines with a mood stabilisers in order to define differentiated indications. Mania associated with either agitation, sleep disturbances or psychotic symptoms requires most of the time to combine mood stabiliser and respectively, sedative and/or anxiolytic, hypnotic or anti-psychotic treatments. Patients suffering from mania associated with other disorders need specific treatment adjustment and combination related to their medical condition. Adjunctive conventional antipsychotic remains widely used in first intention treatment. The conventional antipsychotic is often prescribed alone in the first weeks prior to the association with a mood stabiliser. Nevertheless there are controversies in the literature about their efficiency and their delay of action with regard to other treatments. When the conventional antipsychotic is a part of their initial treatment, manic patients remain taking them when discharged from hospital and are still taking them after 6 Months in a great percentage of the cases. The adverse events with conventional antipsychotic are numerous and severe enough in bipolar patients to restrict their use in first intention mainly to psychotic mania. Moreover, there are evidences for higher sensitivity to adverse effects of the conventional antipsychotics in manic patients. When agitation in acute mania requires an adjunct to mood stabiliser, the conventional antipsychotic treatment could be use for over-excitation without catatonic features and with particular care with the risk of akathisia. Long term effects of conventional antipsychotics, especially on depressive recurrences, should argue to stop them as soon as possible. Since the safety of adjunctive new antipsychotics with mood stabilisers seems until now acceptable, its indication should be limited to acute psychotic manias. Adjunctive benzodiazepine, should be evaluated in the various types of mania with specific concerns with comorbidity frequently met in consultation-liaison psychiatry. Benzodiazepines plus mood stabilisers may be the treatment of choice for the manias in which anxious state, catatonic symptoms or sleeplessness.

Surveillance Is a Powerful Tool to Prevent Suicidal Acts

Is it usefull to keeping under surveillance a suicidal crisis whenever a subject met after a suicide attempt? We advocate an ethic of worriness, keeping the concern of the other, bringing connectedness, etc. But is it effective to keep watch on a suicidal crisis? Several devices have been imagined and tested, although none alone shows a decrease of suicidal behaviors in the general population. Hence, we developped the idea of a simple algorithm (ALGOS) that could combine the qualities of some of the proposed features: a crisis card issued to first attempters, phone call to 15 days for the suicide repeaters, sending a few postcards to uncontactable subjects or diagnosed at risk during the phone call, etc. The ALGOS device is being tested in 23 metropolitan France’s centers, and for now, more than 1000 patients are included in a randomized clinical trial comparing the algorithm effect to a control group of suicide attempters treated as usual (i.e., referred to the general practitioner). This kind of device would be inexpensive to implement and easily generalizable in a territory, can thus bring an important innovation in public health.