Patricia A. Marken

Human Simulators and Standardized Patients to Teach Difficult Conversations to Interprofessional Health Care Teams

Objective. To design and implement a demonstration project to teach interprofessional teams how to recognize and engage in difficult conversations with patients. Design. Interdisciplinary teams consisting of pharmacy students and residents, student nurses, and medical residents responded to preliminary questions regarding difficult conversations, listened to a brief discussion on difficult conversations; formed ad hoc teams and interacted with a standardized patient (mother) and a human simulator (child), discussing the infants health issues, intimate partner violence, and suicidal thinking; and underwent debriefing. Assessment. Participants evaluated the learning methods positively and a majority demonstrated knowledge gains. The project team also learned lessons that will help better design future programs, including an emphasis on simulations over lecture and the importance of debriefing on student learning. Drawbacks included the major time commitment for design and implementation, sustainability, and the lack of resources to replicate the program for all students. Conclusion. Simulation is an effective technique to teach interprofessional teams how to engage in difficult conversations with patients.

Effects of magnesium oxide on the lipid profile of healthy volunteers

Elevated serum cholesterol is a risk factor in the development of coronary artery disease. Magnesium has been reported to decrease total serum cholesterol, low density lipoprotein, and very low density lipoprotein, and increase high density lipoprotein. A randomized, double-blind, placebo-controlled, crossover study was completed to determine if supplemented magnesium, in the form of magnesium oxide, would produce changes in the lipid profile. Fifty normal volunteers received placebo or magnesium oxide, 400 mg capsules, twice a day for 60 days, then switched to the alternate treatment. Weight, height, blood pressure, serum potassium, serum magnesium, and a lipid profile were determined initially and after each treatment. Analysis of variance (ANOVA), comparing the mean of each component of the lipid profile at baseline and after each treatment, showed no significant difference. In conclusion, supplemental magnesium oxide did not produce statistically significant changes in the lipid profile in this group of healthy volunteers.

Characterizing anticholinergic abuse in community mental health.

To identify factors associated with anticholinergic abuse in patients taking antipsychotics and anticholinergics and to document the extent of extrapyramidal side effects in anticholinergic abusers, 21 anticholinergic abusers were matched with 21 controls without a history of anticholinergic abuse for diagnosis and antipsychotic dose. Data were collected prospectively, and extrapyramidal side effects and abnormal involuntary movements were evaluated using the Modified Simpson Angus Scale and the Abnormal Involuntary Movement Scale. The abuse group reported significantly more subjective effects from anticholinergic agents than did those in the control group (mean ± SD = 10.5 ± 5.4 vs. 6.5 ± 3.7, p < 0.05). The abuse group was significantly more likely to report feeling a buzz (p < 0.05) and difficulty learning (p < 0.05) when taking anticholinergic medications. Abusers reported abusing significantly more drugs in the past (2.7 ± 2.1 vs. 0.8 ± 0.9, p < 0.01) and had taken antipsychotics (12.7 ± 6.3 vs. 8.7 ±5.4 years, p < 0.05) and anticholinergics (10.9 ± 3.1 vs. 6.1 ± 4.6 years, p < 0.01) significantly longer than controls had. Patients in the control group spent significantly more years working full-time than did abusers (6.2 ± 7.3 vs. 0.7 ± 1.4, p < 0.01). There was a nonsignificant trend for abusers with a longer duration of antipsychotic use to have higher Abnormal Involuntary Movement Scale scores (r = 0.40, p < 0.10). Although these drugs are potentially abusable, the term “anticholinergic abuse” should be reevaluated in light of accumulating evidence that many patients taking these drugs report improved functioning, with improvement in negative symptoms and minimal or no adverse anticholinergic effects.

Anticholinergic Drug Abuse and Misuse

SummaryAbuse of the centrally acting anticholinergic agents is a phenomenon occasionally reported in the medical literature. Anticholinergics, most often used in psychiatry to treat antipsychotic-induced extrapyramidal symptoms, are also used by some patients for their mood altering and psychedelic effects. The changes in sensorium can range from mild euphoria and increased sociability to hallucinations and toxic psychosis.In this article, we have reviewed 110 cases of reported anticholinergic abuse and identified 3 distinct groups of abusers: (i) those individuals who have no valid medical need for the medication and consume it only for its mind-altering effects; (ii) those with a valid indication for the use of anticholinergics who also abuse the agents for their mind-altering effects; and (iii) those who have an appropriate medical indication for the agents and appear to be using anticholinergics to relieve chronic or subclinical extrapyramidal symptoms, depression or negative schizophrenic symptoms. True abusers (i.e. those individuals in the first 2 groups) can be recognised because they feign extrapyramidal symptoms, repeatedly ‘lose’ their medications or request unnecessary dose increases.In order to reduce the risk of abuse, exposure to anticholinergics should be minimised in patients at risk. Patients who are reluctant to have their anticholinergics discontinued should be carefully evaluated to identify potential risks and benefits of continued use before prolonged therapy is instituted. Anticholinergics should not be abruptly discontinued, but instead tapered over a 2-week period in patients receiving high doses or long term treatment.

Emerging Treatments for Bipolar Disorder: Safety and Adverse Effect Profiles

Objective: To provide an overview of the safety and tolerability of newer agents used to treat bipolar disorder (BPD) and provide clinicians with management strategies for drug-related toxicity and adverse effects. Data Sources: MEDLINE was searched through July 2005 for BPD treatment, adverse effects, tolerability, safety, emerging agents, atypical antipsychotics, new antiepileptic drugs (AEDs), risperidone, quetiapine, clozapine, ziprasidone, aripiprazole, lamotrigine, topiramate, gabapentin, oxcarbazepine, and olanzapine. Study Selection and Data Extraction: Results from randomized controlled trials, open-label studies, and reviews are described. Data Synthesis: Emerging agents recently approved for BPD include atypical antipsychotics and new AEDs. Safety and tolerability are as Important as efficacy because poor adherence in BPD worsens outcome; metabolic and other comorbidities pose specific challenges; and manic patients often require combination therapy, which increases adverse effects. Most atypical antipsychotics cause fewer extrapyramidal symptoms than conventional antipsychotics, but may cause more weight gain and metabolic complications. The newer AEDs generally cause less weight gain than the older agents, and some even promote weight loss. Several newer AEDs used in BPD also offer the advantages of fewer drug interactions and less need for therapeutic drug monitoring compared with older AEDs. Conclusions: Pending the results of ongoing controlled studies, several emerging agents may be useful additions to the therapeutic arsenal for BPD.

Historical Review of Carbamazepine for the Treatment of Bipolar Disorder

The management of bipolar disorder has seen significant evolution in terms of the number of treatment options now approved for both the acutely manic phase and the maintenance stages of the illness. In addition, new formulations of traditional agents are available for clinicians to use in their treatment approach. One such example is carbamazepine, which has approval by the United States Food and Drug Administration for the treatment of acute and mixed mania in an extended‐release formulation that uses a three‐bead delivery system. Although the parent compound has been available for decades, its approval for bipolar disorder is recent despite numerous clinical trials that have supported its use in both the acute and maintenance phases of bipolar disorder. Advantages of the new formulation include less fluctuation in plasma concentration and, in general, improved tolerability. However, issues remain with regard to cytochrome P450 drug‐related interactions and the need for therapeutic drug monitoring (e.g., drug concentrations, epoxide metabolite concentrations, hematology, and liver function tests) as part of the treatment and monitoring process. We review the current body of literature describing the use of carbamazepine in bipolar disorder during both the acute and maintenance phases of the disorder, including trials of both monotherapy and combination therapy, as well as findings from trials that included patients with rapid cycling and mixed episodes.

A program to convert patients from trade-name to generic clozapine

In spring 2000, the Missouri Department of Mental Health mandated that its psychiatric inpatient facilities convert patients from trade‐name to generic clozapine. The pharmacy department at our facility was encouraged to develop a conversion program to oversee and assess the efficacy and tolerability of the change. A protocol to monitor the conversion of patients to generic clozapine hospitalwide was developed. The primary objective was to determine whether therapeutic response and level of tolerability were the same with generic versus trade‐name clozapine. The secondary objective was to determine whether changes in monitoring white blood cell and absolute neutrophil counts were necessary after conversion. Our results showed that most patients did not experience changes greater than a mean of 5 points in their scores on the Brief Psychiatric Rating Scale (BPRS). However, a statistically significant difference was seen in 22 patients who had a mean reduction or an increase of less than 5 points (p=0.0139) in BPRS scores compared with two patients who had a mean increase greater than 5 points. Assessment of percentage change in BPRS scores indicated that 14 (58%) converted patients had a 1–50% decrease in mean BPRS scores, and 10 (42%) had a 1–40% increase. However, of those with a mean BPRS increase, five (50%) had an increase of 10% or less. Our clozapine conversion program resulted in the successful conversion of all 24 patients.

Pharmacologic Treatment of Cocaine Abuse

The recent surge in the use of cocaine has imposed increased financial burdens on society in terms of cocaine-related crimes, and funding for hospitalization/medical treatment and long-term rehabilitation programs. Unfortunately, healthcare costs secondary to chronic cocaine use are likely to increase in the future as drug research into cocaine abuse and effective treatment programs are severely lacking. This article reviews existing literature on treatment of cocaine abuse and is intended to serve as a practical guide to the general clinician involved in drug management of cocaine abuse. Antidepressant agents and the dopamine agonists are emphasized because most of the studies showing benefit have used these agents. Advantages and disadvantages of various interventions are objectively assessed. Additionally, specific implications for both acute and chronic management of cocaine abuse are given along with discussion and recommendations regarding comorbidity.

An Atypical Course of Neuroleptic Malignant Syndrome

Based on the discussion of NMS, certain conclusions may be reached in regard to this patient. In the psychiatric setting, agitation and confusion alone are not suggestive of NMS. However in this patient, the symptoms of agitation, the rapid development of EPS symptoms unresponsive to anticholinergic therapy, autonomic changes (tachycardia, diaphoresis, and incontinence), and elevated CPK, met most of the diagnostic criteria described in Table VI. However, this case may have described an atypical presentation of NMS because of the absence of temperature increases during the onset of symptoms and the 7-week hospitalization for NMS. The patients later onset of temperature elevations was a result of an aspiration pneumonia. Pneumonia and renal failure significantly increased the morbidity and extended the course of the illness. As a result, the diagnosis and specific treatment of NMS were delayed because of atypical symptoms and complications. In this patient, treatment of NMS with bromocriptine did not start until 10 days into hospitalization. A delay in pharmacologic therapy in this patient may have contributed to persistence of symptoms. The patient showed signs of improvement on day 21 during combination bromocriptine, benztropine, and dantrolene therapy. Moreover, this case exemplifies the rigorous need for supportive therapy and adjunctive pharmacologic therapy for primary and secondary complications resulting from NMS. In conclusion, because of the wide range of risk factors and variations of NMS, a systematic approach to diagnosing and treating NMS is critical to a successful outcome. Discontinuation of antipsychotics, maintenance of supportive therapy aimed at preventing dehydration, hemodynamic, and electrolyte imbalances, and pharmacotherapy are essential in the treatment of NMS.

Clozapine-Associated Extrapyramidal Reaction

OBJECTIVE: To report a case of extrapyramidal reaction associated with a dosage increase of clozapine. CASE SUMMARY: A 44-year-old white man with a 20-year history of chronic paranoid schizophrenia was admitted to an inpatient psychiatric facility. His prior medications restarted on admission were clozapine 650 mg at bedtime, haloperidol 10 mg at bedtime, clonazepam 2 mg/d, and aspirin 325 mg/d. Two days after admission (hospital day 3), clozapine and clonazepam were discontinued, and he was prescribed haloperidol 5 mg every morning and 10 mg every evening. Stabilization occurred over the following 24 days, with progressively lower dosages of haloperidol and increasing dosages of clozapine. Haloperidol was discontinued on day 24. On day 47, the patient was agitated and making bizarre statements; thus, the morning dose of clozapine was increased by 50 mg (total 450 mg/d). On day 48 at 2200, a dystonic reaction was diagnosed; he received intramuscular diphenhydramine 50 mg, which caused the reaction to subside. At the time of the adverse reaction, he was prescribed clozapine 450 mg/d, vitamin E 400 IU three times daily, aspirin 325 mg/d, and acetaminophen, milk of magnesia, and Maalox as needed. DISCUSSION: Although the risk of extrapyramidal symptoms (EPS) is significantly lower with clozapine than with conventional agents, elevated clozapine blood concentrations have been reported to cause EPS; other reports have cited severe dystonias and dyskinesias on abrupt clozapine withdrawal. Considering the medications prescribed at the time and the discontinuation of haloperidol 24 days before the event, clozapine was the most likely cause of the extrapyramidal reaction. CONCLUSIONS: Regardless of anticipated safety associated with novel antipsychotics such as clozapine, reports of dystonic reactions must be taken into account and patients monitored appropriately.