Rizwan Ahmed

Combined use of electroconvulsive therapy and antipsychotics (both clozapine and non-clozapine) in treatment resistant schizophrenia: A comparative meta-analysis

Aim To assess the relative efficacies of clozapine plus Electroconvulsive Therapy (ECT) compared against non-clozapine typical and atypical antipsychotics plus ECT for the treatment of “Treatment Resistant Schizophrenia” (TRS). Primarily to assess if clozapine delivers a significant improvement over other antipsychotics when combined with ECT. Design Major electronic databases were searched between 1990 and March 2017 for trials measuring the effects of either clozapine augmented ECT, other antipsychotic-augmented ECT, or both. After the systematic review of the data, a random-effects meta-analysis was conducted measuring the relative effect sizes of the different treatment regimens. Subjects 1179 patients in 23 studies reporting the usage of ECT augmentation with antipsychotics. A total of 95 patients were tested with clozapine, and ECT (9 studies) and 1084 patients were tested with non-clozapine antipsychotics (14 studies) such as flupenthixol, chlorpromazine, risperidone, sulpiride, olanzapine, and loxapine with concurrent ECT treatment considered for systematic review. Of these, 13 studies reported pre and post-treatment scores were included in the meta-analysis. Main outcome measures The main outcome measure was the presence and degree of both positive and negative psychotic symptoms, as measured by either of two standardized clinician administered tests, the Brief Psychiatric Rating Scale (BPRS), and the Positive and Negative Symptom Scale (PANSS). Results The comparison of the different antipsychotics established the supremacy of ECT-augmented clozapine treatment against other typical and atypical antipsychotics. The Forest Plot revealed that the overall standard mean difference was 0.891 for non-clozapine studies and 1.504 for clozapine studies, at a 95% interval. Furthermore, the heterogeneity plots showed that while clozapine studies showed no significant heterogeneity, non-clozapine studies showed an I2 statistic value at 42.19%, suggesting moderate heterogeneity. Lastly, publication bias showed asymmetrical plots and significant values of Kendals tau and Eggers rank test. Conclusion ECT augmentation technique was found to be effective in the reduction of psychometric scale scores, and the resulting improvement was significant. Clozapine maintained its stance as the most effective treatment for Treatment-Resistant Schizophrenia, followed by flupenthixol.

Nicotine Addiction in Schizophrenia, Availability of Better TreatmentOptions as are in General Population

This article reviews literature regarding smoking cessation in Schizophrenia population, its harmful effects on health, finances, role of mental health care providers and better available options for treatment as are in general population. This population not only smokes at higher rates, but also has higher nicotine dependence with lower cessation rates than general population, people of schizophrenia have truncated life span due to smoking related diseases and premature mortality compared with the general population. Contrary to traditional reasoning that this population is not motivated or able to tolerate smoking cessation, but there is extensive literature that negates such rationale, even provides better treatment options to address this huge public health burden. Our review will mainly focusing treatment options particularly drug Varenicline, that shows most effective and promising results in patients of schizophrenia for smoking cessation as in general population, moreover different combination therapies, few new interventions, as well as some clinical areas will be discussed those need to be studied further in future.

FahrâÂÂs Disease: A Rare Neurological Disease Frequently Misdiagnosed as Acute Psychosis, or Mood Disorder

Fahr’s disease is a rare, degenerative neurological disorder characterized by idiopathic symmetrical and bilateral intracranial calcification. We present a case of 32 years old man with Fahr’s disease who presented with episodes of inappropriate excessive laughing, generalized tonic clonic seizures associated with loss of consciousness, frothing from mouth, urine incontinence and difficulty in walking due to neurological deficit. MRI of brain demonstrated calcification of bilateral basal ganglia, thalami and left dentate nucleus of left cerebellum. The clinical presentation similar to our patient is frequently misdiagnosed due to identical manifestation to other neurological and psychiatric disorders especially in young to middle aged individuals. Fahr’s disease may often misdiagnosed as a patient of acute psychosis or epileptic seizures.

Rasmussen's Encephalitis: A Case Report

Abstract We report a case of Rasmussen’s Encephalitis. It is a rare, chronic inflammatory neurological disease of unknown origin that usually affects only one hemisphere of the brain. It is common in children under the age of 10 with average age at disease onset around 6 years but uncommon in adults, adult variant that accounts for about 10% of the cases only. Rasmussen’s Encephalitis is characterized by intractable severe seizures, loss of motor skills and speech, paralysis on one side of the body (dysfunctions associated with the affected hemisphere). Our case is a 21 years old female, presented to emergency department JMPC Karachi with complaint of intractable severe seizures, progressive hemiparesis and deteriorated cognition followed by an episode of encephalitis. Her course of illness was focal seizures and right-sided weakness (hemiparesis) for 5 months. In addition to classical clinical presentation of Rasmussen’s Encephalitis, MRI Brain showed hemispheric atrophy of one cerebral hemisphere and old gliotic changes that further supports diagnosis of Rasmussen’s Encephalitis.

Efficacy and Safety of Varenicline for Smoking Cessation in Schizophrenia: A Meta-Analysis

Objective: Smoking represents a major public health problem among patients with schizophrenia. To this end, some studies have investigated the efficacy of varenicline for facilitating smoking cessation in schizophrenia patients. The present review seeks to synthesize the results of these studies as well as document the reported side effects of using this medication. Methods: An electronic search was performed using five major databases: PubMed, Scopus, EMBASE, Web of Science, and Cochrane Library. Included in the current analysis were randomized clinical trials (RCTs) that have investigated the effect of varenicline in promoting smoking cessation in patients with schizophrenia. Risk of bias among included RCTs was assessed using the Cochrane Collaborations quality assessment tool. Results: Among the 828 screened articles, only four RCTs, which involved 239 participants, were eligible for meta-analysis. In patients with schizophrenia, varenicline treatment when compared to placebo significantly reduced the number of cigarettes consumed per day [SMD (95% CI) = 0.89(0.57–1.22)] and expired carbon monoxide levels [SMD (95% CI) = 0.50 (0.06–0.94)] respectively. Conclusion: Despite a limited number of studies included in the meta-analysis, our results suggest that varenicline is an effective and safe drug to assist smoking cessation in patients with schizophrenia. Future large-scale well-designed RCTs are required to validate these findings.

Adding Psychotherapy to the Naltrexone Treatment of Alcohol Use Disorder: Meta-analytic Review

Background It remains unclear if naltrexone combined with psychotherapy is superior to naltrexone alone in treating alcohol use disorders (AUD). The current meta-analysis examined the hypothesis that psychotherapy is a significant moderator that influences AUD-related outcomes and that naltrexone combined with psychotherapy is associated with significantly better AUD-related outcomes than naltrexone alone. Methods A total of 30 studies (Nnaltrexone = 2317; Nplacebo = 2056) were included. Random effects model meta-analyses were carried out for each of the studied outcomes. Subsequently, the random effects model pooled estimates from studies with and without psychotherapy were compared using a Wald test. A mixed-effect model, incorporating psychotherapy as a moderator, was used to examine the impact of psychotherapy on treatment outcomes. Results Naltrexone had a significant treatment effect on abstinence relapse and Gamma-Glutamyl Transferase levels, but not cravings. The pooled estimates for studies with and without psychotherapy were not significantly different for any of the studied outcomes. Psychotherapy was not a significant moderator in the mixed effects models for any of the studied outcomes. Conclusions Naltrexone treatment is efficacious in reducing alcohol consumption, but not reducing cravings. Adding psychotherapy on top naltrexone did not result in any significant additional benefit for AUD patients.

Safety and Efficacy of Antipsychotics in Pregnancy and Lactation

The clinical profiles of antipsychotic medications have improved dramatically since the first generation was introduced in the 1950s. Second Generation Antipsychotic medications (SGAs), which became available in 1990, generate fewer side effects, including reduced incidence of extrapyramidal symptoms such as hyperprolactinemia. This improves the female patients’ ability to become pregnant, a process which is compromised by first generation drugs. However, use of antipsychotic medications has become increasingly prevalent. The likelihood of females with depression, bipolar disorder, psychosis to have an unplanned pregnancy, and the incidence of foetal exposure to psychotropic drugs during the first trimester of pregnancy has also increased. The paucity of exposure and outcome data leaves the safety and effects of use of antipsychotic medications during pregnancy as a subject to controversy. The evidence is insufficient to provide adequate support for clinical practices, and also to the professionals in the related fields of psychiatry, obstetrics-gynecology, and primary care. There is often contradicting information given to patients due to the lack of current studies pertaining to this area. The studies of SGA’s use during breastfeeding suggest that olanzapine, risperidone, and quetiapine may be safe at certain levels whereas medications like clozapine achieve relatively high concentrations in breast milk and may cause agranulocytosis and somnolence. Therefore, the purpose of this review is to report the most relevant and up-to-date findings of antipsychotic medication use during pregnancy and lactation in detail, so that physicians may have more insight regarding medications and provide female patients of childbearing potential with knowledge of the benefits and risks of antipsychotic drugs.

Translational Science of Psychosis in Parkinsons Disease

Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by loss of dopamine in the substantia nigra. It is predominantly a motor disorder but has shown to present with psychosis in few cases. Psychotic symptoms result from chronic treatment with few anti- Parkinson’s medications, ranging from depression, delusions to visual hallucinations, eventually progressing to auditory hallucinations in a few cases. Presence of psychotic symptoms with loss of insight is indicative of late stage of Parkinson’s disease and has poor prognosis. Accurate diagnosis of symptoms can be difficult due to significant overlapping clinical presentations which can be an admixture of underlying disease, exacerbation of pre-existing psychiatric illness or iatrogenic. The article below portrays the complex interplay between Parkinson’s disease psychosis, medications and underlying disease process which heralds early identification of the symptoms using diagnostic tools and imaging techniques to improve the health of individuals and the community by “translating” findings into diagnostic tools and medicines. It also highlights the dire need to develop neuroprotective drugs as a mode of primary prevention of psychosis. We cannot underemphasize the need to educate the patient and caregiver to seek medical attention at earliest for prompt identification and application of disease modifying therapies to reduce disability and morbidity associated with it and limit nursing home placements

Suicide: A Complex Phenomenon, Risk Assessment, a Dilemma of Emergency Room Physicians

Worldwide, suicide remains a huge public health and social dilemma resulting in the loss of approximately one million lives each year. It is one of the three leading causes of death among the most economically productive age group, i.e., 15-44 years and the second leading cause among the youth. The greatest burden is borne by the low and middle-income countries, ill-equipped to deal with the mental health issues of their populations. High-income countries replete with resources are also struggling with the issue because of inaccessible services or lack of reinforcement of preventative policies. This paper summarizes the theoretical bases of suicide to help better understand the motivations of the most vulnerable groups. In addition, it provides an overview of risk factors and assessment tools. Further, it lays down the guidelines for preventative and management strategies. The aim is to assist clinicians in addressing specific underlying causes of suicidal behaviors and developing quick and effective action plans to help those in dire need.

Transcranial Direct Current Stimulation (tDCS) Therapy for Major Depressive Disorder in the HIV Population: A Safe, Effective Noninvasive Promising Treatment as Compared to Conventional Antidepressant Therapy

Major depressive disorder (MDD) is one of the most prevalent psychiatric disorders in the HIV-positive population. For long periods of time, MDD has been treated with conventional antidepressant therapy in these patients. Novel Antidepressant Therapy for Major Depression in HIV-infected adults is associated with various side effects such as sleep disturbance, nervousness, insomnia, weight loss, and sexual dysfunction that could lead to non-adherence to antiretroviral therapy. To uphold compliance and prevent patients from serious adverse effects of antidepressant therapy; emerging noninvasive innovative transcranial direct current stimulation (tDCS) could serve as a better alternative. tDCS has shown promising results; it is an effective, safe therapeutic strategy with an immediate onset of action as compared to conventional SSRI therapy. The application of tDCS is an easy one and the device for conducting this treatment modality is highly portable. Along with its convenient application, subjects who have been treated with tDCS in study settings, found it tolerable with minimum discomfort and without developing chronic and profound adverse effects. The role of transcranial direct current stimulation therapy is not limited to addressing solely the depressive component in the MDD population; however, it could be critical in assisting these patients by combating their co-morbidities of alcoholism and substance abuse by decreasing their cravings. Furthermore, tDCS has proven itself in improving the cognition in this patient population. This paper will further review this innovative treatment option and will also suggest tDCS to be studied in larger clinical trials as it could serve a huge role in developing better understanding of patient experiences regarding its tolerability, safety, and efficacy. Similarly, it will also provide important evidence to clinicians for the development of better practices in this area.