Tariq Hassan

Clozapine-Induced Myocarditis: Is Mandatory Monitoring Warranted for Its Early Recognition?

Clozapine is an atypical antipsychotic used for treatment resistant schizophrenia. Its potential to induce agranulocytosis is well known but it can also cause myocarditis. Clozapine is the only antipsychotic known to induce this side effect, typically early in the treatment, and literature is scarce on this condition. We are presenting a case report of a 21-year-old schizophrenic male who developed myocarditis within 3 weeks of starting on clozapine for his treatment resistant psychosis. We then aim to review some of the available literature and raise awareness among physicians as this condition can potentially be fatal if not detected early.

Clozapine reinitiation following a "red result" secondary to chemotherapy

We describe a case of a patient whose clozapine was discontinued after a “red result” following R-CHOP (rituximab with cyclophosphamide, hydroxydaunorubicin, Oncovin, and prednisolone) chemotherapy for large B-cell lymphoma. In some cases, manufacturers grant permission, on compassionate grounds, for clozapine to be continued or reinitiated following assessment by their consultant hematologist. Other than a recent case report, there is not much literature surrounding this medical issue. However, since the two leading causes of mortality in schizophrenia are cancer and cardiac disease, this is not an uncommon occurrence. Clinicians are reluctant to prescribe clozapine in view of its side-effect profile, despite its proven efficacy for managing treatment-resistant schizophrenia. The alternative is to prescribe two antipsychotics to manage symptoms. This approach may be associated with increased side effects, and evidence for actual benefits is scant. The consequences were disastrous in this case, as the individual not only relapsed following clozapine discontinuation, but the therapy for this treatable form of lymphoma had to be delayed. He was eventually admitted to an inpatient unit after having been stable for 15 years. We managed to stabilize him with olanzapine and aripiprazole which enabled the heme-oncology group to resume R-CHOP therapy with filgrastim (granulocyte colony-stimulating factor). Even so, he continued to exhibit severe psychotic symptoms, with religious delusions and auditory hallucinations. We therefore applied for permission to rechallenge him on clozapine. Permission was granted when protocol conditions were met, and reinitiation went without any adverse events. The patient’s symptoms showed improvement within a few weeks, and the other antipsychotics were discontinued once clozapine was titrated up to 300 mg. The decision to reinitiate clozapine following a red result is not to be taken lightly, but needs to be considered in terms of the risks versus benefits. More literature surrounding this issue would be of great benefit to clinicians, patients, and their families.

Preliminary evaluation of a “formulation-driven cognitive behavioral guided self-help (fCBT-GSH)” for crisis and transitional case management clients

Background Cognitive behavioral therapy (CBT) is found to be effective for common mental disorders and has been delivered in self-help and guided self-help formats. Crisis and transitional case management (TCM) services play a vital role in managing clients in acute mental health crises. It is, therefore, an appropriate setting to try CBT in guided self-help format. Methods This was a preliminary evaluation of a formulation-driven cognitive behavioral guided self-help. Thirty-six (36) consenting participants with a diagnosis of nonpsychotic illness, attending crisis and the TCM services in Kingston, Canada, were recruited in this study. They were randomly assigned to the guided self-help plus treatment as usual (TAU) (treatment group) or to TAU alone (control group). The intervention was delivered over 8–12 weeks. Assessments were completed at baseline and 3 months after baseline. The primary outcome was a reduction in general psychopathology, and this was done using Clinical Outcomes in Routine Evaluation – Outcome Measure. The secondary outcomes included a reduction in depression, measured using the Hospital Anxiety and Depression Scale, and reduction in disability, measured using the World Health Organization Disability Assessment Schedule 2.0. Findings Participants in the treatment group showed statistically significant improvement in overall psychopathology (P<0.005), anxiety and depression (P<0.005), and disability (P<0.005) at the end of the trial compared with TAU group. Conclusion A formulation-driven cognitive behavioral guided self-help was feasible for the crisis and TCM clients and can be effective in improving mental health, when compared with TAU. This is the first report of a trial of guided self-help for clients attending crisis and TCM services.

Forensic psychiatric service provision in Pakistan and its challenges

In the Islamic Republic of Pakistan the law relating to people who are mentally ill, until 2001, was set out by the Lunacy Act of 1912, which was inherited from the British colonial occupiers. In 2001 the Mental Health Ordinance 2001 took its place but only for this federal law to be superseded in April 2010 with the 18th constitutional amendment. As part of that amendment, provinces have become responsible for (psychiatric) healthcare, including mental health legislation. Forensic psychiatry is practised in Pakistan but is very much in its infancy; it needs to develop and learn from more experienced countries in Europe and North America. Cultural factors and misconceptions arising from religion can at times contribute to, or create, barriers to the implementation of forensic psychiatric services in Pakistan. This paper reviews the current state of forensic psychiatric services in Pakistan and is intended to open the debate on the challenges ahead.

Forensic psychiatry in Pakistan.

This article reviews existing forensic psychiatric services in Pakistan highlighting the role played by the judicial and the medical fraternity in managing the legal and forensic issues of the population of patients with mental illnesses. Until 2001, all legal and forensic issues were dealt with the mental health legislation of 1912, the Lunacy Act of 1912. This was inherited from the British rulers in the Sub-Continent at the time. The Mental Health Ordinance of 2001 could not sustain following the 18th constitutional amendment in 2010, whereby psychiatric healthcare was devolved to the provinces from the previous federal authority. The article also highlights the difficulties and the barriers in implementation of the forensic psychiatric services in Pakistan at various levels within the healthcare system. This article also delves into the current framework of training in forensic psychiatry for postgraduates as well as the assessments and management schedules for the mentally ill offenders at tertiary care institutions in Pakistan.

Psychiatry 2050: from younger psychiatrists' perspective

There have been various opinion pieces on predicting the future of psychiatry and addressing its different domains. This editorial addresses the topic from the vantage point of neuroscientific inquiry. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5) however continues with the tradition of its predecessor (DSM 4 text revision [TR]), addressing most diagnoses with descriptive phenomenology as opposed to attempting to change diagnoses based on causative phenomenology or response to treatment. Advances in genomics and imaging, with time, will hopefully help shape psychiatric diagnoses and classifications with a primary basis on morphology. This may in turn help improve the recruitment of academic psychiatrists to the field. In doing so, the profession will gain respect amongst its peers in other disciplines of medicine and cement its future.

Treatment of anxiety disorders and comorbid alcohol abuse with buspirone in a patient with antidepressant-induced platelet dysfunction: a case report.

The risk of abnormal bleeding with serotonin reuptake inhibitors has been known, but there is insufficient evidence base to guide pharmacological treatment of anxiety in patients with underlying haematological conditions. The following case report is about a 50-year-old female with generalized anxiety disorder, social phobia, obsessive compulsive disorder, and alcohol abuse where pharmacological treatment of anxiety symptoms has been difficult as it would lead to bruising due to the patients underlying qualitative platelet dysfunction. Treatment with venlafaxine, citalopram, escitalopram, and clomipramine resulted in improvement and anxiety symptoms, as well as reduction in alcohol use, but pharmacological treatment has to be discontinued because of bruising and hematomas. In view of an active substance use disorder, benzodiazepines were avoided as a treatment option. The patients anxiety symptoms and comorbid alcohol abuse responded well to pharmacological treatment with buspirone which gradually titrated up to a dose of 30 mg BID. Patient was followed for around a six-month period while she was on buspirone before being discharged to family doctors care. Buspirone is unlikely to have a significant effect on platelet serotonin transponder and could be an effective alternative for pharmacological treatment of anxiety in patients with a bleeding diathesis.