Effects of Long-acting Injectable 3-Monthly Paliperidone Palmitate on the Clinical and Social Performance of Patients with Schizophrenia

Objective@#To investigate the effects of long-acting injectable 3-monthly paliperidone palmitate on the clinical and social functioning of patients with schizophrenia. @*Methods@#This study enrolled patients with schizophrenia receiving long-acting injectable 1-monthly paliperidone palmitate for at least 4 months and who subsequently received 3-monthly paliperidone palmitate. Accordingly, 418 patients were followed up for 24 weeks. Their clinical symptoms and social functioning were measured using the Clinical Global Impression-Severity of Illness and Personal and Social Performance scales. @*Results@#The Personal and Social Performance total score was significantly higher after 3-monthly paliperidone palmitate treatment than at baseline (baseline vs. week 24: 54.3 ± 18.0 vs. 61.0 ± 14.5 [mean ± standard deviation]; p ＜ 0.001; Wilcoxon signed-rank test); the proportion of patients in the mildly ill group (scores 71−100) also increased significantly (baseline vs. week 24: 16.5% vs. 20.6%; p＜ 0.001; McNemar-Bowker test). The mean Clinical Global Impression-Severity of Illness score decreased significantly (baseline vs. week 24: 3.7 ± 1.0 vs. 3.4 ± 0.9; p＜ 0.001; Wilcoxon signed-rank test), as did the proportion of patients in the severely ill group (baseline vs. week 24: 4.1% vs. 2.1%; p ＜ 0.001; McNemar-Bowker test). @*Conclusion@#Continuous 3-monthly paliperidone palmitate treatment significantly enhances the personal and social performance of patients with schizophrenia and reduces the proportion of those with severe illness. These findings suggest that long-acting injectable antipsychotic administration at intervals longer than 1 month might improve the social functioning of and promote return to activities of daily living in patients with schizophrenia.

Benzodiazepines: Pharmacology Up-to-Date and Practical Issues / 신경정신의학

Benzodiazepines have been widely used as anxiolytics, sedatives, hypnotics, anticonvulsants, or central muscle relaxants since the 1960s despite significant adverse effects, the potential for misuse, and consequent overdose. Benzodiazepines exert their pharmacological action by binding to gamma-aminobutyric acid type A (GABA-A) receptors in the brain and facilitateing the inhibitory actions of the neurotransmitter GABA. Recent findings have also elucidated the effects of benzodiazepines on the allosteric modulation of GABA-A receptors, including receptor subtypes and transmembrane proteins, which is a significant step in our understanding of GABA pharmacology. In clinical practice, the use of benzodiazepines to treat psychiatric disorders has been limited due to the challenges associated with the long-term use, namely the risks of abuse, misuse, and overdose, as well as withdrawal effects. Furthermore, the approval of selective serotonin reuptake inhibitors for anxiety disorders has led to their extensive use as a first-line pharmacological option and they have also been promoted in various practice guidelines for the treatment of anxiety disorders. However, although recent systematic reviews and meta-analyses have shown that benzodiazepines are useful and effective drugs for the treatment of various neuropsychiatric disorders, including anxiety, debates over the clinical use of benzodiazepines continue. More than 60 years after the introduction of benzodiazepines in clinical practice, it is necessary to revisit the controversies associated with benzodiazepine use and to update the discussion current approach to practice with thethrough an understanding of the new data on their pharmacological actions and to identify appropriate indications according to the new diagnostic systems of psychiatric disorders through an extensive literature review.

Practical Issues With Clonazepam Use / 신경정신의학

Clonazepam, a 7-nitrobenzodiazepine, has been used for the treatment of various neuropsychiatric disorders such as seizures, sleep disorders, panic disorders, anxiety, and movement disorders. However, clonazepam is officially approved as a therapeutic drug only for epilepsy and panic disorders in Korea. This raises ethical issues in clinical practice, as clonazepam is prescribed off-label for most neuropsychiatric disorders in many other countries as well. The misuse and abuse of clonazepam as a recreational drug have also been commonly reported in global literature. In this review, as a therapeutic drug as the authors aim to highlight the pharmacological aspects, clinical effects, and potential addictive risks of clonazepam use, by reviewing the current literature on clonazepam to increase its clinical use by accurately understanding and identifying its psychopharmacological benefits and characteristics. However, establishing the risk/benefit ratio of clonazepam for use in specific clinical situations is difficult because of the lack of adequate updated data. Therefore, the use of clonazepam needs to be approached from the point of view of personalized drug treatment rather than following fixed guidelines which would not reflect the current real-world clinical practices.

Satisfaction Survey of Patients Toward Electroconvulsive Therapy / 신경정신의학

Objectives@#This study examined the satisfaction of patients who had undergone electroconvulsive therapy to provide important information for improving the social misunderstanding about electroconvulsive therapy, to increase the effectiveness of treatment, and make a decision of effective treatment. @*Methods@#A questionnaire survey was conducted to determine the satisfaction, adverse effects, attitudes, and experiences toward electroconvulsive therapy in patients at 2 to 4 weeks after finishing an acute course of electroconvulsive therapy in three psychiatric hospitals. @*Results@#There were 85 respondents (38 males), whose average age was 42.0±13.6 years and average illness duration was 12.8±8.9 years. Fifty-two patients (61.2%), 19 (22.4%), 8 (9.4%), and 6 (7.1%) were diagnosed with schizophrenia, major depressive disorder, bipolar disorder, and other mental disorders, respectively. The average session number for acute electroconvulsive therapy was 12.6±6.0 sessions, and 61 patients (71.8%) had received maintenance electroconvulsive therapy. Among the respondents, 60.0% reported that they were satisfied with the electroconvulsive therapy. Satisfaction was similar according to sex, age, diagnosis, electrode placement, and use of anesthetic agents. Forty-three (53.8%) patients experienced memory impairment during acute electroconvulsive therapy. @*Conclusion@#This study showed that patients who received electroconvulsive therapy were generally satisfied with the treatment and that memory impairment should be detected early and managed promptly. Follow-up studies with a large number of subjects and variables will be needed to determine the predictive factors affecting satisfaction toward electroconvulsive therapy.

Satisfaction Survey of Patients Toward Electroconvulsive Therapy / 신경정신의학

Objectives@#This study examined the satisfaction of patients who had undergone electroconvulsive therapy to provide important information for improving the social misunderstanding about electroconvulsive therapy, to increase the effectiveness of treatment, and make a decision of effective treatment. @*Methods@#A questionnaire survey was conducted to determine the satisfaction, adverse effects, attitudes, and experiences toward electroconvulsive therapy in patients at 2 to 4 weeks after finishing an acute course of electroconvulsive therapy in three psychiatric hospitals. @*Results@#There were 85 respondents (38 males), whose average age was 42.0±13.6 years and average illness duration was 12.8±8.9 years. Fifty-two patients (61.2%), 19 (22.4%), 8 (9.4%), and 6 (7.1%) were diagnosed with schizophrenia, major depressive disorder, bipolar disorder, and other mental disorders, respectively. The average session number for acute electroconvulsive therapy was 12.6±6.0 sessions, and 61 patients (71.8%) had received maintenance electroconvulsive therapy. Among the respondents, 60.0% reported that they were satisfied with the electroconvulsive therapy. Satisfaction was similar according to sex, age, diagnosis, electrode placement, and use of anesthetic agents. Forty-three (53.8%) patients experienced memory impairment during acute electroconvulsive therapy. @*Conclusion@#This study showed that patients who received electroconvulsive therapy were generally satisfied with the treatment and that memory impairment should be detected early and managed promptly. Follow-up studies with a large number of subjects and variables will be needed to determine the predictive factors affecting satisfaction toward electroconvulsive therapy.

Recent Updates on Electro-Convulsive Therapy in Patients with Depression

Objective@#Electro-convulsive therapy (ECT) has been established as a treatment modality for patients with treatment-resistant depression and with some specific subtypes of depression. This narrative review intends to provide psychiatrists with the latest findings on the use of ECT in depression, devided into total eight sub-topics. @*Methods@#We searched PubMed for English-language articles using combined keywords and tried to analyze journals published from 1995–2020. @*Results@#Pharmacotherapy such as antidepressants or maintenance ECT is more effective than a placebo as prevention of recurrence after ECT. The use of ECT in treatment-resistant depression, depressed patients with suicidal risks, elderly depression, bipolar depression, psychotic depression, and depression during pregnancy or postpartum have therapeutic benefits. As possible mechanisms of ECT, the role of neurotransmitters such as serotonin, dopamine, gamma-aminobutyric acid (GABA), and other findings in the field of neurophysiology, neuro-immunology, and neurogenesis are also supported. @*Conclusion@#ECT is evolving toward reducing cognitive side effects and maximizing therapeutic effects. If robust evidence for ECT through randomized controlled studies are more established and the mechanism of ECT gets further clarified, the scope of its use in the treatment of depression will be more expanded in the future.

Resolution of Persistent Auditory Verbal Hallucinations after Long-term Electroconvulsive Therapy Maintenance: A Case Report of a Patient with Clozapine-resistant Schizophrenia

A 32-year-old woman with schizophrenia and persistent auditory verbal hallucinations (AVHs), which caused continuous suicidal thoughts and depression, was treated with electroconvulsive therapy (ECT) of an acute course followed by maintenance ECT (M-ECT) augmented onto clozapine for 7 years. Although the general psychopathology and AVHs initially reduced slightly with ECT and clozapine, her AVHs and suicidal thoughts did not decrease subjectively. When 3 years of M-ECT, her voices declined sharply, and improvement was maintained for 2 years thereafter. A total 91 ECT sessions were performed. The daily clozapine dose was decreased from 325 to 200 mg and plasma levels remained higher than 350 ng/ml; there were no noticeable cognitive side effects. In summary, we report a case showing a sudden sharp reduction in persistent AVHs after 3 years of long-term M-ECT.

Electroconvulsive Therapy for Psychiatric Disorders in Elderly Adults

Electroconvulsive therapy (ECT) is indicated for various mental disorders (e.g., major depressive disorder, schizophrenia, and bipolar disorder) and the behavioral and psychological symptoms of dementia in elderly patients. Furthermore, ECT is a useful first-line treatment in emergency and crisis situations such as suicide risk, violent behavior, catatonia, and food refusal, which are more frequent in elderly patients. ECT is also effective in the treatment of the motor symptoms of neurological disorders, such as Parkinson’s disease and Huntington’s disease. Due to the high risk of various physical diseases, the comorbid physical conditions of elderly patients should be individually controlled to optimize ECT treatment. Compared to young adults, in elderly patients the seizure threshold is higher, the seizure duration is shorter, and the anesthetic dose is lower. On the contrary, the response rate in the elderly is both faster and higher. Considering potential cognitive decline and the prevention of further deterioration of cognitive function in elderly patients, in the absence of significant comorbidities, twice weekly sessions and right unilateral electrode placement with a lower seizure threshold and less cognitive effect are preferred to bilateral electrode placement, which has a high risk of adverse cognitive effects. After an acute course of ECT, continuation and maintenance of ECT, combined with prescription of therapeutic drugs, may prevent possible relapse or recurrence of mental disorders. In conclusion, ECT can be used to treat mental disorders in elderly adults, with safety and effectiveness comparable to that in young adults.

The Electroconvulsive Therapy in the Prevention of Suicide Risks and Attempts

Suicidality is the most serious complication of mood disorders and psychosis; effective treatment should reduce suicide rates. The Organization for Economic Cooperation and Development age-standardized suicide rate in Korea was 22.6 in 2018, much higher compared to other countries worldwide. As mental and psychiatric problems are the main reasons for suicide attempts, accounting for 31.6% in 2018, targeting such problems should be the focus of efforts to reduce suicide rates. However, the ability of current pharmacotherapeutic and psychotherapeutic interventions to reduce suicide rates is limited due to their delayed effects. Therefore, electroconvulsive therapy (ECT) has been proposed as an alternative treatment. This approach is effective for treating most mental disorders associated with high suicide rates, including severe depression, bipolar disorder, and intractable psychotic disorders; ECT is also effective for Parkinson’s disease, which has the highest suicide rate among all disorders in Korea. The acute, long-term, and prophylactic effects of ECT on suicidality have been reported in the literature, and treatment guidelines outside of Korea recommend that ECT be used at an early stage for rapid reduction of suicide rates, as opposed to being applied as a treatment of last resort. However, only ~0.092 of every 10000 members of the Korean general population received ECT in 2018; this is much lower than the average rate worldwide, of 2.2 per 10000. Elimination of obstacles to the use of ECT, early crisis intervention involving administration of ECT for rapid stabilization, and maintenance ECT to prevent recurrence should reduce suicide rates.

The Determination of the Duration of ElectroconvulsiveTherapy-Induced Seizure Using Local Standard Deviationof the Electroencephalogram Signal and the Changesof the RR Interval of Electrocardiogram

Objectives@#ZZIn electroconvulsive therapy (ECT) research and practice, the precise determination of seizure duration is importantin the evaluation of clinical relevance of the ECT-induced seizure. In this study, we have developed computerized algorithms to assessthe duration of ECT-induced seizure. @*Methods@#ZZSubjects included 5 males and 6 females, with the mean age of 33.1 years. Total 55 ECT sessions were included in theanalysis. We analyzed the standard deviation of a finite block of electroencephalography (EEG) data and the change in the local slope ofRR intervals in electrocardiography (ECG) signals during ECT-induced seizure. And then, we compared the calculated seizure durationsfrom EEG recording (EEG algorithm) and ECG recording (ECG algorithm) with values determined by consensus of clinicians basedon the recorded EEG (EEG consensus), as a gold standard criterion, in order to testify the computational validity of our algorithms. @*Results@#ZZThe mean seizure durations calculated by each method were not significantly different in sessions with abrupt flattenedpostictal suppression and in sessions with non-abrupt flattened postictal suppression. The intraclass correlation coefficients (95% confidenceinterval) of the three methods (EEG algorithm, ECG algorithm, EEG consensus) were significant in the total sessions [0.79(0.70–0.86)], the abrupt flattened postictal suppression sessions [0.84 (0.74–0.91)], and the non-abrupt flattened postictal suppressionsessions [0.67 (0.45–0.84)]. Correlations between three methods were also statistically significant, regardless of abruptness of transition. @*Conclusions@#ZZOur proposed algorithms could reliably measure the duration of ECT-induced seizure, even in sessions with nonabrupttransitions to flat postictal suppression, in which it is typically difficult to determine the seizure duration.

Initial Seizure Threshold in Ultra-Brief Pulse Width Right Unilateral Electroconvulsive Therapy / 신경정신의학

Objectives@#The present study investigates the initial seizure threshold (IST) of an ultra-brief pulse width right unilateral electroconvulsive therapy (UBP-RUL ECT) in Korean patients with mental disorders to identify its predictive factors for clinical improvement. @*Methods@#This study includes thirty patients who received 0.3-ms UBP-RUL ECT using upward titration to measure IST after the use of general anesthesia and muscle relaxation between December 2015 and June 2020. During the second session, the amount of charge that ranged between 500% to 600% of IST was applied as the stimulus intensity (SI). Demographic and clinical information was gathered from electronic medical records, and a stepwise variable selection was conducted to identify the relevant predictors of IST. @*Results@#The mean age of study subjects was 49.7±18.3 years, and 12 (40.0%) patients were male. The mean IST and SI were 31.6±17.2 mC and 176.0±98.5 mC, respectively, which did not differ between males and females. The mean scores of the Clinical Global Impression-severity and the Clinical Global Impression-improvement before and after acute ECT were 5.8±0.8 and 2.1±0.7, respectively. The age and anesthetic dose per body weight were significant predictors of IST. However, the IST and SI were not associated with clinical improvement. @*Conclusion@#The present study demonstrated that the IST distribution for UBP-RUL ECT in Korean patients with mental disorders was comparable to those reported in previous literature. The IST was associated with age and anesthetic dose.

Electroconvulsive Therapy for Psychiatric Disorders in Elderly Adults

Electroconvulsive therapy (ECT) is indicated for various mental disorders (e.g., major depressive disorder, schizophrenia, and bipolar disorder) and the behavioral and psychological symptoms of dementia in elderly patients. Furthermore, ECT is a useful first-line treatment in emergency and crisis situations such as suicide risk, violent behavior, catatonia, and food refusal, which are more frequent in elderly patients. ECT is also effective in the treatment of the motor symptoms of neurological disorders, such as Parkinson’s disease and Huntington’s disease. Due to the high risk of various physical diseases, the comorbid physical conditions of elderly patients should be individually controlled to optimize ECT treatment. Compared to young adults, in elderly patients the seizure threshold is higher, the seizure duration is shorter, and the anesthetic dose is lower. On the contrary, the response rate in the elderly is both faster and higher. Considering potential cognitive decline and the prevention of further deterioration of cognitive function in elderly patients, in the absence of significant comorbidities, twice weekly sessions and right unilateral electrode placement with a lower seizure threshold and less cognitive effect are preferred to bilateral electrode placement, which has a high risk of adverse cognitive effects. After an acute course of ECT, continuation and maintenance of ECT, combined with prescription of therapeutic drugs, may prevent possible relapse or recurrence of mental disorders. In conclusion, ECT can be used to treat mental disorders in elderly adults, with safety and effectiveness comparable to that in young adults.

The Electroconvulsive Therapy in the Prevention of Suicide Risks and Attempts

Suicidality is the most serious complication of mood disorders and psychosis; effective treatment should reduce suicide rates. The Organization for Economic Cooperation and Development age-standardized suicide rate in Korea was 22.6 in 2018, much higher compared to other countries worldwide. As mental and psychiatric problems are the main reasons for suicide attempts, accounting for 31.6% in 2018, targeting such problems should be the focus of efforts to reduce suicide rates. However, the ability of current pharmacotherapeutic and psychotherapeutic interventions to reduce suicide rates is limited due to their delayed effects. Therefore, electroconvulsive therapy (ECT) has been proposed as an alternative treatment. This approach is effective for treating most mental disorders associated with high suicide rates, including severe depression, bipolar disorder, and intractable psychotic disorders; ECT is also effective for Parkinson’s disease, which has the highest suicide rate among all disorders in Korea. The acute, long-term, and prophylactic effects of ECT on suicidality have been reported in the literature, and treatment guidelines outside of Korea recommend that ECT be used at an early stage for rapid reduction of suicide rates, as opposed to being applied as a treatment of last resort. However, only ~0.092 of every 10000 members of the Korean general population received ECT in 2018; this is much lower than the average rate worldwide, of 2.2 per 10000. Elimination of obstacles to the use of ECT, early crisis intervention involving administration of ECT for rapid stabilization, and maintenance ECT to prevent recurrence should reduce suicide rates.

The Determination of the Duration of ElectroconvulsiveTherapy-Induced Seizure Using Local Standard Deviationof the Electroencephalogram Signal and the Changesof the RR Interval of Electrocardiogram

Objectives@#ZZIn electroconvulsive therapy (ECT) research and practice, the precise determination of seizure duration is importantin the evaluation of clinical relevance of the ECT-induced seizure. In this study, we have developed computerized algorithms to assessthe duration of ECT-induced seizure. @*Methods@#ZZSubjects included 5 males and 6 females, with the mean age of 33.1 years. Total 55 ECT sessions were included in theanalysis. We analyzed the standard deviation of a finite block of electroencephalography (EEG) data and the change in the local slope ofRR intervals in electrocardiography (ECG) signals during ECT-induced seizure. And then, we compared the calculated seizure durationsfrom EEG recording (EEG algorithm) and ECG recording (ECG algorithm) with values determined by consensus of clinicians basedon the recorded EEG (EEG consensus), as a gold standard criterion, in order to testify the computational validity of our algorithms. @*Results@#ZZThe mean seizure durations calculated by each method were not significantly different in sessions with abrupt flattenedpostictal suppression and in sessions with non-abrupt flattened postictal suppression. The intraclass correlation coefficients (95% confidenceinterval) of the three methods (EEG algorithm, ECG algorithm, EEG consensus) were significant in the total sessions [0.79(0.70–0.86)], the abrupt flattened postictal suppression sessions [0.84 (0.74–0.91)], and the non-abrupt flattened postictal suppressionsessions [0.67 (0.45–0.84)]. Correlations between three methods were also statistically significant, regardless of abruptness of transition. @*Conclusions@#ZZOur proposed algorithms could reliably measure the duration of ECT-induced seizure, even in sessions with nonabrupttransitions to flat postictal suppression, in which it is typically difficult to determine the seizure duration.

Initial Seizure Threshold in Ultra-Brief Pulse Width Right Unilateral Electroconvulsive Therapy / 신경정신의학

Objectives@#The present study investigates the initial seizure threshold (IST) of an ultra-brief pulse width right unilateral electroconvulsive therapy (UBP-RUL ECT) in Korean patients with mental disorders to identify its predictive factors for clinical improvement. @*Methods@#This study includes thirty patients who received 0.3-ms UBP-RUL ECT using upward titration to measure IST after the use of general anesthesia and muscle relaxation between December 2015 and June 2020. During the second session, the amount of charge that ranged between 500% to 600% of IST was applied as the stimulus intensity (SI). Demographic and clinical information was gathered from electronic medical records, and a stepwise variable selection was conducted to identify the relevant predictors of IST. @*Results@#The mean age of study subjects was 49.7±18.3 years, and 12 (40.0%) patients were male. The mean IST and SI were 31.6±17.2 mC and 176.0±98.5 mC, respectively, which did not differ between males and females. The mean scores of the Clinical Global Impression-severity and the Clinical Global Impression-improvement before and after acute ECT were 5.8±0.8 and 2.1±0.7, respectively. The age and anesthetic dose per body weight were significant predictors of IST. However, the IST and SI were not associated with clinical improvement. @*Conclusion@#The present study demonstrated that the IST distribution for UBP-RUL ECT in Korean patients with mental disorders was comparable to those reported in previous literature. The IST was associated with age and anesthetic dose.

Initial Seizure Threshold in Brief-Pulse Bilateral Electroconvulsive Therapy in Patients with Schizophrenia or Schizoaffective Disorder

OBJECTIVE: The present study aimed to report the initial seizure threshold (IST) of a brief-pulse bilateral electroconvulsive therapy (BP-BL ECT) in Korean patients with schizophrenia/schizoaffective disorder and to identify IST predictors. METHODS: Among 67 patients who received ECT and diagnosed with schizophrenia/schizoaffective disorder based on the criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, we included 56 patients who received 1-millisecond BP-BL ECT after anesthesia with sodium thiopental between March 2012 and June 2018. Demographic and clinical information was gathered from electronic medical records, and a multiple regression analysis was conducted to identify predictors of the IST. RESULTS: The mean age of the patients was 36.9±12.0 years and 30 (53.6%) patients were male. The mean and median IST were 105.9±54.5 and 96 millicoulombs (mC), respectively. The IST was predicted by age, gender, and dose (mg/kg) of sodium thiopental. Other physical and clinical variables were not associated with the IST. CONCLUSION: The present study demonstrated that the IST of 1-ms BP-BL ECT following sodium thiopental anesthesia in Korean patients was comparable to those reported in previous literature. The IST was associated with age, gender, and dose of sodium thiopental.

Long-Term Changes in Self-Report Auditory Verbal Hallucinations in Patients with Schizophrenia Using Clozapine

This study explored long-term changes in self-report auditory verbal hallucinations (AVHs) among patients with schizophrenia taking clozapine. Forty-four patients who were evaluated more than twice and were above the mild severity category on the Hamilton Program for Schizophrenia Voices Questionnaire (HPSVQ) were enrolled. The mean observation period was 492.5±350.1 days (median, 452 days). The mean total, physical, and emotional factor scores on the HPSVQ were significantly reduced from baseline to the final observations except for one item “interference with life,” which was not significantly reduced. Regarding the time-dependent longitudinal changes modeled using linear mixed-effect regression, the total and physical factor scores showed significant changes during the first year, but the emotional factor score did not satisfy a more stringent level of significance. Female gender was negatively associated with the reduction in total and physical factor scores. The duration of treatment with clozapine also had a negative relationship with the reductions in all three scores.

Combination of Electroconvulsive Therapy and Clozapine in Treatment-Resistant Schizophrenia

OBJECTIVE: This study aimed to investigate the effectiveness and tolerability of the combination of electroconvulsive therapy (ECT) in patients with clozapine-treated schizophrenia. METHODS: Patients with clozapine-treated schizophrenia during five years of pre-determined period were recruited from Electronic Medical Record. Clinical effects of acute ECT on psychotic symptoms were investigated. We also tried to identify predictive variables requiring maintenance treatment of ECT. RESULTS: Fourteen patients received ECT and clozapine and sixteen were treated with clozapine alone. In the ECT group, which could be refined as clozapine-resistance, PANSS total score was significantly reduced by 19.0±9.9 points, corresponding to a reduction rate of 18.5±8.3%. The clinical remission defined as 20% PANSS reduction criteria was achieved at 42.9%. The subscale factors were significantly reduced, among which the negative symptom was the least. There was no difference in demographic and clinical information between patients receiving and not receiving maintenance ECT, and not all patients seemed to need maintenance ECT if clozapine is continued. CONCLUSION: Combination of ECT and clozapine in patients with clozapine-resistant schizophrenia resulted in a rapid and substantial reduction of psychotic symptoms. Further studies are needed to improve the effectiveness and tolerability of ECT.

Antipsychotic-Induced Oculogyric Crisis and Paroxysmal Perceptual Alteration / 대한정신분열병학회지

During antipsychotic drug treatment, clinicians occasionally encounter sudden attacks of oculogyric crisis (OGC) and/or paroxysmal perceptual alteration (PPA) which occur mostly in the afternoon or early evening lasting for minutes to hours and are eventually remitted with rests or short sleep and/or medications such as benzodiazepines, anticholinergics and so forth. Moreover, these attacks are usually accompanied with psychiatric symptoms such as various modalities of hallucinations and illusions, delusions, obsessive thoughts, panic attacks, agitation as well as autonomic symptoms. These accompanying psychiatric symptoms can be perceived as a worsening of psychiatric symptoms if the clinician does not understand the symptoms due to the side effects of antipsychotic drugs, which may result in increasing the dosage of antipsychotics instead of reducing doses or switching to less offending drugs. On the other hand, patients could easily recognize the symptoms as the adverse effects of drugs. This literature review and case-series study is aimed to raise awareness of OGC and PPA by providing clinical cases and author's views with the literature reviews about concepts, recognitions and managements from the works of Japanese authors who first reported the clinical importance of these attacks, particularly PPA.

Long-Term Evolution of Metabolic Status in Patients with Schizophrenia Stably Maintained on Second-Generation Antipsychotics

OBJECTIVE: Second-generation antipsychotics (SGAs) increase the risk of metabolic syndrome (MetS). Despite the risk of MetS, SGAs may have to be continued with change in some patients. The aim of this study was to trace the evolution of MetS in these patients. METHODS: Patients with schizophrenia who had been maintained on a fixed SGA regimen for more than a year were followed-up without changing the regimen. Metabolic indicators were evaluated at baseline and at follow-up. Prevalence, incidence and spontaneous normalization rate of MetS were estimated. Risk factors that might have influenced the evolution were scrutinized. RESULTS: A total of 151 subjects were included. During the mean observation period of 389.9±162.4 days, the prevalence of MetS was increased from 35.1 to 45.0%. The incidence rate was 29.6%, while the normalization rate was 26.4%, risk factors affecting incidence were age (OR=1.09, 95% CI: 1.03–1.17), baseline continuous values of metabolic syndrome risk scores (cMetS, OR=1.77, 95% CI:1.29–2.55) and baseline body weight (OR=1.06, 95% CI: 1.01–1.13). Normalization was influenced by age (OR=0.74, 95% CI: 0.57–0.89) and baseline body weight (OR=0.85, 95% CI: 0.72–0.95). CONCLUSION: The prevalence of MetS steadily increased with the continuous use of SGAs. However, individual difference was extensive and about a quarter of the patients were able to recover naturally without specific measurements.