Acute respiratory distress syndrome caused by quetiapine poisoning: a case report / 中华劳动卫生职业病杂志

Quetiapine is a psychotropic drug. Excessive use of quetiapine may lead to drowsiness, blurred vision, respiratory depression, hypotension and extrapyramidal reactions. Acute respiratory distress syndrome (ARDS) is rare due to overdose of quetiapine. On 14 February 2020, a patients with coma, respiratory arrest and hypotension due to overdose of quetiapine were admitted to our hospital. After receiving mechanical ventilation、plasma adsorption and anti-inflammatory treatment, the patient's consciousness turned clear, the machine was successfully removed and extubated, and the patient's condition was improved and discharged from hospital. We analyzed the clinical data of the patient with quetiapine poisoning, and discussed the clinical symptoms and chest CT characteristics of ARDS caused by quetiapine poisoning, in order to improve the understanding of quetiapine poisoning and improve the success rate of rescue.

Home-based nursing interventions improve knowledge of disease and management in patients with heart failure / Intervenções de enfermagem no domicílio melhoram conhecimento sobre a doença e tratamento em pacientes com insuficiência cardíaca / Intervenciones de enfermería en domicilio mejoran conocimiento sobre la enfermedad y tratamiento en pacientes con insuficiencia cardíaca

OBJECTIVE: to assess patient knowledge of heart failure by home-based measurement of two NOC Nursing Outcomes over a six-month period and correlate mean outcome indicator scores with mean scores of a heart failure Knowledge Questionnaire. METHODS: in this before-and-after study, patients with heart failure received four home visits over a six-month period after hospital discharge. At each home visit, nursing interventions were implemented, NOC outcomes were assessed, and the Knowledge Questionnaire was administered. RESULTS: overall, 23 patients received home visits. Mean indicator scores for the outcome Knowledge: Medication were 2.27±0.14 at home visit 1 and 3.55±0.16 at home visit 4 (P<0.001); and, for the outcome Knowledge: Treatment Regimen, 2.33±0.13 at home visit 1 and 3.59±0.14 at home visit 4 (P<0.001). The correlation between the Knowledge Questionnaire and the Nursing Outcomes Classification scores was strong at home visit 1 (r=0.7, P<0.01), but weak and non significant at visit 4. CONCLUSION: the results show improved patient knowledge of heart failure and a strong correlation between Nursing Outcomes Classification indicator scores and Knowledge Questionnaire scores. The NOC Nursing Outcomes proved effective as knowledge assessment measures when compared with the validated instrument. .

OBJETIVO: verificar o conhecimento dos pacientes sobre insuficiência cardíaca, por meio de dois Resultados de Enfermagem em ambiente domiciliar, durante um seguimento de seis meses e, correlacionar a média dos seus indicadores com um Questionário de Conhecimento sobre insuficiência cardíaca. MÉTODOS: neste estudo tipo antes-depois, pacientes com insuficiência cardíaca receberam quatro visitas domiciliares, durante seis meses, após a alta hospitalar. Em cada visita foram implementadas Intervenções de Enfermagem, mensurados os Resultados e aplicado o Questionário do Conhecimento. RESULTADOS: vinte e três pacientes receberam visitas em domicílio. Na visita um, o Resultado Conhecimento: Medicação obteve média de 2,27±0,14 e na visita quatro, 3,55±0.16 (P<0,001), e o Resultado Conhecimento: Regime Terapêutico 2,33±0,13 na visita um e 3,59±0,14 na visita quatro (P<0,001). A correlação entre o Questionário do Conhecimento e os escores da Classificação dos Resultados de Enfermagem foi de forte magnitude na visita domiciliar um (r=0.7, P<0,01), mas fraca e não significativa na visita quatro. CONCLUSÃO: os resultados indicaram progresso do conhecimento sobre insuficiência cardíaca e correlação forte entre a Classificação dos Resultados de Enfermagem e os escores do Questionário do Conhecimento. A Classificação dos Resultados de Enfermagem mostrou-se efetiva na avaliação do conhecimento quando comparada ao instrumento validado. .

OBJETIVO: verificar el conocimiento de los pacientes sobre insuficiencia cardíaca mediante dos Resultados de Enfermería en ambiente domiciliario durante un seguimiento de seis meses y correlacionar el promedio de sus indicadores con un Cuestionario de Conocimiento sobre insuficiencia cardíaca. MÉTODOS: en este estudio tipo antes-después, pacientes con insuficiencia cardíaca recibieron cuatro visitas en domicilio durante un período de seis meses tras el alta hospitalario. En cada visita fueron implementadas Intervenciones de Enfermería, mensurados los Resultados y aplicado el Cuestionario del Conocimiento. RESULTADOS: veinte y tres pacientes recibieron visitas en domicilio. En la visita 1, el Resultado Conocimiento: Medicación alcanzó promedio de 2,27±0,14 y, en la visita 4 3,55±0.16 (P<0,001), y el Resultado Conocimiento: Régimen Terapéutico 2,33±0,13 en la visita 1 y 3,59±0,14 en la visita 4 (P<0,001). La correlación entre el Cuestionario del Conocimiento y los scores de la Clasificación de los Resultados de Enfermería fue de magnitud fuerte en la visita en domicilio 1 (r=0.7, P<0,01), pero débil y no significativa en la visita 4. CONCLUSIÓN: los resultados indicaron mejora del conocimiento sobre insuficiencia cardíaca y correlación fuerte entre la Clasificación de los Resultados de Enfermería y los scores del Cuestionario del Conocimiento. La Clasificación de los Resultados de Enfermería se mostró efectiva en la evaluación del conocimiento cuando comparados al instrumento validado. .

Meta-analysis on the efficacy and tolerability of the augmentation of antidepressants with atypical antipsychotics in patients with major depressive disorder

We assessed the efficacy and tolerability of the augmentation of antidepressants (ATDs) with atypical antipsychotics (AAPs) to treat patients with major depressive disorder. A retrograde study to identify relevant patient data included databases of PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Database of Abstracts of Reviews of Effects. Data from 17 trials, involving 3807 participants, were identified. The remission rate (RR) and overall response rate (ORR) of adjunctive treatment with AAPs were significantly higher than placebo treatment: RR=1.90 (95%CI=1.61-2.23, z=7.74, P<0.00001) and ORR=1.68 (95%CI=1.45-1.94, z=7.07, P<0.00001). We found that the short-term (4 weeks) treatment [ORR=1.70 (95%CI=0.98-2.95, Z=1.89, P=0.06)] was significantly different from the long-term (6-12 weeks) treatment [ORR=1.68 (95%CI=1.45-1.94, z=7.07, P<0.00001)]. No significant difference in ORR was observed between groups with or without sedative drugs. The discontinuation rate due to adverse effects was higher for adjunctive treatment with AAPs: ORR=3.32 (95%CI=2.35-4.70, z=6.78, P<0.00001). These results demonstrate that the augmentation of ATDs with AAPs (olanzapine, quetiapine, aripiprazole, and risperidone) was more effective than a placebo in improving response and remission rates, although associated with a higher discontinuation rate due to adverse effects.

Aggravation of Hypertriglyceridemia and Acute Pancreatitis in a Bipolar Patient Treated with Quetiapine

Pancreatitis is a very rare adverse effect of quetiapine treatment, with only 5 cases of quetiapine-associated pancreatitis reported in the English literature to date. Herein, we report one patient who developed severe hypertriglyceridemia (>1000 mg/dL) after quetiapine administration, resulting in acute pancreatitis. An analysis of the underlying pathogenic mechanisms and a review of relevant literature are also presented. Clinicians should be aware of the potentially life-threatening metabolic disturbances and/or pancreatitis associated with quetiapine therapy.

Comparison of Aripiprazole and Other Atypical Antipsychotics for Pediatric Bipolar Disorder: A Retrospective Chart Review of Efficacy and Tolerability

OBJECTIVE: This study compared the efficacy and tolerability of aripiprazole with that of other atypical antipsychotics by examining patients with pediatric bipolar disorder (PBD) at a child and adolescent psychiatric clinic in a university hospital in Korea. METHODS: We reviewed the medical records of 127 pediatric patients with bipolar disorder aged 4-18 years treated at Department of Child and Adolescent Psychiatric, Yonsei University Severance Hospital between January 2010 and October 2011 to collect demographic and clinical data. Using the Clinical Global Impression (CGI) scales, we evaluated levels of severity of and improvements in symptoms at the first, second, third, fourth, and fifth hospital visits. RESULTS: The mean age of patients was 12.29+/-3.47 years. The sample included 91 (71.7%) male and 36 (28.3%) female patients. Aripiprazole was prescribed to 62 (48.8%) patients, risperidone to 52 (40.9%), quetiapine to 11 (8.7%), and paliperidone to two (1.6%). Patients treated with aripiprazole had lower CGI-Severity (CGI-S) scores than did patients treated with other atypical antipsychotics at the second and third visits. The CGI-Improvement (CGI-I) scores of patients treated with aripiprazole were lower at the second visit. Treatment with atypical antipsychotics was well tolerated, and no serious or fatal side effects were observed. CONCLUSION: The present retrospective chart review suggests that atypical antipsychotics may be effective and safe for the treatment of patients with PBD. In particular, treatment with aripiprazole may be more effective than treatment with other atypical antipsychotics in the early phase. These results should be verified in future multi-center controlled studies.

Korean Addiction Treatment Guidelines Series (II): Pharmacological Treatment of Alcohol Withdrawal / 신경정신의학

OBJECTIVES: In development of Korean addiction treatment guidelines, the aim of this study was to investigate the experts' consensus regarding current pharmacological practice in treatment of alcohol withdrawal. METHODS: Using recommendations from foreign clinical guidelines, which were either lacking in evidence or could not be directly applied to Korea, the executive committee developed a questionnaire consisting of 17 questions. Using a nine-point scale, members of the Korean Addiction Psychiatry, who were experts (n=150) with sufficient experience in treatment of alcohol use disorder, were asked to evaluate the appropriateness of each item on the questionnaire. We classified the experts' opinion according to three categories, based on the lowest scores of 6.5 or greater as a first-line/preferred treatment, 3.5-6.5 as a second-line/reasonable treatment, and lower than 3.5 as a third-line/inappropriate treatment. The consensus was determined by chi-square test (p<0.05). Response rate was 70.4% (81/115). RESULTS: The results of the survey from the experts were as follows: 1) Symptom triggered therapy (STT) was the most appropriate strategy in treatment of alcohol withdrawal (95% CI 7.41-8.04). 2) Prophylactic benzodiazepine was recommended for management of expecting alcohol withdrawal in out-patient-department patients. 3) Among benzodiazepines, lorazepam was the most preferred. 4) For patients with severe withdrawal, lorazepam 7.4 mg/day (95% CI 6.48-8.25, maximum dose=20 mg) was recommended. 5) Risperidone, quetiapine, and haloperidol were the first-line drugs for patients with alcohol withdrawal and combined psychotic symptoms. 6) 127.5 mg (95% CI 111-145) for 2.8 months of prophylactic thiamine and 213.5 mg (95% CI 190-240) for 6.2 months of thiamine for Wernicke-Korsakoff's syndrome were recommended. CONCLUSION: We hope that these Korean addiction treatment guidelines, added by the Korean experts' consensus, will be helpful in promoting the efficacy of treatment for alcohol withdrawal.

Impulsive Behavior and Recurrent Major Depression Associated with Dandy-Walker Variant

Reported herein is a case of recurrent major depression with impulse control difficulty in a 33-year-old man with Dandy-Walker variant. He was diagnosed as having major depressive disorder a year before he presented himself to the authors' hospital, and had a history of three-time admission to a psychiatric unit in the previous 12 months. He was readmitted and treated with sodium valporate 1,500 mg/day, mirtazapine 45 mg/day, and quetiapine 800 mg/day during the three months that he was confined in the authors' hospital, and the symptoms were reduced within three months but remained thereafter. This is the only case so far reporting recurrent depression with impulse control difficulty associated with Dandy-Walker variant. This case implies that any cerebellar lesion may cause the appearance of recurrent depression with impulse control difficulty in major depressive disorder.

Trends in Scientific Literature on Atypical Antipsychotics in South Korea: A Bibliometric Study

OBJECTIVE: We have carried out a bibliometric study on the scientific publications in relation to atypical or second-generation antipsychotic drugs (SGAs) in South Korea. METHODS: With the EMBASE and MEDLINE databases, we selected those publications made in South Korea whose title included the descriptors atypic* (atypical*) antipsychotic*, second-generation antipsychotic*, clozapine, risperidone, olanzapine, ziprasidone, quetiapine, sertindole, aripiprazole, paliperidone, amisulpride, zotepine, asenapine, iloperidone, lurasidone, perospirone and blonanserin. We applied some bibliometric indicators of paper production and dispersion with Price's law and Bradford's law, respectively. We also calculated the participation index (PI) of the different countries, and correlated the bibliometric data with some social and health data from Korea (such as total per capita expenditure on health and gross domestic expenditure on research and development). RESULTS: We collected 326 original papers published between 1993 and 2011. Our results state fulfilment of fulfilled Price's law, with scientific production on SGAs showing exponential growth (correlation coefficient r=0.8978, as against an r=0.8149 after linear adjustment). The most widely studied drugs were risperidone (91 papers), aripiprazole (77), olanzapine (53), and clozapine (43). Division into Bradford zones yielded a nucleus occupied by the Progress in Neuro-Psychopharmacology and Biological Psychiatry (36 articles). A total of 86 different journals were published, with 4 of the first 10 used journals having an impact factor being greater than 4. CONCLUSION: The publications on SGAs in South Korea have undergone exponential growth over the studied period, without evidence of reaching a saturation point.

A Case of Hemiballism in Elderly Stroke Improved by Conventional Rehabilitation Therapy and Low Dose Quetiapine

Hemiballism describes involuntary severe, violent, arrhythmic, rotatory and large amplitude movements of limb from proximal joint. We experienced an elderly stroke patient with hemiballism accompanied dysphagia that persisted for several months severity was evaluated by the Universidade Federal de Minas Gerais Sydenham's chorea rating scale (USCRS) and video fluoroscopic swallowing study (VFSS). In this case, we observed the improvement of hemiballism by conventional rehabilitation therapy and low dose quetiapine. Therefore, we recommend geriatrists considers vthese therapies in elderly patients with hemiballism.

Neuroprotective Effects of Quetiapine on Neuronal Apoptosis Following Experimental Transient Focal Cerebral Ischemia in Rats

OBJECTIVE: This study was undertaken in the belief that the atypical antipsychotic drug quetiapine could prevent apoptosis in the penumbra region following ischemia, taking into account findings that show 5-hydroxytryptamine-2 receptor blockers can prevent apoptosis. METHODS: We created 5 groups, each containing 6 animals. Nothing was done on the K-I group used for comparisons with the other groups to make sure adequate ischemia had been achieved. The K-II group was sacrificed on the 1st day after transient focal cerebral ischemia and the K-III group on the 3rd day. The D-I group was administered quetiapine following ischemia and sacrificed on the 1st day while the D-II group was administered quetiapine every day following the ischemia and sacrificed on the 3rd day. The samples were stained with the immunochemical TUNEL method and the number of apoptotic cells were counted. RESULTS: There was a significant difference between the first and third day control groups (K-II/K-III : p=0.004) and this indicates that apoptotic cell death increases with time. This increase was not encountered in the drug groups (D-I/D-II : p=1.00). Statistical analysis of immunohistochemical data revealed that quetiapine decreased the apoptotic cell death that normally increased with time. CONCLUSION: Quetiapine is already in clinical use and is a safe drug, in contrast to many substances that are used to prevent ischemia and are not normally used clinically. Our results and the literature data indicate that quetiapine could help both as a neuronal protector and to resolve neuropsychiatric problems caused by the ischemia in cerebral ischemia cases.

Antipsychotic Polypharmacy in the Treatment of Patients with Related Psychoses at a University Hospital / 대한정신약물학회지

OBJECTIVE: The practice of antipsychotic polypharmacy is common, despite lack of supporting evidence. The aims of this study were to estimate the prevalence of antipsychotic polypharmacy in a psychiatric university hospital in Korea and find out the clinical factors associated with antipsychotic polypharmacy. METHODS: We reviewed medical records of the patients discharged from Severance Mental Health Hospital (SMH) for the period of 1, January to 31, December 2010. Patients should be diagnosed as having schizophrenia, schizoaffective disorder, schizophreniform disorder, brief psychotic disorder, delusional disorder or psychotic disorder not otherwise specified. RESULTS: In 2010, 260 patients in SMH were prescribed with antipsychotics and 47.3% (n=123) of them were discharged under antipsychotic polypharmacy treatment. The most commonly prescribed antipsychotics for combination therapy was quetiapine (n=64). The most prevalent combination of drugs was risperidone plus quetiapine (n=20). Logistic regression analysis showed that the use of high-dose antipsychotics, first-generation antipsychotics, and long hospital duration were significantly associated with antipsychotic polypharmacy. CONCLUSION: Although the controlled evidence for efficacy and safety as a strategy remains inconclusive, antipsychotic polypharmacy is a common pharmacological strategy as it is illustrated in our study. Considering high antipsychotic doses related with antipsychotic polypharmacy, careful monitoring of side effect and efficacy is needed.

Inhibition of mouse brown adipocyte differentiation by second-generation antipsychotics

Brown adipose tissue is specialized to burn lipids for thermogenesis and energy expenditure. Second-generation antipsychotics (SGA) are the most commonly used drugs for schizophrenia with several advantages over first-line drugs, however, it can cause clinically-significant weight gain. To reveal the involvement of brown adipocytes in SGA-induced weight gain, we compared the effect of clozapine, quetiapine, and ziprasidone, SGA with different propensities to induce weight gain, on the differentiation and the expression of brown fat-specific markers, lipogenic genes and adipokines in a mouse brown preadipocyte cell line. On Oil Red-O staining, the differentiation was inhibited almost completely by clozapine (40 microM) and partially by quetiapine (30 microM). Clozapine significantly down-regulated the brown adipogenesis markers PRDM16, C/EBPbeta, PPARgamma2, UCP-1, PGC-1alpha, and Cidea in dose- and time-dependent manners, whereas quetiapine suppressed PRDM16, PPARgamma2, and UCP-1 much weakly than clozapine. Clozapine also significantly inhibited the mRNA expressions of lipogenic genes ACC, SCD1, GLUT4, aP2, and CD36 as well as adipokines such as resistin, leptin, and adiponectin. In contrast, quetiapine suppressed only resistin and leptin but not those of lipogenic genes and adiponectin. Ziprasidone (10 microM) did not alter the differentiation as well as the gene expression patterns. Our results suggest for the first time that the inhibition of brown adipogenesis may be a possible mechanism to explain weight gain induced by clozapine and quetiapine.

A case report on the relationship between treatment-resistant childhood-onset schizophrenia and an abnormally enlarged cavum septum pellucidum combined with cavum vergae / 中华医学杂志(英文版)

The treatment of refractory schizophrenia has been a clinical challenge for most psychiatrists; the possible reasons include diagnostic errors, medical conditions and brain dysgenesis. Here, we described a patient with childhood-onset schizophrenia who had severe psychiatric symptoms such as auditory hallucinations and persecutory delusions, and etc. We reexamined all his possible medical conditions and found that the patient had an abnormally enlarged cavus septum pellucidum (CSP) combined with cavum vergae (CV) (maximum length >30 mm). Some reports suggested that abnormal CSP (length >6 mm) has a significant association with schizophrenia. However, abnormally large CSP or CSP/CV and related prognosis were reported rarely. This case suggested that abnormally enlarged CSP or CSP/CV may worsen the prognosis.

Dosing Pattern and Effectiveness of Quetiapine for Schizophrenic Patients Treated with Flexible Doses for 6 Weeks / 대한정신약물학회지

OBJECTIVE: Recommended dosage of quetiapine for patients with schizophrenia is from 150 mg to 750 mg, which is based on randomized controlled study. But there are trends of increasing quetiapine dosage in clinical practice. Therefore, we evaluated the clinical aspect of schizophrenic patients who took quetiapine by naturalistic non-intervention study. METHODS: Schizophrenia outpatients in 88 mental hospitals were selected and 170 psychiatrists evaluated Clinical Global Impressions Scale for Severity (CGI-S) before starting quetiapine medication and CGI-S, Clinical Global Impressions Scale for Improvement (CGI-I), quetiapine dosage and medication compliance at 6 weeks after starting quetiapine medication. Overall efficacy and difference of efficacy between drug-naive patients and medication-switch patients were evaluated. We clustered the patients into 4 groups by using cluster analysis with three variables such as quetiapine dose at week 6, baseline CGI-S, and end-point CGI-S. We compared clinical aspect of each cluster with analysis of variance. RESULTS: 841 patients were enrolled. Efficacy of quetiapine was replicated, and improvement rate defined as CGI-I < or =2 was 55.9%. Drug-naive patients show more improvement in CGI-I than medication-switch patients, and efficacy for patients with insufficient treatment was also reported. Dosage for each clustered group was 25-350 mg, 400-500 mg, 600-700 mg and 750-1,500 mg. 750-1,500 mg group shows more decrease in CGI-S than 400-500 mg group and 600-700 mg group. CONCLUSION: This study suggests that there is a cluster of patients who take more benefits in reducing symptoms and show more compliance in high-dose quetiapine.

Changes of Medication Usage in Inpatients of Major Depressive Disorder: One University Hospital among Year 2001, 2006 and 2010 / 대한정신약물학회지

OBJECTIVE: Prescription patterns have changed rapidly due to development of new drugs, results of new researches, and increment of clinician's experience. The goal of this study was to examine and compare the trend of prescription patterns for major depressive disorder at a university hospital among year 2001, 2006, and 2010. METHODS: We reviewed the medication usage of inpatients with major depressive disorder in 2001, 2006 and 2010, including antidepressants used as first choice, switching, and combination, and various augmentation agents. And we investigated the time to switching and combination of antidepressant in 2001, 2006 and 2010. RESULTS: The antidepressants used as first line drug were selective serotonin reuptake inhibitor (SSRI) (49.7%), mirtazapine (24.5%), and tricyclic antidepressant (TCA) (4.9%) in 2001, and SSRI (49.4%), mirtazapine (25.6%) and serotonin-norepinephrine reuptake inhibitor (SNRI) (20.2%) in 2006, SSRI (42.7%), mirtazapine (19.5%) and SNRI (18.3%) in 2010 in frequency order. The antidepressants used as switching drug were TCA (33.3%), mirtazapine (25.0%), and nefazodone (16.7%) in 2001, SSRI (35.0%), mirtazapine (35.0%), and SNRI (20.0%) in 2006, and SSRI (50.0%), SNRI (30.0%) and mirtazapine (20.0%) in 2010. As combination treatment, SSRI and TCA combination was used mostly by far in 2001 (51.1%), but in 2006 and 2010, various combination were used. In 2010 year, SNRI and mirtazapine, SSRI and TCA, SSRI and mirtazapine (42.1%, 21.1%, 15.8%, respectively) combination treatment were used in frequency order. The use of typical antipsychotics as augmentation agent decreased and the use of atypical antipsychotics increased significantly in 2010. Most frequently used atypical antipsychotic was quetiapine in 2010. The use of thyroid hormone was significantly decreased after 2006, but the use of mood stabilizer was increased between 2001 and 2010 (p=0.001). CONCLUSION: The results of the present study suggested that there were lots of change in prescription patterns for major depressive disorder between 2001 and 2010. Especially, these changes could be seen in use of various antidepressants, increment in use of atypical antipsychotics and lamotrigine. It can reflect not only the current progress of psychopharmacology and clinical experience, but also the clinical complexity of treatment of depression.

Antipsychotic-Induced Sexual Dysfunction and Its Management

Sexual dysfunction is a common condition in patients taking antipsychotics, and is the most bothersome symptom and adverse drug effect, resulting in a negative effect on treatment compliance. It is known that hyperprolactinemia is a major cause of sexual dysfunction. Based on the blockade of dopamine D2 receptors, haloperidol, risperidone, and amisulpride are classed as prolactin-elevating antipsychotics, while olanzapine, clozapine, quetiapine, ziprasidone, and aripiprazole are classed as prolactin-sparing drugs. Risperidone and the other typical antipsychotics are associated with a high rate of sexual dysfunction as compared to olanzapine, clozapine, quetiapine, and aripiprazole. With regard to treatment in patients suffering from sexual dysfunction, sildenafil was associated with significantly more erections sufficient for penetration as compared to a placebo. Subsequent studies are needed in order to provide physicians with a better understanding of this problem, thereby leading toward efficacious and safe solutions.

Comparative Study of Efficacy and Safety between Aripiprazole and Quetiapine in the Treatment of Delirium / 대한정신약물학회지

OBJECTIVE: Haloperidol, a typical antipsychotic, has been the preferred agent for the pharmacological treatment of delirium. Recent studies have shown that atypical antipsychotics can be as effective as haloperidol in managing delirium. However, there are few comparative studies between atypical antipsychotics in the treatment of delirium. We investigated the efficacy and side effects of aripiprazole and quetiapine for the treatment of patients with delirium. METHODS: Forty two inpatients with delirium according to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Text Revision and Korean version of Delirium Rating Scale-Revised-98 (K-DRS-98) criteria were included. They were assigned to either aripiprazole or quetiapine groups, with a flexible dosing schedule. K-DRS-98 and Clinical Global Impression-Severity (CGI-S) were used for evaluating the severity of delirium. The degree of sedation was assessed by using the Richmond Agitation-Sedation Scale (RASS) six times per day. The severity of side effect was evaluated with the Drug-Induced ExtraPyramidal Symptoms Scale and the Barnes Akathisia Rating Scale. K-DRS-98 and RASS were conducted daily until the remission of delirium while other measurements were conducted twice at the point of baseline and remission. For statistical analysis, t-test, Fisher's exact test, Mann-Whitney test, analysis of covariance were conducted. RESULTS: The scores of K-DRS-98 in both groups significantly decreased after treatment (p or =-3 (p=0.034). The scores on sleep cycle of K-DRS-98-severity more significantly decreased in the quetiapine group than aripiprazole group (F=4.291, p=0.045). There were no significant side effects both groups including extrapyramidal symptoms. CONCLUSION: These results suggest that both aripiprazole and quetiapine appear to be effective and tolerable in the treatment of delirium. Aripiprazole may be less sedative than quetiapine and it may be more useful than aripiprazole in sleep problem of delirium. To validate our results, further studies with double-blind, placebo-controlled with a large sample will be required.

A Case of Myoglobinuric Acute Kidney Injury due to Rhabdomyolysis Associated with Neuroleptic Malignant Syndrome / 대한신장학회지

Neuroleptic malignant syndrome (NMS) is a rare, adverse reaction associated with the use of neuroleptic medication, which is characterized by altered consciousness, muscle rigidity, autonomic instability, hyperthermia, and elevated serum creatine phosphokinase (CPK) levels. Myoglobinuric acute kidney injury (AKI) is considered as the most serious complication of NMS. We report here a 25-year-old female who developed NMS associated myoglobinuric AKI, and had previously received olanzapine, haloperidol, and quetiapine for the treatment of brief psychotic disorder. The peak level of blood urea nitrogen (BUN) was 53.5 mg/dL, serum creatinine (Cr) 2.2 mg/dL, serum myoglobin 36,745 ng/mL, and a serum CPK of >30,000 IU/L. She was treated supportively with combination therapy including withdrawal of neuroleptics, intravenous hydration, cooling, and oral dantrolene. She gradually improved with clearing of altered sensorium, decrease in rigidity and normalizing of the serum CPK level. Serum BUN and Cr also decreased to 8.0 mg/dL and 0.6 mg/dL, respectively. Early, aggressive volume repletion with alkalinized fluids, along with appropriate pharmacological therapy is needed to prevent myoglobinuric AKI in patients with NMS. Additionally, dipstick urinalysis including urine pH, specific gravity, and occult blood may be useful in monitoring changes in hydration status during periods of fluid therapy.

Korean Medication Algorithm for Bipolar Disorder 2010: Comparisons with Other Treatment Guidelines / 대한정신약물학회지

The Korean Medication Algorithm Project for Bipolar Disorder (KMAP-BP) was developed in 2002 and thereafter revised in 2006. It was secondly revised in 2010 (KMAP-BP 2010). The aim of this study was to compare KMAP-BP 2010 with other recently published treatment algorithm and guidelines for bipolar disorder. The authors reviewed the 4 recently published guidelines and treatment algorithms for bipolar disorder [The British Association for Psychopharmacology Guideline for Treatment of Bipolar Disorder, Canadian Network for Mood and Anxiety Treatments Guidelines for the Management of Patients with Bipolar Disorder, The World Federation Society of Biological Psychiatry Guideline for Biological Treatment of Bipolar Disorder and National Institute for Health and Clinical Experience (NICE) Clinical Guideline] to compare the similarities and discrepancies between KMAP-BP 2010 and the others. In aspects of treatment options, most treatment guidelines had some similarities. But there were notable discrepancies between the recommendations of other guidelines and those of KMAP-BP in which combination or adjunctive treatments were favored. Most guidelines advocated new atypical antipsychotics as first-line treatment option in nearly all phases of bipolar disorder and lamotrigine in depressive phase and maintenance phase. Lithium and valproic acid were still commonly used as mood stabilizers in manic phase and strongly recommended valproic acid in mixed or psychotic mania. Mood stabilizers or atypical antipsychotics were selected as first-line treatment option in maintenance treatment. As the more evidences were accumulated, more use of atypical antipsychotics such as quetiapine, aripiprazole and ziprasidone were prominent. This review suggests that the medication strategies of bipolar disorder have been reflected the recent studies and clinical experiences, and the consultation of treatment guidelines may provide clinicians with useful information and a rationale for making sequential treatment decisions. It also has been consistently stressed that treatment algorithm or guidelines are not a substitute for clinical judgment; they may serve as a critical reference to complement of individual clinical judgment.

Recent advances in the pharmacotherapy of psychiatric disorders

Psychopharmacology has developed over approximately the past five decades. The remarkable proliferation of information in this area has made it difficult for clinicians to understand the characteristics of various psychotropic agents. Atypical antipsychotics including amisulpride, asenapine, aripiprazole, blonanserin, clozapine, iloperidone, lurasidone, olanzapine, paliperidone, quetiapine, risperidone, ziprasidone, and zotepine cause fewer extrapyramidal problems and have many clinical applications, but they can cause metabolic disturbances. Mood stabilizers and lamotrigine are widely used for bipolar disorder. Other novel anticonvulsants such as topiramate, oxcarbazepine, gabapentin, tiagabine, pregabalin, vigabatrin, levetiracetam, and riulzole have also been tested with diverging or inconclusive results. Antidepressants are commonly used in the clinical treatment of depression and anxiety disorder. However, the mechanism of action of medications used in the treatment of psychiatric disorders remains unclear. Understanding the mechanisms of action and clarifying the diagnosis may enhance the treatment outcome in psychiatry. In this review, we analyzed clinical pharmacology data for each drug within a class and discussed clinical strategies for administering currently available antipsychotics, mood stabilizer/anticonvulsants, and antidepressants widely used for various psychiatric indications.