A Case of Clozapine-Induced Myocarditis in a Young Patient with Bipolar Disorder.

We present a case of drug-induced myocarditis manifesting as acute heart failure in a young patient with bipolar disorder being treated for depression. The case describes a 20-year-old man being treated in the psychiatry ward for worsening depression when he started complaining of chest pain and shortness of breath. His list of medications included clozapine, lithium, lorazepam, and haloperidol. The main findings on physical examination were tachycardia, low-grade fever, crackles in both lung bases on auscultation, and the absence of any notable edema. Abnormal labs included a troponin of 0.9, with a CK of 245 and CK-MB of 3.1. An ECG revealed sinus tachycardia and left anterior fascicular block (LAFB). An echocardiogram revealed global hypokinesis, severe left ventricular dysfunction with an ejection fraction estimated at 20%. The patient had an admitting diagnosis of acute left ventricular systolic dysfunction likely secondary to drug-induced myocarditis (suspect clozapine) versus acute coronary syndrome. He was managed conservatively and transferred to another facility for endomyocardial biopsy confirming myocarditis. This case is an example of one of the most typical presentations of suspected drug-induced acute myocarditis and will hopefully prompt the reader to think of this underdiagnosed entity in the right clinical setting.

Olfactory deficits in frontotemporal dementia as measured by the Alberta Smell Test.

The study of olfaction in neurodegeneration has primarily focused on Alzheimer's disease. Research of olfaction in frontotemporal dementia (FTD) has generally not been empirically studied. The current study compared olfaction in FTD to major depressive disorder (MDD) using the Alberta Smell Test (AST). Independent-samples t test results suggested olfaction in FTD was impaired when compared with participants diagnosed with MDD. The AST Total score (out of 20 trials) significantly predicted the diagnostic group and accounted for 40% of the variance in diagnostic group status with an odds ratio of 20.08. Results suggested that a cutoff of ≤2/20 differentiated FTD from MDD with 94% accuracy (91% sensitivity, 97% specificity) and a cutoff of ≤1/20 differentiated the groups with a 95.5% hit rate (91% sensitivity, 100% specificity). Results confirmed olfactory identification deficits in FTD and suggested that the AST is an effective tool for the demarcation of FTD from MDD. This is especially important due to the potential for significant overlap in the behavioral/emotional phenotype and cognitive deficits between the two disorders when presented with early stages of FTD.

Vitamin d deficiency among psychiatric inpatients.

OBJECTIVE: Previous studies in northern Europe and Australia have indicated that vitamin D deficiency is common in psychiatric patients. This study aimed to determine the prevalence of vitamin D deficiency among psychiatric inpatients in a large North American city. The association of vitamin D status with clinical characteristics was also explored, and subgroups of patients that are more vulnerable to vitamin D deficiency were identified. METHOD: This descriptive study looked at 107 unselected consecutive admissions to a psychiatric inpatient service in New York City between September and early December 2010. All patients were aged 18 years and older. Psychiatric diagnoses were established by attending psychiatrists as part of the routine assessment using criteria from the DSM-IV. Serum levels of 25-hydroxyvitamin D were measured by high-performance liquid chromatography, tandem mass spectrometry. A vitamin D-deficient state was defined as serum 25-hydroxyvitamin D level ≤ 20 ng/mL. RESULTS: Fifty-six (52.3%) patients were classified as deficient in vitamin D. Age and 25-hydroxyvitamin D level were significantly correlated (P = .001). Seventy-one percent of patients from age 18 to 34 years were deficient in vitamin D; this rate was significantly higher than the rate of deficiency in older patients (P = .017). No significant relationships were found between 25-hydroxyvitamin D level and gender, race/ethnicity, glycosylated hemoglobin, body mass index, and major psychiatric diagnostic categories. CONCLUSIONS: A high percentage of psychiatric inpatients are deficient in vitamin D. Younger patients were more at risk for deficiency. Screening for vitamin D deficiency should be part of the health assessment of patients with major psychiatric illnesses.

Corollary-and discrepancy-based approaches for examining the appropriateness of premorbid cognitive estimation in geriatric schizophrenia.

OBJECTIVE: This article addresses whether measures for assessing premorbid intellectual functioning are adequate for geriatric schizophrenia. METHOD: We included geriatric schizophrenia-spectrum disorders (SSD; n = 37), frontotemporal dementia (FTD; n = 41), and geriatric controls (n = 107), and employed measures of verbal ability. RESULTS: Pearson's correlations and ANOVAs for discrepancy comparisons showed unique patterns of spared function in SSD when compared to FTD and controls. CONCLUSIONS: Findings lend support to the specificity of cognitive processes in SSD, even when accounting for processes common to the theoretically similar FTD. SSD showed a distinct pattern of spared ability which supports clinical utilization of discrepant measures of premorbid intellectual estimation for SSD.

Pattern of memory compromise in chronic geriatric schizophrenia, frontotemporal dementia and normal geriatric controls.

OBJECTIVE: The purpose of this study was to explore whether memory deficits in schizophrenia are attributable to poor organisation/encoding during initial learning vs. memory decay. METHODS: Subjects included geriatric schizophrenia/schizoaffective disorders [SSD; n = 37; age = 59.92 (55-74); education = 11.70 (7-18)]; frontotemporal dementia [FTD; n = 41; age = 76.59 (64-83); education = 14.61 (12-20)] and geriatric controls [n = 107; age = 70.97 (55-93); education = 13.76 (6-20)]. Subjects were administered the Wechsler Memory Scale, Third Edition and discrepancy scores between immediate and delayed subtests/indices were used to explore possible differences between groups in pattern of impairment. RESULTS: Significant differences were found between groups on age/education and these variables were related to several outcome measures. Gender was not related to diagnostic group and there were no gender differences on study variables. There were differences between the SSD subjects on several variables, with the schizoaffective subjects performing worse despite equivalence on global cognitive function, living status and chronicity. Seven one-way between-subjects ANCOVAs compared groups on discrepancy scores. RESULTS failed to suggest differences between groups on immediate-delayed memory discrepancy scores (p > 0.05). Subsequent analyses revealed differences in percentage retention scores between SSD and FTD on the faces subtest (p = 0.040), with SSD retaining greater information over time. CONCLUSION: RESULTS failed to show distinctions between groups on pattern of memory impairment when using discrepancy comparisons. However, an analysis examining percentage retention scores revealed better maintenance of non-contextual visual information over time in SSD. Findings may suggest deficits in immediate encoding rather than memory decay for some types of memory ability among geriatric SSD. Our failure to document group differences when using discrepancy comparisons may be attributable to relative similarity in pattern between groups or the limited sensitivity of this technique.

Comparative effectiveness of second-generation antipsychotics and haloperidol in acute schizophrenia.

BACKGROUND: There is little information on the comparative effectiveness of second-generation antipsychotic agents. AIMS: To determine if any of five second-generation antipsychotics or haloperidol is more effective in treating acutely ill patients with schizophrenia, schizoaffective disorder or schizophreniform disorder. METHOD: A sample of 327 newly admitted patients were randomised to open-label treatment with aripiprazole, haloperidol, olanzapine, quetiapine, risperidone or ziprasidone for a minimum of 3 weeks. Measures of effectiveness were improvement in mental status so that the patient no longer required acute in-patient care, and changes in Brief Psychiatric Rating Scale (BPRS) scores. RESULTS: By the first measure, haloperidol (89%), olanzapine (92%) and risperidone (88%) were significantly more effective than aripiprazole (64%), quetiapine (64%) and ziprasidone (64%). Changes in BPRS ratings were not significant among treatments. CONCLUSIONS: Haloperidol, olanzapine and risperidone are superior to aripiprazole, quetiapine and ziprasidone for the acute treatment of psychosis in hospitalised patients with schizophrenia, schizoaffective disorder or schizophreniform disorder.

Neurocognitive differential diagnosis of dementing diseases: Alzheimer's Dementia, Vascular Dementia, Frontotemporal Dementia, and Major Depressive Disorder.

Similarities in presentation of Dementia of Alzheimer's Type, Vascular Dementia, Frontotemporal Dementia, and Major Depressive Disorder, pose differential diagnosis challenges. The current study identifies specific neuropsychological patterns of scores for Dementia of Alzheimer's Type, Vascular Dementia, Frontotemporal Dementia, and Major Depressive Disorder. Neuropsychological domains directly assessed in the study included: immediate memory, delayed memory, confrontational naming, verbal fluency, attention, concentration, and executive functioning. The results reveal specific neuropsychological comparative profiles for Dementia of Alzheimer's Type, Vascular Dementia, Frontotemporal Dementia, and Major Depressive Disorder. The identification of these profiles will assist in the differential diagnosis of these disorders and aid in patient treatment.

Reducing restraint use in a public psychiatric inpatient service.

The use of behavioral restraint in psychiatric inpatients can have physically and emotionally damaging effects. However, staff may view the use of restraint as a routine and acceptable means of maintaining safety. The goal of this project was to reduce the use of restraint in a public psychiatric inpatient service that serves an economically disadvantaged urban population. Six interventions that primarily involved changing staff behavior were made to reduce the use of restraint. These included better identification of restraint-prone patients, a stress/anger management group for patients, staff training on crisis intervention, development of a crisis response team, daily review of all restraints, and an incentive system for the staff. The rate of restraint use (number of restraints/1000 patient-days) during the 3 years before the interventions was compared with the rate during the 2 years after the interventions. There was a significant decrease in the rate of restraint use after the restraint reduction initiatives were implemented. The reduction was not accompanied by a sustained increase in incidents of assault, suicidal behavior, or self-injury.

Polypharmacy in patients with schizophrenia.

BACKGROUND: Polypharmacy in patients with schizophrenia is a common practice with little basis in well-controlled studies. The objective of this report is to describe the changes in prescription practices with psychotropic medications for patients diagnosed with schizophrenia in 1995 and 2000. METHOD: The medical records of patients who were discharged from our facility in 1995 and 2000 with the diagnosis of schizophrenia (DSM-IV criteria) were reviewed. The psychotropic medications at discharge were compared. The incidence of adverse drug reactions and indicators of patient outcome were also compared. RESULTS: 459 records were reviewed for 1995 and 584 were reviewed for 2000. Patients discharged in 2000 were significantly more likely to receive antidepressants, mood stabilizers, anxiolytics, and multiple antipsychotics than patients discharged in 1995 (p < .0001). Patients discharged in 2000 were given significantly fewer anticholinergics (p < .0001). There was a large increase in the use of divalproex. No patients were discharged on treatment with more than 1 antipsychotic in 1995, whereas in 2000, 15.9% of patients were. The most common antipsychotic combination was haloperidol and olanzapine. Paralleling the increased use of polypharmacy, there were significantly fewer adverse drug reactions in 2000 than in 1995 (p = .002). In addition, patients with schizophrenia who were discharged in 2000 had significantly shorter lengths of stay (p < .0001) and were significantly more likely to be discharged to the community than to a state hospital (p = .0001). CONCLUSION: This study found that acutely ill hospitalized patients with schizophrenia are being treated with more psychotropic medications, including more than 1 antipsychotic. These changes are coincidental with a decrease in adverse drug reactions and an improvement in indicators of patient outcome.

Accelerated Antidepressant Response in Geriatric Inpatients.

Six elderly depressed inpatients were treated for 2 weeks with low doses of nortriptyline and fluoxeline in combination. All patients showed significant reductions in depressive symptoms with minimal side effects. Clinical improvement appeared unrelated to whether plasma levels of nortriptyline were therapeutic. The implications of this regimen for accelerated antidepressant response as well as the limitations of this report are discussed.