Neuroleptic Malignant Syndrome: Can Be an Unrecognized Chronic Fatal Disease.

This case report concentrates on the fatal consequences of the chronic aspects of neuroleptic malignant syndrome (NMS). It is a life-threatening side effect and has been identified since antipsychotics were developed. Efforts to highlight the propensity to develop NMS for those more sensitive to psychotropic medications have been infrequent. Ethnic groups, such as Asians and African Americans, seem to be at higher risk, and therefore clinicians must be hypervigilant of NMS with these groups. Strategies on how to keep a heightened level of awareness about the use of traditional antipsychotic medications with those at risk for NMS are discussed.

Among the Severely Mentally Ill, Who Responds to Ziprasidone?

So far, demographic variables have not consistently been found to predict clinical response to antipsychotics. This study examines some differences in response to ziprasidone, which has been shown to be effective, with a better metabolic side effect profile, but was little used in New York State Hospitals. The aim was to study state hospital patients switched to ziprasidone. The results led to questions about different responses in different groups. Subjects from state hospitals who needed a change of antipsychotic participated in this open-label, 8-week trial of up to 240-mg ziprasidone. Analyses included comparisons of the very different results from two sites. Of the 36 study subjects, 12 terminated early. The 17 outpatients from Buffalo, who were older and on lower doses of antipsychotics pre-study, improved significantly. The 19 inpatients from the Bronx, overall younger and on higher pre-study doses, barely changed. Improvements in PANSS total score were significantly associated with older age, greater baseline severity, and lower doses of antipsychotics pre-study. The subjects improved on metabolic parameters. The results suggest that ziprasidone may be just as effective as previous antipsychotics taken by these severely mentally ill patients, and with fewer metabolic side effects. Note: The study described here includes a dosage of ziprasidone that has not been approved by the U.S. Food and Drug Administration (FDA). The FDA has approved daily doses of ziprasidone no greater than 100 mg PO bid.

Cardiac Arrest with Clozapine and Olanzapine: Revealing Long QT Syndrome.

The authors describe a rare case of "concealed" congenital Long QT Syndrome (LQTS) Type 3 in a patient with treatment resistant schizophrenia and no known personal or family history of cardiac disease. The patient in this Case Report had a hidden genetic condition revealed only following the essential administration of antipsychotics. As a result, this patient experienced an aborted cardiac arrest and a total of five episodes of ventricular tachycardia (VT) requiring cardioversion. Successful control of the VT occurred with an Automatic Internal Defibrillator (AID), judicious use of antipsychotic medications, and anti-arrhythmic medications. Risk factors for this rare anomaly include history of syncopy, unexplained ventricular arrhythmias, history of sudden cardiac death in a young family member, unusual reaction to initial dosages of medication known to prolong QTc which includes antipsychotics (particularly in combination). The work-up for those with risk factors would be a thorough family history of sudden cardiac death, baseline ECG, electrolytes, cardiology and electrophysiological consultation, and when indicated a genetic analysis for the Long QT Syndrome (LQTS). Monitoring includes ongoing patient assessment for symptoms, ECGs and electrolytes when indicated such as when medication and dosages are adjusted, AID interviewing, and cardiac and electrophysiological follow-up.

Among the severely mentally ill, who responds to ziprasidone?

So far, demographic variables have not consistently been found to predict clinical response to antipsychotics. This study examines some differences in response to ziprasidone, which has been shown to be effective, with a better metabolic side effect profile, but was little used in New York State Hospitals. The aim was to study state hospital patients switched to ziprasidone. The results led to questions about different responses in different groups. Subjects from state hospitals who needed a change of antipsychotic participated in this openlabel 8 week trial of up to 240 mg ziprasidone. Analyses included comparisons of the very different results from two sites. Of the 36 study subjects, 12 terminated early. The 17 outpatients from Buffalo, who were older and on lower doses of antipsychotics pre-study, improved significantly. The 19 inpatients from the Bronx, overall younger and on higher pre-study doses, barely changed. Improvements in PANSS total score were significantly associated with older age, greater baseline severity, and lower doses of antipsychotics pre-study. The subjects improved on metabolic parameters. The results suggest that ziprasidone may be just as effective as previous antipsychotics taken by these severely mentally ill patients, and with fewer metabolic side effects.

Sialorrhea and aspiration pneumonia: a case study.

This case study compares two different clinical outcomes for a patient with a long-standing psychotic disorder prescribed clozapine on two occasions. During the first trial, clozapine was used at a higher dose for this patient (350-450mg/day) and included clinically significant sialorrhea, pneumonia, and pneumonia-like illnesses requiring immediate medical intervention including hospitalization. There were also patient complaints of fatigue, cough, choking, and constipation leading to poor adherence. Clozapine was discontinued when the patient withdrew his consent due to side effects, despite his awareness of its benefits, including reduction of command hallucinations and irritability. The second clozapine trial was associated with lower daily doses and therapeutic serum blood levels. The patient was actively participating in and adhering to the medication plan. A very narrow window of clozapine dose was exceeded for two days and the patient complained of hypersalivation, cough, and lethargy. He was subsequently hospitalized for a two week period to treat aspiration pneumonia. This hospitalization helped establish the ideal daily dose of clozapine for this patient and also brought the relationship between aspiration pneumonia and clozapine to the attention of the psychiatrist and medical specialist. Once the appropriate dosage for this patient was established, his psychotic and affective symptoms were controlled, he was not hampered by adverse side effects, and he started to actively participate in social and recreational activities and plans that culminated in discharge from a state psychiatric facility to a supportive community residence. It is our hope that the lessons we have learned from our shared experience with this patient will be of benefit to other clinicians and patients.

Individuals with threatening or violent criminal behavior: civil commitment or release after incarceration?

Patients who have diagnoses of a major mental illness and an antisocial personality disorder present administrative, clinical, legal, and ethical challenges. Based on an actual case, the authors discuss how clinicians could fulfill the obligation to the patient, mental health system, judicial system, and the community under these circumstances. We explore how clinical presentation of symptomatology and criminal behavior contribute to challenges in determining psychiatric care.

Continuing day treatment programs promote recovery in schizophrenia: a case-based study.

Continuing day treatment programs focus on community stabilization through comprehensive individualized rehabilitation. They promote recovery through a variety of practical clinical therapeutic interventions. This empirically based report describes a continuing day treatment program's rehabilitation of four clients with schizophrenia, chronic type in a western New York mental health clinic who were in each of the specialty services: a two-phase program, a program for seniors, and a program for co-occurring substance dependence. Some particularly difficult psychiatric symptoms of schizophrenia were successfully treated in this continuing day treatment program. Each of these clients showed improvements in their symptoms and overall community adjustment that may well have been unobtainable with less intensive outpatient treatment.

Risperidone long-acting injections: successful alternative deltoid muscle injections for refractory schizophrenia.

Treatment-resistant paranoid schizophrenia is often addressed with long-term intramuscular preparations of conventional antipsychotics (haloperidol and fluphenazine), which can be associated with the development of painful, lumpy nodules at the injection site. In this article, we present a case example of a 58-year-old male patient with paranoid schizophrenia who was treated with risperidone long-acting injection given into the deltoid muscle instead of the US Food and Drug Administration (FDA)-approved gluteal muscle injection site. Use of this agent in the deltoid muscle facilitated healing of the numerous painful lumpy nodules associated with prior trials of conventional long-acting injections. In addition, the patient's psychiatric outcome was improved relative to what had been observed with the previous agents.