Switching between clozapine and risperidone treatment.
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Adult↗
Biomedical subjects
C A Zarate
Publications and source records attributed to C A Zarate.
Applicability of telemedicine for assessing patients with schizophrenia: acceptance and reliability.
BACKGROUND: Telemedicine holds promise for providing expert psychiatric consultation to underserved populations, but has not been quantitatively studied in schizophrenia or any other major mental disorder. This study was conducted to assess the reliability and acceptance of video-conferencing equipment in the assessment of patients with schizophrenia. METHOD: We assessed reliability of the Brief Psychiatric Rating Scale (BPRS), Scale for the Assessment of Positive Symptoms (SAPS), and Scale for the Assessment of Negative Symptoms (SANS) under three conditions: (1) in person, (2) by videoconferencing at low (128 kilobits per second [kbs]) bandwidth, (3) by videoconferencing at high (384 kbs) bandwidth. All 45 patients met DSM-IV criteria for schizophrenia. All patients and the two interviewers rated various aspects of the study interviews against previous live psychiatric interviews. RESULTS: Total scores on both the BPRS and SAPS were assessed equally reliably by the three media. Total score on the SANS was less reliably assessed at the low bandwidth, as were several specific negative symptoms of schizophrenia that depend heavily on nonverbal cues. Video interviews were well accepted by patients in both groups, although patients in the high bandwidth group were more likely to prefer the video interview to a live interview. CONCLUSION: Global severity of schizophrenia and overall severity of positive symptoms were reliably assessed by videoconferencing technology. Higher bandwidth resulted in more reliable assessment of negative symptoms and was preferred over low bandwidth, although patients' and raters' acceptance of video was good in both conditions. Videoconsultation appears to be a reliable method of assessing schizophrenic patients in remote locations who have limited access to expert consultation.
Adult↗
Risperidone in the elderly: a pharmacoepidemiologic study.
BACKGROUND: The possibly limited adverse effects of risperidone encourage interest in its use in geriatric patients. METHOD: Medical records of 122 hospitalized psychogeriatric patients (> or = 65 years old) newly treated with risperidone were reviewed and scored for indications, doses, and effects of this novel neuroleptic. RESULTS: Subjects (83 women, 39 men), mean +/- SD age = 76.5 +/- 6.8 years (range, 65-95), were given risperidone for agitation or psychosis associated with dementia (53%), a major mood disorder (29%), or other disorders (18%). Most (77%) were also medically ill and received other psychotropic (76%) or cardiovascular agents (70%). Daily doses of risperidone averaged 1.6 +/- 1.1 mg (range, 0.25-8.0) (0.025 mg/kg body wt.); 78% received 2.0 mg. Risperidone appeared to be effective in 85% of cases, but 18% were discontinued due to intolerability (11%) or inefficacy (7%). Adverse events occurred in 32% of the patients (36% of those discontinued). These adverse events included hypotension (29%) or symptomatic orthostasis (10%), cardiac arrest (1.6%) with fatality (0.8%), and extrapyramidal effects (11%) or delirium (1.6%). Benefits were associated with younger age and male gender, but not risperidone dose. Adverse effects were associated with cardiovascular disease and its treatment, cotreatment with an SRI antidepressant or valproate, and relatively rapid dose increases. CONCLUSION: Risperidone appeared to be effective and may be safe for many elderly psychiatric patients with comorbid medical conditions provided that doses are low and increased slowly. Particular caution is advised in the presence of cardiovascular disease or cotreatment with other psychotropic agents.
Age Factors↗
EEG abnormalities before clozapine therapy predict a good clinical response to clozapine.
The purpose of this study was to test the hypothesis that minor EEG abnormalities predict a favorable response to clozapine. Eighty-six psychotic clozapine-treated psychiatric inpatients with EEG records before starting clozapine were included in the study. When all diagnostic groups were combined, there were no significant differences in clinical outcome between patients with abnormal EEGs and patients with normal EEGs. However, female patients with abnormal EEGs had a significantly greater improvement in Global Assessment of Functioning (GAF) scores compared to female patients with normal EEGs. In addition, patients with major depressive episodes (bipolar, schizoaffective, unipolar) and abnormal EEGs had a significantly greater improvement in GAF scores compared to the same subgroup of patients with normal EEGs. The results suggest that EEG abnormalities before clozapine treatment many predict a favorable clinical response in specific groups of patients.
Adult↗
Does intolerance or lack of response with fluoxetine predict the same will happen with sertraline?
BACKGROUND: The purpose of this study was to determine whether sertraline would be well tolerated and effective in patients who had failed fluoxetine therapy or were unable to tolerate the medication. METHOD: Hospital records were reviewed for 88 consecutive patients started on sertraline treatment at McLean Hospital from February 11, 1992 to August 28, 1992. Forty-two patients were identified who had received sertraline treatment and who had had previous trials of fluoxetine. Patients were contacted after discharge to determine sertraline efficacy and side effects. A variety of patient characteristics and outcome measures were compared. RESULTS: Thirty-nine subjects (93%) were available for follow-up interviews. The DSM-III-R diagnoses at discharge were as follows: major depression (N=25), bipolar depression (N=6), schizoaffective disorder (N=4), and obsessive-compulsive disorder (N=4). The sertraline discontinuation rate was 64% (25/39) by a mean +/- SD of 2.3 +/- 2.1 months. In patients with major depression (N=25) and bipolar depression (N=6) discharged on sertraline, only 13 (42%) were considered responders to sertraline therapy, and at follow-up, only 8 (26%) of 31 were considered responders to sertraline therapy. Patients who had previously discontinued fluoxetine because of side effects were significantly more likely to have side effects during sertraline treatment (p = .027), and to have discontinued sertraline at follow-up (p = .018). CONCLUSION: Sertraline was found to be modestly efficacious and associated with numerous side effects and discontinuation rates in patients who had previously discontinued fluoxetine.
1-Naphthylamine↗
The use of valproate in an elderly population with affective symptoms.
BACKGROUND: Little is known about the efficacy and tolerability of valproate in the elderly population with affective disorders. This pharmacoepidemiologic study was undertaken to determine the side effect profile and efficacy of valproate in an elderly population with psychiatric symptomatology. METHOD: This was a retrospective chart review of all elderly inpatients at McLean Hospital who received valproate between May 8, 1989, and May 8, 1992. Charts were reviewed to determine gender, discharge diagnosis, indication for the agent, and length of time on each medication. Charts were also reviewed for abnormalities in liver function tests, blood cell dyscrasias, sedation, nausea and vomiting, weight gain, impairment of cognition, tremor, and hair loss. The efficacy of the medication was also determined. RESULTS: Thirty-five elderly subjects who suffered from an affective disorder and who had received valproate were identified. The mean age was 71.3 years. The mean length of time the patient received valproate was 32.7 days. The mean dose was 743 mg/day, and the mean blood drug level was 52.9 mg/L. The valproate was rated as efficacious in 18 (62%) of the 29 patients who had had an adequate drug trial at discharge. Overall the medication was well tolerated. There were no reports of liver function test abnormalities. One patient experienced transient leukopenia. Other adverse events included two reports of nausea, two reports of sedation, and one complaint of confusion. None of the variables examined were found to be statistically significant in regard to efficacy. CONCLUSION: Valproate was well tolerated and efficacious in this elderly population with affective disorders. Further controlled studies are needed to confirm our results.
Affective Disorders, Psychotic↗
Risperidone in the treatment of mania.
BACKGROUND: Risperidone, a 5-HT2 and D2 antagonist, has been shown to be an effective antipsychotic in the treatment of schizophrenia but has unclear efficacy in the treatment of psychotic affective disorders. The purpose of the study was to assess the efficacy of risperidone in the treatment of acute mania with psychotic features. METHOD: We conducted an open-label pilot study of risperidone and concurrent mood-stabilizing drugs in the treatment of acute mania with psychotic features. Patients were diagnosed with the Structured Clinical Interview for DSM-III-R (SCID). Efficacy was measured weekly with the use of the Young Mania Rating Scale (YMRS) and the Brief Psychiatric Rating Scale (BPRS). RESULTS: Ten women and 5 men (mean age = 38 years) were included in the study. Of the 13 patients who completed 2 weeks of treatment, 8 of these 13 had a 50% improvement of the BPRS, and all 13 had at least a 25% improvement (p = .002, 95% confidence interval [CI] = 46.0 to 57.8). Of the 8 patients who completed 6 weeks of treatment, 7 of the 8 had a 50% improvement, and all 8 had a 25% improvement (p = .012, 95% CI = 52.4 to 69.3). Similar results were obtained with the YMRS. By the second week of treatment, 10 of the 13 patients remaining in treatment had at least a 50% improvement, and 12 of these 13 had a 25% improvement (p = .002, 95% CI = 55.1 to 89.9). By the sixth week, all of the 8 patients remaining in treatment had a 75% improvement (p = .012, 95% CI = 90.5 to 102.8). The medication was well tolerated, and no case worsened. CONCLUSION: When used with concomitant mood-stabilizing drugs, risperidone may be effective and well tolerated in patients with acute mania with psychotic features. Considering the open design, small sample size, and limited period of observation, further studies need to be conducted.
Acute Disease↗
Clozapine in severe mood disorders.
BACKGROUND: A growing literature suggests that the atypical antipsychotic agent clozapine may be effective in schizoaffective and psychotic mood disorders. METHOD: To evaluate the efficacy and tolerability of clozapine in severe mood disorders, we reviewed published studies on clozapine in schizophrenia, bipolar disorder, schizoaffective disorder, major depression, and organic disorders with psychotic or major affective syndromes, identified through the MEDLINE data base. RESULTS: Patients in manic or psychotic phases of schizoaffective or bipolar disorder were significantly more likely to respond to clozapine than patients with schizophrenia (p = .006) or severe depressive syndromes (unipolar, bipolar, and schizoaffective depression combined; p = .001). There was no significant difference in the side effect profile secondary to clozapine in patients with severe mood disorders compared to patients with schizophrenia. CONCLUSION: Clozapine appears to be effective and well-tolerated in the short-term and maintenance treatment of severe or psychotic mood disorders, particularly in the manic-excited phases of schizoaffective and bipolar disorders, even in patients who have not responded well to conventional pharmacotherapies.
Bipolar Disorder↗
Prescribing trends of antidepressants in bipolar depression.
BACKGROUND: This study utilizing pharmacoepidemiologic methods was undertaken to determine the prescribing patterns of antidepressants particularly in bipolar depression. METHOD: From pharmacy records of the McLean Hospital, the number of patients receiving antidepressants and given electroconvulsive therapy (ECT) from June 1, 1987, to May 8, 1993, was determined. We later linked these data bases with patients who were diagnosed with DSM-III-R bipolar depression (296.5) during the same period of time. RESULTS: During the 6-year period, it was determined that 3829 inpatients had received tricyclic antidepressants (TCAs), 2981 fluoxetine, 2603 trazodone, 809 bupropion, 743 monoamine oxidase inhibitors (MAOIs), 592 stimulants, 588 sertraline, 48 paroxetine, and 894 ECT. There were significant increases over time in prescriptions of MAOIs compared with fluoxetine (chi 2 = 14.36, p = .006), and bupropion compared with TCAs (chi 2 = 6.45, p = .04). There was a trend for bupropion to be prescribed more over time compared with fluoxetine (chi 2 = 5.09, p = .08). There were no significant changes in the prescribing of other antidepressants or in the use of ECT. CONCLUSION: At our center, prescribing of bupropion and MAOIs in bipolar depression has increased significantly. This may be related to the reports in the literature of the low switch rates to mania with the use of these drugs.
Adult↗
Is clozapine a mood stabilizer?
BACKGROUND: Clozapine has been increasingly shown to be effective in the acute and maintenance treatment of bipolar disorders. For this reason, we studied whether clozapine alone is effective as a mood stabilizer in patients with refractory bipolar disorders. METHOD: Subjects were part of a long-term follow-up study cohort of 193 patients with refractory mood disorders who were treated with clozapine at McLean Hospital prior to July 1, 1992. Patients included in this study were those older than 16 years with bipolar disorder (manic or mixed) and schizoaffective disorder, bipolar type, discharged taking clozapine alone (N = 17). Hospital records on all patients were reviewed by trained raters blind to "best-estimate" diagnoses. Response to clozapine was determined by the Clinical Global Impressions-Improvement (CGI-I) scale. Patients were contacted at least 6 months after clozapine initiation for semistructured follow-up interviews by raters blind to diagnosis and baseline information. RESULTS: Seventeen subjects were contacted 16.1 +/- 5.6 months after clozapine initiation. Most of the 17 patients had previously failed trials of lithium, valproate, carbamazepine, neuroleptics, combinations of these, and electroconvulsive therapy; or had tardive dyskinesia. Of these patients, 65% (11/17) continued to be on clozapine therapy alone at follow-up and had no subsequent rehospitalization or affective episode. At follow-up, there was a significant decrease in the rehospitalization rate (p = .025) than before starting clozapine and a significant improvement in CGI-I scores (p = .02). CONCLUSION: Clozapine monotherapy is an effective mood stabilizer, reducing both the number of affective episodes and rehospitalizations in patients with severe refractory bipolar illness.
Adult↗
Algorithms for the treatment of schizophrenia.
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Algorithms↗
Clozapine therapy in refractory affective disorders: polarity predicts response in long-term follow-up.
BACKGROUND: To determine the efficacy and tolerance of long-term clozapine therapy in refractory affective illness. METHOD: Hospital records were reviewed for 193 treatment-resistant patients with a discharge diagnosis of bipolar disorder (N = 52), schizoaffective disorder (N = 81), unipolar depression (N = 14), schizophrenia (N = 40), or other disorders (N = 6) started on clozapine therapy as inpatients at McLean Hospital. An independent "best-estimate" diagnosis, based on DSM-III-R criteria, was established for each patient. Patients were contacted at least 6 months after clozapine initiation for structured follow-up interviews by raters blind to diagnosis. Patients were stratified by diagnosis, and a variety of patient characteristics and outcome measures were compared. RESULTS: Subjects were followed up a mean of 18.7 months after clozapine initiation. Bipolar manic and schizoaffective bipolar subjects had significantly better outcomes than unipolar, bipolar, and schizoaffective depressed patients on a variety of measures. One or more episodes of depression prior to clozapine predicted clozapine discontinuation (p = .01). Affective and schizoaffective subjects had baseline measures of social functioning similar to that of the schizophrenics but had significantly greater improvement in scores at follow-up. CONCLUSION: Clozapine is an efficacious and well-tolerated therapy for refractory affective illness. Manic symptomatology predicts a more favorable response than depression.
Adult↗
Is there a relationship between clozapine and obsessive-compulsive disorder?: a retrospective chart review.
The emergence of obsessive-compulsive symptoms during clozapine treatment has been reported in recent case studies, yet the incidence and significance of this finding is still unclear pending reliable data from a larger sample of patients. Hospital records of 142 randomly selected inpatients started on clozapine treatment at McLean Hospital before July 1, 1992, were reviewed retrospectively. Based on a limited retrospective chart review, there were no definitive cases of patients who developed obsessive-compulsive disorder (OCD) or whose OCD worsened as a result of clozapine treatment. Although some fluctuation of OCD symptoms may have occurred in two cases, it is unclear whether those symptoms were related to treatment with clozapine (or other psychotropic drugs) or to undulations in the natural history of OCD. No definitive relationship between OCD symptoms and clozapine treatment could be established in this limited study. Further clarification of this matter awaits outcome research using prospective methodologies.
Adult↗
The danger of hopefulness: a clozapine "cure" of chronic psychosis.
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Adult↗
The effect of comorbid substance use disorders on the course of bipolar disorder: a review.
Population-based studies have documented that among all patients with major psychiatric disorders, those with bipolar disorder have the highest prevalence of comorbid substance abuse and dependence. The cause of this high comorbidity rate has not been clearly established, and the relationship is probably bidirectional. Articles published in English from 1980 through 1997 containing the terms comorbidity, mania, outcome, and substance use were identified by searching Medline and then the bibliographies of the articles identified in this search. The literature review showed several risk factors to be associated with comorbid substance use disorders in bipolar disorder patients: early age of onset, gender, family history of substance use disorders, and presence of mixed mania. Methodological enhancements that have helped to advance understanding in this area include distinguishing between primary and secondary disorders, between the different subtypes of bipolar disorder, and between first and subsequent episodes of illness. In order to determine the temporal sequence of onset, longitudinal studies initiated at the onset of either illness need to be pursued. Increased understanding of the association between bipolar disorder and comorbid substance use disorder will facilitate improved detection and intervention, as well as more-effective preventive measures that could improve outcome for patients with bipolar disorder.
Adolescent↗