Hwang et al. (2005) makes several tentative recommendations about the pharmacotherapy of obsessive compulsive (OC) symptoms in schizophrenia patients.
1. Treatment of OC symptoms in schizophrenia with an additional medication should be considered once the patients are otherwise psychiatrically stable on a maintenance antipsychotic regimen. Though use of adjunctive antidepressants in patients with chronic schizophrenia in partial remission appears to be safe, there is some evidence that administering antidepressant agents in acutely psychotic schizophrenic patients may increase the risk of symptom exacerbation.
2. Anti-OCD agents should be prudently selected after careful pharmacologic considerations and after monitoring the patient’s therapeutic and adverse effect profiles. The ability of many of these compounds to induce or exacerbate agitation or akathisia, and the additional anticholinergic side effects that are common with both clomipramine and SSRIs are of particular concern. Furthermore, some SSRIs may increase the blood levels of some antipsychotics by as much as 25% to 30%, potentially resulting in an even greater increase inside effects. Therefore, clinicians must carefully monitor for potential new adverse effects due to pharmacokinetic drug-drug interactions.
3. Patients taking clozapine should be carefully assessed to determine if their OC symptoms preceded the initiation of clozapine therapy. If the OC symptoms appear to have started or worsened with the advent of clozapine treatment, clinicians should consider switching to another atypical antipsychotic after weighing the benefits derived from clozapine against the morbidity caused by an increase in OC symptoms. If clozapine is to be continued, an SSRI might be the anti-obsessional treatment of choice, given the significant adverse effects associated with combined clozapine and clomipramine regimen.
Ref: - Hwang, M., Yum, S.Y., Kwon, J.S., et al. (2005) Management of schizophrenia with obsessive-compulsive disorder. Psychiatric Annals, 35, 1, 36-43.
A new emergence of depression in a patient with a history of schizophrenia might be a harbinger of the emergence of a new episode psychosis, generally within a week or two. An appropriate treatment response for a new episode of depression in such a patient, therefore, is increased surveillance (especially with regard to psychotic or disinhibited behaviour), ensuring adherence with antipsychotic medication regimens, interventions to reduce stress, and the bolstering of nonspecific psychosocial supports (Siris, 2005).
Ref: - Sirius, S.G. (2005) Managing depression in schizophrenia. Psychiatric Annals, 35, 1, 61- 69.
The 2002 Mount Sinai Conference recommended monitoring body mass index (BMI) and waist circumference at every visit for the first six months after a medication initiation or change; a weight gain of one unit BMI identifies the need for intervention (Marder et al., 2004). A 2004 consensus panel sponsored by the American Diabetes Association and the American Psychiatric Association recommended monitoring BMI at baseline and at 4, 8, and 12 weeks after initiating or changing second-generation antipsychotic therapy, and quarterly thereafter. If weight gain occurs in excess of 5%, consideration should be given to changing the second generation antipsychotic by cross-titration. The panel also recommends baseline and annual measurement of waist circumference.
Ref: -
American Diabetes Association, American Psychiatric Association, American Association of Clinical Endocrinologists, North American Association for the study of obesity. Consensus development conference on antipsychotic drugs and obesity and diabetes. (2004) Diabetes Care, 27, 2, 596-601.
Marder, S.R., Essock, S.M., Miller, A.L. et al. (2004) Physical health monitoring of patients with schizophrenia. American Journal of Psychiatry, 161, 8, 1334-1349.
Pretreatment with an antidepressant such as paroxetine starting two weeks before the interferon therapy can reduce depression induced by interferon alpha (Musselman et al., 2001).
Ref: - Musselman, D.L., Lawson, D.H., Gumnick, J,F, et al. (2001) Paroxetine for prevention of depression induced by high-dose interferon alpha. New England Journal of Medicine, 344, 13, 961-966.
Choosing between the available SSRIs for management of obsessive compulsive disorder is difficult, as their effects are very similar. In the absence of comparator data, the selection of the drug depends upon personal preference. Occasionally the possibility of a drug interaction influences the choice. Sertraline and citalopram are relatively weak inhibitors of the hepatic cytochrome P450 enzymes which metabolize many psychotropic and other medications, and may be preferred if drug interactions are likely to be a problem. Fluoxetine and paroxetine are powerful inhibitors of the CYP2D6 isoenzyme, which metabolizes tricyclic antidepressants, antipsychotics, antiarrhythmics and beta blockers. Fluvoxamine inhibits both CYP1A2, which metabolizes warfarin and tricyclics, and CYP3A4, which metabolizes benzodiazepines and some antiarrhythmics. Fluoxetine has a long half-life and an active metabolite resulting in fewer withdrawal effects, which can be advantageous for patients who forget to take their tablets
Ref: - Zohar, J. & Fineberg, N. (2001) Practical pharmacotherapy. In: Obsessive compulsive disorder: a practical guide, (Eds.) Fineberg, N., Marazzitti, D. & Stein, D.J., pp 103-117, London: Marian Dunitz.
Lithium maintenance treatment may be an antisuicide measure in patients of bipolar disorder, even if lithium is not sufficient to reduce episodes. Researchers have observed some patients who were showing inadequate mood response to lithium who committed suicide after discontinuation, apparently because of the loss of separate antisuicide effect of lithium independent of its clinical effect on the affective episode (Muller-Oerlinghausen et al., 1992; Tondo et al., 1998). A metaanalysis detected a 20-fold increased incidence of suicide in those who stop lithium in year 1 vs. those who continue lithium prophylaxis (Baldessarini et al., 1999). These findings necessitate that the clinicians should monitor their patients for suicidal ideation after discontinuation of lithium.
Ref: -
Baldessarini, R.J., Tondo, L. & Hennen, J. (1999) Effects of lithium treatment and its discontinuation on suicidal behaviour in bipolar manic-depressive disorders. Journal of Clinical Psychiatry, 60 (suppl 2), 77-84.
Muller-Oerlinghausen, B., Muser-Causemann, B. & Volk, J. (1992) Suicides and parasuicides in a high-risk patient group on and off lithium long-term medication. Journal of Affective disorders, 25, 261-269.
Tondo, L., Baldessarini, R.J., Hennen, J., et al. (1998) Lithium treatment and risk of suicidal behaviour in bipolar disorder patients. Journal of Clinical Psychiatry, 59, 405-414.
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This blog on Clinical Psychopharmacology is maintained by Dr. Shahul Ameen, M.D., Psychiatrist, St. John's Hospital, Kattappana, Idukki, Kerala, India.
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