Psychopharmacology Consultation Line Questions/Topics:
1. Management of catatonia The current approach to managing catatonia involves use of short acting benzodiazepines, such as lorazepam (e.g. orally or im, 1-12 mg, or even higher) which are effective in improving the catatonic symptoms. It is important to recognize that catatonia is a non- specific manifestation of several disorders, including schizophrenia, depression, mania organic brain syndromes. Appropriate treatment will therefore depend on the underlying cause of catatonia. Sienaert P, Dhossche DM, Vancampfort D, De Hert M, Gazdag G. A clinical review of the treatment of catatonia. Front Psychiatry. 2014 Dec 9;5:181.
2. What are the effects of earlier use of clozapine? This is currently a topic of ongoing research interest. In a recent review, it was found that 2/4 studies looking at clozapine as a first line agent showed clozapine to be superior compared to a standard antipsychotic and not in the two others. Clozapine also has more side effect burden. For this time, clozapine as a first line of antipsychotic drug in early course psychosis patients is not routinely recommended, but more research is needed. Okhuijsen-Pfeifer CActa Psychiatr Scand. 2018 Oct;138(4):281-288. doi: 10.1111/acps.12954. Epub 2018 Sep 14. Clozapine as a first- or second-line treatment in schizophrenia: a systematic review and meta-analysis.
3. Our early psychosis treatment program received a copy of a book promoting clozapine as a first line treatment for psychosis. NAMI was a supporter of the publication. Do you have any thoughts about this? See answer to question 2.
4. What is the role of lithium augmentation in those not overtly bipolar – suicidality, agitation, mood instability? The use of lithium augmentation in patients who do not have clear cut bipolar disorder (e.g. those with recurrent depression, bipolar II disorder) remains uncertain, though this is widely used. There is some evidence that Lithium may be effective in preventing suicidality.
Tondo L1,2,3, Baldessarini RJ4,5. Suicidal Behavior in Mood Disorders: Response to Pharmacological Treatment. Curr Psychiatry Rep. 2016 Sep;18(9):88.
5. Effects of use of first-generation antipsychotic meds in those with high levels of weight gain Some first-generation antipsychotics (such as haloperidol and fluphenazine, molindone) are relatively weight neutral. Some second-generation antipsychotics, such as ziprasidone and lurasidone, are also relatively better.
6. Are there any anticholinergic risks for children with the use of antipsychotic mediation? Children and adolescents can also have anticholinergic side effects such as blurred vision, dry mouth and constipation with some antipsychotics (such as perphenazine, olanzapine, chlorpromazine) anti-Parkinson agents such as benztropine, antihistamines such as Benadryl, hydroxyzine and tricyclic antidepressants. Best avoid unnecessary polypharmacy where possible.
7. Can high/low blood sugar have an impact on the efficacy of antipsychotics in children? Not really. However, choice of antipsychotics in those with high fasting glucose levels and glucose intolerance might be better in favor of more metabolic neutral medications (e.g. first generation APDs, aripiprazole, lurasidone, ziprasidone, etc.
8. What is the first line to treat psychosis in a 16-year-old? First episode, noting auditory and visual hallucinations- no substances, engaged in therapy. If voices are not occurring every day would you still treat this? The first line treatment choice of an APD would have to be made based on considerations of clinician experience, efficacy, side effects, cost as well as ease of administration, in an individualized basis. All FDA approved antipsychotics have about similar efficacy, except for clozapine.
9. In the case of marijuana induced psychosis what would you recommend for treatment? Eliminating substances was my first thought but would you treat with medication if only occurring during substance use? First, the clinician needs to clarify whether this is a cannabis induced psychosis, or whether this is a cannabis- triggered primary psychotic disorder. A careful history of a) what came first (cannabis vs psychosis or prodrome) b) persistence (or not) of symptoms beyond cannabis use and c) risk factors for psychosis such as family history) will help. If cannabis induced psychosis, and patients is willing and stable and no safety concerns, one can try addressing the cannabis misuse and wait before introducing an APD. If acutely ill and unsafe, APD would be needed, with option to attempt gradual dose reduction after stabilization. If primary psychotic disorder, treatment may have to be prolonged, with minimum effective doses, with the goal of preventing relapse.
10. Reasonable indicators for suspicion of autoimmune encephalopathies; appropriate initial assessment; partnership with neurology NMDA encephalopathy should be considered if patients with new onset of psychosis with no prior risk, especially if presentation includes autonomic symptoms, such as heart rate/ blood pressure changes or fever. Look for underlying medical illness, such as ovarian cancers. Blood/ CSF tests for NMDA antibodies are diagnostic. Management involves anti-inflammatory treatments, steroids, immunoglobulins, and sometimes plasmapheresis.