Volume 6, Issue 1, March 2004
The review summarizes experimental and clinical data showing the cardiac side effects of antipsychotic drugs. Some antipsychotics may correlate with prolongation of QT interval, induce ventricular tachycardia, torsades de pointes, TdP, and sudden death. The author surveys the cellular actions of the drugs, the electrophysiological mechanisms and the recent data referring the drug’s effects on ionic currents, mainly potassium currents. Most antipsychotics are associated with the inhibition of delayed rectifier K+ channels. Comparing the potency on K+ channel inhibition and the prolongation of the QT interval with the therapeutic plasma levels of the drugs, the difference between the inhibitory potency and the therapeutic dose is the highest in the case of quetiapine, olanzepine and risperidone, while thioridazine shows the smallest difference. All drugs that cause TdP prolong the QT interval and inhibit the K+ rectifier channel, but the relationship is not precise. Some additional cellular effects of particular agents, modulating conditions, factors (diseases, electrolytes disturbances, genetic damage, drug interactions) make the individual vulnerable to arrhythmia. The paper highlights drug interactions causing risk of arrhythmia during chronic treatment of psychiatric patients.
KEYWORDS: antipsychotic drugs, neuroleptics, cardiac effects, QT prolongation, ventricular tachycardia, TdP, potassium channels
The therapy of bipolar disorders is a challenge for clinicians not only in the acute, but also in the maintenance phase. The choice is hazardous in spite of the many drugs available for this purpose. There are the classical mood stabilizers, antipsychotics, antidepressants, anxiolytics, hypnotics and other medicines that are usable in the treatment, but the resolution of the clinician can significantly influence the actual and prospective condition of the patient. We have evidence based experimental, anecdotal knowledge about the therapy of bipolar disorders, but we do not know the facts of the practice. The aim of the study was to evaluate the current therapeutic trends in Hungary. Method. A questionnaire was compiled and sent to psychiatrists working in different regions of Hungary. The questions referred to the institute, the patient (demographic data, actual condition, disorder) and the actual treatment. The study was blind to the investigator: nor the psychiatrists neither the patients were identified. The study covered patients visiting psychiatrists from 25 November to 6 December 2002. Results. 204 questionnaires were evaluated. 82 male and 122 female patients were included, of the average age of 48 years. The distribution of the disorders was as follows: bipolar I: n=120; bipolar II: n=66; cyclothym: n=18; and the actual condition was diagnosed, too. More than half of patients showed a balanced state. 28% of patients took only one, 35% two and 23% three kinds of psychotropic drugs, and 14% four or more simultaneously. 92% of patients was on “classical mood stabilizers” (lithium, carbamazepine, valproate) and the use of the carbamazepine was the most frequent. 54% took some kind of antipsychotic drugs and three quarter among them some atypical form. The use of anxiolytics was excessive: 44% of patients used one of them. 35% was on antidepressants and more than half of them on SSRI. Conclusion. The study findings show the current state of the treatment of bipolar disorders in Hungary, and are comparable with the relevant international trends and professional expectation. The results are useful in practice and in the education of physicians
KEYWORDS: bipolar disorder, pharmacotherapy, trends
Viktor Hal, László Fehér
Aggression has become a problem of our everyday life; every psychiatrist meets aggressive patients in his practice almost daily. Aggression represents a special problem in the case of institutionalized, mentally retarded (severe and moderate) patients, when it is associated with agitation, deficit of critical functions, impulsiveness, mood disorders. The nursing staff of these institutions is often overworked; the affective outbursts and aggressive behavior of mentally retarded patients may provoke a hostile attitude on the part of the nursing staff towards the patients. In the case of mentally retarded patients, unpredictable events may occur at any time. The structural background of mental retardation, the function of the affected cerebral structures, is not completely clarified. It was found in several studies that risperidone is effective in the treatment of agitation and aggressive behavior; the incidence of side effects is much lower than in the case of typical antipsychotics. We started the treatment with risperidone of 60 mentally retarded patients; we evaluated the therapeutic outcome after a three-month followup period using a rating scale made specially for this purpose. An attempt was made to compare the therapeutic results obtained in the risperidone group with the condition of patients receiving typical antipsychotics. It was found that, in the case of several items (aggression, agitation, deficit of critical functions, mood disorders, sleep disturbances, involvement in therapeutic activities), risperidone was significantly more effective than typical antipsychotics, and the incidence of extrapyramidal symptoms and other adverse events was much lower. It was hardly necessary to impose restraints in the risperidone group. In the care of mentally retarded patients, the use of risperidone has many long-term advantages, and hence it represents an effective alternative to typical antipsychotics.
KEYWORDS: mental retardation, aggression, risperidone, quality of life, rating scale
Central cannabinoid receptors (CB1 receptors) are densely located in the output nuclei of the basal ganglia (globus pallidus, substantia nigra pars reticulata). Endogenous cannabinoids appear to modulate transmitter systems (e.g. dopamine) within the basal ganglia. In the striatum, CB1 receptors are localized on the same neurons as Gi-coupled dopamine D2 receptors. Striatal CB1 receptors are also negatively linked to adenylcyclase, and may modulate dopamine release. The presence of CB1 receptors in dopaminergic neurons strongly suggests that cannabinoids play a modulatory role in dopaminergic neuronal pathways. This co-localization may postulate “cross talk” between endocannabinoids and dopamine-dependent reward mechanisms.
KEYWORDS: addiction, cannabinoids, dopamine, cannabinoid receptors, mesolimbic dopaminerg structures
The traditional biomedical approach separated psychotherapy and pharmacotherapy dichotomously. The biopsychosocial model of medicine stimulated the integration of these basic therapeutic modalities. There are many pieces of evidence testifying to the close relationship of somatic and psychological manifestations, and this connection is mainly represented by psychosomatic medicine. The present paper reviews some essential fields of psychotherapy and pharmacotherapy, e.g. similarities, interference, some important models of therapeutic integration, costbenefit evidences, and some research implications. In today’s medicine, integration is a basic requirement, and hence the dichotomous confrontation of psychotherapy and pharmacotherapy has become unacceptable. One important trend is the recognition that theories of modern psychotherapy cannot do without a sound knowledge of the brain functions.
In the case of elderly patients, the serious side effects of haloperidol should be taken into account. The 83-year-old schizophrenic patient had had successful haloperidol treatment, but developed a sudden paralytic ileus. The unique side effect of haloperidol calls attention to the danger of neuroleptic treatment of elderly patients. The good solution is to change over from haloperidol to a second-generation antipsychotic agent.
KEYWORDS: schizophrenia, haloperidol, paralytic ileus