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Suicide Associated with Akathisia and Depot Fluphenazine Treatment

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Abstract

AKATHISIA is a common and distressing side effect of neuroleptic medication that can he difficult to recognize and treat,1 Several previous reports mention maladaptive behavioral consequences, such as poor compliance with prescribed medication2 and aggressive or self-destructive outbursts2-3 We are reporting suicides in two young Hispanic men who had developed severe akathisia after treatment with depot fluphenazine. Depression with suicidal behavior has been observed following fluphenazine injection,4 but suicide associated with akathisia has not been previously noted.

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... Nevertheless, previous attempts to review 4,8 potential links between akathisia and emerging suicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series. The majority of these reports of suicidal ideation, [9][10][11] attempted [12][13][14] and completed suicides, 15,16 were associated with the emergence of acute akathisia induced by first generation high potency antipsychotics (summarised in Table 1). Although, it has been suggested that the magnitude of the problem may be even bigger due to underreported cases. ...
... It has been shown that younger and, particularly, antipsychotic naive patients are more susceptible to side effects. 25 This appears to be the case for the majority of the published case reports, [10][11][12][13][14][15][16] where mostly young patients were reported to have developed akathisia almost immediately after the initiation of high potency first-generation antipsychotics. Nearly half of the cases of suicidal behaviour were associated with first generation long-acting depot antipsychotics, as described in Table 1. ...
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Objective: We aim to systematically review evidence for a relationship between antipsychotic-induced akathisia and suicidal behaviour, in order to guide further clinical decision making in this area. Methods: Several electronic databases (Embase, Medline, Cochrane and PsychINFO) were systemically searched for articles published up to February 2021, using search terms related to akathisia, antipsychotics and suicidal behaviour. Two reviewers independently evaluated all the relevant studies using predetermined criteria and assessed the risk of bias for each included study. The systematic review was conducted in line with PRISMA methodology and reporting. Results: Following de-duplication, screening and application of exclusion criteria, four eligible studies were identified. All of the available studies were in English and included adult patients. Nevertheless, there was significant variability regarding methodology and overall quality was deemed low due to small sample sizes. There was insufficient data to perform statistical analyses of the results. Of the four studies, two found a weak correlation between antipsychotic-related akathisia and suicidal behaviour, a finding that was not supported by the remaining two studies. Conclusion: The search yielded very few studies for inclusion. On the basis of the existing evidence, akathisia cannot be reliably linked to the presence of suicidal behaviour in patients treated with antipsychotic medication. However, proactive screening for emerging suicidal behaviour in this vulnerable patient group is advisable. Our findings highlight the pressing need for further research in this area.
... Nevertheless, previous attempts to review 4,8 potential links between akathisia and emerging suicidal behaviour were not systematic and were mostly based on a limited number of case reports and small case series. The majority of these reports of suicidal ideation, 9-11 attempted 12-14 and completed suicides, 15,16 were associated with the emergence of acute akathisia induced by first generation high potency antipsychotics (summarised in Table 1). Although, it has been suggested that the magnitude of the problem may be even bigger due to underreported cases. ...
... It has been shown that younger and, particularly, antipsychotic naive patients are more susceptible to side effects. 25 This appears to be the case for the majority of the published case reports, [10][11][12][13][14][15][16] where mostly young patients were reported to have developed akathisia almost immediately after the initiation of high potency first-generation antipsychotics. Nearly half of the cases of suicidal behaviour were associated with first generation long-acting depot antipsychotics, as described in Table 1. ...
... • Akathisia, a sense of inner restlessness that is very distressing. At its most extreme, akathisia causes desperate, suicidal reactions [9][10][11]. • Parkinsonian-like symptoms, which include shaking, muscle rigidity, and slowness of movements. Often patients report feeling listless. ...
Article
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DSM-5 is considering adding a diagnostic category for young people who may be at higher risk of developing schizophrenia. Changing what otherwise would be risk factors for a future disease onset into a disease into its own right would open up floodgates for inappropriate and potentially harmful exposure to antipsychotic medication. The "at risk" population would not benefit from receiving a formal diagnosis because the proposed criteria stipulate that the individual already has to be help-seeking and desire psychiatric treatment, so already by definition these individuals are receiving psychiatric services. The implication that presence of risk factors implies future disease is not supported in epidemiologic studies in that there is insufficient specificity or sensitivity. Including the proposed risk category into DSM-5 therefore violates the basic medical principle of "first do no harm."
... 109,110 Shear et al (1983) reported homicides associated with akathisia after treatment with depot fluphenazine. 111 Schulte (1985) described cases of suicide and homicide associated with haloperidol. 112 Healy et al (2006) described nine cases of murder, suicide, and severe violence in patients who had not been mentally ill before being medicated. ...
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To examine the relation between variant alleles in 3 CYP450 genes (CYP2D6, CYP2C9 and CYP2C19), interacting drugs and akathisia in subjects referred to a forensic psychiatry practice in Sydney, Australia. This paper concerns 10/129 subjects who had been referred to the first author's practice for expert opinion or treatment. More than 120 subjects were diagnosed with akathisia/serotonin toxicity after taking psychiatric medication that had been prescribed for psychosocial distress. They were tested for variant alleles in CYP450 genes, which play a major role in Phase I metabolism of all antidepressant and many other medications. Eight had committed homicide and many more became extremely violent while on antidepressants. Ten representative case histories involving serious violence are presented in detail. Variant CYP450 allele frequencies were higher in akathisia subjects compared with random primary care patients tested at the same facility. Ten subjects described in detail had variant alleles for one or more of their tested CYP450 genes. All but two were also on interacting drugs, herbals or illicit substances, impairing metabolism further. All those described were able to stop taking antidepressants and return to their previously normal personalities. THE PERSONAL, MEDICAL, AND LEGAL PROBLEMS ARISING FROM OVERUSE OF ANTIDEPRESSANT MEDICATIONS AND RESULTING TOXICITY RAISE THE QUESTION: how can such toxicity events be understood and prevented? The authors suggest that the key lies in understanding the interplay between the subject's CYP450 genotype, substrate drugs and doses, co-prescribed inhibitors and inducers and the age of the subject. The results presented here concerning a sample of persons given antidepressants for psychosocial distress demonstrate the extent to which the psychopharmacology industry has expanded its influence beyond its ability to cure. The roles of both regulatory agencies and drug safety "pharmacovigilantes" in ensuring quality and transparency of industry information is highlighted.
... This is another variation of a problem arising from having fewer LAIs than oral antipsychotic options. When an individual is vulnerable to a serious adverse event from the available LAI options (eg, history of severe akathisia from most antipsychotics), 30 then, for practical purposes, treatment with a LAI is not an option. At times, these tolerability issues may be addressed by other means, such as using adjunctive agents, or taking a low-dose approach. ...
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LAIs are underused in the US. Part of the reluctance to their routine use in place of oral therapy is uncertainty about the potential benefits to patient care and ultimate outcome. A starting point in this discussion is to review the potential patient populations where LAIs might be used and compare it with when they are actually used. This shows that only a narrow segment of he schizophrenia patient population- the revolving door patient - is considered a possible LAI candidate. The narrow use of LAIs for only this segment of patients shows a serious misapplication of adherence theory in pharmacologic practice. Initiating LAIs does not immediately change attitudes toward medication adherence, and LAIs are not usually accepted by patients who overtly refuse their current oral therapy. Rather, the advantage of LAIs is their superiority over oral therapy as an adherence tracking method. Failure to recognize nonadherence in day-to-day practice is very common and leads to significant complications in optimizing drug therapy. Furthermore, nonadherence to oral antipsychotics is often unintentional and related to difficulties with handling the daily complexities of an oral medication regimen. In this context, changing to LAI therapy has potential adherence benefits for this type of patient. Perhaps the reluctance of many clinicians can be traced to misunderstanding the potential role of a LAI in overall pharmacologic management. If the expectation is that LAIs will solve the adherence problem, clinicians will be disappointed. However, the benefits of LAIs may not be readily apparent until enough time passes to actually know the true adherence status of a patient. LAI therapy compels patients and cliniciansto enter honest discussions about medication adherence, which in the long run is healthier than the covert nonadherence often associated with oral therapy. Finally, the potential benefits of LAIs for relapse prevention do not happen overnight. Rather, these benefits may take a year or more to appear.
... This res t lessness or agitation is more frequent with high-dose, high-potency neuroleptics, and it has been suggested that this side effect can increase the likelihood of vio lent or suicidal behavior. A possible causal relationship between neuroleptic-induced akathisia and violence has been suggested in several case reports and at least one organized study (Shear et al. 1983;Siris 1985;Herrera et al. 1988). In contrast, numerous other studies have shown that neuroleptics can be useful in controlling the violent behavior sometimes seen in psychotic patients . ...
... It is also identified as a predictor for development of tardive dyskinesia [Goswami and Channabasavanna, 1984]. Furthermore, the marked distress associated with akathisia has been associated with impulsive suicide attempts [Shear et al. 1983;Drake and Ehrlich, 1985;Wirshing et al. 1992;Hansen and Kingdom, 2006]. All these can contribute to noncompliance with antipsychotic drug treatment leading to increased risk for relapse [Barnes, 2003]. ...
Article
Objective: To conduct a systematic review and meta-analysis of randomized placebo-controlled trials of mirtazapine for the treatment of antipsychotic-induced acute akathisia (AIAA). Methods: Studies were identified using online searches of PUBMED/MEDLINE and Cochrane database (CENTRAL), along with websites recording trial information such as www.clinicaltrials.gov, www.controlled-trials.com, and www.clinicalstudyresults.org. The study eligibility criteria were randomized, double-blind clinical trials comparing mirtazapine with placebo for AIAA with standardized rating for akathisia as outcome measure. The methodological quality of included trials was assessed using the Jadad Scale. Separate meta-analyses were undertaken for each outcome (response rate and complete remission) and treatment effects were expressed as Mantel-Haenszel risk ratio (RR). Fixed-effect meta-analysis was performed as heterogeneity was not significant. Number need to treat (NNT) as a measure of relative treatment effectiveness was calculated. Results: A systematic review of the literature revealed six studies that had assessed mirtazapine for the treatment of AIAA. Of these, two studies (n = 86) met the review inclusion criteria and were included in the final analysis. A meta-analysis was performed to see the effect size of response rate and complete remission. For response rate, RR was 6.67 [95% confidence interval (CI) 2.14-20.78], favoring mirtazapine compared with placebo, and the overall effect was significant (p = 0.001, NNT 4, 95% CI 2.6-8.6). For complete remission, RR was 6.20 (95% CI 1.74-22.08), favoring mirtazapine compared with placebo, and the overall effect was significant (p = 0.005, NNT 5, 95% CI 2.9-11.6). Conclusions: Although limited to only two studies and small sample, existing data support the efficacy of mirtazapine for the treatment of AIAA, with one in four patients showing partial response and one in five patients showing complete remission.
... Its association with self-harm is not unsurprising and has been previously reported in the literature. [5][6][7] Previous studies have attempted to investigate the correlation between akathisia and suicide. 8 9 In a study population of patients with schizophrenia and schizophreniform disorder on antipsychotics, those describing subjective feelings of akathisia were more likely to be suicidal than those who did not suffer from akathisia. ...
Article
The authors describe the case of a 38-year-old man with a history of schizoaffective disorder, who attempted suicide following the recent starting of a neuroleptic agent that resulted in the development of intolerable akathisia. He survived the attempt, and following changes in his medications the akathisia resolved with no further suicidal ideation.
... The prevalence rate for akathisia associated with iloperidone use is likely very low; iloperidone appears to be associated with some of the lowest rates of occurrence among currently available atypical antipsychotic agents [13]. Akathisia causes profound suffering in patients and, in extreme cases, is associated with suicide [14]. Akathisia is also associated with poor response to acute treatment, as well as treatment withdrawal [15,16]. ...
Article
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Background: The purpose of this study was to evaluate the safety and effectiveness of iloperidone for the prevention of relapse in schizophrenia. Methods: Study subjects were adults with schizophrenia who started on oral open-label iloperidone titrated to an initial target dose of 12 mg/day (6 mg twice daily) and then stabilized on a flexible-dose iloperidone regimen (range 8-24 mg/day) for up to 24 weeks. Subjects meeting stabilization criteria then entered the relapse-prevention phase and were randomized 1:1 in a double-blind fashion to continue with iloperidone or placebo withdrawal for up to 26 weeks or until meeting relapse or other withdrawal criteria. Results: A total of 303 subjects were randomized to the relapse-prevention phase; 153 continued to receive iloperidone, and 150 were withdrawn to placebo. The modal total daily dose for iloperidone in all phases of the study was 12 mg/day. The pre-defined unblinded interim analysis upon reaching 68 relapse events confirmed the hypothesis that iloperidone (n = 97) was more effective than placebo (n = 96) in preventing relapse events, and the trial was stopped early. The estimated relapse rates were 63.4 % (Kaplan-Meier [KM] estimate) for placebo compared with 20.4 % (KM estimate) for those continuing to receive iloperidone (log rank test: p < 0.0001). The mean time to relapse was 71 days for placebo and 139 days for iloperidone (hazard ratio 4.7; 95 % confidence interval 2.7-8.3; p < 0.0001). The safety profile observed in previous short-term studies was also reaffirmed in this maintenance treatment setting. The most common treatment-emergent adverse events (TEAEs) in the stabilization phase were dizziness (11.6 %), somnolence (8.3 %), and dry mouth (6.8 %). Rates of reported extrapyramidal disorder or akathisia during stabilization were 2.5 and 3.7 %, respectively. Conclusions: Flexible dosing of iloperidone for maintenance-phase therapy, with a modal dose of 12 mg/day was effective in preventing relapse in subjects previously stabilized on iloperidone. The adverse event profile for iloperidone was consistent with other studies, and the low extrapyramidal symptom and akathisia burden during stabilization was sustained during the course of the study. ClinicalTrials.gov identifier: NCT01291511.
... un management a breve termine (situazione d'emergenza), dove il farmaco ha un ruolo essenzialmente sedativo -un management a medio e/o lungo termine, in cui la possibilità di una diagnosi accurata, successiva al controllo dell'acuzie, consente una valenza più specificamente terapeutica e preventiva dell'intervento (Tupin, 1987;Tardiff, 1989 (Keckich, 1978;Shearer, 1984;Herrera et al., 1988;Candilis, 1996) ed aumento del rischio suicidario (Shear et al., 1983;Drake & Ehrlich, 1985;Shulte, 1985). ...
... At the same time, physicians and other caregivers should be aware that severe antipsychotic side-effects can also result in suicidal ideation and behaviour, probably due to the increased motor activity (Mamo 2007). Based on a review and early data from small studies and case series (Mamo 2007) motor sideeffects, especially akathisia (Shear et al. 1983;Drake et al. 1985;Kerwin 2003;Lehman et al. 2004) have been linked to an increased risk for suicidal behaviour. Thus, special attention should be paid to motor side-effects, and in cases of suicidal behaviour antipsychotics with reduced risk for these side-effects should be used (Category of Evidence C3, Level of Recommendation 4). ...
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These updated guidelines are based on the first edition of the World Federation of Societies of Biological Psychiatry (WFSBP) guidelines for biological treatment of schizophrenia published in the years 2005 and 2006. For this 2015 revision, all available publications pertaining to the biological treatment of schizophrenia were reviewed systematically to allow for an evidence-based update. These guidelines provide evidence-based practice recommendations which are clinically and scientifically relevant. They are intended to be used by all physicians diagnosing and treating patients with schizophrenia. Based on the first version of these guidelines a systematic review, as well as a data extraction from national guidelines have been performed for this update. The identified literature was evaluated with respect to the strength of evidence for its efficacy and subsequently categorised into six levels of evidence (A-F) and five levels of recommendation (1-5). This third part of the updated guidelines covers the management of the following specific treatment circumstances: comorbid depression, suicidality, various comorbid substance use disorders (legal and illegal drugs), and pregnancy and lactation. These guidelines are primarily concerned with the biological treatment (including antipsychotic medication and other pharmacological treatment options) of patients with schizophrenia.
... В лечении сложных психических расстройств агресивного поведения начиная с конца 90-х применялись традиционные антипсихотики , в частности, активные для контроля нарушений агрессивного поведения, сочетающегося с острой положительной симптоматикой (Garver et al., 1984; Meltzer, 1987; Reynolds, 1989). Специфическая антиагрессивная эффективность обычных нейролептиков в острой стадии, обусловленная их седативным еффектом с торможением общей двигательной активности (Miczek, 1987), приблизительно в 75% случаев (Van Putten et al., 1984) вызывает экстрапирамидальные расстройства , с которыми часто коррелируется усиление психомоторной ажитации и агрессивности (Keckich, 1978; Shearer, 1984; Herrera et al., 1988; Candilis, 1996), а кроме того, увеличение риска суицида (Shear et al., 1983; Drake & Ehrlich, 1985; Shulte, 1985). В некоторых случаях , терапевтическая доза нейролептика предназначеного для контроля акатезии, имеет обратный эффект, который проявляется обострением тревоги и психомоторной ажитации , что является патологическим индексом . ...
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Резюме. В лечении сложных психических расстройств агрессивного поведения начиная с конца 90-х при- менялись традиционные антипсихотики, в частности, активные для контроля нарушений агрессивного поведения, сочетающегося с острой положительной симптоматикой. В статье будут рассматриваться дей- ствие при использовании клозапина, рисперидона, оланзапина, зипразидона изотепина. Эффект выходит независимо из антипсихотического еффекта антиагрессивности. Summary.. In treatment of composite alienations of aggressive behavior since the end 90, were applied traditional antipsychotics in particular to the control of violations of aggressive behavior combined to an acute positive symptomatology. In the article will be esteemed operating at usage of clozapin, risperidon, olanzapin, ziprazidon, izotepin. The effect appears separately from antipsychotic effect of antiaggressiveness.
... The FDA trials and 52 subsequent studies evaluated in 2000, by John Geddes of Oxford University demonstrated no clear evidence that atypical antipsychotics were more effective or better tolerated than conventional antipsychotics [60]. Thirty-six, that being one in every 145 clinical trial subjects for Risperdal, Zyprexa, Seroquel,) and Sertindole died; most by suicide, yet these deaths are never mentioned in scientific literature or prescriber information. ...
... For example, Battaglia et al. [87] showed that monthly intramuscular injections of fluphenazine decanoate reduce self-harm behavior in outpatients with histories of multiple suicide attempts. Shear et al. [88] reported suicides in two young men who developed severe akathisia after treatment with depot fluphenazine. A Cochrane review by Adams and Eisenbruch [89] compared depot fluphenazine medication to oral fluphenazine for treatment of schizophrenia and found no difference between fluphenazine hydrochloride and its depot form for outcomes such as depressed mood or suicide. ...
Article
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Suicide is an important public health problem. The most frequent psychiatric illnesses associated with suicide or severe suicide attempt are mood and psychotic disorders. The purpose of this paper is to provide an educational overview of suicidal behavior in individuals with schizophrenia. A lifetime suicide rate in individuals with schizophrenia is approximately 10%. Suicide is the largest contributor to the decreased life expectancy in individuals with schizophrenia. Demographic and psychosocial factors that increase a risk of suicide in individuals with schizophrenia include younger age, being male, being unmarried, living alone, being unemployed, being intelligent, being well-educated, good premorbid adjustment or functioning, having high personal expectations and hopes, having an understanding that life’s expectations and hopes are not likely to be met, having had recent (i.e., within past 3 months) life events, having poor work functioning, and having access to lethal means, such as firearms. Throughout the first decade of their disorder, patients with schizophrenia are at substantially elevated suicide risk, although they continue to be at elevated suicide risk during their lives with times of worsening or improvement. Having awareness of symptoms, especially, awareness of delusions, anhedonia, asociality, and blunted affect, having a negative feeling about, or non-adherence with, treatment are associated with greater suicide risk in patients with schizophrenia. Comorbid depression and a history of suicidal behavior are important contributors to suicide risk in patients with schizophrenia. The only reliable protective factor for suicide in patients with schizophrenia is provision of and compliance with comprehensive treatment. Prevention of suicidal behavior in schizophrenia should include recognizing patients at risk, delivering the best possible therapy for psychotic symptoms, and managing comorbid depression and substance misuse.
... Akathisia is an extrapyramidal side effect of antipsychotic drugs and antidepressants that occurs in nearly 20% of patients receiving such drugs, and it has been reported to be associated with severe discomfort for patients sometimes resulting in suicide [2,3]. However, due to the diversity of symptoms, it is often overlooked [4]. ...
Article
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Background: Akathisia is a rather common extrapyramidal side effect of antipsychotic drugs and antidepressants, often resulting in severe discomfort for patients. However, due to the diversity of symptoms, it is often overlooked. We hereby report a case with akathisia that mainly appeared in an amputated leg. Case presentations: A 60-year-old woman, who had undergone external hemipelvectomy for a recurrent soft tissue sarcoma, was referred to the Department of Psycho-Oncology due to worsening anxiety and restlessness. She was not unconscious or disoriented. Her chief complains included restlessness, an itching sensation in the area corresponding to the amputated left leg, and a feeling as if the lost left leg were raising itself. Detailed examination revealed that she had been administered 10 mg per day of oral prochlorperazine maleate for nausea induced by the oxycodone that had been prescribed to control post-operative pain. Akathisia was suspected and prochlorperazine maleate treatment was discontinued. All the symptoms were alleviated on the next day, and disappeared in 3 days. Eventually, she was diagnosed with akathisia. Conclusions: This case indicates that the symptoms associated with akathisia can occur in an amputated extremity. Considering two previous reports of "phantom dyskinesia", extrapyramidal syndromes may result in unusual presentations if occurring in an amputated extremity. Not only should the use of antipsychotic drugs and antidepressants be carefully considered, but also closer observation of psychological symptoms is required after prescription of these drugs because the clinical presentation of akathisia can be various and confusing due to modifications caused by other factors as in this case.
Article
The risk of suicide is a major factor in the morbidity and mortality of schizophrenia, accounting for approximately 10% of deaths in patients with this condition. Indicated risk factors include male gender, social isolation, depression, feelings of hopelessness, a history of suicide attempts, deteriorating health and, uniquely to patients with schizophrenia, young age in men and chronic schizophrenia with numerous exacerbations. There is significant evidence suggesting that clozapine, the gold standard treatment for patients with treatment-resistant schizophrenia, reduces the suicide rate. Although the reasons for this are unknown, beneficial effects of clozapine that are thought to contribute to the reduced suicide rate include improved symptom control, reduced extrapyramidal symptoms, direct antidepressant action, improved cognitive function, and improved compliance. These improve self-perceived quality of life and hence lead to greater desire, and capacity, to survive. Reduced suicide attempts and completed suicide may also reflect the effect of weekly contact with mental health providers to obtain blood for white blood cell monitoring or cohort effects (i.e. time-dependent decrease in suicide attempt rates). Data from a number of studies which have investigated the impact of clozapine on suicide rates in patients with schizophrenia demonstrate that the drug reduces the risk of suicide attempts by approximately 75 to 80%. It had a comparable effect in reducing the completed suicide rate in an epidemiological survey of all US patients in the Clozaril® National Registry. A large scale prospective, randomised study comparing clozapine and olanzapine in patients with a recent history of suicidality is in process. The International Suicide Prevention Trial (InterSePT) will compare the effectiveness of clozapine (300 to 900 mg/day) with olanzapine (10 to 20 mg/day) in reducing suicide and suicide-related events in patients with schizophrenia and schizoaffective disor-der. An overview of the study methodology is provided in this review.
Article
Die neuroleptika-induzierte Akathisie ist ein neuropsychiatrisches Syndrom mit vorwiegend subjektiv erfahrbaren psychischen sowie gut objektivierbaren motorischen Symptomen, deren jeweilige diagnostische Wertigkeit bisher nicht ausreichend evaluiert ist. In Ermangelung eines biologischen Markers stützt sich die Differentialdiagnose dieser Störung von hoher klinischer Relevanz vor allem auf die klinische Beurteilung und gestaltet sich bislang schwierig. Anhand einer systematischen Untersuchung von 27 respektive 20 Patienten mittels eines semistrukturierten Interviews, einer Selbstbeurteilungsskala und etablierter Akathisie-Rating-Skalen (Hillside, Barnes, Prince Henry Hospital und Chouinard) wurden vier charakteristische Merkmale des subjektiven Symptomerlebens von Patienten mit akuter neuroleptika-induzierter Akathisie identifiziert, die die differentialdiagnostische Abgrenzung von anderen Unruhezuständen erleichtern könnten. Die Ergebnisse dieser Pilotstudie werden ausführlich im Kontext der einschlägigen Literatur zur Symptomatik der Akathisie diskutiert. Hierauf basierend wird ein Symptom-Schweregrad-Modell der Akathisie mit Betonung psychodynamischer Aspekte vorgeschlagen, das einen wesentlichen Beitrag zur Diagnose und Quantifizierung dieser Störung leisten könnte und bei zukünftigen Entwürfen neuer Akathisie-Rating- Skalen berücksichtigt werden sollte.
Article
Objective: Family caregivers of cancer patients suffer from physical, psychological, and social distress and therefore are often referred to as second order patients. Akathisia is a common side effect of antipsychotics and antidepressants that causes great discomfort and even agitation and is often described by patients administered these drugs as the most distressing side effect of their treatment. Several studies of akathisia as a cause of distress in cancer patients have been reported. However, akathisia has not been reported as a cause of distress in family caregivers of cancer patients. Method/case report: A 74-year-old spouse caregiver who was under treatment for major depressive disorder was not able to visit the hospital where her husband, a terminally ill cancer patient, was being treated. Initially, the spouse caregiver thought that she could not visit the hospital because of the symptoms of her depression and her grief about losing her husband. However, careful clinical examination revealed that she was suffering from akathisia in addition to her grief. Results: Discontinuation of her sulpiride treatment resulted in the disappearance of her akathisia symptoms, and therefore she became able to visit the hospital and care for her terminally ill husband. Significance of results: Drug induced akathisia is a cause of distress in spouse caregivers taking certain drugs. It is important for clinicians to realize that family caregivers might suffer from not only socioeconomic, physical, and psychological problems but also side effects of medication.
Article
Evidence is emerging that a range of psychotropic drugs may precipitate akathisia and/or panic reactions in predisposed patients. The use of fluoxetine has hitherto been the most notable example of this occurrence. These reactions may foster the genesis of suicidal ideation in a small proportion of patients. At present, it is not clear what biological mechanism may underlie this finding. The serotonin (5-hydroxytryptarnine; 5-HT) system may be involved in these reactions. The best management of such reactions will involve counselling patients beforehand about the possibility of these reactions, stopping treatment with the agents if such a reaction is suspected, or adding an agent with 5-HT1A antagonistic properties (e.g. propranolol) to the treatment regimen.
Article
Prochlorperazine is often used to prevent opioid-induced nausea; however, this drug causes extrapyramidal symptoms. It is important to determine the incidence of such symptoms and identify coping mechanisms because these symptoms induce intense and possibly life-threatening patient suffering. The purpose of this study was to determine the incidences of nausea and extrapyramidal symptoms associated with the use of prochlorperazine and perospirone as preventive antiemetics when initiating opioid treatment(a sustained-release tablet of oxycodone at a dose of 10 mg/day)and to compare the benefits of the 2 drugs. A total of 100 cancer patients who received medical care from a physician in the palliative care department of our center between May 2007 and September 2008 were consecutively enrolled for a retrospective review of the medical records. Of the patients, 50 had received prochlorperazine treatment(10 or 15mg/day, orally)and 50 had received perospirone treatment(4 or 8 mg/day, orally)concomitantly with oxycodone treatment(10mg/day)on an in-patient or outpatient basis. The incidence of nausea and vomiting within 1 week after starting treatment with opioids and the extrapyramidal symptoms during treatment were evaluated. The results showed that the incidence of nausea and vomiting was 8. 0% for the prochlorperazine group and 4. 0% for the perospirone group, and this difference was not statistically significant; however, the incidence of extrapyramidal symptoms was significantly higher for the prochlorperazine group(14%)than for the perospirone group(0%). Furthermore, the extrapyramidal symptom observed in the prochlorperazine group was akathisia, which occurred within a week. The results of this study suggest that careful attention should be paid so as not to overlook akathisia when using prochlorperazine as an antiemetic in cancer patients and that atypical antipsychotics, such as perospirone, could be used as alternatives.
Article
Akathisia is a common and clinically important adverse effect of antipsychotic and some other psychotropic drugs, which has until recently been neglected by researchers and clinicians. It manifests as a subjective feeling of restlessness (particularly referable to the lower limbs) and a compulsion to move, and is objectively characterised by limb and body movements and behavioural features. The association of akathisia with antipsychotic drugs is complex. Subtypes of akathisia (acute, chronic, tardive and withdrawal akathisia) are now recognised, which resemble each other phenomenologically, but may have different pharmacological profiles in terms of treatment and, possibly, aetiology. The clinical diagnosis of akathisia may be difficult, as it has to be distinguished from psychotic agitation, anxiety and other syndromes. However, there are some distinctive features that assist in the identification of akathisia, especially if there is a high index of suspicion. The treatment of akathisia is not always satisfactory, and strategies to prevent or minimise its occurrence should prevail. The 2 classes of drugs most commonly used in the treatment of acute akathisia are anticholinergics and f3-adrenoceptor blockers, but other drugs may playa minor role. The treatment of tardi ve akathisia is insufficiently researched and complicated by its overlap with tardive dyskinesia. However, catecholamine depleters, anticholinergic drugs, anti-adrenergic drugs and clozapine may have a role in the treatment of this subtype.
Article
The risk of suicide is a major factor in the morbidity and mortality of schizophrenia, accounting for approximately 10% of deaths in patients with this condition. Indicated risk factors include male gender, social isolation, depression, feelings of hopelessness, a history of suicide attempts, deteriorating health and, uniquely to patients with schizophrenia, young age in men and chronic schizophrenia with numerous exacerbations.There is significant evidence suggesting that clozapine, the gold standard treatment for patients with treatment-resistant schizophrenia, reduces the suicide rate. Although the reasons for this are unknown, beneficial effects of clozapine that are thought to contribute to the reduced suicide rate include improved symptom control, reduced extrapyramidal symptoms, direct antidepressant action, improved cognitive function, and improved compliance. These improve self-perceived quality of life and hence lead to greater desire, and capacity, to survive. Reduced suicide attempts and completed suicide may also reflect the effect of weekly contact with mental health providers to obtain blood for white blood cell monitoring or cohort effects (i.e. time-dependent decrease in suicide attempt rates).Data from a number of studies which have investigated the impact of clozapine on suicide rates in patients with schizophrenia demonstrate that the drug reduces the risk of suicide attempts by approximately 75 to 80%. It had a comparable effect in reducing the completed suicide rate in an epidemiological survey of all US patients in the Clozaril National Registry.A large scale prospective, randomised study comparing clozapine and olanzapine in patients with a recent history of suicidality is in process. The International Suicide Prevention Trial (InterSePT) will compare the effectiveness of clozapine (300 to 900 mg/day) with olanzapine (10 to 20 mg/day) in reducing suicide and suicide-related events in patients with schizophrenia and schizoaffective disorder. An overview of the study methodology is provided in this review.
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Prospectively examined a comprehensive range of demographic, clinical, and family variables to determine what factors could predict suicide. 401 men and 553 women (all aged 17–79 yrs) participated in the 10-yr study. 569 Ss had unipolar depression, 185 had bipolar Type I disorder, 114 had bipolar Type II disorder, and 80 had schizoaffective disorder. Treatment was administered independently of the study. During the follow-up period, 32 Ss died by suicide. 41% of these suicides occurred within 12 mo of entry into the study, and most had been inpatients. These short-term suicides were associated with panic attacks, severe psychic anxiety, impairment of concentration, psychomotor agitation, global insomnia, moderate alcohol abuse, and severe anhedonia. Fewer than 20% of the suicides occurring more than a year after their enrollment had panic attacks. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Objective: Schizophrenia is characterised by distorted thinking and perception and tends to run a chronic course. The World Health Organization reported that suicide accounts for almost 2% of the world's deaths. There is a close relationship between schizophrenia and suicide. Patients with schizophrenia experience personal distress and socio-occupational dysfunction and reduced life expectancy as a group. The current article presents a review of suicide in schizophrenia. Data sources: The literature search included MEDLINE, CINHAL, EMBASE, and Cochrane Controlled Trials Register databases. Study selection: Search terms used included 'schizophrenia', 'suicide', 'positive symptoms', 'negative symptoms', 'self-harm', 'anti-psychotics', 'risk factors' in different combinations. Data extraction: We included epidemiological findings, socio-demographical variables, symptom profiles, biological underpinnings, risk factors, and management issues. No publication year limits were applied but the search was restricted to articles in English. The abstracts of articles retrieved in the search were manually scanned. Data synthesis: Male gender and being unmarried are associated with an increased risk of suicide among individuals with schizophrenia. The presence of depression and depressive features is associated with an increased risk of suicidality. An association between insight into the illness, a consequent feeling of hopelessness, and increased risk of suicide has also been a consistent finding. In contrast the role of schizophrenia subtype in suicidal risk remains controversial. Conclusions: To date, the impact of specific pharmacotherapeutic agents and non-pharmacological interventions on the suicidal behaviour of individuals with schizophrenia is also yet to be fully explored by robust research.
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Suicidality and aggression during psychiatric inpatient stay: a diagnosis-specific point of view Abstract The relevance of aggression for suicidal behaviour has been documented by many studies. The examination of other-directed overt aggression as a risk factor of suicidal behaviour may contribute to risk assessment. Our study is aimed to explore other-directed overt aggression during psychiatric inpatient care as a risk factor for suicidal behaviour during hospital stay. Based on the data of the German psychiatric basic documentation system (DGPPN-BADO) we examined risk factors of inpatient suicidal behaviour in consideration of aggressive behaviour (physical assault, damage to property, threatening behaviour). We included 8.901 admissions with schizophrenia (ICD-10: F20), 6.210 with depression (ICD-10: F32/F3 3), 3.763 with acute stress disorders/adjustment disorders (ICD-10: F43) and 4.006 widi personality disorders (ICD-10: F60/F61) in our study from 1998 to 2007. Physical assault during inpatient stay turned out to be a risk factor for attempted suicide for all diagnostic groups with exception to schizophrenia. Damage to property increased risk of attempted suicide for admissions with acute stress disorders/adjustment disorders and personality disorders. Other-directed overt aggression seems to be associated with suicidal behaviour for most diagnostic groups and may indicate increased risk of suicidal behaviour. Key words: Inpatient suicide, attempted suicide, aggression, psychiatry
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As part of the current trend in suicide research to focus on specific high-risk groups (1), we have been studying suicide in schizophrenia (2–7). In addition to reviewing the literature (2), we have identified risk factors (3–5), considered the influence of depression and hopelessness (6), and examined the differences between attempters and completed suicides (7). This work, along with that of Roy (8) and others (9–15), enables us to identify high-risk patients rather than to predict specific suicides (16).
Article
Background: To investigate clinical characteristics and adequacy of antipsychotic treatment in different phases of illness and treatment among suicide victims with schizophrenia. Method: As part of the National Suicide Prevention Project, a nationwide psychological autopsy study in Finland, all DSM-III-R schizophrenic suicide victims with a known treatment contact (N = 88) were classified according to the phase of illness (active/residual) and treatment (inpatient/recent discharge/other). Characteristics of victims in terms of known risk factors for suicide in schizophrenia, as well as adequacy of the neuroleptic treatment, were examined. Results: Fifty-seven percent of suicide victims with active phase schizophrenia were prescribed inadequate neuroleptic treatment or were non-compliant, and 23% were estimated to be compliant nonresponders. Inpatient suicide victims had the highest proportion of negative or indifferent treatment attitudes (81%), whereas recently discharged suicide victims had the highest prevalence of comorbid alcoholism (36%), paranoid subtype (57%), and recent suicidal behavior or communication (74%), as well as the highest number of hospitalizations during their illness course and shortest last hospitalization. Conclusion: Suicide risk factors in different treatment phases of schizophrenia may differ. Substantial numbers of suicide victims with schizophrenia are receiving inadequate neuroleptic medication, are noncompliant, or do not respond to adequate typical antipsychotic medication. Adequacy of psychopharmacologic treatment, particularly in the active illness phase, may be an important factor in suicide prevention among patients with schizophrenia.
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The present study attempted to identify risk factors for suicidality and hostility/aggression in patients with bipolar disorders. Data on 3521 patients were extracted from the Japanese Adverse Drug Event Report (JADER) database. There were 134 reports regarding suicidal behavior/ideation, and 129 patients were judged to have it. Standardized Medical Dictionary for Regulatory Activities queries indicated that 248 adverse drug events pertained to hostility/aggression, and 218 patients were considered to show hostility/aggression. A multiple logistic regression analysis revealed the association of the risk for suicidal behavior/ideation with bipolar II disorder [adjusted odds ratio (aOR): 4.55, 95% confidence interval (CI): 1.90–10.9], male sex (aOR: 1.23, 95% CI: 1.02–1.48), age <50 years (aOR: 1.75, 95% CI: 1.43–2.15), the administration of aripiprazole (aOR: 1.27, 95% CI: 1.00–1.60), and akathisia (aOR: 3.05, 95% CI: 1.80–5.18), while lithium carbonate decreased its odds (aOR: 0.664, 95% CI: 0.537–0.821). The risk of hostility/aggression was associated with male sex (aOR: 1.22, 95% CI: 1.06–1.40), lithium carbonate (aOR: 0.823, 95% CI: 0.710–0.953), and carbamazepine (aOR: 0.693, 95% CI: 0.500–0.961). No association between suicidal behavior/ideation and hostility/aggression was recognized. The present study proposes factors related with suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders using the JADER database. Lithium carbonate appeared to decrease the risks of suicidal behavior/ideation and hostility/aggression in patients with bipolar disorders, and akathisia may be associated with the former risk. Further studies are required to evaluate the identified signals.
Article
Objectives: The prevalence of akathisia is variably reported in the literature and its psychiatric impact is little studied. The aim of this study was to establish the prevalence, the associated factors, and the psychiatric impact of akathisia among patients undergoing antipsychotic treatment. Methods: A cross-sectional descriptive study was carried out at the Department of Psychiatry A, at Razi Hospital, in Tunis. It included patients with psychosis, undergoing antipsychotic treatment, from June 2016 to February 2017. Akathisia was diagnosed according to the Barnes Akathisia Scale. Results: The prevalence of akathisia was 19.5% (n = 24, schizophrenia/schizoaffective disorder, n = 20; bipolar disorder, n = 4). The delay between the diagnosis of the disease and the onset of akathisia was 7.1 ± 8.8 years. Among the sample of patients with akathisia, 20/24 were on monotherapy of which 14 on conventional antipsychotics and six on atypical antipsychotics. Patients with akathisia were on atypical (8/24), low-potency conventional (4/24), or high-potency conventional (17/24) antipsychotics. The average dose of antipsychotics in chlorpromazine equivalent was 2294.5 ± 3037.7 mg. After adjusting for confounders, the only factor significantly positively associated with the diagnosis of akathisia was the dose of antipsychotics prescribed (P = 0.01). The following psychiatric manifestations were reported by patients with akathisia: dysphoria/irritability (16/23), anxiety (18/24), sadness (15/24), suicidal thoughts (11/24), heteroaggressivity (8/23), sleep disturbances (16/24), and suicidal attempts (9/24). Conclusions: Despite the high psychiatric and social burden of akathisia, it remains largely underdiagnosed and undertreated, because in part of its subjective component.
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An 81 years old Jewish-Iranian lady, with a psychiatric history of postpartum depression in her twenties and a previous hospitalization due to a depressive episode accompanied by suicidal thoughts and a history of hearing loss and COPD, was hospitalized in the psychogeriatric department of our Mental Health Center due to repetitive incoherent sounds she was uttering for the past month, which increased in intensity and caused suicidal thoughts.
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In our experience, higher doses of neuroleptics are often associated with a dysphoria syndrome. We believe that this dysphoria is underrecognized, and that it is readily correctable by decreasing the dose. Naturalistic studies which compare depression ratings in patients on different doses of neuroleptics are not likely to support such a concept since dysphoric patients either leave treatment or tend to tolerate only a low dose. To study dose-related dysphoria, therefore, patients need to be randomly assigned to fixed doses of antipsychotic drug.
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Der Terminus Akathisie wurde erstmals im Zusammenhang mit Hysterie und Neurasthenie von Haskovec [1904] um die Jahrhundertwende beschrieben. Akathisie bedeutet wörtlich übersetzt „die Unfähigkeit zu sitzen“.
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Objective: This study explores suicide risk in schizophrenia in relation to side effects from antipsychotic medication. Methods: Among patients with a first clinical discharge diagnosis of schizophrenia or schizoaffective disorder in Stockholm County between 1984 and 2000 (n = 4000), those who died by suicide within 5 years from diagnosis were defined as cases (n = 84; 54% male). For each case, one individually matched control was identified from the same population. Information on antipsychotic side effects, including extrapyramidal symptoms (EPS) and akathisia, as well as prescriptions of anticholinergic medication, was retrieved from clinical records in a blinded fashion. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) of the association between suicide and side effects as well as anticholinergic medication were estimated using conditional logistic regression. Results: A lower suicide risk was found in patients with a history of EPS (aOR 0.33, 95% CI 0.12-0.94). There was no statistically significant association between akathisia or anticholinergic medication use and the suicide risk. Conclusions: A lower suicide risk identified among patients with EPS could potentially reflect higher antipsychotic adherence, exposure to higher dosage, or polypharmacy among these patients. Copyright © 2016 John Wiley & Sons, Ltd.
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Adverse drug reactions and interactions are among the major causes of death in the United States. Antidepressants have been reported as causing suicide and homicide and share the class attribute of frequently producing akathisia, a state of severe restlessness associated with thoughts of death and violence. Medical examiners can now identify some pharmacogenetic interactions that cause drugs, deemed safe for most, to be lethal to others. Such deaths do not yet include medication-induced, akathisia-related suicides and homicides. An extrapyramidal side effect, akathisia is a manifestation of drug toxicity whose causes lie, inter alia, in drugs, doses, and co-prescribed medications that inhibit and compete for metabolizing enzymes, which may themselves be defective. In this paper, we report our investigation into adverse drug reactions/interactions in three persons who committed homicide, two also intending suicide, while on antidepressants prescribed for stressful life events. Their histories of medication use, adverse reactions and reasons for changes in medications are presented. DNA samples were screened for variants in the cytochrome P450 gene family; that produce drug metabolizing enzymes. All three cases exhibit genotype-based diminished metabolic capability that, in combination with their enzyme inhibiting/competing medications, decreased metabolism further and are the likely cause of these catastrophic events.
Article
Ten per cent of patients with schizophrenia commit suicide, and 40-50% attempt to commit suicide. This suicidal behaviour is often seen in the first 10 years of the course of the disease. The literature shows that a course with many relapses and repeated admissions increases the risk of suicidal behaviour. The suicidal behaviour is most frequent among schizophrenics with a history of suicide attempts, depression, or hopelessness. Traditional antipsychotic treatment has no substantial effect on suicidal behaviour among schizophrenics. However, clozapine appears to reduce suicidal behaviour. It is recommended that treatment with clozapine is considered for schizophrenics with depressive symptoms or serious suicide attempts and for chronic schizophrenic patients with a sustained low quality of life.
Article
Suicidality in its structural aspects represents a complex entity with a widespread potentiality for influence from a psycho-reactive up to a biological pole. Thus also psychotropic drugs may directly or indirectly affect suicidality. Recent results from biological suicidology show several ways of influence for psychotropic drugs and focus mainly on serotonin and its cerebral pathways. Discussion about single substances and their influence on suicidality reveals some methodological problems in any studies dealing with this question. Projects of drug monitoring and assessment of adverse drug reaction including suicidal events show a distinct point of view regarding this topic and offer further source of knowledge. From the Bavarian Project of Drug Monitoring in Psychiatry (Arzneimitteluberwachung in der Psychiatrie/Bayern: AMUP-Bayern), representing such a scheme, data from 1991 to 1997 regarding the influence of psychotropic drug therapy on suicidality are presented and discussed on the basis of previous publications.
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The authors consider the extent to which psychotropic medications demonstrate benefits in the prevention of suicidal behavior in psychiatric patients. Results of a MedLine search are critically reviewed for lithium, divalproex and other anticonvulsants, conventional and atypical antipsychotics, and antidepressants. The existing literature is almost entirely limited to noncontrolled, often retrospective studies that do not control for potential biases in treatment selection, the use of multiple medications, the impact of medication nonadherence, and nonrandomized treatment discontinuations. Nevertheless, an extensive literature has arisen regarding observed reductions in suicidal behavior with lithium for mood disorders and, to a lesser extent, with clozapine for schizophrenia. A substantially smaller literature suggests more negative than positive data with divalproex or carbamazepine in bipolar disorder, while minimal information exists regarding suicidality with atypical antipsychotics other than clozapine. Studies of antidepressants have mostly been short-term and have focused more on whether they induce (rather than ameliorate) suicidal thoughts or behaviors. The sum of existing studies is generally inconclusive about whether antidepressants appreciably reduce risk for suicide completions. Relatively little is known about pharmacotherapy effects on suicidal ideation as distinct from behaviors. Possible mechanistic considerations for understanding antisuicide properties include a therapeutic impact on depression, impulsivity, or aggression, potentially mediated through serotonergic or other neuromodulatory systems. Recommendations are provided to guide future research as well as clinical practice.
Article
Three cases of akathisia-induced impulsive suicide attempts are reported. In all three cases the patients admitted that the suicidal ideas occurred suddenly. The suicidal attempts may be a result of neuroleptic-induced akathisia as they disappeared as soon as the akathisia was treated.
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Akathisia is a complex syndrome, frequently linked to treatment with antipsychotics. There are no universal diagnostic criteria and no specific locomotor pathognomonic sign is available. Beta-blockers are said to be an effective treatment for akathisia. Inspired by a case study, the recent literature on beta-blockers was examined. There are comparatively few reports of controlled trials and most of these trials were performed in the late eighties. These studies do not state ambiguously that beta-blockers constitute an effective treatment for antipsychotic induced akathisia. Tentative guidelines are proposed for clinical practice.
Article
Individuals with schizophrenia and schizoaffective disorder are at increased risk for attempted and completed suicide throughout their lifespan. No one factor can be highlighted as essential for increasing or reducing this risk. In fact, vulnerable individuals tend to have increased periods of risk, such as during depression, during stressful times, and during changes in support. After a comprehensive evaluation of symptoms, social functioning, and past suicidal behavior, a continual multifaceted evaluation of suicidal behavior and potentially associated factors is necessary for early and effective suicide risk reduction (Table 2). Suicidal behavior recurs and passes, especially when intervention is available. Although it may be impossible to prevent every suicide, effective intervention with attention to quality of life is essential for suicide risk reduction.
Thesis
p>I searched the medical literature for reports of schizophrenia mortality, checking each citation until I found no new references. I then aggregated the data from all studies which met predetermined inclusion criteria and measured mortality by the Standardised Mortality Ratio (SMR) with 95% confidence intervals. I then traced at 13 years a cohort of 370 patients with schizophrenia, identified from service contacts in 1981-2. I took cause of death from death certificates and clinical details from medical records, calculated SMRs from UK national morality tables by the added years method and examined the circumstances of each death. Meta-analysis of the literature showed an overall SMR of 151 (CI 148-154) which was higher among males and the young and fell with length of illness. Nearly half the excess deaths were unnatural, most from suicide. The excess natural mortality was spread across most disease categories. This pattern suggests that suicide is intrinsic to schizophrenia but the excess natural mortality is largely due to altered exposure to environmental risk factors. The local cohort had 58 natural (SMR 232, CI 176-296) and 19 unnatural deaths (SMR 1273, CI 767-1988), an overall SMR of 299 (CI 236-372). The pattern of deaths was similar to previous studies. The excess mortality was not explained by social disadvantage. Some of the mechanisms of excess mortality include unhealthy lifestyle, poor treatment of chronic disease and treatment compliance and failed recognition of acute medical disease.</p
Article
The role of the brain-derived neurotrophic factor (BDNF) in the pathophysiology of major depressive disorder (MDD) remains to be elucidated. Recent post hoc analyses indicated a potential association of three polymorphisms in the BDNF gene with worse treatment outcome in patients with the subtype of melancholic depression. We aimed at replicating these findings in a German naturalistic multicenter follow-up. Three polymorphisms in the BDNF gene (rs7103411, rs6265 (Val66Met) and rs7124442) were genotyped in 324 patients with MDD and 470 healthy controls. We applied univariate tests and logistic regression models stratifying for depression subtype and gender. The three polymorphisms were not associated with MDD as diagnosis. Further, no associations were found in univariate tests. With logistic regression, we only found a tendency towards an association of the rs6265 (Val66Met) polymorphism with overall response to treatment (response rates: GG (val/val) < GA (val/met) < AA (met/met); p = 0.0129) and some gender differences for the rs6265 (Val66Met) and rs7103411 polymorphisms. Treatment outcome stratified for subtypes of depression did not differ significantly between the investigated polymorphisms or using haplotype analyses. However, results showed a tendency towards significance. At this stage, we cannot support an influence of these three polymorphisms. Further studies in larger patient samples to increase sample sizes of subgroups are warranted.
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Akathisia, a common side effect of neuroleptic therapy, is an emotional state and “refers not to any type or pattern of movement, but rather to a subjective need or desire to move.”1,2 Akathisia, in contrast to the other drug-induced extrapyramidal reactions, is subjective, and for this reason it may be difficult to diagnose.Historically, the predominant mental manifestations of akathisia have caused confusion. Haskoves,3 who originally described the syndrome in 1901, concluded that the disorder was of hysterical origin. Bing4 viewed akathisia as a “psychosis” characterized by a “morbid fear of sitting down,” but in another chapter he explained it as a way of overcoming the muscular rigidity of Parkinson's disease. Oppenheim5 considered akathisia as a form of neurosis, “usually a form of phobia.” Wilson6 designated it “hysterical” in one chapter of his classic textbook, but he also described the syndrome in association with Parkinson's disease in a later chapter.Akathisia can be mistaken for an exacerbation of the original mental illness.7–9 Hodge10 stated that akathisia “may appear like an anxiety state… in which real anxiety can be neither recognized nor verbalized.” Raskin11 found that patients often are unable to distinguish between anxiety and restlessness, and he warns that “indications of anxiety-like symptoms” such as “uneasiness,” “hyperactivity,” “pacing,” “vague complaints about medication,” and “insomnia” may be subtle reflections of akathisia.It is the purpose of this paper to stress the clinical importance of this side effect and to aid the clinician in its detection.