Insomnia and depression are frequently encountered in patients during withdrawal from substances. While there are no approved medications for treating them, off-label attempts to address these phenomena with mirtazapine have shown some promising results. This case describes the use of mirtazapine as an aid in benzodiazepine withdrawal and its potential benefits in alleviating insomnia and depression in a 32-year-old man. It was found to ameliorate sleep myoclonus that was thought to be associated with his withdrawal syndrome. It is hoped this report will generate interest and stimulate further research in this area of psychopharmacology.
Clozapine is an atypical antipsychotic with superior efficacy in the treatment of refractory schizophrenia. But it can cause agranulocytosis, which occurs in one to two percent of patients. This paper was prepared to discuss the condoned and controversial issues of therapy with this drug, but only within a haematological context. The feasibility of attempting therapeutically controversial blood monitoring regimes, as opposed to following standardised Western guidelines, given the differences in terms of accessibility, convenience and financial considerations between the public and private sector medical care will also be discussed. The proposal of adopting a structured pro forma, with a risk-benefit assessment, in the event of unavoidable veering from the guidelines may allay medicolegal implications, especially in countries where blood monitoring is not mandatory. It is hoped that this article will stimulate further research in our region, bearing in mind the increasing awareness and focus on genetic polymorphism, and the possibility of drawing up our own monitoring guidelines in the near future.
The Neuropsychiatry Unit Cognitive Screening Instrument (NUCOG) provides more detailed screening of cognition than most commonly available tools and was selected for translation into and validation in Bahasa Malaysia (Malay language). It was first translated to Malay, then back-translated to English until changes made were comparable to the original English version. The Malay-translated NUCOG and the Malay version of the Mini-Mental State Examination (MMSE) were delivered to Malay-speaking subjects (n=24). The Malay NUCOG version was then validated by correlating scores against the Malay version of the MMSE and the data tested for reliability of the tool. The Malay version of the NUCOG proved to be a valid (r=0.98, p<0.001) and internally consistent (Cronbach's α=0.76) tool to assess cognitive function and this multi-dimensional cognitive screening instrument is likely to be valuable in the cognitive assessment of neuropsychiatric patients in Malay.
BACKGROUND: Organic Brain Syndromes (OBS) are often missed in clinical practice. Determining their varied presentations may help in earlier detection, better management, and, assessing prognosis and outcome. We described the in-patient referrals of patients suffering from the psychiatric effects of organic states and compared the symptomatology and mortality between those with the Acute and Chronic varieties. METHODS: 59 patients referred to our Consultation-Liaison (C-L) Psychiatry services and given a clinical diagnosis of OBS were selected over a 6-month period. Psychiatric and cognitive abnormalities and treatment regimes were recorded and fatality rates determined. Information regarding their condition 24 months after their index hospitalization was recorded. All data were entered into a proforma and analyzed after exclusion. RESULTS: The mean duration of detecting the symptoms by the physician was 3.52 days. The presence of a premorbid psychiatric illness had no influence on the clinical presentation but did on the mortality of patients with OBS (p = 0.029).Patients with the Acute syndrome had significantly more symptom resolution as compared to those with the Chronic syndrome (p = 0.001) but mortalityrates did not differ. Elderly patients and those with symptom resolution upon discharge did not show statistically significant higher mortality rates. The most popular combination of treatment was that of a low-dose neuroleptic and a benzodiazepine (34.7%). The need for maintenance treatment was not significantly different in any group, even in those with a past history of a functional disorder. CONCLUSION: Other than the Acute group having a significantly better outcome in terms of symptom resolution, our findings suggest that there was no significant difference in the clinical presentation between those with Acute or Chronic OBS. Mortality-wise, there was also no difference between the Acute and Chronic syndromes, nor was there any difference between the elderly and the younger group. There was also no significant difference in the need for continued treatment in both groups.
Depression is usually associated with changes in the endogenous hormonal system. The most important hormonal modifications are elevation of the serum cortisol level as well as the reduction of endogenous sex hormone levels. These changes have advanced side effects on a bone metabolism and bone remodelling process, which consequently, lead to the declining in bone mineral density and increase the risk of bone fractures, which is reported by current studies.
Lithium therapy is a common treatment for affective disorders and is widely regarded as a lifesaving drug. However, because its elimination is almost wholly unchanged via the kidneys, both acute and long-term adverse effects relating to toxicity may occur, including declining renal function and nephrogenic diabetes insipidus (DI). DI may be difficult to detect and is frequently preceded by dehydration and which, in our patient, was discovered by chance. We describe a case of an elderly woman on chronic lithium therapy for bipolar affective disorder who initially presented with dehydration from vomiting but possibly developed extra-pontine myelinolysis (EPM) after over-zealous correction of hyponatraemia. Steroids administered appeared to have prevented further progression but a persisting hyperosmolar state then alerted us to the presence of nephrogenic DI. Although both conditions were later successfully reversed with no obvious chronic sequelae, the recovery of the patient was protracted. Clinicians should be vigilant for complications of managing dehydration states in people prescribed with lithium.