Drugs used to Treat Antipsychotic-Induced Weight-Gain (Mnemonic)

The following mnemonic is for the drugs used to treat antipsychotic-induced weight gain. The list is not based on priority; however, metformin is the preferred choice, especially when there is comorbid polycystic ovary disease. Orlistat, with calorie restriction, is also an effective choice.

FORMAT-B

• Fluoxetine 
• Orlistat
• Reboxetine
• Metformin, methylcellulose, melatonin
• Topiramate
• Bupropion 

Treatment Guidelines for Generalized Anxiety Disorder

Psychotherapy     

Reassurance

Self-help and psychoeducation

à Pure self-help, guided self-help, group psychoeducation

Relaxation therapy

à applied relaxation, progressive muscle relaxation, deep breathing exercises

Cognitive behavior therapy

Exercise

Pharmacotherapies

Indications of pharmacotherapy

While on psychotherapy, short-term

Psychotherapy ineffective,

Psychotherapies not available

First-line       

Selective Serotonin Reuptake Inhibitors

àThese and SNRIs may initially exacerbate symptoms; a lower starting dose is often required.  Fluoxetine and sertraline are preferred options.  Sertraline is the most tolerable and cost effective, recommended as first choice by NICE. Fluoxetine is most effective choice.

Effexor (venlafaxine) SR up to 225 mg/day

Dulan/Duron (duloxetine) up to 60 mg/day

pregabalin 150–600 mg/day

Second-line choices           

Agoviz (agomelatine) 25 mg                2 x nocte

Agoviz (agomelatine) 25 mg                4 x nocte

Busron (buspirone) 5 mg                      1 x TDS

Steer (buspirone) 10 mg                       2 x TDS

Atarax (hydroxyzine) 25 mg                 1 x BD

Atarax (hydroxyzine) 25 mg                1+ 1 + 2

Qusel (quetiapine)  

Tofranil (imipramine)

Clomixet (clomipramine)

Ramargon (mirtazapine)

Beta-blockers for somatic symptoms, Vortioxetine 2.5–10 mg

Treatment of Guidelines for Psychotic Depression

Treatment of Guidelines for Psychotic Depression

First-line       

Tricyclic with olanzapine or quetiapine

Second choice        

SSRI/SNRI

Consider

Electroconvulsive therapy           

Glutamate Antagonists for the Treatment of Catatonia

Because of its N-methyl-d-aspartic acid antagonist properties, amantadine (100–500 mg three times a day), and its derivative memantine (5–20 mg/day), have been tried in catatonia.

1. Carroll and coworkers identified 25 cases of amantadine and memantine use in the treatment of catatonia. All cases improved, mostly after 1–7 days.

2. It should be noted, however, that six were unpublished, and that seven other were cases experiencing a “catatonia-parkinsonian syndrome” while under treatment with the high-potency neuroleptic drugs haloperidol or fluphenazine.
3. The symptoms diminished when neuroleptics were tapered, and they added amantadine. Since then, they have published eleven additional cases describing the successful use of amantadine or memantine in catatonia.
4. In one case, in an adolescent girl, catatonia that was resistant to ECT improved after the addition of amantadine.
5. Only in a review of Hawkins and coworkers, they report a case in which the use of amantadine remained without effect. Should acknowledge, however, that negative cases are less likely to be published.
6. Given these positive signals in the published literature, and evidence of its efficacy in treating the negative and cognitive symptoms of schizophrenia, amantadine should be further studied as a feasible treatment option for catatonia. There is anecdotal evidence from case reports on the use of various other pharmacological agents, such as bromocriptine and biperiden.
7. Based on the GABA-hypothesis of catatonia, and the GABA-related working mechanism of several anti-convulsive mood stabilizers, these drugs have been proposed as a viable treatment option to treat catatonia in bipolar patients.
8. Only a few cases have published reports.
9. They used valproate in several case reports and found not only to have prophylactic effects but also “an improving effect on the catatonic symptoms”.
10. In a solitary case report, they advocated levetiracetam as a treatment for catatonia in bipolar disorder, given its mood-stabilizing efficacy.
11. It is of note, however, that levetiracetam has also been described to provoke catatonia.
12. Using topiramate and carbamazepine have also been reported.
13. Although lithium has been anecdotally reported to have a beneficial effect on acute catatonic symptoms, they mostly describe it to be of use in the prevention of recurrent catatonia, albeit with sometimes limited results.

References

1. Carroll BT, Goforth HW, Thomas C, Ahuja N, McDaniel WW, Kraus MF, et al. Review of adjunctive glutamate antagonist therapy in the treatment of catatonic syndromes. J Neuropsychiatry Clin Neurosci (2007) 19(4):406–12.10.1176/appi.neuropsych.19.4.406  
2. Gelenberg AJ, Mandel MR. Catatonic reactions to high-potency neuroleptic drugs. Arch Gen Psychiatry (1977) 34(8):947–50.10.1001/archpsyc.1977.01770200085010  
3. Obregon DF, Velasco RM, Wuerz TP, Catalano MC, Catalano G, Kahn D. Memantine and catatonia: a case report and literature review. J Psychiatr Pract (2011) 17(4):292–9.10.1097/01.pra.0000400268.60537.5e  
4. Babington PW, Spiegel DR. Treatment of catatonia with olanzapine and amantadine. Psychosomatics (2007) 48(6):534–6.10.1176/appi.psy.48.6.534  
5. Muneoka K, Shirayama Y, Kon K, Kawabe M, Goto M, Kimura S. Improvement of mutism in a catatonic schizophrenia case by add-on treatment with amantadine. Pharmacopsychiatry (2010) 43(4):151–210.1055/s-0029-1242821  
6. Hervey WM, Stewart JT, Catalano G. Treatment of catatonia with amantadine. Clin Neuropharmacol (2012) 35(2):86–710.1097/WNF.0b013e318246ad34  
7. de Lucena DF, Pinto JP, Hallak JE, Crippa JA, Gama CS. Short-term treatment of catatonia with amantadine in schizophrenia and schizoaffective disorder. J Clin Psychopharmacol (2012) 32(4):569–7210.1097/JCP.0b013e31825ebf6e  
8. Ene-Stroescu V, Nguyen T, Waiblinger BE. Excellent response to amantadine in a patient with bipolar disorder and catatonia. J Neuropsychiatry Clin Neurosci (2014) 26(1):E43.10.1176/appi.neuropsych.13020038  
9. Mahmood T. Bromocriptine in catatonic stupor. Br J Psychiatry (1991) 158:437–810.1192/bjp.158.3.437  
10. Franz M, Gallhofer B, Kanzow WT. Treatment of catatonia with intravenous biperidene. Br J Psychiatry (1994) 164(6):847–810.1192/bjp.164.6.847b  
11. DelBello MP, Foster KD, Strakowski SM. Case report: treatment of catatonia in an adolescent male. J Adolesc Health (2000) 27(1):69–7110.1016/S1054-139X(00)00109-9  
12. Kruger S, Braunig P. Intravenous valproic acid in the treatment of severe catatonia. J Neuropsychiatry Clin Neurosci (2001) 13(2):303–410.1176/appi.neuropsych.13.2.303  
13. Bowers R, Ajit SS. Is there a role for valproic acid in the treatment of catatonia? J Neuropsychiatry Clin Neurosci (2007) 19(2):197–810.1176/appi.neuropsych.19.2.197  
14. Yoshida I, Monji A, Hashioka S, Ito M, Kanba S. Prophylactic effect of valproate in the treatment for siblings with catatonia: a case report. J Clin Psychopharmacol (2005) 25(5):504–510.1097/01.jcp.0000177850.23534.69  
15. Muneer A. Catatonia in a patient with bipolar disorder type I. J Neurosci Rural Pract (2014) 5(3):314–610.4103/0976-3147.133652 [PMC free article]  
16. Chouinard MJ, Nguyen DK, Clement JF, Bruneau MA. Catatonia induced by levetiracetam. Epilepsy Behav (2006) 8(1):303–7.10.1016/j.yebeh.2005.04.016  
17. McDaniel WW, Spiegel DR, Sahota AK. Topiramate effect in catatonia: a case series. J Neuropsychiatry Clin Neurosci (2006) 18(2):234–8.10.1176/appi.neuropsych.18.2.234  
18. Rankel HW, Rankel LE. Carbamazepine in the treatment of catatonia. Am J Psychiatry (1988) 145(3):361–2.   
19. Wald D, Lerner J. Lithium in the treatment of periodic catatonia: a case report. Am J Psychiatry (1978) 135(6):751–2.   
20. Pheterson AD, Estroff TW, Sweeney DR. Severe prolonged catatonia with associated flushing reaction responsive to lithium carbonate. J Am Acad Child Psychiatry (1985) 24(2):235–710.1016/S0002-7138(09)60454-4  
21. Gjessing LR. Lithium citrate loading of a patient with periodic catatonia. Acta Psychiatr Scand (1967) 43(4):372–510.1111/j.1600-0447.1967.tb05774.x  

Zolpidem for the Treatment of Catatonia

Zolpidem, a positive allosteric modulator of gamma-aminobutyric acid receptors, seems to be a safe and effective treatment alternative. 

Benzodiazepines for the Treatment of Catatonia

Benzodiazepines are the first-choice treatment for catatonia, regardless of the underlying condition. Benzodiazepines are positive allosteric modulators of GABA-A receptors and will correct deficient GABA-ergic function in the orbitofrontal cortex.

Following a positive Lorazepam Challenge Test, repeated doses of benzodiazepines can a treatment. Their use is safe, easy, and effective, with remission rates reported to be as high as 70–80%.

About 65% Rates in a Naturalistic Study

In a naturalistic study of 66 children and adolescents with catatonia, they found that benzodiazepines improved catatonia in 65% of cases, that there was no relation between dose and level of improvement, that the dose was higher sometimes (up to 15 mg of lorazepam) than the dose recommended in pediatric patients, and that side effects were few.

Two-thirds Improved in a Trial of 107 adults

In a recent trial in 107 adult inpatients (49% with a psychotic disorder; 44% with a mood disorder), lower success rates they reported lower success rates: two-thirds responded but only one-third of patients remitted. The authors argue that a delay between illness onset and treatment could explain the lower remission rate) but the doses used in the trial (3–6 mg per day) were inadequately low. As described above, studies have repeatedly shown that chronic catatonia associated with schizophrenia is less responsive to benzodiazepines.

Beckmann and Colleagues Found them Ineffective

Beckmann and colleagues, in a 5-year follow-up study, found benzodiazepines ineffective in the treatment of chronic catatonic schizophrenia. Another study reported a comparable poor response (to lorazepam 6 mg per day); it was a randomized double-blind, placebo-controlled trial in 18 patients with chronic catatonia in schizophrenia.

Efficacy Depends on Dose

Efficacy of benzodiazepines in catatonia depends on dosage, and doses from 8 to 24 mg lorazepam per day are common and are tolerated without ensuing sedation, especially when instituted using daily incremental dosages. Most authors suggest starting at 1–2 mg of lorazepam every 4–12 h and adjusting the dose in order to relieve catatonia without sedating the patient. With an adequate dose, we usually see a response within 3–7 days, but sometimes, the response can be gradual. If we use high dosages of lorazepam, patients should be monitored carefully for excessive sedation and respiratory compromise. Whether some benzodiazepines are more efficacious in catatonia is not clear yet.

Clinicians accept lorazepam to be the first-choice drug, demonstrating a 79% remission rate and the highest frequency of use. Studies have also reported the successful use of diazepam, oxazepam, or clonazepam. There is no consensus on how long benzodiazepines to continue benzodiazepines, and we discontinue them once the underlying illness has remitted. In several cases, however, catatonic symptoms will emerge each time lorazepam is tapered off, urging the clinician to continue benzodiazepines for an extended period.

NICE Guidance on Electroconvulsive Therapy

NICE recommends to use electroconvulsive therapy (ECT) only to attain quick and short-term improvement of severe symptoms if an adequate trial of other options has not been effective and/or when the condition is considered to be potentially life-threatening, in individuals with:

• catatonia
  
• a prolonged or severe manic episode.
  

Indication to an individual must be based a documented assessment of the risks and potential benefits to the individual.

Exercise caution when considering electroconvulsive therapy during pregnancy, in older people, and in children and young people.

Valid consent should be obtained in all cases where the individual can grant or refuse consent. The decision to use electroconvulsive therapy should be made jointly by the individual and the clinician(s) responsible for treatment, based on an informed discussion after full information about the risks and potential benefits, without pressure or coercion, the involvement of patient advocates and/or carers is strongly encouraged.

If informed consent is not possible advance directives should be taken fully into account.

Clinical status should be assessed following each electroconvulsive therapy session and treatment should be stopped when a response has been achieved, or sooner if there is evidence of adverse effects.

Cognitive function should be monitored on an ongoing basis, and at a minimum at the end of each course of treatment.

Repeat Course

Consider a repeat course under the circumstances indicated for patients who previously responded. In patients who have not previously responded, a repeat trial should be undertaken only after all options have been considered and following discussion with individual/carer/advocate.

Schizophrenia

Do not recommend to patients with schizophrenia.

Depression

For patients with depression, see use electroconvulsive therapy as recommended in the NICE guidance on the treatment of depression.