Drugs used to Treat Antipsychotic-Induced Weight-Gain (Mnemonic)
- Metformin, methylcellulose, melatonin
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Self-help and psychoeducation
à Pure self-help, guided self-help, group psychoeducation
à applied relaxation, progressive muscle relaxation, deep breathing exercises
Cognitive behavior therapy
While on psychotherapy, short-term
Psychotherapies not available
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
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
Beta-blockers for somatic symptoms, Vortioxetine 2.5–10 mg
Tricyclic with olanzapine or quetiapine
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.
Carroll and coworkers identified 25 cases of amantadine and memantine use in the treatment of catatonia. All cases improved, mostly after 1–7 days.
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%.
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.
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, 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 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 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:
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.
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.
Do not recommend to patients with schizophrenia.
For patients with depression, see use electroconvulsive therapy as recommended in the NICE guidance on the treatment of depression.
ICD-11 Criteria for Gambling Disorder (6C50) A collection of dice Foundation URI : http://id.who.int/icd/entity/1041487064 6C50 Gambling d...