ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

摘要:

A trend towards increased utilisation of polypharmacy in clinical psychiatry has been observed recently. Among the factors contributing to this are the emerging predominance of drug treatment for psychiatric disorders, newer therapeutic agents, attempts to alleviate symptoms in patients who only partially respond to treatment, and the over-interpretation of research data.Problems with polypharmacy include the potential for drug interactions, the unknown safety of newer medicines, and the use of superfluous medication mixtures when one drug might suffice. The complexities inherent in the existing research methodology limit the study of polypharmacy. We suggest a new paradigm for researching multidrug regimens, modelled on that of health services research.

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

摘要:

Although it is wise to be cautious when administering more than one drug to a patient, polypharmacy is not a controversial practice. Rather, it is a useful and an accepted method of treating complicated cases in all medical specialities. There is a need for more rigorous study of multiple-medication therapies. However, physicians must be able to make decisions based on the data that are available and not be limited in their ability to treat a patient by a lack of scientific validation for every aspect of the treatment.

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

摘要:

The introduction of clozapine to the pharmacological armamentarium has led to a redefinition of antipsychotic drugs as a class. Clozapine represents the first genuinely atypical antipsychotic drug from both a clinical and a pharmacological perspective. Despite its clinical advantages, the use of clozapine has been limited by a propensity to induce agranulocytosis in 1% of the patients who are treated with this compound. This article reviews the indications for clozapine treatment and the present knowledge base regarding the incidence, monitoring and management of agranulocytosis.As agranulocytosis cannot be prevented, knowledge of risk factors is important. The risk factors that have been delineated include: increasing age, female gender, specific human leucocyte antigen (HLA) halotypes and the duration of exposure to clozapine (with 76% of cases occurring between week 4 and week 18). Among the patients who develop agranulocytosis, the risk of death is approximately 2%. In addition to agranulocytosis, patients receiving clozapine may manifest several benign and asymptomatic blood dyscrasias including leucocytosis, lymphopenia, eosinophilia and thrombocytosis.White blood cell counts must be followed weekly for the first 18 weeks of treatment and less frequently (every 2 or 4 weeks) thereafter in all patients receiving clozapine (in the US, white blood cell counts must be followed weekly for the duration of clozapine treatment). Assessment should be more frequent when there is a downward trend in the absolute neutrophil count. There is also evidence for the occurrence of a white blood cell upward spike prior to a decline in this parameter. This latter finding has been shown to be highly sensitive, but only moderately specific.If agranulocytosis does occur, a bone marrow aspiration and the addition of granulocyte colony-stimulating factor or granulocyte-macrophage colony-stimulating factor may be indicated.The psychiatric management of patients receiving clozapine who develop agranulocytosis often entails psychiatric hospitalisation. Rechallenge of these patients with clozapine is contraindicated. Risperidone may offer a clinical alternative after the patients have recovered haematologically.The mechanisms of clozapine-induced agranulocytosis remain unknown, however there are several postulated mechanisms. These include a direct toxic effect on the bone marrow, the formation of toxic free radicals, or an immunemediated mechanism involving the formation of antigranulocyte or antimyeloid antibodies.

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

摘要:

Dysthymic disorder (dysthymia) was introduced into the group of affective or mood disorders with the publication of the DSM-III in 1980. Although little was known of dysthymia at the time of its inclusion in this manual, subsequent research has resulted in a more detailed description of the phenomenology, epidemiology and associated comorbidity of the disorder.Accurate diagnosis of dysthymia remains difficult, being dependent on the recall of symptoms by patients. States of chronic mild depression, such as dysthymia, appear to be rather common, with a point prevalence of around 2 to 4%. Comorbidity with other psychiatric disorders is common, leading certain authorities to dispute the existence of ‘pure’ dysthymia.Although chronic mild depression is associated with considerable use of health service resources, and prescriptions of psychotropic drugs are common, the drug treatment of dysthymia has not been investigated extensively. Furthermore, methodological flaws characterise many of the existing published studies of treatments for the disorder.Nevertheless, recent research supports the use of antidepressant medication in certain groups of patients. Imipramine, certain selective serotonin (5-hydroxy-tryptamine; 5-HT) reuptake inhibitors and moclobemide may be of benefit, particularly in patients with ‘double depression’, in whom major depressive episodes complicate an underlying dysthymic disorder.

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

摘要:

This review discusses case reports of patients treated with psychotropic medications for which therapeutic drug monitoring (TDM) was found useful. The use of this approach is based on the assumption that previous papers on TDM have largely used the available database of controlled studies to establish that excessively low concentrations of antidepressants, antipsychotics or mood stabilisers often lead to poor treatment response, whereas excessively high concentrations are associated with an increased risk of unwanted side effects and even poor response for some drugs.Typical situations in which TDM has been found to be clinically useful include poor compliance, patients who are ultra-rapid or poor metabolisers, elderly patients, instances of metabolic inhibition and induction, and patients with liver dysfunction.In order to provide clinically relevant information, certain practical aspects of TDM must be respected. The results of the assays must be rapidly available to the treating physician, selection of medications to be monitored must be based on the daily practice in the given psychiatric institution, analytical methods must be specific, and numerical results should be complemented by a short written comment.Under these conditions, TDM in psychiatry is a cost-effective means to assessing compliance, enhancing therapeutic response, avoiding toxicity, increasing quality of life and improving the therapeutic alliance.

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

摘要:

The abuse liability of nicotine replacement therapies is an important clinical consideration in the pharmacological treatment of nicotine dependence associated with cigarette smoking.Abuse liability is defined as: (i) the likelihood of taking a substance repeatedly, taking into account both factors that are likely to increase use (e.g. faster onset of pharmacodynamic effect) and factors that are likely to decrease use (e.g. adverse effects); and (ii) the likelihood of adverse consequences (both long and short term).It can be concluded that most of the nicotine replacement therapies have lower abuse liability than tobacco cigarettes. Among the alternative therapies available, it would appear that those with a slower onset (e.g. chewing gum and transdermal systems) are less likely to be abused than those with a faster onset.Experience with existing nicotine replacement therapies may be useful for future research into the development of new therapies.

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS

摘要:

Antiepileptic drugs (AEDs) have measurable effects on neuronal membrane and synaptic function. These mechanisms of action partially predict effectiveness in animal models of epilepsy and in human epilepsy. Carbamazepine, phenytoin, lamotrigine, oxcarbazepine and valproic acid (sodium valproate) block voltagedependent sodium channels. Ethosuximide reduces T-type calcium currents. Phenobarbital (phenobarbitone), benzodiazepines, gabapentin, vigabatrin, tiagabine, valproic acid and felbamate enhance the neuronal inhibition induced by &ggr;-aminobutyric acid (GABA). Felbamate also decreases the activity of excitatory neurotransmitters.AEDs with known mechanisms of action will further increase the range of options for patients with epilepsy. A rational approach to polytherapy may emerge in the near future, in which medications with complementary, synergistic mechanisms of action are used. Until then, cautious use of medications alone and in combination, with consideration given to mechanisms of action, will enable the large majority of patients with epilepsy to achieve the best possible control of their seizures within the limits of current therapy.

ISSN:1172-7047    

出版商:ADIS    

年代:1995

数据来源: ADIS