摘要:

When taken in an adequate dose, disulfiram usually deters the drinking of alcohol by the threat or experience of an unpleasant reaction. However, unless its consumption is carefully supervised by a third party as part of the formal or im-plied therapeutic contract, it is usually discontinued and the deterrent effect is therefore lost. In most studies, disulfiram administration has not been supervised and most reviews fail to stress the crucial importance of supervision. Unsupervised disulfiram has little or no specific effect. We have therefore reviewed all published clinical studies in which there was evidence that attempts had been made to ensure that disulfiram administration was directly supervised at least once a week. We found 13 controlled and 5 uncontrolled studies. All but one study reported positive findings, which were usually both statistically and clinically significant in controlled evaluations. In the sole exception, involving ‘skid-row alcoholics’, it seems that adequate supervision was not achieved. In general, the better the supervision, the better the outcome.Provided that attention is paid to the details of supervision and that supervisors are given appropriate training, supervised disulfiram is a simple and effective addition to psychosocial treatment programmes. Compared with unsupervised disulfiram or no disulfiram control groups, it reduces drinking, prolongs remissions, improves treatment retention and facilitates compliance with psychosocial interventions such as community reinforcement, marital and network therapies. The supervisor may be a health professional, workmate, probation officer or hostel worker but is usually a family member. Treatment should probably continue for a minimum of 12 months. Supervised disulfiram appears to be more effective than supervised naltrexone and may be more effective than unsupervised acamprosate. The crucial importance of supervising the consumption of disulfiram has been overlooked or minimised by many reviewers.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Rasmussen's syndrome (chronic encephalitis with epilepsy) is a rare neurological disorder characterised by progressive dysfunction of one cerebral hemisphere. Clinical and radiological features of the syndrome include intractable epilepsy, cognitive and motor decline, progressive unilateral cortical atrophy and the occurrence of epilepsia partialis continua (EPC) in many cases. Histopathological findings include the presence of perivascular cuffing, microglial nodules, gliosis and spongiosis. The aetiology of Rasmussen's encephalitis is unknown but viral, autoimmune and genetic mechanisms have been postulated. Proposed therapies have included anticonvulsants, corticosteroids, antiviral agents, interferon- a, immunogobulin and plasmapheresis. The mainstay of therapy is hemispherectomy. To date, no medical therapies have permanently halted neurological deterioration. A better understanding of pathogenesis is required to develop safe and effective medical therapies.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

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.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

In recent years there has been an increasing number of reports of the development or aggravation of parkinsonism and the development of other movement disorders (‘extrapyramidal symptoms’) associated with exposure to the selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitors (SSRIs) fluoxetine, paroxetine, sertraline, fluvoxamine and citalopram. The exact prevalence of these complications is unknown since available information comes from literature reviews of case reports or data from the manufacturers or from movement disorders units and is therefore subject to reference bias. In addition, many of the patients had previously received or were concurrently being treated with other drugs, mainly antipsychotics. Reported movement disorders include parkinsonism, akathisia, tremor, dystonia, tardive dyskinesia, myoclonus, tics and chorea; parkinsonism and akathisia were the most frequent.Pathophysiological mechanisms are not well established, but the most accepted hypotheses suggest a relationship with interactions between serotonergic and dopaminergic neurotransmitter systems. Anatomical, physiological and pharmacological relationships between these two systems are reviewed in this article.The management of SSRI-induced movement disorders includes avoidance of SSRI use, dose reduction or discontinuation of the offending drug and the same measures that are used for treating antipsychotic-induced movement disorders.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

ObjectivePatients with dementia may be at high risk for psychiatric adverse drug reactions (ADRs). A Bayesian approach was developed for the assessment of changes in cognition and behaviour suspected as being related to psychotropic medications.DesignThis was a prospective observational study. A Bayesian model calculated the posterior probability (PsP) in favour of psychotropic drugs being the cause of the psychiatric adverse events detected. Bayesian results were cross-validated by comparison with an expert clinician and 2 other clinicians using a causality visual analogue scale (VAS).Setting and PatientsThe setting was a cognitive support unit in a long term care facility associated with a teaching hospital. 107 (97 males and 10 females) cognitively impaired institutionalised elderly patients (mean age ± SD = 78 ± 7, range 59 to 98 years) were monitored for 3 months for changes in cognition and behaviour.Results13 behavioural events (6 agitation, 4 confusion and 3 cognitive decline) were detected. Bayesian analysis implicated lorazepam, levomepromazine (methotrimeprazine) plus oxazepam, perphenazine and zopiclone as causing 4 of 13 behavioural events. Bayesian results were correlated to the VAS results of the expert rater (r = 0.78, p = 0.002) and less so to the other clinicians (r = 0.68, p = 0.01; r = 0.49, p = not significant). The expert rater identified the same 4 cases as being most likely to have been drug induced. Bayesian results indicated that drug-induced psychiatric events occurred in 3.7% of patients and the drug-attributable risk was 5.4% over 3 months.ConclusionsThe Bayesian approach identified psychiatric ADRs in high agreement with an expert rating. These results suggest that drug-induced cognitive and behavioural symptoms are an important source of reversible morbidity in patients with dementia.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS

摘要:

Sertraline is a selective serotonin (5-hydroxytryptamine; 5-HT) reuptake inhibitor (SSRI) that inhibits the serotonin transporter with only minor inhibition of the noradrenaline (norepinephrine) and dopamine transporters. It has recently shown efficacy in most, although not all, clinical trials in patients with post-traumatic stress disorder (PTSD). In 2 of 3 randomised, double-blind trials in civilian patients, once daily oral sertraline 50 to 200mg significantly reduced symptoms of PTSD compared with placebo over 12 weeks. Response rates were 53 and 60% for sertraline compared with 32 and 39% for placebo. The quality of life of patients receiving sertraline was significantly improved compared with those receiving placebo in 1 trial. Post-hoc subgroup analysis of pooled results from the 2 trials showed that sertraline has significant efficacy in women with PTSD but efficacy in men was not clearly established. The efficacy of sertraline in combat-induced PTSD has not been clearly established. Sertraline has shown efficacy in 2 longer-term trials of 24 (nonblind, noncomparative) and 28 (double-blind, placebo-controlled) weeks' duration.Sertraline is generally well tolerated. Adverse events associated significantly more frequently with sertraline than placebo in clinical trials of patients with PTSD were insomnia, diarrhoea and nausea. Discontinuation of treatment occurred in approximately the same number of sertraline- and placebo-treated patients.ConclusionsSertraline has demonstrated efficacy in the treatment of PTSD, particularly in female patients and in non−combat-induced PTSD, and is generally well tolerated. It appears to have a lower potential for drug interactions than other SSRIs, although direct comparisons are lacking. Sertraline is currently the only SSRI approved for the treatment of PTSD. As SSRIs are recommended as the first-line pharmacological agents when drug treatment is indicated in patients with PTSD, sertraline may be considered the present drug of choice for PTSD, particularly in females from the civilian population.

ISSN:1172-7047    

出版商:ADIS    

年代:2000

数据来源: ADIS