Abnormal physiological conditions in acute schizophrenic patients on emergency admission: dehydration, hypokalemia, leukocytosis and elevated serum muscle enzymes

Utility of Investigations, History, and Physical Examination in "Medical Clearance" of Psychiatric Patients: A Meta-Analysis

OBJECTIVE

Few reviews and no meta-analyses have explored the utility of investigations, such as laboratory tests, among patients presenting with psychiatric symptoms, and none has explored the yield of history and physical examination. A meta-analysis of studies exploring the utility of "medical clearance" among adult psychiatric patients was conducted.

METHODS

PubMed, PsycInfo, and Web of Science were systematically searched from inception until February 15, 2021. Primary outcome was detection by investigations (e.g., bloodwork and imaging), history, or physical examination of an illness that caused or aggravated psychiatric symptoms or was comorbid and that resulted in change in the patient's diagnosis or management ("yield"). A mixed-effects meta-analysis with inverse-variance weighting was used to pool results.

RESULTS

Twenty-five cross-sectional studies were included. Pooled yield of investigations was 1.1% (95% confidence interval [CI]=0.5%-2.2%), although yield was relatively higher among disoriented, agitated, or older patients. Yield was higher in the inpatient setting, compared with the emergency room, with similar results by approach (protocolized versus nonprotocolized). Compared with investigations, yield of history and physical examination was higher (15.6%, 95% CI=9.1%-25.6%, and 14.9%, 95% CI=8.1%-25.9%, respectively), with nonsignificant differences by evaluator (psychiatrist versus nonpsychiatrist) for physical examination.

CONCLUSIONS

Investigations were of relatively low yield, especially when weighed against cost and potential harm, and they should not be routinely conducted for patients presenting with primarily psychiatric complaints, although certain subgroups may benefit. History and physical examination, by contrast, should be undertaken for all patients, ideally with participation of the consulting psychiatrist.

Real-world effectiveness of antipsychotic treatments in 1011 acutely hospitalized patients with schizophrenia: A one-year follow-up study

PURPOSE

To compare the real-world effectiveness of antipsychotic treatments focusing on long-acting injectable antipsychotic medications (LAIs) and antipsychotic polytherapies except polytherapy involving clozapine (APEC) for patients with schizophrenia.

METHODS

This prospective study was conducted over a 19-month period in 12 psychiatric emergency hospitals in Japan. Patients who were newly admitted to psychiatric emergency wards between September 2019 and March 2020 because of acute onset or exacerbation of Schizophrenia and Other Psychotic Disorders as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, were included. All patients were followed for one-year after discharge or until March 31, 2021. The primary outcome was the risk of treatment failure defined as psychiatric rehospitalization, discontinuation of medication, death, or continuation of hospitalization for one year. Cox proportional hazards multivariate regression was used for analyses.

RESULTS

A total of 1011 patients were enrolled (women, 53.7%; mean [SD] age, 47.5 [14.8] years). During follow-up, 588 patients (58.2%) experienced treatment failure including rehospitalization (513 patients), discontinuation of medication (17 patients), death (11 patients), and continuation of hospitalization for one-year (47 patients). Switching to LAIs (hazard ratio [HR] 0.810, 95%CI 0.659-0.996) and APEC (HR 0.829, 95%CI 0.695-0.990) were significantly associated with a low rate of treatment failure.

CONCLUSIONS

Switching to LAIs and APEC in early non-responders seems to be beneficial for the prevention of treatment failure in acutely admitted patients with schizophrenia. The risk of treatment failure was about 19% and 17% lower in patients treated with LAIs and APEC, respectively, than in patients treated without them.

Early environmental factors and somatic comorbidity in schizophrenia and nonschizophrenic psychoses: A 50-year follow-up of the Northern Finland Birth Cohort 1966

Background.

We studied the cumulative incidence of physical illnesses, and the effect of early environmental factors (EEFs) on somatic comorbidity in schizophrenia, in nonschizophrenic psychosis and among nonpsychotic controls from birth up to the age of 50 years.

Methods.

The sample included 10,933 members of the Northern Finland Birth Cohort 1966, of whom, 227 had schizophrenia and 205 had nonschizophrenic psychosis. Diagnoses concerning physical illnesses were based on nationwide registers followed up to the end of 2016 and classified into 13 illness categories. Maternal education and age, family type at birth and paternal socioeconomic status were studied as EEFs of somatic illnesses.

Results.

When adjusted by gender and education, individuals and especially women with nonschizophrenic psychosis had higher risk of morbidity in almost all somatic illness categories compared to controls, and in some categories, compared to individuals with schizophrenia. The statistically significant adjusted hazard ratios varied from 1.27 to 2.42 in nonschizophrenic psychosis. Regarding EEFs, single-parent family as the family type at birth was a risk factor for a higher somatic score among men with schizophrenia and women with nonschizophrenic psychosis. Maternal age over 35 years was associated with lower somatic score among women with nonschizophrenic psychosis.

Conclusions.

Persons with nonschizophrenic psychoses have higher incidence of somatic diseases compared to people with schizophrenia and nonpsychotic controls, and this should be noted in clinical work. EEFs have mostly weak association with somatic comorbidity in our study.

Real-world effectiveness of antipsychotic monotherapy and polytherapy in 1543 patients with acute-phase schizophrenia

PURPOSE

The effectiveness of antipsychotic treatments in the acute phase of schizophrenia in actual clinical practice remains somewhat unclear. Therefore, the purpose of the present naturalistic, multi-center study conducted from 1 year starting in September 2017 was to examine the response rate to an initial or second antipsychotic in newly admitted patients with acute-phase schizophrenia, as well as the response rate and quality of augmentation with two antipsychotics in patients who failed to respond to both the initial and second antipsychotics.

RESULTS

In total, there were 660 (42.8%) and 243 (15.7%) responders to an initial and a second antipsychotic, respectively; thus, 58.5% of all patients were responders to an initial or second antipsychotic. Among 581 nonresponders (37.7%), the initial antipsychotic or a third antipsychotic was added to the second antipsychotic. Among these patients, 89.8% showed a Clinical Global Impression-Improvement score ≤3 (from 'minimally improved' to 'very much improved'). The rates of adverse events such as hyperglycemia, hyper-low-density lipoprotein cholesterolemia, hypertriglyceridemia, hyperprolactinemia, QTc prolongation, and extrapyramidal symptoms were not high in patients receiving augmentation with two antipsychotics compared with all patients, and no serious adverse events were reported.

CONCLUSION

Antipsychotic augmentation may be an option in acute-phase treatment for patients who do not respond to either an initial or a second antipsychotic.

Elevated allostatic load in individuals presenting at psychiatric emergency services

OBJECTIVE

Individuals requiring psychiatric emergency services are often highly distressed and intoxicated. To provide an objective and comprehensive measure of their stress-related physiological dysregulations, we indexed allostatic load with 14 biomarkers collected within 24 h of patients' admission to the largest psychiatric hospital in the Canadian province of Quebec.

METHODS

This study (N = 278) combines data for emergency patients (n = 76; 65.8% women; M age = 44.97, SE = 1.6) and hospital workers who served as sex- and age-matched controls (n = 202; 70.8% women; M age = 40.10, SE = 0.83). Sex-specific allostatic load indices summarized neuroendocrine (cortisol), immune (tumor necrosis factor-α, interleukin-6, c-reactive protein), metabolic (insulin, glycosylated hemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglycerides, body mass index), and cardiovascular (heart rate, systolic and diastolic blood pressure) functioning. Well-validated questionnaires assessed substance (ab)use.

RESULTS

Individuals presenting at psychiatric emergency showed elevated allostatic load, drug abuse, and tobacco use compared to controls. Elevated allostatic load in emergency patients was driven by elevated cortisol, interleukin-6, systolic blood pressure, and heart rate; however, allostatic load was not explained by substance (ab)use or demographic variables. Sub-group analyses revealed that emergency patients primarily diagnosed with bipolar, depressive, or anxiety disorders showed higher allostatic load than those diagnosed with personality disorder(s).

CONCLUSIONS

This study demonstrates that individuals presenting at psychiatric emergency services show physiological dysregulations associated with chronic stress. Future research should explore the clinical utility of allostatic load in predicting comorbidities among psychiatric patients.

A prospective naturalistic multicenter study on choice of parenteral medication in psychiatric emergency settings in Japan

Aim

To provide information about psychiatric emergency situations in Japan, we examined psychiatrists’ preference among parenteral medication since intramuscular (IM)‐olanzapine became available and clinical characteristics in patients given IM‐olanzapine compared to those given other parenteral medication.

Methods

We conducted a naturalistic study proceeding over a 1‐year period in 9 psychiatric emergency departments.

Results

Among 197 patients, the distribution of IM‐injections (n = 89) was as follows: IM‐olanzapine, 66 patients (74.2%), IM‐levomepromazine, 17 patients (19.1%), IM‐haloperidol, 5 patients (5.6%), and IM‐diazepam, 1 patient (1.1%). The distribution of intravenous (IV)‐injections (n = 108) was as follows: IV‐haloperidol, 78 patients (72.2%), and IV‐benzodiazepines (diazepam, flunitrazepam, or midazolam), 30 patients (27.8%). Advantages of IM‐olanzapine over other parenteral medications in efficacy were found as follows: less frequent needs of an additional injection despite no difference in duration until a patient became cooperative for oral administration, and less frequent needs of restraint after the injection. Furthermore, advantages of IM‐olanzapine over other injections in safety were found as follows: less frequent appearance of extrapyramidal symptoms, no occurrence of ECG abnormality and other serious adverse events except a fall, less frequent needs of an adjunctive anticholinergic drug, and less frequent needs of another kind of drug additionally injected.

Conclusions

Olanzapine has rapidly become the first choice of intramuscular medication in psychiatric emergency situations since it became available in Japan, probably due to the advantages in both efficacy and safety. This study reflecting psychiatric emergency practice in Japan may contribute to periodic international comparison of psychiatric emergency practice.

The association between serum creatine kinase, mood and psychosis in inpatients with schizophrenia, bipolar and schizoaffective disorders

Previous studies demonstrated levels of serum CK (sCK) in the majority of patients undergoing acute psychosis. Records of 1054 patients hospitalized in Geha Mental Health Center during the study period were analyzed. Of them, 743 have been diagnosed with schizophrenia (Sz), 170 with schizoaffective disorder (SzA), and 158 with bipolar disorder (BP-I). Baseline sCK and PANSS values were obtained from each patient upon admission. Our results show that LnsCK is higher in patients with BP-I in comparison with patients with SZ, but not significantly different compared to patients with SzA. A multivariate analysis using linear regression model in which LnsCK was predicted by factors such as PANSS-total and sub-scores, IM injection, BMI, gender, and age among patients at each admission, revealed that PANSS-depression was inversely associated with LnsCK level in SzA and BP-I and not in SZ. A positive association was found between PANSS-total and sCK in SzA and BP-I; however, PANSS-positive scores correlated with sCK only in SzA. After controlling for confounders, it seems that sCK level is associated with the both affective and psychotic components. Serum CK may serve as a biomarker for affective exacerbation rather than psychosis.

Limiting Patients as a Nursing Practice in Psychiatric Intensive Care Units to Ensure Safety and Gain Control

PURPOSE

The aim of this study was to describe how the limitation of patients is being practiced in psychiatric intensive care units.

DESIGN AND METHODS

A focused ethnographic methodology was applied. To gather data, the author conducted fieldwork involving participant observation.

FINDINGS

The results of the study are presented in two categories, which describe the limited access patients had to items and in the ward environments.

PRACTICE IMPLICATIONS

It is advisable for practitioners to critically reflect upon local regulations and policies related to the practice of limiting patients during the worst phase of their mental illness.

Antipsychotic switching versus augmentation among early non-responders to risperidone or olanzapine in acute-phase schizophrenia

PURPOSE

We examined whether augmentation with olanzapine would be superior to switching to olanzapine among early non-responders (ENRs) to risperidone, and whether augmentation with risperidone would be superior to switching to risperidone among ENRs to olanzapine. We performed a rater-blinded, randomized clinical trial at psychiatric emergency sites. Eligible patients were newly admitted patients with acute schizophrenia. ENRs to the initial antipsychotic (Clinical Global Impressions-Improvement Scale: ≥ 4 at 2 weeks) were allocated to receive either augmentation with or switching to the other antipsychotic (RIS+OLZ vs. RIS-OLZ; OLZ+RIS vs.

OLZ-RIS) RESULTS

Sixty patients who completed 2 weeks of risperidone treatment were divided into 33 early responders (RIS-ER) and 27 ENRs (RIS+OLZ, n=14; RIS-OLZ, n=13). Although time to treatment discontinuation for any cause was significantly shorter in RIS+OLZ group (54.1 days [95% confidence interval, 41.3-67.0]) than in RIS-ER group (68.7 [61.2-76.2]; P=0.050), it was not significantly shorter in RIS-OLZ group (58.5 [43.1-73.9]) than in RIS-ER group (P=0.19). Sixty patients who completed 2 weeks of olanzapine treatment were divided into 36 early responders (OLZ-ER) and 24 ENRs (OLZ+RIS, n=11; OLZ-RIS, n=13). Although time to treatment discontinuation for any cause was significantly shorter in OLZ-RIS group (56.1days [40.7-71.5]) than in OLZ-ER group (74.9 [68.5-81.3]; P=0.008), it was not significantly shorter in OLZ+RIS group (64.6 [49.6-79.6]) than in OLZ-ER group (P=0.20).

CONCLUSION

Despite the lack of pharmacokinetic investigation of dose adequacy in this study, it is possible that switching to olanzapine among ENRs to risperidone might have a small advantage over augmentation with olanzapine, while augmentation with risperidone might have a small advantage over switching to risperidone among ENRs to olanzapine. Further research is required before it would be appropriate to modify routine practice in the direction of these findings.

The possibility that requiring high-dose olanzapine cannot be explained by pharmacokinetics in the treatment of acute-phase schizophrenia

We examined clinical characteristics including serum olanzapine concentrations for acute schizophrenia patients who required above conventional doses. We performed a rater-blinded, randomized clinical trial in 12 psychiatric emergency sites. Eligible patients were 18-64 years old and met diagnostic criteria for schizophrenia, acute schizophrenia-like psychotic disorder, or schizoaffective disorder. A total of 42 patients were randomly assigned by means of sealed envelopes to receive risperidone (3-12 mg/day; n=20) and olanzapine (10-40 mg/day; n=22), with follow-up at 8 weeks. The Negative score of the Positive and Negative Syndrome Scale was significantly higher in patients who required high doses than in patients who responded to conventional doses. Serum olanzapine concentrations at the time of oral 20mg/day could be obtained from 5 out of 7 patients who subsequently required high-dose olanzapine. All values were more than 30 ng/mL after 11-16 h from dosing to sample collection, and the mean value was 47.876 (S.D. 21.546) ng/mL. Such concentrations are appropriate with respect to a therapeutic range of 20-50 ng/mL. The present study has shown evidence that the reason for requiring high-dose olanzapine cannot be explained by pharmacokinetics in the treatment of acute-phase schizophrenia.

Value of mandatory screening studies in emergency department patients cleared for psychiatric admission

Introduction:

Laboratory and radiographic studies are often required by psychiatric services prior to admitting emergency patients who are otherwise deemed medically stable. Such testing may represent an unnecessary expense that prolongs emergency department stays without significantly improving care. This study determines the prevalence of such testing and how often it leads to changes in care.

Methods:

We prospectively tracked laboratory testing among psychiatric patients presenting to the emergency departments of two academic tertiary care facilities. For each visit we determined whether laboratory or radiographic studies were ordered, and whether the examination was conducted at the request of the emergency physician as part of a medical screening examination or requested by the psychiatry service. We then determined if this testing changed patient disposition.

Results:

Our study enrolled 598 patients. Of these, emergency physicians ordered testing as a part of medical screening on 155 patients (25.9%). We found the psychiatry service ordered laboratory or radiographic studies for 191 of 434 patients (44.0%) who emergency physicians determined did not require ancillary testing for medical clearance. Of these 191 patients, only one (0.5%; 95% Confidence Interval: 0.01% – 2.9%) had an abnormal result that led to a change in disposition. Total Medicare reimbursement rates for the additional ancillary testing in this study was $37,682.

Conclusion:

Ancillary testing beyond what is required for medical clearance of psychiatric emergency patients rarely alters care. Policies that require panels of testing prior to psychiatric admission are costly and appear to be unnecessary.

A comparison between augmentation with olanzapine and increased risperidone dose in acute schizophrenia patients showing early non-response to risperidone

We examined whether augmentation with olanzapine would be superior to increased risperidone dose among acute schizophrenia patients showing early non-response to risperidone. We performed a rater-blinded, randomized controlled trial at psychiatric emergency sites. Eligible patients were newly admitted patients with acute schizophrenia. Early response was defined as Clinical Global Impressions-Improvement Scale score ≤3 following 2 weeks of treatment. Early non-responders were allocated to receive either augmentation with olanzapine (RIS+OLZ group) or increased risperidone dose (RIS+RIS group). The 78 patients who completed 2 weeks of treatment were divided into 52 early responders to risperidone and 26 early non-responders to risperidone (RIS+OLZ group, n=13; RIS+RIS group, n=13). No difference in the achievement of ≥50% improvement in Positive and Negative Syndrome Scale total score was observed between RIS+OLZ and RIS+RIS groups. Although time to treatment discontinuation for any cause was significantly shorter in the RIS+RIS group (6.8 weeks [95% confidence interval, 5.2-8.4]) than in early responders to risperidone (8.6 weeks [7.9-9.3]; P=0.018), there was no significant difference between the RIS+OLZ group (7.9 weeks [6.3-9.5]) and early responders to risperidone. Secondary outcomes justify the inclusion of augmentation arms in additional, larger studies comparing strategies for early non-responders.

Difference in early prediction of antipsychotic non-response between risperidone and olanzapine in the treatment of acute-phase schizophrenia

PURPOSE

We examined whether early response/non-response to risperidone according to the Clinical Global Impressions-improvement scale (CGI-I) at 2 weeks could predict subsequent response. This prediction was also applied to olanzapine. We then investigated whether early non-responders (ENRs) to risperidone or olanzapine who switched to the other showed significantly greater improvement, compared with those staying on the initial antipsychotic. We performed a rater-blinded, randomized controlled trial in 18 psychiatric emergency sites. Eligible patients were newly admitted patients with acute schizophrenia. Early response was defined as CGI-I ≤ 3 following 2 weeks of treatment. The primary outcome measure was achievement of remission and ≥ 50% improvement in the Positive and Negative Syndrome Scale at 4 weeks.

RESULTS

At 4 weeks, 53% of risperidone early responders (ERs) went into remission, whereas only 9% of ENRs staying on risperidone (n=11) did (P=0.016). Similarly, at 4 weeks, 81% of risperidone ERs achieved ≥ 50% response, whereas only 9% of ENRs staying on risperidone achieved ≥ 50% response (P < 0.0001). In contrast, 58% of olanzapine ERs (n=33) went into remission, whereas 38% of ENRs staying on olanzapine (n=8) did at 4 weeks (P=0.44). Similarly, 61% of olanzapine ERs achieved ≥ 50% response, whereas 25% of ENRs staying on olanzapine achieved ≥ 50% response (P=0.12). The negative likelihood ratio for the prediction of ≥ 50% response at 4 weeks by early response status to risperidone at 2 weeks was 0.057.

CONCLUSION

In newly admitted patients with acute schizophrenia, non-response to risperidone using CGI-I at 2 weeks can predict subsequent response. It looks like there is significant response to olanzapine that doesn't occur until 4 weeks. Thus, clinicians may want to switch to another drug earlier when risperidone is the first drug, and later when olanzapine is the first drug.

Creatine kinase levels in patients with bipolar disorder: depressive, manic, and euthymic phases

OBJECTIVE: Bipolar disorder is a severe, recurrent, and often chronic psychiatric illness associated with significant functional impairment, morbidity, and mortality. Creatine kinase is an important enzyme, particularly for cells with high and fluctuating energy requirements, such as neurons, and is a potential marker of brain injury. The aim of the present study was to compare serum creatine kinase levels between bipolar disorder patients, in the various phases (depressive, manic, and euthymic), and healthy volunteers. METHOD: Forty-eight bipolar patients were recruited: 18 in the euthymic phase; 17 in the manic phase; and 13 in the depressive phase. The control group comprised 41 healthy volunteers. The phases of bipolar disorder were defined as follows: euthymic-not meeting the DSM-IV criteria for a mood episode and scoring < 8 on the Hamilton Depression Rating Scale (HDRS) and Young Mania Rating Scale (YMRS); manic-scoring < 7 on the HDRS and > 7 on the YMRS; depressive-scoring > 7 on the HDRS and < 7 on the YMRS. Patients in mixed phases were excluded. Blood samples were collected from all participants. RESULTS: Creatine kinase levels were higher in the manic patients than in the controls. However, we observed no significant difference between euthymic and depressive patients in terms of the creatine kinase level. CONCLUSION: Our results suggest that the clinical differences among the depressive, manic, and euthymic phases of bipolar disorder are paralleled by contrasting levels of creatine kinase. However, further studies are needed in order to understand the state-dependent differences observed in serum creatine kinase activity.

A prospective naturalistic multicentre study of intravenous medications in behavioural emergencies: haloperidol versus flunitrazepam

A prospective naturalistic multicentre study for deep sedation was conducted in intensive care with continuous electrocardiogram (ECG) monitoring. Clinical purpose was enough sedation, which made uncooperative and disrupted patients receive brain computed tomography (CT), magnetic resonance imaging (MRI), or fluid therapy, with minimum drug doses. A first infusion was either haloperidol (HAL group) or flunitrazepam (FNP group). If enough sedation was not achieved, a second infusion, which was the opposite drug to the first infusion, was given. The proportion requiring a second infusion was higher in the HAL group than in the FNP group (82% vs. 36%, P<0.0001). The mean reduction of the Excited Component for Positive and Negative syndrome scale at 15 min was greater for the FNP first group (FNP+HAL group) than the HAL first group (HAL+FNP group) (68% [S.D. 17] vs. 54% [S.D. 31], P=0.02). The mean dose of flunitrazepam in the HAL+FNP group was significantly lower than that in the FNP+HAL-group (1.3 mg vs. 3.5 mg, P=0.0003). Thus, in terms of monotherapy and speed of action, flunitrazepam has advantages over haloperidol as a first infusion for deep sedation. Regarding drug dosages, haloperidol has an advantage over flunitrazepam as a first infusion in safety.

Abnormal laboratory values during the acute and recovery phases in schizophrenic patients: a retrospective study

During treatment of acute-phase schizophrenia, attention needs to be given to physical as well as psychological symptoms. It is often difficult, however, to obtain information on physical symptoms from patients with psychomotor excitation, and only laboratory examinations can provide objective data. The results of laboratory parameters measured in 68 patients with schizophrenia during psychomotor excitation and approximately 1 month later during the medicated recovery phase have been analyzed retrospectively. Abnormal laboratory values during psychomotor excitation were frequent. The most frequent (>/=35% of patients) were increased white blood cell count, low serum potassium levels, high levels of fasting blood sugar, lactate dehydrogenase and uric acid. There were fewer abnormal values during the medicated recovery phase. The most frequent (>/=25% of patients) were high serum levels of triglycerides, amylase, creatinine kinase, and low-density lipoprotein cholesterol. Abnormal triglyceride levels were found significantly more frequently in patients receiving olanzapine than those receiving risperidone. Abnormal values during the acute phase may be the result of excitation such as increased sympathetic tone and dehydration. Abnormal values during the recovery phase appeared to be related to the adverse metabolic effects of antipsychotic drugs. The frequency of these abnormal values was particularly high in patients receiving olanzapine alone or in combination with other medications.

Biochemical risk factors for development of obesity in first-episode schizophrenia

Obesity is a serious health issue for many patients with schizophrenia. There is a lack of predictors for and understanding of the development of obesity in the early phase of the illness. Therefore we investigated a set of routine biochemistry variables in blood as predictors of the development of obesity and weight gain over 5 years in an observational cohort study of patients with first-episode schizophrenia (n=59). Twelve percent of the patients were obese at baseline and 37% were obese at the 5-year follow-up. The mean body mass index (BMI) change over 5 years was a 4.1 kg/m(2) increase (4.5 SD). Obesity was predicted by baseline hemoglobin levels (odds ratio per standard deviation [OR/SD] 3.3, 95% confidence interval [CI] 1.4 to 7.5), red blood cell count (OR/SD 2.6, 95% CI 1.2 to 5.5), hematocrit (OR/SD 2.8, 95% CI 1.3 to 5.9), gamma-glutamyltransferase (OR/SD 2.8, 95% CI 1.2-6.3) and creatinine (OR/SD 3.1, 95% CI 1.2 to 8.0). After adjustment for baseline BMI, the associations were attenuated for gamma-glutamyltransferase and creatinine. Low baseline BMI was associated with a greater BMI increase. The major conclusion is that easily available routine biochemistry markers can be useful in predicting the development of obesity in first-episode schizophrenia. The mechanisms underlying the observed associations are unknown, but the predictors identified in this study could signify dehydration or insulin resistance. These observations open a new window to future research on the mechanisms underlying the development of obesity in schizophrenia.

Hypokalemia is associated with lengthening of QT interval in psychiatric patients on admission

Several studies have revealed a relatively high frequency of hypokalemia in the general psychiatric population. This may be explained by adrenergic stimulation observed in the acute phase of psychiatric disorders. Little is known about the effects of hypokalemia on cardiac repolarisation in these circumstances. The current study was designed to determine if the hypokalemia observed among patients with acute psychiatric disorders can cause significant QT interval prolongation, and thus increase the risk of ventricular arrhythmia. Electrocardiograms were obtained in 282 non-selected patients admitted to a psychiatric unit. Heart-rate adjusted QT intervals (QTc) were compared to serum potassium levels and to other risk factors for QT prolongation (bradycardia, age, gender, and administration of antipsychotics). Hypokalemia, diagnosed in more than 11% of the patients, was associated with a significantly longer QTc interval (means 423.5+/-40 ms vs 408.5+/-31 ms), as was female sex. Multiple linear regression analysis on the studied risk factors revealed that only hypokalemia and female sex were independently associated with lengthening of the QT interval. According to our results, hypokalemia seems to be one of the most important risk factors for QT prolongation. We therefore strongly recommend that psychiatric patients should be screened for hypokalemia on admission.

Prevalence of i.v. thiopental use in psychiatric emergency settings in Japan

AIM

Because i.v. barbiturates such as thiopental carry the risk of apnea and laryngeal spasm in asthmatic patients, reducing the use of barbiturate in emergency situations is important. The purpose of the present study was therefore to investigate the prevalence of i.v. thiopental as a choice of sedation in behavioral emergency settings, we conducted a cross-sectional multicenter study.

METHODS

Psychiatric emergency departments of seven hospitals were studied during a 4-month period. Patients with a score >15 on the Excited Component of the Positive and Negative Syndrome Scale (PANSS-EC) who received i.v. medication were included in the study. Drugs were chosen according to the Japanese guidelines, in which the first injection was either haloperidol or benzodiazepine in accordance with clinical requirements. A second injection, which was the opposite drug to the first injection was administered as needed. Only when excitement obviously increased following the first injection, which was considered uncontrollable without thiopental according to expert experience, was thiopental given as a second injection. A total of 137 patients were included. The mean age was 40.4 years (SD 13.1), and the rate of male gender, drug-naïve, and F2 (schizophrenia, schizotypal and delusional disorders) on the ICD-10 were 48.9%, 29.9%, and 65.7%, respectively.

RESULTS

The rate of patients treated with thiopental as a second injection was 8.0% (n = 11). All of the first injections in patients treated with thiopental were not haloperidol but benzodiazepines (P = 0.0072).

CONCLUSION

Because this multicenter study has an epidemiological character, the prevalence of i.v. thiopental use in psychiatric emergency settings in Japan is considered to be 8.0%.

Medical and psychiatric comorbidity in psychiatric beds in general hospitals: a cross-sectional study in Tokyo

AIMS

Although somatic diseases in psychiatric patients are increasing with the increase of the aged population, psychiatric wards in general hospitals in Japan have progressively been decreasing. The purpose of this cross-sectional study was to clarify whether psychiatric beds in general hospitals play sufficient roles in medical comorbidities of psychiatric patients or not.

METHODS

This was a cross-sectional study performed all over Tokyo during the 2-month period from April to May 2007. The total number of patients who require admission due to both somatic and psychiatric diseases was investigated with their demographic and clinical characteristics.

RESULTS

The total number of patients admitted to psychiatric beds in general hospitals for the above-mentioned reason was 326, while the number of patients who could not be admitted to them despite the same reason was 88. The rate of surgical diseases in the latter group was higher than that in the former group. In the latter group, diseases requiring orthopedic surgery (22%) and abdominal surgery (22%) were the most frequent, followed by gastrointestinal and hepatic diseases (8%), and gynecological diseases (7%). Patients who had attempted suicide were included more in the latter group than in the former group. Even in the former group, general hospitals could not respond to 34% of requests for emergency admission.

CONCLUSION

Psychiatric beds in general hospitals do not necessarily function for medical comorbidities in psychiatric patients, especially in severe and emergency cases. Not only the quantity but also the quality of psychiatric wards in general hospitals should be reconsidered.

High prevalence of hypokalemia in acute psychiatric inpatients

BACKGROUND

Hypokalemia is an easily identifiable, clinically important but commonly neglected condition in psychiatric patients. This study intended to examine the prevalence of hypokalemia and its clinical correlates in acute psychiatric inpatients.

METHOD

This retrospective study was conducted over a 6 month period in 2008. The case notes, computerized records and laboratory results of all patients who were consecutively admitted to the acute psychiatric wards in a University-affiliated regional psychiatric unit were studied.

RESULT

Three hundred forty-seven patients out of 440 admissions were studied. Hypokalemia, as defined by serum potassium level of less than 3.5 mmol/L, was found in 20.5% of patients with a higher prevalence in psychotic patients (27.7%). The mean potassium level of psychotic patients was lower than that of the overall study population (3.72 vs. 3.81 mmol/L, P<.05). White cell counts among the hypokalemic patients were higher than those without hypokalemia (7.8 vs. 7.1 x 10(9)/L, P=.02).

CONCLUSION

Hypokalemia was common among acute psychiatric inpatients. Both agitation and the use of antipsychotics were postulated to contribute to the high prevalence of hypokalemia among acutely ill psychiatric patients.

The QTc interval and its dispersion in patients receiving two atypical antipsychotics

OBJECTIVE

Treatment with atypical antipsychotics may prolong the rate-corrected Q-T interval (QTc) on electrocardiogram and increase the risk of dangerous ventricular arrhythmias. Polytherapy with atypical antipsychotics is becoming common, but the effect of this practice on the QTc has not been explored in detail.

METHODS

Among 364 adults treated with atypical antipsychotics randomly selected from consecutive admissions to a single hospital, electrocardiograms with measurable Q-T intervals in at least six leads were available for 38 of 49 patients receiving polytherapy with two atypical antipsychotics. Daily chlorpromazine equivalent, QTc duration and QTc dispersion were assessed in this group and in 73 closely matched patients receiving atypical antipsychotic monotherapy.

RESULTS

The daily chlorpromazine equivalent of atypical antipsychotics was significantly greater in the polytherapy group (525.2 vs. 244.7 mg, P = 0.0003). Polytherapy and monotherapy patients were similar with regard to QTc duration, QTc dispersion and proportion of patients with gender-adjusted QTc prolongation (7.9% vs. 9.6%). The QTc duration had only a modest correlation with the total antipsychotic dose (P = 0.064). The presence of hypokalemia (3.0-3.5 mEq/l) was not associated with longer QTc intervals.

CONCLUSIONS

The common practice of polytherapy with two atypical antipsychotics does not seem to lead to significant QTc prolongation compared to monotherapy.

Creatine kinase associated with aggressive behavior in psychiatric patients

INTRODUCTION

The aim of this study was to investigate to what extent pathological creatine kinase (CK) levels are associated with aggressive behavior in patients admitted to psychiatric facilities. It is based on the assumption that CK activity increases prior to a rise in motor activity and aggressive behavior. It should be noted that this assumption requires additional confirmation in more extended studies.

METHOD

Over a period of 3 months, the CK levels of 317 psychiatric inpatients were assessed immediately following admission to a secure ward. During the course of the patients' stay (mean: approximately 11 days), their aggressive behavior was independently assessed using the Staff Observation Aggression Scale (SOAS-R).

RESULTS

A receiver operating characteristic (ROC) analysis estimated an area under the curve (AUC) for subsequent aggressive behavior of 70.7% with a sensitivity of 70.1% and a specificity of 71.2%. When the variables involuntarily admission, lifetime history of aggression and absence of suicide attempts were also taken into account, the AUC was higher at 78.2%.

CONCLUSION

Despite some methodological shortcomings in the collection of data, the study indicates that it could be useful to measure CK levels at the time of admission because elevated levels may indicate an increased risk of successive aggressive behavior for patients on secure psychiatric wards.

Physical illness and schizophrenia: a review of the literature

OBJECTIVE

The lifespan of people with schizophrenia is shortened compared to the general population. We reviewed the literature on comorbid physical diseases in schizophrenia to provide a basis for initiatives to fight this unacceptable situation.

METHOD

We searched MEDLINE (1966 - May 2006) combining the MeSH term of schizophrenia with the 23 MeSH terms of general physical disease categories to identify relevant epidemiological studies.

RESULTS

A total of 44 202 abstracts were screened. People with schizophrenia have higher prevalences of HIV infection and hepatitis, osteoporosis, altered pain sensitivity, sexual dysfunction, obstetric complications, cardiovascular diseases, overweight, diabetes, dental problems, and polydipsia than the general population. Rheumatoid arthritis and cancer may occur less frequently than in the general population. Eighty-six per cent of the studies came from industrialized countries limiting the generalizability of the findings.

CONCLUSION

The increased frequency of physical diseases in schizophrenia might be on account of factors related to schizophrenia and its treatment, but undoubtedly also results from the unsatisfactory organization of health services, from the attitudes of medical doctors, and the social stigma ascribed to the schizophrenic patients.

Acute psychosis leads to increased QT variability in patients suffering from schizophrenia

Patients with schizophrenia have been reported to experience sudden cardiac death 3 times more likely than individuals from the general population. One important factor related to an increased risk of cardiac arrhythmias and sudden death is the prolongation of the QTc interval. This study examined whether acute psychosis might influence the beat-to-beat variability of the QT interval, which reflects effectively cardiac repolarization lability. High resolution electrocardiographic recordings were performed in 25 unmedicated patients suffering from acute schizophrenia and matched controls. From these, parameters of beat-to-beat heart rate and QT variability measures such as approximate entropy and QT variability index (QTvi) were calculated. Measures were correlated with the scale for the assessment of positive symptoms (SAPS) and negative symptoms (SANS). QTvi was significantly higher in patients with schizophrenia compared to controls. While QTvi correlated with the degree of delusions and hallucinations, no correlation with electrolyte concentrations was found. Approximate entropy of heart rate was decreased indicating reduced complexity and decreased vagal tone. In conclusion, increased QT variability in patients with schizophrenia indicates abnormal cardiac repolarization lability, which can result in serious cardiac arrhythmias. The correlation of positive symptoms with QT variability might indicate high sympathetic cardiac activity in these patients, which might be associated with increased cardiovascular mortality.

Serum creatine kinase levels in untreated hospitalized adolescents during acute psychosis

OBJECTIVE

Psychosis-associated creatine kinase (CK)-emia (PACK) is a common and pronounced laboratory abnormality that accompanies adult psychotic conditions. Adult PACK is a relatively consistent individual trait. The authors investigated whether psychotic adolescents also present with such PACK characteristics.

METHOD

Participants were 127 newly admitted, drug-free, psychotic Israeli adolescents. Measures were baseline psychotic severity, serum creatine kinase (CK0), lactate dehydrogenase (LDH0), glutamate oxaloacetate transaminase (SGOT0), white blood cell count (WBC0), urine myoglobulin, and the repeated CK (RepCK) measurements taken during recurrent psychotic episodes.

RESULTS

Schizophrenia was the prevalent diagnosis (53%). CK0 levels did not correlate with the severity of the psychotic symptoms. Twenty-one percent of patients had a CK0 level >1,000 IU/L. CK0 and RepCK levels were higher in males than in females (p < or = .001) and in Jewish Sephardi patients than in Ashkenazi patients (p < .007). There was no difference by diagnosis. Logarithmic (Ln) CK0 correlated with RepCK, SGOT0, LDH0, and WBC0 (r = +0.32-0.74, p < .001) but correlated inversely with serum cholesterol0 (r = -0.36, p = .002) in males. Even prominent PACK was not associated with myoglobinuria. These findings remained significant among the younger patients (aged <18 years). In males from this subgroup, LnCK0 also correlated with age (p < .007) but not with weight.

CONCLUSIONS

In psychotic adolescents, PACK is common, is more prevalent among males, is independent of diagnosis, is influenced by ethnicity, and tends to recur.

The association between intravenous haloperidol and prolonged QT interval

Although intravenous haloperidol (HAL) is an effective medication that is often prescribed to treat agitation, several instances of torsade de pointes or prolonged QT interval have been reported. To investigate the association between intravenous HAL and QT prolongation and between intravenous HAL and ventricular tachyarrhythmia, a cross-sectional cohort study was performed that included measuring corrected QT intervals (QTc) on an emergency basis before intravenous HAL and continuously monitoring electrocardiographic (ECG) findings after intravenous HAL. During a 2-month period, 47 patients received intravenous injections to control psychotic disruptive behavior. According to clinical practice, patients were divided as follows. The FZ-alone group was treated with intravenous flunitrazepam (FZ), and the FZ-plus-HAL group received intravenous FZ followed by intravenous HAL. Although the difference in the mean QTc immediately after intravenous FZ between the two groups was not significant, the mean QTc after 8 hours in the FZ-plus-HAL group was longer than that in the FZ-alone group (p < 0.001). Four patients in the FZ-plus-HAL group had a QTc of more than 500 msec after 8 hours. The change in QTc during 8 hours significantly differed between the two groups (t = 2.64, p > 0.05). Furthermore, the change in QTc was moderately correlated with the dose of intravenous HAL, as evidenced by a coefficient of correlation of 0.48 (p < 0.001). However, ventricular tachyarrhythmia was not detected among 307 patients within a 1-year period, although the ECG was continuously monitored for at least 8 hours after intravenous HAL. The modest nature of QTc prolongation and the apparent absence of ventricular tachyarrhythmia under continuous ECG monitoring indicate that QTc prolongation associated with intravenous HAL is not necessarily dangerous. However, in an emergency situation, clinicians cannot exclude patients predisposed to torsade de pointes, such as those with inherited ion channel disorders. Therefore, clinicians should be aware of the association between intravenous HAL and QT prolongation.

Prolonged QT interval in acute psychotic patients

Some recent clinical studies indicate that hypokalemia is characteristic for acute psychotic patients at the time of emergency admission. As hypokalemia is one of the major causes for prolonged QT interval, it was hypothesized that acute psychotic patients could show prolonged QT interval. Sixty-seven drug-free, acute psychotic patients were evaluated for corrected QT (QTc) interval, as well as demographic and clinical characteristics at the time of emergency admission. The mean QTc interval of psychiatric emergency patients was prolonged, and the mean QTc interval of psychiatric emergency patients was longer than that of psychiatric outpatients (t=5.20, P<0.0001). Age- or gender-related difference, circadian fluctuation of QT interval, medication, concomitant disease, obesity, and serum electrolytes except potassium were not major causes. There was a significant negative correlation as evidenced by a coefficient of correlation of -0.28 (P<0.05). As psychiatric emergency patients often receive parenteral antipsychotics, which may have adverse effects on prolonged QT interval, paying attention to QT interval might have some clinical significance on emergency admission.

Hypokalemia and agitation in acute psychotic patients

Hypokalemia is caused partly by intensive exercise. Some evidence suggests that psychological distress may cause hypokalemia. The relationship between the decline of serum potassium concentration and the level of symptoms of acute agitation, which was defined as a total score on a subset of six categories on the 18-item Brief Psychiatric Rating Scale (anxiety, tension, mannerism and posturing, hostility, uncooperativeness, psychomotor excitement), was examined in 313 schizophrenic men, admitted on an emergency basis during a 24-month period. In addition, change in serum potassium concentration after sedation was investigated. Serum potassium concentration in the severely agitated group was lower than that in the mild group. There was a significant correlation between serum potassium concentration and the level of symptoms of acute agitation (r = -0.30, P < 0.0001). Although the decline of serum potassium concentration in the patients who were sufficiently sedated improved within 8 h, that in the patients showing high scores on the acute agitation subset even 8 h after emergency admission was prolonged. Results indicate that sedation improves acute agitation-induced hypokalemia. rights