Abstract
In this issue, all but one paper deals with some aspect of the use of drugs which are dopamine antagonists. These are drugs which we are learning not to call ‘antipsychotics’ because their spectrum of activity is rarely restricted to that one indication, as the reports in this issue aptly demonstrate.
The main use of dopamine antagonists is, of course, in psychotic disorders. Lars Helldin and colleagues report on their evaluation of paliperidone in over 600 patients with recently diagnosed schizophrenia who required a change in antipsychotic treatment. In those who switched because of poor efficacy, over 60% responded to paliperidone and overall two-thirds of patients rated paliperidone ‘good’ or ‘very good’. Paliperidone was also well tolerated. Clearly this dopamine antagonist is a valuable treatment for recently diagnosed schizophrenia.
Annica Bergendal and coworkers describe their examination of antipsychotic polypharmacy in Sweden (a common practice throughout the world). Their paper has added importance because the authors were able to include the entire population of Sweden. Unsurprisingly, a large minority (25%) of people prescribed antipsychotics received two or more at the same time. These regimens consisted of an astonishing 665 unique combinations of antipsychotics and more than 300 patients were prescribed at least 4 antipsychotics at the same time (an exclamation mark would go well here but the data speak for themselves). One cannot help but think that prescribing of antipsychotics would be of higher quality were therapeutic drug monitoring (TDM) to be more widely employed. This process of optimizing drug treatment by using plasma level measurements is both underused and misused in psychiatry. In another paper in this issue, Maxine Patel’s team surveyed 181 psychiatrists and sought their views on antipsychotic TDM. A large majority felt their use of TDM would increase were drug assays more widely available and most felt that TDM would improve clinical outcomes. Negative views were expressed by only a minority of respondents.
Bastian Wollweber and colleagues from Munich describe three cases of the successful use of dopamine-D1 antagonists (zuclopenthixol and flupentixol) in nonsuicidal self-injury. Interestingly, high doses of venlafaxine (a dopamine re-uptake inhibitor at higher doses) were seen to worsen self-injury. In the 1990s, theories abounded as to the relative importance of D1 and D2 receptors (and D3, D4 and D5, of course) but little came of those theories. Perhaps it is time to return to this line of enquiry.
Two further papers in this issue also deal with unusual usage of psychotropic drugs. A team from Turkey describes a case series of manic patients successfully treated with clozapine. Each of the patients failed to respond to enormous doses of standard drugs but made rapid progress when given clozapine in ‘as needed’ doses of 50 mg. In the second report, a Spanish group describes six cases where the antidepressant agomelatine was observed to greatly reduce the frequency of migraine while also improving symptoms of depression.
The final two reports in this issue deal with unusual adverse effects. Ruth Murphy and colleagues from Ireland describe 6 cases of stuttering related to clozapine – a prevalence of nearly 1% in those prescribed the drug, and Selma BozkurtZincir and co-workers outline a compelling case of quetiapine-associated brain stem stroke.
The number and quality of the papers in this issue ably reflect the journal’s growing reputation and influence in the field of clinical psychopharmacology.