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ps: coke and neuroleptic malignant syndrome, ibogaine and ditto too?

useful info for california residents too.
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Date: Sat, 07 Jun 1997 23:07:18 -0700
To: brianc@infomaniac.com
From: brianc@infomaniac.com (Brian Chiko)
Subject: Living with Schizophrenia - Issue #54
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==============================================================================
            Living with Schizophrenia - A Free Periodic Newsletter
               Brought to you by http://www.schizophrenia.com
                          Issue #54 - June 7th, 1997
                 A Summary of Schizophrenia News and Events
       Note: Please forward this newsletter to others who might benefit.
            To Subscribe or Unsubscribe send a note to Brian Chiko
            at the following email address:  brianc@infomaniac.com
  Back-issues of this newsletter are available at the following web address:
             http://www.schizophrenia.com/news/NEWS1.html
==============================================================================
                                Table of Contents
CNN Story covering Schizophrenia - Sunday, June 8th
1. Influenza and Schizophrenia - Report from Australia
2. National Early Psychosis Project in Melbourne
3. NMS Alert  (neuroleptic malignant syndrome) Update by Eleazar
4. Mental Health Experts Answer Your Questions
5. NAMI News - Caution, Your HMO  May Be Dangerous To Your Health
6. APA Meeting Press Release: Risperdal In Elderly Psychotic Patients
=============================================================================
Letters to the Editor:

CNN Story covering Schizophrenia - Sunday, June 8th

CNN will be presenting a documentary on schizophrenia this Sunday,
June 8 that explores the life of a schizophrenic.  "Cities of Thought" airs
on CNN at 6pm and again at 9pm on the west coast.  It airs at 9pm on the
east coast.  It is going to be aired as part of a CNN magazine show.

=============================================================================
Influenza and Schizophrenia

Dear Brian,

Our research in Western Australia did not find evidence of a major effect
of maternal influenza on the incidence of schizophrenia, affective
psychoses and neurotic depression.  However, a possible effect, warranting
further investigation, was found for mental retardation in males exposed in
the first and second gestational trimester.

The results of this study will be published soon in Schizophrenia Research:

INFLUENZA EPIDEMICS AND INCIDENCE OF SCHIZOPHRENIA, AFFECTIVE DISORDERS AND
MENTAL RETARDATION IN WESTERN AUSTRALIA:NO EVIDENCE OF A MAJOR EFFECT

Authors: Vera Morgan, David Castle, Andrew Page, Sam Fazio, Lyle Gurrin,
Paul Burton, Philip Montgomery, Assen Jablensky

Regards, Vera
****************
Vera Morgan, Research Associate                                              
UWA Dept. of Psychiatry        
Medical Research Foundation Building  
e-mail vmorgan@cyllene.uwa.edu.au
=============================================================================
National Early Psychosis Project in Melbourne

Dear Brian,
I am a project officer setting up a resource centre for the National 
Early Psychosis Project in Melbourne, Victoria, Australia. Part of the 
resource centre is a web page at:

http://ariel.unimelb.edu.au/~nepp

which will allow access to information and discussion groups for 
professional and lay people.  

Heather Potter
=============================================================================

NMS Alert

Hi Everyone, 

Please be reminded that NMS, as a side effect of antipsychotic drugs does
exist and can be serious if not recognized early. The following is brief
information about NMS (neuroleptic malignant syndrome). 

WHAT IS NMS? 

NMS is a serious side effect of antipsychotic drugs. Virtually all
antipsychotics including the newer drugs have been reported to cause this
condition. 

HOW COMMON IS NMS? 

The incidence rate of NMS is estimated to be as low as 0.5% to as high as
2.4%. It is believed that this may be an underestimate as the condition is
considered to be underrecognized. 

WHEN DOES NMS OCCUR? 

Eighty percent of NMS occur in the first 2 weeks of starting an
antipsychotic drug or an increase in the dose of the medication. However,
NMS has also been reported to occur anytime during the course of an
antipsychotic drug treatment. 

HOW DOES NMS OCCUR? 

The exact mechanism or physiologic process involved in the occurrence of
NMS is unknown. However, it has been hypothesized that the blocking effect
of antipsychotic drugs on the dopamine receptors in the brain is to
blame. 

WHAT IS THE MORTALITY RATE OF NMS? 

The mortality rate of NMS is estimated to be as high as 20% and the usual
cause of death is due to acute renal failure. Fortunately, with early
recognition and intervention, it is usually reversible without any serious
complications. 

WHO ARE AT RISK FOR NMS? 

Being on antipsychotic drug places a person at a higher risk for NMS than
those who are not. However, not all people on antipsychotic drugs will
develop NMS. The following are considered risk factors for the occurrence
of NMS: 

1) Use of an antipsychotic drug belonging to the high-potency class e.g.,
Haldol, Prolixin. 

2) A rapid increase in the dose of the antipsychotic drug. 

3) Age and Sex - younger males are at higher risk for developing NMS.
However, NMS has also been reported among the elderly but may not be
readily recognized due to the possibility other concurrent medical problems
in this patient population. 

4) People on antipsychotic drugs with the following diagnoses are at higher
risk compared to schizophrenia: dementia; affective disorder such as
bipolar disorder, psychotic depression; people with mental retardation. 

5) Concurrent use of lithium. 

6) Presence of electrolyte imbalance such as potassium. Also dehydration. 

7) Elevated environmental humidity and temperature. However, NMS has also
been reported to occur during winter time. 

8) Other non-antipsychotic drugs have also been reported to cause NMS e.g.,
metoclopramide (Reglan); cocaine intoxication; abrupt discontinuation of an
antiparkinsonian drug such as L-dopa or amantadine (Symmetrel). 

WHAT ARE THE SIGNS AND SYMPTOMS OF A FULL-BLOWN NMS? 

1) Hyperthermia - significantly elevated body temperature. 

2) Extrapyramidal symptoms - significant muscular rigidity such as
"lead-pipe" rigidity wherein the person "can't move, can't talk, can't
swallow". 

3) Autonomic instability - fluctuating blood pressure, rapid heart beat,
profuse sweating. 

4) Altered consciousness - confusion, mutism, agitation. 

5) Laboratory tests - 

a) a high percentage of people with NMS have significantly elevated CPK
(creatinine phosphokinase), a muscle enzyme. 

b) the following tests are usually normal during NMS: C.T. scan or MRI scan
of the brain, spinal tap. 

Some authors believe that NMS presents as a spectrum of symptoms and that
it usually follows a course prior to the development of the full-blown
condition. For example, Velamoor and others, 1994 did a retrospective
(looking back) study of 340 cases with diagnosis of NMS and found that: 

a) 70% of the cases follow a sequence 

b) 82% of the cases start as mental status changes or muscular rigidity. 

c) Hyperthermia and autonomic disturbances (e.g., profuse sweating) usually
occur at the latter stage of the condition i.e., full-blown stage. 

The clinical significance of this finding is that, if a person on an
antipsychotic drug suddenly deveops confusion with muscular rigidity,
consider the strong possibility that this will develop into a more serious
and full-blown NMS. 

WHAT IS THE TREATMENT OF NMS? 

1) Usually the occurrence of a full-blown stage of NMS can be prevented. A
HIGH INDEX OF SUSPICION should always be exercised (by patient, family and
doctors alike). 

2) If NMS is suspected, STOP THE ANTIPSYCHOTIC MEDICATION IMMEDIATELY. A
lot of times just stopping the antipsychotic drug will reverse the
condition (if NMS is recognized early). 

3) Supportive measures such as providing adequate fluids and hydration. 

4) Pharmacological treatment: 

a) Dopamine agonists (supplementing dopamine) e.g., bromocriptine or
Parlodel. 

b) Muscle relaxant e.g., dantrolene sodium or Dantrium. 

5) A full-blown NMS is a serious condition and almost always require close
medical supervision and treatment such as placing the person in a medical
ICU (intensive care unit). 

WHAT ARE THE COMPLICATIONS OF NMS? 

NMS that is recognized and treated early almost always do not lead to any
medical complication. 

However, the following medical complications have been reported: 

1) renal failure 

2) lung complications such as aspiration pneumonia, pulmonary embolism,
pneumomediatinum (air pocket). 

3) serious blood clotting (disseminated intravascular coagulation or DIC) 

4) heart attack 

5) fractures 

CAN NMS OCCUR WITH THE USE OF THE NEWER ANTIPSYCHOTIC DRUGS SUCH AS
CLOZARIL, RISPERDAL OR ZYPREXA? 

YES! Sacdev and others, 1995 reported that there have been at least 16
published cases of NMS due to the use of clozapine (out of an estimated
750,000 patients worldwide). There have been at least 7 published cases
of NMS from the use of Risperdal (written communication from Janssen
Pharmaceutica, as of April 7, 1997). I am not aware of any published report
of NMS due to Zyprexa but the drug manufacturer includes this condition
in their package insert as a possible side effect. There may be more cases
of NMS from these medications but they might have been misdiagnosed, not
recognized or not published. 

WHAT TO DO IF YOU SUSPECT A FAMILY MEMBER IS DEVELOPING AN NMS? 

Firstly, not all people on antipsychotic drugs will develop NMS. 

Secondly, not all cases of NMS will follow a sequence of events. Sometimes
NMS can rapidly develop into the full-blown stage without premonitory signs
or symptoms. 

If a developing NMS is suspected: 

1) Stop the antipsychotic medication. 

2) Call the doctor immediately. 

3) Stay in a well-ventilated area. 

4) If the person can adequately swallow, give adequate fluids. Do not force
fluids by mouth in someone who cannot swallow. This may cause aspiration
pneumonia. 

5) If a significant rise in body temperature develops along with muscular
rigidity, inability to talk, swallow, profuse sweating, call 911. 

For those interested and want more information on NMS and the Atypical
Antipsychotics such as Clozaril and Risperdal, the following is a list of
reading materials: 

1) Sachdev P, Kruk J, Kneebone M, Kissane D: Clozapine-induced neuroleptic
malignant syndrome: Review and report of new cases. Journal of Clinical
Psychopharmacology 1995;15:365-371. 

2) Meterissian GB: Risperidone-induced neuroleptic malignant syndrome: A
case report and review. Canadian Journal of Psychiatry 1996;41:52-54. 

3) Written communication received from Janssen Pharmaceutica, April 7, 1997
about Risperdal-induced NMS. 

4) Velamoor VR, Swamy GN, Parmar L, William P, Caroff SN: Management of
suspected neuroleptic malignant syndrome. Canadian Journal of Psychiatry
1995;40:545-550. 

-----Sincerely, Eleazar

==============================================================================
The following has been announced by the web site www.mhsource.com - it is
very similar to what volunteer researchers and psychiatrists are already
providing on the www.schizophrenia.com web site - but you might want to
check it out - Brian.

Mental Health Experts Answer Your Questions Live

    IRVINE, Calif., May 28  -- People  around the world will have an
opportunity to ask questions about mental health in two live "Ask the
Expert" Internet Chat Events to be held in June.
Mental Health InfoSource - http://www.mhsource.com -, a web site that
focuses on mental health, will present the events on June 17 and June 24
from 10 p.m. to 11 p.m., EDT.
    The Schizophrenia Chat Session on June 17 and the Depression Chat
Session on June 24 will feature Dr. Stephen Aronson (Clinical Assistant
Professor of Psychiatry, University of Michigan).    Mental Health
InfoSource offers a wide variety of mental health
information.  Some popular MHI features include weekly "Ask the Expert"
e-mails, full-text articles, practice opportunities, mailing
lists/listserve, "What's New," "Healthier You," "Continuing Education,"
"National Alliance for Research on Schizophrenia and Depression" (NARSAD)
and "California Alliance of the Mentally Ill" (CAMI) journal articles.
==============================================================================
Caution, Your HMO  May Be Dangerous To Your Health

 ARLINGTON, Va - May 22, 1997--"Caution, Your HMO  May
Be Dangerous To Your Health," is the lead for a full-page ad  placed by the
National Alliance for the Mentally Ill (NAMI) in  today's "Sacramento Bee"
and in the "San Diego Union Tribune" and  the "San Jose Mercury News" on
Friday.
    The group's ad expresses distress over PacifiCare's decision to
restrict access to the most commonly prescribed psychiatric  medications.
    Earlier this year, PacifiCare, California's second largest  health
maintenance organization (HMO), removed two antidepressants.   Prozac and
Zoloft, and one antipsychotic, Risperdal, from its list  of covered drugs
-- a decision which leaves consumers with few  choices in drug therapy.
This policy limitation will affect more  than 15% of the 2 million members
who belong to PacifiCare.
    NAMI representatives fear that PacifiCare's decision is only the  tip
of the iceberg and that other health care providers will follow  suit.  "If
PacifiCare is to set the standard for the rest of the  industry, then we
need to hold them to the highest treatment  standards," said Laurie M.
Flynn, NAMI's executive director.
    "PacifiCare's decision is based largely on financial  considerations.
In each instance, PacifiCare chose the cheaper drug  to provide to its
members.  This cost-cutting effort puts the bottom  line first and
individuals like my daughter, who has a severe mental  illness, last," said
Flynn.
    NAMI believes PacifiCare's decision will prove extremely  detrimental
to persons with severe mental illnesses, since there is  no one miracle
drug which works for every mental health consumer --  each person's system
reacts differently to various medications, and  each medication produces
different side effects.
    Statistics show that nearly one of every five California  families will
be affected by a serious mental disorder during their  lifetime.  It is
also reported that 15% of people suffering from  depression commit suicide
and another 40% consider committing  suicide.  Mental illnesses are brain
disorders that can be  effectively diagnosed and treated if access to
appropriate health  care, including breakthrough medications, is available.
    "While PacifiCare claims effective alternatives are available,  the
fact is an examination of their formulary proves that they are  not.  What
PacifiCare substitutes in the name of money are older,  cheaper medications
which very often are less effective and have  more side effects.  NAMI
would like to see the newer medications  reinstated immediately, because
lives are at stake," said Flynn.
    Physicians who choose to prescribe a medication not listed on  the
plan's formulary must obtain prior authorization.  This process  could take
24 to 48 hours, and NAMI fears that it presents an  unnecessary obstacle
for appropriate treatment and consigns  consumers to second-class
medications.
    NAMI is the nation's largest grassroots organization dedicated  to
improving the lives of people with severe mental illnesses,  including
schizophrenia, bi-polar disorder (manic depression), major  depression and
anxiety disorders.  NAMI has more than 140,000  individual members and
1,140 state and local affiliates in all 50  states, the District of
Columbia, Puerto Rico and Canada.

CONTACT:  National Alliance for the Mentally Ill
              Mary G. Rappaport, 703/312-7886

==============================================================================
New Research Supports Use of Risperdal In Elderly Psychotic Patients

    SAN DIEGO, May 21  -- Three studies presented today at the
annual meeting of the American Psychiatric Association suggest that
Risperdal(R)(risperidone may be safe, effective and well tolerated in
elderly psychotic patients.  These new data corroborate the safety,
efficacy and tolerability of Risperdal already demonstrated in 27
double-blind and open clinical studies of adults, and clinical experience
in more than three million patients worldwide.  Original clinical studies
of Risperdal did not include sufficient numbers of patients aged 65 and
over to determine whether they respond differently from younger patients.
However, additional data presented today from 103 elderly psychotic
patients has been submitted to worldwide health authorities for review and
concurrence.
    "Psychiatrists are looking for better ways to meet the special
treatment challenges of older psychotic patients, many of whom have
complicated medical histories and are taking multiple medications," said
Dilip V. Jeste, M.D., director of the Geriatric Psychiatry Clinical
Research Center at the San Diego VA Medical Center.  "Together, these
studies provide compelling evidence that low doses of risperidone, in fact,
much lower doses than in younger patients, are effective in managing
psychoses in the elderly.  Overall, the side effects reported for
risperidone in these open-label studies were predictable and manageable --
an important consideration for this fragile patient population."
    In a multicenter, open-label trial of 103 patients who took a mean
daily dose of Risperdal of 2.4 mg for a mean of 72 days(1), clinical
improvement at endpoint was seen in 50 percent of all patients, as measured
by a 20 percent or greater improvement in the Positive and Negative Symptom
Scale (PANSS)(1). When these results were coupled with improvement on the
Clinical Global Impression (CGI) scale, 45 percent of all patients were
improved at endpoint.
Interim results of a long-term, international multicenter study of
elderly psychotic patients treated with Risperdal oral solution (1
mg/mL)(2), found that 70 percent of patients who completed the trial had
improved positive and negative symptom scores as measured by the CGI scale.
Patients received Risperdal over a three-month period, with daily doses
titrated from 0.5 mg to a mean daily dose of 3.7 mg at endpoint.
Substantial improvement was seen on the CGI scale during the first month of
treatment, followed by further reduction of symptom scores over subsequent
months.
    In a study of hospitalized psychotic elderly patients, Risperdal was
effective in 85 percent of the 108 subjects who completed the trial(3).
Patients received a mean dose of 1.6 mg of Risperdal per day.  Nearly half
of the patients enrolled had previously been considered resistant to
another antipsychotic.  More than 75 percent had cardiovascular or other
diseases which required the continued use of other medications.
    "Despite the complications of treating this study population, Risperdal
effectively controlled psychotic symptoms in the majority of patients,"
said Carlos Zarate, Jr., M.D., assistant professor of psychiatry, Harvard
Medical School and director of the Bipolar and Psychotic Disorders
Outpatient Service, McLean Hospital.  "In addition, there was no indication
that Risperdal interacted harmfully with the patients' other medications."
    Risperdal is indicated for the management of the manifestations of
psychotic disorders, including schizophrenia, schizoaffective disorder and
the psychotic features associated with bipolar disorder.  Clinical studies
have shown that the incidence of extrapyramidal symptoms with Risperdal,
while dose dependent, is comparable to placebo at recommended doses.  The
most common side effects reported in clinical trials were insomnia,
agitation, EPS, headache, anxiety and rhinitis; less common were
somnolence, dizziness, constipation, nausea and tachycardia.  Risperdal may
also cause orthostatic hypotension, a form of intermittent low blood
pressure, especially during the initial dosing period.

    (1) Madhusoodanan S, "Risperidone in Elderly Patients with Psychotic
Disorders." Poster presentation at the annual meeting of the American
Psychiatric Association.  Wednesday, May 21, 1997, 3-5 p.m.  Poster #601.
    (2) Davidson M, et al, "Long-Term Efficacy, Safety and Tolerability of
Risperidone in Elderly Psychotic Patients."  Poster presentation at the
annual meeting of the American Psychiatric Association.  Wednesday, May 21,
1997, 3-5 p.m.  Poster #598.
    (3) Zarate CA, Baldessarini, RJ, "Risperidone in Psychogeriatric
Patients."  Poster presentation at annual meeting of the American
Psychiatric Association.  Thursday, May 22, 1997, noon-2 p.m. Poster #724.

SOURCE  Janssen Pharmaceutica
============================================================================
I publish this periodic newsletter in memory of my brother John who
suffered from Schizophrenia and who, to my infinite regret, took his own
life in 1ate 1995.  In it I hope to help communicate important
Schizophrenia news and developments so as to help anyone who's life is
touched by the illness.  Please forward the newsletter to anyone and
everyone who might benefit from it. - Brian



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