Which is the antipsychotic of choice for a 75-year-old man with Parkinson’s disease who presented with psychotic symptoms?
D. The American guidelines recommend the use of Clozapine or Quetiapine for the management of psychosis in Parkinson’s disease. The guidelines also note that Olanzapine should not be used for the same. With few exceptions, all atypical antipsychotics have comparable efficacy against psychosis and the choice is mainly based on their ease of use and the side effect profile. Risperidone and olanzapine are associated with sedation. Risperidone can cause considerable worsening of parkinsonism. Olanzapine has been known to worsen cognition and hyperglycaemia in patients with diabetes. A recent Committee on Safety of Medicines warning suggests an increased risk of strokes associated with the use of risperidone and olanzapine in old people. Clozapine has the best evidence for use in Parkinson’s as this was the first atypical antipsychotic that came on the market. However, due to the tedious monitoring protocols, it is seldom used in the population, and it has a restricted license in the UK. Quetiapine is favoured by many psychiatrists because of its better side-effect profile and being as efficacious as Clozapine, at least in one study. Aripiprazole has been shown to worsen Parkinson’s disease.
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If a patient continues to take sodium valproate throughout her pregnancy what is the risk of the baby having a neural tube defect?
B. Sodium valproate is considered a human teratogen. Although several studies have shown rates of neural tube defect of up to 10%, the risk is generally considered between 1% and 2%. The effect of the drug on neural tube development is related to its use 17–30 days post conception, and the risk is dose related. The neural tube defect found in exposed infants is more likely to be lumbosacral rather than anencephalic, which suggests a drug effect on neural crest closure. The risk of Ebstein’s anomaly among the offspring of lithium users is 1:1000 (0.1%) to 2:1000 (0.05%), or 20 to 40 times higher than the rate in the general population. The most common toxicity effect in offspring exposed to lithium during labour is the ‘floppy baby‘ syndrome, characterized by cyanosis and hypotonicity. Carbamazepine is also considered a human teratogen. In one prospective study of 35 women treated with carbamazepine during the first trimester, craniofacial defects (11%), fingernail hypoplasia (26%), and developmental delay (20%) were found in live-born offspring. The rate for neural tube defects in that report and others ranged between 0.5% and 1%. Regarding antipsychotics, a recent review showed that both first-generation antipsychotics (FGA) and second-generation antipsychotics (SGA) seem to be associated with an increased risk of neonatal complications. However, most SGAs appear to increase the risk of gestational metabolic complications and babies large for gestational age and with mean birth weight significantly heavier than those exposed to FGAs. These risks have been reported rarely with FGAs. Hence, the choice of the less harmful option in pregnancy should be limited to FGAs in drug-naive patients. When pregnancy occurs during antipsychotic treatment, the choice to continue the previous therapy should be preferred.
Which of the following is NOT a feature of chronic fatigue syndrome (CFS)?
A. The Center for Disease Control definition of CFS (also called neurasthenia and myalgic encephalitis in the UK) consists of severe unexplained fatigue for over 6 months. This is of new or definite onset; not due to continuing exertion; not resolved by rest; and is functionally impairing. The criterion also mentions other symptoms that are suggestive of CFS, out of which at least four need to be present for the diagnosis. They are impaired memory or concentration; sore throat; tender lymph nodes; muscle pain; pain in several joints; new pattern of headaches; un-refreshing sleep; postexertional malaise lasting more than 24 hours. Although non-refreshing sleep is a criterion, late insomnia is not.
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Which antidepressant has got good evidence for its use in post-myocardial infarction depression?
E. Two large, multicentre trials were designed to assess the safety, efficacy, and consequence of treating depression in patients with cardiovascular disease. The first, Sertraline Treatment of Major Depression in Patients with Acute MI or Unstable Angina (SADHART) was a randomized, double-blind, placebo-controlled trial conducted in 40 medical centres. The primary objective of SADHART was to evaluate the safety and efficacy of sertraline treatment for major depressive disorder in patients hospitalized for acute MI or unstable angina without other life-threatening medical complications. The results of the study indicated that sertraline was found to be safe and effective in a subgroup of more severely depressed patients. The second multicentre trial, Enhancing Recovery in Coronary Heart Disease Patients (ENRICHD), aimed to determine whether mortality and recurrent infarction are reduced by treatment of depression after an acute MI. Treatment included cognitive behaviour therapy (CBT) and the use of SSRIs when indicated. Similar to the SADHART findings, the interventions did not increase event-free survival; however, they did improve both depression severity and social isolation.
Which of the following is the treatment of choice for premenstrual dysphoric disorder?
A. The term premenstrual syndrome (PMS) was first coined by a physician from England named Katharina Dalton in 1953; however, premenstrual tension was a term used prior to this. More than 150 different symptoms have been attributed to PMS, but the one unifying concept is that these symptoms must occur during the (late) luteal phase of the menstrual cycle, causing significant impairment in a woman’s functioning, and must disappear within the first few days of menses. The American Psychiatric Association recognizes premenstrual dysphoric disorder (PMDD) as a subset of PMS that was designed to focus on women with severe symptoms causing marked impairment in functioning. PMDD has a lifetime prevalence of approximately 2–4% in menstruating women. Sixty-five per cent of women with unipolar mood disorder experience PMS, and women with PMS have a 60% lifetime prevalence of major depression. In a recent meta-analysis on the efficacy of SSRIs in PMDD, 15 randomized controlled trials (RCTs) were found demonstrating SSRIs as effective for behavioural and physical symptom amelioration and have the best evidence to date. Other supplements do not have solid research evidence to support their use to date, including vitamin E, vitamin A, magnesium, primrose oil, dong quai, black cohosh, wild yam, St John’s wort, or kava.
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