 \200 \200 \200 \200 \200 \200 \200 Eliciting symptoms and understanding their signi \201 cance. Forming a \200\230therapeuti c alliance \200\231. Discussing the possible treatment options (when \200\230disease model s \200\231 may be at odds with each other). The attitude of their culture towards mental illness and the implications of a psychiatric diagnosis (e.g. will preclude marriage in some cultures). 22_Semple_Chap22.indd 912 12/7/2012 4:34:37 PM This page intentionally left blank CHAPTER 22 Transcultural psychiatry 914 Culture-bound syndromes Culture-bound or culture-speci \201 c syndromes comprise a wide ra nge of disorders occurring in particular localities or ethnic groups. The behav- ioural man ifestations or subjective experiences particular to these disor- ders may or may not corres pond to diagnostic categories in DSM-IV or ICD-10. They are usually considered to be illnes ses and generally have local names. They also include culturally accepted idioms or explana tory mechanisms of illness that differ from Western idioms and outside of their cultural se tting may be mistaken for psychosis. Awareness of culture- bound syndromes is important to allow psychiatrists and physicians to make culturally appropriate diagnoses. According to Littlewood and Lipsedge (1987),1 these disorders share a number of common general characteristics: \200 Occur in young men or women who are \200\230powerless \200\231 and socially neglected. Usu ally dramatic with the individual unaware or not responsible. The disorder has symbolic cul tural signi \201 cance ( \200\230mystical sanction \200\231) and show a typical triphasic pattern: \200 \200 \200 \200 Dislocation of an individual as representative of a particular group. Emergence of symptoms as exaggerated form of this extrusion. Restitution into normal relationships. In fact, these features could also be applied to many of the Western neuroses (where \200 \230mystical sanction \200\231 is provided by the medical model). Although controversial, s ome commentators regard the neuroses (includ- ing dissociative states, somatoform, and conv ersion disorders) as exam- ples of Western culture-speci \201 c syndromes.2 This would inc lude a range of speci \201 c syndromes such as neurasthenia, fugue, and trance states, as well as the more modern neuroses: multiple personality disorder, ano- rexia nervosa, chroni c fatigue syndrome, alien abduction syndrome, recov- ered memory syndrome, ritual or satani c abuse, Gulf War syndrome, and even shoplifting and overdosing(!). If culture-bound syndromes are categorized according to primary phe- nomenology, a number o f common subtypes emerge (see Box 22.1). Descriptions of speci \201 c syndromes are outlin ed in the following glossary (b p. 916), illustrating the vast range of manifestations.3 22_Semple_Chap22.indd 914 12/7/2012 4:34:37 PM CULTURE-BOUND SYNDROMES 915 Box 22.1 Subtypes of culture-bound syndromes \200 Startle reaction menkeiti, bah-tschi, bah-tsi, baah-ji, imu, mali-mali, silok. Genital retr action Sudden assault sickness, juramentado, Puerto Rican syndrome, iich \200\230aa, going postal. Running Semen loss Food restriction mirabilis/holy anorexia. Spirit possession Obs ession with the deceased shin-byung. Exhaustion fag/brain fog, shenjian shuairuo, nervios. Suppressed rage e.g. latah, amurakh, irkunii, ikota, olan miryachit, \200 e.g. koro, suo yang, jinjinia bemar, rok-joo. e.g. amok, cafard/cathard, mal de pelea, \201 ghting \200 \200 e.g. pibloktoq/arctic hysteria, grisi siknis. e.g. dhat, jiryan, sukra prameha, shenkui. e.g. anorexia nervosa, bulimia nervosa, anorexia \200 e.g. bebainan, spell, zar. e.g. ghost sickness, hsieh-ping, e.g. neuraesthenia, chronic fatigue syndrome/ME, brain e.g. hwa-byung/wool-hwa-bung, bilis, colera. 1 Littlewood R and Lipsedge M (1987) The butter \202 y and the serpent: culture, psychopat hology and biomedicine. Cult Med Psychiat 11: 289 \200\223335. 2 Showalter E (1998) Hystori es. London: Picador Press. 3 For further reading see: Simons RC and Hughes CC (eds) (1985) The culture-bound syndromes: folk illnesses of psychiatric and anthropological interest. Do rdrecht: D. Reidel Publishing Company. 22_Semple_Chap22.indd 915 12/7/2012 4:34:38 PM CHAPTER 22 Transcultural psychiatry 916 Glossary of culture-bound syndromes Amok, Amuck (Malayan males) Literally \200\230battling furiously \200\231: sudden, unprovoked, random acts of violence, for which the subject is amnesic, and after which they may commit suicide. May be preceded by a period of depression or brooding, anxiety, or feelings of hostility following perceived loss of face or being i nsulted. Also called Matal/Mata Elap ( \200\230darkened eye \200\231). Similar syndromes ar e reported in other countries of South East Asia, the Philippines, Polynesia (cafard or cat hard), New Guinea (ahade idzi be), Puerto Rico (mal de pelea; \201 ghting sickness; Puert o Rican syndrome), the Andes of Bolivia, Columbia, Ecuador, and Peru (colerina), and the US (going postal; iich \200\231aa in Navajo Native Americans). Amurakh (Siberian women) \200 \230Copying mania \200\231 characterized by echo- praxia. (See Lata.) Arctic hysteria (See Piblokco.) Ashanti (West African women, e.g. Ghana) Consists of two subtypes: frenzied guil t and fear (FGF) where, sometimes following physical illness and fever, the person believes they are being punished for some offense, becomes frightened, and then frenzied, followed by a period of with- drawal, hallucinations, hebephrenic behavior, dancing, singing, tearin g off clothes, and eating feces; and depressive (DP) where those affected accuse themselves of being witches and harming someone else without conscious intent. In younger women this often follows a dif \201 cult childbirth and subsequent illness, or the death of an infant . Ataque de nervios (Puerto Ricans and other Hispanics) Dissociative trance disorder, usual ly following an acute stressful event (e.g. death or con \202 ict) with brief symptoms inc luding: a trance-like state (with narrowing of awareness, perceptual distortions, depersona lization, loss of conscious- ness, and partial or global amnesia), anxiety, somatic complai nts, impulsive behavior, and depression. Bangungut (young male Filipinos) \200\230Oriental nightmare-death syndrome \200\231 where a series of terrifying dreams culminate in death f rom presumed cardiac arrhythmia. (See also Hmong sudden death syndrome.) Bebainan (Indonesi a) Possession state, believed to be caused by a spirit power, deity, or other person, in wh ich the subject assumes a new iden- tity, associated with stereotyped involuntary movements and amnesia. Beserk, Berserk, Beserkergang (Northern Europe) \200\230Fighting fever \200 \231, very similar to amok. Bilis and colera (Latin America) An idiom of distress in which physical or mental illness is explained as due to extreme emotion (anger) that upsets the h umors (described in terms of hot and cold). Brain fag, brain fog syndrome (West African stu dents) \200\230Brain fatigue \200\231, an idiom of distress with symptoms attributed to ov er-work, tiredness, and \200\230too much thinking \200\231. The subject complains of reduc ed concentra- tion, poor memory, blurred vision, and head/neck pain (often described as 22_Semple_Chap22.indd 916 12/7/2012 4:34:38 PM GLOSSARY OF CULTURE-BOUND SYNDROMES 917 tightness, pressure, heat, or burning). Symptoms closely resemble anxiety, depressive, or s omatoform disorders. Cathard, cafard (See Amok.) Colerina (See Amok.) Curanderismo (Mexican Americans and other Spanish-speaking peo- ple) Folk medicine in which the healers (curande ros [male] or cunderas [female]) use a combination of herbal infusions, dramatic healing ri tuals, and prayers to treat a variety of physical and psychological symptoms including: emb rujo (witchcraft), empacho (intestinal distress), mal ojo (evil eye), mal puesto (hexing), and susto (soul loss). Delahara (Philippine women) A syndrome similar to amok. Dhat (India, rural areas of Nepal, Sri Lanka, and Bangladesh) Semen- loss syndrome \200\224a belief in the passage of semen in the urine following the breaking of taboos concerning masturbation or sexual intercourse. Associated with somatic symptoms (weakness, exhaustion), severe anxi - ety, hypochondriasis, whitish discolouration of the urine, and sexual dys- function. Trad itional remedies consist of herbal tonics to restore semen/ humoral balance. Similar to jir yan (India), sukra prameha (Sri Lanka), and shenkui (China). Echul (Native Americans of Sou th California) Sexual anxiety and convul- sions following severe stress (e.g. the death of a child). Evil eye, mal Ojo (See Curanderismo.) Falling out, blacking out (African American s and Afro-Caribbeans) Collapse, without loss of consciousness, sometimes preceded by dizzi ness. The subject feels paralyzed, but can hear and understand, and may claim to be blind. A type of dissociative/conversion disorder, usually following a traumatic event. Fighting s ickness (See Amok.) Frenzied anxiety state (Kenya) Another syndrome similar to amok. Frigid ophobia (See Wind illness.) Ghost sickness (Native Americans) Preoccupation with death or t he deceased. Subjects may say they have been \200\230bewitched \200\231 and complain of ni ghtmares, weakness, dizziness, episodes of collapse, anxiety, poor appetite, hallucinations , confusion, feelings of futility or apprehension, and sometimes a sense of suffocation. Gr isi siknis (Miskito Indians, Nicaragua) Headache, anxiety, anger, and aimless running. Simi lar to pibloko. Gururumba episode ( \200\230wild man behavior \200\231) (New Guinea) Subjec t (usually male) breaks into houses to steal small items (they believe to be valuable) and then runs off into the forest for some days, later returning (without the items) to their n ormal life. There is associated amnesia and during the episode they may appear vague, agita ted, behave in a clumsy way, and have disturbance of normal hearing and speech. 22_Semple_Chap22.indd 917 12/7/2012 4:34:38 PM CHAPTER 22 Transcultural psychiatry 918 Hi-wa itck (Mohave American Indians) Insomnia, depression, loss of appetite, and sometimes suicide associated with unwanted separation from a loved one. Hmong sudden death syndrome ( Laos) The death of a person whilst sleeping, attributed to being attacked by spirits in a d ream, and often following a traumatic event. (See Bangungut.) Hsieh-ping (Taiwan) A brief t rance state during which the subject is believed to be possessed by an ancestral ghost, who often attempts to communicate to other family members. Symptoms include tremor, disori- en tation, delirium, and (visual/auditory) hallucinations. Hwa-byung, wool-hwa-bung, \200\230 anger syndrome \200\231 (Korea) Epigastric pain attributed to a mass in the upper abdomen t hat the patient fears will lead to death. The belief is related to ideas of bodily imbalanc es caused by anger (cf. bilis and colera.) Other symptoms may include tiredness, mus- cular aches and pains, breathlessness, palpitations, insomnia, dysphoria, panic, loss of appetit e, and other GI problems (indigestion, anorexia). Imu (See Lata.) Juramentado (Malays and M oros) Marked agitation, indiscriminate assault or stabbing, followed by stupor, and subsequ ent amnesia on awak- ening. (Similar to amok.) Kimilue (Native Americans of Southern Califo rnia) Apathy, anhedonia, loss of appetite, and vivid sexual dreams. Koro (Malaysia) Literal ly \200\230to shrink \200\231 or referring to a \200\230tortoise \200\231 (a popular word for penis). \200\230Genital retraction syndrome \200\231 \200\224the fear or delusion tha t the genitals are retracting into the abdomen, and that death will occur once this has hap pened. Prodromal depersonalization usually occurs and elaborate measures may be taken to pr event the penis from retracting (e.g. grasping of the genitals, splints or other devices, h erbal remedies, or fellatio). Occurs more frequently in predominantly young, single males, in Asia and the Middle East (epidemics have been described in the Malay Archipelago, Thaila nd, China, India, Singapore, and Israel). Sporadic cases have been reported in Africa, Euro pe, and North America. The female equivalent (fear or delusion that the labia or nipples ar e retracting) occurs rarely and most reported cases have been during epidemics. There are n o speci \201 c associations with other psychiatric disorders, although phobic anxi- ety di sorders, depression, schizophrenia, and depersonalization syndromes are described. Other na mes for this syndrome include: suk-yeong/suo yang (Chinese: \200\230shrunken penis \200 \231), kattao (Indian: \200\230cut off \200\231), jinjinia bemar (Assam), and rok-joo (Tha iland). Lata, latah, lattah (Malay population) Exaggerated startle reaction seen predominan tly in young girls. Following sudden fright/trauma, there is a behavioral response consisti ng of echopraxia, automatic obedience, coprolalia, and dissociative or trance-like behavior . May be a symptom of disease (e.g. acute psychosis, conversion/dissociative state) or be a n isolated behavioral abnormality. Related syndromes include: amurakh, irkunii, ikota, miry achit, menkeiti, and olan/olonism (Siberia), imu (Ainu 22_Semple_Chap22.indd 918 12/7/2012 4:34:38 PM GLOSSARY OF CULTURE-BOUND SYNDROMES 919 of Japan), bah-tschi, bah-tsi, and baah-ji (Thailand), mali-mali and silok (Philippines), L app panic (Lapps), the Jumpers of New England (a nine- teenth-century Shaker sect), and jum ping Frenchman (Canada). Locura (Latin America) Severe form of chronic psychosis, attribute d to an inherited vulnerability and/or adverse life events, characterized by incoherent spe ech, agitation, auditory/visual hallucinations, impaired social interactions, and unpredict able (possibly violent) behavior. \200\230Lost hunter \200\231 sequence (New Guinea) After period of social with- drawal (following perceived criticism of actions) the person (typic ally male) goes hunting alone in the bush and describes \201 ve episodes of track- ing a large game animal, which suddenly disappears, before he is rescued by a search party. He fe els he has been led astray by supernatural beings. Mal de pelea (See Amok.) Miryachit, mira chat (Russian: \200\230to fool \200\231 or \200\230play the fool \200\231) (See Lata.) Ne r \201 za, nerves, nervios (Latino populations in United States, Latin America, Egypt, Nor thern Europe) Chronic somatic, emotional, and behavioral symptoms (e.g. headache, sleep pro blems, reduced appetite, nausea, fatigue, dizziness, paraesthesia, anxiety, concentration d if \201 culties, and emotional lability/distress). More common in women; associated with a nger, emotional distress, and low self-esteem. Usually treated with tradi- tional herbal te as, \200\230nerve pills \200\231, rest, isolation, and increased family support. (Similar to nevra in Greece.) Olonism (See Lata.) Pibloko, pibloktoq (Polar Eskimo women) \200\230A rctic hysteria \200\231 \200\224an acute dissociative state (lasting about 30 min) followin g the actual (or sym- bolic) loss of someone or something important to the individual. Usua lly mild irritability or withdrawal precedes impulsive or dangerous acts (e.g. screaming, t earing off clothes, breaking furniture, shouting obscenities, eat- ing feces, or rushing ou t into the snow). May be followed by convulsions and coma (lasting up to 12 hrs) with assoc iated amnesia. Although some researchers have suggested it may be due to hypocalcaemic teta ny, it is most probably an anxiety state. Puerto Rican syndrome (See Amok.) Qi-gong psychot ic reaction (China) \200\230Excess of vital energy \200\231 \200\224an acute episode chara cterized by dissociative, paranoid, or other symptoms after participation in the health-enh ancing practice of qi-gong. Rootwork (Haiti and Sub-Saharan Africa) A variety of complaints attributed to hexing, witchcraft, sorcery, voodoo, or the evil in \202 uence of another p erson. Symptoms include anxiety, GI complaints, and fear of being poisoned or killed. Can r esult in death. Associated syndromes: voo- doo death (Haiti), mal puesto or brujeira (Latin America), and hex. Sangue dormido, \200\230sleeping blood \200\231 (Cape Verde Islanders) Somatic symptoms including pain, numbness, tremor, paralysis, convulsions, blind- ness, an d increased risk of heart attack, infection, and miscarriage. 22_Semple_Chap22.indd 919 12/7/2012 4:34:38 PM CHAPTER 22 Transcultural psychiatry 920 Sar (Somalian women) A possession state attributed to Sar spirits that are said to hate men . The syndrome may legitimize behavioral distur- bance in women who feel neglected by their husbands. (See also Zar.) Shenjian shuairuo (China) Similar to neurasthenia \200\224sympto ms include: fatigue, irritability, poor concentration/memory, sleep disturb- ance, and othe r somatic symptoms (dizziness, headaches, pain, GI upset, sexual dysfunction, and other sig ns of autonomic dysfunction). Most cases would meet criteria for depressive or anxiety diso rders. Shenk-k \200\231uei (Taiwan), shenkui (China) Anxiety and panic with somatic complai nts, especially sexual dysfunction (premature ejaculation and impotence). Symptoms are attr ibuted to excessive semen loss from sexual activity or \200\230white turbid urine \200\231 , which reduces \200\230vital energy \200\231. It is viewed as a life-threatening conditio n and described in areas with a Chinese ethnic population. Similar to dhat and jiryan (Indi a), and sukra prameha (Sri Lanka.) Shin-byung (Korea) Possession (dissociative) state attri buted to ances- tral spirits with associated anxiety/fear and somatic complaints (general- ized weakness, dizziness, insomnia, loss of appetite, and GI problems). Shinkeishitsu (Japa n) Syndrome marked by obsessions, perfectionism, ambivalence, social withdrawal, fatigue, a nd hypochondriasis. Spell (Southern United States) A trance state in which individuals \200\230com- municate \200\231 with deceased relatives or with spirits, often accompanied b y brief periods of personality change. In context, \200\230spells \200\231 are culturally nor- mal and do not indicate psychiatric illness. Susto, espanto, \200\230magic fright \200\231, \200\230fallen fontanel syndrome \200\231 (Peru) An acute anxiety state, seen in children and adolescents, usually following an acute stressor or violent (often supernatur al) fright. Characterized by anxiety, agitation, dejection/apathy, sleep disturbance, signi \201 cant weight loss, other somatic symptoms, and a belief that the soul has been, or wi ll be, stolen from the body. (See Curanderismo.) It is also seen in Latinos of the United S tates, Mexico, and other Central/South American countries. Related syndromes: lanti (Philip pines), malgri (Aborigines of Australia), mogo laya (New Guinea), narahati (Iran), and sala dera (in regions around the Amazon). Tabanka (Trinidad) Depression associated with a high r ate of suicide that is seen in men abandoned by their wives. Taijin kyofusho (Japan) Fear a nd guilt about embarrassing others with one \200\231s appearance or behavior, prominent in younger people and similar to the Western concept of social phobia. Ufufuyane, saka (Kenya, Southern Africa; Bantu, Zulu; and af \201 liated groups) Anxiety state attributed to the effects of magical potions (given to them by rejected lovers) or spirit possession, with ch aracteristic sobbing, repeated neologisms, paralysis, trance-like states, or loss of consci ousness. Usually seen in young, unmarried women, who may also experience night- mares with sexual themes, and rarely episodes of temporary blindness. 22_Semple_Chap22.indd 920 12/7/2012 4:34:38 PM GLOSSARY OF CULTURE-BOUND SYNDROMES 921 May be related to aluro (Nigeria), phii pob (Thailand), and zar (Egypt, Ethiopia, Sudan). U quamairineq (Inuits of the Arctic Circle) Syndrome akin to a sleep- state transition disord er or dissociative disorder in which sudden paralysis is associated with a sleep state, mar ked anxiety/agitation, and hallucina- tions. Usually lasts minutes and may be preceded by a transient sound or smell. Traditionally viewed as the result of soul loss, soul wandering, or spirit possession. Vimbuza (Northern Malawi and Zambia) A culturally speci \201 c resp onse to sickness involving herbal medicines and \200\230vimbuza dancing \200\231 that is p er- formed late at night. Often others will dance on behalf of the patient, keeping the rhy thm with metal belts, and inducing a trace state from which the \200\230healed \200\231 pa tient emerges. If the illness is considered severe, the family of the patient may sponsor a \200\230chilopa \200\231 \200\224an entire night of dancing followed by an animal sacri \201 ce at dawn. The patient drinks some of the animal \200\231s blood and then begins to d ance again. The larger the animal (usu- ally either a chicken, a goat, or a cow), the more effective the expected cure. Voodoo death (See Hmong sudden death syndrome and Rootwork.) W acinko (Native American groups \200\224Oglala Sioux \200\224of North America) Anger, withdr awal, mutism, and immobility frequently leading to suicide. Often related to disappointment or interpersonal problems. Wihtigo, whitigo, witiko, windigo, wendigo (Native American gro ups, e.g. Cree, Algonkian Indians of central and northeastern Canada) The fear or delusion of being transformed into a wihtigo, or giant mon- ster that eats human \202 esh. There i s a prodrome of anxiety about physical symptoms (e.g. reduced appetite, nausea and vomiting ) and the person may commit suicide or be the target of violence. The existence of this syn - drome is questioned as no single case has been described in the psychiatric or anthropolo gical literature. Wind illness, p \200\231a leng, frigidophobia (China, South East Asia) An xiety/fear of being cold or of the wind; associated with a loss of yang and upset of natura l balance in the body (believed to produce fatigue, impotence, and death), leading a person to do everything they can to stay warm. Described in areas with Chinese ethnic populations . May be related to agua frio, aire frio, frio of Mexico, Central and South America. Wild m an behavior (See Gururumba episode.) Zar (East and North Africa, the Middle East, e.g. Ethi opia, Somalia, Sudan, Egypt, and Iran) Dissociative symptoms including shouting, laughing, head banging, singing, weeping, and other demonstrative behaviors. The per- son believes th ey are possessed by a spirit, and may develop a long-term relationship with the spirit. Oth er symptoms may include apathy, with- drawal, refusal to eat, and refusal to carry out task s of daily living. Such behavior may be regarded as culturally normal (see Sar). 22_Semple_Chap22.indd 921 12/7/2012 4:34:38 PM This page intentionally left blank 923 Chapter 23 Therapeutic issues Medication adherence 924 Off-label prescribing 926 Plasma level monitoring 928 Paradoxical reactions to benzodiazepines 929 Weight gain with psychiatric medication 930 Antipsychotics and diabetes 934 Hyperprolactinaemia with antipsychotics 936 Sexual dysfunction and psychi atric medication 938 Priapism 942 Antipsychotic-induced Parkinsonism 944 Akathisia 946 Tard ive dyskinesia 950 Dystonic reactions 954 Neuroleptic malignant syndrome 956 Serotonin synd rome (SS) 960 Antidepressant discontinuation syndrome 964 Hyponatraemia and antidepressants 966 Prescribing in pregnancy 968 Prescribing in lactation 970 Prescribing for patients wit h cardiovascular disease 972 Prescribing for patients with liver disease 974 Prescribing fo r patients with renal impairment 976 Prescribing for patients with epilepsy 978 23_Semple_Chap23.indd 923 12/7/2012 5:12:48 PM CHAPTER 23 Therapeutic issues 924 Medication adherence Is adherence important? \200 It has been estimated that only one-third of patients prescribed medication actually adhere to the treatment plan (this applies to all medical specialties, not just psychiatry) and t hat 780% of psychiatric admissions relate to medication non-adherence. Adherence is a parti cular problem when the illness runs a chronic course and requires the patient to be on medi cation for life (e.g. diabetes, IHD, pulmonary disease, schizophrenia). Patients with schiz ophrenia who comply with a suf \201 cient dosage of antipsychotic medication have only abo ut one- \201 fth the risk of relapse compared to patients who do not take their medication . There is good evidence that prophylactic lithium treatment of bipolar disorder reduces th e likelihood of relapse (particularly manic relapse), as well as the risk of suicide. Conti nuation of antidepressant treatment for symptom resolution signi \201 cantly reduces the r isk of further depressive episodes. at least 6mths after Reasons for non-adherence It is important to realize that the patient may have understandab le rea- sons for being reluctant to take prescribed medication. Uncovering these reasons ma y help in negotiation and developing strategies to improve the situation. \200 Continued symptoms of the underlying disorder (e.g. delusions, lack of motivation, impaired insight, and disorganization) or comorbid disorders (e.g. substance misuse, personality di sorder). Negative attitude towards medication in general (versus other forms of treatment) or stigma associated with being \200\230on medication \200\231, particularly where there a re external stigmata of treatment such as Parkinsonism ( \200\230looking like a zombie \200 \231). Unacceptable (or unexpected) side-effects (e.g. weight gain \200\224 p. 930, sedatio n, EPSEs \200\224 b p. 944, sexual dysfunction \200\224 b p. 938, perceived loss of \200 \230good \200\231 symptoms, e.g. hypomania). Forgetting (genuine oversight, disorganization , cognitive impairment). Lack of communication (reasons for medication not fully explained or understood). Failure to obtain (or renew) prescription (through non-attendance, poor com munication or poor relationship with responsible prescriber, e.g. GP). Belief that the medi cation is \200\230not working \200\231. Feeling well and no longer seeing the need for med ication. The \200\230reward \200\231 of freedom from side-effects may be immediate, while the \200\230punishment \200\231 of relapse may be more distant, not taken seriously, or no t directly associated with stopping treatment. b \200 \200 23_Semple_Chap23.indd 924 12/7/2012 5:12:48 PM MEDICATION ADHERENCE 925 Strategies to improve adherence Education \200 Promote insight and understanding about the illness and the bene \201 ts of treatment. Pro vide information about the medication, how to take it, possible side-effects, the length of time needed to see bene \201 ts, and the potential problems of suddenly stopping. Discuss the reasons for prophylactic or continued treatment, especially when patient feels well (e .g. to reduce risk of relapse and improve long-term outcome). Encourage discussion of pros and cons of suggested treatment plan. Encourage openness about potentially embarrassing iss ues that may lead to non-adherence (e.g. sexual side-effects). Regularly ask about and docu ment side-effects at each review. \200 Sensible prescribing \200 Simplify drug regime \200\224use single dose where possible (most psychotropic medications have long half-lives and can be given once daily or are available in slow-release preparati ons). Minimize side-effects through choice of a medication with lowest potential for side-e ffects, and using lowest therapeutic dose. If side-effects are problematic, consider a chan ge to an alternative preparation or (where an alternative would be less effective) co-presc ribing agents to counter signi \201 cant problems. Rational medication choice based on ind ividual acceptability of side- effects (e.g. any weight gain may be unacceptable to a young female patient). Clear communication of any changes in regime both to patient and primary care team (including written instructions for patient and direct communication with GP) esp ecially if the primary care physician is main prescriber. Consider use of depot antipsychot ic preparations \200\224this may sometimes be requested by the patient, but is more often n ecessary when the patient lacks insight, or has had signi \201 cant serious relapses relat ed to non-adherence. Regularly review the need for continued medication. Practical/behavioral measures \200 Written information to patient, particularly where regime is complex or where change of dos e/medication is planned. Establish a regular daily routine for taking medication. Use of a multicompartment compliance aid (e.g. Dosette Supervised administration (e.g. by relative/c arer, at drugstore, in day hospital, by CPN). Active monitoring (e.g. tablet count, blood l evels \200\224 \200 \200 box). b p. 928). 23_Semple_Chap23.indd 925 12/7/2012 5:12:48 PM CHAPTER 23 Therapeutic issues 926 Off-label prescribing1 Essence In the UK, licensed medicines are granted a Marketing Author ization (pre- viously called a product license) by the Medicines and Healthcare prod- ucts Regulatory Agency under the Medicines Act 1968. For each drug, the British National Formula ry (BNF) speci \201 es the doses, indications, cau- tions, and adverse effects, which re \202 ect those in the manufacturer \200\231s data sheet. However, in spite of various licen sed treatments, patients will often remain symptomatic and psychiatrists will consider pres cribing medica- tions outside the narrow terms of their license. Unlicensed prescribing doe s not imply lack of evidence in support of the proposed intervention and can still be safe and bene \201 cial to the patient. In fact, it has also been argued that the product licen se for a drug does not necessarily represent the best use of that compound. General points \200 The real extent of unlicensed prescribing in the UK is largely unknown; however, cross-sect ional surveys in general adult inpatient settings have shown the rate of off-label prescrib ing can be as high as 40% of all prescriptions. Drug companies do not usually test their me dicines on children; hence they cannot apply to license their medicines for use in the trea tment of children. Nonetheless, the British Association for Psychopharmacology2 has stated that it seems reasonable to extrapolate what is known about drug treatment responses in adu lts to children and adolescents with schizophrenia and OCD, but caution is required with mo od and anxiety disorders. No psychotropic medication is currently licensed for use in pregn ancy or in breastfeeding mothers. It has been argued that the \201 nal prescribing decisi on should rest with the clinician, based on the availability of other therapeutic options a nd a careful assessment of the potential risks and bene \201 ts (see Box 23.1 for legal co nsiderations). Types of unlicensed prescribing \200 The prescription of a medication for an indication that is not covered within the terms of the Market Authorization. The prescription of a medication to a patient who lies outside th e age range speci \201 ed within the Summary of Product Characteristics. The prescription of a medication at doses above the maximum recommended dosage. The use of a licensed medica tion for longer periods than those speci \201 ed within the Marketing Authorization. Recommendations for unlicensed prescribing \200 Unlicensed prescribing should only occur when licensed treatments have been used or conside red but excluded on clinical grounds (e.g. contraindications, risk of interactions). 23_Semple_Chap23.indd 926 12/7/2012 5:12:48 PM OFF-LABEL PRESCRIBING 927 The prescriber should be familiar with any possible bene \201 ts and risks of the proposed treatment (ask specialist pharmacist for further guidance). Particular consideration is ne eded with children, older patients, and patients lacking capacity (see b p. 870). Whenever possible a full explanation of the treatment should be given to the patient (and/or his/her relative, when relevant) and documented in the notes. Whenever possible the agreement of t he patient (and/or his/her relative, when relevant) should be obtained, but if not possible , this should be noted. Prescription should be started cautiously and patient \200\231s pro gress monitored closely with full documentation of treatment effectiveness and tolerance. I f unsuccessful, treatment should be withdrawn carefully. Box 23.1 Legal principles applying to unlicensed prescribing \200 Legally unlicensed prescribing would not be held as a breach of the duty of care, if that t reatment was supported by a respected body of medical opinion, as the Bolam test (Bolam v. Friern Hospital Management Committee, 1957) in medical negligence claims asks for proof tha t a body of doctors would act similarly to the doctor in question. According to the case of Bolitho v. City and Hackney Health Authority (1997), medical opinion should also be capabl e of withstanding logical analysis. In unlicensed prescribing this implies that doctors con sider the risks and bene \201 ts of varying treatment options, with due regard to the avai lable evidence. 1 Royal College of Psychiatrists: CR142 (Jan 2007) Use of licensed medicines for unlicensed applica- tions in psychiatric practice. M http://www.rcpsych.ac.uk/ \201 les/pdfversion/c r142.pdf 2 British Association for Psychopharmacology (BAP) Consensus Statement (1997) Chil d and learning disability psychopharmacology. J Psychopathol 11: 291 \200\2234. M http://jo p.sagepub.com/con- tent/11/4/291.full.pdf+html 23_Semple_Chap23.indd 927 12/7/2012 5:12:48 PM CHAPTER 23 Therapeutic issues 928 Plasma level monitoring There are a limited number of drugs with well-established plasma le vels that equate with ef \201 cacy. Plasma monitoring is a regular procedure only for lith ium therapy. However, there may be a number of other reasons for requesting plasma levels ( bear in mind that assays for speci \201 c drugs may not be locally available and may need special arrangements). Many psychiatric drugs have marked variations in metabolism, or larg e numbers of active metabolites, making plasma levels dif \201 cult to interpret. Reasons for monitoring \200 \200 Established therapeutic plasma levels (see Table 23.1). Monitoring of any changes in plasma level that might affect ef \201 cacy (e.g. due to drug interactions, intercurrent illness , pregnancy, or altered pharmacokinetics over time). Clinical evidence of toxicity (e.g. li thium, anticonvulsants). Where there is doubt about patient compliance (e.g. lack of effect despite adequate or even high-dose treatment). In cases where the patient may be unable to report adverse effects (e.g. children, severe LD, dementia). After overdose, to con \201 rm it is safe to restart medication. \200 Plasma level monitoring of other psychotropics (aripiprazole [and dehy- droaripiprazole], o lanzapine, risperidone [and 9-hydroxy-risperidone], quetiapine, amisulpiride, lamotrigine, sulpiride) is available in the UK1 and could be used in assessing adherence, dose optimizat ion, and if acute poi- soning is suspected. However, it is not advised in routine practice and other ways of establishing treatment adherence are preferred (e.g. meas- urement of ser um prolactin if patient is on risperidone \200\224see b p. 936). Table 23.1 Reference ranges for selected drugs Lithium (see b p. 336) 0.6 \200\2231mmol/L (0.6 \200\2230.8mmol/L \200\224as an augmentative agent) Valproate (see b p. 342) Carbamazepine (see b p. 346) Clozapine (see b p. 210) 50 \200\223100mg/L 4 \200\22312mg/L (>7mg/L may be more ef \201 cacious in bipolar disorder) 350 \200\223500mcg/L (0.35 \200\2230.5mg/L) 1 Toxicology Unit, KingsPath Laboratory, King \200\231s College Hospital, London. M www.kin gspath. co.uk/tests/toxicology/ 23_Semple_Chap23.indd 928 12/7/2012 5:12:48 PM PARADOXICAL REACTIONS TO BENZODIAZEPINES 929 Paradoxical reactions to benzodiazepines1 Essence Paradoxical or \200\230disinhibitory \200\231 reactions to BDZs occur in a minority of patients (less than 1% of general populat ion) and are characterized by acute excitement and altered mental state: \200 \200 \200 \200 \200 Increased anxiety. Vivid dreams. Hyperactivity. Sexual disinhibition. Hostility and rage ( \200\230aggressive dyscontrol \200\231). Recognition is important as behavioral disturbance may be exacerbated by inappropriate use of higher doses of BDZs. Note: similar types of reac- tion are described for most CNS depre ssants (e.g. alcohol, barbiturates). Etiology Incompletely understood; theories include: \200\230release behavior \200\231 due to loss of frontal lobe inhibition through GABAA mechanism; BDZ related reduction in 5-HT n eurotransmission; BDZ related reduction in ACh neurotransmission. Risk factors Children, learning disability, history of brain injury, dementia, borderline P D, antisocial PD, history of aggression/poor impulse control, family/ personal history of p aradoxical reaction, use of high-dose/high-potency BDZs (e.g. alprazolam, clonazepam, \202 unitrazepam, triazolam), IV/intra- nasal administration. Management \200 \200 Nurse in safe environment, with constant supervision. Use sedative antipsychotic to treat a cute behavioral disturbance if necessary. In extreme cases consider use of IV \202 umazen il (may require repeated doses). Clearly record occurrence of paradoxical reaction so futur e episodes of acute behavioral disturbance can be managed appropriately. 1 Paton C (2002) Benzodiazepines and disinhibition: a review. Psychiat Bull 26: 460 \200 \2232. 23_Semple_Chap23.indd 929 12/7/2012 5:12:48 PM CHAPTER 23 Therapeutic issues 930 Weight gain with psychiatric medication General points Weight gain is a signi \201 cant ca use of non-compliance with psychiatric medi- cation, and patients often complain about incr eases in weight, even when clinicians may regard it as \200\230clinically insigni \201 ca nt \200\231. Effects on general health, self-esteem, and social embarrassment should not be overlooked. Antipsychotics Proposed mechanisms Sedation (reduced activity), thirst (anticholinergic sid e-effects), reduced metabolism, \202 uid retention, endocrine effects (increased prolacti n, altered cortisol, altered insulin secretion), increases in leptin levels (changes in \200\230set-point \200\231 weight), and altered neurotransmitters (5-HT2C blockade, hista- mine af \201 nity, D2 blockade, CCK changes) have all been proposed. Increased risk Female, previous pattern of overeating, narcissistic traits, family or perso nal history of obesity. Effects of speci \201 c agents (see Table 23.2). Management1 \200 \200 \200 Routine measurement of baseline weight. Warn patient of possibility. Encourage \200\230hea lthy diet \200\231 (involve dietician if necessary), moderate physical exercise, avoid high -calorie \202 uids. Use lowest therapeutic dose, introduce medication increases slowly, c onsider intermittent dosing. Consider adjunctive prescribing (e.g. clozapine lowering of cl ozapine dose). plus quetiapine, to allow Antidepressants Proposed mechanisms Reduced metabolism, carbohydrate craving (Note: may be a symptom of depression itself), central serotonin mechanisms in regulating food intake (ap petite/satiety). Effects of speci \201 c agents (see Box 23.2). Management \200 \200 \200 \200 General advice about diet and exercise. Use lowest therapeutic dose. Consider switching to alternative antidepressant. Adjunctive prescribing (e.g. naltrexone, ranitidine at night: m ay reduce \200\230midnight snacks \200\231).