In episode 135, Mike and James and Adil finally get to the end of their antipsychotic tetralogy as they tackle the especially difficult issue of the use of antipsychotics in the elderly. The problem is non-pharmacological treatments do very little, and one is left with having to decide whether or not to use drugs. We discuss the evidence of effectiveness (or lack thereof) of these drugs and the very real potential for harm. At the end, Adil makes both Mike and James agitated and he sedates them with a high dose of a very fine cognac. 

Show notes

1) Non-pharmacological interventions

Aging Ment Health 2009;13:512-20

2) Use of antipsychotics for psychosis of dementia

Int J Geriatr Psychiatry 2007;22:475-84

Psychother Psychosom 2007;76:213-8

Cochrane Database Syst Rev. 2006 Jan 25;(1):CD003476. 

3) Adverse effects of the antipsychotics

JAMA 2005;294:1934-43

NEJM 2005;353:2335-41

Ann Intern Med 2007;146:775-86

4) DART-AD study – effect of stopping antipsychotics

Lancet Neurol 2009;8:151–7

PLoS Med 5(4):e76.doi:10.1371/journal.pmed.0050076

5) Tools for practice

What are the Risks and Benefits of Stopping Antipsychotics in the Elderly?

In episode 134, we get into the nitty gritty of choosing a second drug for schizophrenia if the first one doesn’t work or is not tolerated. In general, it appears there is some evidence to favour clozapine over other agents but the difference isn’t great and as with virtually all of medicine one has to intermingle the available evidence with a good dose of art to make a beautiful therapeutic picture.   

Show notes

1) CATIE

N Engl J Med 2005;353:1209–23

2) CUtLASS 1

Arch Gen Psychiatry 2006;63:1079–87

3) A meta-analysis of the efficacy of second-generation antipsychotics 

Arch Gen Psychiatry 2003;60:553-64

2) Clozapine versus other atypical antipsychotics for schizophrenia

Cochrane library

3)Clozapine versus typical neuroleptic medication for schizophrenia

Cochrane library

4) CATIE – clozapine versus other agents who do not respond to prior atypical antipsychotic treatment 

Am J Psychiatry 2006;163:600–10

In episode 133, Mike and James again welcome Adil Virani to help us along with our antipsychotic drug discussion. We discuss the differences between the first and second generation antipsychotics, how to start, and when to consider a depot preparation. At the end of the podcast James realises that he has basically been hearing voices for the entire podcast but was reassured to find out the voices were actually Mike and Adil’s and that in general, they were telling the truth. 

Show notes

1) CATIE

N Engl J Med 2005;353:1209–23

2) CUtLASS 1

Arch Gen Psychiatry 2006;63:1079–87

Schizophr Bull 2006;32:715–23

3) Haloperiodol vs risperidone

N Engl J Med 2002;346:16-22

In episode 132, Mike and James bring back their good friend and psych colleague Adil Virani, to help out in thinking about the use of antipsychotics. In part 1, we talk about schizophrenia in general and start to get into a discussion of the use of antipsychotics for this condition and how to decide what drugs to choose. However, at the end our thought process becomes a bit scattered and we decide to leave the discussion about the specific drugs to the next podcast.

Show notes

None