- Email: [email protected]
Response to Hasche's Letter
Letters to the Editor these measures of validity for mental disorders. Leslie Hasche, M.S.W. Washington University in St. Louis References 1. Starkstein SE, Mizrahi R, Garau L: Specificity of symptoms of depression in Alzheimer’s disease: a longitudinal analysis. Am J Geriatr Psychiatry 2005; 13:802–807 2. Olin JT, Katz IR, Meyers BS, et al: Provisional diagnostic criteria for depression of Alzheimer disease: rationale and background. Am J Geriatr Psychiatry 2002;10: 129–141 3. Robins L: Using survey results to improve the validity of standard psychiatric nomenclature. Arch Gen Psychiatry 2004; 61: 1188 –1194
Response to Hasche’s Letter
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DITOR: We thank the author of the letter for the positive comments on our study. The author also raised two important points. First, our findings should be restricted to individuals with Alzheimer disease (AD) attending a memory clinic at a tertiary care center. We are currently studying whether our findings also generalize to patients with AD with more severe dementia living in nursing homes. The second (very important) issue raised by the author of the letter is whether the aim for this type of research should be to validate previous nomenclatures or rather to focus on clinical syndromes as they appear “in nature.” As the author suggests, a host of contextual variables may have a large impact on the phenomenology of a given psychiatric condition. Our strategy is to accept the core symptoms of depression (as included in both the Diagnostic and Statistical Manual of
Am J Geriatr Psychiatry 14:8, August 2006
Mental Disorders, Fourth Edition and the International Classification of Diseases, 10th Revision) as necessary criteria and examine the concordance with other putative symptoms of depression. Ultimately, these emerging neuropsychiatric syndromes will have to be validated against appropriate standards such as biologic markers and response to treatment. Sergio E. Starkstein, M.D., Ph.D. University of Western Australia
Cognitive Behavior Therapy and Clozapine Synergy in an Older Adult With Schizophrenia?
E
DITOR: Clozapine is an effective pharmacotherapy for older patients with treatment-refractory schizophrenia.1 Clozapine may be underused as a result of medication side effects, the need for hematologic monitoring, or paranoia about the medication and monitoring.2 Cognitive behavior therapy (CBT) augmented response to clozapine in adult patients,3 but a PubMed search on November 16, 2005 did not reveal reports of the use of this combination in elderly patients. We report a case of effective combined treatment using clozapine and CBT. An 80-year-old nondemented woman with a diagnosis of paranoid schizophrenia and treatmentresistant auditory hallucinations, delusions of persecution, control and acting on them was hospitalized 20 times. During the last hospitalization, clozapine was initi-
ated but withdrawn because of delusions of being poisoned by blood draws. She was discharged to an assisted living facility on 800 mg quetiapine per day and had persistent auditory hallucinations and delusions of persecution and control. CBT was initiated with a focus on the delusion of being poisoned by blood tests. By providing facts about blood tests, examining evidence for and against the delusion, and assuring that all blood tests would be done in a familiar setting, she consented for clozapine retrial. Clozapine was crosstitrated to 200 mg per day and quetiapine was withdrawn. Serum clozapine levels were 309 ng/mL. Subsequently, she remained adherent to medication and blood draws and therapy focus was broadened to address other delusions and auditory hallucinations. Over the next 14 months, she had 24 sessions of CBT. Between the sessions, a psychiatric nurse visited her to reinforce the cognitive techniques and encouraged homework completion. The symptoms remitted completely and there were no instances of delusional behaviors. She began to enjoy activities with her family and moved in to live with them. The combination of CBT and clozapine led to complete remission of treatment-resistant positive psychotic symptoms and significant improvement in quality of life for this older woman. It is difficult to estimate the relative contribution of each of these therapeutic components to her overall improvement. CBT may have helped in maintaining long-term medication adherence to clozapine, and clozapine may have reduced her psychotic symptoms to an extent that permitted CBT to become more effective.
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Response to Hasche’s Letter
E
DITOR: We thank the author of the letter for the positive comments on our study. The author also raised two important points. First, our findings should be restricted to individuals with Alzheimer disease (AD) attending a memory clinic at a tertiary care center. We are currently studying whether our findings also generalize to patients with AD with more severe dementia living in nursing homes. The second (very important) issue raised by the author of the letter is whether the aim for this type of research should be to validate previous nomenclatures or rather to focus on clinical syndromes as they appear “in nature.” As the author suggests, a host of contextual variables may have a large impact on the phenomenology of a given psychiatric condition. Our strategy is to accept the core symptoms of depression (as included in both the Diagnostic and Statistical Manual of
Am J Geriatr Psychiatry 14:8, August 2006
Mental Disorders, Fourth Edition and the International Classification of Diseases, 10th Revision) as necessary criteria and examine the concordance with other putative symptoms of depression. Ultimately, these emerging neuropsychiatric syndromes will have to be validated against appropriate standards such as biologic markers and response to treatment. Sergio E. Starkstein, M.D., Ph.D. University of Western Australia
Cognitive Behavior Therapy and Clozapine Synergy in an Older Adult With Schizophrenia?
E
DITOR: Clozapine is an effective pharmacotherapy for older patients with treatment-refractory schizophrenia.1 Clozapine may be underused as a result of medication side effects, the need for hematologic monitoring, or paranoia about the medication and monitoring.2 Cognitive behavior therapy (CBT) augmented response to clozapine in adult patients,3 but a PubMed search on November 16, 2005 did not reveal reports of the use of this combination in elderly patients. We report a case of effective combined treatment using clozapine and CBT. An 80-year-old nondemented woman with a diagnosis of paranoid schizophrenia and treatmentresistant auditory hallucinations, delusions of persecution, control and acting on them was hospitalized 20 times. During the last hospitalization, clozapine was initi-
ated but withdrawn because of delusions of being poisoned by blood draws. She was discharged to an assisted living facility on 800 mg quetiapine per day and had persistent auditory hallucinations and delusions of persecution and control. CBT was initiated with a focus on the delusion of being poisoned by blood tests. By providing facts about blood tests, examining evidence for and against the delusion, and assuring that all blood tests would be done in a familiar setting, she consented for clozapine retrial. Clozapine was crosstitrated to 200 mg per day and quetiapine was withdrawn. Serum clozapine levels were 309 ng/mL. Subsequently, she remained adherent to medication and blood draws and therapy focus was broadened to address other delusions and auditory hallucinations. Over the next 14 months, she had 24 sessions of CBT. Between the sessions, a psychiatric nurse visited her to reinforce the cognitive techniques and encouraged homework completion. The symptoms remitted completely and there were no instances of delusional behaviors. She began to enjoy activities with her family and moved in to live with them. The combination of CBT and clozapine led to complete remission of treatment-resistant positive psychotic symptoms and significant improvement in quality of life for this older woman. It is difficult to estimate the relative contribution of each of these therapeutic components to her overall improvement. CBT may have helped in maintaining long-term medication adherence to clozapine, and clozapine may have reduced her psychotic symptoms to an extent that permitted CBT to become more effective.
717