506
I would appreciate further communication with other depot phenothiazine clinics. References Marriott, P. Tardive dyskinesia: Possible drug interaction. British Medical Journal, 2:139,1975.
Marriott, P.; Grigor, j . ; Hiep, A.; empirically as a result of my clinical and Znaniecka, V. A psychiatric work with schizophrenic patients.The clinic for depot phenothiazines. generally excellent results I've had are Medical Journal of Australia, 2:957- evidence to me that I am, for the 960, 1973. most part, approximating appropriate Marriott, P., and Hiep, A. "A conversions. A final comment: These Mirror Image Out-Patient Study at a estimations are fine for clinical work. Depot Phenothiazine Clinic." Pre- But psychopharmacological research accurate, standardized sented at the First Pacific Congress demands of Psychiatry, Melbourne, Australia, conversion tables in order to foster rigorous methodology. May 1975. Dr. Peter Marriott Psychiatrist Royal Park Psychiatric Hospital Parkville, Victoria A ustralia
Kenneth Solomon, M.D. Instructor The Albany Medical College of Union University Albany, N. Y.
To the Editor:
Dr. Lehmann replies:
Heinz E. Lehmann's article on psychopharmacology was excellent and refreshing. I have some questions about the table of chlorpromazine equivalents of other neuroleptics. My major question is: How did Lehmann arrive at these equivalents? I have seen similar tables elsewhere, occasionally with different conversion factors. I am also intrigued because my clinical experience has led me to question the conversion factors for several of the drugs listed. Specifically, I use the following factors that differ from Lehmann's: triflupromazine 1:2, acetophenazine 1:10, fluphenazine 1:20, thiopromazine 1:20, perphenazine 1:12, haloperidol 1:20, thiothixene 1:20, and molindone 1:4. I have not yet had any clinical experience with loxapine succinate; I wonder what Lehmann would consider the conversion factor with this new agent. Finally, conversion to long-acting injectable fluphenazine presents a special problem. I have been estimating that 12.5 mg I.M. q2w is equivalent to chlorpromazine 400 mg daily. Again, I ask Lehmann's opinion with these drugs.
Dr. Marriott's point of the need to individualize the dosage of depot fluphenazine is certainly well taken. It is also a point that has been stressed repeatedly by Johnson in the United Kingdom (cf. Carney and Sheffield 1975). Dr. Marriott observed that some of his patients, after 4 to 6 weeks, still showed the sulfoxide metabolite of fluphenazine in the urine. One wonders whether this is an active metabolite of fluphenazine, since the sulfoxide metabolite of chlorpromazine is inactive. The reduction by 50 percent of days in hospital for Dr. Marriott's patients is in line with the experience of many other investigators. However, Carney and Sheffield report only 10 percent of patients requiring hospital readmission over a 3Vi year period, while Johnson (1976) found that 37 percent relapsed over a 2-year period and that about 20 percent of patients on depot fluphenazine maintenance treatment didn't follow the prescribed routine. However, that is still less than 50 percent of the noncompliance rate to be expected with oral maintenance treatment.
I want to emphasize that all these Dr. Solomon's question of how conversions have been arrived at did I—or for that matter anyone—
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at North Dakota State University on May 16, 2015
oxides) using an ultraviolet spectrophotometric method (M. Traill and P. Marriott, unpublished data, 1974). The survey of 131 outpatients serves to show a group who had received injections for nearly 2 years, with 44 percent having an interval of 5/52 or longer. A mirror-image study on this group revealed that the number of days spent in the hospital before fluphenazine treatment was initiated had been 12,434, whereas, after injections were begun, it was 6,219 days—a reduction of 50 percent. Although I would agree that the incidence of extrapyramidal side effects (EPS) with depot fluphenazine is probably higher than with oral phenothiazines, evaluation in this area has been difficult. The disagreement on a uniform EPS classification and the prescribing of antiparkinsonian drugs prophylactically led to the drugs being monitored more accurately than the side effects were recorded. In June 1973 some 57.49 percent of the clinic patients were on antiparkinsonian drugs. A vigorous teaching program involving the hospital staff saw a reduction in these drugs in February 1975 to 30.34 percent, despite the clinic numbers increasing to 379. We consider there are also sex and age variables with the need to continue such drugs, in some cases for at least 1 year. At present 28 patients have tardive dyskinesia with a female to male ratio of 2 : 1 . Of concern is the appearance of the syndrome some months following the use of benztropine in 11 cases.
SCHIZOPHRENIA BULLETIN
I would appreciate further communication with other depot phenothiazine clinics. References Marriott, P. Tardive dyskinesia: Possible drug interaction. British Medical Journal, 2:139,1975.
Marriott, P.; Grigor, j . ; Hiep, A.; empirically as a result of my clinical and Znaniecka, V. A psychiatric work with schizophrenic patients.The clinic for depot phenothiazines. generally excellent results I've had are Medical Journal of Australia, 2:957- evidence to me that I am, for the 960, 1973. most part, approximating appropriate Marriott, P., and Hiep, A. "A conversions. A final comment: These Mirror Image Out-Patient Study at a estimations are fine for clinical work. Depot Phenothiazine Clinic." Pre- But psychopharmacological research accurate, standardized sented at the First Pacific Congress demands of Psychiatry, Melbourne, Australia, conversion tables in order to foster rigorous methodology. May 1975. Dr. Peter Marriott Psychiatrist Royal Park Psychiatric Hospital Parkville, Victoria A ustralia
Kenneth Solomon, M.D. Instructor The Albany Medical College of Union University Albany, N. Y.
To the Editor:
Dr. Lehmann replies:
Heinz E. Lehmann's article on psychopharmacology was excellent and refreshing. I have some questions about the table of chlorpromazine equivalents of other neuroleptics. My major question is: How did Lehmann arrive at these equivalents? I have seen similar tables elsewhere, occasionally with different conversion factors. I am also intrigued because my clinical experience has led me to question the conversion factors for several of the drugs listed. Specifically, I use the following factors that differ from Lehmann's: triflupromazine 1:2, acetophenazine 1:10, fluphenazine 1:20, thiopromazine 1:20, perphenazine 1:12, haloperidol 1:20, thiothixene 1:20, and molindone 1:4. I have not yet had any clinical experience with loxapine succinate; I wonder what Lehmann would consider the conversion factor with this new agent. Finally, conversion to long-acting injectable fluphenazine presents a special problem. I have been estimating that 12.5 mg I.M. q2w is equivalent to chlorpromazine 400 mg daily. Again, I ask Lehmann's opinion with these drugs.
Dr. Marriott's point of the need to individualize the dosage of depot fluphenazine is certainly well taken. It is also a point that has been stressed repeatedly by Johnson in the United Kingdom (cf. Carney and Sheffield 1975). Dr. Marriott observed that some of his patients, after 4 to 6 weeks, still showed the sulfoxide metabolite of fluphenazine in the urine. One wonders whether this is an active metabolite of fluphenazine, since the sulfoxide metabolite of chlorpromazine is inactive. The reduction by 50 percent of days in hospital for Dr. Marriott's patients is in line with the experience of many other investigators. However, Carney and Sheffield report only 10 percent of patients requiring hospital readmission over a 3Vi year period, while Johnson (1976) found that 37 percent relapsed over a 2-year period and that about 20 percent of patients on depot fluphenazine maintenance treatment didn't follow the prescribed routine. However, that is still less than 50 percent of the noncompliance rate to be expected with oral maintenance treatment.
I want to emphasize that all these Dr. Solomon's question of how conversions have been arrived at did I—or for that matter anyone—
Downloaded from http://schizophreniabulletin.oxfordjournals.org/ at North Dakota State University on May 16, 2015
oxides) using an ultraviolet spectrophotometric method (M. Traill and P. Marriott, unpublished data, 1974). The survey of 131 outpatients serves to show a group who had received injections for nearly 2 years, with 44 percent having an interval of 5/52 or longer. A mirror-image study on this group revealed that the number of days spent in the hospital before fluphenazine treatment was initiated had been 12,434, whereas, after injections were begun, it was 6,219 days—a reduction of 50 percent. Although I would agree that the incidence of extrapyramidal side effects (EPS) with depot fluphenazine is probably higher than with oral phenothiazines, evaluation in this area has been difficult. The disagreement on a uniform EPS classification and the prescribing of antiparkinsonian drugs prophylactically led to the drugs being monitored more accurately than the side effects were recorded. In June 1973 some 57.49 percent of the clinic patients were on antiparkinsonian drugs. A vigorous teaching program involving the hospital staff saw a reduction in these drugs in February 1975 to 30.34 percent, despite the clinic numbers increasing to 379. We consider there are also sex and age variables with the need to continue such drugs, in some cases for at least 1 year. At present 28 patients have tardive dyskinesia with a female to male ratio of 2 : 1 . Of concern is the appearance of the syndrome some months following the use of benztropine in 11 cases.
SCHIZOPHRENIA BULLETIN
