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Is Kemadrine Necessary Along With Risdone For Schizophrenia?
Question: DOCTOR, The psychiatrist has verbally diagnosed my son to have schizophrenia. The prescription for the past one year is Risdone 2 mg (present dose brought down from 5 mg), 2.5 mg Kemadrine twice a day and Zapiz 0.25 mg also twice a day. My son has improved a lot. But still feels a lack of air so much so that all doors & windows must be open, feels extremely hot & feels tired most of the while. Otherwise he is in good cheer, back to working a few hours a day, happy to meet people, etc. Please let me know if Kemadrine is necessary along with Risdone in a low dose? Hope it does not induce Parkinsons? Also, is Zapiz habbit forming & should it be gradually weaned off? Many thanks
Brief Answer:
Generally it is not necessary in 85% cases
Detailed Answer:
Dear XXXXXXX,
Thanks for using healthcare magic.
I don't find any abnormal thing in your son's prescription. It seems to me that it is written by a learned psychiatrist.
Generally the Kemadrine or another anticholinergic was part of standard prescription when first generation (older) antipsychotics were used for treatment of schizophrenia to prevent the development of drug induced parkinsonism.
In last twenty years the older antipsychotics have been replaced by newer antipsychotics (Risdone is one among them) which has lower propensity to develop drug induced parkinsonism. Having said this current guideline recommend not to use anticholinergics (e.g. kemadrine) till the development of side effects of such nature although few of older experts are not convinced with this and still prefer to prescribe anticholinergics as part of standard treatment. It is also recommended to use the anticholinergics if patient have previous history of such side effects.
I feel that anticholinergics to be used only when you develop the requirement. The reason for my preference is that only 15 % of those who receive antipsychotics prescription develop drug induced parkinsonism.
Yes Zapiz is habit forming but many times this nature of Zapiz is used in patient benefit. Many of patients with schizophrenia do not accept medication saying they do not have illness or they are not in the need of treatment. With prescription of zapiz in lowest possible dose patient have good compliance and they stick to the prescribed treatment. I feel if your son is well learned and have awareness of his illness and accepts medication without any problem than gradual withdrawal of zapiz can be planned. But it is not recommended to reduce two drugs at same time and it should be stopped in very gradual manner.
So in my opinion the Kemadrine can be reduced in gradual manner. Please be assure that it does not develop parkinsonism it is used to prevent development of drug induced parkinsonism.
so My current recommendations are
1. Ask the treating psychiatrist to reduce the dose of Kemadrine as there is low risk of development of drug induced parkinsonism with Risdone.
2. As the anxiety symptoms (suffocation) are still a problem prescription of some anti anxiety drug may be the need of hour. Discuss the same although there is chance that removal of Kemadrine is the only thing required.
'Hope I have answered your query. If you have any further questions I will be happy to help".
Thanks
Generally it is not necessary in 85% cases
Detailed Answer:
Dear XXXXXXX,
Thanks for using healthcare magic.
I don't find any abnormal thing in your son's prescription. It seems to me that it is written by a learned psychiatrist.
Generally the Kemadrine or another anticholinergic was part of standard prescription when first generation (older) antipsychotics were used for treatment of schizophrenia to prevent the development of drug induced parkinsonism.
In last twenty years the older antipsychotics have been replaced by newer antipsychotics (Risdone is one among them) which has lower propensity to develop drug induced parkinsonism. Having said this current guideline recommend not to use anticholinergics (e.g. kemadrine) till the development of side effects of such nature although few of older experts are not convinced with this and still prefer to prescribe anticholinergics as part of standard treatment. It is also recommended to use the anticholinergics if patient have previous history of such side effects.
I feel that anticholinergics to be used only when you develop the requirement. The reason for my preference is that only 15 % of those who receive antipsychotics prescription develop drug induced parkinsonism.
Yes Zapiz is habit forming but many times this nature of Zapiz is used in patient benefit. Many of patients with schizophrenia do not accept medication saying they do not have illness or they are not in the need of treatment. With prescription of zapiz in lowest possible dose patient have good compliance and they stick to the prescribed treatment. I feel if your son is well learned and have awareness of his illness and accepts medication without any problem than gradual withdrawal of zapiz can be planned. But it is not recommended to reduce two drugs at same time and it should be stopped in very gradual manner.
So in my opinion the Kemadrine can be reduced in gradual manner. Please be assure that it does not develop parkinsonism it is used to prevent development of drug induced parkinsonism.
so My current recommendations are
1. Ask the treating psychiatrist to reduce the dose of Kemadrine as there is low risk of development of drug induced parkinsonism with Risdone.
2. As the anxiety symptoms (suffocation) are still a problem prescription of some anti anxiety drug may be the need of hour. Discuss the same although there is chance that removal of Kemadrine is the only thing required.
'Hope I have answered your query. If you have any further questions I will be happy to help".
Thanks
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Thank you Doctor. Helpful indeed!
I would like to further know if the 3 symptoms as mentioned in the earlier mail i.e. of 'feeling a lack of air-suffocation, feeling very hot & feeling tired all the time' are what you term 'delusions' in schizophrenia or are these symptoms indications of a previous mental trauma? Background : The person before the onset of the problem had undergone a high pressured 18 hour work schedule for 1 year in an overseas MBA course (as compared to working leisurely in a home business before) and had lived in a cramped small room with very little ventilation (as compared to living in a large open bungalow before).
Also, since the person is not interested in seeking psychological help - Will just taking medications alone help in relieving the symptoms or the symptoms will not go until psychological help / CBT is resorted to?
Thanks
XXXXXX
I would like to further know if the 3 symptoms as mentioned in the earlier mail i.e. of 'feeling a lack of air-suffocation, feeling very hot & feeling tired all the time' are what you term 'delusions' in schizophrenia or are these symptoms indications of a previous mental trauma? Background : The person before the onset of the problem had undergone a high pressured 18 hour work schedule for 1 year in an overseas MBA course (as compared to working leisurely in a home business before) and had lived in a cramped small room with very little ventilation (as compared to living in a large open bungalow before).
Also, since the person is not interested in seeking psychological help - Will just taking medications alone help in relieving the symptoms or the symptoms will not go until psychological help / CBT is resorted to?
Thanks
XXXXXX
Brief Answer:
No it is not delusion
Detailed Answer:
Dear XXXXXX,
Thanks for reverting back to me.
Delusions are very different things in compare to your son's current symptoms. Classicaly they are defined as false belief which patients hold as a true belief and not convinced by any means and that should not be as per patients social and cultural background.
Regarding three symptoms you have mentioned its hard to say whether they are due to previous mental trauma or due to ongoing schizophrenic illness as these symptoms can be found in both conditions.
The mental pressure experienced during MBA can be taken as the illness precipitant and there is possibility that he is still trying to cope with the things. It is possible to find the cause of symptoms after detailed interview (we call it Mental status examination) and accordingly future mode of treatment can be planned.
The current medication available with schizophrenia can control almost all symptoms in around two third of the patients and from available history it seems to me that he is among the good responders. There is no harm in getting psychological help but the usefullness of CBT in schizophrenia is still not beyond doubt.
So I mean to say that he can be treated only with medication but other sort of support from family and surrounding is required so he does not feel isolated and find easy to re integrate in society.
'Hope I have answered your query. If you have any further questions I will be happy to help".
Thanks
No it is not delusion
Detailed Answer:
Dear XXXXXX,
Thanks for reverting back to me.
Delusions are very different things in compare to your son's current symptoms. Classicaly they are defined as false belief which patients hold as a true belief and not convinced by any means and that should not be as per patients social and cultural background.
Regarding three symptoms you have mentioned its hard to say whether they are due to previous mental trauma or due to ongoing schizophrenic illness as these symptoms can be found in both conditions.
The mental pressure experienced during MBA can be taken as the illness precipitant and there is possibility that he is still trying to cope with the things. It is possible to find the cause of symptoms after detailed interview (we call it Mental status examination) and accordingly future mode of treatment can be planned.
The current medication available with schizophrenia can control almost all symptoms in around two third of the patients and from available history it seems to me that he is among the good responders. There is no harm in getting psychological help but the usefullness of CBT in schizophrenia is still not beyond doubt.
So I mean to say that he can be treated only with medication but other sort of support from family and surrounding is required so he does not feel isolated and find easy to re integrate in society.
'Hope I have answered your query. If you have any further questions I will be happy to help".
Thanks
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Dear Doctor,
Many thanks for your views. Much appreciate.
Although the Psychiatrist (under whose treatment is being followed) had verbally diagnosed Schizophrenia - I'm not sure if it may be so, as another Psychiatrist (who also met the patient though recently) felt that it could be Bipolar Disorder but was not sure since he had met the patient only once. The original Psychiatrist is the one who calls these 3 symptoms of lack of air, feeling hot & feeling tired, as "delusions", although not being classic in nature. He has therefore recommended now Chlozapine 25 mg, plus 3 mg Risdone, plus the usual 2.5 mg x2 Kemadrine, plus 40 mg of Inderal and removed Zapiz, expecting this new cocktail of drugs to take care of the ' 3 delusions' as he terms them.
The recent Psychiatrist feels that Chlozapine should not be given at all as Risdone is working and that the same 2 mg Risdone along with a weaning off dose of Zapiz be given for a while till the habbit is removed and that Kemadrine be stopped immediately. He also suggested that the patient meet a Psychologist to see if the 3 persisting symptoms needed attention from that end.
However, the patient is against seeing a Psychologist & reduce medicines and therefore now unwilling to see this recent Psychiatrist again - So he continues to take the old prescription of 2 mg Risdone etc as given in earlier XXXXXXX as he feels that he is doing well with it, which we also endorse except for the 3 persisting symptoms. FYI - It took the patient 2.5 years to see a Psychiatrist and he was in denial for that period.
Grateful if I could get your opinion based on the following data as below:
Present situation as on XXXXXXX 2014:
1. Improved dramatically in the last one year after taking medicines compared to previous 2.5 years before that that were without medicine – Current Dosage 2ml Risdone once/daily, 2.5 mg Kemadrine twice/daily and Zapiz 0.25 mg twice/daily. Peak dosage of Risdone was 5ml for a short while in July 2013 – Present dose of 2ml Risdone is for the last 4 months or so.
2. Medical history – Thalasemia Minor – No known allergies – Apparently, Inderal does not agree with him.
3. Work – Interested in working & works a few hours a day (had stopped for a month or so in the heat). Attends to necessary mob calls /emails. Always had unfixed times of work view home business.
4. Exercise – Walks (not brisk) every day for about 30-40 mins. Swims a few times a week however for only about 5-10 mins each time.
5. Food – Eats simple home food same 2 dishes virtually every day. Has excessive chocolates & cheese spread every day. However, happy to eat out around twice a week in restaurants. Appetite low.
6. Communication – Much improved since with parents.
7. Emotions – Much improved – Sensitive to others by & large.
8. Sociability - Excellent graces with outsiders. Keen to make friends of his type but unable to find the right kind. Wants to get married – Needs companionship.
9. Entertainment - Watches comedies on TV / movies often. Good sense of humour with all.
10. Hygiene – Has 1-2 baths a day in Summer & 1 in Winter. Brushes teeth once a day. Wears clean clothes. Overall good enough.
11. Dress – Alternates between same 2 pairs of outfits every other day.
12. Sleep – Undisturbed sleep at night for about 10-12 hours – Rests/Sleeps another 1-2 hours during the day sometimes.
13. Feels air is inadequate – Keeps all jail windows & jail doors open in the house day & night irrespective of rain / dust storms / heat. Main door also open during day.
Contd …2
14. Feels extremely hot – Needs ac on in the area that he is in the house throughout day & night. Will not close windows / doors for ac effectiveness in view of above air problem.
15. Feels tired very easily – Stopped tennis – Minimises activity in view of this problem.
Background:
1. Stressed 1 year out of country MBA in 2010.
2. B-12 down & a host of symptoms at that time – Unable to breathe/twitching/OCD hands washing/excessive phlegm-nose blowing/excessive sighing-yawning/no sleep at night/unable to concentrate/felt extremely cold/indigestion-burping/fatigue/etc.
3. MRI brain done – all apparently ok / Thyroid test done all ok.
4. Diagnosed GAD by Neuro – Took 3 months of Rexipra in mid 2011. Unwilling to meet a Psychiatrist or Psychologist for 2.5 years.
5. Improved condition for few months only – Got back to a bit of working / tennis / friends.
6. Deteriorated condition thereafter on all fronts to a prominent dysfunctional low in Feb, 2013 wherein became inactive – Did not eat for 10-15 days, kept himself in one room for about a month, no bath/grew beard & very poor hygiene at that time, prayed a lot / did ‘Shavasana’ most of the time and extremely silent. But yet was ALL THERE (not in a world of his own).
7. Came out of his cave like situation in a month & improved a bit until April, 2013. Thereafter became very restless & agitated & drove up & down from one place to another – VERY ACTIVE. Complained of extreme heat & lack of air. Before this episode he used to feel very cold (for 2.5 years) rather than hot. Was somewhat reckless about money and went & stayed in a hotel for the air-conditioning. Wanted to travel to cold places irrespective of the cost.
8. Finally, went to XXXXXXX in XXXXXXX 2013 - Treatment started without his knowledge & then subsequently agreed to see the Psychiatrist in July, 2013 in XXXXXXX
9. Cannot be forced to do anything since childhood. Also resistant to change.
10. Family history of Mental Ill-health.
Look forward to your reply. Much obliged.
Thanks & kind regards
XXXXXXX
Many thanks for your views. Much appreciate.
Although the Psychiatrist (under whose treatment is being followed) had verbally diagnosed Schizophrenia - I'm not sure if it may be so, as another Psychiatrist (who also met the patient though recently) felt that it could be Bipolar Disorder but was not sure since he had met the patient only once. The original Psychiatrist is the one who calls these 3 symptoms of lack of air, feeling hot & feeling tired, as "delusions", although not being classic in nature. He has therefore recommended now Chlozapine 25 mg, plus 3 mg Risdone, plus the usual 2.5 mg x2 Kemadrine, plus 40 mg of Inderal and removed Zapiz, expecting this new cocktail of drugs to take care of the ' 3 delusions' as he terms them.
The recent Psychiatrist feels that Chlozapine should not be given at all as Risdone is working and that the same 2 mg Risdone along with a weaning off dose of Zapiz be given for a while till the habbit is removed and that Kemadrine be stopped immediately. He also suggested that the patient meet a Psychologist to see if the 3 persisting symptoms needed attention from that end.
However, the patient is against seeing a Psychologist & reduce medicines and therefore now unwilling to see this recent Psychiatrist again - So he continues to take the old prescription of 2 mg Risdone etc as given in earlier XXXXXXX as he feels that he is doing well with it, which we also endorse except for the 3 persisting symptoms. FYI - It took the patient 2.5 years to see a Psychiatrist and he was in denial for that period.
Grateful if I could get your opinion based on the following data as below:
Present situation as on XXXXXXX 2014:
1. Improved dramatically in the last one year after taking medicines compared to previous 2.5 years before that that were without medicine – Current Dosage 2ml Risdone once/daily, 2.5 mg Kemadrine twice/daily and Zapiz 0.25 mg twice/daily. Peak dosage of Risdone was 5ml for a short while in July 2013 – Present dose of 2ml Risdone is for the last 4 months or so.
2. Medical history – Thalasemia Minor – No known allergies – Apparently, Inderal does not agree with him.
3. Work – Interested in working & works a few hours a day (had stopped for a month or so in the heat). Attends to necessary mob calls /emails. Always had unfixed times of work view home business.
4. Exercise – Walks (not brisk) every day for about 30-40 mins. Swims a few times a week however for only about 5-10 mins each time.
5. Food – Eats simple home food same 2 dishes virtually every day. Has excessive chocolates & cheese spread every day. However, happy to eat out around twice a week in restaurants. Appetite low.
6. Communication – Much improved since with parents.
7. Emotions – Much improved – Sensitive to others by & large.
8. Sociability - Excellent graces with outsiders. Keen to make friends of his type but unable to find the right kind. Wants to get married – Needs companionship.
9. Entertainment - Watches comedies on TV / movies often. Good sense of humour with all.
10. Hygiene – Has 1-2 baths a day in Summer & 1 in Winter. Brushes teeth once a day. Wears clean clothes. Overall good enough.
11. Dress – Alternates between same 2 pairs of outfits every other day.
12. Sleep – Undisturbed sleep at night for about 10-12 hours – Rests/Sleeps another 1-2 hours during the day sometimes.
13. Feels air is inadequate – Keeps all jail windows & jail doors open in the house day & night irrespective of rain / dust storms / heat. Main door also open during day.
Contd …2
14. Feels extremely hot – Needs ac on in the area that he is in the house throughout day & night. Will not close windows / doors for ac effectiveness in view of above air problem.
15. Feels tired very easily – Stopped tennis – Minimises activity in view of this problem.
Background:
1. Stressed 1 year out of country MBA in 2010.
2. B-12 down & a host of symptoms at that time – Unable to breathe/twitching/OCD hands washing/excessive phlegm-nose blowing/excessive sighing-yawning/no sleep at night/unable to concentrate/felt extremely cold/indigestion-burping/fatigue/etc.
3. MRI brain done – all apparently ok / Thyroid test done all ok.
4. Diagnosed GAD by Neuro – Took 3 months of Rexipra in mid 2011. Unwilling to meet a Psychiatrist or Psychologist for 2.5 years.
5. Improved condition for few months only – Got back to a bit of working / tennis / friends.
6. Deteriorated condition thereafter on all fronts to a prominent dysfunctional low in Feb, 2013 wherein became inactive – Did not eat for 10-15 days, kept himself in one room for about a month, no bath/grew beard & very poor hygiene at that time, prayed a lot / did ‘Shavasana’ most of the time and extremely silent. But yet was ALL THERE (not in a world of his own).
7. Came out of his cave like situation in a month & improved a bit until April, 2013. Thereafter became very restless & agitated & drove up & down from one place to another – VERY ACTIVE. Complained of extreme heat & lack of air. Before this episode he used to feel very cold (for 2.5 years) rather than hot. Was somewhat reckless about money and went & stayed in a hotel for the air-conditioning. Wanted to travel to cold places irrespective of the cost.
8. Finally, went to XXXXXXX in XXXXXXX 2013 - Treatment started without his knowledge & then subsequently agreed to see the Psychiatrist in July, 2013 in XXXXXXX
9. Cannot be forced to do anything since childhood. Also resistant to change.
10. Family history of Mental Ill-health.
Look forward to your reply. Much obliged.
Thanks & kind regards
XXXXXXX
Brief Answer:
I endorse second psychiatrist's opinion
Detailed Answer:
Dear XXXXXX,
Thanks for reverting back with wonderful explanation.
After going through your query I have my impression of patient and I will try to make some short comments.
1. I agree with second psychiatrist regarding diagnosis as well as his treatment.
2. If he is doing well there is no point of adding clozapine or increasing dose of risdon.
3. There is no point in continuing procyclidine 2.5 mg
4.Decision to drop Zapiz is welcome but his three symptoms may aggravate on sudden withdrawal of zapiz.
5. There is chance that inderal will take care of anxiety features but he need to be monitored for development of depressive symptoms with use of inderal (depression is side effect of inderal)
4. Seeing a psychologist is optional but may be useful
5. I think for his current symptoms saying delusion is not the appropriate word. In my view they are anxiety symptoms
6. Other than choice of his clothes (uses only two pair) he is doing well and needs to be motivated enough to continue
7. My earlier suggestion of using SSRI can be used to control these three troublesome symptoms
8. Although he can not be forced for anything but he can be encouraged to do positive things and that should be done
9. Never be critical of the patient
10. Respect his choices but explain him risky behavior for example preference for high calorie diet.
11. Ingestion of medication need to be monitored by the some other person in family not by the patient only. There is chance that he may skip medication deliberately.
I request you to discuss above said points with the treating psychiatrist and make the necessary changes that are agreed upon between your son and the psychiatrist.
'Hope I have answered your query. If you have any further questions I will be happy to help".
Thanks
I endorse second psychiatrist's opinion
Detailed Answer:
Dear XXXXXX,
Thanks for reverting back with wonderful explanation.
After going through your query I have my impression of patient and I will try to make some short comments.
1. I agree with second psychiatrist regarding diagnosis as well as his treatment.
2. If he is doing well there is no point of adding clozapine or increasing dose of risdon.
3. There is no point in continuing procyclidine 2.5 mg
4.Decision to drop Zapiz is welcome but his three symptoms may aggravate on sudden withdrawal of zapiz.
5. There is chance that inderal will take care of anxiety features but he need to be monitored for development of depressive symptoms with use of inderal (depression is side effect of inderal)
4. Seeing a psychologist is optional but may be useful
5. I think for his current symptoms saying delusion is not the appropriate word. In my view they are anxiety symptoms
6. Other than choice of his clothes (uses only two pair) he is doing well and needs to be motivated enough to continue
7. My earlier suggestion of using SSRI can be used to control these three troublesome symptoms
8. Although he can not be forced for anything but he can be encouraged to do positive things and that should be done
9. Never be critical of the patient
10. Respect his choices but explain him risky behavior for example preference for high calorie diet.
11. Ingestion of medication need to be monitored by the some other person in family not by the patient only. There is chance that he may skip medication deliberately.
I request you to discuss above said points with the treating psychiatrist and make the necessary changes that are agreed upon between your son and the psychiatrist.
'Hope I have answered your query. If you have any further questions I will be happy to help".
Thanks
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
Dear Doctor,
Thank you for your patience & helpful advice. May God be with you!
I now assume the following:
1. That the diagnosis appears to be Bipolar Disorder rather than Schizophrenia.
2. That Risdone will over a period of time have a cumulative effect towards normalcy and also in particular towards reduction of the 3 symptoms. If the 3 symptoms persist - then anti anxiety drugs will by & large take care of the problem The gradual phasing out of Kemadrine & maybe Zapiz too is clear.
Are there any other anti anxiety drugs (apart from Inderal) that do not have side effects of depression?
Thanks & kind regards
XXXXXX
Thank you for your patience & helpful advice. May God be with you!
I now assume the following:
1. That the diagnosis appears to be Bipolar Disorder rather than Schizophrenia.
2. That Risdone will over a period of time have a cumulative effect towards normalcy and also in particular towards reduction of the 3 symptoms. If the 3 symptoms persist - then anti anxiety drugs will by & large take care of the problem The gradual phasing out of Kemadrine & maybe Zapiz too is clear.
Are there any other anti anxiety drugs (apart from Inderal) that do not have side effects of depression?
Thanks & kind regards
XXXXXX
Brief Answer:
SSRI or SNRI group of medication can be used
Detailed Answer:
Dear XXXXX,
Welcome back.
Your assumption is perfectly fine but please be informed that in long term there may be many ups and downs of patient which affect over all well being. It may affect response to medicine and there may be requirement to change medication or add on some another medication.
Having said this there is possibility that he may asymptomatic for years or lifelong with low dose of medication and after a certain period of time there is possibility that he does not require any kind of treatment.
I am stressing on these things as the course of bipolar disorder is highly variable and unpredictable so keeping close observation over his symptoms while giving him the due space is of at most importance.
"If you do not have any clarifications, you can close the discussion and rate the answer. Wish you good health and speedy and complete recovery of your son ".
Thanks and Regards
Dr Ashok
SSRI or SNRI group of medication can be used
Detailed Answer:
Dear XXXXX,
Welcome back.
Your assumption is perfectly fine but please be informed that in long term there may be many ups and downs of patient which affect over all well being. It may affect response to medicine and there may be requirement to change medication or add on some another medication.
Having said this there is possibility that he may asymptomatic for years or lifelong with low dose of medication and after a certain period of time there is possibility that he does not require any kind of treatment.
I am stressing on these things as the course of bipolar disorder is highly variable and unpredictable so keeping close observation over his symptoms while giving him the due space is of at most importance.
"If you do not have any clarifications, you can close the discussion and rate the answer. Wish you good health and speedy and complete recovery of your son ".
Thanks and Regards
Dr Ashok
Note: For further guidance on mental health, Click here.
Above answer was peer-reviewed by :
Dr. Vinay Bhardwaj
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