Amyotrophic lateral sclerosis (ALS) is a progressive degenerative syndrome involving upper and lower alpha-motor neuron systems. A substantial body of evidence supports the hypothesis that glutamate-mediated excito-toxicity is responsible for the death of motor neurons in ALS.5 Evidence suggests that having schizophrenia may be associated with an increased risk of developing ALS, and this risk might be explained by the toxic effects of excitatory amino acids on neuronal function.1,6 Recently, Stommel et al7 hypothesized that treating schizophrenia could protect against development of ALS, which is of interest because antipsychotics may have direct and indirect effects on modulating glutamate receptor systems.8
Robert H. Howland, MD
Associate Professor of Psychiatry
University of Pittsburgh School of Medicine
Western Psychiatric Institute and Clinic
Pittsburgh, PA
Treating delirium
Regarding “Atypical antipsychotics for delirium: A reasonable alternative to haloperidol?” (Current Psychiatry, January 2011, p. 37-46): Delirium usually is an acute encephalopathy with cerebral dysfunction caused by varying pathologies, most of which are extracranial. Examples include mental confusion induced by hypoxia or hypoglycemia. Primary treatment of delirium must be aimed at the specific cause.
Antipsychotic drugs are only a symptomatic intervention for delirium. They can and do provide behavioral control; however, these medications may worsen cases of alcohol or sedative withdrawal, ictal-related problems, neuroleptic malignant syndrome, etc. An antipsychotic may complicate other conditions, thus creating additional clinical difficulties for some patients. Recommending antipsychotics as a treatment focuses on symptomatic aspects; however, the critical mandate is to diagnose and specifically manage the etiology. Once the cause is corrected, the delirium usually resolves.
While treating the primary pathology, if behavioral issues still urgently require immediate control, a benzodiazepine is safer than an antipsychotic. Both medications provide symptomatic control, but a benzodiazepine is less likely to add new clinical problems. The only major precaution with a benzodiazepine is to avoid overprescribing. It is simply safer to rely on benzodiazepines for short-term behavioral management.
Steven Lippmann, MD
Professor of Psychiatry
University of Louisville School of Medicine
Louisville, KY