Typicals vs atypicals

“Corticosteroid psychosis: Stop therapy or add psychotropics?” (Med/Psych Update, Current Psychiatry, January 2010) provided excellent information, especially for consultation-liaison psychiatrists. I understand studies have been funded to show efficacy for atypicals, but can the authors point to studies that show efficacy for perphenazine, haloperidol, or other typical antipsychotics? My guess is that typicals and atypicals essentially are equivalent in corticosteroid-induced acute mania.

Corey Yilmaz, MD
Adult and child psychiatrist
Buckeye, AZ

The authors respond

Dr. Yilmaz is correct that typical antipsychotics would be useful for off-label treatment of corticosteroid-induced psychosis. Three publications provide further detail about using these medications for corticosteroid-induced psychosis. A case series by Wada et al¹ and a case report by Ahmad and Rasul² report on the efficacy of low-dose (1 mg/d to 4 mg/d) haloperidol in treating patients who developed acute psychosis following initiation of a corticosteroid. These patients showed a rapid and marked improvement with haloperidol. A brief report by Bloch et al³ describes a patient prophylactically treated with chlorpromazine, 150 mg, before receiving high-dose methylprednisone, initiated at 1 g and titrated over 10 days. The patient did not exhibit any psychiatric symptoms but did develop hypomania when chlorpromazine was stopped, which resolved with readministration of this medication. We did not find any case reports on perphenazine.

Andrew J. Muzyk, PharmD
Assistant professor
Campbell University School of Pharmacy
Clinical specialist in internal medicine/psychiatry
Department of pharmacy, Duke University Hospital

Shannon Holt, PharmD
Clinical pharmacist

Jane P. Gagliardi, MD
Assistant professor of psychiatry and behavioral sciences
Assistant professor of medicine
Duke University School of Medicine
Durham, NC

“Corticosteroid psychosis: Stop therapy or add psychotropics?” (Med/Psych Update, Current Psychiatry, January 2010) provided excellent information, especially for consultation-liaison psychiatrists. I understand studies have been funded to show efficacy for atypicals, but can the authors point to studies that show efficacy for perphenazine, haloperidol, or other typical antipsychotics? My guess is that typicals and atypicals essentially are equivalent in corticosteroid-induced acute mania.

Corey Yilmaz, MD
Adult and child psychiatrist
Buckeye, AZ

The authors respond

Dr. Yilmaz is correct that typical antipsychotics would be useful for off-label treatment of corticosteroid-induced psychosis. Three publications provide further detail about using these medications for corticosteroid-induced psychosis. A case series by Wada et al¹ and a case report by Ahmad and Rasul² report on the efficacy of low-dose (1 mg/d to 4 mg/d) haloperidol in treating patients who developed acute psychosis following initiation of a corticosteroid. These patients showed a rapid and marked improvement with haloperidol. A brief report by Bloch et al³ describes a patient prophylactically treated with chlorpromazine, 150 mg, before receiving high-dose methylprednisone, initiated at 1 g and titrated over 10 days. The patient did not exhibit any psychiatric symptoms but did develop hypomania when chlorpromazine was stopped, which resolved with readministration of this medication. We did not find any case reports on perphenazine.

Andrew J. Muzyk, PharmD
Assistant professor
Campbell University School of Pharmacy
Clinical specialist in internal medicine/psychiatry
Department of pharmacy, Duke University Hospital

Shannon Holt, PharmD
Clinical pharmacist

Jane P. Gagliardi, MD
Assistant professor of psychiatry and behavioral sciences
Assistant professor of medicine
Duke University School of Medicine
Durham, NC

“Corticosteroid psychosis: Stop therapy or add psychotropics?” (Med/Psych Update, Current Psychiatry, January 2010) provided excellent information, especially for consultation-liaison psychiatrists. I understand studies have been funded to show efficacy for atypicals, but can the authors point to studies that show efficacy for perphenazine, haloperidol, or other typical antipsychotics? My guess is that typicals and atypicals essentially are equivalent in corticosteroid-induced acute mania.

Corey Yilmaz, MD
Adult and child psychiatrist
Buckeye, AZ

The authors respond

Dr. Yilmaz is correct that typical antipsychotics would be useful for off-label treatment of corticosteroid-induced psychosis. Three publications provide further detail about using these medications for corticosteroid-induced psychosis. A case series by Wada et al¹ and a case report by Ahmad and Rasul² report on the efficacy of low-dose (1 mg/d to 4 mg/d) haloperidol in treating patients who developed acute psychosis following initiation of a corticosteroid. These patients showed a rapid and marked improvement with haloperidol. A brief report by Bloch et al³ describes a patient prophylactically treated with chlorpromazine, 150 mg, before receiving high-dose methylprednisone, initiated at 1 g and titrated over 10 days. The patient did not exhibit any psychiatric symptoms but did develop hypomania when chlorpromazine was stopped, which resolved with readministration of this medication. We did not find any case reports on perphenazine.

Andrew J. Muzyk, PharmD
Assistant professor
Campbell University School of Pharmacy
Clinical specialist in internal medicine/psychiatry
Department of pharmacy, Duke University Hospital

Shannon Holt, PharmD
Clinical pharmacist

Jane P. Gagliardi, MD
Assistant professor of psychiatry and behavioral sciences
Assistant professor of medicine
Duke University School of Medicine
Durham, NC