Post-ictal psychosis successfully treated with quetiapine: a case report

1. Post-ictal psychosis successfully treated with quetiapine: a case report Alberto Augsten Student Pharmacist Nova Southeastern University College of Pharmacy Fort Lauderdale, FL

2. Post-ictal Psychosis (PIP) • Incidence of psychosis among epileptic population:3-7%1 • PIP accounts for ~25% of the psychosis of epilepsy (POE) population2 • Onset of PIP usually occurs within seven days of a seizure3 • Patients with POE present with positive symptoms as in schizophrenia3

3. Psychosis of Epilepsy (POE) • POE is generally classified as a group of psychotic disorders based on temporal occurrence of psychosis and seizures3 • POE can be divided as follows:3 • Ictal psychosis (when psychosis is an expression of seizure activity) • Post-ictal psychosis (when psychosis occurs within 7 days of a seizure) • Inter-ictal psychosis (when psychosis appears independently of seizures)

4. Treatment • Main challenge for PIP patients is epileptogenic activity of antipsychotics • Various antipsychotics used in the treatment of PIP include: • Haloperidol, molindone, fluphenazine, perphenazine and risperidone (no predefined length of treatment)2,3,4 • Evidence-based treatment with antipsychotics for post-ictal psychosis is limited

5. Differential Diagnosis • Antiepileptic toxicity • Drug induced • Psychogenic seizures • Schizophrenia

6. Patient Case • HPI: 36 yo WM with no previous history of mental illness presented to the psychiatric emergency room following several seizures with no loss of consciousness over the past few days prior to admission • Patient reported his first seizure at the age of 12, making his onset of PIP 24 years • Psychosis developed within one week of his seizure and lasted less than three months • Symptoms: confusion, verbal aggression, auditory and visual hallucinations • Previous episode: mental status changes during the post-ictal state; however, symptoms lasted a few minutes • Current episode: post-ictal state lasted ~24 hours accompanied with persistent confusion, auditory and visual hallucinations

7. Patient Case:Clinical Findings Head CT negative for acute changes/hemorrhage Drug screen urinalysis negative for illegal substances No recent history of alcohol use was documented All labs were within normal limits No other seizure activity was noted during hospital stay PMH • Seizure disorder since age 12 • Combination Grand Mal and Petite Mal seizures (per father) • HTN

8. Patient’s MedicationsPrior to Admission • Oxcarbazepine (Trileptal®) 300 mg PO BID • Zonisamide (Zonegran®) 100 mg PO Daily • Citalopram (Celexa®) 40mg PO Daily • Hydrochlorothiazide 25mg PO Daily • Metoprolol (Lopressor®) 25mg PO BID

9. Hospital Course

10. Follow-up • Patient is currently being followed as an outpatient by his psychiatrist • He denies any auditory or visual hallucinations • Patient has not been readmitted for PIP (seven months since last admission)

11. Review of Literature • MEDLINEsearch revealed no published case reports for the treatment of PIP with quetiapine • Other antipsychotic use in POE is limited to cases and unpublished data

12. Antipsychotics in Post-ictal Psychosis Farooq and Sherin: performed a comprehensive literature review which compared drugs and non-pharmacological interventions in patients with epilepsy with psychotic symptoms 7 • One unpublished, randomized controlled trial met criteria for inclusion • Olanzapine (10 mg/day) vs. haloperidol (12 mg/day) in 16 adult patients with “schizophrenia-like” psychosis of epilepsy • Patients were evaluated with EEG recordings and brief psychiatric rating scale (BPRS) at baseline, 3 and 6 months • Thirteen patients completed the study • Olanzapine treated patients had improvements in BPRS scores at endpoint (p=0.02) • Limitations: small population size, lacked power to evaluate the efficacy of antipsychotics in patients with POE

13. Kanner, et al.8 • “Postictal psychiatric events during prolonged video-electroencephalographic monitoring studies” • Results: • 5/10 patients who experienced PIP after undergoing video EEG monitoring, treated effectively with low dose haloperidol (2-5 mg/day) • One patient required haloperidol 40 mg/day • Remaining patients (3/10) resolved without medication8 • Limitations: lack of reported duration of treatment and efficacy was not measured by any specific scale

14. Epileptogenic Activity of Second Generation Antipsychotics (SGA)6 Alper K, et al BiolPsychiatry 2007;62:345-354.

15. Conclusion • We report the first case of quetiapine used successfully to treat a patient with post-ictal psychosis • During both hospitalizations, patient remained seizure free and had resolution of his psychotic symptoms as his antiepileptic medications were increased and quetiapine was titrated from 25 mg BID to a total daily dose of 200 mg • Further randomized controlled trials with antipsychotics in epileptic patients suffering from psychosis are necessary to determine the most appropriate treatment, dosages and duration of therapy

16. Limitations • Anticonvulsant toxicity was not ruled out • Oxcarbazepine 300 mg twice a day for one month before psychosis developed • Zonisamide (100 mg daily) duration of treatment unknown • Drug serum levels not obtained • Toxicity unlikely since his medications were continued and titrated throughout his admission without further exacerbation of his psychosis

17. Acknowledgements • Jehan Marino, PharmD, BCPP Assistant Professor of Pharmacy Practice Nova Southeastern University College of Pharmacy • Joseph Henry, MD, FAPA Assistant Professor of Psychiatry and Behavioral Sciences University of Miami Leonard M. Miller School of Medicine

18. References • Toone BK. The psychoses of epilepsy. Journal of Neurology, Neurosurgery and Psychiatry 2000; 69:1-3. • Devinsky O. Postictal psychosis: common, dangerous, and treatable. Epilepsy Currents 2008; 8:1-34. • Kanner AM. Psychosis of Epilepsy: A Neurologist's Perspective. Epilepsy and Behavior 2000; 1:219-227. • Devinsky O, Abramson H, Alper K, et al. Postictal Psychosis: A case control series of 20 patients and 150 controls. Epilepsy Research 1995; 20:247-253. • Toone B. Psychosis of epilepsy. In: EH. Reynolds and MR. Trible (Eds.), Epilepsy and psychiatry, Churchill Livingston, London, 1981, 113-137. • Alper K, Schwartz KA, Kolts RL, et al. Seizure incidence in psychopharmacological clinical trials: an analysis of Food and Drug Administration (FDA) summary basis of approval reports. Biological Psychiatry 2007; 62:345-354 • Farooq S, Sherin A. Interventions for psychotic symptoms concomitant with epilepsy. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD 006118. DOI: 10.1002/14651858.CD006118.PUB2. • Kanner AM, Stagno S, Kotagal P, Morris HH. Postictal psychiatric events during prolonged video-electroencephalographic monitoring studies. Arch Neurology 1996;53:258–63.