A CRITICAL ACCOUNT OF THE CURRENT APPROACH TO EDUCATION IN CLINICAL PSYCHOPHARMACOLOGY Slobodan Loga, Svjetlana Loga-Zec & Bojan Sosic Academy of Sciences and Arts of Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina Institute of pharmacology of the Faculty of Medicine, Sarajevo, Bosnia and Herzegovina Board for Neurological and Psychiatric Research of the Department of Medical Sciences of the Academy of Sciences and Arts of Bosnia and Herzegovina, Sarajevo, Bosnia and Herzegovina

BACKGROUND Polypharmacy in psychiatry is becoming the rule rather than the exception. Using more drugs at same time usually occurs where single drugs are considered insufficiently effective. SUBJECTS AND METHODS The sample consisted of 216 patients: 85 from Sarajevo, and 44 and 87 respectively from Mostar and Tuzla. All schizophrenic patients who were hospitalised in three University Centers of F/BiH (Sarajevo, Tuzla, Mostar) on a particular day are included in the study. This included patients of both sexes (131 (60.65%) males and 85 females (39.35%)), 20-60 ages, who were on antipsychotic treatment with an established diagnosis of schizophrenia by the treating psychiatrist. The research was performed in the year 2004. The census of patients was conducted simultaneously in all three Centers, using a questionnaire in which all routine prescribed antipsychotics were registered, as the common method of the administration, and the doses as well saving as data for other medications that were simultaneously prescribed to the patients that day. RESULTS Within the total sample the most frequently applied classical antipsychotics were haloperidol, promazine and from the group of new antipsychotics clozapine. The most frequently used other medications were biperidine and diazepam. The administration of all medication was followed through recording of individual doses, daily doses and frequency of administration. There are statistically significant differences regarding the frequency of biperidine use between the centers (p=0.008). CONCLUSION In three University Clinical Centers of the Federation of Bosnia and Herzegovina (Sarajevo, Tuzla and Mostar), the applied rule is that more drugs in the treatment of schizophrenic psychosis and doing polypharmacy is the inevitable approach to treatment. The concept behind the polypharmacy is based on the fact that antipsychotic drugs do not cover all the symptoms of schizophrenic psychosis, and that additional medications may correct iatrogenic side effects caused by antipsychotic drugs. It is expected that the new atypical antipsychotics will treat much broader symptoms of psychosis and will not cause extrapyramidal side effects, as do the typical antipsychotics.

Patients' attitudes and values, their concept of illness and health as well as their previous experiences with medication may significantly affect the subjective response to antipsychotics. Quality of Life (QOL) has holistic concept that includes consideration of economic development, social vitality and environmental health. For most of the researches, QOL has an umbrella concept, which covers all aspects of life and includes physical and mental health, family relations, friendship, employment, leisure activities, medical treatment and quality of care, psychological and social benefit. In the domain of mental health, increasing the quality of treatment can be demonstrated through improvements of QOL of those using the mental health services. When measuring QOL in patients taking antipsychotics, it is important to acknowledge that a variety of factors may influence the QOL outcomes: these include side effects and daily dosage of the antipsychotic, depressive and negative symptoms, duration of treatment, and subjective tolerability.

There are connection between use of cannabis and many psychiatric disturbances in adolescents, especially "cannabis psychosis", depression, panic attacks and suicide. Negative effects could occur either as a result of a specific pharmacological effect of cannabis, or as the result of stressful experiences during the intoxication of cannabis in young people. Potentially is very dangerous high frequency suicidal ideation among cannabis users.

Algorithms and guidelines in treatment of schizophrenia behind which is the consensus of experts, institutions and associations are more and more in use among psychiatrists. However, the final conclusion about them will be possible only after their use in everyday practice with full freedom of psychiatrists to make changes according their personal judgment about risk and benefit of treatment.

The existence of two or more diagnoses (psychiatric, or a combination with somatic) in one person leads to a dilemma when choosing psychopharmacs for the treatment of the patient. There are no acceptable and comprehensive guidelines or algorithms for the treatment of innumerable possible combinations of psychiatric and somatic disorders. A strategy for treatment of such conditions is needed.

The aim of this study were to determine which antipsychotic are currently in use, to establish which doses are administrated to patients, to find out is there a practice of proscribing simultaneously more then one antipsychotic drug, to determine whether antipsychotic are proscribed in divided doses, to establish whether there is, besides antipsychotics, treatment with other medicaments (co-administration), especially with antiparkinsonics. The research (study) is epidemiological-clinical prospective, descriptive and analytical and it was conducted at University hospitals in Sarajevo, Tuzla and Mostar. Criteria for inclusion, non-inclusion and exclusion from the study were precisely defined as a mean for formation of sample. Based on this hypothesis were established, zero and alterative. According to zero hypothesis in the treatment of schizophrenia at University hospitals in FBiH new antipsychotic drugs are in use, small doses are proscribed (up to 20 mg), not more then one antipsychotic drug is used simultaneously, antipsychotics are administrated once a day and alongside with antipsychotics other medicaments are not co-administrated, especially antiparkinsons. The results of our study are showing that majority of patients are treated with classical antipsychotics. Minority of patients is treated with atypical neuroleptics like olanzapine, which is proscribed only in Sarajevo. Use of risperidone and ziprasidone is registered also only in Sarajevo, but only small number of patients is treated with these drugs. Most frequent antipsychotics were promazine and haloperidol. The range between minimal and maximal daily dose of promazine was from 50 to 450 mg/daily, and for haloperidol from 1 to 75 mg/daily. Above-mentioned drugs were administrated in an average from two to three times a day. Alongside with antipsychotics, other drugs were used. Most frequent was the use of biperidine in oral and parenteral formulation, as well as nitrazepam and diazepam. The importance of this study is following: data are useful for the current mental health care reform in FBiH, results will point out place and position of FBiH in contemporary world trends in the treatment of schizophrenia, they will contribute to rational use of antipsychotic therapy, they will point out possible ways in reduction of side effects, often dangerous adverse effects of antipsychotics, and they will give contribution to faster rehabilitation of schizophrenics with the reduction of financial means for the treatment of patients with schizophrenia.

A compared, 12 week, placebo controlled study, with fixed dose, outpatient study of patients diagnosed with panic disorder with and without agoraphobia according to ICD-10, was conducted to evaluate the efficacy and safety of sertraline and alprazolam. The study included 40 patients, divided in two groups. We evaluated number of ICD-10-defined panic attacks, agoraphobia and anticipatory anxiety. All patients were aged 18 year and older and were randomized to either sertraline or alprazolam. Sertraline applied in fixed doses of 20 mg/day and alprazolam in doses 1-1,5 mg/day significantly reduced the frequency of panic attacks in panic disorder patients, reduced symptoms of agoraphobia and anticipatory anxiety.

Depression is among the most common of chronic health problems. WHO report predicts that depression will be the leading cause of disability in the industrial world by the year 2020. To be successful, treatment for the patients suffering from depression must be continued until complete recovery, but most patients do not stay on their antidepressant medication long enough. One of the most frequent reasons for break down is appearance of unpleasant side effects. In this study we followed up dynamics of the characteristic side effects of antidepressant therapy, with the major goal to assess their frequency and characteristics. The sample was all female patients taking antidepressant drugs in the Department of Psychiatry of Clinical Centre of University in Sarajevo. The treatment with antidepressants was efficient in most of the patients. A major advantage of SSRI over TCA was less pronounced side effects. The most intensive side effects of TCA (amitriptyline) were dry mouth, tremor and tachycardia while the most frequent side effects included blurred vision, tachycardia, dry mouth, tremor and sedation. Side effects of SSRI (fluoxetine/fluvoxamine) were mild, and the most frequent were nausea, tachycardia, swelling, dry mouth.

Antipsychotic drugs produce a wide spectrum of physiological actions. Some of these effects differ among the various classes of antipsychotics. This medications have indications in the treatment of acute psychotic disorders. The main goal of this investigation was to determine the incidence and prevalence of the neuroleptic therapy acute side effects. The reason for this epidemiological investigation performing was the lack of knowledge of the exact neuroleptic therapy side effects incidence. Qualitative study on this problem has not been performed yet. Antipsychotic therapy side effects prevalence rate according to the literature data is ranging from 24% to 74%. Different prevalence rate is a consequence of different antipsychotic drug usage, different drug administration method and different side effects identification. On account of all these facts, we put the hypothesis on the correlation between the antipsychotic therapy and occurred side effects. Our experiment included all patients hospitalised from December 31st 1999 to January 31st 2000 in Intensive Care Unit of Biological Psychiatry Department of Psychiatric Clinic in Sarajevo. All patients were divided in three groups according to the applied therapy. All of them met ICD-10 criteria for schizophrenia (F20-29). During our study the following examinations were performed: psychiatric interview, BRPS, scale of side effects, psychophysiological tests, general clinical impression, scale of appetite, carbon hydrate needs scale. Psychiatric and statistical evaluations were done as well. The evaluation of our examination is showing successful results in all groups of patients. The improvement of psychopathological symptoms was insignificant. Reported side effects were minimal with low incidence rate and relatively high prevalence rate. Statistical tests were calculated from the obtained data after what the null hypothesis was rejected. Consequently, an alternative hypothesis was confirmed and it indicated that the acute side effects incidence and prevalence were within the range of expectation. Intensity of the recorded side effects was moderate to mild. On the basis of the obtained data, it has been concluded that applied antipsychotic agents did not induce more psychophysiological function impairments in the treated patients. Psychophysiological functions remained in physiological range limits and their changes were not significant. Neuroleptic therapy side effects were minimal, meaning no toxic signs or therapy discontinuations were recorded.