At the American Psychiatric Association convention, I viewed the "Impact of Menstrual Cycle Phase on Psychosis" poster session.
Neelambika Revadigar and Evaristo Akerele of Columbia University, Harlem Hospital featured the case presentation of a 22 year-old African American woman with schizophrenia and co-occurring cannabis use who was admitted to their Acute Care Mental Health Inpatient Unit.
Her psychotic symptoms and aggressive behavior were worse in the week preceding each menstruation. At those times, she required higher doses of antipsychotic medications to control her symptoms.
She had failed serial trials of risperidone and olanzapine and was switched to clozapine with partial response of her psychosis. Her Positive and Negative Symptoms Scale (PANSS) score was 119, 107 and 105 during the pre-menstrual period of her first, second and third month, respectively. The score in the first, second and third month during her ovulation period was 95, 89 and 84, respectively.
I was curious if the marijuana use had contributed to her treatment-resistant schizophrenia and was told she hadn't been using the street drug at the time she entered the hospital. Yet I tend to think a history of substance use could impact future results. I will research the literature to see if prior cannabis use is thought to create treatment-resistant schizophrenia.
An earlier Medscape article stated: "In women with severe schizophrenia, adding 110 µg a day of transdermal estradiol significantly reduced symptoms compared with antipsychotic medication alone."
A subset of about 12 women in that trial had a "truly dramatic" recovery, going from a PANSS score of approximately 80 to 10. The lower the score, the greater the chance of achieving remission.
Other clinical studies in the early 1990s indicated that women with schizophrenia relapsed in the low estrogen phase of their menstrual cycle. Other women relapsed when they were perimenopausal. For others, postpartum psychosis also coincided with a sudden decrease in estradiol levels.
The most current Melbourne, Australia study of 102 women was a 28-day double-blind, placebo-controlled study.
A 60 or higher score in total baseline PANSS equals severe schizophrenia.
The presenters of the poster session at this year's American Psychiatric Association Convention suggest these findings are possible:
Their patient was treatment resistant requiring clozapine. "This begs the question as to whether this kind of premenstrual exacerbation of psychotic symptoms is seen only in treatment resistant women."
Alternatively, "is treatment resistance a result of premenstrual exacerbation of psychotic symptoms in a specific subset of women."
The presenters' conclusions:
The data suggest that estrogen protects women from debilitating effects of schizophrenia.
Clinical management of patients with schizophrenia could be enhanced by paying close attention to premenstrual exacerbation of symptoms.
Estrogen could serve as a useful adjunct for the treatment of women who present with premenstrual exacerbation of clinical symptoms. Clearly, there is need for clinical trials to clarify the potential role of estrogen in the treatment of schizophrenia.
I will stay on top of this research to see if there is more promising news in the future.
(Estrogen relieves psychotic symptoms in women with schizophrenia, retrieved on June 22, 2014 from http://www.medscape.org/viewarticle/578772
Published On: June 25, 2014