Extrapyramidal Side Effects in a Patient with Alcohol Withdrawal Symptoms: A Reflection of Quality of the Mental Health Care System

Abstract

Background The burden of substance use disorders is increasing in most countries in sub-Saharan Africa. Individuals with substance use disorders (eg, alcohol use disorder) are at high risk of manifesting extrapyramidal side effects or extrapyramidal symptoms (EPS) during treatment of alcohol-induced mental illness symptoms especially psychosis. EPS management poses a challenge since some of the drugs used for treating EPS have addictive properties. The knowledge about EPS diagnosis and treatment is not well distributed across the health system, with health workers at lower health facilities having least awareness. The present case gives details of a patient who developed EPS during the management of alcohol withdrawal symptoms. Case Details Following cessation of alcohol use, a 54-year-old man with alcohol use disorder presented with a one-week history of visual, auditory and tactile hallucinations, illusions, insomnia, extreme fear and irritability. He was managed with several daily doses of intramuscular chlorpromazine 100 mg, whenever he woke up aggressive from sedation from a peripheral health facility. Four days after his admission, he became mute, stiff, immobile, triple-flexed, tremulous and was drooling saliva. He was referred to a secondary facility for further management while on antipsychotic medication. Finally, he was referred to a tertiary facility, managed with tablets of benzhexol 5 mg twice daily and intravenous diazepam 20 mg per day. Daily follow-up was done using the extrapyramidal symptom rating scale (ESRS) for EPS. EPS symptoms resolved ten days after initiation of treatment. Conclusion EPS among individuals with addictive disorders poses a challenge in its management, especially in countries where the mental health care system is not well developed at lower-level health facilities. The mental health system has to prepare sustainable interventions to properly manage EPS among the growing population of individuals with addictive disorders through strengthening the mental health policy by training and equipping all health providers with knowledge and skills in managing EPS, increasing finances allocated for mental health and controlling the production and use of addictive substances.

Substance use disorder among adolescents before and during the COVID-19 pandemic in Uganda: Retrospective findings from a psychiatric ward registry

“…The following information was extracted from the HMIS form 031 : (i) patient’s number, (ii) patient name initials, (iii) age, (iv) gender (male, female), (v) substances of addiction used (alcohol; cannabis; cigarettes (smoked tobacco), Kuber (smokeless tobacco, commonly used sublingually) [ 30 ]; miraa/khat [ Catha Edulis Forsk ]–plant leaves that contain stimulant similar to Amphetamine [ 31 ]; others such as Akandi [ 32 ], and glue), and (vi) diagnosis. Age was categorized into three groups based on the stage of adolescence [ 33 ]; early adolescents (10–14 years), middle adolescence (15–17 years), and late adolescence (18 to 19 years).…”

Bromocriptine therapy: Review of mechanism of action, safety and tolerability

“…Improvements of extrapyramidal symptoms in hepatic encephalopathy have been reported by some researchers after adding bromocriptine therapy as third line agent to the conventional therapy 201 . Similarly, several case reports has been filed by researchers against the successful use of bromocriptine therapy as an adjunct therapy to the primary treatment in NMS, 178,180,184 alcohol withdrawal syndrome, 18,192 HC 211 and in various neurological disorders, 216 whereas to check its effectiveness in cognitive control and working memory as well as in endometriosis, etc, various animal and human studies have also been conducted 130,221,223 . Furthermore, off label use of bromocriptine has been reported for the treatment of Cushing's disease, 281 OHSS 32 and researchers also suggest bromocriptine as an effective adjunct agent in various cancer treatment protocols 282,296 304,308 310 …”

“…Bromocriptine has been used extensively for clinical purposes for more than 30 years for the treatment of parkinsonism, hyperprolactinemia, pituitary adenomas and galactorrhoea 9–13 . With the passage of time, extensive research evolved with many new potential benefits of bromocriptine such as treatment of acromegaly, 14 paripartum cardiomyopathy, 15 neuroleptic malignant syndrome (NMS), 16 extrapyramidal disorders affected by medications, diabetes mellitus 17 as well as alcohol withdrawal syndrome and much more 18 . There are also many areas in which bromocriptine is supposed to be effective, and research is ongoing in those areas with productive results in animal models, such as management of hypertension and hypercholesterolemia leading to cardiovascular complications, 19–21 dengue virus, 22 Zika virus, 23 etc.…”

Suicide and Suicide Attempts Among Patients Attending Primary Health Care Facilities in Uganda: A Medical Records Review

“…In Uganda, the mental health services are offered at different levels of health facilities starting with health centres II to IV, then general hospitals, regional referral hospitals (tertiary health facility), and at the national referral hospitals. 12 , 13 The expertise and knowledge about mental illness such as suicide assessment and management are better at higher facility levels, beginning at health centre IV. 12 Mental health professionals work from health centres (psychiatric nurses), general hospital (psychiatry nurses and psychiatric clinical officers), and then specialist psychiatrists and other mental health professionals at regional and national referral hospitals.…”

“… 12 , 13 The expertise and knowledge about mental illness such as suicide assessment and management are better at higher facility levels, beginning at health centre IV. 12 Mental health professionals work from health centres (psychiatric nurses), general hospital (psychiatry nurses and psychiatric clinical officers), and then specialist psychiatrists and other mental health professionals at regional and national referral hospitals. 13 The health workers at the lower primary health facilities (II to III) are believed to have lower levels of knowledge, poor attitude, and higher levels of stigma about suicide.…”