November 976

HOSPIaI &
A Journa ot the Community
Amehcon Psychothc
Assoc oton Psychiatry
 Basic tools of
primitive psychiatry

Mankpo: Sceptres or
staffs used by the
Heviosso (lightning
God) cult in medical
ceremonies among
the Ewe of Tongo
and Fon of Dahomey.
Right, staff with
leopard’s head, bared
teeth and tongue
(Ewe, Togo). Left,
staff with ram’s
head-the sacred
animal of the
Heviosso-in the
form of a serpent
symbolizing the
fire-spitting rainbow
God of healing
(Fon, Dahomey).
From the collection
of the Segv Gallery,
New York City.
 Basic tool of
Western psychiatry

TiDTInc,
:YAraT!!#{174}
(chiorpromazine, SK&F)
Tablets: 25 and 50 mg of the HC1

. ‘Thorazine’ controls psychotic symptoms

#{149}
Especially useful in agitated, violent or been reported, but relationship to myocardial
damage is not confirmed ; neuromuscular(extra-
anxious schizophrenic patients pyramidal) reactions; pseudo-parkinsonism.
motor restlessness, dystonias, persistent tardive
dyskinesia. hyperreflexia in the newborn;
#{149}
Unsurpassed clinical experience psychotic symptoms, catatonic-like states,
cerebral edema; convulsive seizures; abnor-

.18 convenient dosage forms and strengths mality of the cerebrospinal fluid proteins;
urticarial reactions and photosensitivity,
exfoliative dermatitis, contact dermatitis; lacta-

vehicles or machinery) especially during the tion and breast engorgement (in females on
Before prescribing, see complete prescribing
large doses), false positive pregnancy tests,
information in SK&F literature or PDR. The first few days’ therapy. Avoid concomitant use
with alcohol. May counteract antihyper- amenorrhea, gynecomastia; hyperglycemia,
following is a brief summary.
tensive effect of guanethidine and related hypoglycemia, glycosuria; dry mouth, nasal
Indications congestion, constipation, adynamic ileus,
compounds.
Based on a review of this drug by the urinary retention, miosis, mydriasis; after
Use in pregnancy only when essential. There
prolonged substantial doses, skin pigmenta-
National Academy of Sciences- are reported instances of jaundice or pro-
National Research Council and/or other tion, epithelial keratopathy, lenticular and
longed extrapyramidal signs in newborn
information, FDA has classified the corneal deposits and pigmentary retinopathy,
whose mothers had received chlorpromazine.
indications as follows: visual impairment; mild fever (after large I.M.
Precautions: tJse cautiously in persons with
dosage); hyperpyrexia; increased appetite and
Effective: For the management of mani- cardiovascular, liver or chronic respiratory weight; a systemic lupus erythematosus-like
festations of psychotic disorders. For
disease, or with acute respiratory infections. syndrome; peripheral edema.
control of the manifestations of manic- Due to cough reflex suppression, aspiration NOTE: Sudden death in patients taking
depressive illness (manic phase). of vomitus is possible. May prolong or in- phenothiazines (apparently due to cardiac
Probably effective: For the control of tensify the action of C.N.S. depressants. organo- arrest or asphyxia due to failure of cough
moderat#{231} to severe agitation, hyper- phosphorus insecticides, heat, atropine and reflex) has been reported, but no causal
activity or aggressiveness in disturbed related drugs. (Reduce dosage of concomitant relationship has been established.
children. C.N.S. depressants.) Anticonvulsant action of
Supplied: Tablets, 10 mg, 25 mg. 50 mg.
Possibly effective: For control of ex- barbiturates is not intensified. Antiemetic
100 mg. and 200 mg., in bottles of 100; in Single
cessive anxiety, tension and agitation as effect may mask signs of toxic drug overdosage
Unit Packages of 100 (intended for institutional
seen in neuroses. or physical disorders. Discontinue high-dose,
use only). Spansule capsules. 50 mg.. 75 mg.,
Final classification of the less-than- long-term therapy gradually.
150 mg. 200 mg and 500 mg. in bottles of 50;
effective indications requires further Patients on long-term therapy. especially high in Single Unit Packages of 100 (intended for
investigation. doses, should be evaluated periodically for institutional use only). Injection, 25 mg/mI.;
possible adjustment or discontinuance of Syrup, 10 mg./5 ml.; Suppositories, 25 mg and
ontraindications: Comatose states, presence drug therapy. 100 mg.; Concentrate (intended for institutional
of large amounts of C.N.S. depressants, or
Adverse Reactions: Drowsiness, cholestatic use only), SO mg/mI. and 100 mg/mI.
bone marrow depression.
jaundice, agranulocytosis, eosinophilia, leu-
Warnings: Avoid using in patients hyper-
kopenia, hemolytic anemia, thrombocytopenic
sensitive
any
(e.g.,
phenothiazine.
blood dyscrasia,
Caution
jaundice)
patients about
to
purpura
tension,
and
tachycardia,
pancytopenia;
fainting,
postural
dizziness
hype-
and,
SK&F
activities requiring alertness (e.g., operating Smith Kline & French Laboratories
occasionally, a shock-like condition; reversal Division of SmtthKtine Corporation
01967. 1968, 1969 SmithKtine Corporation of epinephrine effects; EKG changes have Philadelphia. Pa.

For effective management of schizophrenic symptoms.

 MOSBY
r TiMES MIRROR

Now, a new Mosby book

can help your entire
mental health team
implement comprehensive,
uniform psychiatric care plans
A New Book!
THE PROBLEM-ORIENTED
PSYCHIATRIC INDEX AND
TREATMENT PLANS
Here’s a dynamic new was to standardize psvchiat-
nc treatment and improve the delivery of health
care services. Divided into 10 major domains, this
Two Hundred Years book allows
to formulate
all members
goal statements
of the mental
and treatment
health team
plans.
of Mental Health Care Prevention, diagnosis, treatment, and rehabilita-
in America tion are integrated
plan for care of the
into a comprehensive
individual and
treatment
his family.
You’ll find sections dealing with: a comprehensive
Celebrate the Bicentennial with Hos- review of psychiatric services; patient evaluation-
pita! & Community Psychiatry’s July physical and mental; treatment methods; progress
issue, a richly illustrated review of report; and sample plans.
some of the interesting and important By Monte J. Meldman, M.D.; Gertrude McFarland, RN., MS.;
developments in mental health care and Edith Johnson, BA. July, 1976. 202 pages plus FM l-X;
in America over 200 years-from the 8” x 1 0”, 88 line drawings. Price, $7.50.

time of Benjamin Rush to the con-

struction of the first community men- New 5th Edition!
tal health centers. It’s a brief, lively, MASK OF SANITY
readable history that you’ll want to
Universally recognized as a classic presentation of
keep for years. Limited copies are
sociopathy, this new edition continues to present
available; order yours today! thought-provoking insights into the nature of the
psychopath. In an articulate and explicit format,
[ ] Please send me copies of H&CP’s Bicenten- the author vividly illustrates psychopathic behavior
nial issue at $2 a copy. My check for $ ______ is en- patterns with outstanding clinical anecdotes and
closed. case studies compiled from years of clinical experi-
I I Enclosed is my check for a one-year subscription ence. You’ll find informative material on the pros-
(12 issues) to Hospital & Community Psychiatry. ($12 a pects of rehabilitation and particularly. the need
year for members of the American Psychiatric and for awareness and understanding among family
American Psychological Associations: $l for other sub-
members.
scribers. For subscriptions mailed outside the U.S. add
$3 a year. Make checks payable to the American Psychi- By Hervey Cleckley, M.D. March, 1976. 5th edition, 472 pages
atric Association.)
plus FM -XVI, 6Y2’ X 9V2”. Price, $14.95.
Name __________ ORDER BY PHONE:
Title or Discipline Call (800) 325-4177 ext. 10. In Missouri call collect-
(314) 872-8370 ext. 10. 9 am to 5 pm (CST), Monday through
State 7ir
Friday.
MAIL TO:

Hosplci& MDSBY
1700 18th St.. N.W. TIMES MIRROR
Psychidry Washington, D.C. 20009
THE L V MOSBY COMPANY
1 1830 IVESTLINE INDUSTRAL DRIVE
ST LOUIS MISSOURI 63141
SOUTHERN ILLINOIS UNIVERSITY

VACANCY
Director, Department of Mental Health, State of Missoun. The di-
SCHOOL OF MEDICINE rector is appointed by the Mental Health Commission and by and
with the advice and consent of the State Senate. The department
provides treatment, care, education, and training for persons suf-
feting from mental illness, mental retardation and/or devel-
opmental disabilities, and alcoholism and drug abuse, and has
Positions in Academic Psychiatry administrative control of the state hospitals and other institutions
and centers established for these purposes, and administers
such other programs as provided by law.
Requirements: Psychiatrist. Certification, or proof of eligibility for
Challenging opportunities in Psychiatry in a new corn- certification by the American Board of Psychiatry and Neurology,
munity based medical school. A strong interest and Inc.
competence in teaching are essential qualifications. or
a person experienced in health care administration, psychology,
sociology, public health or a pertinent related field with special-
There are full time academic positions based in various ized training in mental health preferably with a doctoral degree
settings and involve multi-disciplinary relationships would be considered. Candidate must have ability to plan, direct,
with professionals in the community, active teaching and coordinate a statewide system of mental health services. Ap-
roles with medical students, psychiatric residents and plicant must have administrative experience, good management
continuing education with physicians and other health skills, proven leadership ability and the capacity to communicate
care professionals. effectively.
Effective Date: Open. Send vIta and supporting Information
Send curriculum vitae to: A. S. Norris, M.D., Chairman, to:
Department of Psychiatry, Southern Illinois University David J. Plttman, Ph.D.
School of Medicine, Box 3926, Springfield, Illinois ChaIrman, Search CommIttee
62708. Missouri Mental Health Commission
Department of Sociology, Box 1113
Washington UniversIty
“S/U is an Equal Opportunity/Affirmative Action Employer” St. Louis, Missouri 63130
Affirmative Action / Equal Opportunity Employer

PSYCHIATRISTS
MEDICAL
COMPREHENSIVE COMMUNITY
DIRECTOR MENTAL HEALTH CENTER
To carry treatment and supervisory responsibil-
ities in comprehensive community mental health
Community MH/MR Ctr. located center.
in Southwestern Allegheny Free-standing comprehensive center located
in greater Knoxville area, serves varied popu-
County (Pittsburgh, Pa. area) lation and offers multiple treatment modalities.
seeks qualified psychiatrist to Strong community interest a must. Center is un-
dergoing major expansion through NIMH staffing
serve as medical director. Part- grant.
time, 22.5 hrs. per week. Salary Located in NA lake country, near major univer-
sity in a scientific research community with excel-
open. Affirmative Action lent schools.
Employer. Board eligible or Board certified. Salary open,
excellent fringes.
Send curriculum vitae to Contact: Homer Wilkins, Ph.D.
Executive Director
Personnel Committee Chairman, Overlook Mental Health center
Chartiers MR/MR Center 5908 Lyons View Drive
Knoxville, Tennessee 37919
437 Railroad St., Tel: 584-1561
Bridgeville, PA. 15017 An Equal Opportunity Employer
 Schizophrenia
by Royal Doulton

There is a brooding quality

to the #{241}gure.She seems
lost in her world, cut off
from reality, perhaps
suspicious, withdrawn and
anxious...suggestively
schizophrenic in demeanor.

Actual title: ‘Romance’. From

the Royal Doulton Figurine
Collection...one of the many
exquisite figures from the
master craftsmen of ceramic
sculpture, destined to become
a collector’s item.
 Serentil (mesoridazine)

by Aguilar, et al.

‘hard-core’ . chronic schizophrenics who

have either regressed to a lower level of
functioning after initial improvement, or
have failed to respond to previous
psychotropic medication can improve . . .

significantly [with] Serenii”

Aguilar SJ: Dis Nerv Syst, 36:484,1975.

‘.the onset of mesoridazine’s

. activity can be
observed even on the first day of treatment.
This rapid onset of action [with the I.M.
dosageform] makes mesoridazine valuable
. . . . ,,

in the treatment of psychiatric emergencies.

Hamid TA and Wertz WJ: AmJ Psych
I 689 9 ‘ 1 ‘Because of possible hypotensive effects, parenteral administration should be
I” ..,
‘
#{149}
I I
I A
#{149}
reserved
be kept
for bedfast
lying down
patients or for acute
for at least one-half
ambulatory
hour after
cases.
injection.
Patients should

low incidence of adverse

#{149}
remarkably
reactions when compared with other
phenothiazine compounds’
Serentil Prescribing Information, PDR, 1976.
In prescribing Serentil, observe the same precautions as with other phenothiazines, including awareness of all adverse reactions
observed with them. (As with other phenothiazines, patients refractory to previous medications may respond to Serentil.)
Please see next page for a brief summary of the prescribing information, including contraindications and adverse reactions.
 Serentil#{174}
(mesoridazine) as the besylate

Available in 3 dosage forms: Tablets:

10,25, 50 and 100 mg. Concentrate:
25 mg/cc. Injectable: 1 cc (25 mg).

-Side effects are usually mild or moderate.

-Except for tremor and rigidity, adverse

reactions are usually found in patients
receiving high doses early in treatment.

-Low incidence of Parkinson’s syndrome.

-Drowsiness and hypotension are the

most prevalent side effects encountered.
Indication: Schizophrenia. cardiograms would appear to he of questionable
Contrai ndications: Severe central nervous value as a predictive device. Hypotension, rarely
system depression, comatose states and hyper. resulting in cardiac arrest has also been noted.
sensitivity to the drug. Akathisia, agitation, motor restlessness, dystonic
Warnings: Administer autiously and increase reactions, trismus, torticollis, opisthotonos, oculo.
dosage radually to patients participating in activi gyric rises, tremor. musc.ulsr rigidity, akinesia.
ties requiring complete mental alertness (e.g., driv. As with all antipsychotics, tardive dyskinesia may
ing(. Te safety of this drug in pregnancy has not appear on long.term therapy or after long.term
been established; hence it should be given only when therapy is discontinued. Risks seem to be greater in
the anticipated benefits exceed the possible risk to elderly patients on high dose therapy, especially
mother and fetus. Not recommended for use in females. Discontinue all antipsychotic agents if the
children under 12 years ofage since safe conditions symptoms of tardive dyskinesia syndrome appear.
for this use have not been established. Pheno. (See full prescribing information for description of
thiazines are capable of potentiating central nervous the symptoms of the tardive dyskinesia syndrome).
system depressants (e.g., anesthetics, opiates, alco. Menstrual irregularities, altered libido, gyne.
hol, etc.( as well as atropine and phosphorus comastia, lactation, weight gain, edema, false posi.
insecticides. tive pregnancy tests. Retention, incontinence.
Precautions: Ocular changes have been seen with Hyperpyrexia, behavioral effects suggestive of a
other phenothiazines but, to date, have not been paradoxical reaction, including excitement, bizarre
related to mesoridazine. Because of possible hypo. dreams, aggravation of psychoses and toxic confu.
tensive effects, reserve parenteral administration for 4
sional states. Following liing.term therapy, a peculiar
bedfast patients or acute ambulatory cases, and keep skin.eye syndrome marked by progressive pigmenta.
patient lying down for at least one.half hour after tion ofareas ofthe skin or ci)njunctiva and/or accom-
injection. Leukopenia and/or agranulocytosis have panied by discoloration of exposed sciera and cornea;
been attributed to phenothiazine therapy. A single stellate or irregular opacities ofanterior lens and
case of transient granulocytopenia has been associ cornea. Systemic lupus erythematosus.like syndrome.
ated with mesoridazine. Patients receiving anti phenothiazines and should be considered: miosis, How Supplied: Tablets: 10 mg., 25 mg., 50 mg. and
convulsant medication should be continued on that obstipation, anorexia, paralytic ileus. Erythema, 100 mg. mesoridazine (as the besylate); packages of
regimen while receiving mesoridazine to prevent exfoliative dermatitis, contact dermatitis. Agranulo. 100 and 5000.
possible convulsive seizures. As with most medica. cytosis, leu kopenia. eosinophilia, thrombocytopenia, Ampuls: 1 cc. [25 mg. mesoridazine (as the besylate).]
tions, the dosage of mesoridazine should be adjusted anemia, aplastic anemia, pancytopenia. Fever, Inactive ingredients: disodium edetate, U.S.P., 0.5 mg;
to the needs of the individual and the lowest laryngeal edema, angioneurotic edema, asthma. sodium chloride, U.S.P., 7.2 mg.; carbon dioxide gas
effective dosage should always be used. J aundice, biliary stasis. Changes in terminal portion (bone dry) q.s.; water for injection, U.S.P., q.s. to 1 cc.;
Adverse Reactions: Mesoridazine has demonstrated of the EKG, including prolongation of the Q.T boxes of 20 and 100. Concentrate: 25 mg. mesoridazine
a remarkably low incidence of adverse reactions interval, lowering and inversion of the T wave and (as the besylate) per cc., alcohol, U.S.P., 0.61% by
compared with other phenothiazine compounds. appearance of a wave tentatively identified as a volume. Immediate containers. Amber glass bottles
Drowsiness, Parkinsons syndrome, dizziness, bifid T or a u wave have been observed with pheno. of4 11.oz.
weakness, tremor, restlessness, ataxia, dystonia, thiazines, including mesoridazine. These appear to be For complete deta:ls, please see the full prescribing
rigidity, slurring, akathisia, motoric reactions reversible and due to altered repolarization, not information.
(opisthotonos(. Dry mouth, nausea and vomiting, myocardial damage. While there is no evidence that
fainting, stuffy nose, photophobia, constipation and these changes are in any way precursors of any
blurred vision have occurred. Inhibition of ejacula- significant disturbance of cardiac rhythm, several I’ll
tion, impotence, enuresis, incontinence. Itching, sudden and unexpected deaths apparently due to \::iNGIs
rash, hypertrophic papillae of the tongue and angio. cardiac arrest have occurred in patients showing
neurotic edema. Hypotension, tachycardia. EKG characteristic electrocardiographic changes while Boehrlnger Ingelheim
changes. The following reactions have occurred with taking the drug. While proposed, periodic electro. Boehringer lngelheim Ltd. Elmsford, New York 10523
 Inthe hospitalized patient..!

‘1%

1Tq
‘4\
‘c
(,5

.t
 IC mediCation should not interfere with the patient’s ability to participate in your
total therapeutic program. That is why Mellaril (thioridazine) is an excellent choice. It is
highly effective, and although extrapyramidal symptoms are characteristic of this Class of
drug, with Mellaril (thioridazine) extrapyramidal stimulation-notably pseudoparkinsonism-
is infrequent. Adding an antiparkinsonian agent-which can cause its own side effects-can
usually be avoided.
Mellaril (thioridazine) is not habituating and usually does not cause euphoria or undue
sedation. (But, warn patients about undertaking activities requiring complete mental
alertness.) And Mellaril (thioridazine) is contraindicated in patients with severe hypotensive
or hypertensive heart disease.

LJHhIEL#{174}
(THEL’)ill 1PAUlJ
TABLETS: 50 mg, 100 mg, 150 mg, and 200 mg thioridazine HCI, U.S.P.

Before prescribing or administering, see Sandoz literature for full product Cutaneous Reactions-Erythema, exfoliative dermatitis, contact dermatitis.
information. The following is a brief summary Blood Dyscrasias- Agranulocytosis, leukopenia, eosinophilia, throm-
bocytopenia, anemia, aplastic anemia, pancytopenia. Allergic Reactions-
Contraindications: Severe central nervous system depression, comatose states
from any cause, hypertensive or hypotensive heart disease of extreme degree. Fever, laryngeal edema, angioneurotic edema, asthma. Hepatotoxicity-Jaun-
dice, biliary stasis. Cardiovascular Effects-Changes in terminal portion of
Warnings: AdmInister cautiously to patients who have previously exhibited a hy- electrocardiogram, including prolongation of Q-T interval, lowering and inversion
persensitivity reaction (e.g., blood dyscrasias, jaundice) to phenothiazines. of T-wave, and appearance of a wave tentatively identified as a bifid T or a U wave
Phenothiazines are capable of potentiating central nervous system depressants have been observed with phenothiazines, including MelIaril (thioridazine); these
(e.g., anesthetics, opiates, alcohol, etc.) as well as atropine and phosphorus in appear to be reversible and due to altered repolarization, not myocardial damage.
secticides; carefully consider benefit versus risk in less severe disorders. During While there is no evidence of a causal relationship between these changes and sig-
pregnancy, administer only when the potential benefits exceed the possible risks nificant disturbance of cardiac rhythm, several sudden and unexpected deaths ap-
to mother and fetus. parently due to cardiac arrest have occurred in patients showing characteristic
Precautions: There have been infrequent reports of leukopenia and/or electrocardiographic changes while taking the drug. While proposed, periodic
agranulocytosis and convulsive seizures. In epileptic patients, anticonvulsant electrocardiograms are not regarded as predictive. Hypotension, rarely resulting in
medication should also be maintained. Pigmentary retinopathy, observed prirn cardiac arrest. Extrapyramidal Symptoms- Akathisia, agitation, motor restless-
manly in patients receiving larger than recommended doses, is characterized by ness, dystonic reactions, trismus, torticollis, opisthotonus, oculogyric crises,
diminution of visual acuity, brownish coloring of vision, and impairment of night tremor, muscular rigidity, and akinesia. Persistent Tardive Uyskinesia- Persis-
vision; the possibility of its occurrence may be reduced by remaining within rec tent and sometimes irreversible tardive dyskinesia, characterized by rhythmical in-
ommended dosage limits. Administer cautiously to patients participating in ac- voluntary movements of the tongue, face, mouth, or jaw (e.g., protrusion of
tivities requiring complete mental alertness (e.g., driving), and increase dosage tongue, puffing of cheeks, puckering of mouth, chewing movements) and
gradually. Orthostatic hypotension is more common in females than in males. Do sometimes of extremities may occur on long-term therapy or after discontinuation
not use epinephrine in treating drug-induced hypotension since phenothiazines of therapy, the risk being greater in elderly patients on high-dose therapy,
may induce a reversed epinephrine effect on occasion. Daily doses in excess of especially females; if symptoms appear, discontinue all antipsychotic agents.
300 mg should be used only in severe neuropsychiatric conditions. Syndrome may be masked it treatment is reinstituted, dosage is increased, or anti-
Adverse Reactions : Central Nervous System -Drowsiness, especially with psychotic agent is switched. Fine vermicular movements of tongue may be an
large doses, early in treatment; infrequently, pseudoparkinsonism and other ex- early sign, and syndrome may not develop if medication is stopped at that time.
trapyramidal symptoms; rarely, nocturnal confusion, hyperactivity. lethargy, psy- Endocrine Disturbances-Menstrual irregularities, altered libido,
chotic reactions, restlessness, and headache. Autonomic Nervous System- gynecomastia, lactation, weight gain, edema, false positive pregnancy tests. Un-
Dryness of mouth, blurred vision, constipation, nausea, vomiting, diarrhea, nasal nary Disturbances- Retention, incontinence. Others- Hyperpyrexia;
stuffiness, and pallor. Endocrine System- Galactorrhea, breast engorgement, behavioral effects suggestive of a paradoxical reaction, including excitement,
amenorrhea, inhibition of ejaculation, and peripheral edema. Skin- Dermatitis bizarre dreams, aggravation of psychoses, and toxic confusional states; following
and skin eruptions of the urticarial type, photosensitivity. Cardiovascular long-term treatment, a peculiar skin-eye syndrome marked by progressive pigmen-
System-ECG changes (see Cardiovascular Effects below). Other-Rare tation of skin or conjunctiva and/or accompanied by discoloration of
cases described as parotid swelling. exposed sclera and cornea; stellate or irregular opacities of anterior
The following reactions have occurred with phenothiazines and should be con- lens and cornea; systemic lupus erythematosus-like syndrome.
sidered: Autonomic Reactions- M iosis, obstipation, anorexia, paralytic ileus. SANDOZ PHARMACEUTICALS, EAST HANOVER, NEW JERSEY 07936 SANDOZ
SAN s-468
 4

p . . ,

.4, ____ 1

- ‘4..

,#{216}r
.
..
 The Potential
in the management of
modemte to ve anxie
with depression
When time and talk are not enough... your patients on TRIAVIL will be more likely to
The therapist is the primary catalyst for change in take proper doses of the medication.
the psychotherapeutic relationship. However,
TRIAVIL is contraindicated in CNS depression
when patients suffer from moderate to severe
from drugs; in the presence of evidence of bone
anxiety with depression, there are situations when
marrow depression; and in patients
TRIAVIL can often be a useful adjunct.
hypersensitive to phenoth iazines or am itriptyli ne.
It should not be used during the acute recovery
‘ . .TRIAVIL may help phasefollowing myocardial infarction or in
There are three important benefits you patients who have received an MAOI within two
may expect when TRIAVIL is part of the treatment
weeks. Patients with cardiovascular disorders
program: ( 1 ) When symptoms of moderate should be watched closely. Not recommended in
to severe anxiety or agitation with depression are
children or during pregnancy. The drug may
relieved, the patient may become more accessible
impair mental or physical abilities required in the
and cooperative. (2) As somatic manifestations
performance of hazardous tasks and may
are controlled, attention may be focused
enhance the response to alcohol. Antiemetic
on underlying causative factors. (3) Symptomatic
effect may obscure toxicity due to other drugs or
relief may enable the patient to function more
mask other disorders. Since suicide is a possibility
effectively in his daily life while your work with in any depressive illness, patients should not have
the patient progresses.
access to large quantities of the drug. Hospitalize
Tablets TRIAVIL are available in four different as soon as possible any patient suspected of
combinations affording flexibility and having taken an overdose.
individualized dosage adjustment. Since it is MSD
simpler to remember to take one tablet rather
For a brief summary of prescribing
than several (particularly in multiple daily doses), OHM information, please turn to the following page.

when patienis exhibit moderate to marked anxiety

or agitation with symptoms of depression

T RIAa(I containing
and’amitnptylineperphenazine
HCI
a tranquilizer-antidepressant
 for highly effective relief Such treatment should be limited to patients for whom it is essential.
Discontinue several days before elective surgery if possible. Eleva-
of depression with moderate anxiety tion and lowering of blood sugar levels have both been reported. Use
with caution in patients with impaired liver function.
ADVERSE REACTIONS: Similar to those reported with either constit-

TRIAVI I
uent alone.
Perphenazine: Side effects may be any of those reported with
phenothiazine drugs extrapyramidal symptoms (opisthotonus, ocu-
logyric crisis. hyperreflexia. dystonia. akathisia, acute dyskinesia,
containing perphenazine and amitriptyline HCI ataxia. parkinsonism) can usually be controlled by the concomitant
use of effective antiparkinsonian drugs and/or by reduction in dos-
a tranquilizer-antidepressant age. but sometimes persist after discontinuation of the phenothiazine
Available: Tardive dyskinesia may appear in some patients on long-term ther-
apy or may occur after drug therapy with phenothiazines and related
TRIAVIL 2-25: Each tablet contains agents has been discontinued The risk appears to be greater in
2 mg perphenazine and 25 mg amitriptyline HCI elderly patients on high-dose therapy. especially females. Symptoms
TRIAVIL 2-10: Each tablet contains are persistent and in some patients appear to be irreversible. The
2 mg perphenazine and 10 mg amitriptyline HCI syndrome is characterized by rhythmical involuntary movements of
TRIAVIL#{174}4-25: Each tablet contains
the tongue. face, mouth, or jaw (e.g. protrusion . of tongue. puffing of
cheeks, puckering of mouth, chewing movements) Involuntary move-
4 mg perphenazine and 25 mg amitriptyline HCI
ments of the extremities sometimes occur There is no known treat-
TRIAVILZ 4-10: Each tablet contains ment for tardive dyskinesia. antiparkinsonism agents usually do not
4 mg perphenazine and 10 mg amitriptyline HCI alleviate the symptoms It is advised that all antipsychotic agents be
INITIALTHERAPY FOR MANY PATIENTS discontinued if the above symptoms appear If treatment is reinstitu-
TRIAVIL’ 2-25 (or TRIAVIL’ 4-25) t I d or q I d ted. or dosage of the particular drug increased, or another drug sub-
stituted, the syndrome may be masked. It has been suggested that
FOR FLEXIBILITY IN ADJUSTING MAINTENANCE THERAPY fine vermicular movements of the tongue may be an early sign of the
TRIAVIL’ 2-10 (or TRIAVIL’ 4-10) syndrome, and that the full-blown syndrome may not develop if medi-
cation is stopped when lingual vermiculation appears.
CONTRAINDICATIONS: Central nervous system depression from Other side effects are skin disorders (photosensitivity. itching.
drugs ‘(barbiturates, alcohol, narcotics, analgesics, antihistamines); erythema, urticaria, eczema, up to exfoliative dermatitis). other
bone marrow depression; known hypersensitivity to phenothiazines or allergic reactions (asthma, laryngeal edema, angioneurotic edema,
amitriptyline. Do not give concomitantly with MAOI drugs because anaphylactoid reactions). peripheral edema. reversed epinephrine
hyperpyretic crises, severe convulsions, and deaths have occurred effect; hyperglycemia; endocrine disturbances (lactation, galac-
from such combinations Allow minimum of 14 days between thera- torrhea, gynecomastia. disturbances of menstrual cycle); altered
pies, then initiate therapy with TRIAVIL cautiously. with gradual cerebrospinal fluid proteins; paradoxical excitement; hypertension,
increase in dosage until optimum response is achieved Not recom- hypotension, tachycardia. and ECG abnormalities (quinidine-like
mended for use during acute recovery phase following myocardial effect); reactivation of psychotic processes; catatonic-like states;
infarction. autonomic reactions, such as dry mouth or salivation. headache.
WARNINGS: TRIAVIL should not be given with guanethidine or simi- anorexia, nausea, vomiting. constipation. obstipation. urinary
larly acting compounds Use cautiously in patients with history of frequency or incontinence, blurred vision, nasal congestion. and a
urinary retention, angle-closure glaucoma. increased intraocular change in pulse rate, hypnotic effects. pigmentary retinopathy. cor-
pressure, or convulsive disorders. In patients with angle-closure glau- neal and lenticular pigmentation. occasional lassitude. muscle weak-
coma, even average doses may precipitate an attack. Patients with ness, mild insomnia Other adverse reactions reported with various
cardiovascular disorders should be watched closely. Tricyclic antide- phenothiazine compounds include blood dyscrasias (pancytopenia,
pressants, including amitriptyline HCI, particularly in high doses, have thrombocytopenic purpura, leukopenia. agranulocytosis. eosinophil-
been reported to produce arrhythmias. sinus tachycardia, and a); liver damage (jaundice, biliary stasis); grand mal convulsions;
prolongation of conduction time Myocardial infarction and stroke cerebral edema; polyphagia; photophobia; skin pigmentation; and
have been reported with tricyclic antidepressant drugs. Close super- failure of ejaculation.
vision is required for hyperthyroid patients or those receiving thyroid Amitriptyline: Note: Listing includes a few reactions not reported for
medication Caution patients performing hazardous tasks, such as this drug. but which have occurred with other pharmacologically simi-
operating machinery or driving motor vehicles, that drug may impair lar tricyclic antidepressant drugs Cardiovascular Hypotension.
mental and/or physical abilities. Not recommended in children or dur- hypertension; tachycardia. palpitation, myocardial infarction; arrhyth-
ing pregnancy. mias. heart block. stroke CNS and Neuromuscular; Confusional
PRECAUTIONS: Suicide is a possibility in depressed patients and states, disturbed concentration, disorientation, delusions: hallucina-
may remain until significant remission occurs. Such patients should tions; excitement; anxiety; restlessness; insomnia; nightmares; numb-
not have access to large quantities of this drug. ness, tingling, and paresthesias of the extremities; peripheral
Perphenazine: Should not be used indiscriminately. Use with caution neuropathy; incoordination; ataxia; tremors; seizures; alteration in
in patients who have previously exhibited severe adverse reactions to EEG patterns; extrapyramidal symptoms; tinnitus; syndrome of nap-
other phenothiazines. Likelihood of untoward actions is greater with propriate ADH (antidiuretic hormone) secretion Anticholinergic Dry
high doses. Closely supervise with any dosage. The antiemetic effect mouth, blurred vision, disturbance of accommodation, constipation;
of perphenazine may obscure signs of toxicity due to overdosage of paralytic ileus; urinary retention; dilatation of urinary tract. Allergic
other drugs or make more difficult the diagnosis of disorders such as Skin rash; urticaria; photosensitization; edema of face and tongue.
brain tumor or intestinal obstruction A significant. not otherwise Hematologic Bone marrow depression including agranulocytosis;
explained. rise in body temperature may suggest individual intoler- Ieukopenia; eosinophilia; purpura; thrombocytopenia. Gastrointes-
ance to perphenazine. in which case discontinue. final Nausea; epigastric distress; vomiting; anorexia; stomatitis; pecu-
If hypotension develops. epinephrine should not be employed. as liar taste; diarrhea; parotid swelling; black tongue. Rarely hepatitis
its action is blocked and partially reversed by perphenazine. Pheno- (including altered liver function and jaundice). Endocrine Testicular
thiazines may potentiate the action of central nervous system depres- swelling and gynecomastia in the male; breast enlargement and
sants (opiates, analgesics. antihistamines, barbiturates, alcohol) and galactorrhea in the female; increased or decreased libido; elevated or
atropine. In concurrent therapy with any of these, TRIAVIL should be lowered blood sugar levels Other Dizziness. weakness, fatigue;
given in reduced dosage May also potentiate the action of heat and headache; weight gain or loss; increased perspiration; urinary
phosphorous insecticides. frequency. mydriasis. drowsiness; alopecia Withdrawal Symptoms’
Amitriptyline: In manic-depressive psychosis, depressed patients Abrupt cessation after prolonged administration may produce nau-
may experience a shift toward the manic phase if they are treated with sea, headache, and malaise. These are not indicative of addiction.
an antidepressant. Patients with paranoid symptomatology may have OVERDOSAGE: All patients suspected of having taken an over-
an exaggeration of such symptoms. The tranquilizing effect of dosage should be admitted to a hospital as soon as possible. Treat-
TRIAVIL seems to reduce the likelihood of this effect. When am’- ment is symptomatic and supportive. However, the intravenous
triptyline HCI is given with anticholinergic agents or sympathomimetic administration of 1-3 mg of physostigmine salicylate is reported to
drugs. including epinephrine combined with local anesthetics, close reverse the symptoms of tricyclic antidepressant poisoning. Because
supervision and careful adlustmenf of dosages are required. Paralytic physostigmine is rapidly metabolized, the dosage of physostigmine
ileus may occur in patients taking tricyclic antidepressants in combi- should be repeated as required particularly if life-threatening signs
nation with anticholinergic-type drugs such as arrhythmias, convulsions, and deep coma recur or persist
Caution is advised if patients receive large doses of ethchlorvynol after the initial dosage of physostigmine On this basis, in severe over-
concurrently. Transient delirium has been reported in patients who dosage with perphenazine-amitriptyline combinations, symptomatic
were treated with 1 g of ethchlorvynol and 75-150 mg of amitriptyline treatment of central anticholinergic effects with physostigmine salicy-
HCI.
Amitriptyline
effects of barbiturates
HCI may enhance the response
and other CNS depressants.
to alcohol and the
late should be considered
For more
Representative
detailed information. consult
or see lull Prescribing
your
Inlormation
MSD _______
MER K
Concurrent administration of amitriptyline HCI and electroshock Merck Sharp & Dohme, Division of Merck & Co . lrvc , HA
therapy may increase the hazards associated with such therapy. West Point. Pa 19486 OHM
 (-:--7 71?
dI4dtl ‘

10:1’ niore
)
1-_I: I
I

c*iF±h
. .
new from Dome Laboratories: a dual approach to help
the schizophrenic adjust to a more normal life

Daxolin#{174}
(loxapine succinate)
extensively investigated clinically
Loxapine succinate [Daxolin] has been studied
clinically in both chronic and acute schizophrenic
patients .
 evaluated by psychiatrists-BPRS (Brief Psychiatric Rating Scale),
cGI (Clinical Global Impression)
evaluated by psychiatric nurses-NOSIE (Nurse’s Observation Scale
for Inpatient Evaluation)
compared with various other agents including chlorpromazine,
trifluoperazine, thiothixene, as well as placebo-from
11 published, controlled/double-blind studies involving
441 patients1

helps control symptoms of acute and chronic schizophrenia

Evaluation (by BPRS) of symptomatic response in
221 chronic and acute schizophrenic patients’

Percent of Maximum Possible Improvement*

61% 61%

123 chronic
schizophrenic
patients
4

I
S3 acute
schizophrenic
patients
Delusion and Emotional Excitement and
fantasy withdrawal disorientation
(thought disorder)

E1significant improvement noted in behavior patterns, severity of

symptoms significantly reduced
L] helps control symptoms in responsive patients
E dosage strengths to meet individual needs
E manifestations of adverse effects on the central nervous system,
other than extrapyramidal effects, have been seen infrequently. t

t See “Adverse Reactions” and “Actions” sections

in the prescribing information on last page.
 EMP (EMPAThIC) COMMUNICATIONS
The symptoms of schizophrenia can be bizarre and puzzling-especially
to family and others in close contact with the patient. To help them
understand the disease, and thus be more helpful to the patient, Dome
Laboratories offers EMP (Empathic) Communications, a comprehensive
new education program developed especially for lay readers.
By providing authoritative, easy-to-understand booklets, this program
encourages family and friends to cooperate in the patient’s adjustment
to therapy and rehabilitation.

.and
#{149}
. for your information
PSYCHIATRIC INTERFACES
A new and ongoing publication of firsthand information that deals with
current psychiatric trends and offers opinions on mental-health care from
prominent psychiatrists.
 A member
of your
family

EMP (EMPAThIC)
COMMUNICATIONS
for the patient’s family
The first in a series of booklets that
answers a number of worrisome
questions on how to cope with
schizophrenia.

Other booklets offer specific

information for individual members
of the family and others in close
contact with the patient, such as the
employer, co-workers, paramedical
personnel.

now. . . more than symptomatic control for the

schizophrenic
EMP COMMUNICATIONS-an impressive
educational program
PSYCHIATRIC INTERFACES-an

outstanding information service

Daxoli
(loxapine succinate)
a promising neuroleptic agent for
symptomatic control of schizophrenia

See next page for prescribing information.

D axolln#{174}ooxapinesuccinate)
.

individualized dosage strengths to meet the varying needs

of the schizophrenic

- Prscautlons: DAXOLIN should be used with extreme antipsychotic agent, the syndrome may be masked. It
10 mg (light and dark caution in patients with a history ofconvulsive disorders has been suggested that fine vermicular movements of
blue), bottles of 100 S1C it lowers the convulsive threshold. Seizures have the tongue may be an early sign ofthe syndrome; it the
and 1000.
_______________________________________ been reported inepileptic
antipsychotic
patients receiving DAXOLIN at medication
dose levels, and may occur even with develop.
maintenance of routine anticonvulsant drug therapy. Cardr.wascular
is stopped atthattimethe
Effects: Tachycardia,
syndrome
hypotension,
may not
hy-
25 mg (blue and Loxapine has an antiemetic effect in animals. Since pertension, light-headedness, and syncope have been
)
______

white), bottles of 100 this effect also may occur loxapinein man,
may mask reported. A few cases of ECG changes similar to those
and 1000. signs of overdosage
tions such as intestinalof obstruction
toxic drugs and
and brain
obscuretumor.condi- seen
known withwhether
phenothiazines have related
these were been reported.
to loxapine It is ad-
not
DAXOLIN should be used with caution in patients with ministration.
cardiovascular
been reported disease.
Increased pulse rates have Skin Effects: Dermatitis, edema (puffiness of face), pru-
50 mg (blue and in the majority of patients receiving ritus, and seborrhea have been reported with loxapine.
maroon), bottles of 100 antipsychotic doses; and transient hypotension has The possibility of photosensitivity and/or phototoxicity
and 1000. been reported. In the presence of severe hypotension occurring has not been excluded; skin rashes of uncer-
requiring vasopressor therapy, the preferred drugs may tam etiology have been observed in a few patients dunng
be norepinephrine or aniotensin. Usual doses of epi- hot summer months.
nephrine may be ineffective because of inhibition of s Endocrine Effects: No endocrine abnormalities have
DcrIptIon: DAXOLIN (loxapine succinate), a dibenz- vasopressor effect by loxapine. been reported.
oxazepine compound, represents a new subclass of tn- The possibility of ocular toxicity from loxapine cannot Anticholinergic Effects: Dry mouth, nasal congestion,
cyclic antipsychotic agent, chemically distinct from the be excluded at this time, Therefore, careful observation constipation, and blurred vision haveoccurred; these are
thioxanthenes, butyrophenones, and phenothiazines. should be made for pigmentary retinopathy and lenticu- more likelyto occur with concomitant use of antiparkinso-
Chemically, it is 2-chloro-11-(4-methyl-1-piperazinyl) di- lar pigmentation since these have been observed in nian agents.
benz[b,f}[1,4] oxazepine. It is present in capsules as the 5O patients receiving certain other antipsychotic Other Adverse Reactions: Nausea, vomiting, weight
succinate salt. Each 1.36 mg of loxapine succinate is drugs for prolonged periods. gain, weight kss, dyspnea, ptosis, hyperpyrexia, flushed
equivalent to 1 mg of xapine. Because of possible anticholinergic action, the drug facies, headache, paresthesia, and polydipsia have
Actions: Pharmacologically, loxapine is a tranquilizerfor should be used cautiously in patients with glaucoma or a been reported in some patients.
which the exact mode of action has not been estab- tendencyto urinary retention, particularly with concomi- DosagsandAdmiI*at1on: DAXOLIN (loxapine succi-
lished. However, changes in the level of excitability of tat administration of anticholinergic-type antiparkinso- nate)is administered orally, usually in divided doses, two
subcortical inhibtory areas have been observed in sev- nian meditation. tofour times a day. Daily dosage (interms of base equiv-
eral animal species in association wfth such manifesta- Advsrie Rsscons: CNS Effects: Manifestations of alents) should be adjusted to the individual patient’s
tions of tranquilization as calming effects and sup- adverse effects on the central nervous system, otherthan needs as assessed bythe severity of symptoms and pre-
pression of aggressive behavior. extrapyrarnidal effects, have been seen infrequently. vious history of response to antipsychotic drugs. Initial
In normal human volunteers, signs of sedation were Drowsiness, usually mild, may occur at the beginning of dosage of 10 mg twice daily is recommended although,
seen within 20 to 30 minutes after administration, were therapy or when dosage is increased. It usually subsides in severely disturbed patients, initial dosage up to a total
most pronounced within 1 #{189}
to 3 hours, and lasted with continued DAXOLIN (loxapine succinate) therapy. of5O mg daily may be desirable. Dosage shouldthen be
through 12 hours. Similar onset and duration of primary The incidence of sedation has been less than that ofcer- increased fairly rapidly over the first seven to ten days
pharmacologic effect was seen in animals. twn aliphatic phenothiazines and slightly more than the untiithere is effective control ofpsychotic symptoms. The
Absorption of loxapine following oral or parenteral ad- piperazine phenothiazines. Dizziness, faintness, stag- usualtherapeutic and maintenance range is 60 mg to 100
ministration is virtually complete. The drug is removed gering gait, muscle twitching,weakness,and confusion- mg daily. However, as with other antipsychotic drugs,
rapidlyfrom the plasma and distnbuted in tissues. Animal al states have been reported. some patients respond to lower dosage and others re-
studies suggest an initial preferential distribution in Extrapyramidal Reactions-Neuromuscular (extra- quire higher dosage for optimal benefit. Daily dosage
lungs, brain, spleen, heart, and kidney. Loxapine is me- pyramida reactions during the administration of DAX- higher than 250 mg is not recommended. For mainte-
tabolized extensively and excreted mainly in the first 24 OLIN have been reported frequently, often during the first nance therapy, dosage should be reduced to the lowest
hours. Metabolites are excreted in the urine inthe form of few days of treatment In most patients, these reactions level compatible with symptom control; many patients
coniugates but are unconjugated in the feces. involved parkinsonism-like symptoms such as tremor, have been maintained satisfactorily at dosages in the
IndcstIons: DAXOLIN is indicated for the manifesta- rigidity, excessive salivation,
range of 20 ma to 60 mg daily. and masked facies.
tions of schizophrenia Akathi5ia (motor
SUPPIIId restlessness) also has been reported
DAXOLIN’ (lOxpine succinate) is sup-
Contraindlcatlons: DAXOLIN (loxapine succinate) isrelatively frequently. These symptoms are usually not so- plied in the following base-equivalent strengths:
contraindicated in comatoseor severe drug-induced de- vere and can be controlled by reduction of DAXOLIN CAPSULES Hard Shell Printed “DOME”
pressed states (alcohol, barbiturates, narcotics, etc.).
dosage or by administration of antiparkinsonian drugs in 10 mg-Light and Dark Blue; bottles of 100 and 1000.
DAXOLIN is contraindicated in individuals with known usual dosage. Dystonic and dyskinetic reactions have 25 mg-Blue and White; bottles of 100 and 1000.
hypersensitivity to the drug. occurred less frequently, but may be more severe. Dys- #{176} mg-Blue and Maroon; bottles of 100 and 1000.
rnlngs: Usage in Pregnancy: Safe use of DAXOLIN tonias include spasms of muscles ofthe neck and face,
durir#{231}pregnancy or lactation has not been established; tongue protrusion, and oculogync movement. Dyskinetic Manufactured for Dome Laboratories by
theretore,itsuseinpregnancy,innursingmothers,orin reaction has been described in the form of
women of childbearing potential requires that the bene- choreoathetoid movements, These reactions sometimes Lederle Laboratories Division, American Cyanamid
fits oftreatment be weighed againstthe possible risks to require reduction or temporary withdrawal of DAXOLIN Company, Pearl River, N.Y.
mother and child. No embryotoxicity or teratogenicity
dosage in addition to appropriate counteractive drugs.
was observed in studies in rats, rabbits or dogs. With the Frsistent Tardive Dyskinesia-In keeping withthe ac- 1. Data on file, Medical Research Department,
exception of one rabbit study, the highest dosage was tion of all antipsychotic agents, tardive dyskinesia may Dome Laboratories.
twotimes the maximum recommended human dose and appear in some patients on long-term therapy or may ap-
in some studies the dose was lower. Pennatal studies pear after drugtherapy has been discontinued. The risk
have shown renal papillary abnormalities in offspring of appears to be greater in elderlr patients-especially
rats treated from mid-pregnancy with doses of 0.6 and females-on high-dose therapy. I he symptoms are per-
1.8 mg/kg doses which approx’wnate the usual human sistent and, in some patients, appear to be irreversible.
dose but which are considerably below the maximum The syndrome is characterized by rhythmical involuntary
recommended human dose. movement ofthe tongue, face, mouth, or jaw (eg, protru-
Usage/n Children: Studles havenot been performed in sion of tongue, puffing of cheeks, puckering of mouth,
children; therefore this drug is not recommended for use chewing movements Sometimes these may be accom-
in children below the age of 16. panied by involuntary movements of the extremities.
DAXOLIN, like other tranquilizers, may impair mental There is no known effective treatment for tardive dys-
andkr physical abilties, especially dunng the first few kinesia; antiparkinsonian agents usually do not alleviate
days of therapy. Therefore, ambulatory patients should the symptoms of ths syndrome. It is suggested that all
be wamed about activities requiring alertness (eg, oper- antipsychotic agents be discontinued if these symptoms
ating vehicles or machinery), and about concomiffintuse appear, Should be necessaryto reinstitutetreatment, or aa DM5100 Miles LabOratOries Inc
of alcohol and other CNS depressants. increase the dosage ofthe agent, or switch to a different WESt HOV&1 Connecticut 0#{243}516
USA

C 1976 DOME LABORATORIES, DIVISION MILES LABORATORlS, NC. ALL RIGHTS RESERVED. DOM-1534R
 What can a long-acting
injectablephenothiazine
do that a short-acting
oralcant?
. . .‘ -. . . ,.,.,. , .. .,
. ..

: =

1P

,‘1.”,

3:4

/ .j #{231}13

9 1. :“
#{149} #{149}-

. .. 7
#{163} 3 / (7 7 .j.Jo,i ‘1/7

.,,‘

,...,1
.,
:. : .3’

Ct,.

IL
S -
 ItU can save duration
Prolixin of action that(Fluphenazine
Decanoate
on maintenance therapy,
time.
4 weeks or
may last up toDecanoate longer inwith
Injection), patients
can effect important savings in nursing

time
Approximate Staff Time Required to Medicate
1 8 Schizophrenic Patients*

--I
8 am. 3/4 hr. 1 injection every
1 p.m. 3% hr. 28 days for most
6 p.m. 3/4 hr. patients
= 2/ hours 4 minutes required
nursing time for each injection

2Y hrs. x 28 days 1 hr., 10 minutes nursing

= 63 hours of nursing time in 28 days

#{14
time every 28 days

NURSING TIME SAVED IN 61 hours and 50 minutes or

28 DAYS more than 71/2 eight-hour
workingdays
‘Adapted from Platt R Br J Social P sychiatry 2 1 87-1 91 1968

Martin and
Townend1, who found from their study of Prolixin

It can save Decanoate

every
that 1 5 of 39 patients
4 weeks,
on chlorpromazine
could be maintained
also note that on this basis “a year’s maintenance
represents the order of 1 10 grams
on 25 mg.

of

money phenothiazine
Translating
savings
as opposed
this into dollars
to 0.33 gram of fluphenazine.”
shows
on the basis of patient population:
the following potential hospital

Cost/500
Agent and Cost/patient! patients,’
amount/year Form year year

Chlorpromazine 8 oz. concen- $48.75* $24,375

(SKF brand) trate 100 mg/mIt
110 grams

Prolixin Decanoate 5 ml. vials $26508** $13,040

533 grams 25 mg/mI.

SAVINGS $22.67 $11,335

patient, year 500 pts/yr.
‘ calculated from prices published in 1976 Red Book
‘* calculated from Squibb 1976 price catalogue
t With tablets, the annual cost is even greater

The controlled drug delivery system of Prolixin Decanoate helps

It can even get schizophrenic
stay out. It promotes
drug defaulting
patients
continuity
from approximately
out of the hospital
of therapy-reducing
and helps them
outpatient
50% with oral medications

Save people -
accordingto
It reduces
one report2 to about
the number
study of 103 patients
16% according
and length of rehospitalizations.
maintained on injections
to another report3.
In one
of long-acting

b y reducing fluphenaZines, total hospital

from 191 to 50 and inpatient
readmissions for a year were cut
time from 8,713 days to 1,335 days4.
It facilitates return to a productive life. A 1 2-month followup of
readmissions 103 discharged
or household
patients revealed
duties and only
77% in full-time
23% unemployed4.
employment

,
References:
1 Martin CA and Townend RA: Brit J Psychiat 1 24: 1 73-6, 1974.
2 Goldberg HL, DiMascio A. chaudha B: Psychosomatics 1 1 173-177, 1970.
3. Medical World News, February 1 1 1972, p. 58H

Prolixin Decanoate
4 Denham J and Adamson L. can Psychiat Assoc J 18: 235-7, 1973

am #{174} ‘*

symptoms for up to weeks

SQUiBB
U #{149} I orlongerinp.tlentson
Flu phenazi ne Decanoate Injection I maintenance therapy.

See next page for brief summary of prescribing information.

Fluphenazine
.i I rnDecanoate Decanoate Injection
may control schizophrenic symptoms for up to 4 weeks or longer in patients on maintenance therapy.

Prolixin Decanoate (Fluphenazine Decanoate Injection) provides 25 mg. Autonomic Nervous System-Hypertension and fluctuations in blood pres-
fluphenazine decanoate per ml. in a sesame oil vehicle with 1 .2% (w/v) benzyl sure have been reported. Although hypotension is rarely a problem, patients
alcohol as a preservative. with pheochromocytoma, cerebral vascular or renal insufficiency or severe
cardiac reserve deficiency such as mitral insufficiency appear to be particu-
CONTRAINDICATIONS: In presence of suspected or established subcortical larly prone to this reaction and should be observed carefully. Supportive
brain damage. In patients who have a blood dyscrasia or liver damage, or who measures including intravenous vasopressor drugs should be instituted im-
are receiving large doses of hypnotics, or who are comatose or severely mediately should severe hypotension occur; Levarterenol Bitartrate Injection
depressed. In patients who have shown hypersensitivity to fluphenazine; U.S.P. is the most suitable drug; epinephrine should not be used since pheno-
cross-sensitivity to phenothiazine derivatives may occur. thiazine derivatives have been found to reverse its action. Nausea, loss of
Not intended for use in children under 12. appetite, salivation, polyuria, perspiration, dry mouth, headache and constipa-
tion may occur. Reducing or temporarily discontinuing the dosage will usually
WANlNGS: Mental and physical abilities required for driving a car or oper- control these effects. Blurred vision, glaucoma, bladder paralysis, fecal
ating heavy machinery may be impaired by use of this drug. Physicians should impaction, paralytic ileus, tachycardia, or nasal congestion have occurred in
be alert to the possibility that severe adverse reactions may occur which some patients on phenothiazine derivatives.
require immediate medical attention. Potentiation of effects of alcohol may Metabolic and Endocrine-Weight change, peripheral edema, abnormal
occur. Safety and efficacy in children have not been established because of lactation, gynecomastia, menstrual irregularities, false results on pregnancy
inadequate experience in use in children. tests, impotency in men and increased libido in women have occurred in
some patients on phenothiazine therapy.
Usage In Pregnancy: Safety for use during pregnancy has not been estab-
lished; weigh possible hazards against potential benefits if administering this Allergic Reactions-Itching, erythema, urticaria, seborrhea, photosensi-
drug to pregnant patients. tivity, eczema and exfoliative dermatitis have been reported with phenothia-
zines. The possibility of anaphylactoid reactions should be borne in mind.
PRECAUTIONS: caution must be exercised if another phenothiazine com- Hematologic-Blood dyscrasias including leukopenia, agranulocytosis,
pound caused cholestatic jaundice, dermatoses or other allergic reactions thrombocytopenic or nonthrombocytopenic purpura, eosinophilia, and pan-
because of the possibility of cross-sensitivity. When psychotic patients on cytopenia have been observed with phenothiazines. If soreness of the mouth,
large doses of a phenothiazine drug are to undergo surgery, hypotensive gums or throat or any symptoms of upper respiratory infection occur and
phenomena should be watched for; less anesthetics or central nervous sys- confirmatory leukocyte count indicates cellular depression, therapy should
tem depressants may be required. Because of added anticholinergic effects, be discontinued and other appropriate measures instituted immediately.
fluphenazine may potentiate the effects of atropine.
Hepatic-Liver damage manifested by cholestatic jaundice, particularly
Use fluphenazine decanoate cautiously in patients exposed to extreme
during the first months of therapy, may occur; treatment should be discon-
heat or phosphorus insecticides; in patients with a history of convulsive
tinued. A cephalin flocculation increase, sometimes accompanied by altera-
disorders since grand mal convulsions have occurred; and in patients with
tions in other liver function tests, has been reported in patients who have had
special medical disorders such as mitral insufficiency or other cardiovascular no clinical evidence of liver damage.
diseases, and pheochromocytoma. Bear in mind that with prolonged therapy
there is the possibility of liver damage, pigmentary retinopathy, lenticular Others-Sudden deaths have been reported in hospitalized patients on
and corneal deposits, and development of irreversible dyskinesia. phenothiazines. Previous brain damage or seizures may be predisposing
Fluphenazine decanoate should be administered under the direction of a factors. High doses should be avoided in known seizure patients. Shortly
physician experienced in the clinical use of psychotropic drugs. Periodic before death, several patients showed flare-ups of psychotic behavior pat-
checking of hepatic and renal functions and blood picture should be done. terns. Autopsy findings have usually revealed acute fulminating pneumonia
Renal function of patients on long-term therapy should be monitored; if BUN or pneumonitis, aspiration of gastric contents, or intramyocardial lesions.
becomes abnormal, treatment should be discontinued. “Silent pneumonias” Although not a general feature offluphenazine, potentiation of central nervous
are possible. system depressants such as opiates, analgesics, antihistamines, barbiturates,
and alcohol may occur.
ADVERSE REACTIONS: Central Nervous System-Extrapyramidal symp- Systemic lupus erythematosus-li ke syndrome, hypotension severe enough
toms are most frequently reported. These include pseudoparkinsonism, dys- to cause fatal cardiac arrest, altered electrocardiographic and electroen-
tonia,dyskinesia, akathisia, oculogyriccrises, opisthotonos, and hyperreflexia; cephalographictracings, altered cerebrospinal fluid proteins, cerebral edema,
most often these are reversible, but they may be persistent. One can expect asthma, laryngeal edema, and angioneurotic edema; with long-term use, skin
a higher incidence of such reactions with fluphenazine decanoate than with pigmentation and lenticular and corneal opacities have occurred with pheno-
less potent piperazine derivatives or straight-chain phenothiazines. The mci- thiazines. Local tissue reactions occur only rarely with injections of fluphena-
dence and severity will depend more on individual patient sensitivity, but zine decanoate.
dosage level and patient age are also determinants. As these reactions may For full prescribing information, consult package insert.
be alarming, the patient should be forewarned and reassured. These reactions
can usually be controlled by administration of antiparkinsonian drugs such as HOW SUPPLIED: 1 ml. Unimatic single dose preassembled syringes and
benztropine mesylate or intravenous caffeine and Sodium Benzoate Injection cartridge-needle units, and 5 ml. vials.
U.S.P., and by subsequent reduction in dosage.
Persistent Tardive Oyskinesia: As with all antipsychotic agents, persistent
and sometimes irreversible tardive dyskinesia may appear in some patients
on long-term therapy or may occur after discontinuation of drug. The risk
FILMS ON PSYCHIATRIC MANAGEMENT
seems greater in elderly patients, especially females, on high dosages. The AVAILABLE FROM SQUIBB
syndrome is characterized by rhythmical involuntary movements of tongue,
face, mouth, or jaw (e.g., protrusion of tongue, puffing of cheeks, puckering
of mouth, chewing movements) and may be accompanied by involuntary S A Step Beyond
movements of extremities. There is no known effective therapy for tardive . A Chance for Change
dyskinesia; usually the symptoms are not alleviated by antiparkinsonism
agents. If the symptoms appear, discontinuation of all antipsychotic agents
Way Out
is suggested. The syndrome may be masked if treatment is reinstituted, or . Community Treatment of the Psychotic Patient
drug dosage
that fine vermicular
increased, or a different
movements
antipsychotic
of the tongue
agent used. Reports
may be an early sign of the
are CA New Concept in Psychiatric Management
syndrome which may not develop if medication is stopped at that time. . Psychiatric Services in General Hospitals
Phenothiazine derivatives have been known to cause restlessness, excite- . The Quality of Care
ment, or bizarre dreams; reactivation or aggravation of psychotic processes
For further information contact your Squibb Representative
may be encountered. If drowsiness or lethargy occur, the dosage may have or write: Squibb, P.O. Box 4000, Princeton, N.J. 08540
to be reduced. Dosages, far in excess of the recommended amounts, may
induce a catatonic-like state.

S Q1J1BB#{174}‘The is thePriceless
honor Ingredient
and integrity ofof every product TM
its maker.

©1976 E. R. Squibb & Sons, Inc. H426-504

In clinically significant depression

TABLETS, 5mgand 10mg

. :‘

Vi :,Ti1LL
(ProtriptylineHC1IMSD)

* When
you want an antidepressant
that is characteristically nonsedating for
the patient under close medical supervision
(Symptoms such as anxiety or agitation
may be aggravated.) MSO ___

MERCK
SHARP&
For a brief summary of prescribing information please see following page. DOHME
 In clinically significant depression
TABLETS, 5 mg and 10 mg

(ProtriptylineHCIMSD)
Contraindications: Known hypersensitIvity; acute Adverse Reactions: Note: Included in this listing are a
recovery phase following myocardlal Infarction. Should few adverse reactions which have not been reported
not be given concomitantly wIth an MAOI; hyperpyretlc with this specific drug. However, the pharmacologic
crises, severe convulsions, and deaths have occurred in similarities among the tricyclic antidepressant drugs re-
patients receiving tricyclic antidepressant and MAOI quire that each of the reactions be considered when
drugs simultaneously. When it is desired to substitute protriptyline HCI is administered. Protriptyline HCI is
protriptyline HCI for an MAOI, a minimum of 14 days more likely to aggravate agitation and anxiety and pro-
should be allowed to elapse after the latter is discon- duce cardiovascular reactions such as tachycardia and
tinued. Protriptyline HO should then be initiated hypotension.
cautiously with gradual increase in dosage until op- Cardiovascular: hypotension, hypertension, tachycardia,
timum response is achieved. palpitation, myocardial infarction, arrhythmias, heart
Warnings: May block the antihypertensive effect of block, stroke.
guanethidine or similarly acting compounds. May impair Psychiatric: confusional states (especially in the elderly)
mental and/or physical abilities required for the perform- with hallucinations, disorientation, delusions, anxiety,
ance of hazardous tasks, such as operating machinery restlessness, agitation; insomnia, panic, and nightmares;
or driving a motor vehicle. Should be used with caution in hypomania; exacerbation of psychosis.
patients with a history of seizures and, because of its Neurological: numbness, tingling, and paresthesias of
autonomic activity, in patients with a tendency to urinary extremities: incoordination, ataxia, tremors, peripheral
retention or increased intraocular tension. neuropathy; extrapyramidal symptoms: seizures; altera-
Tachycardia and postural hypotension may occur more tion in EEC patterns, tinnitus.
frequently than with other antidepressant drugs. Should Anticholinergic: dry mouth and rarely associated
be used with caution in elderly patients and patients sublingual adenitis: blurred vision, disturbance of ac-
with cardiovascular disorders; such patients should be commodation, mydriasis: constipation, paralytic ileus;
observed closely because of the tendency of the drug to urinary retention, delayed micturition, dilatation of the
produce tachycardia, hypotension, arrhythmias, and
urinary tract.
prolongation of the conduction time. Myocardial infarc-
Allergic: skin rash, petechiae. urticaria, itching, photo-
tion and stroke have occurred with drugs of this class.
On rare occasions, hyperthyroid patients or those receiv- sensitization (avoid excessive exposure to sunlight).
edema (general, or of face and tongue), drug fever.
ing thyroid medication may develop arrhythmias when
this drug is given. Hematologic: bone marrow depression; agranulocytosis;
leukopenia; eosinophilia: purpura: thrombocytopenia.
Usage in Children: Not recommended for use in children
because safety and effectiveness in the pediatric age Gastrointestinal: nausea and vomiting, anorexia,
group have not been established. epigastric distress, diarrhea, peculiar taste, stomatitis,
abdominal cramps, black tongue.
Usage in Pregnancy: Safe use in pregnancy and lacta-
tion has not been established; therefore, use in pregnant Endocrine: gynecomastia in the male: breast enlarge-
women, nursing mothers, or women who may become ment and galactorrhea in the female: increased or
pregnant requires that possible benefits be weighed decreased libido, impotence: testicular swelling: eleva-
against possible hazards to mother and child. tion or depression of blood sugar levels.
Precautions: When protriptyline HCI is used to treat Other: jaundice (simulating obstructive): altered liver
the depressive component of schizophrenia, psychotic function; weight gain or loss; perspiration: flushing: un-
symptoms may be aggravated; likewise, in manic- nary frequency, noctunia; drowsiness, dizziness, weakness
depressive psychosis, depressed patients may experi- and fatigue; headache: panotid swelling: alopecia.
ence a shift toward the manic phase; paranoid delu- Withdrawal Symptoms: though not indicative of addic-
sions, with or without associated hostility, may be exag- tion, abrupt cessation of treatment after prolonged
gerated. In any of these circumstances, it may be advisa- therapy may produce nausea, headache, and malaise.
ble to reduce the dose of protriptyline HOl or to use a
major tranquilizing drug concurrently. Symptoms, such Overdosage: Hospitalize as soon as possible all pa-
as anxiety or agitation, may be aggravated in overactive tients suspected of having taken an overdose Treatment
or agitated patients. is symptomatic and supportive In addition, the n
travenous administration of 1 to 3 mg physostigmine
When given with anticholinergic agents or sym-
salicylate is reported to reverse the symptoms of other
pathomimetic drugs. including epinephrine combined
tnicyclic antidepressant poisoning. Because physostig-
with local anesthetics, close supervision and careful ad-
mine is rapidly metabolized, the dosage should be re-
lustment of dosages are required. May enhance
peated as required, particularly if life-threatening signs
response to alcohol and effects of barbiturates and other
such as arrhythmias, convulsions, and deep coma recur or
CNS depressants. Possibility of suicide in depressed pa-
persist after the initial dosage of physostigmine
tients remains during treatment and until significant
remission occurs, this type of patient should not have How Supplied: Tablets. containing 5 mg and 10 mg
access to large quantities of the drug. Concurrent ad- protniptyline HCI each, in single-unit packages of 100
ministration with electroshock therapy may increase and bottles of 100 and 1000.
hazards of therapy, such treatment should be limited to
patients for whom it is essential. Discontinue drug For more detailed information, consult your MSD repre-
several days before elective surgery, if possible. Both sentative or see full prescribing information. MSD
elevation and lowering of blood sugar levels have been Merck Sharp & Dohme,Division ofMerck & Co,,lNc., jpc
reported West Point, Pa. 19486.