The Addition of Intravenous Caffeine During an Amobarbital Interview W. Vaughn McCall, M.D. Department of Psychiatry, Bowman Gray School of Medicine, Winston-Salem, North Carolina Submitted: February 12, 1992 Accepted: October 5, 1992

Although the amobarbital interview is an effective means of temporarily relieving catatonic mutism, some catatonic patients simply fall asleep during an amobarbital interview. We are examining the feasibility of administering intravenous caffeine benzoate during an amobarbital interview to prevent patients from falling asleep. This paper describes an open trial of the administration of 500 mg caffeine benzoate during amobarbital interviews with ten patients. The procedure was well tolerated, but further studies are needed to determine whether or not caffeine is an advantage over amobarbital alone. Key Words: catatonia, amobarbital, amytal interview, caffeine

INTRODUCTION The catatonic syndrome carries a relatively favorable prognosis and responds completely in 85% to 95% of cases to either psychotropic medications or electroconvulsive therapy (Abrams and Taylor 1976; McCall 1992). Catatonia may be under-recognized and under-treated (Fink and Taylor 1991). The amobarbital interview is widely believed to be useful in quickly relieving catatonic symptoms (McCall et al 1992). Although the procedure has relatively few risks, its use is limited by the tendency of patients to fall asleep during the administration of amobarbital. Catatonic patients who fall asleep during an amobarbital interview fail to benefit from the usual temporary period of lucidity that enables them to eat and move about normally (Lewis et al 1989). Even worse, physicians may mistakenly believe that patients who fall asleep during an amobarbital interview have "organic brain disease" with a poor prognosis; physicians may therefore fail to offer useful treatment (McCall 1992). The administration of intravenous stimulants during a sedative interview has been suggested to make the interview more productive and prevent patients from falling asleep (Hurwitz 1988; Davidoff Address reprint requests to: W. Vaughn McCall, Department of Psychiatry, Bowman Gray School of Medicine, Medical Center Blvd., Winston-Salem, North Carolina, USA 27157. J Psychiatr Neurosci, VoL 17, No. 5, 1992

et al 1941; Neki and Kishore 1968). Parenteral methylphenidate and dextroamphetamine, however, are no longer recognized as having medical value and are not routinely available. Oral stimulants may be useful for keeping patients awake during an amobarbital interview (Shale and Gelenberg 1980), but catatonic patients often refuse all oral intake. Based on the use of caffeine during electroconvulsive therapy (Shapira et al 1985), it was felt that caffeine might be a suitable adjunct stimulant during the amobarbital interview. This paper reports the results of an open trial of intravenous caffeine during amobarbital interviews with ten patients.

METHOD Subjects Ten subjects were examined - five men and five women - with a mean age of 41 years (range = 20 to 75), all with catatonic mutism. Catatonic mutism was defined as persistent mutism, stupor and a lack of reaction to the environment. Prior to the interview, none of the patients had their eyes closed or otherwise appeared to be asleep. Mean body weight was 63.7 kg (range = 43 kg to 91 kg). All patients had been free of medication for at least 48 hours. The subjects' diagnoses at the time of discharge were major depression 195

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(n = 5), schizophrenia (n = 2), conversion disorder (n = 2) and mania (n = 1). The nature of catatonic illness prevented these patients from providing informed consent to the procedure. Therefore, the local investigational review board approved the protocol, provided that the consent of a family member was obtained. Consent was obtained from a family member for each patient. Amobarbital and caffeine were administered through an intravenous line in the patient's arm. Amobarbital was given as a five percent solution at a rate not exceeding 50 mg per minute. Amobarbital administration was stopped when the patient's speech was slurred, he or she fell asleep or a total dose of 500 mg was reached, whichever came first. All patients received 500 mg of injectable caffeine benzoate (equal to 242 mg of caffeine) in a single bolus during the amobarbital infusion after 200 mg of amobarbital had been given. A semi-structured interview for patients with catatonic mutism was followed (McCall et al 1992).

Assessment of wakefulness The patients' level of consciousness was assessed at the end of the interview. The patients were judged to be asleep or awake based on a simple assessment of their behavior. Closed eyes, flaccidity of the limbs, deep and regular breathing and failure to arouse to a sternal rub were interpreted as signs of sleep. The agreement of two psychiatrists at the interview was required to determine whether a patient was asleep or awake.

RESULTS The subjects received a mean of 386 mg of amobarbital (range = 300 mg to 500 mg) equivalent to 6.1 mg/kg. One patient had fallen asleep by the end of the interview, while the other nine appeared to be fully awake. Eight of the ten patients were speaking freely by the end of the interview. None of the patients complained of new somatic or psychological symptoms after the interview, and no untoward behavioral reactions resulted. Furthermore, there was no evidence (i.e., precipitation) that caffeine and amobarbital were incompatible in the intravenous line.

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this report (6.1 mg/kg). Thus, in comparison to patients receiving amobarbital alone, a smaller percentage of the patients given caffeine fell asleep despite receiving a larger dose of amobarbital. The administration of caffeine during an amobarbital interview is not a new idea. It was previously used, however, to reverse complications of the procedure. Bleckwenn (1930), in one of his initial reports of the amobarbital interview, described a case of hypotensive shock after the administration of amobarbital, which was reversed over 20 minutes after the administration of intravenous caffeine and epinephrine. Hart et al (1945) described one case of respiratory arrest from their experience with 500 amytal interviews and reported that the patient's respiration promptly returned after intravenous caffeine was administered. Hart recommended the routine use of intravenous caffeine toward the end of the amobarbital interview to limit medication "hangover". Patients who were groggy and had slurred speech during an amobarbital interview have been known to become alert and speak clearly within one to two minutes after the administration of intravenous caffeine. In summary, the administration of intravenous caffeine benzoate during ten amobarbital interviews was favorable. The initial study was uncontrolled, not blind, and the sample was too small to draw conclusions. Nevertheless, this preliminary report suggests that intravenous caffeine benzoate is at least tolerated during the amobarbital interview and may be given in the same intravenous line as amobarbital. Despite the lack of any adverse reactions to caffeine in these subjects, such side-effects as hallucinations, tachycardia and ventricular ectopy have been attributed to intravenous caffeine (Kellner and Bachman 1992; Acevedo and Smith 1988; Jaffe et al 1990). This new technique should therefore be used with caution for patients known to have cardiovascular disease.

ACKNOWLEDGEMENT The author thanks Dr. Frank Shelp for his assistance in performing the interviews.

REFERENCES

DISCUSSION The sample was too small to determine whether or not the addition of caffeine to an amobarbital interview is an improvement over amobarbital 4lone. Nevertheless, the caffeine was well tolerated, and only ten percent of the subjects fell asleep; in a previous study, 25% of the subjects fell asleep after receiving amobarbital alone (McCall et al 1992). In that study, 11 of the 20 patients were receiving various psychotropic medications at the time of the amobarbital interview, but these patients received a smaller average dose of amobarbital (4.8 mg/kg) than the subjects in

Abrams RA, Taylor MA (1976) Catatonia: a prospective study. Arch Gen Psychiatry 33:579-581. Acevedo AG, Smith JK (1988) Adverse reaction to use of caffeine in ECT. Am J Psychiatry 145:529-530. Bleckwenn WJ (1930) Production of sleep and rest in psychotic cases. Archives of Neurology and Psychiatry 24:365-372. Davidoff E, Reifenstein E, Goodstone G (1941) Amphetamine sulfate-sodium amytal treatment of schizophrenia. Archives of Neurology and Psychiatry 45:439-445.

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Caffeine and the amobarbital interview

Fink M, Taylor MA (1991) Catatonia: a separate category in DSM-IV? Integrative Psychiatry 7:2-5. Hart WL, Ebaugh FG, Morgan DW (1945) The amytal interview. Am J Med Sci 210:125-13 1. Hurwitz TA (1988) Narcosuggestion in chronic conversion symptoms using combined intravenous amobarbital and methylphenidate. Can J Psychiatry 33(2):147-152. Jaffe R, Brubaker G, Dubin W, Roemer R (1990) Caffeineassociated cardiac dysrhythmia during ECT: a report of three cases. Convulsive Therapy 6:308-313. Kellner CH, Bachman DL (1992) Olfactory hallucinations after intravenous caffeine. Am J Psychiatry 149:422. Lewis JL, Santos AB, Knox EP (1989) Inducing patients to eat with daily administration of amobarbital sodium. South MedJ 82:1315-1316.

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McCall WV (1992) The response to an amobarbital interview as a predictor of therapeutic outcome in patients with catatonic mutism. Convulsive Therapy 8:174-178. McCall WV, Shelp FE, McDonald WM (1992) Controlled investigation of the amobarbital interview in catatonic mutism. Am J Psychiatry 149:202-206. Neki J, Kishore B (1968) Narcostimulation in depressive states. Am J Psychiatry 124:1196-1202. Shale JH, Gelenberg AJ (1980) The amobarbital interview. Milit Med 145:825-828. Shapira B, Zohar J, Newman M, Drexler H, Belmaker R (1985) Potentiation of seizure length and clinical response to electroconvulsive therapy by caffeine pretreatment: a case report. Convulsive Therapy 1:58-60.

The addition of intravenous caffeine during an amobarbital interview.

Although the amobarbital interview is an effective means of temporarily relieving catatonic mutism, some catatonic patients simply fall asleep during ...
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