Faculty Bibliography

This is a report of a patient with an acute schizoaffective episode who developed severe cervical dystonia while being treated with a combination of quetiapine and valproic acid. A 60-year-old woman with schizoaffective disorder was admitted to the inpatient psychiatry unit at the University Hospital in Basel, Switzerland due to symptoms of mania and psychosis. She had recently been discharged from the hospital on quetiapine monotherapy 500 mg/day, which led her to remission and had been well tolerated. During that last hospitalization, she suffered two generalized seizures. She discontinued the quetiapine on her own, resulting in a rapid return of psychotic symptoms. She developed paranoia about being poisoned, as manifested by her persistent refusal of food and fluid intake. Upon readmission to the hospital, quetiapine was rapidly increased to 800 mg/day. The cervical dystonia improved with biperiden and resolved totally after reduction of both quetiapine and valproic acid. The patient was discharged on a combination of olanzapine and valproic acid.

While currently available treatments, such as selective serotonin reuptake inhibitors (SSRIs) and cognitive-behavioral therapy (CBT), are efficacious in obsessive-compulsive disorder (OCD), only approximately 40% to 60% of patients experience significant reduction of symptoms, with many others demonstrating either partial or no response. Little practical advice is available to clinicians on next-step treatment strategies for patients who have not responded to >=2 trials of SSRIs. Augmentation with various agents, including dopamine antagonists, typically are recommended. In severe, resistant cases, neurosurgery may even be used. The following is a report on the successful use of the atypical antipsychotic aripiprazole in combination with the serotonergic tricyclic antidepressant clomipramine in a patient with severe, refractory OCD.

Dopamine acts to inhibit the release of prolactin, a hormone that initiates and sustains lactation. In women, prolactin elevation can cause galactorrhea, amenorrhea, cessation of normal cyclic ovarian function, loss of libido, hirsutism, and increased long-term risk of osteoporosis and breast cancer. Presented here is a case of hyperprolactinemia and galactorrhea associated with sequential use of the serotnin norepinephrine reuptake inhibitors (SNRIs) venlafaxine and duloxetine A 40-year-old Caucasian female with three children and without any history of endocrine or reproductive pathology presented with dysthymic disorder. The patient appears to represent the first published case of SNRI-induced, dose-dependent, nonmenstrual vaginal spotting and galactorrhea accompanied by prolactin elevation. Since serum levels were not obtained it is not known if use of bupropion ER resulted in elevated levels of venlafaxine or duloxetine. Interestingly, the dopaminergic effects of bupropion were not enough to offset this patient's hyperprolactinemia, although it is possible but unproved that it may have attenuated it.

While use of the anticonvulsant phenytoin has been associated with delirium, a substantial majority of cases occur in the context of either hepatic compromise or drug-drug interaction. The following is a report of an individual undergoing treatment for metastatic brain tumor who subsequently developed delirium likely related to an interaction between the chemotherapy agent temozolomide and phenytoin. A 68-year-old man was in his usual state of good health when he developed a personality change as well as word-finding and memory difficulty. Compared with his previous neurologic evaluation, the patient was noted to be profoundly confused, averbal, and unresponsive to most questions. No new focal neurologic findings were evident. The rapid onset and marked changes in behavior, cognition, hallucinations, and sleep-wake cycle all point to a delirium, most probably caused by an elevation in phenytoin levels; the latter possibly resulted from inhibition of phenytoin's metabolism by the coadministered temozolomide. Subsequently, the patient was lost to follow-up.

For over 30 years, lithium carbonate has been a mainstay in the treatment of bipolar disorder. With a narrow therapeutic index, toxicity associated with lithium ranges from gastrointestinal complaints to marked neurologic impairment. Electrocardiogram (ECG) manifestations of lithium toxicity include prolonged QT interval, T wave flattening and inversion, first-degree atrioventricular conduction delay and, rarely ventricular tachycardia and fibrillation resulting in death.

Previous Psychopharmacology Reviews have discussed the association between serotonin reuptake inhibitors (SRIs) and the syndrome of inappropriate antidiuretic hormone secretion (SIADH), which is characterized by the sustained release of antidiuretic hormone (ADH) from the posterior pituitary gland. The norepinephrine reuptake inhibitor reboxetine, approved in Europe for the treatment of depression, has also been associated with SIADH. Other medications associated with SIADH include tricyclic antidepressants (TCAs), bupropion, neuroleptics, carbarnazepine, sodium divalproex, vincristine, and cyclophosphamide.

Presents a case study, of 34-year-old woman with a history of psychotic depression commenced citalopram 20 mg/day and quetiapine 25 mg/day, with the latter titrated up to 100 mg/day. Approximately 6 weeks later, she noticed significant hair loss, involving whole strands. One week after onset, quetiapine was withdrawn. The hair loss resolved. At last follow-up, the patient remained on citalopram. In the second report, another 34-year-old woman with a history of bipolar disorder was taking quetiapine 300 mg/day, zopiclone 7.5-15 mg/day, clonazepam 1 mg as needed, and salbutamol inhaler as needed. There are two main mechanisms presumed to underlie druginduced alopecia. Typically, medication-induced alopecia is reversible upon dosage reduction or discontinuation of the offending drug. Other options for managing this side effect include waiting for accomodation to occur or the use of zinc and selenium.

A 34-year-old man was brought by his family to the psychiatric emergency room of a Turkish hospital in May 2005. For the prior 3 days, the patient had suffered from insomnia, talked too much, and exhibited increased psychomotor activity. He claimed that God talked to him and told him that he was special. Upon admission, further evaluation revealed excessive alcohol consumption for 15 years. On average, he drank 5--7 standard units of alcohol per weekend. Mental status examination revealed that the patient had auditory hallucinations. Diagnosed with manic psychosis, the patient was started on haloperidol 20 mg/day, chlorpromazine 100 mg/day, and biperiden 10 mg/day. Within 2 days, the auditory hallucinations disappeared, mystic and megalomanic delusions improved, and insight was restored. In typical practice, disulfiram is initiated at a dose of 500 mg/day then 1 or 2 weeks later decreased to a maintenance dose of 250 mg/day. The temporal sequence of events described above, including a 12-day alcohol-free period in the context of use of higher than normal doses of disulfiram, supports an association between disulfiram and emergence of manic psychosis.

Topiramate is a sulfamate-substituted monosaccharide approved for monotherapy in partial seizures, generalized tonic clonic seizures, and migraine prophylaxis. It blocks voltage-gated sodium channels, enhancesgamma -aminobutyric acid (GABA) via action on the GABA-sub(A) receptor, antagonizes the kainate aminomethyl phosphonic acid (AMPA) subtype of the glutamate receptor, and inhibits carbonic anhydrase. Due to its ability to suppress appetite and cause weight loss, topiramate has gained increasingly widespread use among clinicians as a treatment for psychotropic-induced weight gain, binge-eating disorder, and even bulimia nervosa. Other research suggests that topiramate may also be effective for the treatment of posttraumatic stress disorder (PTSD), obstructive sleep apnea, opiate and benzodiazepine withdrawal, kleptomania, alcohol dependence, self-injurious behavior, aggression) non paraphilic sexual addiction, olfactory hallucinations, and even for the promotion of scar healing.

Presents the first published report of bilateral eyelid edema in association with use of olanzapine. A 41-year-old previously healthy man experienced a first psychotic episode and attempted suicide by opening the veins of his forearm. This act was motivated by the delusional idea that he was infected with human immunodeficiency virus (HIV). He was diagnosed with schizoaffective disorder. Over the weeks, trials of risperidone, aripiprazole, and venlafaxine failed. With a combination of duloxetine 90 mg/day and amisulpride 400 mg/day, psychotic and depressive symptoms improved. Within 24 hours of the first (evening) dose of olanzapine 5 mg, the patient complained of a 'swollen face,' with his eyelids found to be turgid. After 10 days, olanzapine was discontinued and the eyelid swelling disappeared completely the following day. The temporal course of events described suggests an association between olanzapine and the development of bilateral eyelid edema.