Faculty Bibliography

This column presents a case of treatment-resistant depression (TRD) in which the transdermal--but not the oral--formulation of selegiline was effective.

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 One week after onset, quetiapine was withdrawn.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.

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.

The occurrence and duration of paroxysmal atrial fibrillation are influenced by vagal tone. The selective serotonin reuptake inhibitor (SSRI) paroxetine can modulate vagal tone at the level of the mid-brain and inhibit the vasovagal reflex. Paroxysm of refractory neurally mediated syncope has been reduced with paroxetine. That finding supports the notion that paroxetine may modulate the occurrence of atrial fibrillation that is under the influence of the vagus nerve. In one study, oral paroxetine 10 mg/day was administered to nine patients with multidrug-resistant paroxysmal atrial fibrillation. Conventional antiarrhythmic drugs were used for all the patients for a minimum of 2 weeks, and, in the case of amiodarone, at least 3 months. These agents decreased the frequency of arrhythmia events by < 30% in all patients. In contrast, the frequency decreased significantly in all patients after paroxetine was added. Notably, in three patients, atrial fibrillation resolved completely. In three other patients, the daily doses of antiarrhythmic drugs were decreased by 33% to 50%, although the frequency of atrial fibrillation still remained low. For the group as a whole, the mean atrial fibrillation frequency declined from a baseline of 13.2 to 1.0 episodes per month. These preliminary results indicate that some patients with atrial fibrillation may respond very favorably to oral treatment with paroxetine. While the pathophysiology underlying this effect is not known, several possibilities exist, including modulation of central serotonin metabolism at the level of the mid-brain and anxiolysis resulting in decreased myocardial irritability. Whether the reputed benefit of paroxetine or other SSRIs in the treatment of atrial fibrillation depends upon the presence of comorbid depression is a question worthy of further study.

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.

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.

A side effect reported in association with olanzapine is metabolic dysregulation, which includes weight gain, hyperinsulinemia, and lipid abnormalities. The following a report of olanzapine induced chylomicronemia resulting in acute pancreatitis. A 36-year-old Libyan man presented with a 3-day history of epigastric pain. While there have been several prior reports describing the association of olanzapine with acute pancreatitis, the exact mechanism remains unclear. Based on the case described here, it appears that chylomicronemia may underlie the association between olanzapine and acute pancreatitis. Regular monitoring of serum lipids is essential not only for general cardiovascular health, but to prevent this potential life-threatening condition.

Tactile hallucinations of insects, snakes, or other vermin crawling on the skin is known as formication. Overdoses of the norepinephrine-dopamine reuptake inhibitor bupropion have been associated with formication. The following is a report of two cases of formication occurring in association with therapeutic doses of bupropion. In the first case, a 39-year-old African-American woman suffered from posttraumatic stress disorder, major depressive disorder (MDD), and cocaine dependence in full remission for 10 months. There was no history of psychosis or mania. Her medication regimen consisted of buspirone, felodipine, fluoxetine, hydrochlorothiazide, omeprazole, simvastatin, sulindac, and psyllium powder. Bupropion sustained release (SR), titrated over 2-3 weeks to 200 mg BID, was added to augment fluoxetine. Within 3 weeks, the patient complained of bugs crawling on her skin, noting that, when using cocaine, she had similar experiences. Her symptoms abated after her total daily dose of bupropion SR was reduced to 300 mg. In the second case, a 40-year-old white woman had recurrent MDD with no history of psychosis or mania. She was taking levothyroxine, loratadine, montelukast, ranitidine, riboflavin, butalbital as needed for migraines, gabapentin or trazodone as needed for insomnia, and ibuprofen. Bupropion SR was initiated and then titrated over 3 months to 200 mg BID. The depression remitted. However, 11 months into treatment, the patient admitted that soon after increasing her dosage of bupropion to 200 mg BID she developed continuous, mild, tactile hallucinations like bugs crawling on her skin. Her tactile hallucinations resolved after the total daily dose of bupropion SR was reduced to 300 mg. The cases described above are consistent with bupropion-associated formication. Clinical caution is advised.

Presents a case of bilateral complicated cataract and glaucoma following large-dose methylphenidate use for 2 years. A 10-year-old boy presented with progressive blurred vision in both eyes over the past year. He had no history of systemic disease, ocular trauma, or ocular disorder except myopia before this episode. Three months before the current visit, decreased visual acuity had been noted during a routine school physical check-up. Glaucoma and cataract were diagnosed at the ophthalmic clinic. History revealed that the patient had ADHD and had been taking methylphenidate hydrochloride 40 mg/day in two divided doses as prescribed by his psychiatrist. Over the prior 2 years, however, at the instruction of his mother, the patient had been taking 60 mg/day. A diagnosis was made of methylphenidate-associated cataract and glaucoma. Methylphenidate was discontinued. Despite maximal anti-glaucomatous medication, IOP still could not be controlled. The patient then received combined cataract and glaucoma surgery, with intraocular lens implantation for both eyes. Postoperatively, visual acuity improved with IOP within normal limits in both eyes. These improvements were sustained at 1 year follow-up.