Faculty Bibliography

Anxiety disorders are common in depressed patients. Several studies of the full range of Diagnostic and Statistical Manual of Mental Disoroters-defined anxiety disorders in depressed psychiatric outpatients each found that when diagnoses are based on semi-structured diagnostic interviews >40% of the patients had a comorbid anxiety disorder. The recognition of comorbidity is not simply of academic interest, but it has important clinical significance. Epidemiological studies, such as the National Comorbidity Study, have demonstrated that depressed individuals with a history of anxiety disorders are at increased risk for hospitalization, suicide attempt, and greater impairment from the depression. The co-occurrence of anxiety disorders in depressed patients has been associated with a more chronic course of depression in psychiatric patients, primary care patients, and epidemiological samples. Recent research has suggested that clinicians underrecognize anxiety disorder comorbidity in depressed patients. The clinical significance of this underrecognition is highlighted by the finding that patients often want treatment to address their anxiety disorder comorbidity. When anxiety disorders are detected they often influence clinicians' selection of antidepressant medication, though some of clinicians' prescribing biases are not supported by empirical data. In this monograph, Iwona Chelminski, PhD, reviews the significance of anxiety in patients with depression as well as diagnostic instruments for recognizing this comorbidity. Next, Mark Zimmerman, MD, addresses the factors that affect the clinician's choice of antidepressant, focusing on the influence of comorbid anxiety. Finally, Sidney Zisook, MD, discusses the differential efficacy of antidepressants as well as the role of psychotherapy in patients with comorbid anxiety and depression. (journal abstract)

Hypothermia is a life-threatening emergency. Besides exposure to cold, causes of hypothermia include sepsis, hypothyroidism, hypoglycemia, or drug overdose. Classically, neuroleptics have been associated with hyperthermia, particularly in relation to the neuroleptic malignant syndrome (NMS). The February 1999 'Psychopharmacology Journal Watch' cited an article on neuroleptic-associated hypothermia. At the time, the authors reported on 10 cases of neuroleptic-associated hypothermia reported to the drug safety surveillance program of the German Federal Institute for Drugs and Medical Devices between 1988 and 1997. The reports involved 6 women and 4 men, ranging from 19-86 years of age (average age = 50 years). In all cases, neuroleptics were given for either paranoid psychosis or schizophrenia. The substances involved included various neuroleptics, some of which are not available in the United States. Nine of the patients were treated with neuroleptics (clozapine, risperidone, chlorprothixene, zotepine, levomepromazine, and pipamperone) that are more potent antagonists at the serotonin 5-HT2 receptor than at the dopamine D2 receptor. In most cases, there was a period of several days from initial exposure to medication to the onset of hypothermia. The following is a report of hypothermia in a patient taking the atypical neuroleptic risperidone in combination with the selective serotonin reuptake inhibitor paroxetine.

Wagstaff et al (2003) have summarized case reports of statin-induced memory problems in patients treated with simvastatin. This article presents a report of new-onset cognitive difficulties in an older patient after initiation of simvastatin therapy. A 64-year-old white male presented with memory problems shortly after initiation of simvastatin therapy. The man had a history of bipolar disorder, characterized predominantly by depressive episodes, which had been stable over the past 2 years. At the time of presentation, the patient's medications included venlafaxine, quetiapine fumarate, simvastatin, terazosin, and carbamazepine extended-release. Simvastatin had been initiated by the patient's primary care physician for dyslipidemia. Within 1 week of starting simvastatin, the patient complained of additional memory problems. The temporal sequence of events supports a highly probable association between simvastatin and cognitive decline in this patient.

Zonisamide is a synthetic 1,2-benzisoxazole derivative and anticonvulsant that was Food and Drug Administration approved in March 2000 for the treatment of partial seizures in adults. An open-label study and a case report suggest that zonisamide may be beneficial as an anti-manic agent. Other evidence suggests that zonisamide may have therapeutic potential in protecting against ischemic cerebral damage such as stroke. In patients with epilepsy, side effects reported in association with zonisamide include dizziness, headache, kidneys stones, diplopia, altered mental status, and even psychosis. Presented here is a study of zonisamide-induced suicidality in a 34-year-old woman with a 20-year history of complex partial seizures.

Oxcarbazepine, an anticonvulsant medication indicated primarily for partial seizures, neuropathic pain, and trigeminal neuralgia, is also used off-label as a mood stabilizer for the treatment of bipolar disorder. One of the reputed advantages of oxcarbazepine, compared with carbamazepine, is that it is free of hematologic toxicity. The package insert of oxcarbazepine mentions the possibility of thrombocytopenia, but states that the information is derived from uncontrolled and open-label trials and that therefore causality cannot be reliably determined. Presented here is the first published case report of oxcarbazepine- induced thrombocytopenia in an adult. The case is of a 63-year-old Asian-American woman with a history of multiple past psychiatric admissions for psychotic depression, brought to the hospital for increasingly disorganized behavior and paranoid ideation.

We present a report of urinary retention in an olanzapine-treated patient. A 24-year-old white man with paranoid schizophrenia was hospitalized for a psychotic episode characterized mainly by paranoid ideas and auditory hallucinations. He consumed alcohol and cannabis regularly and was an active smoker. Upon admission the patient received olanzapine 20 mg/day, but no other medication on a regular basis. Four days following admission, he received haloperidol 5 mg and lorazepam 2 mg orally. Two days later, he began to show clinical improvement consisting of decreased hallucinations and agitation and improved social interactions. However, he had difficulty initiating urination and was completely unable to void. Olanzapine was discontinued, with the urinary retention progressively disappearing over the next 24 hours.

Baclofen, the Upsilon -aminobutyric acid (GABA)-sub(B) agonist muscle relaxant, has been commonly used to treat muscle spasms associated with various neurologic conditions including spinal injury, hemi-facial spasm, multiple sclerosis, trigeminal neuralgia, and neuroleptic-induced tardive dyskinesias. The usual dosage ranges from 10-200 mg/day. While baclofen is generally well tolerated, adverse effects are not uncommon, especially when higher doses are used. The following is a report of psychosis associated with use of therapeutic doses of baclofen.

Venlafaxine is a serotonin norepinephrine reuptake inhibitor widely used for the treatment of depression, generalized anxiety disorder, and social anxiety disorder, as well as a number of other psychiatric conditions for which serotonergic antidepressants are often employed. Reported side effects for venlafaxine include nausea, somnolence, insomnia, dizziness, constipation, sweating, anorexia, asthenia, nervousness, dose-dependent blood pressure elevation, increased urinary frequency, and sexual dysfunction. The following is a report of venlafaxine-induced rapid and severe edema, otherwise known as anasarca.