Faculty Bibliography

This article discusses the uses of aripiprazole and presents a report of a case of dose-dependent incomplete right bundle-branch block in association with aripiprazole. This is the first such published report. While the incidence appears to be low, its appearance as an adverse event underscores the value of routine EKG monitoring of patients on aripiprazole as well as the other atypical antipsychotics.

Ciprofloxacin hydrochloride is a fluoroquinolone antimicrobial often used in ophthalmic and general medical practice. The October 2002 'Psychopharmacology Journal Watch' column contained a story on an acute psychotic reaction following the use of ciprofloxacin eyedrops. This article presents a report of hallucinations in a 19-year-old male apparently induced by another fluoroquinolone, gatifloxacin.

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)

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.

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.

Clonidine is an alpha -sub-2 adrenergic receptor agonist often used for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children. Presented here is a study of hyperprolactinemia and gynecomastia in association with the use of clonidine in a 6-year-old male.

The first of the atypical neuroleptics Food and Drug Administration-approved for the treatment of schizophrenia, clozapine is known to have a lower risk of causing parkinsonism and tardive dyskinesia in patients with schizophrenia. The drug is indicated for treatment-resistant schizophrenia and for reducing the risk of recurrent suicidal behavior in those with schizophrenia or schizoaffective disorder. Agranulocytosis occurs in 1% to 2% of patients using clozapine, typically within the first 4 months of treatment. According to a report, however, agranulocytosis can occur even after 11 years of continuous treatment. Described here is a study of fatal agranulocytosis occurring 4 years after discontinuation of clozapine in a 49-year-old Finnish man being treated for behavioral problems associated with moderate mental retardation.

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.

Previous 'Psychopharmacology Reviews' columns have discussed the use of lamotrigine for bipolar disorder, refractory unipolar depression, treatment-resistant schizophrenia, posttraumatic stress disorder, frontal lobe dementia, and post-stroke pathological laughing and crying. Lamotrigine is an anticonvulsant that blocks voltage-gated sodium channels where it inhibits the excessive release of the excitatory amino acids glutamate and gamma -aminobutyric acid. In addition to its actions on ion channels, lamotrigine weakly inhibits monoamine transporters. At a concentration of 100-1,000 mM, lamotrigine is an inhibitor of 5-hydroxytryptamine uptake in both rat and human tissues. At similar concentrations, lamotrigine also inhibits norepinephrine and dopamine uptake into rat brain synaptosomes. Now comes a report of a woman with bipolar disorder who developed hair loss as a side effect of lamotrigine. (journal abstract)

Priapism, characterized by abnormal, prolonged, painful erection of the penis, is a urologic emergency. If not treated within 4-6 hours, complications may occur, including difficulty urinating, urinary retention, impotence, cavernosa fibrosis, and gangrene. Even with surgery, approximately 40% to 50% of patients with priapism will become impotent. Priapism results from decreased venous outflow from the corpora cavernosa. This can be caused by physical obstruction of the venous system, blood dyscrasias that impede venous flow, solid tumors, trauma, spinal cord injuries, stroke, or blockade of postsynaptic alpha 1-adrenergic receptors that normally mediate sympathetically controlled detumescence of the penis or clitoris. In general, drug-induced priapism is believed to be mediated by the degree of aradrenergic antagonism. Opposing this tendency are anticholinergic effects. Thus, when a medication has more antiadrenergic than anticholinergic properties, it is more likely to be associated with priapism. Based on a review of available evidence, medication-induced priapism does not appear to correlate with either dose or length of treatment.