Faculty Bibliography

Reports the case of a 42-year-old physically healthy woman with a 12-year history of depression and alcohol abuse received a prescription for citalopram 40 mg/day. Despite near abstinence from alcohol for 6 months, she continued to experience episodes of depression and hypomania, consistent with a diagnosis of bipolar type 2 disorder. She had no prior history of auditory, visual, or tactile hallucinations. Lamotrigine 25 mg/day was initiated, and then increased to 50 mg/day after 2 weeks. The patient reported improved mood without any side effects. After another 2 weeks, lamotrigine was increased to 100 mg/day. At this point, the patient's sleep became disturbed, with frequent waking and vivid dream-like experiences during which time the patient was not fully asleep. Five days later, she experienced visual hallucinations involving seeing her daughter and her nurse. She also reported headaches and hypersensitivity to noise. After lamotrigine was reduced to 50 mg/day, the hallucinations subsided over the next 48-72 hours.

Reports the case of a 53-year-old married Vietnam veteran with PTSD and bipolar disorder not otherwise specified (NOS). In 2004, the patient received a trial of duloxetine 60 mg/day. However, within the first week he experienced a severe exacerbation of PTSD symptoms including daily flashbacks of Vietnam, nightmares, emotional numbing, increased startle response, and extreme hypervigilance. The rest of his depressive symptoms remained unchanged. Upon reduction of his daily duloxetine dosage to 30 mg, his PTSD symptoms lessened but still were more severe compared to before the introduction of duloxetine. After duloxetine was totally discontinued, his PTSD symptoms returned to baseline.

This article reviews certain drug therapies in the field of psychopharmacology. The first review presents a case study in which memantine was used to treat catatonic schizophrenia. The second review presents a case report of ropinirole-induced psychosis. The third review presents a case report in which pindolol was used successfully in the treatment of psychogenic polydipsia. The fourth review describes how off-label use of tiagabine, an adjunct anticonvulsant for the treatment of partial seizures, has been associated with new-onset seizures. The final review presents a case report of bupropion-induced subacute cutaneous lupus erythematosus.

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.

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.

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.

Tourette's disorder (TO) was first described by Georges Gilles de la Tourette in 1885. It is characterized by multiple motor and one or more vocal tics. The lifetime prevalence of TD is 4-5/10,000, the ratio of males to females being 3:1. Up to 50% of TD patients also have attention-deficit/hyperactivity disorder, and approximately 40% also have obsessive-compulsive disorder. The pathophysiology of TD is unclear, but likely involves disordered presynaptic release of dopamine or dysfunction in postsynaptic dopamine receptors. Other possible factors associated with TD include abnormal serotonin uptake, a hyperactive endogenous opioid system, a disorder of the noradrenergic system, or excessive inhibition of excitatory amino acids that regulate dopamine uptake in neurons within the basal ganglia. While the effects of various medications on the symptoms of TD are variable, agents that reduce central activity of dopamine, norepinephrine, and opiates generally appear to reduce the severity of TD. (journal abstract)

Anxiety disorders are common in depressed patients. Several studies of the full range of Diagnostic and Statistical Manual of Mental Disorders--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)

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)