Jefferson Journal of Psychiatry

Sudden Cardiac Death with Clozapine and Lorazepam Combination

Sriram Ramaswamy et al. — Tue, 05 Jun 2012 13:50:58 PDT

Objective: To report a case of sudden cardiac death in a patient taking a combination of clozapine and lorazepam.

Case summary: A 31-year-old white man with schizophrenia was found dead at his apartment. His medication regimen included clozapine 500 mg at bed time, lorazepam 0.5 mg three times daily and levothyroxine 75 mcg once a day. Autopsy studies revealed cardiac hypertrophy, pulmonary congestion and edema.

Discussion: Clozapine therapy may cause cardiomyopathy and reduction in heart rate variability (HRV) indices. Benzodiazepines can reduce vagal tone and increase sympathetic activity. This combination can have an enhanced potential for sudden cardiac death.

Conclusions: Clozapine induced cardiomyopathy and arrhythmias from clozapine and/or lorazepam use may have contributed to this man's death.

Using Transcranial Magnetic Stimulation (TMS) to Compare Cortical Excitability Among Depressed Patients, Sleep-Deprived Controls, and Rested Controls

Rajani Rajan et al. — Tue, 05 Jun 2012 13:15:46 PDT

Objective: To compare cortical excitability among sleep-deprived and rested controls, and depressed subjects.

Methods: 3 controls and 4 depressed patients (average HAM-D 19) wererecruited. Sleep-deprived controls were instructed to sleep <=4 hours the previous night. TMS-produced motor evoked potentials (MEPs) were measured before and after subjects engaged in sets of non-fatiguing manual exercise.

Results: Post-exercise MEP increased 71+1-19% for rested controls, 28+1-32% for sleep deprived controls, and 8+1-15% for depressed patients. This increase, "facilitation," was significantly greater in rested controls than in depressed patients (p=0.011). No significant difference in facilitation was found between sleep-deprived controls and depressed patients.

Conclusion: Sleep-deprivation may partially account for reduced cortical excitability in depressed patients.

Antidepressant Pharmacotherapy: Prescription Practices in Psychiatric Resident Care

Rachel Dew et al. — Tue, 05 Jun 2012 13:15:40 PDT

Background: Research on treatment of depression has raised concerns regarding adequacy of medication trials and rationality of drug choice. Little data exists regarding pharmacotherapy by psychiatric residents. As practice habits begun in training will likely persist after graduation, examination of residents' antidepressant use may ultimately improve treatment by psychiatrists.

Methods: Charts of new patients presenting to the Wake Forest University Psychiatry Resident Clinic were reviewed. Survey was made of medications prescribed to 112 patients diagnosed with major depression, dysthymia, depressive disorder NOS, adjustment disorder with depressed mood, or bipolar disorder with a documented depression during the studied period. Drug choice and maximum dose were noted.

Results: Most-prescribed antidepressants included sertraline, trazodone, citalopram, mirtazapine, venlafaxine, and bupropion. The most used tricyclic antidepressant was amitriptyline (n=7), with an average highest dose of 110.7 mg per day. No MAOIs were prescribed. Augmentation treatment with lithium was prescribed twice and thyroid hormone once. No patients received ECT.

Conclusions: Depressed patients in this resident clinic were treated primarily with SSRIs and other newer antidepressants. Little use was made of TCAs, MAOIs, ECT or traditional augmentation strategies. Further research should aim to determine whether more education in older antidepressant treatment modalities should be emphasized.

The Duty to Warn/Protect Doctrine and Its Application in Pennsylvania

Clarence Watson — Tue, 05 Jun 2012 13:15:35 PDT

Despite the almost universal familiarity of mental health professionals with the Tarasoff case, many questions regarding its associated legal requirements often arise when evaluating potentially dangerous patients. The principles of the duty to warn/protect, while appearing nebulous at times, contain key concepts that the clinician must consider in the face of potential danger to third parties. This article reviews the landmark decision of the Tarasoff case and outlines its key concepts. In addition, given that state jurisdictions vary in treatment of Tarasoff-like cases, this article explores the Pennsylvania Supreme Court decision, Emerich v. Philadelphia Center for Human Development, Inc.

Editor's Note

Anika Vaughn-Cooke — Tue, 05 Jun 2012 13:15:29 PDT

Electroconvulsive Therapy: A Review of Its Current Status

Tyler Kenning et al. — Tue, 05 Jun 2012 13:15:24 PDT

This article presents an overview of the current knowledge and practice of ECT. It provides a brief history of the development of ECT followed by a discussion of the accepted indications for ECT in psychiatric practice, including major depression, bipolar disorder (mania and depression), and schizophrenia. Moreover, a description of the technique of performing ECT is given. Also examined are the use of ECT in medically ill patients and the risks associated with ECT. In conclusion, with the aid of advances in anesthesia and the delivery of ECT, electroconvulsive therapy is a safe and effective treatment of mood and psychotic disorders that have been resistant to other treatment modalities.

The Efficacy and Toxicity of Bupropion in the Elderly

William T. Howard M.D., M.S. et al. — Tue, 31 Jan 2012 13:43:48 PST

Bupropion is an antidepressant with excellent tolerability and few side effects or drug interactions. These characteristics suite it well for use both in the elderly and in the medically ill. However, early reports of seizures with bupropion therapy in patients with bulimia limited its use. The pharmacology, efficacy, toxicity, and side effect profile of both the immediate release (IR) and the recently available sustained release (SR) formulations of bupropion are reviewed. Bupropion SR is associated with a reduced seizure incidence (0.1%) compared to that found with the IR formulation (0.4%). Recent reports, however, demonstrate that the half-life of bupropion is prolonged in the elderly and that the elderly accumulate bupropion metabolites. Potential toxic effects, including seizures and psychosis, may result from high bupropion plasma levels and the accumulation of bupropion metabolites in the elderly or in those with impaired renal or liver function. Clinical reports in the elderly demonstrate that lower (75-225 mg/day) doses of bupropion are associated with fewer side effects and equal efficacy to that found with higher doses. Bupropion is a good antidepressant choice for the elderly and the medically ill, provided additional precautions, including the use of low doses, are taken. Bupropion should either be avoided or be used with extreme caution in anyone who is at increased risk of seizures or who has a history of psychosis or an eating disorder.

The Malingering of Psychotic Disorders

Michael R. Harris M.D. — Tue, 31 Jan 2012 13:43:46 PST

The phenomenon of malingered psychosis is examined through a review of the available literature. Possible motivations for malingering are discussed, and clinical indicators of feigned psychotic symptoms are reviewed. The methods discussed focus on the inpatient evaluation of suspected malingerers and include discussions of interview techniques and psychometric testing to supplement clinical impressions. A differential diagnosis is presented, and techniques for confronting a malingering patient are reviewed.

Lilliputian Hallucinations and Marijuana Dependence in a Bipolar Patient

Matthew L. Bush M.S. IV et al. — Mon, 30 Jan 2012 12:02:52 PST

Lilluputian hallucinations are rarely seen in manic patients. Here we present a case of isolated lilluputian hallucinations against a backdrop of psychosis and marijuana use. The phenomenon is interesting and worth following up with. The patient recovered and a brief literature search is included.

A New Onset Paranoid Psychosis Associated With Fluoxetine and Bupropion: A Case Report

Vassili V. Arkadiev M.D. et al. — Mon, 30 Jan 2012 12:02:49 PST

Current methodological Issues in Candidate Gene Association Studies in Psychiatric Disorders

Leo Sher M.D. — Mon, 30 Jan 2012 12:02:47 PST

One of the most rapidly emerging areas of neuroscience research is the study of genetic approaches to complex psychiatric disorders. The author discusses potential benefits and pitfalls of candidate gene association studies. Association studies search for correlations in the population between a DNA marker and a disorder. The so-called candidate gene approach is frequently used in association studies. Candidate gene studies are usually based on hypotheses about relationships between specific known loci and particular phenotypes. The aim of molecular genetic studies of behavioral disorders includes the development of predictive and diagnostic testing for psychiatric disorders that can help to establish the accurate diagnosis and the identification of target for therapeutic drugs. To date, case-control association studies investigating polymorphisms of candidate genes in psychiatric disorders have produced a lot of positive and negative findings with few consistent replications. The false positive and false negative findings in candidate gene association studies are due to population stratification, heterogeneity of psychiatric disorders, multiple tests, low prior odds of association, and small sample size. A researcher planning a genetic association study for a psychiatric disorder needs to have the following: 1) suitable phenotypes; 2) a good rationale for studying not only the gene in question, but the specific polymorphism; 3) enough subjects and control for meaningful analyses; and 4) use of ethnically homogenous case-control data sets or family based association designs.

Addiction Professionals' Attitudes Regarding Treatment of Nicotine Dependence

Baljit S. Gill M.D. et al. — Mon, 30 Jan 2012 11:45:43 PST

The objectives of this study were: to establish the extent to which addiction professionals are willing to treat nicotine addiction concurrently with other addictions, and to evaluate what factors affect their attitudes.

A 21-item questionnaire was developed and distributed to therapists, physicians and other mental health workers in different treatment settings in Southeastern Virginia.

CD staffers own smoking histories were significantly related to: their perceptions of the impact of nicotine use, and how likely they were to intervene in patients' nicotine use. Intervention in CD staffers own smoking behavior may increase the treatment of nicotine dependence in their patients.

Psychosis in Azheimer's Disease

George M. Strickland M.D. et al. — Mon, 30 Jan 2012 11:45:40 PST

Much of the basic science literature on Alzheimer's Disease (AD) reflects ongoing research into pathophysiology and neuropathology. Yet, despite reports of the association between psychotic symptoms and Alzheimer's disease, relatively little is known about why such symptoms develop in certain patients and not in others. Neuroimaging and genetic studies may provide greater understanding of this association and allow clinicians and researchers to prevent, predict and treat the onset of psychotic symptoms in the future. This paper will review the current literature on the topic of psychosis in Alzheimer's disease and focus on current recommendations for interventions by clinicians and caregivers.

Neuroleptic Malignant Syndrome: Review, Diagnostic Critique

Khurram K. Durrani M.D. — Mon, 30 Jan 2012 11:27:03 PST

Neuroleptic malignant syndrome (NMS) can be defined as an idiosyncratic and potentially fatal reaction to neuroleptic agents that consists of fever, mental status changes, muscle rigidity, autonomic dysfunction, respiratory distress and rhabdomyolysis. The pathogenesis of NMS is still not fully understood. The diagnosis presents a challenge and the diagnostic criteria need further refinement. The presentation and course of NMS are quite variable and can range from a progressive, fulminating, downhill course to a relatively benign and self-limiting course. Despite great improvements in the management of the syndrome, prevention and early diagnosis are the most important aspects of treatment.

Treatment Response of Opium Smoking Hmong Refugees to Methadone Maintenance

Muhammad Waqar Azeem M.D. et al. — Mon, 30 Jan 2012 11:11:30 PST

Objective: To examine the outcome of methadone maintenance in opium dependent Hmong refugees.

Methods: Medical records were searched for Hmong patients in methadone treatment between 01/1995 and 09/1997. Patient's progress was assessed over nine months.

Results: 44 Hmong patients were found. Data was available on 40 patients, mean age of 47.7 years, 33 males/7 females. At admission 100% met the DSM-IV criteria for Opium Dependence, 75% Major Depressive Disorder and 68% PTSD. Patients showed marked improvement by having mostly negative urine drug screens, improvement on Addiction Severity Index and 70% being highly successful on outcome criteria modified by Drug Abuse Research Project over 9 months.

Conclusions: These findings suggest that opium dependent Hmong patients can show marked improvement while in methadone maintenance program. Prospective controlled studies are warranted.

Editor's Note

Manoj Mohata M.D. — Mon, 30 Jan 2012 11:11:27 PST

Psychiatric Training: The Culture and Its Contradictions by T.M. Luhrmann

Carolyn Myers M.D. — Wed, 25 Jan 2012 06:49:31 PST

Methylphenidate, Bupropion, and SSRI Triple Therapy

William Bobo M.D. — Wed, 18 Jan 2012 11:34:06 PST

Methylphenidate and bupropion have been demonstrated as being effective adjuncts to serotonin reuptake inhibitors in the treatment of depression (1,2). The use of these medications in case of a depressed patient whose condition was resistant to several forms of monotherapy, monotherapy with "standard" augmentation and ECT. After only a partial response to fluoxetine and methylphenidate, bupropion was added, resulting in full, sustained remission.

Severe Generalized Edema Associated with Phenelzine

William Bobo M.D. et al. — Wed, 18 Jan 2012 11:34:03 PST

Rabkin, et al. describes a 4% incidence of phenelzine-induced edema, which appears to be due to increased capillary permeability (1,2). This adverse effect is not further characterized in the literature and is not readily mentioned as one of the many drug effects that could result in severe physical morbidity. We present the case of a depressed patient who developed a generalized edema severe enough to deserve an extensive medical workup. Once the drug was tapered, the edema and its associated symptoms rapidly resolved.

Personality Traits in Juvenile Delinquents: Associations with Peer and Family Relations

Jeffrey J. Wilson M.D. et al. — Wed, 18 Jan 2012 11:34:00 PST

Objective: To establish family and peer correlates of personality traits shown to be predictive of future criminal recidivism.

Method: 137 incarcerated boys aged 13-18 (x = 16 ± 1.2), 35% black, 21% Hispanic, 43% white, and 1% other completed the Weinberger Adjustment Inventory (WAI) and a psychosocial history obtained by a social worker. Records were summarized using two raters who assigned numerical ratings to dimensions of family and peer relations.

Results: As expected, observer ratings of family and peer relationships were correlated with the personality characteristics of distress, denial and restraint as measured by the WAI.

Conclusion: Family and peer relations are associated with certain personality traits that are predictive of criminal recidivism in delinquents. This study further expands the knowledge base regarding the social and interpersonal correlates of individual traits predicting criminal recidivism.