Aim: to assess whether pharmacogenetic polymorphisms are associated with increased adverse effect... more Aim: to assess whether pharmacogenetic polymorphisms are associated with increased adverse effects or nonresponse with certain antidepressants whose metabolism is highly dependent on specific CYP450 isoenzymes This is interim analysis of an ongoing study We used a Case Control design comparing patients with major depressive disorder or generalized anxiety disorder who had had increased adverse effects from specified antidepressants (Cases) to patients who were poor responders to an antidepressant but without significant adverse effects (Controls) Genecept Assay™ (battery of pharmacogenetic tests relevant to psychiatry) was obtained using saliva or cheek swab Importantly, 57.1% of Cases were poor or intermediate metabolizers on the concerned isoenzyme vs. 17.2% of Controls (p= .006) 52.9% of subjects who had at least one severe adverse effect were found to be poor or intermediate metabolizers on the concerned isoenzyme compared to 24.2% of those who did not. This difference showed a trend towards statistical significance (p= .061) 69.2% of subjects who had more than one severe adverse effect were found to be poor or intermediate metabolizers on the concerned isoenzyme compared to 21.6% of those who did not (p= .005) 27.6% of Controls were ultrarapid metabolizers on the concerned isoenzyme vs. 14.3% of Cases (p= .221) No statistically significant differences in the proportions of Cases vs. Controls who were homozygous (TT) for methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism, or for the Short/Short form of the serotonin transporter promoter region allele. Patients on certain commonly used antidepressants who had increased adverse effects were very likely to be poor or intermediate metabolizers on the relevant CYP450 isoenzyme Pharmacogenetic testing should routinely be considered in these patients
Patients' failure to keep appointments is a common problem. On average, patients miss approxi... more Patients' failure to keep appointments is a common problem. On average, patients miss approximately 15% of follow-up psychiatric appointments, (1) but the percentage is much higher in some patient populations, such as patients with significant socioeconomic difficulties. Those who miss appointments often have worse outcomes and even a higher likelihood of psychiatric readmission. (2) We present strategies to help patients keep appointments and to handle occasional and repeated absences. Although the problem of missed appointments will never go away, following these suggestions could help minimize it. Prevent the problem Explain to the patient why regular appointments are important. The most important point is that clinician and patient must agree that--to best help the patient--treatment requires that all appointments be kept, barring emergencies. Communicate clearly. Avoid emphasizing rules, such as that patients must keep 80% of appointments, give 48-hours' notice for cancellations, or pay a no-show fee. These suggest that patients may miss appointments as long as they follow the rules. Fix structural problems in your practice that may be barriers to making, rescheduling, or cancelling appointments. Be clear with patients about: * the phone number they should call for appointments * if they or you must cancel, that person is to reschedule at the earliest opportunity. To avoid phone tag, ask the patient to provide a mobile phone number. If you are unable to reach the patient, leave a message with 2 potential times you could see the patient and ask the patient to call back to confirm one of these times. If the patient is missing appointments because the frequency is too burdensome, in many cases less frequent but more regular visits may be better. During your early sessions with patients, be sure they understand that you reserve specific times for them. Make sure, however, that patients don't interpret this to mean that attending every appointment is for your benefit, rather than important for their treatment. Emphasize responsibility. At the end of each session, set a goal with patients for the next appointment. With a patient who has missed appointments, ask for a commitment that he or she will come to the next session. We have found that stating that you are concerned the patient might not come to the next session can paradoxically be helpful. Having your receptionist call and remind patients the day before their visits might not be a good idea in many cases. Patients might think these calls relieve them of the responsibility for remembering to keep appointments. With patients you think might miss appointments--especially those on a medication that requires careful monitoring--consider writing prescriptions to last no longer than the next appointment. …
Anxiety disorders and anxiety symptoms are highly prevalent in the general population and more so... more Anxiety disorders and anxiety symptoms are highly prevalent in the general population and more so in the medically ill. They have a number of negative consequences for these patients and may worsen the outcome of the medical illness and increase health care utilization. In the evaluation of these patients, it is of paramount importance to identify the etiology of the anxiety and, in particular, to differentiate primary from secondary anxiety. Management includes medications (especially benzodiazepines and selective serotonin reuptake inhibitors) and psychotherapy (particularly cognitive-behavioral therapy).
Evaluations of patients' capacity to make medical decisions are among the most common and most co... more Evaluations of patients' capacity to make medical decisions are among the most common and most complex consultations that psychiatrists are asked to perform. We describe tips that we have found to be helpful while performing capacity evaluations. We also share tips that should help the clinician make up his or her mind regarding the patient following capacity evaluations.
... By Rajnish Mago, MD | December 1, 2009. Dr Mago is director of the Mood Disorders Program at ... more ... By Rajnish Mago, MD | December 1, 2009. Dr Mago is director of the Mood Disorders Program at Thomas Jefferson University in Philadelphia. ... Please e-mail me at [email protected] with your questions and comments. ...
Sir: Barbarich et al. 1 report the potential benefits of olanzapine in treating anorexia nervosa.... more Sir: Barbarich et al. 1 report the potential benefits of olanzapine in treating anorexia nervosa. I disagree with their results and conclusions for the following reasons. The study's small sample size of 17 patients, 12 of whom completed the study, could result in a type II error. That 71% of patients completed the study is not "noteworthy," as the authors claim. Powers and colleagues 2 published a 10-week trial of olanzapine treatment of anorexia nervosa with a 64% completion rate. Fassino and colleagues 3 reported a 75% completion rate in a randomized, placebo-controlled study of citalopram treatment of anorexia nervosa. Curiously, for the 3 patients who terminated the study against medical advice, Barbarich et al. did not explain their reasons for doing so. It is reasonable to conclude that weight gain resulting from olanzapine treatment was a factor. By definition, patients with anorexia nervosa have a morbid fear of weight gain and obesity, and olanzapine-induced weight gain makes this medication a poor treatment option. Woodside and colleagues 4 found that concerns about weight gain among anorexia nervosa patients were a predictor in their premature termination from inpatient programs specializing in treating eating disorder. Proposed mechanisms of olanzapine-induced weight gain include increased food intake, decreased motor activity, and increased ratio of weight gain:weight of food consumed. 5 In fact, olanzapine may not be a suitable medication for treating patients with anorexia nervosa due to its high incidence of weight gain. Studies reporting weight gain during olanzapine use can be divided into short-term (less than 2 months) and long-term (3 months or more). Numerous short-term studies report significant weight gain during olanzapine treatment. 2,6,7 Patel and colleagues 6 found that patients treated with olanzapine gained an average of 3.8 kg. A 10-week, single-blind study of children aged 7 to 13 years with Tourette's syndrome found that olanzapine's most common side effect was weight gain (mean = 12.0 lb). 7 An open-label, 10-week study of olanzapine treatment of anorexia nervosa found an average 8.75-lb weight gain. 2 Regarding long-term studies, Eli Lilly's package insert for Zyprexa 8 disclosed that, during treatment lasting a median of 238 days, 56% of patients gained more than 7% of their baseline weight, with an average weight gain of 5.4 kg. Haberfellner and Rittmannsberger 9 found that 67% of olanzapine-treated patients gained more than 7% of baseline initial body weight with a mean weight gain of 7.7 kg during the first year of treatment. In a 3-year, retrospective chart review, 86% of patients on olanzapine treatment gained an average of 3.65 kg. 10 Four studies comparing olanzapine with other atypical antipsychotics found olanzapine was significantly associated with a greater weight gain. 6,[11][12][13] A retrospective analysis of children and adolescents receiving olanzapine or quetiapine found that patients taking olanzapine had significantly increased weight and body mass index (BMI) compared with other patients taking quetiapine. 6 A long-term study 11 comparing olanzapine and risperidone found a statistically significant (p < .005) difference in weight gain between these atypical antipsychotics (8.34 vs. 2.74 kg). A 6-month, open, observational study 12 comparing olanzapine and risperidone found significant weight gains in both groups, with 11.3 kg of weight gain in the olanzapinetreated group (p = .001) and 5.9 kg in the risperidone group (p = .023). Another long-term study 13 of risperidone and olanza-
Background: Antidepressant-induced excessive sweating (ADIES) occurs in 5% to 14% of patients tak... more Background: Antidepressant-induced excessive sweating (ADIES) occurs in 5% to 14% of patients taking antidepressants, usually persists throughout treatment, and causes subjective distress and functional impairment. We conducted the first clinical trial of any treatment for ADIES. Methods: Clinical features of ADIES were assessed using a semi-structured form. Twenty-three patients with moderate or greater ADIES were assessed for a 2-week baseline period , followed by 6 weeks of open-label treatment with flexible dose terazosin, 1 to 6 mg/d. Improvement in ADIES was measured by the Clinical Global Impressions (CGI) scale and other measures. Results: ADIES commonly was prominent in the scalp (62%), face (95%), neck (48%), and chest (57%); usually occurred either episodically or with episodic bursts (82%); and was persistent (median 63 months). Twenty-two of the 23 patients responded to terazosin (CGI-I scores 1 or 2), with CGI-Severity improving from median of 5 to median of 2 (P < .0001). Patient-rated daytime and nighttime severity of ADIES and proportion of time in ADIES also improved significantly. The most common adverse effects of terazosin therapy were dizziness/lightheadedness (n = 9) and dry mouth (n = 4). No patient dropped out because of adverse effects. Sitting and standing systolic blood pressure decreased by median values of 3 (P = .044) and 5 (P = .063) mm Hg, respectively. Conclusions: Terazosin may be an effective treatment for ADIES. Although dizziness/lightheadedness may occur in some patients, the treatment generally was well tolerated.
Various psychiatric symptoms can occur in epilepsy or be induced by antiepileptic medications. Zo... more Various psychiatric symptoms can occur in epilepsy or be induced by antiepileptic medications. Zonisamide is an antiepileptic medication used as adjunctive therapy for partial seizures. Depression, 1 mania, 1,2 obsessive-compulsive disorder, 3 and psychotic ...
Newer antidepressants that are more selective in their neurotransmitter effects include the selec... more Newer antidepressants that are more selective in their neurotransmitter effects include the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and others (agomelatine, bupropion, mirtazapine, reboxetine, vilazodone, vortioxetine). This article systematically reviews data from a variety of sources regarding the potential adverse effects of these medications on various cardiovascular parameters. Potential biochemical mechanisms by which these antidepressants may adversely affect the cardiovascular system are also discussed. Antidepressants that are associated with higher cardiovascular risk (SNRIs, reboxetine), lower risk (SSRIs), and without current evidence of cardiovascular risk (agomelatine, mirtazapine, vilazodone, vortioxetine) are identified. The FDA&amp;amp;amp;amp;amp;amp;amp;amp;#39;s recommendations regarding citalopram are organized and summarized, and situations with higher risk of cardiovascular adverse effects are identified.
It appears that the risk is greater with antidepressant use during late pregnancy but may be elev... more It appears that the risk is greater with antidepressant use during late pregnancy but may be elevated with use during early pregnancy as well.
Lamotrigine is an important option in bipolar disorders. However, many clinicians also use it in ... more Lamotrigine is an important option in bipolar disorders. However, many clinicians also use it in patients with a (unipolar) depressive disorder who have not responded adequately to conventional antidepressants.
While SSRIs and SNRIs are valuable in the treatment of major depression, partial response or nonr... more While SSRIs and SNRIs are valuable in the treatment of major depression, partial response or nonresponse occurs in many patients. Research has found that bupropion was the most frequently chosen agent for addition to an SSRI after inadequate response.
This is the second installment of a new series in which clinically relevant research is briefly d... more This is the second installment of a new series in which clinically relevant research is briefly discussed and, perhaps more important, a few tips on how to read and interpret research studies are presented. Your feedback, suggestions, and questions are eagerly solicited at [email protected].
We refer to the interesting article from Drs. Kanaan and Kerwin 1 concerning the adjunctive use o... more We refer to the interesting article from Drs. Kanaan and Kerwin 1 concerning the adjunctive use of lithium to treat clozapine-induced neutropenia. Immediate discontinuation of clozapine treatment has always been the first therapeutic step in cases of severe to moderate neutropenia and impending agranulocytosis. However, some physicians are reluctant to terminate or even to interrupt clozapine treatment in patients with neutropenia, as the drug is often a last resort for those with complex symptomatologies. The retrospective study by Drs. Kanaan and Kerwin suggests that lithium coadministration is an effective and safe strategy that may allow continuation of clozapine treatment despite the occurrence of neutropenia. This result is of considerable clinical relevance because it potentially provides an alternative to the interruption of clozapine treatment in severe cases in which other antipsychotic drugs are ineffective. However, some clozapine-associated neutropenia may be transient and harmless, and therefore may not require discontinuation of the drug treatment nor lithium adjunction. Transient neutropenia (defined as a return of the neutrophil count to normal values without changing the clozapine dosage) has been shown to occur in 22% of 68 patients treated with clozapine for the first time. 2 Neutropenia of short duration (2-5 days) and weekly benign variations of the neutrophil count have been reported. Marked circadian variations in the number of circulating neutrophils, i.e., morning pseudoneutropenia, have also been described in several clozapine-treated patients. 3,4 It seems therefore essential, before interrupting clozapine treatment, to determine whether drug-induced neutropenia is transient or malignant. Laboratory screening tests, including the use of a hydrocortisone test, are being devised to make such a distinction. 5 Until these tests become available for routine use, it is necessary to increase the frequency with which neutrophil counts are determined. As first suggested by Ahokas and Elonen, 3 when the absolute neutrophil count is below the normal range in the morning, the test should be repeated the same day in the afternoon before a decision to stop clozapine treatment or to consider lithium coadministration is made.
Nonadherence to medications is common and associated with poor or limited clinical outcomes in th... more Nonadherence to medications is common and associated with poor or limited clinical outcomes in the treatment of bipolar disorder. A review of the literature discloses that adverse effects are one of the commonly reported reasons for nonadherence to mood stabilizers by patients with bipolar disorder. Nevertheless, other than such broad summaries, relatively little attention has been given to the role of adverse effects in relation to nonadherence. This review article is the first to consolidate the available data on this topic. Weight gain, perceived cognitive impairment, tremors, and sedation are the adverse effects most likely to lead to nonadherence. Further research is needed to anticipate, identify, manage, and potentially minimize the impact of adverse effects.
Background: Cognitive behavioral treatment (CBT) of residual symptoms after successful pharmacoth... more Background: Cognitive behavioral treatment (CBT) of residual symptoms after successful pharmacotherapy yielded a substantially lower relapse rate than did clinical management in patients with primary major depressive disorders. The aim of this study was to test the effectiveness of this approach in patients with recurrent depression (Ն3 episodes of depression). Methods: Forty patients with recurrent major depression who had been successfully treated with antidepressant drugs were randomly assigned to either CBT of residual symptoms (supplemented by lifestyle modification and well-being therapy) or clinical management. In both groups, during the 20-week experiment, antidepressant drug administration was tapered and discontinued. Residual symptoms were measured with a modified version of the Paykel Clinical Interview for Depression. Two-year follow-up was undertaken, during which no antidepressant drugs were used unless a relapse ensued. Results: The CBT group had a significantly lower level of residual symptoms after discontinuation of drug therapy compared with the clinical management group. At 2-year follow-up, CBT also resulted in a lower relapse rate (25%) than did clinical management (80%). This difference attained statistical significance by survival analysis. Conclusions: These results challenge the assumption that long-term drug treatment is the only tool to prevent relapse in patients with recurrent depression. Although maintenance pharmacotherapy seems to be necessary in some patients, CBT offers a viable alternative for other patients. Amelioration of residual symptoms may reduce the risk of relapse in depressed patients by affecting the progression of residual symptoms to prodromes of relapse.
Aim: to assess whether pharmacogenetic polymorphisms are associated with increased adverse effect... more Aim: to assess whether pharmacogenetic polymorphisms are associated with increased adverse effects or nonresponse with certain antidepressants whose metabolism is highly dependent on specific CYP450 isoenzymes This is interim analysis of an ongoing study We used a Case Control design comparing patients with major depressive disorder or generalized anxiety disorder who had had increased adverse effects from specified antidepressants (Cases) to patients who were poor responders to an antidepressant but without significant adverse effects (Controls) Genecept Assay™ (battery of pharmacogenetic tests relevant to psychiatry) was obtained using saliva or cheek swab Importantly, 57.1% of Cases were poor or intermediate metabolizers on the concerned isoenzyme vs. 17.2% of Controls (p= .006) 52.9% of subjects who had at least one severe adverse effect were found to be poor or intermediate metabolizers on the concerned isoenzyme compared to 24.2% of those who did not. This difference showed a trend towards statistical significance (p= .061) 69.2% of subjects who had more than one severe adverse effect were found to be poor or intermediate metabolizers on the concerned isoenzyme compared to 21.6% of those who did not (p= .005) 27.6% of Controls were ultrarapid metabolizers on the concerned isoenzyme vs. 14.3% of Cases (p= .221) No statistically significant differences in the proportions of Cases vs. Controls who were homozygous (TT) for methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism, or for the Short/Short form of the serotonin transporter promoter region allele. Patients on certain commonly used antidepressants who had increased adverse effects were very likely to be poor or intermediate metabolizers on the relevant CYP450 isoenzyme Pharmacogenetic testing should routinely be considered in these patients
Patients' failure to keep appointments is a common problem. On average, patients miss approxi... more Patients' failure to keep appointments is a common problem. On average, patients miss approximately 15% of follow-up psychiatric appointments, (1) but the percentage is much higher in some patient populations, such as patients with significant socioeconomic difficulties. Those who miss appointments often have worse outcomes and even a higher likelihood of psychiatric readmission. (2) We present strategies to help patients keep appointments and to handle occasional and repeated absences. Although the problem of missed appointments will never go away, following these suggestions could help minimize it. Prevent the problem Explain to the patient why regular appointments are important. The most important point is that clinician and patient must agree that--to best help the patient--treatment requires that all appointments be kept, barring emergencies. Communicate clearly. Avoid emphasizing rules, such as that patients must keep 80% of appointments, give 48-hours' notice for cancellations, or pay a no-show fee. These suggest that patients may miss appointments as long as they follow the rules. Fix structural problems in your practice that may be barriers to making, rescheduling, or cancelling appointments. Be clear with patients about: * the phone number they should call for appointments * if they or you must cancel, that person is to reschedule at the earliest opportunity. To avoid phone tag, ask the patient to provide a mobile phone number. If you are unable to reach the patient, leave a message with 2 potential times you could see the patient and ask the patient to call back to confirm one of these times. If the patient is missing appointments because the frequency is too burdensome, in many cases less frequent but more regular visits may be better. During your early sessions with patients, be sure they understand that you reserve specific times for them. Make sure, however, that patients don't interpret this to mean that attending every appointment is for your benefit, rather than important for their treatment. Emphasize responsibility. At the end of each session, set a goal with patients for the next appointment. With a patient who has missed appointments, ask for a commitment that he or she will come to the next session. We have found that stating that you are concerned the patient might not come to the next session can paradoxically be helpful. Having your receptionist call and remind patients the day before their visits might not be a good idea in many cases. Patients might think these calls relieve them of the responsibility for remembering to keep appointments. With patients you think might miss appointments--especially those on a medication that requires careful monitoring--consider writing prescriptions to last no longer than the next appointment. …
Anxiety disorders and anxiety symptoms are highly prevalent in the general population and more so... more Anxiety disorders and anxiety symptoms are highly prevalent in the general population and more so in the medically ill. They have a number of negative consequences for these patients and may worsen the outcome of the medical illness and increase health care utilization. In the evaluation of these patients, it is of paramount importance to identify the etiology of the anxiety and, in particular, to differentiate primary from secondary anxiety. Management includes medications (especially benzodiazepines and selective serotonin reuptake inhibitors) and psychotherapy (particularly cognitive-behavioral therapy).
Evaluations of patients' capacity to make medical decisions are among the most common and most co... more Evaluations of patients' capacity to make medical decisions are among the most common and most complex consultations that psychiatrists are asked to perform. We describe tips that we have found to be helpful while performing capacity evaluations. We also share tips that should help the clinician make up his or her mind regarding the patient following capacity evaluations.
... By Rajnish Mago, MD | December 1, 2009. Dr Mago is director of the Mood Disorders Program at ... more ... By Rajnish Mago, MD | December 1, 2009. Dr Mago is director of the Mood Disorders Program at Thomas Jefferson University in Philadelphia. ... Please e-mail me at [email protected] with your questions and comments. ...
Sir: Barbarich et al. 1 report the potential benefits of olanzapine in treating anorexia nervosa.... more Sir: Barbarich et al. 1 report the potential benefits of olanzapine in treating anorexia nervosa. I disagree with their results and conclusions for the following reasons. The study's small sample size of 17 patients, 12 of whom completed the study, could result in a type II error. That 71% of patients completed the study is not "noteworthy," as the authors claim. Powers and colleagues 2 published a 10-week trial of olanzapine treatment of anorexia nervosa with a 64% completion rate. Fassino and colleagues 3 reported a 75% completion rate in a randomized, placebo-controlled study of citalopram treatment of anorexia nervosa. Curiously, for the 3 patients who terminated the study against medical advice, Barbarich et al. did not explain their reasons for doing so. It is reasonable to conclude that weight gain resulting from olanzapine treatment was a factor. By definition, patients with anorexia nervosa have a morbid fear of weight gain and obesity, and olanzapine-induced weight gain makes this medication a poor treatment option. Woodside and colleagues 4 found that concerns about weight gain among anorexia nervosa patients were a predictor in their premature termination from inpatient programs specializing in treating eating disorder. Proposed mechanisms of olanzapine-induced weight gain include increased food intake, decreased motor activity, and increased ratio of weight gain:weight of food consumed. 5 In fact, olanzapine may not be a suitable medication for treating patients with anorexia nervosa due to its high incidence of weight gain. Studies reporting weight gain during olanzapine use can be divided into short-term (less than 2 months) and long-term (3 months or more). Numerous short-term studies report significant weight gain during olanzapine treatment. 2,6,7 Patel and colleagues 6 found that patients treated with olanzapine gained an average of 3.8 kg. A 10-week, single-blind study of children aged 7 to 13 years with Tourette's syndrome found that olanzapine's most common side effect was weight gain (mean = 12.0 lb). 7 An open-label, 10-week study of olanzapine treatment of anorexia nervosa found an average 8.75-lb weight gain. 2 Regarding long-term studies, Eli Lilly's package insert for Zyprexa 8 disclosed that, during treatment lasting a median of 238 days, 56% of patients gained more than 7% of their baseline weight, with an average weight gain of 5.4 kg. Haberfellner and Rittmannsberger 9 found that 67% of olanzapine-treated patients gained more than 7% of baseline initial body weight with a mean weight gain of 7.7 kg during the first year of treatment. In a 3-year, retrospective chart review, 86% of patients on olanzapine treatment gained an average of 3.65 kg. 10 Four studies comparing olanzapine with other atypical antipsychotics found olanzapine was significantly associated with a greater weight gain. 6,[11][12][13] A retrospective analysis of children and adolescents receiving olanzapine or quetiapine found that patients taking olanzapine had significantly increased weight and body mass index (BMI) compared with other patients taking quetiapine. 6 A long-term study 11 comparing olanzapine and risperidone found a statistically significant (p < .005) difference in weight gain between these atypical antipsychotics (8.34 vs. 2.74 kg). A 6-month, open, observational study 12 comparing olanzapine and risperidone found significant weight gains in both groups, with 11.3 kg of weight gain in the olanzapinetreated group (p = .001) and 5.9 kg in the risperidone group (p = .023). Another long-term study 13 of risperidone and olanza-
Background: Antidepressant-induced excessive sweating (ADIES) occurs in 5% to 14% of patients tak... more Background: Antidepressant-induced excessive sweating (ADIES) occurs in 5% to 14% of patients taking antidepressants, usually persists throughout treatment, and causes subjective distress and functional impairment. We conducted the first clinical trial of any treatment for ADIES. Methods: Clinical features of ADIES were assessed using a semi-structured form. Twenty-three patients with moderate or greater ADIES were assessed for a 2-week baseline period , followed by 6 weeks of open-label treatment with flexible dose terazosin, 1 to 6 mg/d. Improvement in ADIES was measured by the Clinical Global Impressions (CGI) scale and other measures. Results: ADIES commonly was prominent in the scalp (62%), face (95%), neck (48%), and chest (57%); usually occurred either episodically or with episodic bursts (82%); and was persistent (median 63 months). Twenty-two of the 23 patients responded to terazosin (CGI-I scores 1 or 2), with CGI-Severity improving from median of 5 to median of 2 (P < .0001). Patient-rated daytime and nighttime severity of ADIES and proportion of time in ADIES also improved significantly. The most common adverse effects of terazosin therapy were dizziness/lightheadedness (n = 9) and dry mouth (n = 4). No patient dropped out because of adverse effects. Sitting and standing systolic blood pressure decreased by median values of 3 (P = .044) and 5 (P = .063) mm Hg, respectively. Conclusions: Terazosin may be an effective treatment for ADIES. Although dizziness/lightheadedness may occur in some patients, the treatment generally was well tolerated.
Various psychiatric symptoms can occur in epilepsy or be induced by antiepileptic medications. Zo... more Various psychiatric symptoms can occur in epilepsy or be induced by antiepileptic medications. Zonisamide is an antiepileptic medication used as adjunctive therapy for partial seizures. Depression, 1 mania, 1,2 obsessive-compulsive disorder, 3 and psychotic ...
Newer antidepressants that are more selective in their neurotransmitter effects include the selec... more Newer antidepressants that are more selective in their neurotransmitter effects include the selective serotonin reuptake inhibitors (SSRIs), serotonin-norepinephrine reuptake inhibitors (SNRIs), and others (agomelatine, bupropion, mirtazapine, reboxetine, vilazodone, vortioxetine). This article systematically reviews data from a variety of sources regarding the potential adverse effects of these medications on various cardiovascular parameters. Potential biochemical mechanisms by which these antidepressants may adversely affect the cardiovascular system are also discussed. Antidepressants that are associated with higher cardiovascular risk (SNRIs, reboxetine), lower risk (SSRIs), and without current evidence of cardiovascular risk (agomelatine, mirtazapine, vilazodone, vortioxetine) are identified. The FDA&amp;amp;amp;amp;amp;amp;amp;amp;#39;s recommendations regarding citalopram are organized and summarized, and situations with higher risk of cardiovascular adverse effects are identified.
It appears that the risk is greater with antidepressant use during late pregnancy but may be elev... more It appears that the risk is greater with antidepressant use during late pregnancy but may be elevated with use during early pregnancy as well.
Lamotrigine is an important option in bipolar disorders. However, many clinicians also use it in ... more Lamotrigine is an important option in bipolar disorders. However, many clinicians also use it in patients with a (unipolar) depressive disorder who have not responded adequately to conventional antidepressants.
While SSRIs and SNRIs are valuable in the treatment of major depression, partial response or nonr... more While SSRIs and SNRIs are valuable in the treatment of major depression, partial response or nonresponse occurs in many patients. Research has found that bupropion was the most frequently chosen agent for addition to an SSRI after inadequate response.
This is the second installment of a new series in which clinically relevant research is briefly d... more This is the second installment of a new series in which clinically relevant research is briefly discussed and, perhaps more important, a few tips on how to read and interpret research studies are presented. Your feedback, suggestions, and questions are eagerly solicited at [email protected].
We refer to the interesting article from Drs. Kanaan and Kerwin 1 concerning the adjunctive use o... more We refer to the interesting article from Drs. Kanaan and Kerwin 1 concerning the adjunctive use of lithium to treat clozapine-induced neutropenia. Immediate discontinuation of clozapine treatment has always been the first therapeutic step in cases of severe to moderate neutropenia and impending agranulocytosis. However, some physicians are reluctant to terminate or even to interrupt clozapine treatment in patients with neutropenia, as the drug is often a last resort for those with complex symptomatologies. The retrospective study by Drs. Kanaan and Kerwin suggests that lithium coadministration is an effective and safe strategy that may allow continuation of clozapine treatment despite the occurrence of neutropenia. This result is of considerable clinical relevance because it potentially provides an alternative to the interruption of clozapine treatment in severe cases in which other antipsychotic drugs are ineffective. However, some clozapine-associated neutropenia may be transient and harmless, and therefore may not require discontinuation of the drug treatment nor lithium adjunction. Transient neutropenia (defined as a return of the neutrophil count to normal values without changing the clozapine dosage) has been shown to occur in 22% of 68 patients treated with clozapine for the first time. 2 Neutropenia of short duration (2-5 days) and weekly benign variations of the neutrophil count have been reported. Marked circadian variations in the number of circulating neutrophils, i.e., morning pseudoneutropenia, have also been described in several clozapine-treated patients. 3,4 It seems therefore essential, before interrupting clozapine treatment, to determine whether drug-induced neutropenia is transient or malignant. Laboratory screening tests, including the use of a hydrocortisone test, are being devised to make such a distinction. 5 Until these tests become available for routine use, it is necessary to increase the frequency with which neutrophil counts are determined. As first suggested by Ahokas and Elonen, 3 when the absolute neutrophil count is below the normal range in the morning, the test should be repeated the same day in the afternoon before a decision to stop clozapine treatment or to consider lithium coadministration is made.
Nonadherence to medications is common and associated with poor or limited clinical outcomes in th... more Nonadherence to medications is common and associated with poor or limited clinical outcomes in the treatment of bipolar disorder. A review of the literature discloses that adverse effects are one of the commonly reported reasons for nonadherence to mood stabilizers by patients with bipolar disorder. Nevertheless, other than such broad summaries, relatively little attention has been given to the role of adverse effects in relation to nonadherence. This review article is the first to consolidate the available data on this topic. Weight gain, perceived cognitive impairment, tremors, and sedation are the adverse effects most likely to lead to nonadherence. Further research is needed to anticipate, identify, manage, and potentially minimize the impact of adverse effects.
Background: Cognitive behavioral treatment (CBT) of residual symptoms after successful pharmacoth... more Background: Cognitive behavioral treatment (CBT) of residual symptoms after successful pharmacotherapy yielded a substantially lower relapse rate than did clinical management in patients with primary major depressive disorders. The aim of this study was to test the effectiveness of this approach in patients with recurrent depression (Ն3 episodes of depression). Methods: Forty patients with recurrent major depression who had been successfully treated with antidepressant drugs were randomly assigned to either CBT of residual symptoms (supplemented by lifestyle modification and well-being therapy) or clinical management. In both groups, during the 20-week experiment, antidepressant drug administration was tapered and discontinued. Residual symptoms were measured with a modified version of the Paykel Clinical Interview for Depression. Two-year follow-up was undertaken, during which no antidepressant drugs were used unless a relapse ensued. Results: The CBT group had a significantly lower level of residual symptoms after discontinuation of drug therapy compared with the clinical management group. At 2-year follow-up, CBT also resulted in a lower relapse rate (25%) than did clinical management (80%). This difference attained statistical significance by survival analysis. Conclusions: These results challenge the assumption that long-term drug treatment is the only tool to prevent relapse in patients with recurrent depression. Although maintenance pharmacotherapy seems to be necessary in some patients, CBT offers a viable alternative for other patients. Amelioration of residual symptoms may reduce the risk of relapse in depressed patients by affecting the progression of residual symptoms to prodromes of relapse.
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