Blood pressure effects of monoamine oxidase inhibitors--the highs and lows

Clinical guidelines for the management of the most common side effects associated with monoamine oxidase inhibitors (postural hypotension and hypertensive episodes) are offered. When non-pharmacological interventions fail to alleviate MAOI induced postural hypotension, the use of volume expanders (salt tablets or fludrocortisone) may be effective alternatives to drug discontinuation. Phentolamine and chlorpromazine are traditional drug treatments for MAOI hypertensive emergencies. The newer drug treatments evolved in the last decade for treating hypertensive emergencies is not reflected in the psychiatric or emergency medicine literature on treating MAOI induced hypertensive states. Nifedipine, diazoxide, or sodium nitroprusside appear to be more rational choices for this problem.

Memory effects of restricted environmental stimulation therapy (REST) and possible applications to ECT

Restricted environmental stimulation (REST) has been shown to facilitate learning and memory in both human and animal experimental subjects. This paper reports early data from a test of the usefulness of REST in reducing post-ECT amnesia in depressive patients. Two such patients were placed in a quiet, dimly illuminated room for 2-4 hrs. after recovering from each ECT administration in a series of treatments; three others, following standard practice, were returned to their normal hospital rooms. Measures of memory (verbal, numerical, nonverbal, life event, and self-rating) were given prior to the first ECT treatment; after the first post-recovery session; after the last post-recovery session; and one week after the last ECT administration. The major difference found was that the REST group showed an improvement in self-rated memory functioning from the first to the last ECT administration that was 15 times as great as that reported by the control group. This finding is interesting because of the major role played by self-reported memory disturbances in the scientific, clinical, and popular evaluation of ECT. The sample size is being increased, as it must be for any reliable conclusions to be drawn from this study.

The art of pharmacotherapy in depressed outpatients

There is an art to prescribing medications to depressed patients. Both patient and therapist factors are important to a successful outcome with appropriate timing and prescribing of treatment. Two case reports are provided as examples. Specific strategies used by experienced clinicians are presented in the discussion.

Clinical aspects and treatment of rapid cycling mood disorders

Eight female patients with rapid cycling mood disorders (at least four discrete affective episodes per year) were examined from a clinical perspective. Assessment suggested several different etiologies to the rapid cycling pattern in these patients. These included that the rapid mood swings were: a natural expression of the affective disorder, tricyclic induced, a result of frequent medication changes and/or poor medication compliance, and a combination of the aforementioned etiologies. All patients were helped significantly with treatment. Treatment was individualized for each patient's unique illness and possible etiological factors in the rapid cycling. Treatment strategies and guidelines include: A psychotherapeutic approach involving the patient and his family which emphasizes the lengthy nature of treatment before expected results; The necessity of rigorous drug adherence, The sole use of "high dose" lithium therapy (greater than 1.2 MEQ/L) in some patients, and the consideration of "high dose" lithium in conjunction with tricyclics, MAO inhibitors or "adjuvant" medication in certain bipolar II patients; The discontinuation of tricyclics in bipolar rapid cyclers; The combination of lithium salts and carbamazepine or the use of carbamazepine alone in selected patients.

Tardive dyskinesia: an unrecognized cause of orofacial pain

Tardive dyskinesia has not previously been discussed in the dental literature. It is a drug-induced movement disorder commonly involving the perioral and masticatory muscles. It can sometimes be a cause of orofacial pain. Two brief cases reports are provided as examples. Clinical features of tardive dyskinesia are presented to assist the dental practitioner in recognizing the syndrome. Suggestions for management are included.

Antidepressants: which one?

There are now 15 effective antidepressant medicines marketed in Canada (eight tricyclic antidepressants, three monoamine oxidase inhibitors, and four medicines with novel chemical structures). The tricyclics remain the drug of first choice for major depressions, because of their proven efficacy over three decades, their known side effect profiles, and the cheaper cost of imipramine and amitriptyline compared to other tricyclics and the new antidepressants. The monoamine oxidase inhibitors are an excellent alternative, and are far safer than earlier reports suggested. Maprotiline offers few advantages over the tricyclics and costs significantly more. Trazodone may be a second- or third-line drug with the advantage of minimal anticholinergic properties. Adequate clinical evaluation of nomifensine has not yet occurred. Neuroleptic and cardiotoxic properties of amoxapine suggest other medicines should be tried first.

A comparison of the safety and efficacy of alprazolam and desipramine in moderately severe depression

Fifty-four patients (34 outpatients, 20 inpatients) fulfilling Research Diagnostic Criteria for Definite Major Depressive Disorder were enrolled in a double-blind study comparing the antidepressant effects of alprazolam versus desipramine. The mean daily dose of alprazolam and desipramine at study termination was 3.78 mg and 208 mg respectively. As there were no significant demographic or clinical differences between outpatients and inpatients, both groups were combined in data analysis. Using the Hamilton Depression Rating Scale (HAM-D) both drug groups showed highly significant improvement beginning with the first week of active drug treatment. HAM-D scores continued to decrease through study termination (six weeks of active drug). There were no significant differences when comparing alprazolam and desipramine (outpatients, inpatients, or both groups combined) on any of the subjective or objective psychometrics used in this study. Clinically, only twelve of thirty-four outpatients (35.3%) were felt to be "markedly or moderately" improved, suggesting that neither the outpatient alprazolam nor desipramine patients did particularly well with drug treatment. In terms of drug safety there was no difference between the alprazolam and desipramine in the number of excessive or serious drug side effects. However, five of twenty-nine alprazolam patients had to discontinue therapy because of excessive drowsiness, and two of the alprazolam outpatients had motor vehicle accidents directly related to this adverse event. Alprazolam appeared as effective as desipramine in the pharmacotherapy of this group of depressed outpatient and inpatients. Alprazolam appeared well-tolerated by most subjects although drowsiness was a common--and at times serious--medication side effect.

A case report of obstructive sleep apnea in a patient with bipolar affective disorder

A patient with a bipolar mood disorder developed obstructive sleep apnea which altered the clinical presentation of the mood disorder and affected compliance with prophylactic treatment. Significant improvements in the management of her mood disorder and in her life adjustment followed surgical relief of the upper airway obstruction.

Dexamethasone suppression test results in delusional versus nondelusional depression: preliminary evidence of distinct clinical entities

Two patients with major affective disorder--one unipolar and one bipolar--exhibited normal DSTs while psychotically depressed (mood congruent delusions), yet exhibited nonsuppression on the DST in the course of subsequent separate nonpsychotic depressive episodes. If valid, these results may provide further evidence for considering psychotic and nonpsychotic depression as clinically distinct entities.

Electrodermal activity among subtypes of depression

To determine whether subgroups of depressed patients could be differentiated on the basis of electrodermal activity (EDA), the skin conductance of 36 depressed patients was recorded for two experimental conditions. In the first condition, subjects heard 10 85-dB tones after receiving instructions that were intended to relax the patients. In the second experimental condition, subjects heard 12 105-dB tones, one-half of which were signal tones containing a brief gap in the middle. The subjects were required to respond to the tones containing the gap by pressing a foot pedal. No differences in tonic or phasic EDA were detected on the basis of unipolar or bipolar subtype, response to the dexamethasone suppression test, severity of depression, medication status, or sex. However, patients who exhibited features of psychomotor retardation had significantly lower levels of tonic EDA than did their nonretarded counterparts. The EDA of the depressed patients as a group was uniformly low. These results are consistent with other reports indicating that, with the exception of the retarded/nonretarded distinction, there are no differences in EDA among the various subtypes of depression.

Massive eosinophilic reaction to desipramine in conjunction with pneumonia

The authors report on a female patient with bipolar affective disorder who presented with marked eosinophilia in conjunction with pneumonia five days after a medication change from amitriptyline to desipramine (for intolerable dry mouth). She improved with discontinuance of medications and supportive management, and her eosinophilia normalized. Reinstitution of desipramine was followed by prompt appearance of asymptomatic eosinophilia, which resolved with discontinuation of desipramine. A subsequent depression managed with amitriptyline was followed by no abnormal white blood count findings. Eosinophilia is occasionally encountered in imipramine or desipramine therapy and, although usually asymptomatic, appears to be manageable by switching to amitriptyline or nortriptyline.

The psychiatric referral in dentistry: indications and mechanics

Psychiatric consultation is sometimes a part of the diagnostic evaluation of facial pain. The indications for referral arise out of the history. Several brief questions may indicate whether or not a psychiatric illness is present. Patients may hold beliefs or attitudes about their illness or about psychiatric treatment that make referral difficult. Successful referral depends on the relationship that the dentist establishes with the patient. Recommendations to facilitate the referral are presented.

A comparative study of bupropion and amitriptyline in depressed outpatients

A double-blind controlled trial comparing a standard antidepressant drug, amitriptyline, with a new compound, bupropion, was conducted at six centers. There was a placebo washout, after which patients were assigned in a randomized fashion to one of the two treatments. No significant difference was found in therapeutic response to the two drugs after 4 weeks of treatment. Anticholinergic and cardiovascular side effects were less common in the bupropion-treated patients.

Ineffective dental and surgical treatment associated with atypical facial pain

Patients with atypical facial pain (AFP) are subject to ineffective dental and surgical procedures for their pain complaints. Twenty-one of fifty-eight patients (36.2 percent) with AFP had sixty-five dental and surgical treatments, with only one patient showing less pain as a result of the treatment. While the majority of patients (69 percent) with AFP suffered from a psychiatric illness, fourteen (24 percent) of the patients referred for AFP had a specific medical or dental disorder that was causal in their pain complaints. There is a trend for the AFP patient with a psychiatric diagnosis to receive more ineffective treatments than those AFP patients for whom a specific medical or dental diagnosis was made. Patients with AFP should receive conservative dental and medical treatment and a psychiatric assessment before dental and surgical procedures are contemplated.

Psychiatric disorders associated with atypical facial pain

Atypical facial pain (AFP) patients classically present with a chronic discomfort that is neither anatomic nor dermatomal in distribution. Neuropsychiatric assessment of 68 patients with AFP indicated that 46 (68%) had a specific psychiatric disorder by DSM-III criteria. A wide spectrum of psychiatric disorders was present. The authors emphasize that psychiatric assessment of patients with AFP should be an integral part in early assessments of this disorder, rather than relying on psychiatric opinions after extensive dental and other invasive procedures have been tried in vain and often to the detriment of the patient. Comments on the excellent prognosis in treating the psychiatric syndromes associated with AFP are made.

Clinical aspects of xerostomia

The physiology of saliva flow and hyposalivation is discussed. Drug-induced hyposalivation results in a higher incidence of dental caries, causes discomfort for denture wearers, and increases the risk of oral infections. Guidelines for preventing and treating drug-induced xerostomia are offered.