Mania induced by risperidone: dose related?

Mirtazapine reduces susceptibility to hypocapnic central sleep apnea in males with sleep-disordered breathing: a pilot study

Studies in humans and animal models with spinal cord injury (SCI) have demonstrated that medications targeting serotonin receptors may decrease the susceptibility to central sleep-disordered breathing (SDB). We hypothesized that mirtazapine would decrease the propensity to develop hypocapnic central sleep apnea (CSA) during sleep. We performed a single-blind pilot study on a total of 10 men with SDB (7 with chronic SCI and 3 noninjured) aged 52.0 ± 11.2 yr. Participants were randomly assigned to either mirtazapine (15 mg at bedtime) or a placebo for at least 1 wk, followed by a 7-day washout period before crossing over to the other intervention. Split-night studies included polysomnography and induction of hypocapnic CSA using a noninvasive ventilation (NIV) protocol. The primary outcome was CO₂ reserve, defined as the difference between eupneic and end of NIV end-tidal CO₂ ([Formula: see text]) preceding induced hypocapneic CSA. Secondary outcomes included controller gain (CG), other ventilatory parameters, and SDB severity. CG was defined as the ratio of change in minute ventilation (V̇e) between control and hypopnea to the change in CO₂ during sleep. CO₂ reserve was significantly widened on mirtazapine than placebo (-3.8 ± 1.2 vs. -2.0 ± 1.5 mmHg; P = 0.015). CG was significantly decreased on mirtazapine compared with placebo [2.2 ± 0.7 vs. 3.5 ± 1.9 L/(mmHg × min); P = 0.023]. There were no significant differences for other ventilatory parameters assessed or SDB severity between mirtazapine and placebo trials. These findings suggest that the administration of mirtazapine can decrease the susceptibility to central apnea by reducing chemosensitivity and increasing CO₂ reserve; however, considering the lack of changes in apnea-hypopnea index (AHI), further research is required to understand the significance of this finding.NEW & NOTEWORTHY To our knowledge, this research study is novel as it is the first study in humans assessing the effect of mirtazapine on CO₂ reserve and chemosensitivity in individuals with severe sleep-disordered breathing. This is also the first study to determine the potential therapeutic effects of mirtazapine on sleep parameters in individuals with a spinal cord injury.

Inhibition of the Voltage-Dependent K+ Current by the Tricyclic Antidepressant Desipramine in Rabbit Coronary Arterial Smooth Muscle Cells

We describe the effect of a tricyclic antidepressant drug desipramine on voltage-dependent K⁺ (Kv) currents in freshly isolated rabbit coronary arterial smooth muscle cells using a conventional whole-cell patch clamp technique. Application of desipramine rapidly decreased the Kv current amplitude in a concentration-dependent manner, with an IC₅₀ value of 5.91 ± 0.18 μM and a Hill coefficient of 0.61 ± 0.09. The steady-state inactivation curves of the Kv channels were not affected by desipramine. However, desipramine shifted the steady-state inactivation curves toward a more negative potential. Application of train pulses (1 or 2 Hz) slightly reduced the Kv current amplitude. Such reduction in the Kv current amplitude by train pulses increased in the presence of desipramine. Furthermore, the inactivation recovery time constant was also increased in the presence of desipramine, suggesting that desipramine-induced inhibition of the Kv current was use-dependent. Application of a Kv1.5 inhibitor (DPO-1) and/or a Kv2.1 inhibitor (guangxitoxin) did not change the inhibitory effect of desipramine on Kv currents. Based on these results, we concluded that desipramine directly inhibited the Kv channels in a dose- and state-dependent manner, but the effect was independent of norepinephrine/serotonin reuptake inhibition.

Risperidone-induced mania: An emergent complication of treatment

The occurrence of manic/hypomanic switch in patients being treated with risperidone has been reported by various authors, and they have described a variety of strategies for their management. In this report, we describe two cases of induction of elevated mood symptoms in patients treated with risperidone. We propose that the emergence of these symptoms may be a complication of treatment with this drug in susceptible individuals, of which the clinicians should be aware, mainly in those diagnosed with schizophrenia and bipolar disorder. We then discuss a few findings that might be useful in the management of such cases. We thereby also propose a mechanism for such an induction.

Contemporary concepts in the pharmacotherapy of depression in older people

Late-life depression is common in older people. Its incidence increases significantly after age 70 to 85, as well as among those living in long-term care facilities. Depression contributes to excess morbidity and complicates management of comorbid conditions in older people. Diagnosis and management of depression often present clinicians with a challenge. Indeed, symptoms of depression in older people may not always be the same as those associated with depression in younger people. Additionally, age-related changes in pharmacokinetics and pharmacodynamics also impact selection, dosing, and monitoring of psychopharmacologic regimens. Optimizing management of depression and providing sound advice to older patients with depression requires knowledge and understanding of many clinical factors. The purpose of this review is to highlight salient issues in late-life depression, with a focus on the pharmacotherapy of depression.

International study on antidepressant prescription pattern at 20 teaching hospitals and major psychiatric institutions in East Asia: Analysis of 1898 cases from China, Japan, Korea, Singapore and Taiwan

The purpose of the present study was to review the prescription patterns of antidepressants in different countries in East Asia. The survey was conducted in China, Japan, Korea, Singapore and Taiwan from October 2003 to March 2004 using the unified research protocol and questionnaire. Twenty teaching hospitals and major psychiatric hospitals participated and a total of 1898 patients receiving antidepressants were analyzed. The survey provided a number of interesting characteristics on the prescription patterns of antidepressant in East Asia. Out of 56 antidepressants listed in the Anatomical Therapeutic Chemical Classification (ATC) index by the World Health Organization (WHO) Collaborating Center for Drug Statistics Methodology (Oslo), only 26 antidepressants were prescribed in participating countries in East Asia. On average 38.4% of prescriptions of antidepressants were for patients with diagnoses other than depressive disorders. The availability and commonly prescribed antidepressants varied greatly by country. The selective serotonin re-uptake inhibitors (SSRI) and other newer antidepressants were prescribed in approximately 77.0% of all cases. At the time of the survey, only two SSRI medications were available in Japan. However, five types of SSRI were available and were often prescribed in Korea.

Atypical antipsychotics for the treatment of bipolar disorder: more shadows than lights

Atypical antipsychotics are utilised more frequently for the treatment of bipolar disorder than first-generation antipsychotics because of their improved neurological tolerability. Furthermore, recent studies suggest that psychiatric outcomes are improved in patients treated with atypical agents. The aim of this article is to review the studies evaluating the effectiveness of atypical antipsychotics in treating acute bipolar episodes (bipolar mania, bipolar depression and mixed episodes), as well as those investigating the effectiveness of atypical antipsychotics as maintenance treatment for the disorder. Because of several relevant methodological limitations affecting the vast majority of clinical trials, evidence-based information about the effectiveness of atypical antipsychotics in treating bipolar disorder is somewhat discouraging. Moreover, data indicating effectiveness in managing the acute manic phase and in long-term maintenance treatment are quantitatively robust only for olanzapine. However, olanzapine seems to have no advantages in terms of tolerability and therapy compliance when compared with classical mood stabilisers or first-generation antipsychotics. In addition, only a few studies have investigated the efficacy of atypical antipsychotics for treating bipolar depression. Hence, information regarding the effectiveness of such medications in treating this specific phase of bipolar disorder should be considered as still preliminary. Given this situation, further independent and well-designed studies are urgently needed before definitive conclusions on the effectiveness of most atypical antipsychotics in the different clinical situations characterising the natural course of bipolar disorder can be drawn.

Atypical antipsychotics in bipolar depression: neurobiological basis and clinical implications

The use of atypical antipsychotics is rapidly expanding in the management of bipolar disorder. This therapeutic class appears to have benefits across the spectrum of moods found in bipolar disorder, and a re-examination of the monoamine hypothesis is required. This paper reviews the evidence for the role of monoamines, and particularly dopamine, in bipolar depression and its implications in the treatment of patients, focusing upon the response to atypical antipsychotics. Relevant papers were identified undertaking a literature search using PubMed: preclinical and clinical studies that incriminate the dopaminergic system in bipolar depression, and recent controlled trials supporting the use of atypical antipsychotics, are reviewed. There is substantial evidence indicating that not only serotonin, but also dopamine may still play an important role as a mediator of antidepressant response in bipolar depression. A regionally selective balance between the dopamine and serotonin systems may account for the mood-stabilizing properties of these drugs, and in fact, a low D(2) occupancy might be more relevant to bipolar depression than greater 5-HT(2) action. This mechanism might correlate with the ability to induce neurogenetic effects. Hence, the greater the atypical profile, the more suitable for bipolar depression. Further studies are needed to confirm this hypothesis.

Manic/hypomanic symptoms induced by atypical antipsychotics: a review of the reported cases

The widespread use of atypical antipsychotics (APs) in clinical practice has advanced the pharmacotherapy of schizophrenia regarding treatment resistant cases as well as the negative symptoms of the disorder. Atypical antipsychotics manifest a favourable side effect profile compared to the conventional APs. Atypical APs are also being used as adjunct therapy or monotherapy in patients with manic episodes of bipolar and schizoaffective disorder as well as in patients with psychotic (delusional) depression. On the other hand, atypical APs are also used in combination with (selective) serotonin reuptake inhibitors [(S) SRIs] in the treatment of resistant depression. Shortly after the introduction of atypical APs several cases of manic/hypomanic symptoms during treatment with these compounds have been described in the literature. The reported cases and the possible pathogenetic mechanisms involved in their occurrence are reviewed and discussed.

The use of atypical antipsychotics beyond psychoses: efficacy of quetiapine in bipolar disorder

BACKGROUND AND RATIONALE

Atypical antpsychotics have been sucessfully used in the treatment of bipolar disorder (BD), either as adjunctive or as monotherapy. Quetiapine is an atypical antipsychotic extensively used in the treatment of psychotic disorders. It has serotonergic and dopaminergic activity and it appears to be selective for the mesolimbic and mesocortical dopamine system. The aim of this paper was to review the recent literature on the use of quetiapine in the treatment of BD.

METHODS

The literature databases currently available online were searched for papers on quetiapine and BD. Papers and reports published between January 1995 and June 2005 were selected and reviewed critically.

RESULTS

Augmentative low dose quetiapine was found to be effective in BD partially responsive to conventional mood-stabilizers. Manic and mixed episodes have been the best studied, and quetiapine was found to be effective either as monotherapy or as adjunctive therapy in both randomized clinical trials and open-label studies. Data on the use of quetiapine in bipolar depression showed a significant efficacy and high remission rates. Maintenance data suggested a role of quetiapine as a good alternative to classical mood stabilizers in reducing recurrence rates of BD. A few studies on the efficacy in rapid cycling BD have also been published.

CONCLUSIONS

Quetiapine is an effective agent for the short- and long-term treatment of BD. The mechanism of action of quetiapine as a mood stabilizer is still unknown. Some preliminary data suggest the involvement of glutamate pathways but further studies are needed to clarify this issue.

[Mixed states in bipolar disorders: a review of current therapeutic strategies]

Mixed states are characterized by the mixture or rapid alternation, within hours, of manic and depressive symptoms. They bear a high suicidal risk and therefore represent a major therapeutic issue. We performed a computerized bibliographic search and reviewed the efficacy of the available treatments of mixed states. It confirmed the recognized poor efficacy of lithium and the need to discontinue antidepressants. Among mood stabilizers, divalproate and its derivatives are those with the highest level of evidence. As regards new anticonvulsants, the data are yet too limited to recommend them as first line treatments. They may however be used as second line or adjunct treatments in case a monotherapy with a reference treatment has failed. Among antipsychotic drugs, clozapine has demonstrated its efficacy but also remains a second line treatment due to its high risk of neutropenia and agranulocytosis. Electroconvulsive therapy is a useful alternative in treatment resistant cases or when there is an imminent risk for suicide. Some degree of uncertainty remains for the treatment of the so called "agitated depressions" as no study has yet focused on this issue with a specifically selected sample of patients. Such a study would also enlighten the uncertain nosological status of this clinical entity and would answer as to whether they belong to the category of mixed states.

Antidepressants, warfarin, and the risk of hemorrhage

BACKGROUND

Case reports suggest that some selective serotonin reuptake inhibitors can interact with warfarin to increase the likelihood of bleeding. We speculated that, among patients receiving warfarin, initiation of selective serotonin reuptake inhibitor treatment would be associated with an increased risk of hospitalization for upper gastrointestinal tract bleeding (UGIB).

METHODS

We conducted a population-based, nested, case-control study involving Ontario residents 66 years or older continuously treated with warfarin for at least 1 year. Cases admitted with UGIB were compared with matched controls (1:10) to explore the odds ratio for initiation of various antidepressants within 42, 90, and 180 days before the index admission.

RESULTS

From January 1994 to December 2002, we identified 98,784 elderly patients continuously receiving warfarin for at least 1 year; of whom 1538 (0.6%) were admitted to hospital for UGIB. The adjusted odds ratio for fluoxetine/fluvoxamine exposure in 90 days before UGIB hospitalization is 1.2 (95% confidence interval, 0.8-1.7), and the adjusted odds ratio for other selective serotonin reuptake inhibitors in the same period was 1.1 (95% confidence interval, 0.9-1.4). The odds ratios for exposure to antidepressants in 180 days before UGIB hospitalization were similar.

CONCLUSION

The initiation of selective serotonin reuptake inhibitor treatment in patients receiving warfarin was not associated with a significant increase in the risk of hospitalization for UGIB.

Antipsychotic and antidepressive effects of second generation antipsychotics: two different pharmacological mechanisms?

Second generation antipsychotics display antidepressive effects in schizophrenic patients that are more pronounced than those of traditional neuroleptics and that go beyond antidepressive effects secondary to the reduction of positive symptoms. The antidepressive potential of second generation antipsychotics is presumably related to their pharmacological mechanisms, which differ from those of traditional neuroleptics. Among others, 5-HT(2A) antagonism is of special relevance for most of the new antipsychotics in this respect. But also special interactions with the dopaminergic system, as is the case with amisulpride and aripiprazole, or noradrenalin- and/or serotonin-reuptake-inhibition, as with ziprasidone and zotepine, should be considered. It can be summarised that the antipsychotic and antidepressive effects of second generation antipsychotics are mostly based on different pharmacological mechanisms. This might be especially true for direct antidepressive effects, i. e. antidepressive effects that are not mediated by the reduction of positive symptoms.

Treatment of acute mania

Mood stabilizers have evolved considerably over the past decade. Lithium, divalproex, and olanzapine are currently Food and Drug Administration-approved for the treatment of acute mania. A number of new and traditional medications have also been tested and are commonly used in clinical practice. Several strategies for managing treatment-resistant mania have been suggested, but few have been rigorously tested. Emphases on rapid stabilization and fewer side effects have raised the bar for what is expected from mood stabilizers and the successful treatment of mania involves a delicate balance between swiftness, short-term tolerability, and long-term safety.

Avoiding drug-induced switching in patients with bipolar depression

Antidepressant-induced switching is a major risk during the treatment of bipolar depression. Despite several clinical studies, questions remain regarding both the definition of these mood switches and the most appropriate therapeutic strategy to avoid this adverse effect. This review will first briefly consider the current guidelines for the acute treatment of bipolar depression. We will then review the mechanisms of action of antidepressant and mood stabilisers, and the switches induced by various types of antidepressant treatments, or triggered by antidepressant withdrawal, as well as by atypical antipsychotics. We then will address the risk of mood switch according to the type of mood stabiliser used. The propensity to mood switches in bipolar patients is subject to individual differences. Therefore we will describe both the clinical and biological characteristics of patients prone to mood switches under antidepressant treatment. However, the clinical characteristics of the depressive syndrome may also be a key determinant for mood switches. Various data help identify the most appropriate drug management strategies for avoiding mood switches during the treatment of bipolar depression. Selective serotonin reuptake inhibitors appear to be the drugs of first-choice because of the low associated risk of mood switching. Antidepressants must be associated with a mood stabiliser and the most effective in the prevention of switches seems to be lithium. Whatever the mood stabiliser used, effective plasma levels must be ensured. The optimal duration of antidepressant treatment for bipolar depression is still an open issue - prolonged treatments after recovery may be unnecessary and may facilitate mood elation. Moreover, some mood episodes with mixed symptoms can be worsened by antidepressants pointing to the need for a better delineation of the categories of symptoms requiring antidepressant treatment. Finally, as a result of this review, we suggest some propositions to define drug-induced switches in bipolar patients, and to try to delineate which strategies should be recommended in clinical practice to reduce as far as possible the risk of mood switch during the treatment of bipolar depression.

Alternatives to lithium and divalproex in the maintenance treatment of bipolar disorder

OBJECTIVES

The role of lithium carbonate in the maintenance treatment of bipolar disorder is well established. Unfortunately, many patients fail to respond adequately to this agent or are unable to tolerate its adverse effects. Divalproex has become a commonly used alternative to lithium, but it also is ineffective or poorly tolerated in many patients. This article attempts to review the available data on maintenance therapy in bipolar disorder with a variety of anticonvulsants and antipsychotics (both conventional and novel), with reference to relevant studies in acute mania and bipolar depression as well.

METHODS

Evidence on maintenance therapy and relevant acute-phase data were collected using MEDLINE database searches.

RESULTS

Data on maintenance therapy with agents other than lithium and divalproex are sparse, and often derived from open, uncontrolled studies. Implications and flaws of available data are discussed.

CONCLUSIONS

Other than lithium, there are few robust double-blind data to support the use of a variety of agents in the maintenance phase. However, uncontrolled data suggest that a number of agents merit further study.

Manic symptoms associated with quetiapine treatment

This case illustrates the induction of manic-like symptoms in a 26-year-old male patient with DSM-IV paranoid schizophrenia following treatment with quetiapine. The only drug he had received prior to quetiapine was risperidone which was occasionally taken in the previous 3 years. The manic symptoms remitted after quetiapine withdrawal.

Ziprasidone-associated mania: a case series and review of the mechanism

Atypical antipsychotics are now commonly used in the treatment of bipolar disorder, as they have been shown to have effects on mania as well as psychosis. Shortly after the introduction of atypical antipsychotics, several cases of associated hypomania and mania were reported. Ziprasidone is an atypical antipsychotic recently approved by the Food and Drug Administration for the treatment of psychosis. Although ziprasidone has also been shown to be effective in treating mania, it may be associated with the induction of mania or hypomania. We report four cases of mania associated with initiation of ziprasidone, which, to our knowledge, are the first reported for this drug in bipolar patients. As ziprasidone has substantial serotonergic and noradrenergic action, we hypothesize, it may more likely induce mania than other atypical antipsychotics. We advocate future studies to evaluate ziprasidone's efficacy in treating bipolar disorder and caution clinicians that induction of mania or hypomania may be possible with this agent.

Tryptophan and Quality of Life in Colorectal Cancer

We tested the hypothesis that reduced tryptophan availability due to immunological stimulation in colorectal cancer impairs quality of life (QoL) by measuring serum tryptophan levels, and correlating them with serum immunological markers and with QoL indices. Serum tryptophan level was significantly reduced in cancer patients compared with healthy controls. Serum tryptophan/kynurenine ratio and neopterin level were significantly increased in cancer, with a significant correlation between the two variables. Reduced serum tryptophan correlated significantly with worse QoL scores. The results support the hypothesis that in colorectal cancer, QoL impairment may be due to serum tryptophan depletion mediated by immunological activation.

Considerations in the management of the patient with comorbid depression and anxiety

PURPOSE

To provide clinicians with guidelines for the assessment, evaluation, diagnosis, and management of comorbid depression and anxiety in the primary care setting.

DATA SOURCES

Research-based articles in the medical and psychiatric literature, literature reviews by experts in the field, and DSM-IV-TR.

CONCLUSIONS

Comorbid anxiety and depression occurs at a high rate in primary care, and is costly to both the individual and to society. These patients most often present in primary care settings, have more severe symptoms, and require more health care resources. The presentation of depression and anxiety together pose complicated diagnostic and treatment challenges, leading to inadequate diagnosis and treatment resulting in unnecessary patient distress and increased utilization of health care services.

IMPLICATIONS FOR PRACTICE

This article is a review of comorbid depression and anxiety with a focus upon societal and patient significance and impact, under recognition and under treatment, diagnostic challenges, medical comorbidity, treatment considerations, and educational strategies. Effective assessment, evaluation, diagnosis and treatment can lead to better treatment outcomes and improved quality of life in primary care patients.

Placebo-controlled trials do not find association of olanzapine with exacerbation of bipolar mania

BACKGROUND

Published case reports describe apparent induction or exacerbation of manic-like symptoms during treatment with the atypical antipsychotics olanzapine and risperidone. To date, such reports are from uncontrolled clinical experience and therefore cannot clarify whether the atypical antipsychotics caused such manic-like states or simply failed to prevent them. Presumably, bipolar patients would be at increased risk for this putative adverse event. Therefore, we evaluated the potential of olanzapine to exacerbate symptoms of mania compared to placebo during treatment of bipolar mania.

METHODS

Two inpatient, double-blind, randomized trials investigating the efficacy of olanzapine 5-20 mg daily versus placebo for the treatment of acute mania were combined. Two hundred and fifty-four subjects participated (placebo n=129; olanzapine n=125) in the two studies. Severity of mania was quantified with the 11-item Young-Mania Rating Scale (Y-MRS). In a post-hoc analysis, after double-blind therapy up to 3 weeks, categorical comparison of olanzapine and placebo groups was made for any worsening and worsening by 10 or 20% from baseline Y-MRS scores (LOCF).

RESULTS

The percentage of subjects with exacerbation at endpoint were: any worsening, placebo 37.7%, olanzapine 21.8% (P=0.005); >or=10% worsening, placebo 24.6%, olanzapine 14.5% (P=0.039); >or=20% worsening, placebo 15.6%, olanzapine 8.1% (P=0.064).

CONCLUSION

Mania rating scores worsened for some patients during olanzapine therapy. However, this was significantly less common with olanzapine than with placebo. These controlled data suggest that clinical case reports of occurrence of 'mania' during treatment with olanzapine, and possibly those with other atypical antipsychotics, reflect exacerbation in the natural history of bipolar illness, rather than an adverse pharmacological effect.

LIMITATIONS

Post-hoc analysis of pooled data from two different studies.

Pharmacotherapy of bipolar disorder: the role of atypical antipsychotics and experimental strategies

Bipolar disorder, despite being a common and debilitating illness, has remarkably few pharmacological therapeutic options, the majority of which, with the exception of lithium, have been borrowed from other medical indications. Furthermore the quantity and quality of controlled clinical data are considerably smaller than in conditions of comparable severity and frequency. Not surprisingly, the clinical outcome of bipolar disorder is frequently suboptimal. Fortunately there are a growing number of novel therapeutic options for its treatment such as atypical antipsychotics, calcium channel blockers and omega-3 fatty acids. This paper summarizes some of the data regarding these "experimental" therapeutic options, focusing principally on atypical antipsychotics as these are now widely prescribed in the management of bipolar disorder.

Association between flupenthixol treatment and emergence of manic symptoms

BACKGROUND

Flupenthixol is an antipsychotic drug with known mood-elevating properties. Its propensity to induce manic symptoms has not been investigated.

METHODS AND RESULTS

We describe six patients, four with schizophrenia and two with bipolar disorder, in whom flupenthixol treatment was associated with emergence of manic symptoms.

CONCLUSIONS

Patients treated with flupenthixol should be carefully monitored for the emergence of manic symptoms.

Serum tryptophan decrease correlates with immune activation and impaired quality of life in colorectal cancer

Cancer-related indoleamine (2,3)-dioxygenase up-regulation by interferon-gamma might influence quality of life by depleting serum tryptophan. We correlated serum tryptophan levels with immune activation and quality of life in patients with colorectal liver metastases. Venous blood was sampled from patients with primary colorectal cancer and from patients with metachronous colorectal liver metastases who completed quality of life and psychological questionnaires. Serum tryptophan, kynurenine, neopterin, interleukin 2 soluble receptor alpha (IL-2 sRalpha), soluble tumour necrosis factor receptor I (sTNF RI), interleukin 6, and C-reactive protein were measured. Liver metastasis volume was estimated by computerised tomography, and survival from blood sampling was noted. Sixty-six patients with colorectal cancer were studied (39 males; median age 66 years) of whom 25 had colorectal liver metastases only (17 males; median age 62 years; median liver metastasis volume 208 ml; median survival 234 days). Reduced serum tryptophan was significantly associated with Rotterdam Symptom Checklist physical symptom (r=-0.51, P=0.01) and Sickness Impact Profile (r=-0.42, P=0.04) scores, and correlated with increased serum neopterin (r=-0.36, P=0.003), IL-2 sRalpha (r=-0.51, P=0.01) and sTNF RI (r=-0.45, P=0.02) levels. Stepwise regression analyses suggested that serum tryptophan was an independent predictor of Rotterdam Symptom Checklist physical symptom (regression coefficient -20.78, P=0.01) and Sickness Impact Profile (regression coefficient -109.09, P=0.04) scores. The results supported a role for interferon-gamma-mediated serum tryptophan decrease in cancer-induced quality of life deterioration.

Determination of reboxetine, a recent antidepressant drug, in human plasma by means of two high-performance liquid chromatography methods

Reboxetine is a new norepinephrine reuptake inhibitor (NRI) drug recently introduced in the therapy for depressed patients. It is effective in the treatment of severe depression and safer to use than traditional tricyclic antidepressants. In this paper an original high-performance liquid chromatography (HPLC) method with ultraviolet detection for the determination of reboxetine in human plasma is described. It uses a C8 reversed-phase column and a mobile phase composed of acetonitrile and aqueous tetramethylammonium perchlorate. For the analysis of plasma samples containing very low levels of reboxetine, another HPLC method with fluorimetric detection was developed (limit of quantitation, LOQ=11 ng ml(-1); limit of detection, LOD=4 ng ml(-1)). The fluorimetric method is based on precolumn derivatisation of reboxetine with 9-fluorenylmethyl chloroformate. An accurate sample pretreatment of human plasma samples has been implemented by means of solid-phase extraction (SPE) on Oasis HLB (hydrophilic-lipophilic balance) cartridges with very high extraction yields (>95%). Both methods were applied to the analysis of plasma samples from depressed patients undergoing therapy with reboxetine and gave satisfactory results in terms of precision (RSD<4.5%) and accuracy (mean recovery>94%).

Tolerability profile of atypical antipsychotics in children and adolescents

Antipsychotics are frequently used in the treatment of a variety of neuropsychiatric conditions in children and adolescents. Atypical antipsychotics have come to the forefront in child psychiatry due largely to their tolerability profiles as well as their efficacy. Potential treatment options include clozapine, risperidone, olanzapine, quetiapine and ziprasidone. A number of studies investigating the use of clozapine have been published in children; however, owing to the frequent monitoring required for agranulocytosis, the use of clozapine may be restricted to patients with treatment-refractory disease. With accumulating data on the development of glucose intolerance in adults receiving clozapine, closer monitoring of bodyweight and fasting blood glucose is imperative. Clozapine also has an increased seizure risk, therefore a baseline electroencephalogram should be performed, as well as continued vigilance for this adverse effect. Risperidone is an atypical antipsychotic that is generally well tolerated and numerous studies have been published investigating this drug in children. Unlike clozapine, its receptor interaction profile lends itself toward increased risk of extrapyramidal symptoms (EPS) and hyperprolactinaemia. Bodyweight gain is a common adverse effect, although somewhat less than that reported with olanzapine. Baseline liver function studies prior to initiation of this medication are recommended. Risperidone-induced mania has been reported in adults and, therefore, increased caution should be used when deciding to treat children and adolescents with risperidone, particularly in those with a predisposition toward mania. Olanzapine, like risperidone, has also been associated with onset of mania in adults. Olanzapine has a receptor profile that results in significant risk for bodyweight gain and sedation. Furthermore, this drug has been linked to the development of glucose intolerance; thus, it is important to monitor bodyweight and fasting blood glucose on a frequent basis. Less information is known about quetiapine in children and adolescents. Reports about its efficacy and tolerability vary. Quetiapine appears to have increased risk for sedation and bodyweight gain, albeit less than that of olanzapine. The compound appears to be less likely to induce EPS. Finally, ziprasidone has recently been approved for use in the adult population. This compound, in terms of its receptor profile, has more in common with risperidone. This suggests a potential for increased risk of EPS and hyperprolactinaemia. It also has an increased risk of QTc prolongation; thus, a baseline electrocardiogram is suggested, particularly in those patients with a history of cardiovascular illness. Lack of evidence for bodyweight gain with ziprasidone is a considerable advantage.

Shifting from haloperidol to risperidone for behavioral disturbances in dementia: safety, response predictors, and mood effects

For agitated dementia showing insufficient response to conventional antipsychotics, the feasibility of transition to atypical agents remains unknown. Sixty-two Chinese inpatients with dementia and disruptive behaviors were recruited into an 8-week screening trial of haloperidol. Thirty-five (56%) of them responded insufficiently. They then entered a prospective, 16-week, open-labeled study. Haloperidol was abruptly shifted to risperidone 0.5 mg/day at weeks 1 to 4 and then 1 mg/day at weeks 5 to 12. At weeks 13 to 16, the regimen was shifted back to haloperidol at previous doses, mostly 1 mg/day. Safety, efficacy, cognition, and moods were evaluated at least every 4 weeks. Generalized estimating equation methods were used for determining the effects of the prognostic variables on the outcome values. Risperidone, particularly at 0.5 mg/day, was generally tolerable. The Brief Psychiatric Rating Scale (BPRS) score decreased progressively under risperidone treatment; at week 12, 16 (46%) patients showed response (>or=25% reduction in the BPRS). Patients with vascular dementia were more likely to respond than those with Alzheimer's disease ( p = 0.02). Haloperidol reinstitution resulted in no further improvement, except trend increments in motor symptoms. Risperidone also tended to benefit the performance on the Behavioral Pathology in Alzheimer's Disease Rating Scale. Six (17%) patients improved on moods and self-care with risperidone. These preliminary results suggest that crossover from haloperidol to risperidone is generally safe and effective and may produce favorable moods in agitated dementia patients. Vascular dementia is a predictor of treatment response. In contrast to the dose (1 mg/day) recommended for most white individuals, 0.5 mg/day could be tried at first in Chinese patients. Because of the design's limitations, further controlled studies are warranted.

Serotonin syndrome induced by fluvoxamine and mirtazapine

OBJECTIVE

To document a case of serotonin syndrome associated with the combined use of fluvoxamine and mirtazapine, and to discuss the pharmacodynamic and pharmacokinetic interactions that were the likely causes of this potentially serious adverse drug reaction (ADR).

CASE SUMMARY

A 26-year-old white woman with a 12-year history of anorexia nervosa was being treated with fluvoxamine. After mirtazapine was added to her therapy, she developed tremors,restlessness, twitching, flushing, diaphoresis, and nausea,symptoms that are consistent with serotonin syndrome.

DISCUSSION

The possible causes of this ADR are discussed, including the effects of fluvoxamine and mirtazapine alone, the possible pharmacodynamic and pharmacokinetic interactions of these two drugs, and the patients underlying anorexia nervosa.

CONCLUSIONS

An increasing number of drugs that affect serotonin are available and are indicated for various disorders. Since there is a significant likelihood of these agents being prescribed concomitantly, clinicians must be aware of possible interactions that could lead to serotonin syndrome.

Sertraline in underweight binge eating/purging-type eating disorders: five case reports

Control trials show that antidepressants are efficacious in eating disorders. Although selective serotonin reuptake inhibitors (SSRIs) are used in clinical practice, there are relatively few controlled or open trials demonstrating that SSRIs are effective. We report five cases of underweight women with binge eating/purging-type eating disorders who gained weight and had reduced core eating disorder behaviors in response to sertraline.

Does risperidone have a place in the treatment of nonschizophrenic patients?

There is a now a substantial body of evidence that suggests the new antipsychotic agent, risperidone, may be safe and effective for treating psychotic, affective or behavioural symptoms associated with various disorders other than schizophrenia, schizophreniform disorder or schizo-affective disorder. These conditions include bipolar disorder, obsessive-compulsive disorder, Tourette's syndrome, dementia, Lewy body disease, mental retardation, Parkinson's disease, idiopathic segmental dystonia and organic catatonia. Although much of the data is anecdotal or in the form of open studies, there is now emerging a small number of well controlled investigations supporting efficacy for mania, dementia, behavioural disturbance in mental retardation and conduct disorder. Conventional antipsychotics have long been used, either in a primary capacity or as an adjunct to treat these disorders; however, they have limited benefit, pose significant risks of extrapyramidal side-effects, and may cause the potentially life-threatening neuroleptic malignant syndrome. In contrast, risperidone at the recommended low doses may be efficacious and pose reduced risk of motor side-effects. This article reviews the evidence that risperidone may be an effective new treatment for disorders other than schizophrenia.

Pharmacotherapy of behavioral and psychological symptoms of dementia: time for a different paradigm?

Behavioral and psychological symptoms of dementia can occur in 60-80% of patients with Alzheimer's disease or other dementing illnesses, and are important in that they are a source of significant caregiver stress and often precipitate nursing home placement. These symptoms, namely, aggression, delusions, hallucinations, apathy, anxiety, and depression, are clinically managed with a variety of psychotropic drugs such as antipsychotics, antidepressants, antiepileptic drugs, and benzodiazepines. Various advances in the neuropathophysiology and pharmacotherapy must be considered in the optimal design of regimens for patients with these symptoms.

Risperidone in the treatment of psychotic depression

Risperidone has been primarily marketed for the treatment of schizophrenia. There are reports about its potential role for the treatment of affective illness. We report here another case of a patient with psychotic depression who was treated successfully with risperidone as monotherapy. This case report suggests that risperidone can be an efficient treatment mode for psychotic depression; however, it needs more data based on controlled study.