Cherry W. Jackson

Possible dihydroepiandrosterone-induced mania

BACKGROUND Dehydroepiandrosterone (DHEA) is among the most abundant steroids in the human body and appears to have diverse biochemical activities. This multifunctional hormone has long been a compound of interest to research psychiatrists. Its recent promotion and availability as an over-the-counter supplement to the general public has led to widespread use. Little is known about potential adverse effects of DHEA when consumed on an acute or chronic basis. We report a case of mania in an older man acutely admitted to our psychiatric facility with no previous personal or family history of bipolar disorder that appeared to be related to recent DHEA use. The patient had initiated DHEA use 6 months prior to admission and was taking 200-300 mg/day at the time of presentation. METHODS He was treated with valproic acid 500 mg twice daily. RESULTS The patient showed sufficient improvement to be discharged following a 7-day inpatient hospitalization. CONCLUSIONS A wide range of medications have been associated with the induction of hypomania and mania, and we have provided a brief discussion of the potential for DHEA to trigger manic symptoms.

Is Valproate Pharmacotherapy Associated with Polycystic Ovaries

OBJECTIVE: To review and evaluate the published data associating the use of valproate with the development of polycystic ovaries. DATA SOURCES: A computerized search of MEDLINE (1966–May 1999) and Current Contents was performed. Also, bibliographies were cross-referenced to yield additional pertinent publications. All articles written in English were considered for review. STUDY SELECTION AND DATA EXTRACTION: All pertinent clinical studies and review articles associating valproate with polycystic ovaries and other endocrinologic disorders were evaluated. DATA SYNTHESIS: Valproate is among the most commonly used medications today effective in the treatment of a variety of neurologic and psychiatric disorders. An accumulating body of literature has suggested an increase in the incidence of polycystic ovarian syndrome among women treated with valproate. The syndrome is characterized as hyperandrogenism and chronic anovulation in the absence of identifiable adrenal or pituitary pathology. It is a highly prevalent syndrome, affecting 2–22% of women in the general population. CONCLUSIONS: Although a number of studies have found clear evidence of neuroendocrine perturbations in patients treated with valproate, there are presently limited data from large controlled studies involving valproate monotherapy. Nonetheless, there appears to be a greater incidence of polycystic ovaries associated with valproate use in comparison with other anticonvulsants. The mechanism by which valproate may induce polycystic ovarian syndrome is unknown, but could possibly be secondary to valproate-induced weight gain or direct interference with steroid metabolism. Further study of the potential association of valproate treatment with the development of polycystic ovarian syndrome is warranted. Until the issue is clarified, clinicians should at least be aware of the possibility of valproate-induced polycystic ovarian syndrome and monitor patients accordingly.

Antidepressants in the Treatment of Chronic Pain

Antidepressants have been successfully used for chronic pain syndromes for approximately 30 years. One theory is that analgesic action is secondary to the antidepressant effects of the medications. Placebo-controlled trials have documented that antidepressants treat neuropathic pain, musculoskeletal pain, chronic pain, and cancer pain. The most frequently studied antidepressant for pain is amitriptyline. Other antidepressants that have shown analgesic activity include imipramine, citalopram, paroxetine, nortriptyline, desipramine, and mianserin. Fluoxetine and trazodone have not been shown to successfully treat pain syndromes. Venlafaxine, a new antidepressant, most recently was shown to have antidepressant activity in fibromyalgia. More studies need to be done with newer antidepressants to confirm their place in treating pain syndromes.

Obsessive-Compulsive Disorder in Elderly Patients

SummaryObsessive-compulsive disorder (OCD) is a common illness which starts in young adulthood and persists into late life. OCD is associated with dysregulation of the serotonin system and may also be related to the dysregulation of dopamine. When OCD starts in an elderly patient, either an organic or a neurological diagnosis should be considered.Clomipramine and serotonin reuptake inhibitors are the mainstay of treatment for OCD. Choice of a particular agent should be based on the patient’s previous response and the adverse effect profile of the drug. Pharmacokinetics should also be a consideration due to age-related changes in hepatic and renal function leading to increased plasma concentrations as well as prolonged elimination half-lives of these agents. Behavioural therapy, in addition to pharmacological management, is essential to treat compulsions and to improve response.

Book Review: Epilepsy: 199 Answers (A Doctor Responds to His Patients' Questions):

Pharmacy and the US Health Care System is one of very few books that discuss the interface between pharmacy and the contemporary healthcare system. It contains 18 chapters that discuss issues related to the changing healthcare environment and the challenges and opportunities that pharmacists face within this environment. This edition contains 3 new chapters that address current issues affecting the profession: “Cost and Utilization Controls,” “Emerging Roles for Pharmacists,” and “Pending Other Issues.” Missing from this edition is a concluding or summary chapter. Fincham and Wertheimer are recognized leaders in pharmacy who assembled an excellent group of collaborators, most of whom are members of the pharmacy academic community. The book introduces the reader to the US healthcare system through several chapters that discuss the historical evolution and structure of the system, the financing mechanisms for health care, the types of cost and utilization controls, the types and number of health professionals, and the types and number of hospitals and other healthcare institutions. There is an excellent chapter on the development, conceptualization, and future directions of managed care in the US. Other chapters explore the importance of pharmaceuticals in the healthcare system. There are chapters on the role of the pharmaceutical industry in the development of drug products; the role of manufacturers, wholesalers, and retailers in the supply and distribution of pharmaceutical products; the drug use process as influenced by patient behavior and patient compliance; and the effect of consumer characteristics, such as beliefs, attitudes, values, and ethnic and racial background, on their decisions to use healthcare products and services. Furthermore, several chapters provide a more in-depth discussion of the role of pharmacists within the healthcare system. Issues addressed include the supply of and demand for pharmacists; educational requirements and controversies; emerging roles within the changing environment (including the provision of pharmaceutical care in a diverse number of practice settings such as community pharmacies, hospitals, long-term-care facilities, and home health agencies); professional, trade, education, regulatory, and foundation organizations and their role in shaping the profession; and the importance of information technology in the distribution of drugs and the delivery of patient care. The material presented in the book is current and extremely useful for anyone who wants to learn more about the US healthcare system and the role of pharmacists within the system. The presentation of the topics is clear and the content is easy to read. Most of the chapters are well referenced and contain information that is up to date. There is very little cross-referencing between chapters and most of them are self-contained, which allows for their use in different courses. One area that in my opinion is underemphasized is health and public policy as it relates to the practice of pharmacy. For future editions, the chapters could be organized in sections that correspond to the content of the chapters (e.g., The US Healthcare System, Pharmaceuticals and the US Healthcare System, Pharmacists and US Healthcare System). Future editions would also be strengthened by including study questions or questions for discussion at the end of each chapter. In conclusion, this is ideal as a textbook for introductory pharmacy courses. It is very reasonably priced and should be a welcome addition to personal as well as institutional libraries.

Pharmacologic Treatment of Bipolar Disorder Through the Life Cycle

Bipolar disorder is a long-term illness associated with multiple relapses and recurrences throughout the life cycle. Lithium, carbamazepine, and valproate are the mainstays of treatment for this illness. Each of these agents will be reviewed as well as alternatives for patients who fail treatment with lithium, have manic agitation, psychosis, depression, rapid cycling, and mixed mania. Compliance issues will also be dis cussed. Copyright