Kenneth R. Kaufman

Lamotrigine toxicity secondary to sertraline

Blood level monitoring helps to determine the therapeutic and toxic ranges for anticonvulsants and antidepressants. We investigated initial drug-drug interactions between lamotrigine and sertraline. We report on case histories of two epileptic patients who were initially on lamotrigine and to whom sertraline was added to control psychiatric features. In case 1, a total daily dose of 25 mg sertraline, with nondetectable sertraline and desmethylsertraline blood levels, resulted in a doubling of the lamotrigine blood level with symptoms of toxicity. In case 2, a 25 mg reduction in the total daily dose of sertraline resulted in halving of the lamotrigine blood level even though the lamotrigine dosage was increased by 33%. This shows that sertraline has potent interactions with lamotrigine metabolism. The authors hypothesize that inhibition of glucuronidation is responsible. Clinicians are advised to observe for symptoms of toxicity and to do serial blood levels to monitor this interaction.

Antiepileptic drugs in the treatment of psychiatric disorders

The clinical interface between psychiatry and neurology is epilepsy; the pharmacological expression of this interface is antiepileptic drugs (AEDs), as they are used to treat both epilepsy and psychiatric disorders, especially bipolar disorders. The prevalence of psychiatric comorbidity and the risk of suicidal behavior/ideation/suicide are markedly increased in patients with epilepsy (PWE). Though AEDs receive initial indications for the treatment of epilepsy, currently the majority of AEDs are used to treat pain and psychiatric disorders. Thus in selecting the appropriate AEDs for treatment of PWE, consideration should be given to which AEDs best treat the epileptic disorder and the psychiatric comorbidity. This review is an overview of 21 AEDs in which negative psychotropic properties, approved indications in psychiatry, off-label studied uses in psychiatry, and principal uses in psychiatry are presented with literature review. A total of 40 psychiatric uses have been identified. Of the 21 AEDs reviewed, only 5 have U.S. Food and Drug Administration and/or European Medicines Agency psychiatric approval for limited uses; the majority of AEDs are used off-label. Many of these off-label uses are based on case reports, open-label studies, and poorly controlled or small-sample-size studies. In some instances, off-label use persists in the face of negative pivotal trials. Further placebo-controlled (augmentation and monotherapy) parallel-arm research with active comparators is required in the complex field of AED treatment of psychiatric disorders to minimize the treatment gap not only for PWE with psychiatric disorders, but also for psychiatric patients who would benefit from properly studied AEDs while minimizing adverse effects.

Caffeinated beverages and decreased seizure control

Seizure control is often affected by seizure threshold lowering behaviours. In this case report, the authors address excessive caffeine ingestion from tea with increased seizure frequency. When decaffeinated beverages were substituted for the tea, seizure frequency returned to baseline. Similar findings occurred when the patient was re-challenged. The authors recommend avoidance of excessive caffeine in patients with epilepsy.

Adjunctive tiagabine treatment of psychiatric disorders: three cases.

Anticonvulsants which effectively treat complex partial seizures are noted to have mood stabilizing effects (carbamazepine, valproate, lamotrigine, gabapentin). Tiagabine, a novel GABA uptake inhibitor anticonvulsant with similar indications, was used as adjunctive therapy to control psychiatric symptoms in three patients—two with bipolar disorder and one with schizoaffective disorder, bipolar type. All three patients improved during adjunctive low dosage tiagabine treatment and no untoward side effects were noted. Clinicians are advised to consider this new anticonvulsant as a potential adjunctive agent in the treatment of bipolar and schizoaffective disorders. Controlled trials are indicated.

Epilepsy, seizures, physical exercise, and sports: A report from the ILAE Task Force on Sports and Epilepsy

People with epilepsy (PWEs) are often advised against participating in sports and exercise, mostly because of fear, overprotection, and ignorance about the specific benefits and risks associated with such activities. Available evidence suggests that physical exercise and active participation in sports may favorably affect seizure control, in addition to producing broader health and psychosocial benefits. This consensus paper prepared by the International League Against Epilepsy (ILAE) Task Force on Sports and Epilepsy offers general guidance concerning participation of PWEs in sport activities, and provides suggestions on the issuance of medical fitness certificates related to involvement in different sports. Sports are divided into three categories based on potential risk of injury or death should a seizure occur: group 1, sports with no significant additional risk; group 2, sports with moderate risk to PWEs, but no risk to bystanders; and group 3, sports with major risk. Factors to be considered when advising whether a PWE can participate in specific activities include the type of sport, the probability of a seizure occurring, the type and severity of the seizures, seizure precipitating factors, the usual timing of seizure occurrence, and the persons attitude in accepting some level of risk. The Task Force on Sports and Epilepsy considers this document as a work in progress to be updated as additional data become available.

And Then the Dog Died

ABSTRACT Childhood grief and mourning of family and friends may have immediate and long-lasting consequences including depression, anxiety, social withdrawal, behavioral disturbances, and school underachievement. Childhood pet bereavement is no less important, because the pet is often considered a member of the family by the child. However, society does not always acknowledge the significance of pet bereavement, which can result in unresolved grief. This article, a case analysis with literature review, addresses childhood pet bereavement in the context of multiple prior losses (K. R. Kaufman & N. D. Kaufman, 2005). This case mirrors both old and new findings in grief research and therapy: (a) beneficial response to emotional expression of grief in context of search for meaning; (b) beneficial response to cognitive approach toward grief with ability to prevent development of complicated grief even in the face of multiple losses; (c) beneficial effects associated with supportive family and with positive self-concept; (d) intensity of grief magnified by the childs degree of attachment to the pet, the suddenness of the pets death, the multiple prior losses, and the role of the pet in the childs life; and (e) resiliency. This case further emphasizes the need for parents not to trivialize death of pets, to appreciate the role pets have in childrens lives, and to assist the child in multiple approaches toward expression (be it verbal, written, or artistic). Finally, this case reinforces the ability of the child to assist in family bereavement and to serve as teacher.

MELAS with recurrent complex partial seizures, nonconvulsive status epilepticus, psychosis, and behavioral disturbances: Case analysis with literature review

Mitochondrial encephalopathy, lactic acidosis, and strokelike episodes (MELAS) is a progressive neurodegenerative disorder associated with polygenetic, maternally inherited, mitochondrial DNA mutations. MELAS has multisystem presentation including neurological, muscular, endocrine, auditory, visual, cardiac, psychiatric, renal, gastrointestinal and dermatological symptoms. Clinical course and prognosis are variable, often leading to cognitive decline, disability, and premature death. Both convulsive status epilepticus (CSE) and nonconvulsive status epilepticus (NCSE) are reported with MELAS. This report illustrates a case of MELAS with recurrent complex partial seizures, NCSE, confusion, aggressive behaviors, hallucinations, and paranoid delusions. Rapid video/EEG confirmation of diagnosis and aggressive antiepileptic drug intervention are required. Further education of medical professionals regarding this disorder, its appropriate management, and the significance of NCSE is indicated to avoid delay of treatment.

Neuroleptic Malignant Syndrome and Serotonin Syndrome in the Critical Care Setting: Case Analysis

BACKGROUND Serotonin syndrome (SS) and neuroleptic malignant syndrome (NMS) are medical emergencies associated with psychotropic administration. Differentiation and treatment can be complex, especially when features of both syndromes are present and the patient has taken both serotonergic and neuroleptic agents. METHOD Case analysis of a poly-drug overdose (venlafaxine, topiramate, divalproex sodium, risperidone, and carbamazepine) presenting with mixed SS/NMS features and whose clinical management suggests a practical algorithm for treatment of undifferentiated SS/NMS in critical care settings. RESULTS The suggested algorithm includes: 1) Supportive care and withdrawal of all potentially offending agents; 2) Laboratory evaluation with prompt initiation of treatment for both disorders--cyproheptadine for SS and dantrolene for NMS; 3) Do not use bromocriptine (contraindicated in SS) or chlorpromazine (contraindicated in NMS) initially; 4) Add bromocriptine when clinical presentation becomes consistent with NMS (SS can be prolonged if serotonergic agent has long half-life). CONCLUSIONS Prompt and appropriate identification and intervention are essential for successful management of SS and NMS. The suggested treatment algorithm allows for specific treatment of both disorders and avoids potentially exacerbating either one. The algorithm derived from this case could serve as both a practical guideline and impetus for further investigation in light of increasing psychotropic co-administration.

CHILDHOOD MOURNING: PROSPECTIVE CASE ANALYSIS OF MULTIPLE LOSSES

ABSTRACT Multiple losses within short time periods make one question life and can exponentially influence ones coping skills. But what are the effects on a child and what should be done when the next loss occurs? This case addresses the multiple losses suffered by a child while assessing coping skills of the child and coping strategies used by the parents to assist the child.

Gabapentin-induced sexual dysfunction

Sexual dysfunction is a key adverse effect leading to medication noncompliance. Psychotropic drugs associated with sexual dysfunction include antiepileptic drugs, antidepressants, and antipsychotics. Gabapentin, frequently used off-label to treat psychiatric and pain disorders, has previously been reported to cause sexual dysfunction at a minimum total daily dose of 900 mg. This report addresses dose-dependent gabapentin-induced sexual dysfunction reaching total sexual dysfunction (loss of libido, anejaculation, anorgasmia, and impotence) at a total daily dose of only 300 mg.