Mark E. Ladner

Antidepressant-induced suicidality: an update.

Evidence suggests that antidepressant treatment may in some cases result in worsening depression and increased risk of suicidality in pediatric and adolescent patients. The United States Food and Drug Administration requires that antidepressants carry a black box warning regarding such a risk in patients up to age 24. Many studies of antidepressant‐induced suicidality among adults have also reported an increased risk, while several other investigations involving that population have not supported such a finding. This article provides an update of the controversy surrounding antidepressants as a potential cause of suicidal ideations or behavior. Antidepressant‐induced suicidality appears to be an uncommon occurrence but also a legitimate phenomenon. Close monitoring and a follow‐up care should be provided for patients after initiation of a new antidepressant.

Potentiation of the effect of buprenorphine/naloxone with gabapentin or quetiapine.

“Mr. A,” a 38-year-old man, began misusing heroin and prescription opioids in his late twenties. After being arrested for drug possession, he completed a treatment program and was placed on probation that stipulated periodic drug screens. He was prescribed buprenorphine (8 mg)/ naloxone (2 mg), two films sublingually as a single daily dose. He initially appeared to do well. After presenting to his probation officer in an apparently intoxicated state, he was taken back into custody. His urine drug screen was negative. Mr. A admitted he had been misusing buprenorphine/ naloxone in conjunction with other prescription medications as a partial substitute for illicit opiates. He wanted to maintain negative drug screens but also “still get high.” He described taking buprenorphine/naloxone simultaneously with up to 1,000 mg of quetiapine or with up to 2,400 mg of gabapentin. With buprenorphine/naloxone and either additional medication, he experienced a relaxed euphoric state that was not as intense as with illicit opiates but was still quite desirable. He entered another drug treatment program to address this problem.

Antidepressant-induced suicidality: implications for clinical practice.

The risk of suicidal behavior associated with antidepressant treatment is an issue of debate and concern. The US FDA has required that antidepressants carry a black box warning that there may be a risk of suicidal ideations in depressed pediatric patients treated with these medications, and recently extended the warning to include individuals up age 24. However studies of antidepressant-induced suicidality in adults have yielded contradictory findings and conclusions. This article discusses investigations of this poorly understood phenomenon and the clinical implications of research findings and FDA warnings for clinicians treating adults with depression. Although antidepressant-induced suicidality apparently occurs only rarely, close monitoring and follow up care after the initiation of a new antidepressant is indicated.

Abuse of medications that theoretically are without abuse potential.

Abstract The potential for abuse of medications that are controlled substances is well known. Abuse of certain noncontrolled prescription drugs and over-the-counter medications also may occur. To some degree, any medication that exerts psychoactive effects may be abused if taken in high enough doses or by means that result in high serum or cerebrospinal fluid levels. Many clinicians may be unaware of the potential for abuse of these medications. This review examines evidence of the possibility of abuse of several common medications that theoretically do not have abuse potential, including cough and cold preparations, antihistamines, anticholinergics, antipsychotics, antidepressants, anticonvulsants, skeletal muscle relaxants, and antiemetics. Means by which such medications may be abused and biochemical and physiological mechanisms fostering their abuse also are discussed.

Abdominal Trigger Points and Psychological Function.

Myofascial trigger points (TPs) are a poorly understood phenomenon involving the myofascial system and its related neural, lymphatic, and circulatory elements. Compression or massage of a TP causes localized pain and may cause referred pain and autonomic phenomena. The authors describe a 58-year-old woman who experienced precipitation of substantial psychological symptoms directly related to her treatment for a lower abdominal TP. Her symptoms resolved after 2 weeks of receiving high-velocity, low-amplitude manipulation and soft tissue massage. Particularly in the abdomen, TPs may be associated with psychological reactions as well as physical aspects of bodily function.

Effect of inpatient electroencephalography on clinical decision making: EEG is more valuable than findings suggest.

We read with interest the findings of the retrospective investigation of the role of electroencephalography (EEG) in the treatment of hospitalized patients by Harmon and colleagues in the December 2013 issue of The Journal of the American Osteopathic Association.1 In their cohort of 200 inpatients, EEG was found to rarely contribute to clinical decision making and in no case resulted in a change in diagnosis or management. We have some concerns that if the findings are not viewed in the context of the overall value of EEG, these results may lead clinicians generally used to assess focal lesions, focal slowing visible on EEG recordings can sometimes reveal pathology in a specific brain region that would not be detected on structural imaging.2 In addition, EEG is one of the most helpful modalities available for diagnosing and monitoring delirium. The fluctuating state of awareness in delirium is accompanied by characteristic EEG changes, and the varying levels of a patient’s attention parallel the slowing of background EEG rhythms.3 To some degree, the same type of findings may apply to patients in a coma; in some such cases, continuous or frequent EEG monitoring in the intensive care unit setting may be of value.4 Slowing of EEG rhythms that accompany dementia can also progress as dementia advances, providing a modality for monitoring disease severity. Electroencephalography may also be quite useful for conclusively distinguishing dementia from pseudodementia (a syndrome in which dementia is mimicked by depression or other psychiatric disorders).2 Quantitative EEG, the transformation of selected EEG activity such as frequency or voltage by Fourier analysis into numeric values, which are often mapped, was not considered in the study. Quantitative EEG may provide valuable information in several clinical conditions. For example, quantitative EEG has been shown to be useful in the assessment of mild traumatic brain injury, even in the absence of brain abnormalities on magnetic resonance images.5 Quantitative EEG analysis of frequency and mean theta power may be sensitive to the early presence of subjective cognitive dysfunction and might be useful in the inito believe that EEG is not as useful a diagnostic modality as was previously believed and could result in decreased orders for EEGs when clinically appropriate. Although EEG ordered apart from specific indications may not always contribute to clinical decision making, there remain many instances in which EEG is a valuable clinical tool. For example, EEG remains the most useful laboratory test for the classification of seizures and specific epileptic syndromes.2 A generalized seizure and a partial seizure with rapid secondary generalization may be very difficult to distinguish clinically, but the seizure type may be readily determined with an EEG if a recording is made during the onset of a seizure. In some cases, EEG may be the only modality that can conclusively distinguish a seizure from a pseudoseizure. Although computed tomography and magnetic resonance imaging are now The Journal of the American Osteopathic Association (JAOA) encourages osteopathic physicians, faculty members and students at colleges of osteopathic medicine, and others within the health care professions to submit comments related to articles published in the JAOA and the mission of the osteopathic medical profession. The JAOA’s editors are particularly interested in letters that discuss recently published original research.