Roy R. Reeves

Ciprofloxacin-Induced Psychosis

OBJECTIVE: To report a case of ciprofloxacin-induced psychosis and to discuss occurrence rates, risk factors, possible etiologies, preventive measures, and treatment courses for this adverse reaction. DATA SOURCES: Case reports and review articles identified by MEDLINE. DATA EXTRACTION: Data from pertinent published sources were reviewed and abstracted. DATA SYNTHESIS: A 49-year-old man developed symptoms of severe psychosis concomitant with ciprofloxacin (250 mg bid) treatment. Central nervous system effects secondary to ciprofloxacin treatment are uncommon and usually consist only of minor dizziness or mild headache, although rare occurrences of seizures and hallucinations have been reported. The mechanism by which ciprofloxacin causes these adverse effects is not fully understood. It has been suggested that quinolones may produce an epileptogenic effect by inhibiting the binding of gamma-aminobutyric acid to its receptor sites in the brain. There is yet no explanation for the occurrence of hallucinations or psychosis. CONCLUSIONS: Caution should be exercised when using ciprofloxacin in the treatment of patients with personality abnormalities or symptoms of psychosis.

Neuropsychiatric complications of traumatic brain injury.

Traumatic brain injury (TBI) may be defined as any extracranial mechanical force to the brain that results in any period of loss of consciousness, any loss of memory for events immediately before or after the event, or any alteration in mental status at the time of the event. The major causes are automobile accidents, falls, sporting injuries, and assaults. Many soldiers returning from combat in Afghanistan and Iraq have also experienced TBI. This article provides an overview of the neuropsychiatric complications of TBI, including impairment of consciousness, posttraumatic amnesia, cognitive disorders and dementia, posttraumatic epilepsy, aphasia, depression, mania, psychosis, anxiety disorders, personality changes, aggression, behavioral dyscontrol, fatigue/apathy, and increased risk of suicide. Discussion will focus primarily on issues affecting mental health clinicians. Because mental health providers are more involved in care of chronic issues related to TBI, these issues will be discussed in more detail, although acute neuropsychiatric complications of TBI will be briefly explained.

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.

A randomized trial of the effect of prayer on depression and anxiety.

Objective: To investigate the effect of direct contact person-to-person prayer on depression, anxiety, positive emotions, and salivary cortisol levels. Design, Setting, and Participants: Cross-over clinical trial with depression or anxiety conducted in an office setting. Following randomization to the prayer intervention or control groups, subjects (95% women) completed Hamilton Rating Scales for Depression and Anxiety, Life Orientation Test, Daily Spiritual Experiences Scale, and underwent measurement of cortisol levels. Individuals in the direct person-to-person prayer contact intervention group received six weekly 1–hour prayer sessions while those in the control group received none. Rating scales and cortisol levels were repeated for both groups after completion of the prayer sessions, and a month later. ANOVAs were used to compare pre- and post-prayer measures for each group. Results: At the completion of the trial, participants receiving the prayer intervention showed significant improvement of depression and anxiety, as well as increases of daily spiritual experiences and optimism compared to controls (p < 0.01 in all cases). Subjects in the prayer group maintained these significant improvements (p < 0.01 in all cases) for a duration of at least 1 month after the final prayer session. Participants in the control group did not show significant changes during the study. Cortisol levels did not differ significantly between intervention and control groups, or between pre- and post-prayer conditions. Conclusions: Direct contact person-to-person prayer may be useful as an adjunct to standard medical care for patients with depression and anxiety. Further research in this area is indicated.

The Effects of Donepezil on Quantitative EEG in Patients with Alzheimer's Disease:

Donepezil is a cholinesterase inhibitor which has been previously shown to affect the cognitive evoked potentials (EPs) of patients with Alzheimers Disease (AD) during treatment with the drug. The purpose of this study was to determine the effect of treatment with donepezil 5 mg daily for 1 month on quantitative EEG (QEEG) in patients with AD. Treatment was associated with no significant differences between the pre- and post-treatment QEEGs for (1) absolute power (all four frequency bands), (2) percent relative power (all four frequency bands), (3) total mean frequency, (4) mean frequency for theta and beta, (5) absolute power asymmetry across homologous electrode pairs (all four frequency bands), and (6) interhemispheric coherence across homologous electrode pairs (all four frequency bands). There were significant decreases in mean alpha and delta frequencies that were consistent across broad electrode arrays except for an increase in the delta frequency at T3. The implications of these changes are not yet clear. Studies of QEEG changes with higher doses of donepezil over longer periods of time may yield a better understanding of the neurophysiological effects of the medication.

The Effect of Prayer on Depression and Anxiety: Maintenance of Positive Influence One Year after Prayer Intervention

Objective: To investigate whether the effect of direct contact person-to-person prayer on depression, anxiety, and positive emotions is maintained after 1 year. Design, Setting, and Participants: One-year follow-up of subjects with depression and anxiety who had undergone prayer intervention consisting of six weekly 1-hour prayer sessions conducted in an office setting. Subjects (44 women) completed Hamilton Rating Scales for Depression and Anxiety, Life Orientation Test, and Daily Spiritual Experiences Scale after finishing a series of six prayer sessions and then again a month later in an initial study. The current study reassessed those subjects with the same measures 1 year later. One-way repeated measures ANOVAs were used to compare findings pre-prayer, immediately following the six prayer sessions, and 1 month and again 1 year following prayer interventions. Results: Evaluations post-prayer at 1 month and 1 year showed significantly less depression and anxiety, more optimism, and greater levels of spiritual experience than did the baseline (pre-prayer) measures (p < 0.01 in all cases). Conclusions: Subjects maintained significant improvements for a duration of at least 1 year after the final prayer session. Direct person-to-person prayer may be useful as an adjunct to standard medical care for patients with depression and anxiety. Further research in this area is indicated.

Similar Effects of Tramadol and Venlafaxine in Major Depressive Disorder

The analgesic tramadol has many characteristics in common with the antidepressant venlafaxine. The drugs are structurally similar, share both serotonergic and noradrenergic properties, and undergo a similar metabolic fate. In this study, a patient, who developed significant depression following cessation of tramadol after several years of therapy, is described. Her depression was then treated with venlafaxine with excellent response. It appears that tramadol may have provided a prophylactic antidepressant effect in this patient. Because of its similarities to venlafaxine, tramadol may possibly exert a degree of antidepressant effect in certain patients, particularly those with chronic pain.

Neurotoxic Syndrome Associated with Risperidone and Fluvoxamine

OBJECTIVE: To report a case of a neurotoxic syndrome in a patient undergoing concomitant treatment with risperidone and fluvoxamine. CASE REPORT: A 24-year-old African American woman hospitalized for psychosis was unresponsive to risperidone. Because of obsessive symptoms, low doses of fluvoxamine were added to her treatment regimen. Within 2 days, she developed confusion, diaphoresis, diarrhea, hyperreflexia, and myoclonus, which then progressed to rigidity, fever, and unresponsiveness, requiring endotracheal intubation. Symptoms resolved over 10 days with discontinuation of medication, hydration, and bromocriptine 5 mg 3 × daily. Ultimately, she was treated with olanzapine and fluvoxamine without adverse effects. DISCUSSION: This represents the first reported case of a neurotoxic syndrome secondary to treatment with risperidone and fluvoxamine. Differential diagnosis between neuroleptic malignant syndrome (NMS) and serotonin syndrome (SS) could not be accurately determined because of the overlap of signs and symptoms of both syndromes. NMS and SS may represent different aspects of a more generalized neurotoxic syndrome. This could be an important consideration in formulating treatment for neurotoxic syndromes. CONCLUSIONS: Clinicians should be aware of potentially serious adverse reactions that may occur during concomitant treatment with antipsychotics and selective serotonin-reuptake inhibitors.

Carisoprodol: Abuse Potential and Withdrawal Syndrome

Carisoprodol (N-isopropyl-2 methyl-2-propyl-1,3-propanediol dicarbamate; N-isopropylmeprobamate) is a centrally acting skeletal muscle relaxant whose primary active metabolite is meprobamate, a substance with well established abuse potential similar to that of benzodiazepines. A number of reports show that carisoprodol has been abused for its sedative and relaxant effects, to augment or alter the effects of other drugs, and by the intentional combination of carisoprodol and other noncontrolled medications because of the relative ease (as compared to controlled substances) of obtaining prescriptions. The diversion and abuse of carisoprodol and its adverse health effects appear to have dramatically increased over the last several years. Clinicians have begun to see a withdrawal syndrome consisting of insomnia, vomiting, tremors, muscle twitching, anxiety, and ataxia in patients who abruptly cease intake of large doses of carisoprodol. Hallucinations and delusions may also occur. The withdrawal symptoms are very similar to those previously described for meprobamate withdrawal, suggesting that what may actually be occurring is withdrawal from meprobamate accumulated as a result of intake of excessive amounts of carisoprodol. However carisoprodol itself is capable of modulating GABA(A) function, and this may contribute both to the drugs abuse potential and to the occurrence of a withdrawal syndrome with abrupt cessation of intake. Carisoprodol has been classified as a controlled substance in several states in the US and restrictions on the use of the drug have been imposed in some European countries. Carisoprodol is metabolized to a controlled substance, has clear evidence of abuse potential and increasing incidence of abuse, and has shown evidence of a withdrawal syndrome with abrupt cessation from intake. This article will discuss the abuse potential of carisoprodol and the associated withdrawal syndrome, and consider implications for future use of the drug.

Carisoprodol Withdrawal Syndrome

A 43‐year‐old man with chronic back and shoulder pain was treated with hydrocodone. He began taking excessive amounts of the drug, so his physicians stopped prescribing it. The patient then obtained the muscle relaxant carisoprodol on his own from several sources. He was consuming up to 30 or more tablets/day (≥ 10,500 mg/day) for several weeks, then abruptly stopped taking the drug. Within 48 hours he developed anxiety, tremors, muscle twitching, insomnia, auditory and visual hallucinations, and bizarre behavior. The symptoms intensified and peaked on the fourth day after carisoprodol cessation. The patient required brief treatment with olanzapine and tapering dosages of lorazepam while the symptoms gradually resolved. To our knowledge, this is the first documented case of a withdrawal syndrome with carisoprodol. The symptoms most likely resulted because of accumulation of meprobamate, the active metabolite of carisoprodol in humans. Clinicians prescribing carisoprodol should be aware of the possibility for abuse or addiction. Further, we recommend that carisoprodol be designated a controlled substance at the federal level.